Continuing Healthcare Of Gahanna

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review, interviews and facility policy review, the facility failed to honor one resident's preference of no male caregivers. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's medical record revealed no plan of care addressing the resident's preference of no male caregivers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. Review of

the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. On 08/19/25 at 10:48 A.M., an observation of the resident's room during morning medication administration revealed a sign behind the resident's bed indicating she preferred to have no male caregivers. On 08/20/25 at 9:00 A.M. interview with Resident #17 revealed she preferred no male caregivers due to past physical and sexual abuse. The resident revealed the facility was aware of the preference however continued to assign the male Licensed Practical Nurse (LPN) #116 to the resident's room assignment. On 08/20/25 at 12:34 P.M., interview with LPN #116 revealed usual assignment consisted of Resident #17's care. The LPN revealed he was aware the resident preferred no male caregivers. On 08/20/25 at 10:52 A.M., interview with the Director of Nursing (DON) verified she was aware of the resident's preference of no male caregivers. The DON revealed she was unaware the sign specified aides and nurses. Review of the facility policy titled, Resident Rights, dated 04/24 revealed the facility protects and promotes the rights of each resident. The facility staff will uphold the resident's dignity and individuality providing care that fosters their quality of life in a respectful environment. This deficiency is a recite to the complaint and annual survey completed on 03/12/25.This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review, interview and facility policy review, the facility failed to ensure one resident's bed was bariatric in size. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed

an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. On 08/19/25 at 9:00 A.M., observation of Resident #17 revealed the resident was obese and was too large for the standard bed she occupied.

Interview with the resident at the time of the observation revealed she had asked for a larger bed, however

the room was not large enough. On 08/20/25 at 1:05 P.M., an interview with Director of Nursing (DON) revealed every bed is capable to be a bariatric bed however the resident doesn't want her room moved around so they cannot accommodate the larger bed. Review of the facility policy titled, Resident Rights, dated 04/24 revealed the facility protects and promotes the rights of each resident. The facility will provide a clean, safe, comfortable and home like environment. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm

resident's condition and provide guidance for the notification of the residents and their responsible party regarding changes in condition. The resident and the resident's family member/legal representative will be notified of any changes in medical condition or treatment plan. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to report an allegation of abuse to the required state agency. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83. Findings Include:Review of

the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. On 08/20/25 at 9:00 A.M., an interview with Resident #17 revealed Licensed Practical Nurse (LPN) #116 had abused her. She revealed the LPN entered her room to apply cream to her legs and she told him she did not like men touching her and preferred female caregivers. The resident revealed the LPN grabbed her leg and jerked her leg out and applied the cream against her will. The resident revealed the incident was reported but nothing was done and LPN #116 continues to provide care to her. On 08/20/25 at 11:18 A.M., an interview with Resident #17's Case Manager revealed the resident had reported the incident to him while at the facility. The Case Manager revealed the Former Social Worker (FSW) was notified of the incident immediately and was told she would take care of it. The Case Manager revealed he was at the facility at the minimum of weekly and the accused LPN continues to provide care to the resident despite the allegation of abuse and the preference of only female caregivers. Review of the facility's SRI's revealed no reported incident of the allegation of abuse. On 08/20/25 at 1:05 P.M., an interview with the Director of Nursing (DON) revealed the incident was not reported to her and verified LPN #116 continued to provide care to the resident. The DON verified the allegation of abuse was not reported to the required state agency. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, not dated revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. All incidents and allegations of abuse, neglect, exploitation, misappropriation of resident property and injuries of unknown origin must be reported to immediately to the Administrator or designee. If any form of abuse is alleged or serious bodily injury is identified related to any other reportable injury, the Administrator or his/her designee will notify the Ohio Department of Health (ODH) immediately but not later than two hours after the allegation is made or the serious bodily injury identified. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.This deficiency is a recite to the complaint survey completed 07/23/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to investigate an allegation of abuse. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83.Findings include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment.On 08/20/25 at 9:00 A.M., an

interview with Resident #17 revealed Licensed Practical Nurse (LPN) #116 had abused her. She revealed

the LPN entered her room to apply cream to her legs and she told him she did not like men touching her and preferred female caregivers. The resident revealed the LPN grabbed her leg and jerked her leg out and applied the cream against her will. The resident revealed the incident was reported but nothing was done and LPN #116 continues to provide care to her. On 08/20/25 at 11:18 A.M., an interview with Resident #17's Case Manager revealed the resident had reported the incident to him while at the facility. The Case Manager revealed the Former Social Worker (FSW) was notified of the incident immediately and was told

she would take care of it. The Case Manager revealed he was at the facility at the minimum of weekly and

the accused LPN continues to provide care to the resident despite the allegation of abuse and the preference of only female caregivers. Review of the facility's SRI's revealed no reported incident of the allegation of abuse. On 08/20/25 at 1:05 P.M., an interview with the Director of Nursing (DON) revealed the incident was not reported to her and verified LPN #116 continued to provide care to the resident. The DON revealed the allegation of abuse was not investigated as required. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, not dated revealed residents have the right to be free from abuse, neglect, exploitation and misappropriation of resident property. Once the Administrator and the Ohio Department of Health (ODH) are notified, an investigation of

the allegation violation will be conducted. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.This deficiency is a recite to the complaint survey completed 07/23/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699

Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review and interviews, the facility failed to identify, assess and implement care and services to prevent triggers of past trauma. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's initial social service assessment dated [DATE REDACTED] revealed the resident had no Trauma Informed Care Triggers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. The resident also reported having medical conditions that had caused trauma her life like a brain aneurysm. The assessment indicated the resident reported the development of emotional and behavioral symptoms in response to an identifiable stressor occurring within three months of the onset of the stressor. The resident reported that being in the facility was hard on her. The plan was to continue the resident's current psychotropic medications as prescribed, engage in therapeutic behavioral services (TBS) to address symptoms related to adjustment disorder. The resident was given the diagnoses adjustment disorder with mixed anxiety and depressed mood. Review of the resident's quarterly social service assessment dated [DATE REDACTED] revealed the resident had trauma informed care triggers. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment.

Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. The assessment indicated depression, anxiety or post-traumatic stress disorder (PTSD) was not

a current diagnosis. On 08/20/25 at 9:00 A.M., an interview with the resident revealed she had past trauma of sexual abuse and identified the reason for preferring no male caregivers. Observation during the time of

the interview revealed a sign hanging on the wall behind the bed indicating the resident preferred no male caregivers. On 08/20/25 at 10:04 A.M., interview with the Licensed Social Worker (LSW) #240 verified the resident had no trauma assessment reflecting the past trauma, identification of triggers or plan of care for

the trauma. On 08/20/25 at 11:18 A.M., an interview with the resident's Case Manager #245 revealed he was aware of the sexual abuse she endured as a child. He revealed she spoke to the Former Social Worker (FSW) #241 regarding the preference of no male caregivers and the reasoning behind the request. This deficiency is a recite to the complaint and annual survey completed 03/12/25.This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with

the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of

the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. The resident also reported having medical conditions that had caused trauma her life like a brain aneurysm. The assessment indicated the resident reported the development of emotional and behavioral symptoms in response to an identifiable stressor occurring within three months of

the onset of the stressor. The resident reported that being in the facility was hard on her. The plan was to continue the resident's current psychotropic medications as prescribed, engage in therapeutic behavioral services (TBS) to address symptoms related to adjustment disorder. The resident was given the diagnoses adjustment disorder with mixed anxiety and depressed mood. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. Review of

the medical record revealed no documented evidence TBS was arranged and provided for the resident. On 08/20/25 at 1:05 P.M., interview with the Director of Nursing (DON) verified the resident had not received

the TBS services as recommended by the Psychiatric Nurse Practitioner. This deficiency represents non-compliance investigated under Complaint Number 2597120 and Complaint Number 2595339.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review, interview and facility policy review, the facility failed to ensure medications were administered as physician ordered. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83.Findings Include:Review of the medical

record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the plan of care dated 10/24/24 revealed

the resident had hypertension. Interventions included to administer hypertensive medications as ordered, monitor for side effects and effectiveness, obtain blood pressure readings every shift and as needed and take the blood pressure under the same condition each time. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. Review of

the resident's monthly physician orders for August 2025 identified an order dated 07/02/25 Losartan Potassium 50 milligrams (mg) with the special instructions to administer two tablets by mouth daily for hypertension. On 08/19/25 at 10:48 A.M., observation of Licensed Practical Nurse (LPN) #202 administer Resident #17's morning medications revealed the LPN removed a clear plastic cup from the top drawer of

the cart with Resident #17's name written on the side. The plastic cup had one small round yellow pill (Aspirin 81 milligrams (mg)), a round white pill (Vitamin D3 1.000 units), and one orange round bill (Multivitamin). The LPN then added to the cup Metformin 500 mg, Norvasc 10 mg, Coreg 25 mg, Ferrous Sulfate 325 mg and Losartan Potassium 50 mg one tablet. The LPN walked into the resident's room, obtained the resident's blood pressure and set her medications down and exited the room without ensuring

the resident ingested the medications. On 08/19/25 at 10:51 A.M., an interview with LPN #202 verified only one Losartan Potassium 50 mg tablet was administered to Resident #17 instead of the physician ordered two tablets. Review of the facility policy titled, Administration Procedures for All Medications, dated 09/18 revealed medications will be administered in a safe and effective manner. At a minimum review the five rights at each of the following steps of medication administration. Prior to removing the medication from the container check the label against the order on the medication administration record (MAR). This deficiency is a recite to the complaint and annual survey completed on 03/12/25. This deficiency represents non-compliance investigated under Complaint Number 2594301 and Complaint Number 2564232.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Continuing Healthcare of Gahanna

167 North Stygler Road Gahanna, OH 43230

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, medical record review, interview and facility policy review, the facility failed to ensure medications were not left at bedside during medication administration. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83.Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident had no cognitive impairment. On 08/19/25 at 10:48 A.M., observation of Licensed Practical Nurse (LPN) #202 administer Resident #17's morning medications revealed the LPN removed a clear plastic cup from the top drawer of

the cart with Resident #17's name written on the side. The plastic cup had one small round yellow pill (Aspirin 81 milligrams (mg)), a round white pill (Vitamin D3 1.000 units), and one orange round bill (Multivitamin). The LPN then added to the cup Metformin 500 mg, Norvasc 10 mg, Coreg 25 mg, Ferrous Sulfate 325 mg and Losartan Potassium 50 mg one tablet. The LPN walked into the resident's room, obtained the resident's blood pressure and set her medications down and exited the room without ensuring

the resident ingested the medications.On 08/20/25 at 8:54 A.M., observation of LPN #200 administer the resident's morning medications revealed the LPN prepared the following medications Aspirin 81 mg, Ferrous Sulfate 325 mg, Vitamin D3 1,000 units, Multivitamin one tablet, Metformin 500 mg, Norvasc 10 mg, Losartan 50 mg two tablets and Coreg 25 mg. The LPN then entered the resident's room and set the medications down in two individual cups on the resident's bedside table. The LPN obtained the resident's blood pressure and exited the resident's room without ensuring the ingested the medications.On 08/20/25 at 9:05 A.M., LPN #200 entered the room and stated, checking to make sure you took your medications.

The LPN verified she had not observed the resident ingest the medications.Review of the facility policy titled, Administration Procedures for All Medications, dated 09/18 revealed medications will be administered

in a safe and effective manner. After administration, return to cart, replace medication container and document administration in the medication administration record (MAR) or treatment administration record (TAR) and the controlled substance sign out record, if necessary.

Event ID:

Facility ID:

If continuation sheet