Storypoint Gahanna North

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure Resident #56's weights were monitored. This affected one resident (Resident #56) of three residents reviewed for weights. The census was 86.

Findings Include:

Resident #56 was admitted to the facility on 06/13/25. Her diagnoses were fracture of unspecified part of neck of right femur, encounter for other orthopedic aftercare, osteoarthritis, macular degeneration, gastro-esophageal reflux disease, Barrett's esophagus, cardiac murmur, muscle weakness, other abnormalities of gait and mobility, and other symbolic dysfunctions. Review of her Wellness Evaluation, dated 12/23/25, revealed she was cognitively intact.

Review of Resident #56 weight measurements, dated December 2025 to May 2026, revealed there were no weights taken in January, February, March, or April of 2026.

Interview with Executive Director #201 on 06/03/26 at 11:25 A.M. confirmed the facility does not have evidence Resident #56 weights were taken from January 2026 to April 2026 as they should have been.

Review of facility Resident Weights policy, dated 10/17/22, revealed each resident will be routinely weighed upon move in, monthly, and when returning from an alternate healthcare setting unless otherwise directed by the resident's healthcare provider. After the four week time period, the wellness leader or designee will review the weights and notify the resident/legally responsible party and healthcare provider of persistent weight gain/loss and implement appropriate interventions. Return to monthly weights if the weight has stabilized. The wellness director or designee will review all weights monthly and as needed.

Based on medical record review, staff interview, and facility policy review, the facility failed to notify the provider with a change in weight as ordered. This affected one (Resident #48) of three residents reviewed for nutritional status. The census was 86.

Findings Include:

Resident #48 was admitted to the facility on 09/16/21. Her diagnoses were cardiac arrhythmia, dementia, abnormalities of gait and mobility, hypertension, pain in left knee, stress incontinence, chronic kidney disease (stage III), family history of diabetes mellitus, anxiety disorder, hypothyroidism, hyperlipidemia, glaucoma, and depression. Review of her Wellness Assessment, dated 02/13/26, revealed she had a mild cognitive impairment.

Review of Resident #48 physician orders, dated 01/10/25, revealed she is to have her weight taken daily for heart failure. The facility is to call the heart failure clinic if Resident #48 has a two pound weight gain from day to day or five pounds in a week.

Review of Resident #48 weights, dated 02/23/26 to 04/05/26, revealed the following dates and weights in which there was at least a two pound change from day to day: on 02/23/26, her weight was 153.8 pounds and then on 02/24/26, her weight was 156.6 (2.8 pound increase); on 03/16/26, her weight was 156.2 pounds, and then on 03/17/26, her weight was 158.2 (2.0 pound increase); and on 04/04/26, her weight was 156.4 pounds, and then on 04/05/26, her weight was 159.7 pounds (3.3 pound increase).

Review of Resident #48 progress notes, dated 02/23/26 to 04/10/26, revealed no documentation to support the heart failure center was notified of the weight increase as ordered.

Interview with Licensed Practical Nurse (LPN) #200 on 06/03/26 at 11:18 A.M. confirmed she will enter weights into the electronic medical records. If a resident has an order to report to a provider when they have a significant weight change (or a change outside the parameters ordered), they will contact the provider that same day. When they contact the provider, they will document this in the resident's progress notes.

Interview with Executive Director #201 on 06/03/26 at 11:25 A.M. confirmed there was no documentation to support the facility contacted Resident #48 provider when her weight changes were outside the parameters ordered.

Review of facility Resident Weights policy, dated 10/17/22, revealed each resident will be routinely weighed upon move in, monthly, and when returning from an alternate healthcare setting unless otherwise directed by the resident's healthcare provider.

Based on medical record review, observation, staff interview and facility skill instruction procedure, the facility failed to maintain infection control when completing perineal care for Resident #30. This affected one resident (#30) of one resident observed for perineal care. The facility census was 78.

Findings include:

Review of Resident #30's medical record revealed she was admitted to the facility on 08/07/23. Diagnoses included Parkinson's disease, neurocognitive disorder with Lewy body dementia, diabetes and insomnia.

On 02/27/26 at 10:34 A.M. observation of incontinence care to Resident #30, two staff members put on gloves without washing their hands. (Care Associate (CA) #154 and CA #228). The blinds were left open to the window. After removing the soiled adult brief, CA #154 gathered premoistened wipes and cleansed the front pubic area, not changing positions on the wipes or separating the labia to clean the vaginal area, CA #154 then turned Resident #30 to her side and obtained a clean premoistened wipe and cleansed from back to front then front to back with the same wipe and placed a new adult brief on the resident. CA #154 then removed her gloves. CA #154, with the assistance of CA #228, hooked up the Hoyer (mechanical) lift and got Resident #30 back into her Broda chair. CA#154 then brushed the resident's hair and washed her hands.

On 02/27/26 at 10:47 A.M., the above observation was verified during interview with CA #154.

Review of the skill instruction procedure Perineal Care dated 03/11/25 revealed for female perineal care to separate the labia, cleanse downward from front to back with one stroke. Repeat step until area is clean. Use a clean part of the washcloth for each stroke and use more than one washcloth if needed. Rise and pat area dry from front to back. Then turn the resident to the side, clean the rectal area from vagina to anus. Use a clean part of the washcloth for each stroke and use more than one washcloth if needed.

This violation represents non-compliance investigated under Complaint Number OH00169832.

Based on observations, record review, and staff interviews, the facility failed to ensure residents were provided with personal care services. This affected one resident (#136) of six sampled residents. The facility census was 80.

Findings include:

Review of the medical record for Resident #136 revealed an admission date of 04/22/25 with diagnoses of anxiety disorder, essential tremor, functional urinary incontinence, and secondary parkinsonism.

Review of the Saint Louis University Mental Status (SLUMS) dated 10/22/25 for Resident #136 revealed a score of six which indicates dementia.

Review of the service plan created 04/22/25 revealed Resident #136 required reminders for grooming to include combing hair.

Observation on 11/12/25 at 8:34 A.M. revealed Resident #136's was dressed and seated at the table for breakfast. Resident #136's hair was flat and sticking up on the right side of her head. Licensed Practical Nurse (LPN) #390 confirmed the condition of Resident #136's hair at the time of the observation. LPN #390 stated it looked like they didn't comb her hair.

Review of the Care Associate Job Description undated revealed you provide compassionate and competent care for residents by performing the following services: bathing, showering, and grooming/dressing assistance.

Review of the Competency Checklist Caregiver undated revealed caregivers must demonstrate grooming hair as one of the competencies for a caregiver at facility.

Based on interviews, observation, record review, review of manufactures guide, and facility policy review, the facility failed to safely administer insulin to one (Resident #94) of one observed for insulin administration. This had the potential to affect two residents who receive insulin at the facility. The census was 80.

Findings include:

Record review of Resident #94's medical record revealed an admission date of 06/21/24 with diagnoses to include but not limited to gastro-esophageal reflux disease, hypertension, muscle weakness, osteoarthritis, Type Two Diabetes, and dementia.

Review of Resident #136's service plan last review service completed dated 01/24/25 stated Resident #136 required assistance with all medication administration.

Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed an order dated 10/01/25 for Humalog Kwik injection 100 milliliters (mL) inject four units subcutaneously every morning.

Observation on 11/12/25 at 8:18 A.M. revealed Licensed Practical Nurse (LPN) #390 did not prime the insulin pen prior to administration of four units of Humalog to the left abdomen of Resident #136.

Interview on 11/12/25 at 8:18 A.M. LPN #390 stated priming the pen is when you dial up two units of insulin, then make sure it goes through the needle and then dial up the ordered dose to be given. LPN #390 stated she should have primed before she gave the four units. LPN #390 stated she was nervous and forgot to prime.

Review of the manufacturer's instructions for Humalog KwikPen Subcutaneous Solution Pen injector 100 unit/ milliliter (mL) revealed prime your pen before every injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, an 0 is seen in the dose window. Hold dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps six to eight, no more than four times. If you still do not see insulin, change the needle and repeat priming steps six to eight.

Review of the facility policy Assist with Insulin Pen Injectors dated 10/17/22 stated you must prime the pen before you set your dose and inject the insulin. You will do this by giving an air shot. This removes the air bubbles and ensures the pen and needle are working properly. Dial two units (to the number two) on the dose selector dial by turning it clockwise. You will hear and feel a faint click for each unit as you turn the dial. The plunger button on the pen will also rise. If you dial past two units, you can turn the dose counter-clockwise to correct it. Point the needle up. Press the plunger button against the tabletop and push out the two units of insulin. The dose selector dial will return to zero (0) if all the units were pushed out. If necessary. Repeat these steps until a drop or stream of insulin appears at the needle tip. If you are using a brand new pen, you may have to prime it up to three times to get a drop of insulin at the tip. Shake the insulin off the needle.

Based on observations and staff interviews, the facility failed to ensure expired medication were not available for use. This had the potential to affect 80 residents who live at the facility. The facility census was 80.

Findings include:

Observation on 11/12/25 at 8:36 A.M. revealed Lantus insulin pens for Resident #93 and Resident #94 were opened and in top drawer of the medication cart on the memory care unit and did not have open dates or discard dates. Additionally, in the medication cart on the memory care unit, there was a bottle of Nature's Bounty Anxiety and Stress Relief (supplement)expired 09/25/25 and a bottle of AZO cranberry Gummies (supplement) expired 10/2025.

Interview on 11/12/25 at 8:36 A.M. with Licensed Practical Nurse (LPN) #390 it was verified the Lantus insulin pens were opened and undated at time of observation. LPN #390 confirmed the medications were expired and in the medication cart for use. Furthermore, LPN #390 stated the facility had a chemical destroyer liquid and should have disposed of the expired medications.

Review of the facility policy Medication Storage dated 06/10/22 stated medication labels must include: resident name, medication name, medication/strength, dose, frequency, route, and expiration date. Over the counter medication must be labeled with pharmacy printed label and no stock meds are allowed for multiple resident use.

Review of the facility policy Medication Disposal-Destruction dated 07/03/25 stated expired medications are not to be administered. The designated staff person will inspect containers for expiration dates on a routine basis. When appropriate, replacement medication will be ordered. To properly dispose of expired medications the designated staff person will: if permitted, return the medication to the dispensing pharmacy for disposal; or destroy the medication following medication disposal policy.

Based on observations and staff interviews, the facility failed to ensure medications were disposed of properly. This had the potential to affect 80 residents who live at the facility. The facility census was 80.

Findings include:

Observation on 11/12/25 at 8:36 A.M. revealed the opened medications of a resident who had been deceased for over a month remained in the bottom drawer on the right side of the medication cart in memory care unit.

Interview on 11/12/25 at 8:36 A.M. with Licensed Practical Nurse (LPN) #390 verified that the facility had a chemical destroyer liquid and should have disposed of the deceased resident's medications.

Review of the facility policy Medication Disposal-Destruction dated 07/03/25 stated upon resident move-out, unused medication should be returned to the resident or returned to the pharmacy. If neither the resident nor the pharmacy accepts the unused medication, they should be destroyed at the community within 30 days.

Based on record review, interviews, and facility policy review the facility failed to ensure a newly hired staff member completed initial Tuberculosis (TB) screening. This had the potential to affect all 80 residents in the facility. The census was 80.

Findings include:

Observation on 11/12/25 at 2:30 P.M. of personnel record revealed Server #770's second step of TB skin testing upon hire, or chest x-ray or blood test were not found to be completed upon hire. Server #770's hire date was 08/26/25. First step TB skin test screening was completed 09/01/25.

Interview 11/12/25 at 3:35 P.M. with the Executive Director (ED) stated the TB regulation had changed and required newly hired staff to have initial TB screening completed within six months.

Review of the facility's TB risk assessment on 11/12/25 noted healthcare workers are tested for tuberculosis upon hire.

Interview 11/12/25 at 3:35 P.M. with the Executive Director (ED) verified the TB risk assessment for the facility states healthcare workers will have TB screening upon hire and stating she had not updated the TB risk assessment to reflect the new regulation changes.

Interview on 11/13/25 at 2:06 P.M. with the Regional Wellness Director verified the facility was following new regulations stating newly hired employees could have the second step of TB skin testing completed within six months.

Interview on 11/13/25 at 3:08 P.M. with the Regional Wellness Director confirmed she could not find a changed regulation regarding TB screening and stated Server #770 should have received second step of TB skin test screening within one to three weeks after the first step.

Review of the Center for Disease Control and Prevention (CDC) Clinical Testing Guidance for Tuberculosis: healthcare personnel dated 12/15/23 confirms TB screening programs should include anyone working or volunteering in care settings and all U.S. health care personnel should be screened for TB upon hire including an individual TB risk assessment.

Review of the CDC's Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test dated 01/31/25 confirms if the TB skin test is used for baseline testing of U.S. health care personnel, use two- step testing. If the first TB skin test is negative, a second TB skin test should be done 1 to 3 weeks later.

Review of the facility's Tuberculosis Infection Control Plan- Ohio RCF Policy dated 02/11/25 confirmed TB screening and testing is to be completed for all new employees and residents. Testing may include two step testing (TST) or BAMT (Mycobacterium tuberculosis blood test). New employees shall be screened within 30 days before the start of employment and before occupational exposure. For two-step testing: read test within 48-72 hours of placement. Employee may start work after TST read and symptom/risk factors are negative. Administer Test two between 7-21 days from test one.

Based on observation, interview and facility policy review the facility failed to follow infection control practices with laundry process. This had the potential to affect all 24 Residents residing in the memory care unit. The census was 80.

Findings include:

Observation on 11/12/25 at 8:46 A.M. of the memory care unit revealed a uncovered laundry basket placed on a chair outside resident rooms with a gallon of tide laundry detergent placed on top of the pile of laundry.

Observation on 11/12/25 at 8:55 A.M. of the memory care unit revealed the uncovered laundry basket placed on a chair outside resident rooms with a gallon of tide laundry detergent placed on top of the pile of laundry remained in the hallway.

Interview on 11/12/25 at 9:06 A.M. with Care Associate #320 verified laundry was left uncovered, on chair and had a gallon bottle of tide detergent on top of the laundry.

Review of the facility's laundry and linen policy dated 02/11/22 revealed to consider all soiled linen to be infectious. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Handle soiled linen as little as possible and minimize agitation.

Review of the facility's laundry guide dated 02/28/23 confirmed wet or soiled laundry will be will be removed from the apartment and processed as needed.

Based on observation, interviews, and facility policy review the facility failed to safely store and prepare food in both the kitchen and memory care kitchen. This had the potential to affect all 80 residents receiving food from both kitchens. The census was 80.

Findings include:

1. Observation on 11/12/25 at 9:15 A.M. of the memory care kitchen revealed a reach in refrigerator with a five pound (lb) container of sour cream (open date labeled as 06/03/25 and expiration date of 04/08/25), gallon of milk (no open date), coleslaw on a white plate wrapped in plastic wrap (no date), a small metal container of yogurt with plastic wrap (no open date, no expiration date), and a piece of cake wrapped in a white paper towel.

Observation on 11/12/25 at 9:20 A.M. of the memory care kitchen revealed a reach in freezer revealed a ice container with ice (no lid), corner of a frozen strawberry cheesecake bar torn off with icicles on it.

Observation on 11/12/25 at 9:22 A.M. of the memory kitchen ice machine revealed a black substance on the left inner wall of the machine.

Interview on 11/12/25 at 9:22 A.M. with care associate #320 verified items in refrigerator should be labeled, stored properly and stated the ice machine is maintained by the main kitchen staff.

2. Observation on 11/12/25 from 10:50 A.M. to 10:58 A.M. in the main kitchen it was observed the walk in refrigerator have no internal thermometer in the refrigerator, and contained an uncovered apple cake on a sheet tray below the refrigerator fan with black substance on exterior part of fan. The walk in freezer in the main kitchen was observed to have no internal thermometer in the freezer.

Interview on 11/13/25 at approximately 10:52 A.M. with Chef #510 verified there were no internal thermometers in the walk-in refrigerator and freezer, stating they must have fallen off shelving, and verified the apple cake should be covered, and the fan was dirty with black substance.

Observation on 11/12/25 at approximately 10:53 A.M. in the main kitchen revealed Culinary Staff Member #920 put soiled dishes to wash using the dishwasher with gloved hands and use same gloved hands to cut and mix melon in to a large container.

Interview on 11/12/25 at approximately 10:54 A.M. with Culinary Staff Member #920 verified gloves were not changed and hand hygiene was not performed after placing soiled dishes in the dish machine prior to cutting up melon with the same soiled gloves.

Review of the facility's proper food storage policy dated 06/06/2022 confirms maintain proper cleaning and sanitation of all refrigerators and freezers.

Review of the facility's proper food storage policy dated 06/06/2022 revealed food should be properly wrapped or covered and dated with date opened and date expires.

Review of the facility's hand hygiene policy, not dated, confirms the hand hygiene needs to be repeated after any activities that may contaminate hands, such as working with food, changing tasks in the kitchen, touching your face/ hair or using the bathroom.

This violation is a recite to annual survey completed 02/06/25.

Based on review of the fire drill records, staff interviews and review of facility policy, the facility failed to conduct resident evacuations during the past nine months. This had the potential to affect 80 residents who live in the facility. The facility census was 80.

Findings include:

Observation on 11/12/25 at 10:30 A.M. of the fire drill records indicate there were no fire drill evacuations conducted during the months of March 2025, April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, and October 2025.

Interview on 11/12/25 at 11:40 A.M. with the Executive Director confirmed she could not find any resident evacuations noted on the fire drill documentation and did not verbalize the fire drill evacuations as being completed.

Interview on 11/12/25 at 12:00 P.M. with Maintenance Leader #870 verified there were no fire evacuations of the residents for the past twelve months. Maintenance Leader #870 stated he thought the planned evacuation drill for 11/25/25 would cover the evacuations. Maintenance Leader #870 stated the drill is being held with the Mifflin Township fire inspector.

Review of the facility policy Fire Safety dated 06/10/25 stated the evacuation plan/training shall, at a minimum include the following: exit route diagrams showing the primary evacuation routes from all areas of the community and the location of fire alarm pull stations, fire extinguishers, and the destinations(s) outside the community/apartment. Exit routes diagrams showing all available escape routes and escape routes from all areas of the community/apartment. Descriptions of the special characteristics and/or evacuation techniques for everyone residing within the community. Description of the procedural rules for all employees to follow in the event of fire emergency and whether staff should re-enter the community/apartment after all occupants are accounted for. Basic information about fire, including ways fire can spread, ways to contain a fire, and when and how to attempt to extinguish a fire. Methods for operating all fire safety features in the community/apartment, including the location of battery-operated smoke detectors and spare batteries, how to activate and reset integrated alarm system pull stations and control panel, sprinkler system, etc., and how often each is tested. No outside evacuation. Go behind the smoke barrier door. Defend in place, unless fire personnel instruct to evacuate.

Based on observation, interviews, medical record review and facility policy review the facility failed to post no smoking signs on the door where oxygen is in use. This had the potential to affect one resident (Resident #72). The census was 80.

Findings include:

Record review of Resident #72's medical record revealed an admission date of 10/24/2025. Diagnoses include essential hypertension, gastro-esophageal reflux disease, chronic obstructive pulmonary disease, pulmonary fibrosis, circadian rhythm sleep disorder, benign prostatic hyperplasia and cervicalgia.

Review of Resident #72's medical record revealed an oxygen order to administer 4 liters/min nasal cannula as needed for dyspnea.

Review of Resident #72's service plan dated 10/27/25 confirms Resident #72 requires assistance from staff with respiratory treatments such as continuous oxygen use.

Observation on 11/12/25 at 8:08 A.M. of Resident #72's room revealed Resident #72 had an oxygen concentrator on and there was not a no smoking sign visible outside the apartment door.

Interview with 11/12/25 at 2:30 P.M. with License Practical Nurse #812 verified Resident #72 wears oxygen and verified there was not a no smoking sign/oxygen in use sign outside of the apartment door.

Review of the facility's Oxygen Therapy Use and Storage policy dated 10/17/22 confirms a sign must be posted outside resident apartment indicating that oxygen is in use.

Based on observation, interviews, facility policy review and safety data sheet review, the facility failed to safely store hazardous chemicals in assisting living and memory care units. This had the potential to affect 23 residents who the facility listed as cognitively impaired and independently ambulatory. The facility census was 80.

Findings include:

1. Observation on 11/12/25 at 8:44 A.M. of the common use restroom on the memory care unit revealed two bottles of protect cream, one bottle of Shampoo and body wash, one spray bottle of Fragrance Mist, one container of powder deodorant, two bottles of Cleanse No rinse foam cleanser, one roll on anti-antiperspirant, and one container of wet wipes. Concurrent interview with Licensed Practical Nurse (LPN) #390 confirmed the containers were in the common restroom at the time of the observation. LPN #390 stated these items were not supposed to be in the common restroom used by residents. LPN #390 verified the restroom is used by residents and it is kept unlocked at all times.

2. Observation on 11/12/25 at 8:46 A.M. of the memory care unit revealed a uncovered laundry basket placed on a chair outside resident rooms with a gallon of tide laundry detergent sitting on top of the laundry.

Observation on 11/12/25 at 8:55 A.M. of the memory care unit revealed the laundry basket with the Tide liquid detergent remained on the on chair outside Resident rooms, unsecured.

Interview on 11/12/25 at 9:06 A.M. with Care Associate #320 verified Tide detergent bottle was unsecured on a chair in outside resident rooms.

Review of Tide liquid detergent material safety and data sheet (SDS) states the hazards can cause eye irritation and harmful if swallowed.

3. Observation and interview on 11/12/25 at 7:51 A.M. with housekeeper #490 revealed the clean linen laundry room on the first floor was unsecured and there were industrial washing machine and dryer inside the room. House Keeper #490 stated the clean linen laundry room is to be locked at all times and staff have keys as the aides sometimes need to use the washer and dryer if the other washer and dryers are not working.

Observation on 11/12/25 at 8:09 A.M. revealed a clean linen laundry room on the first floor unlocked.

Observation on 11/13/25 at 9:30 A.M. revealed a clean linen laundry room on the first floor unlocked with housekeeping carts present in the room.

Observation on 11/13/25 at 1:50 P.M. revealed a clean linen laundry room on the first floor unlocked with housekeeping carts in the room. Inside the two housekeeping carts unlocked top cover was observed a 32 oz bottle of comet crème deodorizing cleanser (label stating keep out of reach of children), Array furniture polish spray (if on skin, rinse skin, if in eyes rinse eyes, and if swallowed rinse mouth, if inhaled move to fresh air- get medical attention if symptoms occur), 32 oz spray bottle of Clorox cleanup cleaner and bleach (if swallowed call poison control or doctor immediately for treatment advice), 32 oz bottle low acid bowl cleaner (label states hazards to humans), 32 oz spray bottle of Windex multi-surface cleanser, Envirox concentrate 118 sanitizer/virucide cleanser (harmful if swallowed, absorbed through the skin, or inhaled), 8 oz bottle of Bissell spot and stain (in case of eye contact flush thoroughly with water), 16 oz spray bottle of Array water-based stainless steel polish (label states may be fatal if swallowed and enters airways, causes eye irritation), and Envirox concentrate 118 sanitizer/virucide light duty cleanser (harmful if swallowed, absorbed through the skin, or inhaled).

Interview on 11/13/25 at 1:51 P.M. with the Maintenance Director it was verified the chemicals observed above should be locked up and secured.

Review of the facility's hazardous materials quick guide, not dated, confirmed chemicals should be locked in a storage area. Keep chemicals locked and/or stored in an area which is not accessible to residents or visitors. Maintain visual control of chemical containers while in use.

Review of the facility's hazard communication: proper handling and storage of chemicals dated 09/13/2022 confirms staff should refer to section 7 of the chemicals SDS for proper handling and storage guidelines.

This violation is a recite to complaint survey completed 08/19/25.

Based on observations, record review, staff interviews, review of police call log, review of Google maps, and review of facility policy, the facility failed to provide supervision to prevent resident elopement, and failed to complete a thorough investigation after the elopement. This affected one, (Resident #102) of three reviewed for elopement. This facility census was 80.

Findings include:

Review of the medical record for Resident #102 revealed an admission date of 04/04/22 with medical diagnoses of malignant neoplasm of unspecified right female breast, mild cognitive impairment, venous insufficiency, hypertension, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity.

Review of the Saint Louis University Mental Status (SLUMS) dated 08/20/25 for Resident #102 revealed a score of eight which indicated dementia.

Review of the Elopement Risk Evaluation dated 08/20/25 for Resident #102 revealed a score of sixteen which indicated a high risk for elopement.

Review of the Wellness Evaluation dated 08/19/25 Resident #102 required a walker for mobility and for staff to be present for the duration of the activity of mobility. Resident #102 was assessed as required supervised movement while off campus and was noted as a fall risk.

Review of the progress note dated 10/25/25 at 6:18 P.M. revealed at 3:15 P.M. this nurse was notified by the morning nurse (Licensed Practical Nurse (LPN)#120) that Resident (#102) could not be found. She was not in her room and not at the front desk where she normally sits at. Resident's daughter was in the community at this time and was looking for her. All the initial protocol was done by checking the signed out book to determine if her son had come to take her out but nothing was found. All staff were notified to check all the rooms, as other staff went outside to check around the building. Her son was called several times by this nurse and the morning nurse but could not get in touch with him and a message was left to call us back. All the room in Assisted Living and Memory Care were all checked and cleared without finding Resident #102. Executive Director was notified immediately. Resident #102's son called back and stated he has not come for her and he also came over to the community immediately. At about 4:25 P.M. her son received a call from the police department stating they had the resident in their custody and the son told them to bring her to the community. She was returned to the community by ambulance on a stretcher at 4:32 P.M.

Interview on 11/12/25 at 2:17 P.M. with Care Associate #880 revealed she worked on 10/25/25 when Resident #102 left the building unsupervised. Care Associate #880 stated she left at the end of her shift and didn't know that Resident #102 was missing until someone called her and asked when she had last seen Resident #102. Care Associate #880 stated she told the facility that she thought Resident #102 was at breakfast but had not seen her afterwards.

Interview on 11/12/25 at 2:55 P.M. with Receptionist #990 who stated the cameras are at the door and exit signs. Receptionist #990 stated the cameras are monitored by the front desk. Additionally, Receptionist #990 stated the camera does not always stay up on the monitors and the receptionists must log in to pull up the cameras. Furthermore, Receptionist #990 confirmed at the time of this interview that the camera was not pulled up and she couldn't visualize anything until she logged in.

Interview on 11/12/25 at 3:34 P.M. with Care Associate #850 who stated she came in at 3:00 P.M. on 10/25/25 and someone asked about Resident #102. Care Associate #850 stated the care associates on day shift told the staff they had not seen Resident #102 since between 10:00 A.M. and 12:00 P.M. The nurses had us immediately start looking outside, and Care Associate #850 stated she started driving up and down the road looking for Resident#102 for about 15 minutes and asked at the gas station if they had seen Resident #102. Care Associate #850 stated Resident #102 was returned to the facility. Care Associate #850 stated Resident #102 said she didn't know where she was because they didn't tell her.

Interview on 11/12/25 at 3:49 P.M. with LPN #120 confirmed she was working on 10/25/25 when Resident #102 left the community unsupervised. LPN #120 stated she first found out Resident #102 was missing when she was going home a little after 3:00 P.M.. LPN #120 stated she had clocked out for the shift, but overheard Resident #102's daughter telling the receptionist that she couldn't find her mother. LPN #120 stated she asked the daughter of Resident #102 if she could help her. Resident #102's daughter stated she couldn't find her mother and LPN #120 stated she had given Resident #102 her morning medications and that Resident #102 usually sits at the front entrance in the receptionist area near the front door. LPN #120 stated she checked the area where Resident #102 usually sits and she wasn't there. LPN #120 stated she went to Resident #102's room and looked for her. LPN #120 stated she then came back to the front desk and reviewed the sign out sheet and determined no one had signed out Resident #102. LPN #120 then alerted the nurse she had given report to that Resident #102 was missing. Then LPN #120 started the elopement process which included the receptionist calling a Code Silver and pictures of Resident #120 being given to the staff along with areas to search. LPN #390 and #120 walked down the street looking for Resident #102 and then heard that Resident #102 had been returned to the facility by ambulance. LPN #120 stated she returned to the facility and the Executive Director was there, so she left the facility around 4:30 P.M. LPN #120 stated no one had asked her about the incident after it occurred. LPN #120 stated Resident #102 was wearing the same type of attire as today which is a light jacket over a shirt, pants, and tennis shoes when she returned to the facility.

Interview on 11/13/25 at 8:14 A.M. with Resident #102 who stated it's ok living here. Resident #102 stated she doesn't remember leaving the building a few weeks ago. Resident #102 stated Are you saying I left of my own accord? Resident #102 then said she doesn't remember that, but maybe it was because I wanted to go home. Resident #102 stated she grew up in California and doesn't remember moving to Ohio. Resident #102 is unable to answer any more questions.

Interview on 11/13/25 at 9:38 A.M. with the Executive Director (ED) who stated the incident on 10/25/25, not an elopement, so we didn't report it. The ED stated this is an assisted living resident who had no previous history of wandering outside of the community. Resident #102 never showed signs of wandering off site, so we did not report it. When Resident #102 was returned there was action taken; we tested for a urinary tract infection (UTI) and Resident #102 was positive. Immediately, after Resident #102's return, the ED talked to the family about moving her to memory care where she would be safe and so this did not happen again. We tried to piece together when she had left, because she didn't sign out. The ED stated Resident #102 had lunch on 10/25/25 before she left. The ED stated a full body assessment of Resident #102 and vital signs were taken, the Emergency Medical Service (EMS) had also assessed Resident #102. The ED stated she talked to all the staff and family. The ED stated she talked to Resident #102 who had no recollection that she had left. The ED stated the staff searched in and out of the community for Resident #102. The ED stated that Resident #102 had never left our community and didn't think she even went outside prior to this incident. The ED stated Resident #102 was moved to the memory care unit the same evening on 10/25/25. The ED stated that because this wasn't an elopement, then there wasn't a full investigation.

Interview on 11/13/25 at 11:32 A.M. with the LPN Interim Wellness Director #1100 who stated there are about ten residents in the assisted living unit which are cognitively impaired. The LPN Interim Wellness Director #1100 stated she completed the wellness evaluations and if a resident is assessed to have a high risk for elopement, then she recommends the resident to be moved from assisted living to memory care unit. The LPN Interim Wellness Director #1100 stated that if she completed the wellness evaluation and she recommended memory care then the notes would be in the resident's electronic medical chart.

Review of the progress notes for Resident #102 for the months of August 2025, September 2025, and October 2025 do not note any recommendations from the LPN Interim Wellness Director #1100 to move Resident #102 from assisted living unit to the memory care unit.

Interview on 11/13/25 at 11:59 A.M. with the Regional Director of Operations who stated the residents are free to come and go as they please, this is a Residential Care Facility (RCF) and not a nursing facility. The Regional Director of Operations stated that if the residents are assessed and not safe in the RCF, then we recommend memory care. The Regional Director of Operations stated that if the family isn't agreeable to the move to the memory care unit, then we recommend a nursing facility or we do a hard discharge. The Regional Director of Operations stated Resident #102 had a UTI, and there was nothing for us to suspect she wasn't safe in assisted living. Additionally, the Regional Director of Operations stated there are no safety checks, the residents are free to come and go as they please. The Regional Director of Operations stated we aren't doing anything any other RCF doesn't do, and we are not outside the regulations. The Regional Director of Operations stated that until 10/25/25, there was nothing that warranted the facility, staff, or the family into thinking that Resident #102 would leave the facility. The Regional Director of Operations confirmed that she had not reviewed Resident #102's care plan and stated she is not reading 1500 care plans for each individual resident. The Regional Director of Operations stated she is not a nurse and declined to answer if she knew Resident #102 had a SLUMS score of eight on 08/20/25 and was assessed as a high risk for elopement on 08/20/25.

Review of the investigation paperwork received from the ED on 11/13/25 at 9:38 A.M. revealed no statements from any staff or family, no assessments of other cognitively impaired residents in the assisted living unit, no re-education of the staff on elopements, no indication that the police had been called, and no police call log or report.

Review of the police call log dated 10/25/25 received on 11/13/25 revealed that a call was received on 10/25/25 at 3:18 P.M. which stated woman is lost//doesn't know where she is older lady with a walker white lady. Officers and medical were dispatched to 812 Windward Lane which is one mile from the facility. The call log stated contact with Resident #102's son was made at 4:19 P.M. and he requested Resident #102 to be brought to the facility. Resident #102 returned to the facility by ambulance and arrived at 4:32 P.M.

Review of Google map revealed the distance from the facility to where Resident #102 was located was one mile. The roads Resident #102 was walking along are a high traffic area.

Interview on 11/13/25 at 4:12 P.M. with the ED who stated she attempted to review the cameras, but the camera system is outdated, and she didn't have time to review all the recordings. The ED stated she couldn't determine how or when Resident #102 left the facility. Additionally, the ED stated that they are getting an updated system soon and she has been working with her Information Technology (IT) Department.

Review of the Weather Archives for Gahanna, OH on October 25, 2025 (Closest NEWS Station) on October 25, 2025, The National Weather Service station at Columbus (KCMH) experienced a high temperature of 56°F, with a low of 35°F and an average of 45°F. Wind speeds reached a maximum of 7 MPH and an average speed of 2.2 MPH. Dew point readings were a high of 37°F, low of 31°F and average of 34°F. Relative humidity levels ranged from 40% to 92%, averaging at 68%. Barometric pressure peaked at 30.41 in., dropped to 30.32 in. and averaged 30.37 in. Station KCMH is located 1.3 miles south of central Gahanna. https://www.weatherforyou.com/archives/gahanna-oh/10-25-2025/nws

Review of the Elopement Policy dated 06/30/21 stated if not found after a search of building is complete, the Lead Caregiver/Nurse/Designee will ensure Resident Fact Sheet is on hand and completed, as well as follow up with the Wellness Director and Operations Director, the Lead Caregiver/Nurse/Designee will contact police.

Review of the facility Internal reportable Events grid dated 02/05/25 stated resident elopement/missing person are to be reported immediately, and the Wellness Director and ED are listed as the responsible parties for reporting the incident.

Review of the facility Internal Reportable Events policy dated 01/29/25 stated follow the internal reportable events grid for reporting. All situations that a resident or employees safety is at risk must be elevated to the President. If email communication is used as a means of reporting, it must include the following: all applicable attachments surrounding the incidents that is being reported. This should include: incident report, insurance report, pictures/video, witness statements, detailed timeline of events.

Based on observations, staff interview, and facility safety data sheet review, the facility to safely secure hazardous chemicals. This had the potential to affect 22 (Residents #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #70, #71, #72, #73, #74, #75, #76, #77, and #78) of 22 residents in the memory care unit. The census was 78.

Findings Include:

Observations on 08/19/25 at 9:35 A.M., 11:10 A.M., and 11:58 A.M. revealed the locked soiled laundry room door was ajar; not closed all the way. Inside the soiled laundry room, there was a plastic jug of Suds Laundry Detergent and Low Acid Bowl Cleaner. Both items were marked as hazardous and to keep out of the reach of children.

Interview with Licensed Practical Nurse (LPN) #87 on 08/19/25 at 12:05 P.M. confirmed the laundry door should not be open and accessible to the residents in the memory care unit. She confirmed the door was opened and shut it herself. She confirmed there were chemicals/detergents in the laundry room that the residents should not have access to.

Interview with Executive Director #150 on 08/19/25 at 12:25 P.M. confirmed the laundry door in memory care should be shut/locked.

Review of facility Safety Data Sheet (SDS) for Highly Concentrated Premium Laundry Suds revealed a hazardous warning that this material should be kept out of the reach of children.

Review of facility SDS for Low Acid Bowl Cleaner revealed a hazardous warning that this material should be kept out of the reach of children.

This violation represented non-compliance with complaint number OH00167699.

Based on observations and staff interview, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 78 residents residing in the facility. The facility identified all residents received food and/or beverages from the facility main kitchen.

Findings include:

1. Observation of the facility kitchen on 02/06/25 at 8:33 A.M. revealed that the exterior of the walk-in freezer had approximately four inches of ice on the floor on the exterior of the freezer door. Observation of the wall near the door seal revealed approximately one inch of ice surrounding the door frame of the exterior of the freezer door. Upon opening the freezer door, observation revealed that there was also ice build up on the internal component of the door, where the rubber seal was located. Observation of the inside of the freezer revealed an unsealed, open-to-air container of onion rings. Further observation revealed a container labeled beef stew that had visible white ice crystals covering the top layer of the food. There was no internal thermometer located in the walk-in freezer.

Interview with Executive Chef #173 on 02/06/25 at 9:02 A.M. confirmed the presence of ice buildup on the exterior of the freezer door, around the doorframe of the exterior and interior of the freezer door. Executive Chef #173 further confirmed the absence of an internal thermometer in the walk-in freezer, confirmed the presence of an open-to-air bag of onion rings, and the presence of ice crystals on the surface of the beef stew that had been stored in the walk-in freezer.

2. Observation of the ice machine on 02/06/25 at 9:07 A.M. revealed that there was a black slimy substance on the internal components of the ice machine. Observation of a gloved hand touching the black slimy substance inside the ice machine revealed that the substance was able to removed from the ice machine surfaces and was not a discoloration or scratch.

Interview with Executive Chef #173 on 02/06/25 at 9:09 A.M. confirmed that there was a black slimy substance on the inside of the ice machine.

3. Observation of the kitchen from 02/06/25 from 8:33 A.M. to 9:10 A.M. and on 02/06/25 from 11:29 A.M. to 11:45 A.M. revealed that Executive Chef #173 was not wearing a hair net or beard net while walking through food preparation areas. Executive Chef #173 had a beard that was approximately one inch in length. Cook #111 was also observed not wearing a beard net and had a beard that was approximately one inch in length while he prepared pureed food items.

Interview with Executive Chef #173 on 02/06/25 confirmed that Cook #111 was not wearing a beard net while preparing pureed food and that Executive Chef #173 was not wearing a hair net or beard net while standing approximately one foot away from where a food service worker was chopping potatoes. Executive Chef #173 stated that he usually only wore a hair net if he was behind the tray line.

Based on observation, interview, policy review and meal recipe review, the facility failed to ensure proper puree food texture for residents receiving pureed food. This had the potential to affect two (#15 and #77) out of two residents who the facility identified as having a pureed diet order. The facility census was 78.

Findings include:

During the test tray puree preparation observation on 02/06/25 at 11:45 A.M. with Dietary Cook #111, the pureed roasted potatoes were observed with multiple pieces of potato skins in them.

Interview on 02/06/25 at 11:50 A.M. with Executive Chef #173 confirmed the pieces of potato skin on the test fork and also confirmed that the potato skin should have been taken off the potatoes before they were pureed.

Review of the Standard Operating Procedure policy for Dietary, dated 06/20/22, revealed pureed level foods were to be modified to be smooth in consistency and culinary teams should use a spoon test to ensure the food had been prepared according to guidelines for pureed level foods.

Review of the 2025 facility recipe for pureed roasted potatoes revealed roasted potatoes should be smooth like pudding or soft mashed potato consistency.

Based on observation, staff interviews, policy review, and review of the facility safety data sheets, the facility failed to prevent access to harmful chemicals for memory care unit residents. This had the potential to affect 18 (Residents #55, #56, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #70, #71, #73, #74, #76) independently mobile residents in the memory care unit. There were a total of 23 residents who reside in the memory care unit.

Findings include:

Observation on 02/06/25 at 9:45 A.M. revealed an unlocked housekeeping storage room with the door slightly ajar. Inside the housekeeping storage room were two containers of Envirox Concentrate Sanitizer/Virucide Cleaner (hydrogen peroxide). There were no staff observed in the immediate vicinity.

Observation on 02/06/25 at 3:31 P.M. revealed the housekeeping storage room unlocked. The two containers of Envirox Concentrate Sanitizer/Virucide Cleaner (hydrogen peroxide) were still in the room.

Interview on 02/06/25 at 3:32 P.M. with Licensed Practical Nurse (LPN) #176 confirmed the housekeeping storage room door was unlocked within the memory care unit. LPN #176 further confirmed that it should have been locked, as evidenced by keypad lock on door and due to the chemicals stored inside. She was unaware there were issues with the door not latching shut. LPN #176 confirmed that they would not want the memory care residents to have access to the chemicals stored in this room.

Interview on 02/06/25 at 3:52 P.M. with the Maintenance Manager #188 confirmed that he saw the housekeeping storage door close two times without latching and locking. He stated he had not received a report of there being an issue with the door. He denied any issues with any other doors in the facility.

Interview on 02/06/25 at 4:02 P.M. with the Executive Director confirmed that 18 of 23 residents in the Memory Care unit were independently mobile.

Review of the undated facility policy titled Hazardous Materials Policy revealed hazardous materials needed to be locked/stored in an area not accessible to residents.

Review of the Safety Data Sheet for Evirox Concentrate 118 revealed instructions that the hydrogen peroxide concentrate should be kept away from children and only handled with proper personal protective equipment.