Gables of Westerville

Based on observation, interview and facility policy review, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all residents at the facility. Facility census was 82.

Findings include:

Observation of the walk-in refrigerator on 11/06/25 at 9:20 A.M. with Dietary Manager (DM) # 555 revealed an open and undated one quart bottle of lemon juice that had an expiration date of 10/11/25, an opened and undated one gallon container of apple cider and a large container of approximately 20 sausage patties opened with no date.

Observation of the reach in refrigerator on 11/06/25 at 9:25 A.M. with DM # 555 revealed an open and undated five-pound container of sour cream, an open and undated one gallon container of jalapeno's, and open and undated five-pound container of cottage cheese and an open and undated one gallon container of garlic parmesan dressing.

Observation of the Freezer on 11/06/25 at 9:30 A.M. with DM # 555 revealed a large open and undated bag with three remaining bread sticks and a large open and undated bag of breaded pork chops.

Interview 11/06/25 at 9:22 A.M. with DM #555 revealed that all items once opened should be dated with open dates and discarded within seven days of open dates.

Review of the facilities undated Assisted Living Food Storage Policy revealed under refrigerated storage: all prepared and opened food items should be labeled and dated, and under frozen storage: items should be labeled and dated upon freezing.

Based on observation, interview, and policy review, the facility failed to ensure hazardous chemicals were properly secured on the memory care unit. This had the potential to affect all 23 residents that resided on the memory care unit. The facility census was 82.

Findings include:

An observation on 11/06/25 at 8:30 A.M. revealed the spa room on the memory care unit was unlocked. No staff or residents were observed near the spa room. A spray can of OdoBan disinfectant was sitting on the counter near the whirlpool tub. The counter was at a height where a resident standing or sitting in a wheelchair could reach the Odoban disinfectant spray. OdoBan cleans, disinfects, sanitizes, and freshens and had a warning on the front of the can to keep out of reach of children. Housekeeper #208 verified the door to the spa unit was supposed to be locked and required a four-digit code to open the door. Housekeeper #208 stated she had unlocked the spa door to check it. Housekeeper #208 also verified the Odoban disinfectant spray was sitting where a resident could reach it if they entered the spa area when the door was unlocked.

An observation on 11/12/25 at 7:55 A.M. revealed the door to the spa on the memory care unit was unlocked. No staff or residents were observed near the spa room. A spray can of OdoBan was sitting on the counter near the whirlpool tub.

An interview on 11/12/25 at 7:58 A.M. Licensed Practical Nurse (LPN) #216 verified the door to the spa was unlocked and the OdoBan disinfectant spray was not properly stored out of reach of residents. LPN #216 also verified many residents on the memory care unit wandered throughout the unit.

Review of Preventing Ingestion of Toxic Materials policy 2018 revealed routine inspections of the community to ensure anything that may pose a hazard to a resident is identified and stored safely. Staff is trained to observe for these materials and proper storage. In addition to employees' awareness, preventive measures are put in place. The preventive measures include proper storage of anything that may pose a hazard and routine community inspections.

This deficiency represents non-compliance investigated under Complaint Number OH00168728.

Based on observation and interview the facility failed to ensure the rights of residents, home's rules, policies and procedures, list of residents' rights advocates, and most recent licensure inspection reports were posted in a prominently and readily accessible area of the facility. This had the potential to affect all 82 residents. Facility census was 82.

Findings include:

During a tour of the facility on 11/06/25 at 8:50 A.M. resident rights, the home rules, policies and procedures, list of residents' rights advocates, and survey results were not observed.

On 11/06/25 at 9:11 A.M. Executive Director (ED) provided a white binder at the receptionist's desk. The spine was marked as survey results but was facing the receptionist. Review of the survey results revealed only the re-licensure survey results dated 06/06/23 were present. The results for the complaint survey on 01/19/24, re-licensure survey on 02/06/25, and complaint survey on 09/04/25 were not included in the survey book. ED stated resident rights and advocate phone numbers were given to residents upon admission. ED verified resident rights, the home rules, policies and procedures, and list of residents' rights advocates were located on a bulletin board located behind the Activities Coordinator desk in the activity room. ED also verified there was not anything prominently posted notifying residents and visitors where the rights of residents, home's rules and policies and procedures, list of residents' rights advocates, and most recent licensure inspection report were located.

Based on record review, interviews, review of facility investigations, review of facility Self-Reported Incidents (SRI), review of disciplinary actions, review of facility educations, and review of facility policy, the facility failed to initiate and implement appropriate interventions for two residents who eloped from the facility. This affected two residents (#2 and #25) out of three reviewed for elopement. The facility census was 24.

Findings Include:

1. Review of the medical record for Resident #2 revealed an admission date of 01/29/24 and medical diagnosis of dementia, hallucinations, chronic respiratory disease, hypertension, sleep terrors, and amnesia.

Review of the progress note dated 05/11/25 at 2:30 P.M. indicated Resident #2 had exhibited wandering behaviors and required redirection and reorientation several times.

Review of the comprehensive review assessment dated 05/15/25 revealed Resident #2 exhibited exit seeking behavioral expressions with or without wandering into resident rooms and personalized interventions were to be added, though there was no documented evidence of what the personalized interventions were. The assessment also listed Resident #2 as having behavioral issues, but they were controlled with redirection.

Review of the Elopement Risk Assessment dated 06/11/25, revealed Resident #2 had a total score of 20, indicating he was a moderate risk for elopement. The assessment stated if a resident was moderate or high risk, the prevention protocol was to be implemented and documented on the service plan.

Review of Resident #2's record revealed no documented evidence of any prevention protocols or interventions listed.

Review of the incident report dated 07/27/25 at 2:00 P.M. revealed the alarm to the side door of the Memory Care Unit was alarming and two residents were standing by it. A Care Partner went to the door and noted no residents outside on patio. Staff of the Memory Care Unit then began to account for all residents. A staff member that lived by the facility noted Resident #2 at the end of the field, the staff member turned around and called the facility. Another Care Partner heard a resident was outside, the Care Partner ran across the field to get Resident #2 and helped redirect him back towards the facility. Resident #2 was cooperative and got into a staff members car and was returned to the facility without difficulty. The residents family was called, but did not answer the phone, a message was left to call the facility. The family was made aware of the situation on 07/28/25 in the morning as they were on vacation at the time of incident.

Review of the SRI number 263307, dated 07/28/25, revealed it was filed under the area of neglect and it was unsubstantiated. The SRI stated at approximately 2:00 P.M. on 07/27/25, the alarm to the side door of the Memory Care Unit was alarming and two residents were standing by it. A Care Partner went to the door and there were no residents outside that she could see. The Care Partner then began to account for all residents. Off duty staff saw Resident #2 at the end of the adjoining field and called the facility. Staff immediately went to the resident and escorted the resident back to facility and assisted back into unit and checked for injuries; none were present. As a result of the facilities investigation, the facility noted that they re-trained all nursing staff on the proper procedures for alarm doors and elopements.

Review of the Elopement Risk Assessment dated 07/29/25 revealed Resident #2 scored a 16, indicating he was a moderate risk for elopement. The assessment stated if a resident was moderate or high risk, the prevention protocol was to be implemented and documented on the service plan.

Review of Resident #2's record revealed no documented evidence of any new interventions listed related to the 07/27/25 elopement.

Review of the Employee Disciplinary Action Notice dated 07/29/25 revealed Licensed Practical Nurse (LPN) #307 was given a written warning for the 07/27/25 incident in which while he was on break, a Care Partner was also on break and the two other Care Partners were helping residents with showers, when Resident #2 exited out of the north door. LPN #307 was in the nurses station with the door closed. The corrective action stated the Memory Care nurse needed to communicate with Care Partners regarding breaks to ensure coverage on the floor at all times. LPN #307 refused to sign the form.

Review of the email Human Resource Director (HRD) #303 sent to all Care Partners and nurses on 08/01/25 stated due to recent events all Care Partners and nurses were required to read information on memory care and elopement and watch a video from YouTube. The video was 15 minutes and 9 seconds long.

Review of the staff elopement training's on 08/28/25 revealed 10 staff that had not completed the required training (video) that was initiated from Resident #2's elopement on 07/27/25.

Interview on 08/28/25 at 10:00 A.M. with Human Resource Director (HRD) #303 revealed there were eight Care Partners and two Licensed Practical Nurses as of 08/28/25 at 10:00 A.M. that had not completed the required training, per the SRI 263307's investigation and plan of correction.

Interview on 08/28/25 at 10:00 A.M. with Care Partner (CP) #301, verified that Resident #2 was frequently witnessed standing by the north exit door of the memory care unit. She also stated that Resident #2 had attempted several times to get out of the facility. CP #301 stated Resident #2 usually required redirection and reorientation and then would calm down and not try to elope.

Interview on 08/28/25 at 11:05 A.M. with CP #302, verified that Resident #2 frequently tried to leave the facility as the resident wanted to see friends and family. CP #302 stated that elopement behaviors for Resident #2 were worse in the afternoons, but usually the resident could be redirected.

Interview on 08/28/25 at 2:15 P.M. with the Executive Director verified that the prevention protocol and/or new interventions after the elopement for Resident #2 were not documented on the service plan as indicated by the Elopement Risk Assessment dated 07/29/25.

Review of the undated policy titled, Elopement Prevention and Elopement Actions - Assisted Living/Memory Care

Based on observation, staff interview, and policy review, facility staff failed to wear a beard restraint in the kitchen. This deficient practice had the ability to affect all 99 residents in the facility. The facility census was 99.

Findings include:

Observation made on 02/06/25 at 9:49 A.M., revealed Culinary Director #15 toured the kitchen and took food temperatures without wearing a beard restraint. Culinary Director #15 was observed to have a beard.

Interview on 02/06/25 at 9:49 A.M., with Culinary Director #15 confirmed he was not wearing a beard restraint.

Interview on 02/06/25 at 10:21 A.M., with Executive Director #4 revealed she expects Culinary Director #15 to wear a beard net in the kitchen but not in his office or the dining room.

Review of the policy titled, Gables of Westerville Culinary Policies and Procedures dated 2018, stated hair must be secured away from face with clips or rubber bands. Long hair must be confined.

Review of the policy titled, Food Safety Program Memorandum Hair restraints - effectiveness dated May 2019, stated Beard Restraints: All facial hair that is longer than ¼ inch must be restrained through the use of a beard net or snood.

Based on record review, staff interviews, and policy review, the facility failed to have 12 monthly fire drills, conduct fire drills on each shift every 3 months, and evacuate residents in at least two fire drills a year on each shift. This deficient practice had the ability to affect all 99 residents who reside in the facility. The facility census was 99.

Findings include:

Review of the monthly fire drills from 02/29/24 to 01/28/25 revealed the facility did not complete 12 fire drills for the year. The facility did not complete a fire drill during the month of August 2024.

Fire drills for the day shift were as follows: 02/29/24 at 11:30 A.M, 03/30/24 at 12:57 P.M., 06/24/24 at 1:10 P.M., 11/27/24 at 12:00 P.M. and 01/28/25 at 10:00 A.M.

Fire drills for the evening shift were as follows: 04/30/24 at 8:15 P.M., 07/07/24 at 4:51 P.M., 09/26/24 at 4:15 P.M. and 12/17/24 at 10:00 P.M.

Fire drills for the night shift were as follows: 05/30/24 at 5:45 A.M. and 10/07/24 at 2:36 A.M.

Evacuation drills for the 12 month period 02/29/24 to 01/28/25 revealed only two evacuation drills completed on 01/28/25 and 11/27/24.

Interview on 02/06/25 at 11:00 A.M. with Executive Director #4 confirmed the facility did not complete a fire drill in August of 2024.

Interview on 02/06/25 at 1:47 P.M. with Maintenance Director #5 confirmed the facility did not complete a fire drill in August of 2024 and fire drills were not completed on three different shifts every three months last year. Maintenance Director #5 confirmed residents were only evacuated two times in the last twelve month period during fire drills.

Review of the policy titled, Gables of Westerville Plant Operations Policies and Procedures dated 2018, stated Staff responsible for residents shall participate in a mock drill on a monthly basis that reviews evacuation procedures for each shift quarterly, and/or as required by state regulations. A community full evacuation drill should be performed at least annually and/or as required by state regulations. Fire alarm drills shall be completed for all shifts, on a quarterly basis, unless state or local laws and regulations require a more frequent drill schedule. The Maintenance Director shall, on a monthly basis, perform a fire drill to establish ongoing safety in-service for all staff.

This violation is an eaxmple of the continued noncomplaince from the survey dated 06/06/23.

Based on observations, staff interviews, and policy review, the facility failed to ensure the proper storage of hazardous material. This deficient practice had the potential to affect 11 of 22 ambulatory cognitively impaired residents in the memory care unit. The facility census was 99.

Findings include:

Observation on 02/06/25 at 9:09 A.M., revealed a container of Clorox wipes was found in an unlocked cupboard in the memory care spa room. On 02/06/25 at 9:13 A.M., a second container of Clorox wipes and a spray bottle of Buckeye Neutral Disinfectant were found in the memory care unit. The container and bottles contained precautionary labels harmful if ingested or in the eyes.

Interview on 02/06/25 at 09:18 A.M., with Caregiver #10, confirmed that a container of Clorox wipes were left in an unlocked cupboard in the memory care spa room and a second container of Clorox wipes and a bottle of Buckeye Neutral Disinfectant were left in a unlocked cupboard in the memory care unit. Caregiver #10 confirmed hazardous materials should be locked in a secure area. Both containers of Clorox and the spray bottle of Buckeye Neutral Disinfectant were removed from the care area by Caregiver #10.

Review of the undated policy titled, Hazardous Material