Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Wexner Heritage House during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for care did not receive proper incontinence care from a CNA, who failed to dry the vaginal area and did not cleanse or dry the buttocks, rectal, or coccyx area, contrary to facility policy.
Staff failed to perform hand hygiene during meal tray service, as observed with three residents who required assistance with meal setup and feeding. Despite the availability of hand sanitizer and facility policy requiring hand hygiene, a CNA assisted residents without sanitizing hands before or after contact, potentially affecting all residents on the unit. The residents involved had complex medical conditions, including dementia, diabetes, and chronic kidney disease.
A resident with severe cognitive impairment and multiple health conditions was admitted with a skin alteration that was inconsistently assessed and documented by staff. Despite care plans and physician orders for skin care, there was no evidence of consistent repositioning or timely notification of the wound nurse and wound physician. Incomplete assessments and lack of documentation led to the worsening of the wound, resulting in an unstageable pressure ulcer with necrosis requiring debridement.
A resident with severe cognitive impairment alleged sexual assault by a male staff member. The facility's investigation was incomplete, as only night shift staff were interviewed, key staff statements were delayed, and new bruising was not fully documented or investigated. The facility did not follow its own policy for abuse investigations, resulting in an insufficient response to the allegation.
A resident with multiple complex conditions did not receive physician-ordered wound care on several days, and there was no evidence that critical medications for low potassium were administered as ordered. Nursing staff failed to document or recall the administration of these treatments, and required orders were not entered into the medical record, resulting in non-compliance with facility policy.
A resident with multiple serious health conditions experienced a critically low potassium level, prompting a physician to order immediate potassium administration and additional lab tests. Although the RN relayed the orders to an LPN, only a basic metabolic panel was completed, and the required comprehensive metabolic panel and magnesium tests were not performed. The DON confirmed the orders were not entered into the medical record, and staff interviews revealed a breakdown in communication and follow-through.
Two residents experienced harm due to the facility's failure to promptly assess, monitor, and implement individualized interventions for pressure ulcer prevention and care. One resident developed an unstageable heel ulcer that was not identified or treated in a timely manner, while another was admitted with existing unstageable ulcers that were not comprehensively assessed or treated for two days. The facility did not follow its own wound care policies, resulting in delayed interventions and inadequate documentation.
Two residents with indwelling urinary catheters were observed with their catheter collection bags uncovered and visible to others, despite physician orders requiring privacy covers. LPNs confirmed the lack of privacy bags, resulting in urine being visible from the hallway and during resident mobility, which failed to uphold resident dignity.
A resident with multiple medical conditions developed an unstageable deep tissue injury to the left heel, which was identified by staff and reported to management and the resident's power of attorney, but not to the primary care physician as required by facility policy. Medical records showed no evidence of physician notification or immediate intervention for the wound at the time of discovery, despite the resident being at risk for skin breakdown.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital without proper documentation of the transfer or required information being provided to the receiving provider. The DON confirmed that essential details such as responsible physician, representative information, advance directives, and care instructions were missing from the record, contrary to facility policy.
A resident with a gastrostomy tube and multiple complex medical conditions received incontinence care from CNAs who wore gloves but did not don a gown, as required by the facility's enhanced barrier precautions policy for residents with indwelling medical devices. Both staff confirmed that the required precautions were not followed during the observed care.
The facility failed to conduct accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. One resident had a skin alteration under the right breast with no documented weekly assessments, while another had multiple wounds with delayed treatment orders and insufficient documentation. The facility's policies on wound care were not adhered to, resulting in non-compliance.
A facility failed to report an abuse allegation involving a resident with multiple medical conditions to the State agency within the required two-hour timeframe. The incident was reported to an LPN and then to the DON, who informed the Administrator. However, the Administrator delayed reporting to the State agency until the next day, misunderstanding the policy requirements.
A resident with a DNRCC code status was mistakenly given CPR after experiencing cardiac arrest due to a miscommunication about their code status. The error occurred when an LPN provided the wrong room number to the ADON, leading to the incorrect assumption of a full code status. CPR was administered until emergency services arrived, but the resident did not survive.
A facility failed to obtain a urine sample for a resident with end-stage renal disease and urinary tract infections, despite a verbal order due to cloudy urine. The resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed. After reinsertion, 350 ml of urine was returned, but no sample was collected. The resident was later hospitalized with an acute complicated UTI. The DON revealed that the nurse involved could not recall if the physician was updated about the situation.
A facility failed to maintain infection control during catheter care for a resident with end-stage renal disease and urinary tract infections. A CNA used alcohol wipes incorrectly and failed to change gloves after care, as confirmed by the ADON. The facility's hand hygiene policy requires hand hygiene before and after resident care and glove removal.
Inadequate Incontinence Care Provided by CNA
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate incontinence care to a resident who was always incontinent of bowel and bladder. The resident had severe cognitive impairment and required total assistance with activities of daily living, including toileting and personal hygiene. During observed incontinence care, the CNA washed and rinsed the vaginal area and creases, then applied a clean adult brief, but did not dry the vaginal area as required by facility policy. Additionally, the CNA did not cleanse or dry the resident's buttocks, rectal, or coccyx area during the care process. The CNA confirmed in an interview that these steps were omitted. Facility policy specifies that after washing and rinsing, the genital area should be dried, and the rectal area should be washed, rinsed, and dried using a clean area of the washcloth for each stroke. The failure to follow these procedures resulted in non-compliance with the facility's incontinence care policy.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to maintain infection control practices during meal tray service, as observed with three residents. Certified nursing assistant (CNA) #100 was seen assisting residents with meal tray setup and other tasks, such as raising the head of the bed and removing linens, without performing hand hygiene before or after these activities. This occurred despite the presence of hand sanitizer on the meal delivery cart and the facility's policy requiring hand hygiene by all employees. CNA #100 confirmed during interviews that hand hygiene was not performed during the lunch tray pass. The residents involved had significant medical histories, including dementia, diabetes mellitus with chronic kidney disease, Crohn's disease, heart failure, arthritis, peripheral vascular disease, and cognitive impairment. Observations were made both in resident rooms and the dining area, affecting all three residents observed during the meal service. The failure to perform hand hygiene had the potential to impact all thirteen residents on the unit, with a total facility census of seventy-six.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
A cognitively impaired resident with multiple comorbidities, including diabetes, peripheral vascular disease, and a recent surgical amputation, was admitted to the facility with a documented skin alteration to the coccyx. Upon admission, there were inconsistencies in the assessment and documentation of the resident's skin condition, with records alternately describing the area as moisture-associated skin damage (MASD), an open area, and an unstageable pressure ulcer. The initial assessments failed to provide a comprehensive description, staging, or measurements of the wound, and there was no clear photographic evidence to support the presence or stage of a pressure ulcer. Despite care plans and physician orders for skin care interventions, such as the application of Triad paste and HydraGuard, there was no documented evidence that staff consistently provided or encouraged turning and repositioning every two hours as required. Additionally, the facility failed to ensure timely notification and involvement of the wound nurse and wound physician when the skin alteration was first identified. The wound physician was not made aware of the resident's condition until several days after admission, and the wound nurse was not notified at all during the initial period. Weekly skin assessments and wound documentation were either incomplete or missing, with staff failing to document wound descriptions, measurements, or photographs as required by facility policy. The lack of comprehensive assessment, documentation, and timely intervention led to the deterioration of the resident's skin condition, resulting in the development of an unstageable pressure ulcer with necrosis that required debridement. The facility's failure to implement a resident-centered plan for the prevention and treatment of pressure ulcers, including appropriate assessment, documentation, and communication among staff and consulting clinicians, directly contributed to actual harm to the resident.
Failure to Conduct Thorough Investigation of Alleged Sexual Assault
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual assault involving a resident with severely impaired cognitive skills, who was admitted with multiple diagnoses including a urinary tract infection, Parkinson's disease, fibromyalgia, and dystonia. The resident, who was incontinent of bowel and bladder, reported to her daughter that she had been raped by a male staff member. The allegation was reported to the facility, and a self-reported incident was created. The resident described the alleged perpetrator as a short man with short black hair, but the only male CNA on duty did not match this description, and no other males were present according to the staff schedule and employee list. The resident was assessed, and no immediate signs of abuse were found, though a full body assessment later revealed multiple bruises and a hematoma. The facility's investigation was limited in scope. Only staff working the night shift on the date of the alleged incident were interviewed, and staff who provided care during the following day were not questioned about the resident's condition or demeanor. Statements from key staff, including the accused CNA, were not obtained until several days after the incident, and the investigation did not address new findings of bruising to the back of the resident's knees. Documentation of the bruising was incomplete, lacking photographs, measurements, or detailed descriptions. The facility's policy required interviews with all relevant witnesses and thorough documentation, but these steps were not fully followed. The resident was ultimately sent to the hospital for examination, where a rape kit was performed, and a police report was filed by the family. The family also requested additional safety measures for the resident. Despite these actions, the facility's internal investigation did not meet its own policy standards for thoroughness, as it failed to interview all potentially relevant staff, did not fully document physical findings, and delayed obtaining statements from involved personnel. The deficiency centers on the incomplete and insufficient investigation of the abuse allegation.
Failure to Complete Physician-Ordered Treatments, Medications, and Lab Testing
Penalty
Summary
The facility failed to provide treatments, administer medications, and obtain laboratory testing as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open surgical wound. The resident was at risk for skin breakdown and had a physician order for daily wound care, but the treatment administration record showed no evidence that the wound care was completed on several specified days. The Director of Nursing confirmed there was no documentation of the required treatments on those dates, despite facility policy requiring immediate documentation after treatment. Additionally, the resident experienced critically low potassium levels as revealed by laboratory results. Although the physician provided orders for immediate administration of potassium and anti-nausea medication, there was no evidence in the medical record that these medications were administered or that the orders were entered as required. Interviews with nursing staff confirmed a lack of recall or documentation regarding the administration of these medications, and the DON verified the absence of evidence for the ordered interventions. Facility policy required that verbal orders be transcribed and executed or safely handed off, but this process was not followed in this case.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, and an open wound. The resident had a critically low potassium level identified through laboratory testing, which prompted the physician to order immediate administration of potassium chloride and additional laboratory tests, specifically a comprehensive metabolic panel (CMP) and magnesium level. The orders were communicated by an RN to an LPN, who acknowledged understanding of the instructions. Despite these orders, only a basic metabolic panel (BMP) was completed, and the required CMP and magnesium tests were not performed. The failure was confirmed through closed record review and interviews, with the DON verifying that the orders for the additional blood work were not entered into the medical record. The LPN involved could not recall details about the potassium or the ordered blood work, and the RN confirmed that the orders were relayed but not executed. Facility policies required nurses to transcribe and execute physician orders or ensure a safe hand-off, and to contact laboratory services as needed, but these procedures were not followed in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to assess, monitor, and implement a comprehensive and individualized pressure ulcer prevention program for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was dependent on staff for bed mobility and used a wheelchair, was admitted without skin issues but was identified as at risk for skin breakdown. Despite care plans and physician orders for preventive measures such as floating heels and regular repositioning, the resident developed an unstageable pressure ulcer on the left heel. The ulcer was not discovered until it had progressed significantly, and there was no evidence of timely intervention, assessment, or notification to the physician at the time of discovery. The facility did not implement appropriate offloading interventions or wound care until several days after the ulcer was identified. Another resident was admitted with multiple complex medical conditions, including end-stage renal disease and an unstageable pressure ulcer to the sacrum and right heel, as documented in the hospital discharge summary. However, the facility's admission assessment failed to identify these skin issues, and the resident was not comprehensively assessed for pressure ulcers upon admission. There was a delay of two days before any wound treatment was initiated, and the required comprehensive wound assessment and documentation were not completed as per facility policy. Both cases demonstrate a lack of timely and thorough skin assessments, failure to implement and document individualized interventions, and delays in initiating appropriate wound care. The facility's actions did not align with its own wound care policy, which requires prompt assessment, documentation, and intervention for residents at risk of or presenting with pressure ulcers. These deficiencies resulted in actual harm to at least one resident and affected two out of three residents reviewed for pressure ulcers.
Failure to Ensure Privacy for Residents with Indwelling Catheters
Penalty
Summary
Surveyors identified that two residents were not treated in a dignified manner due to the facility's failure to ensure privacy for residents with indwelling urinary catheters. One resident, admitted with multiple diagnoses including surgical aftercare, chronic kidney disease, and lymphoma, was observed with a visible urinary catheter collection bag containing clear yellow urine that could be seen from the hallway. The resident's medical orders specified that the urinary drainage bag should have a cover over it every shift, but no privacy bag was present in the room at the time of observation. An LPN confirmed that the catheter bag was not contained in a privacy bag and was visible from the hallway. Another resident, with a history of acute transverse myelitis, quadriplegia, and other chronic conditions, was observed mobilizing in a power wheelchair with the indwelling urinary catheter collection bag resting on the footrest, uncovered and visible while moving down the hallway. This resident's physician orders also required a privacy cover for the urinary drainage bag every shift. An LPN verified that the catheter bag was not contained in a privacy bag and urine was visible as the resident moved through the hallway. These observations demonstrated the facility's failure to maintain resident dignity as required by their care plans and physician orders.
Failure to Notify Physician of Unstageable Deep Tissue Injury
Penalty
Summary
The facility failed to notify a resident's primary care physician of an unstageable deep tissue injury (DTI) to the resident's left heel at the time of discovery. The resident, who had multiple diagnoses including COPD, pressure-induced deep tissue damage, and a history of traumatic brain injury, was found by a CNA to have a dark, painful mark on the left heel. The nurse observed an 8.0 cm unstageable pressure area with intact skin and notified management and the resident's power of attorney, but did not notify the physician. The weekly skin and wound evaluation confirmed the presence of an unstageable pressure ulcer with slough and/or eschar, but lacked a detailed wound description. Medical record review showed no evidence of treatment or intervention for the unstageable DTI at the time of discovery, nor documentation that the physician was informed. The resident's quarterly MDS assessment indicated risk for skin breakdown and the presence of an unstageable pressure ulcer not present on admission, with interventions such as pressure-reducing devices and skin care in place. The Director of Nursing later verified that the physician had not been notified when the wound was first identified. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this instance.
Failure to Document and Communicate Required Transfer Information
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia with behavioral disturbances, diabetes, hypertension, and a history of repeated falls, was transferred from the facility to an acute care hospital. The resident, who had a severe cognitive deficit, was assessed by a nurse after becoming unresponsive to commands, and the transfer to the emergency room was initiated at the request of the resident's son. However, the medical record review revealed that there was no documentation of the disposition of the resident's transfer or the required information provided to the receiving provider. Specifically, the facility failed to document essential transfer information such as the physician responsible for the resident's care, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary details to ensure a safe and effective transition. The Director of Nursing confirmed that there was no evidence in the medical record that the receiving facility received the required information, and the transfer itself was not properly documented, which was not in accordance with the facility's own policy.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for a resident with an indwelling medical device. During an observation of incontinence care provided to a resident with multiple diagnoses, including dementia, chronic pulmonary edema, hepatic failure, and a stage IV sacral pressure ulcer, staff were seen performing incontinence care without donning a disposable gown, despite the presence of a gastrostomy tube. The care plan for the resident indicated a high risk for infection due to incontinence and the use of an indwelling device. Certified Nursing Assistants (CNAs) washed their hands and wore gloves but did not use a gown during high-contact care activities, such as changing briefs and cleansing the resident. Both CNAs confirmed in an interview that EBP, specifically the use of a disposable gown, was not maintained during the procedure. Facility policy required the use of gowns and gloves during high-contact care for residents with indwelling medical devices, but this protocol was not followed during the observed care event.
Deficiencies in Skin Assessment and Treatment Orders
Penalty
Summary
The facility failed to ensure accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. Resident #21, who was admitted with conditions including unspecified dementia and a need for assistance with personal care, had a treatment order for a skin alteration under the right breast. However, there were no weekly skin assessments documented to monitor the wound, as confirmed by the Director of Nursing (DON). Resident #41, admitted with conditions such as acute kidney failure and type 2 diabetes, had multiple wounds upon admission, including arterial wounds on the right leg and a surgical wound on the right knee. The plan of care did not include these wounds, and there were no documented skin assessments or treatments for these wounds from admission through mid-November. The DON confirmed that the orders for wound care were placed late, and there was a lack of documentation regarding the wounds' types, locations, and descriptions. The facility's policies required specific documentation and weekly assessments for wounds, which were not followed in these cases. The deficiencies were identified during an investigation under several complaint numbers, highlighting the facility's non-compliance with its wound and skin care program guidelines.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident abuse to the State agency within the required timeframe. Resident #46, who was cognitively intact and had multiple medical conditions including chronic respiratory failure, cirrhosis, and dementia, was involved in the incident. An allegation of abuse was reported to an LPN on the evening of 12/16/24, who then informed the DON. The DON subsequently notified the Administrator. However, the Administrator did not report the allegation to the State agency until the following day, exceeding the two-hour reporting requirement for abuse allegations. The facility's policy mandates that allegations of abuse or serious bodily injury be reported to the State Department of Health immediately, but no later than two hours after the allegation is made. The Administrator misunderstood the policy, believing he had 24 hours to report the incident due to the absence of significant injury to the resident. This misunderstanding led to the delay in reporting the abuse allegation, resulting in a deficiency finding during the survey related to Complaint Number OH00160901.
Failure to Honor DNRCC Code Status
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate Comfort Care (DNRCC) code status, resulting in the administration of life-saving measures and cardiopulmonary resuscitation (CPR) after the resident experienced cardiac arrest. The resident, who had diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, and viral hepatitis B, was found by a State tested Nursing Assistant (STNA) to be having difficulty breathing. A Licensed Practical Nurse (LPN) was informed and, upon assessing the situation, called for assistance from the Assistant Director of Nursing (ADON). Despite the resident's DNRCC status, CPR was initiated due to a miscommunication regarding the resident's code status. The incident occurred when the LPN, after being alerted to the resident's distress, mistakenly provided the wrong room number to the ADON, leading to the incorrect assumption that the resident had a full code status. As a result, CPR was administered until emergency medical services arrived. It was only after the resident was transported to the hospital that the error was discovered, revealing that the resident had a DNRCC code status. Unfortunately, the resident did not survive the incident.
Failure to Obtain Urine Sample and Incorrect Catheter Placement
Penalty
Summary
The facility failed to obtain ordered urine samples for testing due to cloudy urine for Resident #196, who was admitted with diagnoses including end-stage renal disease and urinary tract infections. The resident required an indwelling catheter for urine elimination and was dependent on staff for personal care. On a specific date, a nurse received a verbal order to change the Foley catheter and perform a urine dip test due to the cloudy appearance of the urine. However, the urine sample was not obtained, and the order was not documented as completed. Subsequently, the resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed in the vagina instead of the bladder. After reinsertion, 350 ml of urine was returned, but there was no documentation indicating that a urine sample was collected. The resident later presented with symptoms of nausea, labored breathing, and confusion, leading to hospitalization where she was diagnosed with an acute complicated urinary tract infection due to the chronic indwelling Foley catheter. The Director of Nursing (DON) revealed that the nurse involved could not recall if the physician was updated about the inability to obtain the urine sample. The facility's policy on catheter care emphasizes meeting the psychosocial, physical, and emotional needs of residents, yet the failure to complete the urine test and the incorrect catheter placement contributed to the resident's hospitalization. This deficiency was investigated under a specific complaint number.
Infection Control Deficiency During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures during catheter care for a resident. The resident, who had end-stage renal disease, urinary tract infections, and required assistance with personal care, was observed to have intact cognition and was dependent on staff for toileting and personal hygiene. During an observation, a CNA was seen wearing a gown and gloves while performing catheter care but used alcohol wipes incorrectly by wiping towards the body instead of away. Additionally, the CNA used the same gloves to adjust the bed and cover the resident after completing the care, which violated infection control protocols. The Assistant Director of Nursing (ADON) was present during the procedure and confirmed that infection control measures were not maintained. The facility's policy on hand hygiene, dated March 31, 2022, requires hand hygiene before and after caring for a resident and after glove removal. This incident was identified during an investigation for a specific complaint, indicating a deficiency in the facility's infection control practices.
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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) |
|---|---|---|---|---|
| Bella Terrace Rehabilitation And Nursing Center | 2.1 mi | — | 4 | 1 |
| Mohun Health Care Center | 3 mi | — | 0 | 0 |
| Eastland Rehabilitation And Nursing Center | 3.2 mi | — | 1 | 0 |
| Majestic Care Of Whitehall | 3.7 mi | — | 9 | 0 |
| Ohio Living Westminster-thurber | 4.4 mi | — | 0 | 0 |
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