Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Pickerington Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with complex medical conditions, intact cognition, and dependence on assistance for ADLs lost insurance coverage and was informed of appeal options and potential nonpayment but had no documented assistance from facility staff in applying for or changing Medicaid coverage. After an unsuccessful insurance appeal, the administrator and social services issued a 30‑day discharge notice for nonpayment, and no further social service notes were documented. The resident was later sent to the hospital for severe diarrhea and discharged from the facility the same day; the hospital social worker and the resident’s family reported the facility stated the resident owed a large balance, would not be accepted back, and did not provide an itemized bill or assist with Medicaid changes, despite a policy stating residents appealing discharge would be allowed to return from the hospital.
A dependent, severely cognitively impaired resident with multiple comorbidities, including post-CVA hemiplegia, contractures, HTN, anemia, diabetes, depression, and chronic pain, required staff assistance with all ADLs except eating. Documentation showed the resident refused hair washing on several shower days, but there was no documentation of refusals for hair care on non-shower days. On multiple observations, the resident’s hair was found matted to the back of the head, and a CNA acknowledged the hair was matted and needed to be combed, resulting in a cited deficiency related to inadequate hair care.
A resident with severe cognitive impairment, hemiplegia, and multiple chronic conditions was found to be living in a room where a brown stain on the floor under a small bedside dresser and a dry, crumbly brown substance on the dresser’s lower front and corner were observed on two separate occasions the same day. A CNA confirmed the presence of these soiled areas. Review of the facility’s routine cleaning and disinfection policy showed that visibly soiled surfaces were to receive detailed cleaning, but this was not done, resulting in a failure to maintain a clean and comfortable environment.
Two residents' room flooring was found peeling and in disrepair, and facility carpeting throughout hallways and common areas was observed to be dirty and stained. The Maintenance Director confirmed both issues, noting slow progress on repairs and unsuccessful cleaning efforts, with no documentation of steps taken toward carpet replacement.
Staff failed to follow infection control protocols during fingerstick blood glucose monitoring and meal service. An LPN did not perform hand hygiene between glove changes or properly disinfect a glucometer, and a CNA did not perform hand hygiene while serving and assisting with meal trays for three residents, all of whom had significant medical conditions.
Staff failed to provide privacy during care and treatment for three residents with significant cognitive and physical impairments. In separate incidents, a nurse administered medications and a respiratory therapist performed trach care without closing doors or pulling privacy curtains, and a certified nursing aide left a resident exposed during incontinence care with the door open. Staff later acknowledged that privacy should have been maintained, in violation of facility policy.
Two residents with impaired cognition and high care needs were found in unsanitary conditions, including a dirty wheelchair and soiled wall padding, which remained unaddressed by staff despite multiple opportunities to clean or report the issues, contrary to facility policy.
Three dependent residents with cognitive and physical impairments were found to have long, dirty, or jagged fingernails and toenails due to staff not consistently providing nail care as required by facility policy. Documentation and observations confirmed that nail care was missed during multiple showers, and staff interviews acknowledged the issue.
A resident with a Foley catheter did not receive documented catheter care or urine output monitoring for several months, and when the catheter came out, staff did not replace it or notify the physician due to missing orders. Facility policy requiring regular catheter care, monitoring, and prompt physician notification was not followed, as confirmed by staff interviews and record review.
A resident with complex medical conditions developed a new sacral pressure ulcer due to inadequate care and inconsistent treatment documentation. The facility failed to follow proper protocols for pressure ulcer management, including inappropriate use of dressings and insufficient repositioning. Observations revealed improper dressing changes and failure to float the resident's heels, violating facility policies.
A facility failed to maintain accurate medical records for a resident with a sacral wound. Initially documented as a non-pressure wound, the wound was later identified by a physician as a chronic sacral ulcer. Despite this, nursing assessments continued to inaccurately record it as a non-pressure wound, and a progress note incorrectly stated the resident's skin was intact. Interviews with staff confirmed these documentation inaccuracies.
The facility failed to maintain infection control practices for two residents. One resident's air mattress pump was improperly placed and non-functional, causing discomfort. Another resident had an outdated droplet isolation sign, leading to a visitor entering without PPE. Staff confirmed these lapses in protocol.
The facility failed to post daily nursing staff data, affecting all 65 residents. On a specific day, the Daily Staffing Log was outdated, and the responsible staff was off due to a holiday. The Administrator confirmed the required information was not updated. This was found during a complaint investigation.
The facility failed to dispose of expired Covid-19 vaccine syringes, potentially affecting residents receiving vaccines. An opened box of Spikevax vaccine with expired syringes was found in the medication storage refrigerator. An LPN confirmed the expired syringes, stating they would be administered upon request. Manufacturer guidelines indicate syringes should be refrigerated for up to 30 days.
A resident with multiple health conditions, including Parkinson's and dementia, was observed inadequately dressed in a hospital gown, exposing his chest to passersby. Despite the facility's policy on resident rights, staff failed to ensure the resident was dressed in personal clothing, attributing the oversight to being busy and actions of the night shift.
The facility failed to complete initial comprehensive MDS assessments within 14 days for two residents with complex medical conditions. Additionally, a resident's oral status was inaccurately coded on the annual MDS, despite evidence of edentulous status. Interviews confirmed these deficiencies.
The facility failed to assess medication side effects for two residents on psychoactive medications. One resident exhibited involuntary mouth movements, while another had upper body tremors. Despite these observations, AIMS evaluations and medication records did not document these side effects. Staff interviews confirmed the presence of these movements, but assessments failed to capture them, indicating a gap in monitoring and documentation.
A facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident with a complex medical history. Despite pharmacist recommendations for GDR on medications like Lexapro and Buspar, the CNP disagreed without providing specific reasons or symptoms, contrary to facility policy. The Director of Nursing confirmed the need for documentation of the rationale for such decisions.
A facility failed to maintain proper infection control practices for a resident on droplet isolation due to human metapneumovirus pneumonia. Staff, including an RN and a housekeeper, were observed not using the required PPE, such as gowns, gloves, and properly worn masks, as per the facility's policy. This non-compliance was confirmed through interviews with the staff involved.
A resident, who was non-verbal and dependent on staff for daily activities, had their call light placed on the floor out of reach, preventing them from alerting staff for assistance. This was observed on two consecutive days and confirmed by STNAs, despite facility policy requiring call lights to be accessible to residents.
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for a resident with multiple serious diagnoses. Observations and staff interviews revealed inconsistencies in oxygen rates and a lack of documented guidelines for titration and monitoring, leading to a deficiency in care.
Failure to Provide Appropriate Discharge Planning and Allow Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate discharge planning and to permit a resident to return following hospitalization after issuance of a 30‑day discharge notice. The resident was admitted with multiple complex diagnoses, including cervical spine fusion, Ehlers‑Danlos syndrome, secondary malignant neoplasm of the lung, depression, anxiety, and neoplasm‑related pain, and had a care plan goal to eventually discharge to an apartment with cancer support. The admission MDS showed intact cognition and a need for supervision or touching assistance with ADLs. On 11/10/25, social services documented that the resident’s insurance coverage ended with a last covered day of 11/08/25, discussed appeal options and upcoming cancer treatment, and noted the resident required assistance with dressing, meal setup, and incontinence care and could not return to her previous residence. There is no documentation that staff provided or documented assistance with Medicaid application or plan changes despite the resident’s dependence on a payor source. On 12/03/25, social services documented that the resident’s appeal of the insurance termination was unsuccessful, that the family was exploring other medical plans with LTC benefits, and that the resident was informed she might receive a 30‑day discharge notice if no payor was secured. The resident expressed that she felt at home and hoped to stay, and there is no documentation that staff offered or provided assistance with the Medicaid application or plan change process. On 12/23/25, the administrator and social services director issued a 30‑day discharge notice for nonpayment, citing failure to pay or to have Medicare or Medicaid pay on the resident’s behalf, with a planned discharge date of 01/22/26. No further social service progress notes were documented in the resident’s record after issuance of the notice. On 01/04/26, nursing documented that the resident was sent to the hospital for nonstop diarrhea, and the record shows the resident was discharged from the facility that same day, with no further documentation after transfer. A hospital social worker later documented that he contacted the facility multiple times and was told the resident owed $28,000, had been given a notice to leave before hospitalization, and that the facility was unable to take her back. The appeal decision dated 01/20/26 found the facility had not met its burden to prove the discharge and denied the facility’s request to discharge the resident. The resident’s daughter and the hospital social worker reported that the facility told the hospital the resident could not return due to nonpayment, that the family did not receive an itemized bill despite requesting it, and that the facility did not assist with changing Medicaid plans. The administrator confirmed there was no documentation that the resident or family did not want to return, no documented communication with the hospital regarding discharge planning, and that facility policy required allowing a resident to return from the hospital during an appeal, which did not occur in this case.
Failure to Provide Hair Care to Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to failure to provide hair care to a dependent resident. The resident was admitted with multiple diagnoses including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. An admission MDS initiated but not yet completed showed, through assessments dated 01/26/26, that the resident was severely cognitively impaired with a brief interview for mental status score of zero and was dependent on staff for all ADLs except eating, for which setup assistance was required. Review of shower sheets for several dates showed the resident refused to have her hair washed on those shower days. Record review revealed no documentation that the resident refused hair care on days other than scheduled shower days. On 01/27/26, surveyors twice observed the resident’s hair to be matted to the back of her head, first at 11:55 AM and again at 1:49 PM. During the second observation, a CNA confirmed that the resident’s hair was matted and acknowledged that it needed to be combed. This deficiency was cited as non-compliance and was investigated under Complaint Numbers 2727003 and 2678134.
Failure to Maintain Cleanliness of Resident Room Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and comfortable environment in a resident’s room, as required by its own routine cleaning and disinfection policy. The resident involved had been admitted with multiple diagnoses, including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. Assessment information completed in preparation for the admission MDS showed the resident was severely cognitively impaired, with a brief interview for mental status score of zero, and was dependent on staff for all activities of daily living except eating, for which setup assistance was required. On two separate observations conducted on the same day, surveyors noted a brown stain on the floor under the resident’s small two-drawer bedside dresser and a dry, crumbly brown substance adhered to the lower front and corner of the dresser. These conditions were observed in the resident’s room both late morning and early afternoon. A CNA interviewed at the time confirmed the presence of the brown stain on the floor and the dry, crumbly brown substance on the dresser. Review of the facility’s undated “Routine Cleaning and Disinfection” policy showed that routine surface cleaning and disinfection was to be conducted with a detailed focus on visibly soiled surfaces, which was not carried out in this instance. This deficiency was investigated under Complaint Numbers 2727003, 2685197, and 2678134.
Failure to Maintain Safe and Sanitary Flooring and Carpeting
Penalty
Summary
The facility failed to maintain safe and sanitary flooring for two residents, as observed by surveyors. The flooring under and around the room air conditioner in these residents' room was peeling up about an inch off the floor, affecting approximately eight tiles. The Maintenance Director confirmed awareness of the issue and stated that the facility was working through a list of rooms needing flooring replacement, but progress had been slow, with only five rooms completed over several months. Additionally, the facility did not maintain carpeting in a clean and sanitary manner throughout the building. Observations revealed dirty carpeting in hallways, with grime, dark staining, and old moisture marks visible outside resident rooms, down hallways, and around offices and nursing stations. The Maintenance Director confirmed the carpet's condition and stated that cleaning attempts had been unsuccessful. There was no evidence of steps taken toward carpet replacement, such as obtaining quotes or order confirmations. The facility's policy requires maintaining a safe, functional, and sanitary environment, but these standards were not met in the areas observed.
Infection Control Deficiencies During Blood Glucose Monitoring and Meal Service
Penalty
Summary
The facility failed to maintain proper infection control practices during fingerstick blood glucose monitoring for one resident, with the potential to affect three additional residents receiving similar care. During observation, an LPN placed a glucometer directly on a resident's overbed table without a barrier, used gloves to obtain a blood sample, and then placed the glucometer on a tissue. The LPN changed gloves multiple times without performing hand hygiene between glove changes, and cleaned the glucometer for only five seconds, despite manufacturer guidelines requiring a two-minute contact time for disinfection. The LPN also prepared medication after glove removal, using hand sanitizer only after several glove changes without prior hand hygiene. These actions were confirmed during an interview with the LPN, and a review of facility policy indicated that hand hygiene should be performed after glove removal. Additionally, the facility failed to ensure hand hygiene was performed during meal service for three residents in the main dining room. A CNA was observed serving and assisting with meal trays for these residents without performing hand hygiene before or during the process. The CNA confirmed during an interview that hand hygiene was not completed as required. Facility policy identifies hand hygiene as the primary means to prevent the spread of healthcare-associated infections. The affected residents had various medical conditions, including high blood pressure, dysphagia, dementia, respiratory failure, epilepsy, anxiety, depression, and heart failure.
Failure to Provide Privacy During Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that residents were treated with dignity by providing adequate privacy during care and treatment, as evidenced by observations and staff interviews involving three residents. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, received medication administration via gastrostomy tube from a registered nurse who did not close the door or pull the privacy curtain during the procedure. The nurse later confirmed that privacy was not provided. In another case, a resident dependent on staff for all activities of daily living, including tracheostomy care, had trach suctioning and tie changes performed by a respiratory therapist with the door and blinds open and the privacy curtain not pulled. The therapist acknowledged that privacy should have been provided. Additionally, a resident with impaired cognition and dependence for toileting was observed receiving incontinence care with the curtain only partially closed and the door wide open, allowing the resident to be exposed and visible from the hallway. A soiled brief was also observed being tossed onto the floor by a certified nursing aide, who admitted that the door should have been closed but did not do so, mistakenly believing it was stuck. Review of facility policy confirmed that residents have the right to privacy and confidentiality during medical treatment and personal care.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and staff interviews. One resident with impaired cognition and dependent on staff for bathing and hygiene was observed sitting in a wheelchair with a stained cushion, food particles in the seams, and rails and footrest pegs covered in a white substance and dried food. Staff confirmed the wheelchair was dirty and stated that while the night shift usually cleaned wheelchairs, they would clean them if visibly soiled. The facility's cleaning schedule indicated wheelchairs were to be cleaned weekly, but this was not adhered to in this instance. Another resident, also with impaired cognition and dependent on staff for personal hygiene, was found to have a navy-blue wall padding next to their bed that was smeared with a dried brownish material. Multiple observations over the course of a day showed the soiled padding remained uncleaned despite several staff entering and exiting the room to provide care. A CNA confirmed the presence of the dirty substance but did not take action to clean it or alert other staff. The soiled mat remained unaddressed until the following day when housekeeping staff cleaned it. Facility policy required all personnel to report and address unclean or defective equipment and furnishings, but this was not followed in these cases.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for dependent residents, as evidenced by record reviews, observations, and staff interviews. Three residents with significant cognitive and physical impairments, who were dependent on staff for activities of daily living (ADLs), were found to have long, dirty, or jagged fingernails and toenails. Documentation showed that nail care was not completed during multiple showers for these residents, and there were no refusals documented for some of the missed care. Observations confirmed the poor nail condition, including long nails with dark substances underneath and thick, jagged toenails. Staff interviews corroborated the findings, with CNAs acknowledging the residents' unkempt nails and stating that nail care should be performed after bathing or showering. The facility's policy required staff to provide care and services for ADLs, including grooming and personal hygiene, but this was not consistently followed for the affected residents. The deficiency was identified through a combination of medical record review, direct observation, and staff confirmation.
Failure to Provide and Document Required Catheter Care and Monitoring
Penalty
Summary
A deficiency was identified regarding the care and management of a resident with a Foley catheter. The resident, who had multiple diagnoses including cardiac arrest, open wound, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, and urinary retention, was admitted with a Foley catheter in place due to obstructive uropathy. The care plan indicated the need for regular catheter care, monitoring of urine output, and prompt physician notification of any changes. However, review of the medical record revealed no evidence that catheter care was provided or that urine output was measured and documented from July through September. Additionally, there were no documented physician orders for the catheter prior to late September. An incident occurred when the resident's catheter came out overnight. The resident reported waiting for a nurse to replace it, but staff interviews revealed that the night nurse did not attempt to replace the catheter or notify the physician. The following day, the LPN on duty discovered the lack of catheter orders and contacted the physician for clarification. The RN on duty also did not replace the catheter or notify the physician, citing the absence of orders. There was no documentation of the resident's urine output during the 16-hour period without a catheter, nor was there evidence of physician notification regarding the catheter's removal. Facility policy required prompt physician notification of significant changes, regular catheter care each shift, and comprehensive care planning. Interviews with the DON and other staff confirmed that catheter care was not documented for several months and that the lack of orders was an oversight. The deficiency was substantiated by the absence of documentation, lack of physician notification, and failure to provide required catheter care and monitoring as outlined in facility policy.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a history of pressure ulcers, leading to the development of a new sacral pressure ulcer. The resident, who was admitted with multiple complex medical conditions including functional quadriplegia and ventilator dependence, was initially assessed to have a resolved sacral Stage IV pressure ulcer. However, subsequent assessments revealed the development of a right lateral sacrum abscess, which was not properly managed according to the facility's guidelines. The facility's records indicated inconsistencies in the treatment and documentation of the resident's pressure ulcer care. The treatment plan included the use of Calcium Alginate dressings, which were not appropriate for dry wounds, and there was a lack of documented evidence that wound treatments were completed on several occasions. Additionally, the air mattress settings were not specified, and the resident was observed lying on a static air mattress, which may not have provided adequate pressure relief. Observations and interviews with staff revealed further deficiencies in care, including improper dressing changes and failure to reposition the resident adequately. The resident's heels were not floated off the bed surface as required, and the soiled dressing was left in the resident's room, contributing to an unpleasant odor. These actions and inactions were in violation of the facility's policies on pressure injury prevention and management, as well as turning and repositioning protocols.
Inaccurate Medical Record Documentation for Resident's Sacral Wound
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #100, who was admitted with multiple diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, functional quadriplegia, and encephalopathy. The resident's quarterly Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making and noted the presence of a pressure-relieving device on the bed, with no pressure ulcers reported. However, a nursing Skin Grid Non-Pressure assessment later documented a right lateral sacrum abscess, which was initially recorded as a non-pressure wound. Further review revealed discrepancies in the documentation of the resident's sacral wound. A physician's progress note indicated the presence of a chronic sacral ulcer, recommending evaluation by the wound team for possible debridement. Despite this, a nursing progress note inaccurately stated the resident's skin was intact, and subsequent weekly assessments continued to document the sacral pressure ulcer as a non-pressure wound. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed the inaccuracies in the documentation, highlighting a failure to accurately record the resident's medical condition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two separate incidents involving residents. In the first case, Resident #103, who was admitted with multiple diagnoses including primary central nervous system lymphoma and depression, was found to have an air mattress pump sitting on the floor without a barrier, and the pump was not functioning because it had been unplugged. The air mattress was deflated, causing discomfort to the resident. The Occupational Therapist confirmed the absence of a footboard, which typically supports the pump, and the Registered Nurse acknowledged that the pump should not have been on the floor without a barrier. In the second incident, Resident #9, who was admitted with acute respiratory failure and other serious conditions, was observed with a droplet isolation sign on the door, despite the isolation precautions having expired. A visitor was seen in the room without personal protective equipment, which was required under the posted isolation precautions. The Assistant Director of Nursing verified that the isolation sign should have been removed after the precautions ended, indicating a lapse in updating the resident's status and ensuring compliance with infection control protocols.
Failure to Post Daily Nursing Staff Data
Penalty
Summary
The facility failed to ensure that daily nursing staff data was posted as required, which had the potential to affect all 65 residents residing within the facility. On December 26, 2024, at 8:10 A.M., an observation of the reception area revealed that the Daily Staffing Log posted was dated December 24, 2024. This was verified by the Business Office Manager (BOM) at the time of the observation. During an interview at 9:17 A.M., the BOM confirmed that the nursing staff information had not been posted on December 25 or December 26 because the staff responsible for posting the data was off on December 25 due to the holiday and had just returned to work. Later, at approximately 4:15 P.M., an interview with the Administrator revealed that the required nursing staff information was behind the posting dated December 24, 2024, but had not been flipped over on December 25. This deficiency was identified as an incidental finding during a complaint investigation.
Expired Covid-19 Vaccine Syringes Not Disposed
Penalty
Summary
The facility failed to properly dispose of expired Covid-19 vaccine syringes, which could potentially affect any resident receiving a Covid-19 vaccine or booster. During an observation, an opened box of Spikevax (Covid-19) vaccine was found in the medication storage refrigerator in the North unit's medication storage room. The box contained two pre-filled syringes from an original set of ten, with a lot number #3032713 and an expiration date that had passed. There were no opened dates on the box or syringes. An interview with an LPN Unit Manager confirmed the presence of the expired syringes, and it was stated that the vaccines would be administered upon resident request. The manufacturer's guidelines for the Moderna Spikevax vaccine indicate that single-dose pre-filled syringes may be stored refrigerated for up to 30 days prior to use.
Resident Dignity Compromised Due to Inadequate Dressing
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by multiple observations of the resident being inadequately dressed. The resident, who was dependent on staff for all activities of daily living due to conditions such as Parkinson's disease and dementia, was observed sitting in a Broda chair wearing only a hospital gown with a blanket covering his legs. On one occasion, the gown had fallen down to the resident's waist, exposing his chest to staff and passersby. This situation was not addressed by the staff, as evidenced by an interview with a State Tested Nursing Assistant (STNA) who acknowledged the resident should have been dressed in personal clothing but had not considered it due to being busy. The resident's medical record indicated a range of diagnoses, including human metapneumovirus pneumonia, pulmonary fibrosis, and generalized muscle weakness, which contributed to his dependency on staff for care. Despite the facility's policy on resident rights, which mandates that all direct care staff are educated on the rights of residents, the staff failed to uphold these rights by not ensuring the resident was dressed appropriately. The STNA attributed the resident's state of dress to the night shift's actions and did not take steps to rectify the situation, highlighting a lapse in the facility's adherence to its own policies regarding resident dignity and care.
Deficiencies in MDS Completion and Oral Status Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive, accurate standardized Minimum Data Assessment (MDS) within the first 14 days following admission for two residents. Resident #175, who was admitted with multiple complex diagnoses including pneumonia, Parkinsonism, and dementia, had an MDS assessment with an assessment reference date (ARD) that remained incomplete beyond the required 14-day period. Similarly, Resident #177, admitted with conditions such as metabolic encephalopathy and acute respiratory failure, also had an incomplete MDS assessment with an ARD that exceeded the 14-day requirement. Interviews with the MDS Coordinator confirmed that the assessments were not completed within the mandated timeframe. Additionally, the facility failed to accurately assess and code the oral status of Resident #30 on the annual MDS. Despite being documented as edentulous in dental consultations and observed without visible teeth, the MDS assessments inaccurately reflected the resident's dental status. The MDS nurse confirmed the discrepancy in coding, which did not align with the resident's actual oral condition as noted in previous assessments and consultations.
Failure to Assess Medication Side Effects
Penalty
Summary
The facility failed to comprehensively assess residents for possible medication side effects, affecting two residents. Resident #19, diagnosed with schizophrenia and Parkinson's disease, was on multiple medications, including antipsychotics and antidepressants. Despite observations of involuntary mouth movements, the AIMS evaluations and medication administration records did not document any side effects. Interviews with staff confirmed the presence of these movements, yet the assessments and progress notes failed to identify them. Resident #11, diagnosed with schizoaffective disorder, was also on several medications, including antipsychotics and anticonvulsants. Observations noted upper body tremors, but the AIMS evaluations and medication records did not reflect these findings. Although psychiatry progress notes documented fine hand tremors, there was no further assessment or documentation regarding the cause or treatment. Staff interviews confirmed the presence of tremors, but the assessments did not capture these involuntary movements. The facility's policy required routine monitoring for side effects using the AIMS assessment for residents on psychoactive medications. However, the assessments for both residents failed to identify involuntary movements, and there was a lack of documentation and reporting of these side effects. The deficiency highlights a gap in the facility's adherence to its policy for monitoring and documenting medication side effects.
Failure to Document Rationale for Declining GDR of Antipsychotropic Medications
Penalty
Summary
The facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident. The resident, who had a complex medical history including conditions such as muscular dystrophy, anxiety disorder, and depression, was receiving medications like Buspar and Lexapro via a peg-tube. Despite recommendations from the pharmacist for GDR on multiple occasions, the Certified Nurse Practitioner (CNP) disagreed with these recommendations without providing a rationale or symptoms for the denial. This lack of documentation was contrary to the facility's policy, which requires the attending physician to document the rationale for any decision not to change medication. The resident's medical record showed that the pharmacist recommended GDR for Lexapro and Buspar on several dates, but the CNP consistently disagreed, citing potential increased distressed behavior or worsening of target symptoms. However, the CNP did not provide specific reasons or symptoms to support these decisions. An interview with the Director of Nursing confirmed that the CNP should have documented the reason for declining the GDR. The facility's policy mandates that any irregularity identified by the pharmacist must be reviewed and documented by the attending physician, including the rationale for not making any changes to the medication regimen.
Inadequate Infection Control Practices in Droplet Isolation
Penalty
Summary
The facility failed to maintain proper infection control practices in the area of droplet isolation, affecting one resident who was admitted with human metapneumovirus pneumonia. The resident's care plan required droplet isolation due to the infection, with specific interventions outlined to manage the condition and prevent the spread of infection. However, observations revealed that staff did not adhere to the required personal protective equipment (PPE) protocols. A registered nurse was observed taking the resident's blood pressure without wearing the necessary PPE, including a gown, gloves, and surgical mask. Further observations showed a housekeeper cleaning the resident's room with a mask improperly worn under the nose and only wearing gloves, failing to utilize the full required PPE. Interviews with the staff members confirmed the lack of proper PPE usage. The facility's policy on transmission-based precautions required healthcare personnel to wear a facemask for close contact with infectious residents and additional PPE if there was a risk of exposure to respiratory secretions. The failure to adhere to these precautions was a direct violation of the facility's infection control policy.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical means for the resident to alert staff for assistance. The deficiency was observed when the call light for a resident, who had no speech and was dependent on staff for activities of daily living, was found on the floor out of reach. This was confirmed by two separate observations on consecutive days, where the call light was noted to be on a floor mat next to the resident's bed, rendering the resident unable to summon facility staff for needs. Interviews with State tested Nursing Assistants verified the resident's inability to access the call light, which was the only means to alert staff of any needs. The facility's policy requires that call lights be within reach of residents and secured as needed, but this was not adhered to in this instance.
Failure to Ensure Proper Ventilator and Oxygen Monitoring
Penalty
Summary
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for Resident #23. The resident, who was admitted with multiple serious diagnoses including chronic obstructive pulmonary disease and malignant neoplasms, did not have a physician order specifying the rate of oxygen or guidelines for titrating oxygen levels. This lack of documentation persisted from December 2023 to April 2024, with no evidence of pulse oxygen levels being checked according to facility policy and professional standards. Observations on April 16, 2024, revealed inconsistencies in the resident's oxygen rate, which varied from eight liters per minute to approximately 3.5 liters per minute. Interviews with various staff members, including RNs, LPNs, and the respiratory therapist, confirmed that there were no documented instructions or guidelines in the resident's medical record for titrating oxygen or monitoring it after titration. The staff admitted that the orders for oxygen rate and titration were only added to the resident's medical records on the day of the surveyor's inquiry. The Director of Nursing and the Administrator acknowledged the lack of proper documentation and adherence to the facility's oxygen administration policy. The facility's guidelines require checking the resident's pulse oxygen level five minutes and one hour after titration, but these steps were not consistently followed. The respiratory therapist admitted to not documenting titration events specifically in progress notes, further contributing to the deficiency in care for Resident #23.
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 554 citations issued within 25 miles in the last 12 months — including the 9 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 Pickerington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Violet Springs Health Campus | 2.3 mi | — | 19 | 0 |
| Embassy Of Winchester | 3.3 mi | — | 5 | 0 |
| Altercare Of Canal Winchester Post-acute Rc | 3.8 mi | — | 18 | 1 |
| Canal Winchester Care Center | 4 mi | — | 17 | 0 |
| Robert A Barnes Center | 4.9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pickerington Care And Rehabilitation.
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 August 2026) and official state health department websites.