Continuing Healthcare of Gahanna: Wrong Dose Given - OH
The medication error at Continuing Healthcare of Gahanna affected Resident #17, who has been at the facility since October 2024 with diagnoses including hypertension, diabetes, and shoulder pain. Federal inspectors observed the incident during a complaint investigation on August 19, 2025.
Licensed Practical Nurse #202 was preparing morning medications for the resident when she pulled a clear plastic cup from her medication cart drawer. The cup already contained three pills: a small yellow aspirin tablet, a round white Vitamin D3 pill, and an orange multivitamin.
The nurse then added five more medications to the cup, including Metformin for diabetes, Norvasc for blood pressure, Coreg for heart conditions, iron supplements, and one tablet of Losartan Potassium 50 milligrams. But the resident's physician had ordered two Losartan tablets daily, not one.
The resident's medical record showed a July 2, 2025 physician order specifically directing "Losartan Potassium 50 milligrams with the special instructions to administer two tablets by mouth daily for hypertension."
When the nurse entered the resident's room at 10:48 a.m., she took the patient's blood pressure reading and set the medication cup down. Then she left.
She never watched the resident take the pills. She never confirmed the medications had been swallowed.
Three minutes later, when inspectors interviewed the nurse, she confirmed she had given only one Losartan tablet instead of the prescribed two.
The resident's care plan, updated in October 2024, specifically addressed hypertension management. Staff were supposed to administer blood pressure medications as ordered, monitor for side effects and effectiveness, and obtain blood pressure readings every shift. The plan emphasized taking blood pressure "under the same condition each time."
The resident showed no cognitive impairment according to their most recent quarterly assessment, meaning they would have been capable of understanding medication instructions if properly given.
Facility policy required nurses to follow the "five rights" of medication administration at each step of the process. Before removing any medication from its container, nurses were supposed to check the label against the order on the medication administration record.
The policy, dated September 18, stated medications "will be administered in a safe and effective manner." It required verification at multiple points during the medication preparation and delivery process.
This wasn't the first time Continuing Healthcare of Gahanna had medication problems. The August inspection was investigating complaints, and inspectors noted this deficiency represented "non-compliance investigated under Complaint Number 2594301 and Complaint Number 2564232."
The facility had faced a similar medication administration deficiency during its annual survey completed March 12, 2025. Federal regulators classified the August incident as a repeat violation.
The 83-bed facility serves residents with complex medical conditions requiring precise medication management. Hypertension affects millions of Americans and requires consistent daily medication to prevent strokes, heart attacks, and other cardiovascular complications.
Missing half a prescribed blood pressure medication dose can allow dangerous spikes in blood pressure, particularly in elderly residents who may have multiple cardiovascular risk factors.
The inspection revealed systemic problems with medication oversight. Nurses were preparing medications correctly in some cases but failing to ensure residents actually received the prescribed doses. The practice of leaving medication cups in rooms without supervision created opportunities for missed doses, wrong doses, or medications taken by the wrong person.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the medication error occurred during routine care, suggesting similar mistakes could happen to other residents receiving blood pressure medications.
The resident affected by the dosing error remained at the facility during the inspection. Their current condition and whether the missed medication dose caused any health complications was not documented in the inspection report.
Continuing Healthcare of Gahanna was required to submit a plan of correction addressing how it would prevent future medication administration errors and ensure nurses properly supervise residents taking their prescribed medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Healthcare of Gahanna from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CONTINUING HEALTHCARE OF GAHANNA in GAHANNA, OH was cited for violations during a health inspection on August 25, 2025.
Federal inspectors observed the incident during a complaint investigation on August 19, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.