Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belmont Health & Rehabilitation, The during CMS and state inspections, most recent first.
The facility did not consistently document meal consumption for several residents with various medical conditions, resulting in missing records for multiple meals over an extended period. Despite residents remaining in the facility for their meals, required documentation of their nutritional intake was not completed as per facility policy.
Two residents developed Stage 3 pressure ulcers that were not identified or treated in a timely manner. One resident, with severe cognitive impairment and multiple health conditions, had a coccyx wound that was not documented or observed prior to being found as a Stage 3 ulcer. Another resident, who was cognitively intact and had several chronic conditions, developed a Stage 3 pressure ulcer on the ankle that was not recorded or treated until it reached an advanced stage. Nursing staff and documentation failed to identify and address these wounds as required by facility policy.
Staff failed to follow physician orders for cardiac medication administration by giving a resident midodrine when blood pressure was above the specified threshold, and did not complete required neurological assessment documentation after a fall for another resident. These actions resulted in incomplete care and failure to adhere to established protocols.
A resident admitted with a fractured left humerus did not have physician orders for an icing protocol transcribed into their medical record, resulting in a delay in the application of ice therapy as prescribed. The omission was discovered after a family member raised concerns, and staff interviews confirmed that the required process for order transcription and verification was not followed.
The facility failed to follow physician's orders for medication hold parameters for five residents, leading to inappropriate administration of medications. Residents received medications despite vital signs being outside prescribed thresholds, such as insulin given with low blood sugar and antihypertensives given with low blood pressure. Interviews with staff revealed a lack of adherence to hold parameters and failure to notify physicians when necessary.
A resident with a history of stroke and diabetes developed a pressure ulcer that was not properly assessed or treated, leading to its progression from Stage II to Stage III. The facility's documentation errors and inconsistent monitoring and treatment contributed to this deficiency.
A resident with a history of seizures and physical limitations was left in a high bed position without supervision, contrary to safety protocols. Staff acknowledged the bed should not have been left elevated, and the resident's care plans indicated a need for assistance with bed mobility and a risk for injury.
The facility failed to maintain sanitary dining services, as an Activities Assistant was observed holding clean clothing protectors against their chest and touching their face mask before serving drinks to residents. This violated the facility's policies on linen handling and glove use during meal service.
The facility failed to follow infection control guidelines for COVID-19 precautions and wound care. A resident with COVID-19 did not receive proper PPE use from staff, as observed with a physical therapist and an LPN. Another resident with a pressure ulcer received wound care from an RN who did not follow proper hand hygiene and glove use protocols. These actions were against the facility's policies for infection control and wound care procedures.
The facility failed to collect a urine sample in a timely manner and did not notify the physician or attempt interventions for a resident's refusal of antibiotic administration related to a UTI. The resident, who was severely cognitively impaired, had multiple instances where urine specimens were not collected promptly, and prescribed antibiotics were not administered on several occasions due to the resident's refusal or condition. There was no documentation of specific times or interventions attempted for these refusals, nor any documented physician notification.
The facility failed to administer prescribed medications to a resident with heart failure, hypertension, and renal insufficiency on multiple occasions. The EMAR showed delays and missed doses without adequate explanations, despite the facility's policy requiring clear and accurate administration of physician's orders.
Failure to Document Resident Meal Consumption
Penalty
Summary
The facility failed to document meal consumption values for 8 out of 10 residents reviewed for nutrition, as evidenced by missing entries in the Meal Consumption Records for multiple dates across August and September 2025. The residents affected had a range of medical conditions, including heart failure, hypertension, stroke, COPD, bipolar disorder, diabetes, dementia, anxiety, depression, malnutrition, anemia, wound infection, and psychotic disorder. The documentation gaps included missing records for breakfast, lunch, and dinner on various days, with some residents lacking documentation for all meals on certain dates. Interviews and record reviews confirmed that residents typically ate their meals within the facility and did not leave to eat elsewhere. For example, one resident stated that he always ate all meals in his room and had not eaten outside the facility. Despite this, the corresponding meal consumption records for these residents showed numerous undocumented meals, indicating a failure to consistently monitor and record daily nutritional intake as required by facility policy. The facility's policy mandates that the percentage of meals consumed daily be recorded on a designated document to monitor residents' daily intakes. However, the lack of documentation for multiple meals across several residents demonstrates noncompliance with this policy. The deficiency was identified through both clinical record reviews and staff interviews, which confirmed that the expected documentation process was not consistently followed.
Failure to Identify and Treat Pressure Ulcers Before Progression to Stage III
Penalty
Summary
The facility failed to identify and treat pressure ulcers before they progressed to Stage III for two residents. For one resident with severe cognitive impairment, multiple comorbidities, and who was dependent on staff for all activities of daily living, a coccyx wound was not documented or identified in care records or shower sheets prior to being found as a Stage 3 pressure ulcer with undermining and drainage. The wound was not present on admission, and there was no indication in the records that staff had observed or reported any skin issues in the weeks leading up to its identification. The facility wound nurse confirmed that the wound should have been identified before reaching this advanced stage. Another resident, who was cognitively intact and had diagnoses including anemia, heart failure, wound infection, and diabetes, developed a Stage 3 pressure ulcer on the right lateral ankle. The wound was not documented in the clinical record or on shower sheets prior to being identified as a Stage 3 ulcer. Although there were physician orders for weekly skin inspections and wound care, there was no documentation of the wound or its treatment until after it had progressed to Stage 3. Interviews with nursing staff confirmed that the wound should have been identified earlier, and the facility's own policy required daily observation and reporting of skin issues, which was not followed in these cases.
Failure to Follow Medication Parameters and Complete Neurological Assessments
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration and did not complete required neurological assessments after a resident fall. For one resident with a history of heart failure, hypertension, and coronary artery disease, staff administered midodrine, a medication for low blood pressure, even when the resident's systolic blood pressure was above the ordered threshold of 90. The medication was given multiple times when the resident's blood pressure readings were above this parameter, contrary to the physician's specific instructions. In another case, a resident with diagnoses including diabetes, anemia, seizure disorder, malnutrition, anxiety, and depression experienced a fall while attempting to use the bathroom independently. Although the resident complained of hip pain and refused hospital transfer, the neurological assessment documentation was incomplete. Multiple required elements such as pupil size, level of consciousness, orientation, pain complaints, and extremity assessments were missing from the neurological check flowsheet at several time points following the fall. Interviews with nursing staff and review of facility policies confirmed that staff were expected to follow medication administration parameters and complete thorough neurological assessments after unwitnessed falls. However, in these instances, staff did not adhere to established protocols or physician orders, resulting in incomplete care and documentation for the affected residents.
Failure to Transcribe and Implement Physician Orders for Wound Care
Penalty
Summary
The facility failed to properly transcribe and implement physician orders for a resident who was admitted with a diagnosis that included a displaced comminuted fracture of the left humerus. Upon review of the resident's clinical record, it was found that instructions for wound care, specifically an icing protocol outlined in the After Visit Summary, were not transcribed into the resident's medical record. As a result, there was no order for the application of ice to the resident's wound until several days after admission. Interviews with facility staff revealed that the process for transcribing new admission orders involved Unit Managers entering the orders into the computer, with a second nurse expected to verify them. However, this process was not followed, and the omission was only discovered after a family member alerted staff that the resident was not receiving the prescribed ice therapy. The lack of transcription led to a delay in the implementation of the physician's wound care instructions.
Failure to Adhere to Medication Hold Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication hold parameters for five residents, leading to inappropriate administration of medications. Resident 76, who was cognitively intact and diagnosed with diabetes, heart failure, and hypertension, received Humalog insulin on multiple occasions despite blood sugar levels being below the prescribed threshold of 120. This occurred on four separate dates in August and September 2024, with blood sugar readings ranging from 100 to 105. Resident 4, also cognitively intact and diagnosed with anemia, hypertension, and atrial fibrillation, was administered metoprolol despite systolic blood pressure readings being below the hold parameter of 120. This occurred on four occasions in August and September 2024, with systolic blood pressure readings as low as 106. Similarly, Resident 98, who had multiple diagnoses including stroke and diabetes, received aspart niacinamide insulin and hydralazine despite blood sugar and pulse readings being below the hold parameters. This resident's medication errors spanned several dates in August and September 2024. Resident 65, who was severely cognitively impaired, received midodrine for hypotension even when systolic blood pressure exceeded the hold parameter of 130. This occurred on numerous occasions in August and September 2024. Lastly, Resident 38, with moderate cognitive impairment, was given losartan despite systolic blood pressure readings being below the hold parameter of 130 on multiple dates from June to September 2024. Interviews with nursing staff revealed a lack of adherence to hold parameters and a failure to notify physicians when vital signs were outside the prescribed range.
Failure to Properly Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and treatment of a pressure ulcer for a resident. The resident, who was moderately cognitively impaired and had a history of stroke, heart failure, peripheral vascular disease, and diabetes, was initially assessed to have a Stage II pressure ulcer on the left lateral ankle. However, there was a discrepancy in the documentation, as the wound location was initially recorded as the right ankle. This error led to confusion in monitoring and treatment, as evidenced by the EMAR documentation showing that the wound was not monitored on certain dates because the wound could not be found. Additionally, the prescribed treatment for the pressure ulcer was not administered on several occasions, with comments indicating reasons such as 'na' and 'other.' The wound, initially a Stage II ulcer, progressed to a Stage III ulcer by 05/02/24, indicating a deterioration in the resident's condition. The facility's failure to accurately document and consistently monitor and treat the pressure ulcer contributed to this progression. The facility's policies on pressure ulcer prevention and physician orders were not effectively implemented, as evidenced by the lack of clear, accurate, and complete documentation and transcriptions of physician's orders.
Failure to Ensure Safe Bed Position for Resident
Penalty
Summary
The facility failed to provide a safe environment for a resident, identified as Resident 15, by not ensuring the resident's bed was in a safe position. During incontinence care, two CNAs raised the resident's bed to a high position and left the bedside unattended while the bed remained elevated. This occurred despite the resident's inability to adjust the bed height due to physical limitations, including being non-verbal, non-responsive, and having contracted hands. The resident's medical history included cancer, dementia, and a seizure disorder, which increased the risk of injury. Further observations revealed that the resident's bed was left in a high position without staff present in the room or nearby. A CNA later entered the room and lowered the bed, acknowledging that it should not have been left elevated. Interviews with staff confirmed that the resident was physically unable to adjust the bed height and that beds should not be left in a high position when a resident is in bed. The resident's care plans indicated a need for assistance with bed mobility and a risk for injury due to seizure activity.
Sanitation Deficiencies in Dining Services
Penalty
Summary
The facility failed to maintain sanitary dining services for several residents during meal service in the Main Dining Room. During observations, an Activities Assistant (AA) was seen holding a stack of clean clothing protectors against their chest, which was in contact with their clothes, purse strap, and a coiled wrist band holding keys. The AA assisted multiple residents with these clothing protectors and was observed touching the front of their face mask and then handling the clothing protectors and serving drinks to residents. This behavior was repeated during another meal service observation, where the AA touched their face mask, used hand sanitizer, and then served drinks to residents without maintaining proper hygiene standards. The facility's policies on linen handling and glove use during meal service were not adhered to, as evidenced by the AA's actions. The LINEN, HANDLING policy explicitly states that linen should not be carried against the body to prevent the spread of infection. Additionally, the Glove Use & Meal Service policy requires that any objects that could potentially contaminate food be removed and that employees must wash their hands immediately after touching any area of their body. These policies were not followed, leading to the observed deficiencies in dining service sanitation.
Infection Control and Wound Care Deficiencies
Penalty
Summary
The facility failed to adhere to infection control guidelines for transmission-based precautions related to COVID-19 and wound care. In the case of Resident 20, who was COVID-19 positive, staff did not consistently use the required personal protective equipment (PPE). A physical therapist was observed disposing of PPE improperly and not wearing an N95 mask when exiting the resident's room. Additionally, an LPN entered the resident's room wearing only a surgical mask, despite the requirement for an N95 mask, face shield, gown, and gloves. The resident's clinical record confirmed a positive COVID-19 test, and the facility's policy required strict adherence to PPE protocols for such cases. In another instance, the facility failed to follow proper wound care procedures for Resident 69, who had an unstageable pressure ulcer. An RN was observed adjusting the resident's bed and blinds with gloved hands before performing wound care, which is against the facility's policy. The RN acknowledged that she should have performed these tasks without gloves and washed her hands before donning gloves for wound care. The resident's clinical record indicated severe cognitive impairment and multiple diagnoses, including cancer and hypertension. The facility's policy required handwashing and proper glove use during wound care, which was not followed in this instance.
Failure to Collect Urine Sample and Notify Physician of Antibiotic Refusal
Penalty
Summary
The facility failed to collect a urine sample in a timely manner and did not notify the physician or attempt interventions for a resident's refusal of antibiotic administration related to a Urinary Tract Infection (UTI). Resident B, who was severely cognitively impaired and occasionally incontinent of bladder and frequently incontinent of bowel, had multiple instances where urine specimens were not collected promptly as per physician's orders. For example, a specimen ordered on 02/02/24 was not collected until 02/05/24. Additionally, the resident's prescribed antibiotics, including Macrobid, Ciprofloxacin, and Bactrim, were not administered on several occasions due to the resident's refusal or condition, and there was no documentation of specific times or interventions attempted for these refusals, nor was there any documented physician notification of the refusals on multiple dates in February and March 2024. During interviews, an LPN indicated that urine specimens should ideally be collected within 24 hours of receiving the order, and the DON confirmed that the facility did not have a policy on collecting urine specimens. The lack of timely specimen collection and failure to document or notify the physician about the resident's medication refusals contributed to the deficiency. This citation relates to Complaints IN00433423 and IN00433659.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide prescribed medications for one resident, identified as Resident F, who was reviewed for pharmacy services. During an observation and interview, Resident F indicated that there were times when they had not been receiving their medications as prescribed. The clinical record review showed that Resident F, who was cognitively intact and diagnosed with heart failure, hypertension, and renal insufficiency, had a physician's order for Furosemide, 40 milligrams, twice a day. However, the medication was not administered on multiple occasions in January 2024, with various reasons documented such as 'Other and days,' 'Other and detained,' and 'Resident Unavailable.' The charting on the EMAR was often completed hours after the scheduled administration times, indicating a delay or failure in medication administration. During an interview, the DON confirmed that staff should follow the physician's orders but did not provide an explanation for the reasons/comments listed on the EMAR. The facility's current policy on physician orders, dated October 2014, mandates that orders be administered upon clear, complete, and signed instructions from an authorized prescriber. The policy also requires nursing personnel to ensure clear, accurate, and complete physician's orders and to contact the prescribing physician for any clarification needed. This deficiency was related to Complaint IN00433659.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Crossing Health & Rehabilitation Center | 5.8 mi | — | 14 | 0 |
| Silver Oaks Health Campus | 6 mi | — | 1 | 0 |
| Four Seasons Retirement Center | 6.7 mi | — | 0 | 0 |
| Hickory Creek At Columbus | 7.5 mi | — | 7 | 0 |
| Brown County Health And Living Community | 13 mi | — | 2 | 0 |
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