Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview, resident interview, family interview, review of the self-reported misappropriation incident
investigation and review of the abuse policy, facility failed to ensure allegations of misappropriation were
reported to the state agency in a timely manner. This affected one (Resident #89) of one reviewed for
misappropriation. The facility census was 96.
Findings include
Review of the medical record for Resident #89 revealed an admission date of 09/06/24. Diagnoses included
unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis, and
cognitive communication deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively
impaired with a Brief Interview of Mental Status (BIMS) of 03 and required extensive assistance for bed
mobility and transfers, partial/moderate assist for bathing and dressing, and substantial maximum
assistance for personal hygiene.
Review of the plan of care dated 12/30/24 revealed the resident had a behavior problem and fidgets with
most things including jewelry and remote. Interventions included to develop more appropriate methods for
coping and interacting, monitor behaviors for delusions and paranoia.
Review of the Self-reported Incident investigation (SRI) for Misappropriation dated 12/31/24 revealed
Resident #89's family member had reported her wedding ring was missing. Facility staff searched for the
ring, checked laundry and could not locate the ring. Staff statement from Unit Manager #67 dated 01/03/24
revealed on 12/24/24 Resident #89's sister contacted her to report the missing wedding ring. She revealed
she informed family she would look for it and follow up with them on any outcome. She searched for the ring
that day without success. On 12/31/24 Director of Nursing was informed by Resident's husband of the
missing wedding band and an SRI was initiated.
Review of disciplinary action dated 01/02/25 with meeting on 01/03/25 revealed Unit Manager #67 received
a written warning related to not following the abuse policy. Facility management was not informed timely
after a report of the missing wedding ring for Resident #89 and the SRI was therefore not reported in a
timely manner.
Interview on 01/14/25 at 10:40 A.M. with Unit Manager #67 revealed she was informed of the missing ring
by residents family prior to Christmas and looked for it but did not tell anyone as the typical staff she would
alert were off work. She revealed she then went on vacation and did not return
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
365839
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Alzheimer's Care Ctr
700 Jasonway Avenue
Columbus, OH 43214
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
until after the new year. When she returned she was informed family had brought up the ring again to the
Director of Nursing and an investigation was started. Unit Manager reported she received a write up for not
reporting the concern to management back on 12/24/24 when it was reported to her.
Interview on 01/14/25 at 2:20 P.M. with Director of Nursing (DON) revealed Unit Manager should have
reported the concern of the missing wedding ring to management on 12/24/24 when it was first reported to
her. DON also confirmed this led to a delay in facility reporting the SRI to the Department of Health.
Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident
Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the
Administrator and Ohio Department of Health in accordance with procedures in this policy. Facility shall
ensure staff know how to identify Abuse, neglect and misappropriation of resident property. Events of
misappropriation shall be reported to the Ohio Department of Heath (ODH) within 24 hours from the time
the incident is known to a staff member.
This deficiency represents non-compliance investigated under Complaint Number OH00161067.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365839
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Alzheimer's Care Ctr
700 Jasonway Avenue
Columbus, OH 43214
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interviews, review of self-reported incident investigations (SRI) and policy review, the facility failed to
ensure allegations of abuse, neglect, misappropriation and injuries of unknown origin were thoroughly
investigated and interventions put in place. This affected eight Residents (#20, #21, #33, #48, #52, #54,
#89 and #100) of nine reviewed for abuse, neglect and misappropriation investigations. The facility census
was 96.
Residents Affected - Some
Findings include
1. Review of the medical record for Resident #54 revealed an admission date of 10/18/24. Diagnoses
included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis
and restlessness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively
impaired with a Brief Interview of Mental Status (BIMS) of 05 and required substantial assistance for
showering bathing and dressing
Review of SRI 252935 regarding an injury of unknown origin for Resident #54 dated 10/12/24 revealed no
resident interviews or statements were completed and an intervention of 15-minute checks was to be
initiated. The facility had no evidence of any 15-minute checks being completed for Resident #54.
Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no evidence of
15-minute checks being completed. She acknowledged the interventions were not typical for an injury of
unknown origin but confirmed it was mentioned multiple times in the investigation.
2. Review of the medical record for Resident #89 revealed an admission date of 09/06/24. Diagnoses
included unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis,
and cognitive communication deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively
impaired with a BIMS of 03 and required extensive assistance for bed mobility and transfers,
partial/moderate assistance for bathing and dressing, and substantial maximum assistance for personal
hygiene.
Review of SRI 255726 and SRI 255654 for misappropriation involving Resident #89 dated 12/31/24 and
01/03/25 revealed no resident interviews or statements were completed. The investigation did not include
the questions asked of staff and was not specific to a missing wedding ring and clothes but included
information about a different ring sent home with family.
Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility investigation was a mix of
information related to the previous ring that was reported missing and the new ring that Resident #89's
family had provided. DON also revealed facility spoke with the abuse department at Ohio Department of
Health and did not include any of those interactions in the investigation steps and when new information
was found, facility provided no information indicating the abuse officer was updated. The facility also agreed
they did not consider staff working prior to the allegation of the ring being missing but only considered and
looked at staff working after the allegation was made on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365839
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Alzheimer's Care Ctr
700 Jasonway Avenue
Columbus, OH 43214
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
12/24/24. DON revealed the staff would have also worked prior to the allegation.
Level of Harm - Minimal harm
or potential for actual harm
3. Review of the medical record for Resident #52 revealed an admission date of 03/21/24. Diagnoses
included dementia, catatonic disorder, aphasia, depression, and muscle weakness.
Residents Affected - Some
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively
impaired with a BIMS of 00.
Review of the medical record for Resident #100 revealed an admission date of 09/17/24 and discharge
date [DATE]. Diagnoses included dementia, muscle weakness, bipolar disorder, and pulmonary disease.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively
impaired with a BIMS of 10.
Review of SRI 253374 for physical abuse of a resident-to-resident altercation between Resident #52 and
Resident #100 dated 10/27/24 revealed no resident interviews or statements were completed. An
intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of
15-minute checks being completed for Resident #100 showed the incident occurred at 9:00 A.M. missing
entries 10/27/24 from 9:00 A.M. to 9:30 A.M., at 3:15 P.M., 3:45 P.M. to 4:15 P.M., 6:30 P.M., 7:00 P.M., 8:15
P.M., and 9:00 P.M.
Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence
of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries
and documentation was missing several sections. DON revealed each box should be completed and
confirmed staff used lines and arrows for shorthand and confirmed several sections were left with no
documentation to prove 15-minute checks were completed.
4. Review of the medical record for Resident #33 revealed an admission date of 08/05/22. Diagnoses
included heart disease, depression, hypertension, aphasia, chronic pain, and muscle weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively
impaired with a BIMS of 07.
Review of the medical record for Resident #48 revealed an admission date of 05/19/22. Diagnoses included
dislocation of left humerus, Alzheimer's disease, malnutrition, aphasia, heart disease and vascular
dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively
impaired with a BIMS of 08.
Review of SRI 254391 for physical abuse of a resident-to-resident altercation between Resident #33 and
Resident #48 dated 11/22/24 revealed no resident interviews or statements were completed. An
intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of
15-minute checks being completed for Resident #48 which showed the incident occurred at 10:39 P.M. and
was missing all entries on 11/23/24 from 2:00 A.M. to 9:30 A.M.
Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence
of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365839
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Alzheimer's Care Ctr
700 Jasonway Avenue
Columbus, OH 43214
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
5. Review of the medical record for Resident #20 revealed an admission date of 05/22/23. Diagnoses
included vascular dementia, hemiplegia and hemiparesis, aphasia and diabetes.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively
impaired with a BIMS of 08.
Residents Affected - Some
Review of the medical record for Resident #21 revealed an admission date of 06/27/23. Diagnoses included
vascular parkinsonism, insomnia, aphasia, vascular dementia and cognitive communication deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively
impaired with a BIMS of 01.
Review of SRI 254574 for physical abuse of a resident-to-resident altercation between Resident #20 and
Resident #21 dated 11/28/24 revealed no resident interviews or statements were completed. An
intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of
15-minute checks being completed for Resident #20 showed the incident occurred at 9:00 P.M. and had two
separate forms dated 11/29/24 completed by two different staff and stated resident was in two different
locations for the entirety of this time period 3:00 P.M. through 3:45 P.M.
Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility had no additional evidence of
15-minute checks being completed. She acknowledged the intervention was completed on different forms
for the same time period and provided no reasoning for two different staff completing the checks and
different information being provided for the same residents at the same times.
Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident
Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the
Administrator. Facility shall complete an investigation into the alleged violation within five working days. The
actions to be taken include interview the resident, the accused, and all witnesses including anyone who
come in contact with the resident(s) the day of the incident. If there were no direct witnesses, interviews
should be expanded for example all staff on the shift in question. For injuries of unknown origin facility may
generally interview staff working on the shift the injury was discovered as well as shifts prior to the incident.
Facility shall review all applicable medical records and document all evidence of the investigation. At the
end of the investigation, facility shall make a conclusion whether to substantiate the claim vs
unsubstantiated the claim. Facility shall follow up by completing any necessary staff education and
implementing any other measures deemed appropriate.
This deficiency represents non-compliance investigated under Complaint Number OH00161067.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365839
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365839
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Columbus Alzheimer's Care Ctr
700 Jasonway Avenue
Columbus, OH 43214
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations and staff interviews the facility failed to ensure call lights were in reach and accessible for
resident use. This affected two residents (#35 and #54) of two observed laying in their bed in their rooms.
Facility census was 96.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #35 revealed an admission date of 11/21/24. Diagnoses
included dementia, osteoarthritis, aphasia, and anxiety.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively
impaired with a BIMS of 99 (unable to determine due to lack of responses in answering) and required
extensive assistance of two staff members for bed mobility and extensive assistance of one staff member
for transfers.
Observation and interview on 01/14/25 at 9:35 A.M. revealed Resident #35's call light was not within reach.
It was hung back behind the headboard over the clock hanging on the wall about 6 feet from the ground.
Registered Nurse (RN) #53 confirmed the call light was hung up over the wall clock and was out of reach
for the resident. She revealed possibly the staff feeding her hung it up then forgot to give it back. RN #53
confirmed the call light should be left in resident reach at all times, while she was in bed.
2. Review of the medical record for Resident #54 revealed an admission date of 10/18/24. Diagnoses
included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis
and restlessness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively
impaired with a BIMS of 05 and required substantial assistance for showering bathing and dressing
Observation and interview on 01/14/25 at 12:20 P.M. revealed Resident #54's call light was not within
reach. It hung from the plug against the wall and under the bed at the foot board end of the bed. RN #53
confirmed the call light was on the floor under the foot board side of the bed and had to climb around the
bed to retrieve it. RN #53 confirmed the call light should always be left in resident reach, while the resident
was in bed.
Interview on 01/14/25 at 2:30 P.M. with Administrator and Director of Nursing revealed they did not believe
the facility had a policy related to residents having access to their call light devices but would check. No
policy was provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365839
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the January 15, 2025 survey of COLUMBUS ALZHEIMER'S CARE CTR?
This was a inspection survey of COLUMBUS ALZHEIMER'S CARE CTR on January 15, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COLUMBUS ALZHEIMER'S CARE CTR on January 15, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.