Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Scioto Pointe during CMS and state inspections, most recent first.
The facility failed to maintain a complete infection prevention and control program because its infection log did not capture key surveillance details such as bacteria, symptoms, or whether infections met McGeer's Criteria, and some antibiotic-treated residents were listed without meeting current criteria. The facility also lacked evidence of required initial and annual TB screening for multiple staff members, including a CNA, housekeepers, and an LPN, and the DON was unavailable when the missing records were identified.
A facility failed to keep resident rooms, common areas, and the kitchen free of pests. Live cockroaches were observed in multiple resident rooms, including on a toilet seat and on the floor, and staff confirmed the issue had been ongoing. In the kitchen, cockroach-like insects were seen near the walk-in fridge and on a shelf below the steam table, while staff and pest control records documented repeated roach activity throughout the building.
Surveyors found that multiple residents were living in unclean and poorly maintained rooms, including mattresses with holes, rotted bathroom vanities, very dirty floors, and bed frames coated with dust and food particles. In several bathrooms, shower doors were removed from their tracks and left inside the showers. Dried feces were observed on the floor and bed in one room, and cockroaches were seen emerging from a toilet and crawling across the floor in another, with a resident reporting that cockroaches were present throughout the area and that nothing was being done. A resident’s representative also reported that the facility was not clean and had cockroach infestation issues, and facility maintenance and housekeeping leadership confirmed these environmental and housekeeping problems, which were inconsistent with the facility’s policy requiring a safe, clean, and homelike environment.
Expired Assure Prism glucometer control solutions were found on medication carts on two resident halls, stored with the glucometers, lancets, and other blood glucose monitoring supplies. RNs confirmed the solutions were expired, and staff stated night shift performed QC testing of the glucometers. The facility policy required checking expiration dates before use and discarding expired control solutions.
Antibiotic stewardship was not followed because the facility used outdated and incorrect McGeer-based forms to justify antibiotic starts for multiple residents. Antibiotics were given for respiratory, urinary, skin, dental, wound, post-surgical, and unknown infections even though the documented findings often did not meet current NHSN definitions, and in several cases the facility could not provide McGeer criteria at all. An RN confirmed the forms in use did not match McGeer criteria and that some residents on antibiotics did not even meet the facility’s own criteria. One resident with agitation and pacing but no urinary symptoms was also treated for a UTI despite not meeting McGeer criteria.
A resident’s MDS 3.0 assessments did not accurately reflect a chronic right leg wound. The resident had diagnoses including dementia, DM2, and an open wound of the right lower leg, but the MDSs showed intact cognition and no skin issues. A wound assessment documented cellulitis of the right leg, and an RN confirmed the chronic wound should have been marked on the MDS.
Failure to provide activities according to resident preference. A resident with dementia, schizoaffective disorder, auditory hallucinations, and anxiety had documented preferences for group activities and favorite pastimes such as rummy, basketball, music, walking, and family contact, but activity records showed repeated nonattendance at bingo, cards/games, music programs, and social hour over several months. Staff could not verify the resident received activities per preference, and the care plan did not reflect the resident’s preferred activities.
Failure to monitor nutritional intake and address weight loss for a resident with dementia, dysphagia, schizophrenia, and other diagnoses. The resident had a mechanically altered diet, a 15.13% weight loss, and numerous missing meal intake records across multiple days. The RD noted the resident may benefit from Remeron, but the NP review did not result in an order at that time, and the dietician confirmed no follow-up was completed after the notification.
Accurate resident records were not maintained for falls and wound care. One resident with schizophrenia, vascular dementia, and a prior CVA had two falls with injuries, but the incident reports did not match the documented arm/wrist fracture and head laceration. Another resident with bipolar disorder and cognitive impairment had a fall with no nursing progress note on the day of the event. A third resident with multiple psychiatric and wound diagnoses had inconsistent hospice status in skin notes and several missed MAR entries for ordered wound treatments.
A resident with multiple health conditions was diagnosed with Legionella pneumonia after being treated for pneumonia at the facility and then hospitalized. The facility's water management and legionella prevention plan lacked comprehensive monitoring and clear protocols, and recommended mitigation strategies such as restricting water usage and installing point-of-use filters were not implemented. Shared bathrooms and shower rooms remained in use without filtration, and maintenance practices were inconsistently documented, leading to a deficiency in preventing the potential spread of Legionella.
The facility did not provide enough dietary staff, leading to the use of disposable Styrofoam containers and cups for serving meals and drinks. The Dietary Manager confirmed that staff shortages prevented proper dishwashing, and a resident stated that meals are always served on disposable products, with regular dishware used only occasionally.
Surveyors observed that meals and drinks were consistently served in disposable Styrofoam containers and cups due to an inadequate supply of dishes. The DM confirmed the shortage, and a resident stated that meals are always served on disposable products, with regular dishes rarely provided.
Multiple unresolved maintenance and cleanliness issues, including leaking sinks, damaged fixtures, unsecured drain covers, and buildup of a black substance in rooms and hallways, were documented through resident council minutes, direct observation, and staff interviews. These deficiencies persisted over several months and affected all residents, with staff confirming that concerns were repeatedly raised but not addressed in a timely manner.
Surveyors found that a resident's indwelling urinary catheter collection bag was left uncovered and visible from the hallway, contrary to care plan instructions, and that another resident consistently received meals and drinks in disposable containers due to staffing and supply shortages. Both situations failed to uphold resident dignity as required by facility policy.
Two residents with complex medical and psychiatric conditions did not have comprehensive care plans addressing their ADL needs or elopement risk, despite assessments indicating these needs. Facility staff, including the DON and an RN, confirmed the absence of appropriate care plans for these residents.
Three residents with significant medical and psychiatric conditions were not properly assessed for elopement risk, and physician-ordered interventions such as wander prevention devices were not consistently implemented or maintained. Staff confirmed that required risk assessments were not completed, and in some cases, residents were able to remove prevention devices or attempt to leave the facility without proper supervision.
Surveyors identified that staff failed to follow infection control protocols during catheter care and wound dressing changes for two residents with complex medical needs. In one case, a nurse did not change gloves or perform hand hygiene between cleaning a resident's rectal area and their urinary catheter, and the catheter bag was found on the floor. In another case, a nurse did not implement Enhanced Barrier Precautions during a dressing change for a resident with a chronic wound, despite care plan and physician orders requiring it.
A resident with paranoid schizophrenia reported an alleged sexual assault by an LPN, but the facility failed to promptly investigate or document the incident. The resident reported the incident to a trusted staff member, but the facility did not assess her for injuries or notify the police until she called them herself. The facility's investigation was insufficient, lacking documentation and timely action, and the allegation was unsubstantiated based solely on the resident's word.
A resident with paranoid schizophrenia reported being sexually assaulted by an LPN, but the LTC facility failed to document the allegation or conduct a proper follow-up. Despite the resident's report to staff, there was no record of an assessment for injuries or psychosocial follow-up. The resident eventually contacted the police herself, as the facility did not take appropriate action. Interviews revealed a lack of documentation and adherence to facility policies on abuse investigation and reporting.
The facility failed to manage resident funds exceeding Medicaid limits and did not convey funds to authorized representatives within 30 days of discharge or death, affecting multiple residents. The Business Office Manager confirmed the oversight, which violated the facility's policy requiring notification when account balances approached the SSI resource limit.
The facility failed to assess and monitor behaviors for four residents with mental health diagnoses. Care plans lacked specific target behaviors and tracking, affecting residents with conditions like schizoaffective disorder and PTSD. Staff confirmed the absence of behavior tracking and incomplete care plans.
A resident with multiple diagnoses frequently returned intoxicated from LOAs, and the facility failed to notify the attending physician before administering Seroquel and Keppra. Staff interviews confirmed the oversight, which violated the facility's policy requiring physician notification of significant condition changes.
A resident's bed footboard was broken, posing a safety risk. Despite the resident's report to the DON, the issue was not resolved promptly. The MD contacted a medical bed company for a replacement but did not provide the required measurements, delaying the repair. This failure compromised the resident's right to a safe and homelike environment.
A resident with multiple diagnoses frequently left the facility unsupervised and returned intoxicated, yet the care plan lacked guidelines for these absences. Despite discussions with the DON about the resident's intoxication and missed medications, the care plan was not updated to address these issues. Staff interviews confirmed the resident's frequent unsupervised LOAs and the absence of a comprehensive care plan.
A facility failed to assist a resident with grooming needs, despite the resident's care plan indicating a self-care deficit in grooming due to impaired ability and lack of fine motor skills. Observations showed the resident's chin hairs were unkempt, and interviews confirmed the resident required staff assistance, which was not provided. The facility's policy stated that appropriate ADL support should be given to residents unable to perform these tasks independently.
The facility failed to monitor two residents after falls, as required by policy. One resident with dementia had falls without injuries, while another with vascular dementia had falls resulting in injuries. The DON confirmed the lack of required post-fall monitoring and documentation.
A resident in an LTC facility, who required assistance with oral intake, did not receive adequate fluids between meals. Despite a care plan intervention for fluid intake, observations showed no fluids at the bedside, and staff confirmed the resident could not ask for fluids. The DON acknowledged insufficient fluid intake documentation, and the facility lacked a hydration policy.
A facility failed to monitor a resident's blood pressure before administering Lasix, as ordered by the physician. The resident had a history of obsessive-compulsive personality disorder, paranoid schizophrenia, polydipsia, and hypoosmolality and hyponatremia. Despite the physician's order to hold Lasix if the systolic blood pressure was less than 100, the medication was administered without recording blood pressure on multiple occasions. Interviews with staff confirmed the oversight, which was contrary to the facility's medication administration policy.
A resident with multiple medical conditions experienced inadequate pain management due to the facility's failure to conduct and document pain assessments as per their policy. Despite receiving scheduled oxycodone, the resident's pain was not assessed before or after administration, nor were weekly pain assessments completed, as confirmed by the DON.
Incomplete Infection Surveillance and Missing TB Screening Records
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not maintain comprehensive infection surveillance and did not ensure staff had completed required TB screening. Review of the infection control log for January, February, and March 2026 showed it listed resident name, room number, date, type of infection, antibiotic, and whether the infection was facility acquired, but it did not include the type of bacteria, whether symptoms were present, or whether infections met McGeer's Criteria. It was also unclear whether the date reflected infection onset or the date antibiotics were started. The log included residents who received antibiotics for respiratory infection, post-surgery, UTI, tooth infection, skin infection, and pneumonia, including residents who were admitted and then treated with ciprofloxacin, Keflex, Macrobid, azithromycin, amoxicillin, doxycycline, and other antibiotics. For March 2026, the facility tracked residents receiving antibiotics and noted nosocomial or community acquired infections, but McGeer's criteria was not included on the log and the separate McGeer's form provided by the facility did not match current criteria. Several residents listed as receiving antibiotic treatment for infections were identified as not meeting McGeer's criteria, including residents treated for unknown infection, pneumonia, post-surgery, sepsis, wound infection, and UTI. In addition, review of personnel files showed no evidence of an initial two-step Mantoux for one CNA and no evidence of annual TB screening for multiple staff members, including housekeepers, a CNA, and an LPN. The Administrator stated the DON was responsible for maintaining evidence of staff initial and annual TB screening, but the DON was unavailable and the evidence could not be found.
Pest Control Program Failed to Keep Areas Free of Cockroaches
Penalty
Summary
The facility failed to ensure common areas, resident rooms, and the kitchen were free from pests. During observations, live cockroaches were seen in Resident #24’s room, including on the toilet seat in the bathroom, and Resident #24 stated she sees them all the time, including on her bed and crawling from under her bed. Live cockroaches were also observed in Resident #12’s room, and Resident #12 stated he sees them all the time. An LPN confirmed the live cockroaches and stated the facility had an ongoing issue that was difficult to get rid of, while a CNA stated several residents had cockroaches in their rooms and that the issue was hard to eliminate because of resident cleanliness and behaviors. In the kitchen, a cockroach-like insect was observed crawling on the wall near the walk-in refrigerator and later another was seen on a shelf below the cutting surface of the steam table during lunch preparation. Cooks stated they had occasionally seen roaches or other insects in the kitchen, and the AD/DM stated she believed the insect was a roach and had seen one or two in the kitchen from time to time, though she denied a current infestation. Review of pest control invoices from August 2024 through March 2026 showed repeated cockroach activity in the kitchen, break room, sink areas, cooler areas, hallways, and resident units, including heavier activity and ongoing treatment discussions. Additional observations found an insect outside Resident #66’s room that went under the door into the room, and a dead insect in Resident #70’s bathroom; an LPN stated bugs similar to the one observed had been seen for at least the last couple of months and that the issue had worsened again after previously improving.
Failure to Maintain Clean, Sanitary, and Pest-Free Resident Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with a safe, clean, sanitary, and homelike environment as required by facility policy. Observations on multiple dates showed environmental issues in several resident rooms. One resident’s room contained a mattress with several holes on the top and a larger hole on the side facing the doorway, and the bathroom vanity had rotted wood at the bottom. Another resident’s room had a very dirty floor, a bed frame coated with dust and food particles, and shower doors that had been removed from their tracks and were sitting inside the shower. In a different room, dried feces were observed on the floor and bed, and the shower doors were also removed from the tracks and placed inside the shower. Additional observations revealed more unclean and damaged conditions. One resident’s room had a dirty bed frame with food stains, and cockroaches were seen coming from the toilet and crawling across the bathroom floor; this resident stated that cockroaches were everywhere and expressed frustration that the facility was not addressing the issue. Another resident’s room had a bed frame dirty with food stains and dust, and a damaged window sill with exposed wood. A resident’s representative reported that the facility was not clean and had issues with cockroach infestation. The Maintenance Supervisor and Housekeeping Supervisor later verified the environmental and housekeeping issues. Review of the facility’s “Homelike Environment” policy dated February 2021 confirmed that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting, which was not maintained in these instances.
Expired Glucometer Control Solutions Kept With Blood Sugar Monitoring Supplies
Penalty
Summary
The facility failed to ensure glucometers were properly calibrated with control solutions that were not expired on the 400 hall and the 200 hall. On the 400 hall medication cart, a box of Assure Prism glucometer control solutions was observed in the same drawer as the glucometer, lancets, and other blood glucose monitoring supplies, and the box had an expired expiration date. RN #15 confirmed the control solutions were expired and stated they should not be used for testing the glucometer. RN #15 also stated that quality control of the glucometer with control solutions occurs every night shift and that the control solutions should be checked to ensure they are not expired before use. On the 200 hall medication cart, two bottles of Assure Prism glucometer control solutions were observed next to the glucometer, lancets, and other glucose monitoring supplies, and both bottles were expired. RN #115 confirmed that both bottles were expired and stated that night shift nursing staff is responsible for using the control solutions to test the glucometers in the facility. Review of the facility policy for the Assure Prism Multi Blood Glucose Monitoring System stated that the expiration dates on the control solution bottles should be checked before use and that bottles past their printed expiration date should be discarded.
Antibiotic Stewardship Criteria Not Followed
Penalty
Summary
The facility failed to ensure antibiotic stewardship was followed by using outdated and incorrect criteria to determine whether residents met minimum requirements for antibiotic initiation. Review of the infection control logs for February 2026 and March 2026 showed the facility tracked residents receiving antibiotics, but the McGeer criteria forms used for review did not match current McGeer/NHSN definitions. Several residents were documented as meeting criteria for antibiotic treatment even though the facility’s forms did not align with current surveillance definitions, and in some cases the facility could not provide McGeer criteria at all. In February 2026, residents were identified on the infection control log as receiving antibiotics for respiratory, urinary, skin, dental, and post-surgical infections. Examples included a resident given ciprofloxacin for a respiratory infection, a resident given Macrobid for a UTI, a resident given azithromycin for a respiratory infection, a resident given doxycycline for a skin infection, and a resident given ciprofloxacin for pneumonia. The facility’s forms stated that findings such as productive cough, respiratory rate above 25, urgency and frequency, redness and tenderness, or a new infiltrate on chest x-ray were sufficient to meet criteria, but review of the NHSN surveillance definitions dated January 2026 showed these findings were not sufficient for those infections. The facility was also unable to provide McGeer criteria for some residents, including residents treated with Keflex for post-surgery and amoxicillin for a tooth infection. In March 2026, the infection control log again showed residents receiving antibiotics for multiple conditions, including pneumonia, post-surgery, wound infection, UTI, sepsis, and an unknown infection. The facility could not provide McGeer criteria for several of these residents, and for others the forms again did not match current definitions. One resident treated for pneumonia had a productive cough and a new infiltrate on chest x-ray, which the facility marked as meeting criteria, but the NHSN definitions did not support that as sufficient. Another resident treated for a UTI had suprapubic pain and urinary incontinence, which the facility marked as sufficient, but the NHSN definitions did not support that as sufficient. Interview with the charge nurse confirmed the facility should have been using McGeer criteria, that the form in use did not match McGeer criteria, and that some residents on antibiotics did not even meet the criteria on the form. For one resident with an admission diagnosis including adult failure to thrive, schizoaffective disorder, narcolepsy without cataplexy, and secondary parkinsonism, Bactrim DS was ordered for a UTI despite progress notes showing agitation and pacing but no urinary symptoms; the resident’s urinalysis was positive for E. coli, and the charge nurse verified the resident did not meet McGeer criteria for UTI treatment.
MDS Did Not Reflect Resident’s Chronic Wound
Penalty
Summary
The facility failed to ensure Resident #6’s MDS 3.0 assessment accurately reflected the resident’s wound status. Resident #6 was admitted on 12/06/24 with diagnoses including adult failure to thrive, an unspecified open wound of the right lower leg, unspecified dementia, type 2 diabetes mellitus, schizoaffective disorder, unspecified psychosis, antisocial personality disorder, delusional disorder, and conduct disorder. Review of the resident’s comprehensive MDS 3.0 assessments dated 08/12/25, 11/03/25, and 02/03/26 showed intact cognition and no skin issues marked. However, review of the wound assessment revealed cellulitis to the resident’s right leg that had been present since 12/08/24. During interview on 04/02/26 at 12:45 P.M., RN #40 verified that the resident’s chronic wound had not been marked on the MDS assessments and should have been.
Failure to Provide Activities According to Resident Preference
Penalty
Summary
The facility failed to complete activities according to Resident #18’s preferences. The resident was admitted with diagnoses including dementia, schizoaffective disorder, bipolar type, auditory hallucinations, obsessive compulsive personality disorder, high risk sexual behavior, and anxiety. The care plan noted altered mood state related to confusion, auditory hallucinations, and schizoaffective disorder-bipolar type, with interventions including diversional activities, reminiscing, group sing-alongs, 1:1 visits as needed, small activities outside the room, and encouragement to come out of the room for activities of interest. The most recent MDS showed a BIMS of 13 and that the resident preferred to do things with a group of people. Activity assessments identified favorite activities as rummy, basketball, music, walking, calling family, and family visits, and documentation showed the resident attended some group activities such as chat sessions, bingo, watching TV, cards, movies, patio time, smoking, and church service. However, activity documentation for December 2025 through March 2026 showed the resident did not attend bingo, cards/games, music listening or music programs, or party/social hour on multiple occasions, with only limited attendance noted in February and March. During interview, the resident stated he does not do much related to activities, and he was observed in bed with his eyes closed. Activity staff stated documentation was kept in a hall book and that 1:1 activities depended on preferences and behaviors, while the Activity Director could not verify the resident received activities per preference. MDS staff also verified the care plan did not indicate the resident’s preferred activities.
Failure to Monitor Nutritional Intake and Address Weight Loss
Penalty
Summary
The facility failed to ensure nutritional recommendations were addressed and meal intakes were adequately monitored for Resident #88, who was admitted with diagnoses including metabolic encephalopathy, severe unspecified dementia with behavioral disturbance, extrapyramidal and movement disorder, paranoid schizophrenia, schizoaffective disorder, dysphagia, muscle wasting and atrophy, and vitamin D deficiency. The care plan identified altered nutritional status related to obesity, dysphagia, psychiatric diagnoses, GERD, depression, recent and historical weight loss, poor intake, weight fluctuations, and a mechanically altered diet. The resident’s quarterly MDS reflected moderate cognitive impairment and weight loss, with a mechanically altered diet and no therapeutic diet ordered. Weights showed the resident declined from 193 lbs. to 163.8 lbs., a 15.13% weight loss. Meal percentage records for October and November 2025 contained multiple missing documented intakes for breakfast, lunch, and dinner on numerous days. The dietician’s significant weight change report noted the resident may benefit from Remeron, and the nurse practitioner reviewed the recommendation but no order was entered at that time; the physician order for Remeron was not written until later. During interview, the dietician stated she reviews meal intakes, notifies the administrator when meal percentages are missing, and notifies the NP when a medication recommendation is made, and she verified the NP was notified but no follow-up was completed. Facility policy stated nursing personnel, with assistance from food and nutrition services staff, will evaluate and document food and fluid intake for residents with or at risk for significant nutritional problems.
Inaccurate fall records and incomplete wound documentation
Penalty
Summary
The facility failed to maintain accurate resident records and documentation for falls and wound care. For Resident #5, who had diagnoses including undifferentiated schizophrenia, vascular dementia with behaviors, and a history of cerebral infarction, the record showed two falls with injury. After the first fall, the resident reported falling while getting up to use the restroom and complained of pain in the left arm and wrist; the nurse noted redness to the left wrist, obtained x-rays, and the resident was later found to have a moderately displaced transverse fracture of the left distal radial metaphysis. After the second fall, the resident was found on the floor after attempting to transfer from a wheelchair to the bed and had a laceration to the left side of the head. However, the incident/accident reports for both falls did not accurately reflect the injuries documented in the nursing notes. For Resident #13, who had diagnoses including bipolar disorder, chronic obstructive pulmonary disorder, and mild cognitive impairment, the record showed a fall with minor injury, but there were no nursing progress notes describing the fall on the date it occurred. The next nursing progress note was entered two days later and referenced a new intervention placing the resident within sight of staff when out of bed as tolerated following the fall. The MDS nurse confirmed that a nursing progress note should have been completed for the fall. For Resident #6, who had diagnoses including adult failure to thrive, an open wound of the right lower leg, unspecified dementia, schizoaffective disorder, unspecified psychosis, antisocial personality disorder, delusional disorder, and conduct disorder, the record contained inconsistent wound documentation. Skin progress notes continued to state the resident was on hospice after a note indicated she had graduated from hospice, and the MAR showed multiple dates when ordered wound treatments were not documented as completed. The physician orders required cleansing and dressing changes to the right calf and right ankle wounds, but the MAR did not show treatment entries on several dates in February and March. The charge nurse confirmed the resident was no longer on hospice and stated that a nurse had forgotten to document treatments that were completed.
Failure to Implement Effective Legionella Prevention and Water Management
Penalty
Summary
The facility failed to maintain an effective water management and legionella prevention plan, and did not implement recommended mitigation strategies to prevent the potential spread of Legionella pneumonia. A resident with multiple comorbidities, including stroke, diabetes, and cardiac arrhythmia, was treated for pneumonia at the facility and subsequently hospitalized, where laboratory results confirmed a diagnosis of Legionella pneumonia. The facility's policy required assessment, prevention, monitoring, and control of legionella risks, but the water management plan lacked clear instructions for out-of-range measures and did not include comprehensive monitoring or chemical testing, despite the use of city water. Following the positive legionella result, the facility notified the local and state health departments and collected water samples for testing. However, the facility did not restrict water usage or install point-of-use filters as recommended by the local health department. Observations confirmed that the affected resident's bathroom and shower room, which were shared with a roommate, remained in full use without any filtration devices installed. Staff interviews verified that no water restrictions or filtration measures were implemented, and the facility's water management plan was acknowledged as insufficient by both facility leadership and the local health department. Maintenance staff reported conducting weekly water temperature checks and periodic chlorine testing, but there was inconsistent documentation and follow-up when chlorine levels were outside the recommended range. The facility's legionella prevention plan was found to be lacking in basic elements such as routine visual inspections, chemical testing, and clear protocols for responding to abnormal findings. The local health department indicated that the facility's plan was not thorough and recommended consultation to improve their water management practices.
Insufficient Dietary Staffing Resulting in Use of Disposable Dishware
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, as evidenced by multiple observations and interviews. During breakfast and lunch meals, residents were served food and drinks in disposable Styrofoam containers and cups rather than standard dishware. The Dietary Manager confirmed that when the department is short-staffed, disposable products are used because cooks are unable to assist with washing dishes, and verified that there was insufficient staff for food and nutrition services. A resident reported that meals are always served on disposable products and expressed a preference for regular dishes, noting that standard dishware is only used occasionally. These findings were observed during several meal services and were confirmed through staff and resident interviews.
Inadequate Supply of Dishes Leads to Use of Disposable Containers
Penalty
Summary
The facility failed to provide an adequate supply of dishes for residents, resulting in meals and drinks being served in disposable Styrofoam containers and cups. Observations during breakfast and lunch on multiple hallways and in the dining room confirmed the use of disposable products for serving food and fluids. The Dietary Manager verified that there were not enough dishes available, necessitating the use of disposable containers. A resident reported that meals are always served on disposable products and expressed a preference for regular dishes, noting that actual plates are only provided occasionally. These findings were based on direct observations and interviews conducted during the survey.
Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, as evidenced by multiple unresolved maintenance and cleanliness issues in resident rooms, hallways, and bathrooms. Resident Council Minutes over several months documented repeated requests from residents for deep cleaning and repairs, including leaking sinks and toilets, a hole under a bathroom sink, and broken or damaged fixtures such as bed, blinds, and door handles. Observations confirmed these concerns, with findings such as drywall patches, loose door handles, unsecured drain covers posing accident hazards, missing paint, and a buildup of a black substance on doors and floors throughout the resident hallways. Staff interviews corroborated that residents' concerns about maintenance and cleanliness were ongoing and not being addressed in a timely manner. A registered nurse acknowledged awareness of the building's need for repairs and deep cleaning, and confirmed that residents had been voicing these issues during council meetings without resolution. The Maintenance Director, who had been absent due to illness, stated that some repairs had been made upon his return, but the report documents that the deficiencies persisted during the survey period, affecting all 96 residents in the facility.
Failure to Maintain Resident Dignity in Catheter Care and Dining Experience
Penalty
Summary
Surveyors identified deficiencies related to resident dignity and the right to a dignified existence. One resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, and an indwelling urinary catheter, was observed with their catheter collection bag lying on the floor and visible from the hallway. The collection bag was not covered, and urine was visible to passersby. This was confirmed by a registered nurse at the time of observation. The resident's care plan included instructions for the catheter collection bag to remain covered, and staff were to monitor and remind the resident as appropriate, but these interventions were not followed. Another deficiency was observed regarding the dining experience for residents. One resident, with diagnoses including chronic obstructive pulmonary disease, vascular dementia, and severe morbid obesity, was served meals and drinks in disposable Styrofoam containers and cups during both breakfast and lunch. The resident reported that meals were always served on disposable products and expressed a preference for regular dishes. Observations confirmed that disposable containers and cups were used throughout the facility during meal times. The dietary manager confirmed that disposable products were used when the department was short-staffed and that the facility did not have enough dishes to serve all residents. Facility policy stated that residents should be provided with a dignified dining experience, but this was not upheld due to the use of disposable products. These findings were based on record review, observation, resident and staff interviews, and policy review.
Failure to Develop Comprehensive Care Plans for ADL and Elopement Risk
Penalty
Summary
The facility failed to develop comprehensive care plans to address the specific needs of two residents in the areas of activities of daily living (ADL) and elopement risk. For one resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, heart failure, diabetes, schizophrenia, and morbid obesity, the quarterly Minimum Data Set (MDS) assessment indicated total dependence on staff for toileting, bathing, dressing, and personal hygiene. However, there was no care plan in place to address these ADL needs, a fact confirmed by both the Director of Nursing (DON) and a Registered Nurse (RN). In another case, a resident with a history of diabetes, schizophrenia, major depressive disorder, and partial blindness was identified as being at risk for elopement according to the facility's own risk assessment protocol. Despite this, the resident's care plan did not address elopement risk, even though the facility's policy required such planning for residents identified as at risk. This omission was also verified by the DON and RN during interviews.
Failure to Assess and Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that residents at risk for elopement were properly assessed and that physician-ordered interventions were implemented to prevent possible elopement. Three residents with significant medical and psychiatric histories were identified as being at risk for elopement, but deficiencies were found in their care and supervision. For one resident, the care plan included the use of a wander prevention device as ordered by a physician, but observation revealed the device was not in place, and staff confirmed the resident would remove and discard the device. The system did not alert staff when the resident was at the door, and the Director of Nursing acknowledged the absence of the device. Another resident, identified as high risk for elopement, did not have a care plan addressing this risk, and the required quarterly elopement risk assessments were not completed as per facility protocol. Staff interviews confirmed that the resident had previously attempted to leave the facility by removing a window and that the resident would not keep a wander prevention device on. The resident was subsequently moved to a different room, but documentation of ongoing risk assessments was lacking. A third resident, also with a history of cognitive and behavioral issues, was found to have a care plan and physician order for a wander prevention device, but the required quarterly elopement risk assessments were not completed. Staff interviews confirmed that these assessments were not being conducted as required. Additionally, the facility's elopement policy and protocol were not provided upon request. These findings demonstrate a pattern of inadequate assessment and failure to implement or maintain interventions for residents at risk of elopement.
Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain appropriate infection control practices, specifically in the care of residents with indwelling urinary catheters and chronic wounds. In one instance, a registered nurse provided catheter care to a resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, and a history of urinary tract infections. During the procedure, the nurse did not change gloves or perform hand hygiene after cleansing the resident's rectal area and before cleaning the indwelling urinary catheter, despite facility policy requiring hand hygiene when moving from a soiled to a clean body site. Additionally, the resident's catheter collection bag was observed lying on the floor, which was acknowledged by the nurse as a potential infection risk. In another case, a nurse performed a dressing change for a resident with a chronic scalp wound and multiple comorbidities such as diabetes, heart failure, and a history of skin picking. Although the nurse followed hand hygiene and glove use protocols during the dressing change, Enhanced Barrier Precautions (EBP) were not implemented as required by the resident's care plan and physician orders. The Director of Nursing confirmed that EBP were not utilized during the dressing change, and there were no orders for EBP in place for this resident at the time of the observation. Facility policy reviews indicated that both hand hygiene and EBP are essential components of infection prevention and control, particularly for high-contact care activities such as wound care and device management. The observed lapses in infection control practices and failure to implement EBP during resident care directly contributed to the identified deficiencies.
Failure to Timely Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to initiate a timely investigation of an alleged staff-to-resident sexual abuse incident involving Resident #80. The resident, who had a history of paranoid schizophrenia, reported the incident to a trusted staff member, Activities Aide #336, on the afternoon of 08/25/24. The allegation was that Licensed Practical Nurse (LPN) #200 had sexually assaulted her in the shower room early that morning. Despite the seriousness of the allegation, the facility did not immediately assess the resident for injuries, nor did they document the incident in the resident's medical record. The Director of Nursing (DON) was informed, and an SRI was initiated, but the police were not notified until the resident herself called them the following day. Interviews with various staff members revealed a lack of immediate action and documentation regarding the incident. The Administrator, DON, and other staff members held a meeting with Resident #80 on 08/26/24, where the resident felt pressured and not believed. The facility did not offer to contact the police or arrange for a hospital examination, which led the resident to take matters into her own hands by contacting law enforcement. The police then advised a sexual assault examination, which was conducted at a local hospital two days after the alleged incident. The facility's investigation was deemed insufficient as it lacked thorough documentation and timely action. The Administrator unsubstantiated the allegation based on the resident's word alone, without considering the need for a comprehensive investigation. The facility's policies on abuse investigation and reporting were not adequately followed, as there was no immediate assessment of the resident's condition, and the police were not notified promptly. This deficiency highlights a significant lapse in the facility's response to serious allegations of abuse, failing to ensure the safety and well-being of the resident involved.
Failure to Document and Follow Up on Sexual Abuse Allegation
Penalty
Summary
The facility failed to document an allegation of staff-to-resident sexual abuse and record follow-up action in the medical record of Resident #80. Resident #80, who had a history of paranoid schizophrenia, reported being sexually assaulted by a nurse, LPN #200, in the early hours of 08/25/24. Despite the serious nature of the allegation, there was no documentation in the resident's medical record regarding the incident, any assessment for injuries, or psychosocial follow-up by nursing or social services. The incident was initially reported by Resident #80 to Activities Aide #336, who then informed RN #320. However, RN #320 did not document the allegation in the medical record, initiate an incident report, or assess the resident. The Director of Nursing (DON) was informed and created a Self-reported Incident (SRI) to the State Agency, but there was no record of an assessment or any actions taken to ensure the resident's safety. The Administrator and other staff were aware of the allegation but did not offer to contact the police or arrange for a hospital examination, leading Resident #80 to contact the police herself. Interviews with facility staff revealed a lack of documentation and follow-up regarding the incident. The Administrator acknowledged that staff should document allegations of abuse and any assessments or actions taken in the resident's medical record. The facility's policies on abuse investigation and reporting, as well as clinical protocols, were not followed, as there was no prompt reporting to local authorities or thorough investigation documented in the resident's medical record.
Failure to Manage and Convey Resident Funds
Penalty
Summary
The facility failed to implement a plan to manage resident funds that exceeded the Medicaid allowable limit, affecting 15 residents. These residents had account balances that surpassed the Supplemental Security Income (SSI) resource limit of $2,000, yet the facility did not send spend down notices to the residents or their representatives. This oversight was confirmed by the Business Office Manager, who acknowledged that the facility should have notified residents when their account balances were within $200 of the Medicaid allowance amount. Additionally, the facility did not convey resident personal funds to the authorized representatives within 30 days of the residents' discharge or death, affecting three residents. The financial records showed that these residents had significant balances remaining in their trust accounts, which were not disbursed as required. The Business Office Manager confirmed that the funds had not been distributed within the stipulated timeframe. The facility's policy, dated April 2021, required that a representative of the business office inform residents or their representatives when their personal funds account balance approached the SSI resource limit. However, this policy was not followed, leading to the deficiencies noted in the report. The failure to manage and convey resident funds appropriately highlights a significant lapse in the facility's financial management practices.
Failure to Monitor and Track Resident Behaviors
Penalty
Summary
The facility failed to appropriately assess and monitor resident behaviors, affecting four residents with various mental health diagnoses. Resident #31, who was cognitively intact, had a care plan that did not include specific behaviors to track and monitor, nor did it include staff interventions in response to the behaviors. Similarly, Resident #69, also cognitively intact, exhibited physically aggressive and socially inappropriate behaviors, but there was no documentation of tracking or monitoring these behaviors to determine the effectiveness of the care plan. The Director of Nursing confirmed the lack of behavior tracking for these residents. Resident #10, with moderate cognitive impairment, had a care plan that did not list specific target behaviors associated with their mental health diagnoses, and there was no tracking of these behaviors. Licensed Practical Nurse #102 confirmed the inability to document target behaviors due to the incomplete care plan. Resident #16, cognitively intact, also lacked a care plan with specific target behaviors for their mental health conditions, and there was no behavior tracking. Registered Nurse #170 and the Director of Nursing confirmed the absence of specific target behaviors in the care plans and the lack of behavior tracking for Resident #16.
Failure to Notify Physician of Resident's Intoxicated Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for a resident diagnosed with peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder. The resident frequently left the facility on leaves of absence (LOA) and returned intoxicated, which was documented in nurse progress notes. Despite the resident's intoxicated state upon returning on two occasions, the nursing staff administered Seroquel and Keppra without consulting the attending physician to ensure it was safe to do so. Interviews with staff, including a Registered Nurse, Licensed Practical Nurses, and the Director of Nursing, confirmed that the resident often returned intoxicated and that the physician was not notified of the resident's condition before medication administration. The facility's policy required notifying the physician of significant changes in a resident's condition, which was not followed in this case. The deficiency affected one resident out of a sample of 26, with the facility census being 94 residents.
Failure to Repair Broken Footboard in a Timely Manner
Penalty
Summary
The facility failed to ensure the timely repair of a broken footboard on a resident's bed, compromising the resident's right to a safe and homelike environment. The deficiency was identified through observations and interviews with the resident, staff, and a review of facility policy. The footboard was broken at approximately two-thirds of its length, leaving a sharp, jagged edge that posed a potential risk to the resident. The resident expressed concern about the possibility of injury and had reported the issue to the Director of Nursing (DON) shortly after a room change. Despite the resident's report, the issue remained unresolved for an extended period. The DON had informed the Maintenance Director (MD) about the broken footboard, who then contacted a medical bed company for a replacement. However, the MD failed to provide the necessary measurements to the company, resulting in a delay in obtaining the replacement part. This inaction contributed to the facility's failure to maintain a safe and comfortable environment for the resident, as outlined in their policy.
Failure to Develop Care Plan for Resident's Unsupervised LOAs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with frequent unsupervised leaves of absence (LOA) from the facility. The resident, who has diagnoses including peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder, was admitted on an unspecified date. Despite the resident's frequent LOAs and returning to the facility intoxicated, the care plan updated on 05/23/24 did not include guidelines to ensure the resident's safety during these absences. The Director of Nursing (DON) had discussions with the resident about returning intoxicated and missing medications, which potentially led to seizure activity, but these issues were not addressed in the care plan. Interviews with staff confirmed that the resident often left the facility around 11:00 A.M. and returned intoxicated late in the evening. The DON and the Minimum Data Set (MDS) Nurse acknowledged that the care plan should have included parameters for the resident's frequent LOAs and behavior upon return. The facility's policy on care planning requires the interdisciplinary team to develop person-centered care plans based on resident assessments, which was not adhered to in this case.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living (ADL) care, specifically in grooming. Resident #53, who has diagnoses including schizoaffective disorder bipolar type, polyosteoarthritis, and chronic pain syndrome, was identified as having a potential self-care deficit in grooming due to impaired ability and lack of fine motor skills. The care plan for Resident #53 included interventions for staff to cue and assist the resident in grooming tasks to ensure the resident was well-groomed. However, observations on two consecutive days revealed that the resident's chin hairs were approximately one inch long and unkempt. Interviews with the resident and a registered nurse confirmed that the resident disliked the whiskers and required staff assistance to remove them. The facility's policy on ADL support stated that appropriate care and services should be provided to residents unable to perform ADLs independently, in accordance with their care plan.
Failure to Monitor Residents Post-Fall
Penalty
Summary
The facility failed to adequately monitor residents who had experienced falls, affecting two residents out of four reviewed for falls. Resident #10, who had multiple diagnoses including cerebrovascular disease and dementia, experienced falls on two occasions without injuries. However, there was no documented post-fall monitoring for this resident on the days following each fall, as required by the facility's policy. Similarly, Resident #63, with diagnoses including vascular dementia and muscle weakness, experienced falls that resulted in injuries, yet there was no documented post-fall monitoring on the subsequent days. The Director of Nursing confirmed that staff should monitor and document on residents who have fallen at least twice in the 24-hour period following the fall, but this was not done for the falls experienced by Resident #10 and Resident #63. The facility's policy, which requires monitoring and documentation every shift for 72 hours after a fall, was not adhered to, leading to a deficiency in the care provided to these residents.
Failure to Provide Adequate Oral Fluids to Resident
Penalty
Summary
The facility failed to ensure that a resident received adequate oral fluids between meals, which affected one resident out of a sample of 26. The resident, who was cognitively intact but required assistance with eating and oral intake, had a care plan intervention to encourage good fluid intake due to risks associated with decreased cardiac output and altered nutritional status. Despite this, the resident's Medication Administration Record (MAR) indicated that the required daily fluid intake of 1600-1700 milliliters was not consistently documented as consumed. Observations over several days revealed that the resident did not have oral fluids available at the bedside, and interviews with staff confirmed that the resident could not ask for fluids and needed assistance with oral intake. The Assistant Director of Nursing and the Director of Nursing confirmed that staff were required to provide and assist with fluids, but the facility lacked a specific policy for hydration or water pass. The Director of Nursing acknowledged that the resident's MAR showed insufficient fluid intake on most days.
Failure to Monitor Blood Pressure Before Administering Lasix
Penalty
Summary
The facility failed to monitor a resident's blood pressure as ordered by the physician before administering a diuretic medication, Lasix. This deficiency was identified through a review of medical records, staff interviews, and facility policy. The resident involved had a history of obsessive-compulsive personality disorder, paranoid schizophrenia, polydipsia, and hypoosmolality and hyponatremia. The physician's order specified that Lasix should be held if the systolic blood pressure (SBP) was less than 100. However, the Medication Administration Record (MAR) showed that Lasix was administered on multiple occasions without recording the resident's blood pressure beforehand. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the staff did not take the resident's blood pressure prior to administering Lasix on the specified dates, as required by the physician's order. The facility's policy on administering medications indicated that vital signs should be checked if ordered before medication administration. This oversight affected one of the six residents reviewed for medications, highlighting a lapse in following physician orders and facility protocols.
Inadequate Pain Management Due to Lack of Assessment
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with multiple medical conditions, including peripheral vascular disease, major depression, COPD, paroxysmal atrial fibrillation, type two diabetes, and acute kidney failure. The resident was admitted with a care plan that included administering pain medications as per medical doctor orders and assessing for nonverbal signs of pain. Despite receiving scheduled and as-needed pain medications, the resident experienced pain almost constantly, as noted in the Minimum Data Set (MDS) assessment. However, the facility did not conduct pain assessments prior to or after administering oxycodone, a narcotic pain medication, as ordered by the physician. The facility's policy required regular pain assessments, including at least one assessment per shift for acute pain or significant changes in chronic pain, and at least weekly for stable chronic pain. Despite this policy, the facility did not complete any weekly pain assessments for the resident from April to June. The Director of Nursing confirmed that the nurses had not documented any pain assessments before or after administering the scheduled oxycodone. This lack of documentation and assessment was a direct violation of the facility's pain management protocol, leading to inadequate pain management for the resident.
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What surveyors actually found near you
We read the 811 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.
Illustrative
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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 Columbus Llc | 1 mi | ★★★★★ | 6 | 0 |
| Ohio Living Westminster-thurber | 2.2 mi | ★★★★★ | 6 | 0 |
| Capital City Gardens Rehabilitation And Nursing Ce | 2.4 mi | ★★★★★ | 13 | 0 |
| Embassy Of Woodview | 2.9 mi | ★★★★★ | 7 | 0 |
| West Park Care Center Llc | 2.9 mi | ★★★★★ | 0 | 0 |
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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.