Westerville Senior Living

Based on interview, record review and policy review, the facility failed to ensure a physician order was obtained prior to admitting Resident #56 to a secured memory care unit. This affected one (#56) of four residents whose comprehensive assessments were reviewed. The facility census was 51. Findings include: Review of Resident #56's medical record revealed the resident was admitted to the facility on 04/08/25 with pertinent diagnoses of Alzheimer's disease, hyperlipidemia, hypertension, generalized anxiety disorder and other recurrent depressive disorders. Review of Resident #56's medical record revealed a physician letter dated 07/21/25 addressed to whom it may concern noting that while Resident #56 had a Saint Louis University Mental Status (SLUMS) score of 17 out of 30 indicating cognitive impairment, Resident #56 had no elopement attempts and therefore was deemed appropriate to safely remain in assisted living. Review of progress note dated 08/12/25 at 2:17 P.M. revealed Resident #56 moved into memory care (secured unit) on this date. Review of physician orders revealed no order for Resident #56 to reside in a secured unit. Review of medical record for Resident #56 revealed a document titled, Secured Environment Addendum signed by the resident's primary care physician (PCP) on 09/08/25 which attested to the benefit of Resident #56 residing in a secured environment. Interview on 11/18/25 at 12:49 P.M. with the Director of Nursing (DON) confirmed they did not have order for Resident #56 to be admitted to Memory Care Unit prior to the resident moving there. Interview on 11/18/25 at 1:28 P.M. with the DON confirmed that they had no other physician orders authorizing Resident #56's move to the memory care aside from what was signed on 09/08/25. She noted they had faxed the form to the physician for signature on 08/21/25, after the resident had moved to the memory care unit. Review of facility policy titled, Admission - Assisted Living and Memory Care - Ohio SpecificBased on interview, record review and policy review, the facility failed to ensure a physician order was obtained prior to admitting Resident #56 to a secured memory care unit. This affected one (#56) of four residents whose comprehensive assessments were reviewed. The facility census was 51.

Findings include:

Review of Resident #56's medical record revealed the resident was admitted to the facility on 04/08/25 with pertinent diagnoses of Alzheimer's disease, hyperlipidemia, hypertension, generalized anxiety disorder and other recurrent depressive disorders.

Review of Resident #56's medical record revealed a physician letter dated 07/21/25 addressed to whom it may concern noting that while Resident #56 had a Saint Louis University Mental Status (SLUMS) score of 17 out of 30 indicating cognitive impairment, Resident #56 had no elopement attempts and therefore was deemed appropriate to safely remain in assisted living.

Review of progress note dated 08/12/25 at 2:17 P.M. revealed Resident #56 moved into memory care (secured unit) on this date.

Review of physician orders revealed no order for Resident #56 to reside in a secured unit.

Review of medical record for Resident #56 revealed a document titled, Secured Environment Addendum signed by the resident's primary care physician (PCP) on 09/08/25 which attested to the benefit of Resident #56 residing in a secured environment.

Interview on 11/18/25 at 12:49 P.M. with the Director of Nursing (DON) confirmed they did not have order for Resident #56 to be admitted to Memory Care Unit prior to the resident moving there.

Interview on 11/18/25 at 1:28 P.M. with the DON confirmed that they had no other physician orders authorizing Resident #56's move to the memory care aside from what was signed on 09/08/25. She noted they had faxed the form to the physician for signature on 08/21/25, after the resident had moved to the memory care unit.

Review of facility policy titled, Admission - Assisted Living and Memory Care - Ohio Specific

Based on observation, interview, and record review, the facility failed to administer medications as ordered for Resident #18. This affected one resident (#18) of four whose medications were reviewed. The facility census was 51.

Findings include:

Review of Resident #18's medical record revealed the resident was admitted to the facility on 06/22/24 with diagnoses of atherosclerotic heart disease of native coronary artery with refractory again pectoris, polyneuropathy, chronic kidney disease stage three, and trigeminal neuralgia.

Review of physician orders for Resident #18 revealed an order for Carbamazepine 12 hour extended release 200 milligram capsule to be given by mouth twice daily at morning and bedtime.

Observation on 11/18/25 at 7:57 A.M. of morning medication administration by Licensed Practical Nurse (LPN) #234 to Resident #18 did not include the Carbamazepine capsule.

Review of the November 2025 Medication Administration Record for Resident #18 revealed the Carbamazepine medication was not given on 11/16/25 in the morning or evening, 11/17/25 in the morning or evening or 11/18/25 in the morning.

Interview on 11/18/25 at 2:45 P.M. with LPN #234 confirmed the Carbamazepine capsule had not been administered for the past three days for Resident #18 as they were waiting on the medicine from the pharmacy. She said she had made the DON aware.

Based on observation, interview, and review of the facility policy, the facility failed to ensure food was prepared in a sanitary manner. This had potential to affect 51 of 51 residents who consumed food from the kitchen. The facility census was 51. Findings include: Observation of tray line service on 11/18/25 from 11:53 A.M. to 12:15 P.M. revealed Sous Chef #228 used gloved hands to handle food, then used the same gloved hands to handle rags that he used to open oven doors and wipe off counters. At 11:58 P.M. the same rag was used to wipe meat thermometer and knife and at 12:02 P.M. Sous Chef #228 used one rag to wipe an oven surface, the cutting board and then with that rag, he wiped the meat thermometer off after obtaining the temperature of a hot dog. At 12:06 P.M. after handling food directly with gloved hands, Sous Chef #228 wiped the gloved hands on the rag that had just been used to wipe the meat thermometer and then used the rag to open the oven door. Interview on 11/18/25 at 12:15 P.M. with Food and Beverage Director #258 verified meat thermometers should be cleaned with alcohol or a sanitized cloth and not a cloth that had been used for other purposes in the kitchen. Review of facility policy titled, Sanitation PolicyBased on observation, interview, and review of the facility policy, the facility failed to ensure food was prepared in a sanitary manner. This had potential to affect 51 of 51 residents who consumed food from the kitchen. The facility census was 51.

Findings include:

Observation of tray line service on 11/18/25 from 11:53 A.M. to 12:15 P.M. revealed Sous Chef #228 used gloved hands to handle food, then used the same gloved hands to handle rags that he used to open oven doors and wipe off counters. At 11:58 P.M. the same rag was used to wipe meat thermometer and knife and at 12:02 P.M. Sous Chef #228 used one rag to wipe an oven surface, the cutting board and then with that rag, he wiped the meat thermometer off after obtaining the temperature of a hot dog. At 12:06 P.M. after handling food directly with gloved hands, Sous Chef #228 wiped the gloved hands on the rag that had just been used to wipe the meat thermometer and then used the rag to open the oven door.

Interview on 11/18/25 at 12:15 P.M. with Food and Beverage Director #258 verified meat thermometers should be cleaned with alcohol or a sanitized cloth and not a cloth that had been used for other purposes in the kitchen.

Review of facility policy titled, Sanitation Policy

Based on record review and staff interview, the facility failed to ensure staff completed new hire orientation including layout, job responsibilities, obtaining emergency assistance fire control and evacuation procedures. This had potential to affect all 62 residents residing in the facility.

Findings include:

Review of the employee files revealed Licensed Practical Nurse (LPN) #109 started on 01/07/24, LPN #135 started on 02/28/24, LPN #158 started on 04/17/24, Caregiver #156 started on 12/21/23, Caregiver #142 started on 02/03/25 and Caregiver #157 started on 03/13/24. There was no evidence staff completed new hire orientation including layout, job responsibilities, obtaining emergency assistance fire control and evacuation procedures.

Interview on 02/12/25 at 5:10 P.M. with the Executive Director (ED) stated the facility provides a packet to the new employee and verified LPN #135, LPN #158, Caregiver #156, Caregiver #142, and Caregiver #157 did not sign the paperwork acknowledging they had received the training on layout, job responsibilities, obtaining emergency assistance fire control and evacuation procedures.

Based on record review and staff interview, the facility failed to ensure staff were checked in the nurse aide registry prior to hire. This had potential to affect all 62 residents residing in the facility.

Findings include:

Review of employee files revealed Licensed Practical Nurse (LPN) #109 started on 01/07/24, LPN #135 started on 02/28/24, and Caregiver #156 started on 12/21/23. There was no evidence of the employees being checked in the nurse aide registry prior to their first day of employment.

Interview on 02/12/25 at 5:10 P.M. with the Executive Director (ED) verified LPN #109, LPN #135, and Caregiver #156 had evidence of being checked in the nurse aide registry.

Based on observation and staff interview, the facility failed to ensure a local newspaper was made available in print or electronic format. This had potential to affect all 62 residents residing in the facility.

Findings include:

Observation on 01/12/25 at 10:00 A.M. to 11:00 A.M. revealed no local newspaper was observed.

Interview on 02/12/25 at 11:30 A.M. with the Executive Director (ED) confirmed the facility did not provide residents with access to a local newspaper. The ED verified residents shall get their own copy and voiced she was unaware of any requirement related to newspaper availability in assisted living.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 62 residents residing in the facility who received food from the kitchen.

Findings include:

Observation on 02/12/25 at 9:45 A.M. revealed in the dry storage area, there was one can of seafood that had a large dent and was on the for-use shelf. There were two opened and undated bags of dried pasta shells and an opened and undated jug of butter alternative. The refrigerator contained two opened and undated gallons of milk and two opened and undated bags of cheese.

Interview on 02/12/25 at 9:45 A.M. with Kitchen Manager #190 confirmed the dented seafood can, two opened and undated bags of pasta shells, opened and undated butter alternative, two opened and undated gallons of milk, and two opened and undated bags of cheese. Kitchen Manager #190 stated they should be labeled and dated with the opened date.

Review of the facility's undated policy titled Ohio Food Handling and Storage revealed no specific information to labeling. The policy stated, You can consult your local health department for more specific information.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure fire drills were conducted monthly on each shift every quarter, and failed to document fire alarm transmission and the receipt of the alarm by the alarm company for each drill. This had potential to affect all 62 residents residing in the facility.

Findings include:

Review of the fire drill documentation from 01/01/24 to 12/31/24 revealed there was no evidence a third shift fire drill was completed the first quarter of 2024 (January through March 2024) and the third quarter (July to September 2024). There was no first shift fire drill the third quarter (July to September 2024) and fourth quarter (October through December 2024).

The fire drills dated 02/07/24 at 4:00 P.M. and 04/30/24 at 3:10 P.M. found no evidence of verification of receipt of the fire alarm signal by the security company or 911. There was no fire drill documentation a fire drill was conducted in 08/2024 and 09/2024.

Interview on 02/12/25 on 3:47 P.M. with Maintenance Director (MD) #130 stated the facility had no maintenance staff from 08/2024 and 09/2024 for fire drills and confirmed they likely were not done. MD #130 confirmed the facility had no evidence of a first shift drill in third and fourth quarter of 2024 and no third shift drills in the first and third quarter of 2024. MD #130 also confirmed the facility does not have verification of receipt of the fire alarm either by security company for fire drills 02/2024 and 04/2024.

Review of the facility policy titled Fire Drills dated 03/06/24 revealed the facility shall conduct fire drills monthly rotating.

Based on record review and staff interview, the facility failed to ensure fire drill evaluations included all required pieces of information including the number of residents evacuated and weather conditions present at the time of the drill. This had potential to affect all 62 residents residing in the facility.

Findings include

Review of the facility's fire drill documentation revealed the fire drills completed on 01/11/24, 02/07/24, 03/25/24, 04/30/24, 05/24/24, 06/21/24, 07/29/24, 10/31/24, 11/26/24, 12/20/24, and 01/30/25 did not include the number of residents evacuated or weather conditions present at the time of the drill.

Interview on 02/12/25 on 3:47 P.M. with Maintenance Director (MD) #130 stated he was not aware of the requirement to document weather conditions and confirmed the drills did not include the number of resident evacuated and weather condition at the time of the drill.

Based on staff interview and record review, the facility failed to ensure a grievance committee was established for any concerns that may arise. This had potential to affect all 62 residents residing in the facility.

Findings include:

Interview on 02/12/25 at 11:30 A.M. with the Executive Director (ED) confirmed facility did not have a grievance committee and was unaware of the requirement for Ohio assisted livings. She stated they had resident council meetings and a grievance policy, but the facility had no designated members of a grievance committee for when concerns were brought to the attention of management staff.

Record review revealed no evidence of a grievance committee was established at facility.

Review of the policy titled Grievance - Ohio Specific dated 01/2015 revealed resident can voice concerns at resident council meetings or with community management. If the resident feels their concerns was not satisfactorily resolved, they make a formal complaint in writing to the ED and shall receive a response within five working days. The policy did not include any language related to a grievance committee or a group of staff and residents reviewing and addressing official grievances.

Based on record review and staff interview, the facility failed to ensure staff signed acknowledgements and placed them in the employee file for transfers/discharges and local and state agency contacts. This had potential to affect all 62 residents residing in the facility.

Findings include:

Review of the employees files revealed Licensed Practical Nurse (LPN) #109 started on 01/07/24, LPN #135 started on 02/28/24, LPN #158 started on 04/17/24, Caregiver #155 started on 12/21/23, and Caregiver #157 started on 03/13/24 revealed no evidence staff completed signed acknowledgements for transfer/discharge and local and agency contacts such as the ombudsman and local health departments.

Interview on 02/12/25 at 5:10 P.M. with the Executive Director (ED) confirmed the employee files on LPN #109, LPN #135, LPN #158, Caregiver #155, Caregiver #157 did not contain evidence of the required signed acknowledgements.

Based on observation and staff interviews, the facility failed to ensure the most recent results were readily available and accessible to the residents. This has the potential to affect 62 residents residing in the facility.

Findings include:

Observation and interview on 02/12/25 at 11:20 A.M. with Concierge #168 found no evidence of survey results within easy access. Concierge #168 stated the survey results were kept in a binder behind Concierge #168's desk, where the survey results would have to be requested from staff. Concierge #168 stated multiple staff members may utilize this desk.

Interview on 02/12/25 at 3:10 P.M. with Director of Nursing (DON) stated there was no written policy at the facility regarding placement of survey results.