Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
89 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: Jul 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding failure to notify responsible parties, improper food handling practices, and inadequate infection prevention and control measures.
Complaint Details
The investigation was triggered by complaints numbered 1327655, 1327653, and 1327647 concerning failure to notify family of therapy orders, improper food handling and hair net use, and inadequate infection control practices including scabies outbreak management and catheter care hygiene.
Findings
The facility failed to notify a resident's responsible party of a new therapy order, did not ensure staff wore hair nets in the kitchen, and failed to implement proper infection control practices during a scabies outbreak affecting multiple residents. Additionally, staff failed to perform proper hand hygiene after catheter care.
Deficiencies (3)
Failed to ensure a resident's responsible party was notified of a new order for therapy evaluation and treatment.
Failed to ensure staff wore hair nets in the kitchen as required, risking food contamination.
Failed to provide and implement an infection prevention and control program, including inadequate management of a scabies outbreak and failure to perform proper hand hygiene after catheter care.
Report Facts
Facility census: 89
Residents affected: 1
Residents affected: 88
Residents affected: 2
Residents in unit 300: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #177 | Signed therapy order but failed to document family notification | |
| Staff member #168 | Observed not wearing hair net properly in kitchen | |
| Maintenance Director (MD) #213 | Entered kitchen without hair net | |
| Assistant Director of Nursing (ADON) #177 | Interviewed regarding scabies outbreak and infection control | |
| Former Employee #510 | Interviewed regarding scabies outbreak and staff education | |
| Licensed Practical Nurse #184 | Confirmed resident with scabies wandered the facility | |
| Nurse Practitioner (NP) #500 | Diagnosed resident with crusted scabies | |
| Regional Clinical Director #400 | Provided additional surveillance log and interview on scabies outbreak | |
| Laundry Representative #109 | Interviewed about washing contaminated linen | |
| City of Columbus Health Department Representative #600 | Confirmed lack of notification of scabies outbreak to health department | |
| Certified Nurse Aide (CNA) #158 | Failed to perform hand hygiene after catheter care |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to thoroughly investigate and obtain staff statements for injuries of unknown origin involving Resident #50 and Resident #101.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00158297.
Findings
The facility failed to obtain documented staff interviews or statements during investigations of injuries for Resident #50 and Resident #101. Despite multiple attempts and interviews, no documented statements from key staff were obtained. The facility's investigation process did not meet policy requirements for thorough abuse and injury investigations.
Deficiencies (1)
Failure to thoroughly investigate and obtain statements from staff for injuries of unknown origin for Resident #50 and Resident #101.
Report Facts
Facility census: 85
Residents reviewed for abuse: 3
Self-Reported Incident (SRI) control number: 252375
Self-Reported Incident (SRI) control number: 250845
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Staff working when fractures were identified; not interviewed or asked to write statements |
| STNA #14 | State Tested Nursing Assistant | Staff working when fractures were identified; not interviewed or asked to write statements |
| Assistant Director of Nursing #11 | Assistant Director of Nursing | Designated to interview nursing staff and STNA on duty during incident; conducted telephone interviews without documentation |
| Director of Nursing | Director of Nursing | Signed statement regarding investigation process and staff interviews |
Inspection Report
Routine
Census: 86
Deficiencies: 12
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely reporting of injuries, response to alleged violations, provision of care, activities offered, fall prevention, nutrition, respiratory care, dialysis services, medication monitoring, infection control, environmental cleanliness, and pest control.
Findings
The facility was found deficient in multiple areas including failure to timely report and investigate an injury of unknown origin, inadequate nail care for dependent residents, insufficient activities offered especially on weekends and evenings, failure to implement fall prevention interventions, inadequate hydration and diet provision, improper oxygen administration, incomplete dialysis documentation, inadequate monitoring of medication effects, failure to notify physicians of abnormal lab results, incomplete infection control tracking, unsanitary resident environment, and presence of pests in resident rooms.
Deficiencies (12)
Failed to timely report an injury of unknown origin to the State Survey Agency.
Failed to thoroughly investigate an injury of unknown origin.
Failed to ensure adequate nail care was provided for dependent residents.
Failed to ensure activities were offered throughout the week based on assessment, care plan, and resident preference.
Failed to ensure fall interventions were in place and resident transfers were performed to prevent falls.
Failed to ensure adequate fluids were available and provided throughout the day to promote hydration.
Failed to administer supplemental oxygen as ordered.
Failed to ensure dialysis services were completed thoroughly including obtaining resident weights before and after dialysis.
Failed to ensure adequate monitoring was completed for a medication as ordered.
Failed to timely complete an order for laboratory values and failed to notify the physician of abnormal laboratory results.
Failed to maintain a clean and sanitary environment in resident rooms.
Failed to maintain a pest free environment; ants observed in resident room sink.
Report Facts
Facility census: 86
Fluid intake days documented: 6
Fall risk score: 9.5
Nifedipine dose: 60
Psychotropic medication dose: 5
Dialysis days missing weights: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #105 | Licensed Practical Nurse | Interviewed regarding Resident #6's injury of unknown origin |
| STNA #145 | State Tested Nurse Aide | Interviewed regarding Resident #6's injury and nail care findings |
| Regional Nurse #200 | Interviewed regarding Resident #6 injury reporting and Resident #50 fall | |
| Director of Nursing | DON | Verified multiple deficiencies including injury reporting, fall prevention, oxygen administration, medication monitoring, infection control, and environmental issues |
| STNA #156 | State Tested Nurse Aide | Interviewed regarding hydration and water availability for Resident #6 |
| Dietary Technician #201 | DT | Interviewed regarding fluid provision and dialysis weight monitoring |
| Activities Director #122 | AD | Interviewed regarding activities offered to residents including Residents #6 and #55 |
| Registered Nurse #164 | RN | Interviewed regarding nail care and fall interventions |
| Licensed Practical Nurse #110 | LPN | Interviewed regarding oxygen administration and environmental cleanliness |
| Dietary Supervisor #134 | Interviewed regarding diet provision for Resident #42 | |
| Assistant Director of Nursing #123 | ADON | Interviewed regarding lab test delays and abnormal lab notification |
| Maintenance Staff #112 | Interviewed regarding pest control and ant presence |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Oct 14, 2023
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse of a resident by staff on 09/21/2023.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146683. The verbal abuse allegation was found inconclusive due to lack of information about the context prior to the video and audio footage, but video evidence showed a verbal altercation involving STNA #104 and Resident #65's daughter.
Findings
The facility failed to ensure a resident was not verbally abused by staff, specifically involving STNA #104 using inappropriate language while providing care to Resident #65. The investigation was inconclusive regarding verbal abuse due to lack of full context, but video and audio evidence confirmed a verbal altercation occurred. STNA #104 was terminated due to inappropriate behavior toward a resident's family member.
Deficiencies (1)
Failure to protect residents from verbal abuse by staff, including use of inappropriate language during care.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 3
Facility census: 87
Duration of video recording: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #104 | State Tested Nursing Assistant | Named in verbal abuse finding and terminated due to incident |
| STNA #111 | State Tested Nursing Assistant | Originally assigned to Resident #65 but called off on 09/21/23 |
| RN #106 | Registered Nurse | Nurse on duty during alleged verbal abuse, reported no witnessing of abuse |
| LSW #112 | Licensed Social Worker | Resident #65's guardian who provided video and audio footage |
| LPN #110 | Licensed Practical Nurse | Spoke with Resident #65's daughter and verified video footage |
| Administrator | Facility Administrator | Conducted verbal abuse investigation and found allegation inconclusive |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Date: Jul 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate care in activities of daily living, fall prevention, and incontinence care at Crown Pointe Care Center.
Complaint Details
The deficiencies were investigated under Complaint Numbers OH00143835, OH00132743, OH00132578, and OH00144046. The fall-related deficiency was investigated under Complaint Number OH00144046. The shaving and incontinence care deficiencies were investigated under Complaint Numbers OH00143835, OH00132743, and OH00132578.
Findings
The facility failed to provide adequate assistance with shaving for a resident requiring extensive help, failed to provide adequate supervision to prevent a resident's fall resulting in a hip fracture and subsequent death, and failed to provide timely incontinence care to two residents. These deficiencies affected a few residents and represented non-compliance with regulatory requirements.
Deficiencies (3)
Failed to ensure a resident who required extensive assistance with shaving was provided adequate care and services.
Failed to provide a resident with adequate supervision to prevent an avoidable fall resulting in actual harm (hip fracture) and subsequent death.
Failed to provide timely incontinence care to residents, risking skin integrity and comfort.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #804 | State Tested Nursing Aide | Verified Resident #15 required assistance with shaving and had not been shaved recently. |
| Director of Nursing | Director of Nursing | Stated the facility did not have a policy on personal care or activity of daily living. |
| Regional Nurse #300 | Regional Nurse | Verified Resident #15 had facial hair more than a week old. |
| STNA #130 | State Tested Nursing Aide | Left Resident #86 unattended briefly in shower chair, resulting in resident's fall and hip fracture. |
| RN #220 | Registered Nurse | Responded to Resident #86's fall and initiated medical evaluation. |
| STNA #777 | State Tested Nursing Aide | Assisted with incontinence care for Resident #23. |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 8
Date: Aug 31, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, dietary services, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify residents of bed hold policies, failure to apply physician-ordered devices, medication administration errors, failure to follow dietary menus, improper food handling, and lapses in infection prevention and control protocols.
Deficiencies (8)
Failed to provide a bed hold notification to a resident discharged to the hospital.
Failed to apply a physician ordered palm guard device for a resident with limited range of motion.
Failed to administer physician ordered medication (Levothyroxine) consistently to a resident.
Medication error rate exceeded 5 percent, with errors including wrong insulin doses and missed medications.
Failed to ensure residents were free from significant medication errors, including administration of wrong insulin doses.
Failed to follow dietary spreadsheet for residents on pureed diet; tomato juice was not provided as required.
Failed to ensure food was prepared and served in a sanitary manner, including improper glove use and hand hygiene by kitchen staff and aides.
Failed to maintain transmission-based precautions for residents, failed to use appropriate isolation signage, and failed to ensure staff wore appropriate eye protection during medication administration.
Report Facts
Facility census: 80
Medication error rate: 14.8
Number of medications administered: 26
Number of medication errors: 4
Residents affected by medication errors: 3
Residents on pureed diet affected: 4
Residents affected by infection control deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #130 | Licensed Practical Nurse | Signed off on Treatment Administration Record for palm guard application but did not apply device |
| RN #141 | Registered Nurse | Administered wrong doses of insulin to Resident #44 |
| RN #142 | Registered Nurse | Inadvertently threw away prescribed medication for Resident #33 |
| RN #151 | Registered Nurse | Observed not wearing face shield properly during medication administration |
| AA #101 | Activities Aide | Touched serving cart and residents' dinner rolls without changing gloves or washing hands |
| DS #500 | Dietary Supervisor | Intervened to correct improper glove use by kitchen staff |
| RD #203 | Regional Dietitian | Confirmed dietary discrepancies and improper glove use in kitchen |
| ADON #103 | Assistant Director of Nursing | Confirmed visitor PPE noncompliance and uncertainty about visitor policy |
| Social Services Designee #154 | Social Services Designee | Confirmed visitor PPE noncompliance for Resident #334 |
| DON | Director of Nursing | Confirmed attempts to educate visitor on PPE and acknowledged face shield noncompliance |
Inspection Report
Routine
Census: 83
Deficiencies: 4
Date: Apr 11, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, accident hazard prevention, medication regimen review, infection control, and overall resident care.
Findings
The facility was found deficient in providing timely transfer/discharge notifications with appeal rights, ensuring safe wheelchair transport for residents, timely acting on pharmacy medication recommendations, and maintaining infection control during wound care. These deficiencies affected multiple residents and posed minimal to potential actual harm.
Deficiencies (4)
Failed to provide a transfer/discharge letter with appeal rights when residents were discharged to the hospital.
Failed to ensure the resident had a safe wheelchair during transport to an outside appointment.
Failed to timely act on pharmacy recommendations regarding medication dosage reduction.
Failed to maintain infection control measures to prevent contamination while providing wound care.
Report Facts
Residents reviewed for hospitalization: 3
Residents sampled: 18
Residents reviewed for unnecessary medications: 5
Residents reviewed for pressure ulcers: 3
Facility census: 83
Medication dose: 100
Medication dose recommended: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verified failure to provide discharge letter; stated communication with resident's spouse about medication; involved in medication management |
| Outside Transportation Driver #94 | Transportation Staff | Reported unsafe wheelchair transport and lack of proper chair for transport |
| Physical Therapist #97 | Physical Therapist | Explained use of Broda chair for positioning and availability of regular wheelchairs for transport |
| Supervisor of Outside Transportation #93 | Transportation Supervisor | Reported investigation of unsafe wheelchair transport and inability to secure chair safely |
| Licensed Practical Nurse #92 | Nurse | Approved use of Broda chair for transport despite safety concerns |
| Consultant Pharmacist #95 | Consultant Pharmacist | Made recommendations for medication dosage reduction and follow-up requests |
| Registered Nurse #90 | Registered Nurse | Observed failing to maintain infection control during wound care |
| Corporate Nurse #96 | Corporate Nurse | Intervened to correct infection control breach during wound care |
| Administrator | Facility Administrator | Acknowledged lack of formal policy on transporting residents to outside appointments |
Viewing
Loading inspection reports...
