Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Continuing Healthcare Of Gahanna during CMS and state inspections, most recent first.
A resident with encephalopathy, DM, CVA, and HTN had a urinary catheter bag observed hanging uncovered on the bed and facing the door, with yellow urine visible in the drainage bag. The bag was in view of staff, residents, and visitors in the hallway, and an RN verified it was not dignified for the resident to have the catheter uncovered and visible to others.
Failure to maintain privacy during wound care. An RN left the blinds open to a window facing the parking lot while completing a sacral dressing change for a resident with intact cognition and significant ADL dependence. The resident’s partially naked body was visible from outside, and the resident stated she wanted the blinds closed during treatment. Facility policy required a closed door, a drawn curtain, or both during personal care and treatment procedures.
Failure to Prevent Staff-to-Resident Verbal Abuse: A resident with intact cognition and multiple medical diagnoses was involved in an escalating interaction with the Administrator over the smoking policy while recording on his phone. The Administrator made an inappropriate hand gesture toward the resident, and the resident reported the Administrator also placed hands on his shoulders and took the phone. Police reviewed the video and saw the gesture but no assault, and the SSD stated he believed the incident was verbal abuse.
Incomplete wound tracking and missing pressure relief measures were identified for two residents with pressure ulcers or high pressure ulcer risk. One resident with a coccyx pressure injury had a missing week of comprehensive wound measurements, while another resident with diabetes, dementia, and chronic foot wounds was observed with heels and feet resting on the mattress instead of being elevated, despite care plans calling for pressure reduction, turning/repositioning, and weekly skin checks.
A resident with aphasia, HTN, hemiplegia/hemiparesis, and idiopathic peripheral neuropathy had two calloused areas on the bottom of the right foot noted on admission, but the record showed no follow-up skin assessments, no wound measurements, no physician notification, and no treatment started. During observation, the resident indicated pain in the foot, and the RN stated she had been waiting for the MD to see the resident; however, no padding was in place and the areas were not being protected.
Failure to Provide Ordered Catheter Care: A resident with an indwelling urinary catheter had no physician orders for the catheter or for catheter care, and the record showed no evidence that catheter care was provided. During observation, the catheter was draining yellow urine, and the DON verified the lack of orders and documented care.
Failure to Manage Diabetes During Resident LOA A resident with DM, cognitive impairment, and a guardian left the facility on an LOA after receiving basal insulin and eating only part of breakfast. The resident had no documented diabetes education for time away, did not sign out, did not take meds or a glucometer, and later went to the ED by EMS with severe hypoglycemia after not eating. Hospital records showed highly labile BS requiring IV dextrose, an insulin drip, and transfer for endocrine management.
The facility failed to complete annual performance evaluations for three CNAs and failed to document at least 12 hours of annual in-service education. File review showed no evaluations or in-service records for the CNAs reviewed, and the DON confirmed the missing documentation.
Missing Monthly Medication Regimen Reviews: The facility failed to ensure a licensed pharmacist completed monthly MRRs, including chart review, for four residents. The DON confirmed missing pharmacy reviews for multiple months. Affected residents had diagnoses including bipolar disorder, depression, epilepsy, heart failure, dementia, atrial fibrillation, and cognitive impairment, and were receiving multiple medications such as antipsychotics, antidepressants, anticoagulants, anticonvulsants, insulin, and antianxiety meds with documented indications.
A resident with HTN, HF, and chronic AFib received metoprolol tartrate despite repeated SBP readings below the ordered hold parameter of 110. MAR review showed the med was given on multiple occasions when BP was outside the physician’s parameters, and an LVN confirmed it should have been held and the MD notified. Facility policy required staff to confirm the physician order before administering meds.
A resident’s preference for no male caregivers was not honored. The resident, who had no cognitive impairment and a history of physical abuse and trust issues, had a sign in her room stating the preference, but the facility continued assigning a male LPN to her care. The DON confirmed awareness of the preference, and the resident stated the facility knew about it but still assigned the male LPN.
A resident who was obese was observed to be too large for the standard bed she occupied. The resident said she had asked for a larger bed, but the room was not large enough. The DON stated every bed could be bariatric, but the resident did not want her room moved around, so the larger bed was not accommodated. The facility policy stated it protects resident rights and provides a clean, safe, comfortable, and home-like environment.
A resident with HIV, dysphagia, seizures, and cognitive impairment had multiple seizure or seizure-like episodes documented in the chart, including brief convulsive activity and shaking/stiffness. The physician was notified for at least one episode, but there was no documented evidence that the resident's POA or family representative was informed of the change in condition, and the DON confirmed the representative was not notified.
Failure to Report Allegation of Abuse: A resident with no cognitive impairment alleged that an LPN grabbed her leg and applied cream against her will after she said she preferred female caregivers. The case manager said the former social worker was notified, but the allegation was not entered in the facility’s SRI system, the DON was not informed, and the allegation was not reported to the state agency; the LPN continued to provide care to the resident.
Failure to investigate an allegation of abuse involving a resident who had no cognitive impairment. The resident reported that an LPN grabbed and jerked her leg while applying cream against her wishes after she said she preferred female caregivers. The case manager said the former social worker was notified, but the incident was not found in the facility’s SRI records, the DON was not informed, and the accused LPN continued to provide care to the resident. The facility policy stated that abuse allegations are to be investigated once the Administrator and ODH are notified.
Failure to identify and address trauma triggers for a resident with a history of abuse and adjustment disorder. The resident reported past physical and sexual abuse, trust issues, and difficulty being in the facility, and also preferred no male caregivers. Although the chart later noted trauma-informed care triggers, the LSW confirmed there was no trauma assessment, trigger identification, or care plan reflecting the resident’s past trauma.
Failure to Provide Recommended Behavioral Health Services: A resident with a psych hx of abuse, trust issues, and adjustment disorder with mixed anxiety and depressed mood was assessed as having emotional and behavioral symptoms related to an identifiable stressor. The psych plan included psychotropic meds and TBS, but the record showed no evidence that TBS was arranged or provided, and the DON verified the resident did not receive the recommended services.
An LPN did not administer medications as ordered for a resident with HTN, DM, HLD, GERD, and right shoulder pain. The resident was ordered Losartan Potassium 50 mg, 2 tablets daily, but only 1 tablet was given during observed med pass. The LPN also left the room without ensuring the resident ingested the medications. Facility policy required medications to be given safely and to follow the five rights.
Medications were left at a resident's bedside during med pass when an LPN prepared multiple scheduled meds, entered the room, set the cups on the bedside table, obtained the resident's BP, and left without confirming the meds were taken. On a later observation, another LPN similarly set prepared meds down in the room and exited without ensuring ingestion; she later returned and acknowledged she had not observed the resident take the medications.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a deficiency for not following the established care plan.
Several residents with a history of falls were not timely assessed or provided with comprehensive care plans, and the facility failed to complete thorough fall investigations or implement appropriate interventions after multiple fall events. As a result, two residents suffered repeated falls with serious injuries, including head trauma, fractures, and acute blood loss anemia, while another resident's fall was not properly investigated or addressed. Staff interviews and record reviews confirmed that required post-fall procedures and care plan updates were not consistently followed.
A resident with multiple medical conditions reported to hospital staff that facility staff forced them out of a chair, resulting in serious injuries including fractures and artery damage. The allegation of staff-to-resident physical abuse was not reported to the State Survey Agency as required, and facility leadership confirmed they were unaware of the incident until after hospital records were uploaded.
A resident with multiple medical conditions and minimal cognitive impairment was hospitalized after a fall resulting in serious injuries. While hospitalized, the resident alleged that facility staff forced them out of a chair, causing the fall. Although this allegation was documented in hospital records and uploaded to the facility's electronic medical record, the facility did not investigate the claim, and leadership was unaware of the allegation, contrary to facility policy requiring investigation of all suspected abuse.
The facility did not accurately document falls in the MDS assessments for two residents, one of whom experienced multiple falls with injuries and another who had an unwitnessed fall. Despite clear evidence in medical records and staff confirmation, the MDS assessments failed to reflect these incidents, resulting in inaccurate reporting of falls and injuries.
A resident with a history of falls and multiple risk factors experienced two falls during their stay. Despite identification of new root causes and recommended interventions, such as visual reminders to lock a walker and increased observation after a UTI, the care plan was not updated to reflect these changes before the resident was discharged. The care plan was only revised after discharge, in violation of facility policy.
The facility failed to provide timely and complete bed-hold notifications to several residents, affecting their awareness of remaining bed-hold days. This deficiency was confirmed through interviews and record reviews, highlighting a lack of communication and documentation for residents who were cognitively intact and had various medical conditions.
The facility failed to develop comprehensive care plans for several residents, omitting critical interventions for conditions such as contractures, oxygen use, and PTSD. Residents with severe cognitive impairments and complex medical needs were affected, as their care plans did not accurately reflect their requirements, leading to deficiencies in their care.
The facility failed to address pharmacy recommendations for four residents, leading to deficiencies in medication management. A resident's Ondansetron was not discontinued despite the physician's agreement, and another resident's Lorazepam order remained active beyond the recommended period. Two residents' records lacked documentation of pharmacy recommendations, and medications like Benzonate, Guaifenesin, and Zofran were not discontinued as advised. The DON confirmed these discrepancies.
The facility failed to reheat food items that did not meet the required hot holding temperature, potentially affecting 79 residents. A staff member noted that the ground chicken and gravy were below the required temperature but proceeded with meal service without reheating. The Dietary Manager confirmed the expectation for food temperatures, and the facility's policy required reheating to 165 degrees Fahrenheit if not within appropriate parameters.
The facility's 'Voluntary Arbitration Agreement' failed to include provisions for residents or their responsible parties to communicate with federal, state, or local officials. This deficiency was identified through interviews and document reviews, affecting 23 residents admitted since a new company took over. The administrator confirmed the absence of such provisions in the agreement.
The facility's 'Voluntary Arbitration Agreement' failed to specify a convenient venue and neutral arbitrator, potentially affecting 23 residents admitted since a company takeover. The agreement defaulted to the American Arbitrators Association (AAA) without ensuring neutrality, and the Administrator could not provide evidence of compliance.
The facility failed to manage risks for residents, including inadequate elopement risk assessment for a resident with dementia, lack of smoking assessment for a cognitively impaired resident, absence of a fall mat for a resident with a fall risk order, and improper storage of smoking materials for another resident. These deficiencies were confirmed through staff interviews and observations.
A resident's dignity was compromised when his catheter bag was left uncovered in the common area, as observed by surveyors. The Director of Nursing confirmed the issue, and the Administrator acknowledged it as a dignity concern. The resident had multiple medical conditions, including an indwelling catheter.
A facility failed to document the hospital transfer of a resident with multiple health issues, including heart failure and diabetes. The resident was sent to the hospital due to low oxygen saturation, but the medical record lacked documentation of this transfer. The DON confirmed the absence of necessary records.
A facility failed to complete a Significant Change MDS assessment for a resident after starting hospice services. The resident, with multiple diagnoses including cognitive impairment, was admitted to hospice care, but the required assessment was not conducted within 14 days. The DON confirmed this oversight.
The facility failed to ensure accurate MDS 3.0 assessments for two residents, leading to discrepancies in their medical records. One resident was inaccurately documented as being in a PVS despite being able to answer questions, while another was documented as not being in a PVS despite being in one. These inaccuracies were confirmed by the DON.
A facility failed to implement PASRR Level II recommendations for a resident with multiple diagnoses, including traumatic brain injury and PTSD. The resident was approved for a six-month stay with specific required services, but the facility did not have a care plan addressing these services, nor was there evidence of adherence to the recommendations or discharge time frame.
A facility failed to maintain accurate PASRR documentation for a resident with multiple diagnoses, including cerebral palsy and mood disorder. The PASRR form only listed a mood disorder, omitting schizoaffective and anxiety disorders, which were later documented. The DON confirmed the incorrect coding, highlighting a lapse in documentation accuracy.
A facility failed to implement an accurate baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including a colostomy and PEG tube. The care plan only noted the PEG tube, omitting the colostomy, which was confirmed by a Unit Manager.
The facility failed to conduct quarterly care plan reviews and updates for residents, affecting their comprehensive care. Two residents did not have care conferences every three months as required, and another resident's smoking care plan was not updated to reflect their current needs. The facility's policy mandates quarterly reviews and updates, which were not followed.
A resident with a history of multiple medical conditions sustained a non-pressure related skin impairment to the right lower leg. The facility failed to implement a comprehensive wound management program, resulting in inadequate documentation and follow-up on the resident's condition. Despite hospital discharge orders for wound care, the facility did not complete the treatments as ordered, leading to the resident's condition worsening and requiring hospital admission for intravenous antibiotics and wound debridement.
The facility failed to ensure proper documentation and implementation of splint use for two residents with contractures. One resident was observed without necessary splints, and their medical records lacked orders and care plan interventions. Another resident had a contracted hand with no documented interventions, despite recommendations for a palm protector. Staff confirmed the oversight in medical records.
A resident with multiple health conditions, including diabetes and heart failure, was found to have an indwelling catheter without any physician orders or documentation for catheter care. This was confirmed by the DON, highlighting a deficiency in the facility's management of catheter care.
A facility failed to enforce and document a fluid restriction for a dialysis resident, who was observed with a large water bottle despite a 1500 ml daily limit. Staff were aware of the noncompliance, but it was not recorded in the medical record. The dietary department was unaware of the restriction, and the plan of care did not address it.
A facility failed to administer a resident's tube feeding at the ordered rate, affecting their nutritional intake. The resident, with a complex medical history, required tube feeding via a gastrostomy tube. Observations showed the feeding was below the ordered rate on two consecutive days. A nurse confirmed the discrepancy and was unaware of the current order, highlighting a lapse in following physician instructions.
A resident with chronic respiratory failure was ordered oxygen at two liters continuously, but observations showed it was administered at four liters. The DON confirmed the discrepancy between the physician's order and the actual administration.
A facility failed to assess and plan for a resident's PTSD triggers, who was diagnosed with PTSD following an assault at a previous nursing home. The resident's medical record lacked identification of PTSD triggers or a care plan, which was confirmed by the DON.
A facility failed to provide a dementia care plan for a resident with severe cognitive impairment and multiple diagnoses, including dementia and traumatic brain injury. The resident was observed in the common area without a tailored care plan, which was confirmed by the DON.
Two residents in the facility did not receive medications as ordered, leading to deficiencies in pharmaceutical services. One resident frequently left the facility without taking prescribed medications, missing several doses of critical medications. Another resident, with severe cognitive impairment, did not receive prescribed Buspirone due to an error in the electronic medication administration record. The facility failed to ensure proper medication administration for both residents, impacting their health and well-being.
The facility failed to ensure proper parameters and documentation for as-needed pain medication for two residents. One resident received Oxycodone despite a pain rating of zero, with no non-pharmacological interventions attempted. Another resident's pain medications were administered without parameters, and documentation of pain details was lacking. The DON confirmed these deficiencies.
Uncovered urinary catheter bag visible in hallway
Penalty
Summary
The facility failed to maintain a resident's dignity in regard to a urinary catheter. Resident #92 was admitted with diagnoses including encephalopathy, diabetes, cerebral infarction, and high blood pressure. During observations on 05/20/26, the resident's urinary catheter bag was seen hanging on the bed uncovered and facing the door, with yellow urine visible in the drainage bag. The catheter bag was in view of staff, residents, and visitors in the hallway. RN #101 verified during interview that it was not dignified for the resident to have the urinary catheter uncovered and in view of others. The facility's Catheter Care policy dated 02/2024 stated that urinary catheter bags were to be stored in a privacy bag to maintain dignity.
Failure to Maintain Privacy During Wound Care
Penalty
Summary
The facility failed to provide resident privacy during treatment of a pressure wound for Resident #16, who was admitted with diagnoses including cirrhosis of the liver, depression, HTN, anxiety, urinary retention, adult failure to thrive, and alcohol dependence. Her admission MDS indicated intact cognition, and she required assistance with multiple ADLs, including being dependent on staff for toileting, showering/bathing, dressing the lower body, turning and repositioning, and partial/moderate assistance with personal hygiene. During an observed dressing change to her sacrum, RN #101 left the blinds open to the window facing the parking lot while completing the treatment, leaving the resident's partially naked body visible to anyone in the parking lot. The RN later confirmed she had left the blinds open, and the resident stated she wanted the blinds closed during treatment and would be very upset if someone had seen her exposed from the window. The facility policy stated staff were to use a closed door, a drawn curtain, or both to shield the resident during personal care and treatment procedures.
Failure to Prevent Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident verbal abuse involving Resident #89. Resident #89 was admitted with diagnoses including osteomyelitis of the right ankle and foot, foot ulcers, diabetes, right BKA, absence of the left leg, and kidney disorder. His MDS assessment indicated intact cognition, and he required varying levels of assistance with ADLs. During a conversation about the smoking policy, the Administrator and Resident #89 became involved in an escalating interaction while the resident was recording on his phone. The Administrator told the resident he did not have permission to record him, and the resident continued to record and move toward the Administrator. The Self-Reported Incident documented that the Administrator raised his middle finger toward Resident #89, and a staff member intervened to de-escalate the situation. The resident requested police notification, and police later reported that the only thing visible on video was the Administrator making the inappropriate gesture; no physical contact was seen on the video reviewed by police. The resident stated the Administrator placed hands on his shoulders and took the phone from his hands, while the police report noted no charges were issued because the video did not show an assault and witness statements did not observe one. The facility social services director stated he believed the incident was verbal abuse and said he had seen the video showing the Administrator flip the resident off and try to take his phone.
Incomplete Wound Tracking and Missing Pressure Relief Measures
Penalty
Summary
The facility failed to ensure comprehensive weekly assessments for residents with pressure ulcers and failed to ensure pressure relief interventions were in place for two residents. One resident was admitted with multiple diagnoses including cirrhosis of the liver, depression, HTN, anxiety, urinary retention, adult failure to thrive, and alcohol dependence, and was identified as high risk for pressure ulcer development. Her plan of care addressed existing pressure injuries to the coccyx and included low air loss mattress use, turning and repositioning, wound monitoring, and ordered treatments. Review of wound measurements showed ongoing documentation of the coccyx wound, but comprehensive wound measurements were missing for the week of 04/28/26. An RN later verified the lack of comprehensive wound measurements for this resident. A second resident was admitted with diagnoses including chronic osteomyelitis of the left foot and ankle, diabetes, atrial fibrillation, HTN, dementia, cellulitis of the left foot, non-pressure chronic ulcer of the left foot, CHF, and lymphedema, and was identified as high risk for pressure ulcer development. Her plan of care included weekly skin checks, turning and repositioning, and use of a pressure reducing device for bed and wheelchair. Observations showed her heels and feet were not elevated off the mattress on multiple occasions, and an RN verified that her heels were on the mattress and should have been elevated off the mattress to promote healing and prevent future development of pressure ulcers. The facility policy stated that wound evaluation and treatments are documented in point click care and on the appropriate form, and that tracking of all wounds will be completed weekly on the wound tracking sheet.
Failure to Monitor and Treat Foot Skin Breakdown
Penalty
Summary
The facility failed to ensure a resident with impaired skin integrity received necessary care and treatment to promote healing of wounds on the bottom of the right foot. Resident #7 was admitted with diagnoses including aphasia, high blood pressure, hemiplegia and hemiparesis, and idiopathic peripheral neuropathy. The admission skin assessment noted two hard calloused areas on the bottom of the right foot, but there was no additional information such as size or color, and there was no evidence the physician was aware of the areas. The physician order required weekly skin evaluations and documentation under skin observations, with physician notification of new skin conditions every Tuesday for skin assessment. The medical record showed no additional skin assessments of the calloused areas and no evidence of any skin treatments being provided. During observation, the resident pointed to the right foot and implied pain; two white calloused areas approximately 1.5 cm in diameter were seen on the bottom of the foot, closed with no drainage. The RN stated the resident had come in with the areas and that she had been padding them to protect them while waiting for the doctor to see the resident, but at the time of observation there was no padding in place and nothing protecting the areas. Later interview with the RN confirmed no treatment had been started, the physician had not been notified, and no weekly measurements had been completed since admission. The facility policy required weekly tracking of all wounds on the Wound Tracking Worksheet.
Failure to Provide Ordered Catheter Care
Penalty
Summary
Resident #92, who was admitted with diagnoses including encephalopathy, diabetes, cerebral infarction, and high blood pressure, had an indwelling urinary catheter. Review of the medical record found no physician orders for the catheter and no orders for catheter care, and there was no evidence that any catheter care had been provided. During observation, the resident's urinary catheter was seen draining yellow urine. The DON later verified that there were no physician orders for the indwelling urinary catheter and no evidence that catheter care had been provided for the resident.
Failure to Manage Diabetes During Resident LOA
Penalty
Summary
The facility failed to ensure a resident’s diabetes was managed during a leave of absence (LOA). Resident #14 had diagnoses including diabetes mellitus, cognitive impairment, developmental delay, chronic kidney disease, and a guardian for healthcare decisions. The resident’s care plan addressed diabetes monitoring and symptoms of hyperglycemia and hypoglycemia, but it did not include interventions related to LOAs. The resident had insulin orders for basal insulin and sliding-scale lispro, and the record showed unstable blood glucose readings in the days before the event. On the morning the resident left the facility on an LOA, the resident’s blood glucose was 108 and 15 units of insulin glargine were administered. The resident ate 75 percent of breakfast, then left the facility at 7:43 A.M. There was no evidence the resident was educated on diabetes management while out of the facility, no evidence the resident ate lunch or dinner while away, and the resident did not sign out on the LOA form. Later that day, the resident was documented as having left in the morning and not returned, and it was discovered the resident had been taken to the local hospital due to hypoglycemia. Hospital records showed the resident presented to the ED by EMS for low blood sugar after taking Lantus that morning and not eating breakfast. Blood glucose was 38 on arrival, and the resident later became hyperglycemic after treatment. The resident was transferred to another hospital for management by endocrinology and was admitted for symptomatic, refractory hypoglycemia and metabolic acidosis. Hospital documentation described extremely labile blood sugars, including glucose values that dropped to 23 and required IV dextrose, dextrose-containing IV fluids, an insulin drip, and transition back to subcutaneous insulin. Facility interviews also showed staff knew the resident left without signing out, did not have a personal glucometer, and did not take medications with her when leaving the building.
Missing CNA Evaluations and In-Service Education
Penalty
Summary
The facility failed to complete annual performance evaluations for CNAs #242, #324, and #325 and failed to document a minimum of 12 hours of in-service education for the previous year. Review of employee files showed no annual evaluations completed in the last 12 months and no documentation of in-service education for these three CNAs, who were all employed for more than one year. The facility census was 91. During an interview, the DON confirmed there was no record of CNA education for the last year and no record of performance evaluations in the past 12 months for the CNAs whose files were reviewed.
Missing Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews, including review of the medical chart, in accordance with its policies and procedures. Review of medication regimen review records and interviews with the DON showed missing pharmacy reviews for multiple months for four residents reviewed for unnecessary medication: Resident #93, Resident #99, Resident #3, and Resident #02. The facility policy titled Medication Administration and Management stated that nursing and pharmacy services would assess, monitor, and evaluate the effectiveness of the medication regimen. Resident #93 was admitted with diagnoses including bipolar disorder, heart failure, and major depressive disorder, and had an MDS BIMS score of 12 indicating cognitive impairment; no MRRs were found for April, May, July, and August 2025. Resident #99 was admitted with diagnoses including epilepsy, major depressive disorder, and systolic heart failure, had a BIMS score of 15, and had no MRRs for May, June, July, and August 2025. Resident #3 was admitted with diagnoses including fracture of the left femur, cardiac arrest, atrial fibrillation, cognitive communication deficit, anxiety disorder, heart failure, and major depressive disorder, had a BIMS score of 3, received insulin for 5 days during the look-back period, and received antipsychotic, antidepressant, anticoagulant, antibiotic, antiplatelet, and anticonvulsant medications with documented indications; no pharmacy reviews were available for April through July 2025. Resident #02 was admitted with diagnoses including anxiety, bipolar disorder, dementia, and depression, had a BIMS score of 15, received antipsychotic, antidepressant, and antianxiety medications with indications, and had no resident reviews for April through July 2025.
Failure to Follow BP Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders for Resident #93’s metoprolol tartrate, a blood pressure medication ordered at 50 mg twice daily with parameters to hold for systolic blood pressure under 110 or heart rate under 60. Resident #93 was admitted on 03/01/24 with diagnoses including hypertension, heart failure, and chronic atrial fibrillation, and had an MDS 3.0 dated 03/02/26 showing a BIMS score of 12, indicating moderate cognitive impairment. Review of the MAR showed the medication was administered on multiple dates in January, February, and March 2026 when the resident’s systolic blood pressure readings were below the ordered hold parameter of 110, including readings such as 102/60, 106/58, 103/61, 109/65, 109/64, 104/58, and 107/62. During interview, LVN #319 stated that when a medication has parameters, it should be held if vital signs are outside the ordered parameters and the physician should be notified, and confirmed the metoprolol tartrate should have been held on the days the systolic blood pressure was below 110. The facility policy stated staff administering medications are to identify and confirm the physician order prior to administering a medication.
Failure to Honor Resident Preference for No Male Caregivers
Penalty
Summary
The facility failed to honor one resident’s preference of no male caregivers. Resident #17 was admitted on 10/08/24 with diagnoses including other specific arthropathies of the right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in the right shoulder, and gastro-esophageal reflux disease. The resident’s medical record did not include a plan of care addressing the preference for no male caregivers. A psychiatric note dated 01/28/25 documented that the resident had been physically abused by her ex-husband and had trust issues, and the quarterly MDS assessment indicated no cognitive impairment. During observation on 08/19/25, a sign behind the resident’s bed indicated she preferred no male caregivers. On 08/20/25, the resident stated she preferred no male caregivers due to past physical and sexual abuse and said the facility was aware of this preference but continued to assign male LPN #116 to her room assignment. The LPN stated his usual assignment included the resident’s care and that he was aware of her preference. The DON confirmed awareness of the preference and stated she was unaware the sign specified aides and nurses. The facility policy titled Resident Rights stated the facility protects and promotes residents’ rights and provides care that fosters dignity and individuality in a respectful environment.
Resident Not Provided Bariatric-Sized Bed
Penalty
Summary
The facility failed to ensure one resident's bed was bariatric in size. Resident #17 was admitted on 10/08/24 with diagnoses including other specific arthropathies of the right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in the right shoulder, and gastro-esophageal reflux disease. The quarterly MDS assessment dated [DATE] indicated the resident had no cognitive impairment. On 08/19/25 at 9:00 A.M., observation showed the resident was obese and too large for the standard bed she occupied. During interview at that time, the resident stated she had asked for a larger bed, but the room was not large enough. On 08/20/25 at 1:05 P.M., the DON stated every bed is capable of being a bariatric bed, but the resident did not want her room moved around, so the larger bed could not be accommodated. Review of the facility policy titled Resident Rights, dated 04/24, stated the facility protects and promotes the rights of each resident and will provide a clean, safe, comfortable, and home-like environment.
Failure to Notify POA of Seizure-Related Change in Condition
Penalty
Summary
The facility failed to notify the resident's POA of changes in condition involving seizure activity for one resident reviewed for notification. The resident had a history that included HIV, psoriasis, protein calorie malnutrition, dysphagia, seizures, GERD, asthma, major depressive disorder, and anxiety disorder. The care plan identified seizure disorder and included seizure precautions, monitoring, documentation of seizure characteristics, and reporting results to the physician. The resident's quarterly MDS indicated a moderate cognitive deficit, rejected care, and a current seizure disorder treated with anticonvulsant medications. The medical record documented seizure activity on multiple occasions, including a 35-second seizure, a two-minute seizure, and seizure-like activity with shaking and stiffness lasting one minute and 30 seconds. The physician was notified for at least one event, and no new orders were received. The record showed no documented evidence that the resident's representative or POA was notified of the seizure activity. The POA document identified the resident's parents as the resident's POA, and the DON verified that the resident's representative was not notified of the seizure activity.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the required state agency involving Resident #17, who was admitted on 10/08/24 and had diagnoses including other specific arthropathies of the right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in the right shoulder, and gastro-esophageal reflux disease. The resident’s quarterly MDS assessment indicated no cognitive impairment. On 08/20/25, the resident stated that LPN #116 abused her when he entered her room to apply cream to her legs, despite her telling him she did not like men touching her and preferred female caregivers. She reported that he grabbed her leg, jerked it out, and applied the cream against her will, and she said the incident was reported but nothing was done. An interview with the resident’s case manager confirmed the resident had reported the incident and that the former social worker was notified immediately and said she would take care of it. The case manager also stated that LPN #116 continued to provide care to the resident despite the allegation and her preference for female caregivers. Review of the facility’s self-reported incidents showed no report of the allegation of abuse. The DON verified the incident was not reported to her, confirmed LPN #116 continued to provide care to the resident, and verified the allegation of abuse was not reported to the required state agency. The facility policy required all allegations of abuse to be reported immediately to the Administrator or designee and, if abuse is alleged, to notify the Ohio Department of Health immediately but no later than two hours after the allegation is made.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #17, who was admitted on 10/08/24 with diagnoses including other specific arthropathies of the right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in the right shoulder, and gastro-esophageal reflux disease. The resident’s quarterly MDS assessment indicated no cognitive impairment. During an interview, the resident stated that LPN #116 entered her room to apply cream to her legs, despite her telling him she did not like men touching her and preferred female caregivers, and that he grabbed her leg, jerked it out, and applied the cream against her will. She stated the incident was reported but nothing was done, and that the LPN continued to provide care to her. The resident’s case manager stated the resident reported the incident to him, that the former social worker was notified immediately and said she would take care of it, and that the accused LPN continued to provide care to the resident despite the allegation and her preference for female caregivers. Review of the facility’s self-reported incidents showed no reported incident for the allegation of abuse. The DON stated the incident was not reported to her, confirmed the LPN continued to provide care to the resident, and verified the allegation of abuse was not investigated as required. The facility policy stated that once the Administrator and ODH are notified, an investigation of the allegation will be conducted.
Failure to Identify and Address Trauma Triggers
Penalty
Summary
The facility failed to identify, assess, and implement care and services to prevent triggers of past trauma for one resident reviewed for preferences. The resident was admitted with diagnoses including right shoulder arthropathy, hypertension, hyperlipidemia, diabetes mellitus, right shoulder pain, and GERD. The initial social service assessment documented no trauma-informed care triggers, but a later psychiatric note stated the resident had been physically abused by her ex-husband, had trust issues, and reported trauma related to medical conditions including a brain aneurysm. The note also described adjustment disorder with mixed anxiety and depressed mood, and the resident reported that being in the facility was hard on her. The quarterly social service assessment later documented trauma-informed care triggers, and the quarterly MDS showed no cognitive impairment and no current depression, anxiety, or PTSD diagnosis. During interview, the resident stated she had a history of sexual abuse and preferred no male caregivers; observation confirmed a sign on the wall behind her bed indicating that preference. The LSW verified there was no trauma assessment reflecting the resident’s past trauma, identification of triggers, or plan of care for the trauma. The case manager stated he was aware of the resident’s childhood sexual abuse and that she had discussed her preference for no male caregivers with the former social worker.
Failure to Provide Recommended Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to help a resident attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident was admitted with diagnoses including right shoulder arthropathy, hypertension, hyperlipidemia, diabetes mellitus, right shoulder pain, and GERD. A psychiatric note documented that the resident had been physically abused by her ex-husband, had trust issues, and reported trauma related to medical conditions including a brain aneurysm. The assessment stated the resident was experiencing emotional and behavioral symptoms in response to an identifiable stressor within three months of the onset of the stressor, and that being in the facility was hard on her. The resident was diagnosed with adjustment disorder with mixed anxiety and depressed mood. The psychiatric plan was to continue psychotropic medications and engage the resident in therapeutic behavioral services (TBS) to address symptoms related to the adjustment disorder. Review of the quarterly MDS showed no cognitive impairment. However, the medical record contained no documented evidence that TBS was arranged or provided. During interview, the DON verified that the resident had not received the TBS services recommended by the Psychiatric Nurse Practitioner.
Medication Administration Error for Antihypertensive Order
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when medications were not administered as ordered for one resident. The resident had diagnoses including right shoulder arthropathy, hypertension, hyperlipidemia, diabetes mellitus, right shoulder pain, and gastro-esophageal reflux disease. The care plan identified hypertension and directed staff to administer antihypertensive medications as ordered, monitor for side effects and effectiveness, obtain blood pressure readings every shift and as needed, and take blood pressure under the same condition each time. The resident’s quarterly MDS indicated no cognitive impairment. The physician’s orders for August 2025 included Losartan Potassium 50 mg with instructions to administer two tablets by mouth daily for hypertension. During observation of morning medication administration, an LPN removed the resident’s prepared medications from the cart, added multiple medications including Losartan Potassium 50 mg, and entered the resident’s room to obtain blood pressure before leaving without ensuring the medications were ingested. In interview, the LPN verified that only one Losartan Potassium 50 mg tablet was administered instead of the ordered two tablets. The facility policy stated medications are to be administered in a safe and effective manner and that the five rights are to be reviewed during medication administration.
Medications Left at Bedside During Administration
Penalty
Summary
Medications were left at the bedside during medication administration for a resident admitted on 10/08/24 with diagnoses including right shoulder arthropathy, HTN, hyperlipidemia, DM, right shoulder pain, and GERD. The resident's quarterly MDS assessment indicated no cognitive impairment. On 08/19/25, an LPN prepared the resident's morning medications in a clear plastic cup labeled with the resident's name, entered the room, obtained the resident's blood pressure, set the medications down, and exited without ensuring the resident ingested them. On 08/20/25, another LPN prepared the resident's morning medications, entered the room, and placed the medications in two individual cups on the resident's bedside table before obtaining the resident's blood pressure and leaving the room without confirming ingestion. Later that morning, the LPN returned and stated she was checking to make sure the resident had taken the medications, and verified she had not observed the resident ingest them. Facility policy titled, Administration Procedures for All Medications, stated medications will be administered in a safe and effective manner and, after administration, staff are to return to the cart, replace the medication container, and document administration in the MAR or TAR.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident’s preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Timely Assess, Investigate, and Intervene After Resident Falls
Penalty
Summary
The facility failed to timely assess and develop comprehensive care plans for residents with a history of falls prior to admission, and did not complete thorough fall investigations or implement timely and appropriate interventions for residents who experienced falls. This deficiency was identified through medical record reviews, hospital records, fall investigations, staff interviews, and policy reviews. Three residents with a history of falls were affected, with two residents suffering multiple falls within short periods, resulting in serious injuries such as closed head injuries, lumbar spine fractures, hematomas, rib fractures, humerus fracture, and acute blood loss anemia requiring hospitalization and blood transfusion. One resident was admitted with a history of falls and multiple risk factors, including metabolic encephalopathy, Parkinson’s disease, muscle weakness, and cognitive deficits. Despite being assessed as high risk for falls, the resident experienced four falls in eight days, with no new interventions added to the care plan after each event. Fall investigations were incomplete, lacking witness statements, environmental checks, and care plan updates. Another resident with repeated falls and minimal cognitive impairment also experienced multiple falls, including two that resulted in hospitalizations for significant injuries. The facility did not provide fall investigations or implement new interventions after these incidents, and there was insufficient documentation regarding the circumstances of the falls and whether existing interventions were in place at the time. A third resident with a history of falls prior to admission also experienced a fall in the facility, but the care plan was not updated and no fall investigation was completed. Staff interviews confirmed that fall investigations were not consistently performed, care plans were not updated with new interventions, and incident reports were sometimes missing. The facility’s fall management policy required individualized care plans, post-fall evaluations, and documentation of fall incidents, but these procedures were not followed for the affected residents.
Removal Plan
- Resident #88 was sent to the hospital and did not return to the facility.
- Resident #99 was sent to the hospital and did not return to the facility.
- The Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON and Medical Director #910 to discuss the Immediate Jeopardy template and plan of removal.
- Regional Minimum Data Set (MDS) Coordinator #920 educated MDS Coordinator #100 regarding the facility’s fall management program which included an individualized fall prevention for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented appropriately and the physician is notified of each fall event.
- MDS Coordinator #100 reviewed the care plans of 13 residents who were currently active in the facility and had experienced a fall in the last 30 days to ensure adequate interventions are in place and care plans are up to date with interventions.
- RDCO #900 educated the Administrator and DON on completing thorough fall investigations to include completing risk management, conducting witness interviews if applicable, updating care plans with appropriate fall interventions, identifying root cause analysis, and post fall interdisciplinary notes (IDT) for all fall events.
- The clinical interdisciplinary team (IDT) will review all residents who experience a fall event during the next scheduled clinical IDT meeting which is held Monday through Friday. This meeting includes the Administrator, DON, Social Worker, and Director of Rehabilitation. The clinical IDT will complete a thorough post-fall investigation, including a root cause analysis (RCA) to determine contributing factors and intervention opportunities. The clinical IDT will ensure the individualized intervention opportunity is updated to reflect in the fall care plan with the goal of reducing the recurrence. The DON will champion the meeting and ensure compliance with documentation, investigation/RCA determination, care plan updates, and intervention implementation. Any identified concerns will result in immediate staff training and, if appropriate, progressive disciplinary action.
- The Administrator reviewed the facility’s Fall Management and Care Plan Revision policies. No changes were made. Fall trends will be brought to QAPI and reviewed monthly with Medical Director #910.
- The DON/Designee completed in-service training for all 22 licensed nursing staff focused on fall management. This included completing a fall Situation, Background, Assessment, and Recommendation (SBAR), incident report within the medical record and fall related details. Nurses are responsible for the direct care of the resident at the time of the fall.
Failure to Timely Report Alleged Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls was admitted and later discharged after sustaining injuries. Hospital documentation indicated that the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was uploaded to the resident's electronic medical record several days after the incident. A review of the facility's Self-Reported Incidents (SRI) logs showed no record of the abuse allegation being reported to the State Survey Agency during the relevant period. Interviews with the Administrator and DON confirmed they were unaware of the abuse allegation and that it had not been reported as required. The facility's policy mandates immediate reporting, or no later than two hours after an allegation is made, but this was not followed in this case.
Failure to Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls. The resident, who had minimal cognitive impairment and required assistance with activities of daily living, was sent to the hospital following a fall with injuries. While at the hospital, the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was documented in the hospital records and subsequently uploaded to the resident's electronic medical record. Despite the hospital documentation and the facility's policy requiring investigation of all suspected abuse allegations, the facility did not conduct an investigation into the resident's claim of staff-to-resident physical abuse. Interviews with the Administrator and DON confirmed that they were unaware of the abuse allegation and had not initiated an investigation. The hospital records, which contained the resident's allegation, were uploaded by an offsite staff member, and the facility leadership did not review or act upon this information.
Inaccurate MDS Fall Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents' falls, as identified through record reviews and staff interviews. For one resident with a history of muscle wasting and falls, documentation showed four separate falls within a nine-day period, resulting in injuries including abrasions, fractures, a closed head injury, hematoma, and laceration. Despite these incidents, the discharge MDS assessment only recorded one fall with no injury and omitted the falls with both minor and major injuries. The Administrator and DON confirmed that the MDS assessment did not accurately capture the resident's fall history and related injuries. Another resident, admitted with vascular dementia, experienced an unwitnessed fall in her room shortly after admission. Both the admission and discharge MDS assessments for this resident were coded as having no falls since admission, despite documentation of the incident. The DON confirmed the inaccuracy of the MDS assessment for this resident. This deficiency was identified during a complaint investigation and was noted as a continued non-compliance from a previous survey.
Failure to Timely Update Fall Prevention Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that new interventions to prevent falls were added to the care plan in a timely manner for a resident with a history of falls and multiple risk factors, including difficulty walking, Parkinson’s disease, cognitive deficits, and amnesia. The comprehensive care plan, developed after admission, identified the resident as being at risk for falls and included general interventions such as providing prompt assistance, ensuring adequate lighting, and keeping the call light within reach. However, these interventions were not updated or revised from the baseline care plan, despite subsequent falls and identified root causes. The resident experienced two documented falls during their stay. After the first fall, the root cause was determined to be the resident forgetting to lock their wheeled walker, and a visual reminder was recommended as a new intervention. After the second fall, which was associated with an unsteady gait and a urinary tract infection, close observation and neuro-checks were recommended. Despite these findings and recommendations, the care plan was not updated to include the new interventions before the resident was discharged. Staff interviews and record reviews confirmed that the care plan was only updated after the resident had already left the facility, contrary to the facility’s own fall management policy.
Failure to Provide Timely Bed-Hold Notifications
Penalty
Summary
The facility failed to provide timely and complete bed-hold notifications to residents or their representatives, affecting four out of six residents reviewed for bed-hold notices. Resident #16, who was cognitively intact, left the facility multiple times on leave of absence but was not informed of the remaining bed-hold days until after several absences. Similarly, Resident #18, also cognitively intact, was sent to the hospital and returned without being informed of the remaining bed-hold days, and the notice was only provided upon their return. Resident #45, who was cognitively intact, did not receive a bed-hold notice, and there was no evidence of notification regarding the remaining bed-hold days. Resident #11, with a history of cerebral palsy and other conditions, was discharged to the hospital and returned without being informed of the remaining bed-hold days. The facility's failure to provide the number of remaining bed-hold days and timely notifications was verified through interviews with the Social Work Director, who confirmed the deficiencies in communication and documentation for these residents.
Inadequate Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were accurate and comprehensive for several residents, leading to deficiencies in addressing their specific needs. For instance, Resident #68's care plan did not include her smoking status or the use of a palm protector for contracture management, despite her severe cognitive impairment and multiple diagnoses, including cerebral infarction and end-stage renal disease. Similarly, Resident #69's care plan failed to address the use of splints for contractures, even though occupational therapy had recommended splinting for both elbows and hands. Resident #82's care plan inaccurately included interventions for psychotic disorder and depression, conditions the resident did not have, despite his severe cognitive impairment and multiple diagnoses such as metabolic encephalopathy and chronic respiratory failure. Additionally, Resident #192's care plan incorrectly stated that he was independent in meeting his activity needs, which was not the case due to his severe cognitive impairment. The Activities Director confirmed that the care plan did not reflect the resident's actual needs. Other residents also experienced deficiencies in their care plans. Resident #74's care plan lacked identification of PTSD triggers and did not include a behavior management safety plan as required by the Level II PASSR outcome. Resident #30's care plan did not address oxygen use for chronic respiratory failure, and Resident #36's care plan failed to include interventions for visual impairment, despite the resident's need for corrective lenses. These omissions highlight the facility's failure to develop and implement comprehensive care plans tailored to the residents' specific medical and cognitive conditions.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for four residents, leading to deficiencies in medication management. Resident #11 had a recommendation to discontinue Ondansetron, an anti-nausea medication, which was not acted upon despite the physician's agreement. The medication was not used for several months, yet it remained active in the resident's orders. The Director of Nursing (DON) confirmed that the recommendation was not implemented. Resident #74 had a recommendation to discontinue Lorazepam, an anti-anxiety medication, or to limit its use to 14 days, which was not followed. The medication order remained active beyond the recommended period, and the DON verified that the recommendation was not addressed. Resident #66's records lacked documentation of pharmacy recommendations for two months, and a recommendation for a dose reduction of Zoloft was declined by the physician without a documented reason or date. Resident #30's records showed multiple instances where pharmacy recommendations were not implemented. Medications such as Benzonate, Guaifenesin, and Zofran were not discontinued as recommended, despite physician agreement. Additionally, there was a lack of documentation supporting the diagnosis for the use of Invega, an antipsychotic medication. The DON confirmed these discrepancies, indicating a failure to act on pharmacy recommendations and maintain accurate medication records.
Failure to Reheat Food to Safe Temperatures
Penalty
Summary
The facility failed to ensure that foods not meeting the required hot holding temperature were reheated, potentially affecting 79 of 79 residents who consumed food from the kitchen. During an observation of the lunch meal, a staff member took the temperature of food on the hot holding unit and found the ground chicken for residents on a mechanical soft diet was at 122 degrees Fahrenheit, and the gravy was at 102 degrees Fahrenheit. Despite noting that these items needed to be reheated, the staff member proceeded with the tray line without reheating the food items. The Dietary Manager confirmed that foods on the steam table should be at 160 degrees Fahrenheit and should be reheated if they do not reach that temperature. The facility's policy 'Safe Food Temperatures' stated that hot foods should be held at 140 degrees Fahrenheit or higher during meal service, and if not within appropriate parameters, should be reheated to 165 degrees Fahrenheit.
Arbitration Agreement Lacks Communication Provisions
Penalty
Summary
The facility failed to ensure that their 'Voluntary Arbitration Agreement' included provisions allowing residents or their responsible parties to communicate with federal, state, or local officials. This deficiency was identified through interviews and document reviews, revealing that the arbitration agreement did not address this right. The issue potentially affected 23 residents who had been admitted since the new company took over in August 2024, as all these residents had signed the arbitration agreement. The facility's administrator confirmed the absence of such provisions in the agreement during interviews conducted on March 10, 2025.
Arbitration Agreement Lacks Venue and Neutrality
Penalty
Summary
The facility failed to ensure that its 'Voluntary Arbitration Agreement' provided for a convenient venue and a neutral arbitrator, which could potentially affect 23 residents admitted since August 2024. The agreement did not specify a venue for arbitration and did not guarantee a neutral arbitrator, as it stated that arbitration would be administered by the American Arbitrators Association (AAA). If the AAA did not enforce pre-dispute arbitration agreements, the facility would choose another reasonably comparable arbitration association. During interviews, the Administrator was unable to provide evidence that the arbitration agreement allowed for a convenient venue or neutral arbitrator. The current company took over in August 2024, and all residents admitted since then had signed this arbitration agreement.
Deficiencies in Resident Safety and Risk Management
Penalty
Summary
The facility failed to accurately assess and manage the elopement risk for a resident with multiple diagnoses, including dementia and cognitive communication deficit. Despite the resident leaving the facility without informing staff and being brought back by police, the facility did not update the elopement risk assessment to reflect the incident. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, and the resident's responsible party expressed concern about the resident's worsening dementia and safety. Another resident with severe cognitive impairment was observed smoking independently without a completed smoking assessment or care plan in place. The facility's policy required a smoking-safety screen and care plan, which were not implemented, leaving the resident unsupervised in the smoking area. The DON confirmed the oversight, acknowledging the absence of a smoking assessment for the resident. Additionally, a resident with a physician's order for a fall mat was observed without the mat in place on multiple occasions. The resident's care plan included interventions for fall risk, but the absence of the fall mat was verified by a registered nurse. Furthermore, another resident was found with a lighter in her room, contrary to the smoking assessment that required staff to store smoking materials. The DON confirmed the resident should not have smoking supplies in her room and removed the lighter.
Resident Dignity Compromised by Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #192, by not covering his catheter bag while he was in the common area with other residents. This incident was observed on two occasions, at 12:30 P.M. and 12:48 P.M., on March 5, 2025. The Director of Nursing confirmed the catheter bag was uncovered during an interview at 12:48 P.M. The facility's Administrator acknowledged that an uncovered catheter bag is a dignity issue during an interview on March 10, 2025. Resident #192's medical record indicates he was admitted with multiple diagnoses, including metabolic encephalopathy, type two diabetes mellitus, severe protein-calorie malnutrition, cognitive communication deficit, dysphagia, aphasia, contracture of the right knee, psychosis, and heart failure. The comprehensive Minimum Data Set (MDS) 3.0 dated February 20, 2025, confirmed the resident had an indwelling catheter.
Failure to Document Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure proper documentation for the discharge of a resident, identified as Resident #85, who was hospitalized. The resident, who had been admitted with diagnoses including metabolic encephalopathy, heart failure, severe protein-calorie malnutrition, type two diabetes mellitus, and chronic kidney disease, was transferred to the hospital due to low oxygen saturation as ordered by a doctor. However, there was no documentation in the medical record regarding the transfer to the hospital. This lack of documentation was confirmed through interviews with the Director of Nursing, who acknowledged the absence of records related to the resident's transfer.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for Resident #42 after the initiation of hospice services. Resident #42, who had a range of diagnoses including lumbar degeneration, chronic obstructive pulmonary disease, alcoholic cirrhosis of the liver, anxiety, chronic viral hepatitis C, seizures, and psychosis, was admitted to hospice care as per a physician's order. Despite this significant change in condition, there was no evidence of a Significant Change MDS assessment being completed within the required 14-day period following the start of hospice services. The annual MDS indicated cognitive impairment and did not reflect the resident's terminal status or hospice care, as required by the Long Term Care Facility Resident Assessment Instrument 3.0 User Manual. The Director of Nursing confirmed the oversight during an interview, acknowledging that the assessment was not conducted during the resident's hospice care period.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) 3.0 assessments for two residents, leading to discrepancies in their medical records. Resident #192, who was admitted with multiple diagnoses including metabolic encephalopathy and severe cognitive impairment, was inaccurately documented as being in a persistent vegetative state (PVS) on the MDS. However, the resident was able to answer some questions during the Brief Interview of Mental Status (BIMS), indicating that he was not in a PVS. This inconsistency was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #69, who was admitted with conditions such as anoxic brain damage and respiratory failure, was inaccurately documented as not being in a PVS on the quarterly MDS assessment. The DON verified that Resident #69 was indeed in a PVS, and the MDS should have reflected this status. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's assessment process, affecting the accuracy of the residents' medical records.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations of the Pre-Admission Screening and Resident Review (PASRR) Level II determination into the assessment, care planning, and transitions of care for Resident #74. This resident, who was admitted with multiple diagnoses including traumatic brain injury, PTSD, and major depressive disorder, was approved for a six-month stay in the nursing facility with specific required services. These services included a behavior management safety plan, ongoing evaluation of psychotropic medications, mental health counseling, and a behaviorally based treatment plan, among others. Upon review, it was found that the facility did not have a care plan addressing the PASRR Level II services, nor was there evidence that the facility was following the Level II recommendations or the six-month discharge time frame. An interview with the Social Work Director confirmed the absence of a PASRR care plan and the lack of adherence to the Level II recommendations, indicating a deficiency in the facility's compliance with the required care planning and service provision for the resident.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) documents for a resident, which is a requirement for residents with mental disorders or intellectual disabilities. The deficiency was identified during a review of the records for a resident who was admitted with multiple diagnoses, including cerebral palsy, hemiplegia, and mood disorder, among others. The PASRR document dated 05/11/22 only listed a mood disorder, omitting other significant diagnoses such as schizoaffective disorder and anxiety disorder, which were later documented in the resident's medical record on 07/01/24. An interview with the Director of Nursing confirmed that these diagnoses were not correctly coded on the PASRR form, indicating a lapse in maintaining accurate and up-to-date documentation for the resident's conditions.
Failure to Implement Accurate Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement an accurate baseline care plan within 48 hours of admission for a resident, affecting one out of six residents reviewed for baseline care plans. The resident, who was admitted and later discharged, had multiple diagnoses including surgical aftercare, type II diabetes, Crohn's disease, severe protein-calorie malnutrition, major depressive disorder, chronic kidney disease, colostomy, malignant neoplasm of the colon, and psychosis. Upon admission, the resident was alert and oriented, with a colostomy incision and bag, and a PEG tube. However, the baseline care plan only noted the PEG tube for clinical acuity review and failed to identify the resident's colostomy. This deficiency was confirmed during an interview with the Unit Manager.
Deficiency in Quarterly Care Plan Reviews and Updates
Penalty
Summary
The facility failed to ensure comprehensive resident care plans were reviewed and revised at least quarterly and were prepared and developed with an interdisciplinary team, including the resident. This deficiency affected two residents who did not have care conferences every three months as required. One resident, who was moderately cognitively impaired and used a wheelchair, only had two care conferences in the last year, despite having quarterly assessments completed. Another resident with severely impaired cognition also had only two care conferences since admission, contrary to the facility's policy that care plans should be scheduled quarterly. Additionally, the facility failed to update or revise a care plan for a resident who was cognitively intact and had a history of smoking. The resident's care plan indicated the need for supervision and a smoking apron, but subsequent assessments showed the resident could smoke without supervision and did not require a smoking apron. The care plan was not updated to reflect these changes until after the deficiency was identified. The facility's policy required smoking assessments and care plan updates upon admission, quarterly, and with any condition or behavioral changes, which was not adhered to in this case.
Failure in Wound Management for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered wound management program for a resident who sustained a non-pressure related skin impairment to the right lower leg. The resident, who was cognitively intact and used a wheelchair, had a medical history that included prepatellar bursitis, cellulitis, cerebral infarction, dependence on renal dialysis, end-stage renal disease, and type II diabetes. The resident reported hitting a bookshelf, resulting in a swollen and discolored right leg, and was administered pain medication that was ineffective. Despite the resident's insistence on going to the hospital, the facility did not adequately document or follow up on the resident's condition. Upon returning from the hospital, the resident was diagnosed with a hematoma and was ordered to have the right lower extremity wrapped with an elastic bandage. However, the facility failed to document the application of the bandage or monitor the leg from the time of hospital discharge until the end of January. The resident continued to experience pain and requested to be sent to the hospital again, where further assessments revealed no evidence of deep vein thrombosis. Despite new orders for wound care, the facility did not complete the treatments as ordered, and the resident's condition worsened, leading to a hospital admission for intravenous antibiotics and wound debridement. Interviews with facility staff revealed that skin assessments were incomplete, lacking details such as wound location, size, and description. The facility also failed to transcribe and follow hospital discharge orders for wound care, resulting in a lack of treatment from February 20 to February 25. The Director of Nursing confirmed these deficiencies, acknowledging that the facility did not complete the necessary treatments as ordered, which contributed to the resident's deteriorating condition.
Failure to Document and Implement Splint Use for Residents
Penalty
Summary
The facility failed to ensure that two residents, who required splints or braces, had appropriate orders and monitoring for their use. Resident #69, who had multiple diagnoses including anoxic brain damage and contractures, was observed without the necessary splints on multiple occasions. The resident's medical records lacked orders for these devices, and the plan of care did not address the resident's contractures or necessary interventions. Interviews with staff confirmed that the resident was supposed to wear splints for up to eight hours a day, but this was not documented in the medical records. Similarly, Resident #68, who had severe cognitive impairment and range of motion issues, was observed with a contracted hand and no interventions in place. Although a palm protector was noted in the occupational therapy discharge summary, there were no corresponding physician orders or care plan interventions documented. The Director of Nursing and Occupational Therapy Aide confirmed the oversight in the medical records, indicating a failure to properly document and implement necessary care interventions for the resident's condition.
Lack of Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident had orders for an indwelling catheter, affecting one of three residents with such a device. The resident, admitted with multiple diagnoses including metabolic encephalopathy, type two diabetes mellitus, and heart failure, was observed to have a catheter bag hanging from his bed. However, a review of the resident's medical records revealed no physician orders for the indwelling catheter or for catheter care. This was confirmed during an interview with the Director of Nursing, who verified the presence of the catheter without corresponding orders or documentation for care.
Failure to Document and Enforce Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident on dialysis, identified as Resident #68, adhered to a prescribed fluid restriction, and did not document the resident's noncompliance in the medical record. Resident #68, who had a range of medical conditions including end-stage renal disease, was on a fluid restriction of 1500 ml per day as ordered by the physician. Despite this, observations on two separate occasions revealed the resident with a large water bottle filled with water, indicating noncompliance with the fluid restriction. Interviews with staff confirmed awareness of the resident's noncompliance, yet there was no documentation of this in the medical record. Additionally, the dietary department was unaware of the fluid restriction, and the dietary progress notes lacked sufficient documentation regarding the restriction. The dietitian acknowledged the resident's noncompliance and the fact that the supplements provided exceeded the fluid restriction, but this was not documented. The plan of care for Resident #68 also did not address the fluid restriction, highlighting a lack of communication and documentation within the facility regarding the resident's care needs.
Failure to Administer Tube Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident's tube feeding was administered at the ordered rate, affecting one resident. The resident, who had a complex medical history including anoxic brain damage, respiratory failure, and a persistent vegetative state, was admitted with a gastrostomy tube for feeding due to dysphagia. The resident's care plan required tube feeding via a gastrostomy tube, with specific interventions to monitor and manage the feeding process. However, observations on two consecutive days revealed that the tube feeding was running below the ordered rate of 85 ml per hour, first at 81 ml per hour and then at 70 ml per hour. A registered nurse confirmed the discrepancy and was unaware of the current order, indicating a lapse in following the physician's instructions for the resident's nutritional needs.
Oxygen Administration Error
Penalty
Summary
The facility failed to administer oxygen to a resident as ordered by the physician. The resident, who was admitted with diagnoses including heart failure, chronic respiratory failure, and other conditions, was ordered to receive oxygen at two liters continuously. However, observations on multiple occasions revealed that the resident was receiving oxygen at four liters instead. The Director of Nursing confirmed that the oxygen was being administered at the incorrect rate, contrary to the physician's order.
Failure to Assess and Plan for PTSD Triggers
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the resident's PTSD and to minimize triggers and/or re-traumatization. This deficiency affected a resident who was admitted with multiple diagnoses, including traumatic brain injury, PTSD, and major depressive disorder. The resident was severely cognitively impaired and used a wheelchair for mobility. An interview with the resident's family revealed that the PTSD diagnosis resulted from an assault at a previous nursing home. However, a review of the resident's medical record showed no identification of PTSD triggers or a care plan addressing these triggers. The Director of Nursing confirmed the absence of a PTSD assessment or care plan for the resident.
Lack of Dementia Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, impacting the resident's highest practical physical, mental, and psychosocial well-being. The resident, who was admitted with multiple diagnoses including traumatic brain injury, dementia, and major depressive disorder, was observed in the common area watching television. Despite being severely cognitively impaired and using a wheelchair for mobility, the resident did not have a dementia care plan in place. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a person-centered dementia care plan to address the resident's specific needs.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that Resident #16 received medications as ordered during periods when the resident left the facility to stay with friends and family. Resident #16, who had multiple diagnoses including chronic obstructive pulmonary disease, bipolar disorder, and hypertension, was frequently away from the facility without taking prescribed medications. The resident missed several doses of critical medications such as Amlodipine, Aspirin, Plavix, and others during these absences. Interviews with the resident and facility staff confirmed that the resident did not have medications during these times, and there was no evidence that the facility attempted to address this issue. Resident #82, who had severe cognitive impairment and was diagnosed with conditions such as metabolic encephalopathy and chronic respiratory failure, was also affected by medication administration issues. The resident was prescribed Buspirone for anxiety, with an order indicating unsupervised self-administration. However, interviews with facility staff revealed that Resident #82 did not self-administer medications, and due to an error in the electronic medication administration record, the resident did not receive the medication from 01/27/25 to 03/03/25. The Director of Nursing verified that Resident #82 should have been receiving Buspirone but had not been due to the oversight. The facility's failure to ensure proper medication administration for both residents highlights significant deficiencies in their pharmaceutical services, impacting the health and well-being of the residents involved.
Lack of Pain Medication Parameters and Documentation
Penalty
Summary
The facility failed to ensure that two residents, Resident #45 and Resident #66, had appropriate parameters in place for administering as-needed pain medication. For Resident #45, the medical record showed that Oxycodone was administered multiple times despite a pain rating of zero, and there were no pain scale parameters included in the physician's orders. Additionally, there was no documentation of non-pharmacological interventions being attempted before administering the medication. The Director of Nursing confirmed that the medication should not have been given for zero pain and that parameters and documentation were lacking. Similarly, Resident #66's records revealed that pain medications, including Oxycodone and Morphine, were administered without parameters for administration. The Medication Administration Record showed multiple instances of medication being given without documentation of non-pharmacological interventions or the location and description of the pain. The Director of Nursing verified that the nursing staff had not been documenting these details as required, and the medications lacked administration parameters, leaving nurses to decide which medication to provide.
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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 Gahanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Taylor Springs Health Campus | 2.2 mi | ★★★★★ | 1 | 0 |
| Otterbein Gahanna | 2.4 mi | ★★★★★ | 9 | 0 |
| The Laurels Of Gahanna | 3 mi | ★★★★★ | 27 | 0 |
| Mother Angeline Mccrory Manor | 3.5 mi | ★★★★★ | 1 | 0 |
| Allbridge Rehabilitation And Nursing Center | 3.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.