Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Columbus Oaks Healthcare Community during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition did not have numerous evening and HS medications documented as given on one night, including antihypertensives, psychotropics, anticonvulsants, and pain-related medications, and later missed a scheduled hydrocodone dose for fibromyalgia pain. MAR entries were left blank for several ordered drugs and required BP/pulse parameters were not recorded, while staff interviews revealed that some nurses, including agency staff, did not consistently sign the MAR and that agency nurses lacked direct e-kit access. The facility’s own policy required timely administration and documentation of all medications, and the report notes that these failures could cause residents to experience unnecessary and avoidable pain.
Surveyors found that hot foods were not consistently served at safe temperatures, as mixed vegetables measured well below the stated 135°F holding temperature when checked by the Dietary Manager. Residents reported that their meals were always cold upon arrival and that they preferred warmer food. The DON reported that a Dietician’s prior audit had found full compliance with food temperatures, and the Administrator stated that food was delivered directly to the halls on carts. Review of the facility’s "Taking Temperatures" policy showed it required temperature checks and correction or discarding of foods not at the correct temperature but did not specify exact temperature standards, contributing to the deficiency.
A resident with Alzheimer’s disease, hypotension, muscle wasting, and total dependence for ADLs received incontinent care during which a CNA repeatedly removed gloves and donned new ones without performing hand hygiene, contrary to the facility’s infection control guidelines requiring alcohol-based hand rub use after glove removal. During the same episode of care, the CNA used a single wet wipe on one groin area, then folded and reused it on the opposite groin, despite another CNA advising that wipes should not be folded and reused. The resident was incontinent of bowel and bladder and care-planned to remain clean and dry, but the observed technique did not follow established infection prevention procedures.
A resident with multiple mental health diagnoses did not receive prescribed Lorazepam for several scheduled doses after admission due to failures in communication and follow-up between nursing staff, the pharmacy, and the prescriber. The medication was not ordered or delivered in a timely manner, and the issue was not escalated according to facility policy, resulting in missed doses.
A medication error rate of 10% was observed in an LTC facility, involving two residents. One resident received an incorrect dosage of Sertraline and missed a dose of Potassium Chloride, while another resident was given crushed Divalproex Sodium against administration instructions. The errors were attributed to staff not following medication administration protocols, including checking medication labels and confirming dosages with the MAR.
A resident with hypokalemia did not receive her prescribed Potassium Chloride for seven days due to a medication administration error. The medication aide failed to administer the medication despite marking it as given, and the facility's DON acknowledged a lapse in staff training.
The facility failed to comply with food safety standards, as expired foods were not discarded, and several items lacked proper labeling and dating. Additionally, food storage practices were inadequate, with items stored directly on the floor, contrary to policy requirements. The Dietary Food Service Manager acknowledged these issues.
A resident with severe cognitive impairment and multiple medical conditions was not administered Divalproex Sodium as prescribed. The LVN crushed the medication, contrary to instructions to swallow whole, potentially affecting absorption. The LVN was unaware of the administration instructions despite having received training.
Failure to Administer and Document Scheduled Medications and Pain Management Dose
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, dispensing, administration, and documentation of medications for a cognitively intact resident with multiple chronic conditions. The resident, an older female with hypertension, type 2 diabetes, dementia, atherosclerotic heart disease, fibromyalgia, generalized anxiety disorder, major depressive disorder, insomnia, Parkinson’s disease, and low back pain, had a BIMS score of 14 indicating high cognitive intactness. Her care plan included interventions for pain, hypertension, anticonvulsant therapy for Parkinson’s disease, anti-anxiety medications, and melatonin for insomnia, all requiring medications to be administered as ordered and monitored for side effects. Record review showed that on one night in January, multiple scheduled evening and bedtime medications for this resident were left blank on the MAR, with no documentation that they were administered. These included atorvastatin, donepezil, duloxetine, melatonin, trazodone, buspirone, divalproex, losartan (with required BP and pulse parameters also not documented), nifedipine ER, pregabalin, and primidone. The January MAR also showed that the resident’s blood pressure for that month did not exceed the limits set by the physician’s orders. During interviews, a medication aide stated she passed regular medications and documented them on the MAR and believed the resident received all blood pressure medications, while an LVN stated some nurses did not sign the MAR and that agency nurses worked night shift and would have given medications on days they were not documented. The DON stated medications should have been documented in the records and acknowledged that if medications were not documented, the facility could not prove they were given. A separate deficiency occurred in March when the resident did not receive a scheduled dose of hydrocodone-acetaminophen ordered for fibromyalgia pain. The hydrocodone order was active with a defined start and end date, but the 8:00 p.m. dose on one March date was not administered, even though the MAR was signed with an agency nurse notation and the resident’s pain level was not checked. Progress notes showed an LVN signed for hydrocodone pulled from the e-kit earlier that day, and an agency nurse later documented that hydrocodone was ordered, but there was no documentation that the medication was given on that night shift. The DON confirmed that agency staff did not have direct access to the e-kit and would have needed to ask someone, and also stated that no one had reported that the resident’s medications were out and that nurses should have notified the physician of missed doses. Interviews with the resident indicated she felt she sometimes did not get medications on time when agency nurses worked and that medications were sometimes late due to reordering issues, although she did not specifically identify hydrocodone at that time. The facility’s medication administration policy required that medications be administered safely, timely, as prescribed, and that the individual administering each medication sign the MAR/EMAR after giving each medication and before administering the next, which was not followed in these instances. The surveyors concluded that the facility failed to ensure that the resident’s medications on the identified January night shift were documented as given and that a scheduled hydrocodone dose in March was administered per physician orders. The report states that this failure could cause residents to have unnecessary and avoidable pain.
Failure to Serve Hot Foods at Safe Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices related to serving food at safe temperatures. During observation of the kitchen at lunchtime, the Dietary Manager measured the temperature of mixed vegetables (peas and carrots) and obtained readings of 114.6°F and 105.8°F from two separate bowls. The Dietary Manager stated these temperatures were not within the acceptable range for service and that the food temperature should not have dropped below a 135°F holding temperature from the steam table to the point of service. The Dietary Manager also acknowledged that if food was not at the correct temperature for residents, they could get sick. In confidential interviews, residents reported that their food was always cold when it arrived and that they would prefer it to be warmer. In an interview, the DON stated that a Dietician had previously audited the kitchen and found full compliance, including with food temperatures, and the Administrator reported that food was delivered directly to the halls on carts. Review of the facility’s policy titled "Taking Temperatures" showed it required staff to take and record temperatures of all foods prior to service and to correct or discard foods not at the correct temperature, but the policy did not specify exact temperature standards. The combination of resident reports of cold food, observed substandard food temperatures at lunch, and a policy lacking specific temperature parameters led to the identified deficiency in storing, preparing, distributing, and serving food in accordance with professional standards.
Failure to Perform Hand Hygiene and Proper Perineal Cleaning During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain its Infection Prevention and Control Program during incontinent care for one resident. The resident was an elderly female with Alzheimer’s disease, shortness of breath, hypotension, and muscle wasting/atrophy, who was totally dependent on staff for ADLs and was incontinent of bowel and bladder. Her care plan specified that she was to remain clean, dry, without odor, and comfortable every shift, with all needs anticipated and met by staff. During an observation of incontinent care, a CNA transported the resident from the nurse’s station to her room, transferred her from wheelchair to bed, and began incontinent care by donning clean gloves and unfastening the resident’s soiled brief. The CNA then removed her gloves and repeatedly failed to perform hand hygiene, neither washing her hands nor using hand sanitizer after doffing gloves and before donning new gloves. She donned clean gloves and used a wet wipe to clean the resident’s right groin, then folded the same wipe and used it to clean the left groin. Another CNA present advised her that the wipe should not be folded and reused. The first CNA again removed gloves without hand hygiene, donned new gloves, repositioned the resident, and used wet wipes to clean between and around the buttocks, then applied a clean brief. After doffing soiled gloves, she again failed to wash her hands or use hand sanitizer before going to the clean linen area to obtain a top cover sheet. The facility’s written Infection Control Guidelines required use of alcohol-based hand rub after removing gloves and specified hand hygiene before and after direct resident contact, but these procedures were not followed during the observed care.
Failure to Provide Timely Pharmaceutical Services for Controlled Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring that Lorazepam, a controlled medication, was ordered, received, and dispensed upon the resident's admission. The resident, who had multiple diagnoses including anxiety, psychosis, and schizoaffective disorder, was admitted with a physician's order for Lorazepam 0.5 mg twice daily. However, review of the medication administration record and nurse's notes showed that the medication was not administered for several scheduled doses due to it being pending delivery. Interviews with nursing staff revealed a breakdown in communication and follow-through regarding the ordering and delivery of the medication. The admitting nurse believed the medication was already in the facility and did not confirm its status until prompted by the surveyor, at which point it was discovered that the pharmacy had not received the necessary authorization to dispense the medication. Subsequent shifts were informed of the missing medication, but the issue was not escalated to the DON in a timely manner as required by facility policy. Facility policy states that nursing staff are responsible for communicating prescriber orders to the pharmacy and for following up if medications are not available for administration. The policy also requires that pharmacy services be available 24/7 and that residents have a sufficient supply of prescribed medications. In this case, the lack of timely communication and follow-up resulted in the resident not receiving Lorazepam as ordered during the initial days of admission.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during a medication pass observation. This deficiency involved two residents, with errors identified in the administration of medications. Resident #11 did not receive the correct dosage of Sertraline, as only 50 mg was administered instead of the prescribed 150 mg. Additionally, Potassium Chloride was not administered to Resident #11, despite being marked as given on the Medication Administration Record (MAR). The medication aide responsible for these errors admitted to not having recent medication training and was unaware of the mistake until it was pointed out. Resident #67 was also affected by a medication error when Divalproex Sodium, which should not be crushed, was administered in a crushed form mixed with pudding. The Licensed Vocational Nurse (LVN) involved was unaware of the administration instructions and admitted to not checking the medication label thoroughly. This error was identified during a medication observation, and the LVN acknowledged the potential impact on medication absorption due to improper administration. The facility's policy on administering oral medications was not followed, as evidenced by the failure to check medication labels and confirm dosages with the MAR. Interviews with the Director of Nursing (DON) and the Administrator revealed an expectation for nursing staff to adhere to facility policies, which was not met in these instances. The report highlights the lack of adherence to medication administration protocols, leading to significant medication errors for the residents involved.
Failure to Administer Potassium Chloride to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Potassium Chloride Microencapsulated Crystals ER. The resident, a severely cognitively impaired elderly female with multiple diagnoses including hypokalemia, was not administered her prescribed Potassium Chloride for seven days. This lapse was discovered during a medication observation where the medication aide (MA) did not administer the medication as required, despite having initialed the medication administration record (MAR) indicating it was given. Further investigation revealed discrepancies in the medication supply and administration process. The local pharmacy confirmed that Potassium Chloride was delivered to the facility in a timely manner, suggesting that the medication should have been available for administration. However, the MA admitted to not having recent medication training and could not recall the details of her training. The Director of Nursing (DON) acknowledged the oversight and the responsibility for staff training, indicating a gap in the facility's medication administration protocol.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Expired foods were not discarded, with items such as sliced American cheese and canned sliced apples being past their use-by dates. Additionally, several food items, including sliced bologna, deli ham, and sour cream, were found without labels or dates, which is against the facility's policy that requires all food to be labeled with the name, date stored, and date it must be used or discarded. Furthermore, the facility did not ensure proper storage of food items, as evidenced by the observation of frozen chicken breast and French fries stored directly on the floor in the walk-in freezer. The facility's policy mandates that all items should be stored at least six inches above the floor to prevent contamination. The Dietary Food Service Manager acknowledged these lapses, confirming that leftover food should have been used or discarded before the use-by date and that all food should be stored off the floor.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #67, as observed during a medication administration process. Resident #67, an elderly female with severe cognitive impairment and multiple medical conditions including Parkinson's disease and neuromuscular dysfunction, was prescribed Divalproex Sodium 250 mg to be taken orally twice a day. However, during a medication observation, it was noted that the Licensed Vocational Nurse (LVN) crushed the medication and mixed it with pudding before administering it to the resident, despite the blister packet instructions indicating that the medication should be swallowed whole and not crushed. The LVN admitted to being unaware of the specific administration instructions for Divalproex Sodium and acknowledged having received in-service training on medication administration but could not recall the details. The failure to administer the medication as per the pharmaceutical recommendation could potentially affect the medication's absorption. The Director of Nursing (DON) and the Administrator were informed of the incident, and it was noted that the facility's policy was not followed in this instance.
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 83 citations issued within 25 miles in the last 12 months — including the 3 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) |
|---|---|---|---|---|
| Trucare Living Centers-columbus | 1.7 mi | ★★★★★ | 1 | 0 |
| Parkview Manor Nursing And Rehabilitation | 14.1 mi | ★★★★★ | 8 | 0 |
| Arbor Hills Rehabilitation And Healthcare Center | 14.5 mi | ★★★★★ | 4 | 0 |
| Schulenburg Regency Nursing Center | 21.8 mi | ★★★★★ | 8 | 0 |
| Paradigm At The Oak | 22.5 mi | ★★★★★ | 30 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Columbus Oaks Healthcare Community.
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.