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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to ensure accurate advanced directive information was
present throughout the medical record. This affected one (Resident #41) of one resident reviewed for
advanced directives. The facility census was 67.
Findings include:
Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that
included type two diabetes mellitus, chronic kidney disease, generalized anxiety disorder, depression
hyponatremia, hypokalemia, and iron deficiency anemia.
Review of the signed documents section of Resident 41's medical record revealed a signed do not
resuscitate comfort care- arrest (DNRCC-A) consent dated [DATE].
Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #41 was
cognitively intact and required extensive assistance with one-person physical assistance for activities of
daily living.
Review of Resident #41's care plan dated [DATE] revealed the resident was a DNRCC-A code status
signifying that cardiopulmonary resuscitation (CPR) was not to be conducted in case of cardiac or
respiratory arrest.
Review of the [DATE] to [DATE] physician orders for Resident #41 revealed an ordered dated [DATE] for
Full Code status signifying that CPR measures were to be conducted in case of cardiac or respiratory
arrest.
Observation on [DATE] at 8:14 A.M. revealed Resident # 41's physician's orders for [DATE] to [DATE]
indicated the resident was a Full Code. The hard chart had a face sheet and on the stem of the hard chart
was a sticker that indicated DNR-CCA. This was verified by Registered Nurse (RN) #203 on [DATE] at 8:20
A.M.; RN #203 stated that they should both match.
Review of the facility policy dated 11/2022 titled, Residents' Rights Regarding Treatment and Advanced
Directives revealed during the care planning process, the facility would identify, clarify, and review with the
resident or legal representative whether they desired to make any changes related to any advanced
directives. Any decision making regarding the resident's choices would be documented in the medical
record and communicated to the interdisciplinary team and staff responsible for the resident's care.
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 4
Event ID:
366135
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
366135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mohun Health Care Center
2340 Airport Dr
Columbus, OH 43219
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses
included type two diabetes mellitus with hyperglycemia, nonexudative age-related macular degeneration,
Rhabdomyolysis and nonrheumatic aortic valve stenosis.
Residents Affected - Some
Review of the quarterly MDS assessment dated [DATE] revealed Resident #61's cognition was intact.
Resident #61 was independent with set up help only for personal hygiene and eating. Resident #61 utilized
a walker for mobility assistance. Further review of the quarterly MDS assessment dated [DATE] indicated
Resident #61 was on insulin.
Review of Resident #61's physician's orders dated 05/12/22 revealed an order for Ozempic (hyperglycemic
medication) 0.25 milligram (mg) subcutaneously every week on Tuesday. There was no order for the
resident to receive insulin.
Interview on 01/26/23 at 11:23 A.M. Director of Nursing #297 verified the Ozempic was coded on the MDS
assessment as insulin.
4. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included but were not limited to encephalopathy, bipolar, metabolic syndrome, and diabetes
mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44's cognition was
intact and the resident required extensive assistance with one staff for activities of daily living. Further
review of the quarterly MDS assessment indicated Resident #44 was on insulin.
Review of Resident #44's physician's orders dated 06/26/22 revealed an order for Trulicity (hyperglycemic
medication) 0.5 milliliter (ml) subcutaneously every week on Saturday. There was no order for Resident #44
to receive insulin.
Interview on 01/26/23 at 11:10 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified that Trulicity
was coded as insulin.
5. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified
psychosis, and Alzheimer's disease. Review of the most recent MDS 3.0 assessment dated [DATE]
revealed the resident required extensive assistance with one staff for activities of daily living except eating
was coded for supervision with two staff.
Interview on 01/26/23 at 8:11 A.M. with MDS Licensed Practical Nurse (LPN) #309 verified Resident #13
required one staff for supervision of eating, not two.
Based on medical record review and staff interview, the facility failed to have accurate Minimum Data Set
(MDS) assessments for four (Resident #3, #36, #44, and #61) of 10 residents who received injectable
hyperglycemic medication and for one (Residents #13) of 20 residents whose records were reviewed that
required assistance for eating. The census was 67.
Findings include:
1. Review of Resident #3's medical record revealed the resident was admitted to the facility on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366135
If continuation sheet
Page 2 of 4
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
366135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mohun Health Care Center
2340 Airport Dr
Columbus, OH 43219
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 0641
Level of Harm - Minimal harm
or potential for actual harm
[DATE]. Diagnoses included displaced fracture of the second vertebra, major depression, high blood
pressure, osteoarthritis, diabetes, and repeated falls. Review of the quarterly MDS assessment dated
[DATE] revealed Resident #3's cognition was intact. Resident #3 was independent with set up help only for
bed mobility and eating. Resident #3 required extensive assistance of one staff member for dressing. The
quarterly MDS assessment dated [DATE] also indicated Resident #3 was on insulin.
Residents Affected - Some
Review of the physicians orders dated 08/12/21 revealed an order for Ozempic (hyperglycemic
medication)1 milligram (mg) every week on Thursday, Resident #3 did not receive insulin.
Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded
on the MDS assessment as insulin.
2. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included acute embolism and thrombosis (05/11/21), diabetes and osteoarthritis. Review of the
quarterly MDS assessment dated [DATE] revealed Resident #36's cognition was intact. Resident #36 was
independent with set up help only for bed mobility and eating and supervision with one staff physical
assistance for personal hygiene. Resident #36 received antidepressant and anticoagulant daily. Further
review of the quarterly MDS assessment dated [DATE] indicated Resident #36 received insulin.
Review of Resident #36's physicians orders dated 07/24/21 revealed an order for Ozempic 1 mg every
Sunday.
Interview on 01/25/23 at 4:00 P.M. of Licensed Practical Nurse (LPN) #309 verified the Ozempic was coded
on the MDS assessment as insulin.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366135
If continuation sheet
Page 3 of 4
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
366135
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mohun Health Care Center
2340 Airport Dr
Columbus, OH 43219
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 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to serve food at the proper portion size to meet
the nutritional needs of residents who received the alternate entrée. This affected two residents
(#13 and #24) out of eleven (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119) who
selected to receive a full portion of the alternate. The facility census was 67.
Findings include:
Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that
included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and
Alzheimer's disease. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed
the resident required extensive assistance with one staff for activities of daily living.
Review of the physicians' orders for January 2023 revealed Resident #13 was on a regular diet with no
restrictions.
Review of Resident #13's diet ticket revealed a five-ounce chicken Caesar wrap.
Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that
included but were not limited to heart failure, diabetes mellitus, and major depressive disorder. Review of
the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderately
cognitively impaired and required extensive assistance with one staff for activities of daily living and for
meals required supervision for set up only.
Review of the physicians' orders for January 2023 revealed Resident #24 was on a consistent carbohydrate
no added salt diet.
Review of Resident #24's diet ticket revealed a five-ounce chicken Caesar wrap.
Observation of tray line on 01/25/23 at 11:40 A.M. revealed Resident # 13 and Resident #24 received a half
portion (1/2) of a Caesar chicken wrap instead of the whole Caesar wrap (5 ounce) alternative which was
identified on the meal ticket. Interview with [NAME] #277, at the time of the observation, revealed she has
always served 1/2 of a wrap to residents.
Interview on 01/25/23 at 11:43 A.M. with Registered Diet Technician (DTR) #289 verified Residents #13
and #24 should have been given a full Caesar wrap.
Interview on 01/25/23 at 3:00 P.M. with DTR #289 revealed the following residents ordered full wrap
sandwiches (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119). Residents #12 and #49
were to receive 1/2 portions of the chicken Caesar wrap.
Interview on 01/26/23 at 8:24 A.M. with DTR #289 revealed the facility was having trouble printing recipes
with the program and tray line was audited as needed for accuracy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366135
If continuation sheet
Page 4 of 4
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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.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
FAQ · About this visit
Common questions about this visit
What happened during the January 26, 2023 survey of MOHUN HEALTH CARE CENTER?
This was a inspection survey of MOHUN HEALTH CARE CENTER on January 26, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOHUN HEALTH CARE CENTER on January 26, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
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.