Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observations, resident and staff interview, medical record review, and facility policy review, the facility failed
to provide adequate accommodations for a resident to elevate his legs when he was out of bed as ordered.
This affected one resident (#42) of two reviewed for environment. The facility census was 50.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #42 revealed an admission date on 03/03/23. Medical diagnoses
included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder (COPD),
hypertensive chronic kidney disease Stage 3, lymphedema, morbid obesity, and Type II Diabetes Mellitus.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42
had mildly impaired cognition and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS)
assessment. Resident #42 required extensive assistance from one to two staff to complete Activities of
Daily Living (ADLs).
Review of the physician orders dated March 2023 revealed Resident #42 had the following order: Alternate
from bed to chair at intervals, bilateral extremities MUST be elevated when resident out of bed per Nurse
Practitioner (NP) twice daily. The order was dated 03/16/23.
Review of the care plan dated 03/18/23 revealed the care plan did not address Resident #42's diagnosis of
lymphedema.
Observations on 04/03/23 at 3:50 P.M., 04/04/23 at 11:25 A.M., 04/05/23 at 12:39 P.M., and 04/06/23 at
10:31 A.M. of Resident #42 revealed the resident was out of bed, sitting in a recliner chair in his room. The
residents legs were hanging down to the floor. Both legs appeared to be nearly twice the normal size and
were wrapped in ace bandages.
Interview on 04/03/23 at 3:50 P.M. with Resident #42 revealed he was not able to elevate his legs when he
was sitting up in his recliner because the leg rest would not stay up when he placed his legs on it. Resident
#42 stated he was aware he should elevate his legs as much as possible but did not have any way to do
that when he was not laying in bed.
Interview and observation on 04/05/23 at 12:39 P.M. with Certified Resident Medication Assistant (CRMA)
#111 confirmed Resident #42 was sitting in his recliner chair with his legs hanging down. Resident #42
agreed to allow CRMA #111 attempt to raise the leg rest in order for the resident to elevate his legs.
Resident #42 reclined back in his chair and the leg rest raised up under the resident's
(continued on next page)
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
Page 1 of 19
Event ID:
366480
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
legs. Resident #42 proceeded to place the full weight of his legs down on to the leg rest and the rest
immediately collapsed back down. CRMA #111 confirmed the leg rest did not support the weight of
Resident #42's legs in order to keep them elevated. Resident #42 stated he informed therapy of the issue
but no additional recommendations or follow up was provided to the resident.
Interview on 04/05/23 at 2:30 P.M. with Physical Therapist (PT) #250 and Occupational Therapy Assistant
(OTA) #251 revealed they would recommend Resident #42 elevate his legs while sitting in the recliner chair.
PT #250 and OTA #251 confirmed they were aware Resident #42 was not elevating his legs but denied
being aware the resident's recliner would not support the weight of his legs. PT #250 and OTA #251 stated
according to the resident's Prior Level of Functioning, the resident was not elevating his legs prior to being
admitted to the facility.
Interview on 04/06/23 at 10:31 A.M. with Resident #42 revealed he would like to keep his legs elevated
when he was out of bed and stated, it would be good for them. Resident #42 stated the facility contacted
his wife yesterday and requested she bring in his lift chair from home so he can keep his legs elevated.
Review of the facility policy, Resident Rights Guidelines, revised 05/11/17, revealed the policy stated, the
purpose of the policy was to ensure resident rights are respected and protected and provide an
environment in which they can be exercised.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 2 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and facility policy review, the facility failed to provide a written notice
of transfer to a resident upon being transferred to the hospital. This affected one (#44) of one resident
reviewed for hospitalization. The facility census was 50.
Findings Include:
Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The
resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure
(CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and
encephalopathy (a brain disease).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's
cognition was not assessed. However, per staff assessment, Resident #44 had moderately impaired
cognition. Resident #44 required extensive assistance from one to two staff to complete Activities of Daily
Living (ADLs).
Review of the progress notes revealed on [DATE] at 10:17 A.M., Resident #44 was having shortness of
breath and was not maintaining oxygen sat above 90% on three liters of oxygen. The resident was not
responding to verbal commands and was not able to eat breakfast or take medications. Resident #44's vital
signs were temperature 98.1 degrees, blood pressure 102/62, pulse 98, and respirations 16. The on call
Certified Nurse Practitioner (CNP) was notified and she ordered to send Resident #44 to the hospital.
Emergency Medical Services (EMS) took resident out around 9:25 A.M.
There was no evidence of a transfer notice in Resident #44's medical record.
Interview on [DATE] at 4:35 P.M. with the Administrator confirmed there was no evidence that a transfer
notice was completed or provided to Resident #44 or the representative when the resident was transferred
to the hospital on [DATE].
Review of the facility policy, Guidelines for Transfer and Discharge (including AMA), revised [DATE],
revealed the facility policy stated, Emergency transfer procedures should include the following: nursing
should print and send the resident's Continuum of Care Document (CCD) which includes current
diagnoses, most recent vital signs, allergies, attending physician, current medications, treatments, and
Advance Directives.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 3 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and facility policy review, the facility failed to provide a written bed
hold notice to a resident upon being transferred to the hospital. This affected one (#44) of one resident
reviewed for hospitalization. The facility census was 50.
Findings Include:
Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The
resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure
(CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and
encephalopathy (a brain disease).
Review of Resident #44's payer source revealed the resident had Medicaid.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's
cognition was not assessed. However, per staff assessment, Resident #44 had moderately impaired
cognition. Resident #44 required extensive assistance from one to two staff to complete Activities of Daily
Living (ADLs).
Review of the progress notes revealed on [DATE] at 10:17 A.M., Resident #44 was having shortness of
breath and was not maintaining oxygen sat above 90% on three liters of oxygen. The resident was not
responding to verbal commands and was not able to eat breakfast or take medications. Resident #44's vital
signs were temperature 98.1 degrees, blood pressure 102/62, pulse 98, and respirations 16. The on call
Certified Nurse Practitioner (CNP) was notified and she ordered to send Resident #44 to the hospital.
Emergency Medical Services (EMS) took resident out around 9:25 A.M.
There was no evidence of written bed hold notice being provided to Resident #44 or the resident's
representative in the medical record.
Interview on [DATE] at 4:35 P.M. with the Administrator confirmed there was no evidence that a bed hold
notice was completed or provided to Resident #44 or the representative when the resident was transferred
to the hospital on [DATE].
Review of the facility policy, Guidelines for Transfer and Discharge (including AMA), dated [DATE], revealed
the policy stated, Before the facility transfers a resident to a hospital or allows a resident to go on
therapeutic leave, the discharging nurse or other designated staff member should provide written
information to the resident and a family member or legal representative of the bed-hold and admission
policies. In cases of emergency transfers, the notice of the bed-hold policy under the State plan and the
facility's bed-hold policy should be provided to the resident or resident's representative within 24 hours of
the transfer. This may be sent with other papers accompanying the resident to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 4 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview, document review, and policy review the facility failed to coordinate assessments with the
pre-admission screening and resident review (PASARR) for Resident #1 when she had a new diagnosis of
schizophrenia and Resident #8 when they did not have a correct mental health diagnosis. This affected two
residents (#1 and #8) of two residents reviewed for PASARR. The facility census was 50.
Findings include:
1. Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnoses of:
schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma,
hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified
dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary
incontinence.
Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was
cognitively intact and required physical help in bathing, supervision for personal hygiene and was
independent in all other activities of daily living. The resident used a walker to aid in mobility and was
frequently incontinent of bowel and bladder.
Review of Resident #1 medical record diagnosis list revealed a diagnosis of schizoaffective disorder,
depressive type on 09/27/22.
Review of Resident #1's medical record revealed there was not an updated PASARR with the diagnosis of
schizophrenia.
Review of the 01/24/22 pre-admission screening and resident review (PASARR) revealed the only mental
health diagnosis listed was delusional disorder.
Interview with Director of Social Services #169 on 04/04/23 at 3:36 P.M. confirmed the PASARR needed to
be updated for Resident #1 due to a schizophrenia diagnosis.
2. Review of the medical record for Resident #8 revealed an admission date on 03/20/21. Medical
diagnoses included vascular dementia (12/19/22), major depressive disorder (09/15/21), and psychotic
disorder with delusions (09/29/21).
Review of the physician orders dated March 2023 revealed Resident #8 had an order with a start date of
01/18/23 for: Zoloft 75 milligrams (mg) (an anti-depressant medication).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had
impaired cognition and scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) assessment.
Resident #8 required extensive assistance from one to two staff to complete Activities of Daily Living
(ADLs).
Review of the Preadmission Screening and Resident Review Identification Screen (PASARR) dated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 5 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
03/22/21 revealed no mental health diagnoses or psychotropic medications were included on the
screening.
Interview on 04/04/23 at 3:36 P.M. with the Director of Social Services (DOSS) #169 confirmed Resident
#8's PASARR screening should have been updated to include all mental health diagnoses and medications
used to treat the resident's mental health. DOSS #169 stated she was currently working on completing a
whole house audit for PASARR screenings.
Review of the facility policy, PASARR Quick Sheet, undated, revealed the policy stated, If any of the
following triggers a positive response on current residents without a Level II PASARR; contact the PASARR
office: progress note with treatment, prescription initiated and/or adjustments by a psych physician that may
require a PASARR review to determine if a response to referral or new Level II is needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 6 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0646
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the appropriate authorities when residents with MD or ID services has a significant change in
condition.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interview, document review, and policy review the facility failed to notify the state mental health
authority for Resident #1 when she had a new diagnosis of schizophrenia and Resident #8 when had a new
mental health diagnoses of vascular dementia, major depressive disorder, and psychotic disorder with
delusions. This affected two residents (#1 and #8) of two residents reviewed for mental health screening.
The facility census was 50.
Findings include:
1. Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnosis of:
schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma,
hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified
dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary
incontinence.
Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was
cognitively intact and required physical help in bathing, supervision for personal hygiene and was
independent in all other activities of daily living. The Resident used a walker to aid in mobility and was
frequently incontinent of bowel and bladder.
Review of Resident #1 medical record diagnosis list revealed a diagnosis of schizoaffective disorder,
depressive type on 09/27/2022.
Review of the medical record revealed there was not an updated PASARR with the diagnosis of
schizophrenia.
Review of the 01/24/22 pre-admission screening and resident review (PASARR) revealed the only mental
health diagnosis listed was delusional disorder.
Interview with Director of Social Services #169 on 04/04/23 at 03:36 P.M. confirmed the PASARR needs to
be updated for Resident #1 due to a schizophrenia diagnosis and that she did not notify the state mental
health authority of the new diagnosis.
2. 2. Review of the medical record for Resident #8 revealed an admission date on 03/20/21. Medical
diagnoses included vascular dementia (12/19/22), major depressive disorder (09/15/21), and psychotic
disorder with delusions (09/29/21).
Review of the physician orders dated March 2023 revealed Resident #8 had an order with a start date of
01/18/23 for Zoloft 75 milligrams (mg) (an anti-depressant medication).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had
impaired cognition and scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) assessment.
Resident #8 required extensive assistance from one to two staff to complete Activities of Daily Living
(ADLs).
Review of the Preadmission Screening and Resident Review Identification Screen (PASARR) dated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 7 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0646
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
03/22/21 revealed no mental health diagnoses or psychotropic medications were included on the
screening.
Interview on 04/04/23 at 3:36 P.M. with the Director of Social Services (DOSS) #169 confirmed Resident
#8's PASARR screening should have been updated to include all mental health diagnoses and medications
used to treat the resident's mental health and the state mental health board should have been contacted
about the changes. DOSS #169 states she was currently working on completing a whole house audit for
PASARR screenings.
Review of the facility policy, PASARR Quick Sheet, undated, revealed the policy stated, If any of the
following triggers a positive response on current residents without a Level II PASARR; contact the PASARR
office: progress note with treatment, prescription initiated and/or adjustments by a psych physician that may
require a PASARR review to determine if a response to referral or new Level II is needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 8 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop and implement a comprehensive
person centered dental care plan. This affected one resident (#6) of two residents reviewed for dental care.
The facility census was 50.
Findings include:
Resident observation on 04/03/23 at 10:45 A.M. revealed Resident #6 had natural teeth with several broken
or missing, teeth were discolored. Gums were moist and pink in color with no bleeding observed. Tongue
was pink in color. No food particles were observed.
Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Parkinson's
disease, vascular dementia, weakness and depression disorder. The resident had a diet order for regular
textured foods with special instructions for mechanical soft foods on request by resident.
Record review revealed Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed
Resident #6 indicated oral pain and difficulty with chewing. The MDS revealed Resident #6 had obvious or
likely cavity or broken natural teeth.
Review of Resident #6's comprehensive care plan revealed no dental care plan was implemented since
admission to facility.
Interview on 04/04/23 at 2:30 P.M. with Minimum Data Set (MDS) Registered Nurse (RN) #151 verified the
MDS-RN was responsible for the creating and implementation of resident comprehensive person centered
care plan.
Interview on 04/05/23 at 12:33 P.M. with Minimum Data Set (MDS) Registered Nurse (RN) #151 confirmed
Resident #6's dental care plan wasn't developed until 04/04/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 9 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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, staff interview, and facility policy review, the facility failed to appropriately assess
and monitor pressures ulcers. This affected one resident (#152) of four residents reviewed for pressure
ulcers. The census was 50.
Residents Affected - Few
Findings Include:
Record review revealed Resident #152 was admitted to the facility on [DATE]. Her diagnoses were
encounter for surgical aftercare following surgery of the skin and subcutaneous tissue, fibromyalgia,
cervical disc degeneration, rheumatoid arthritis, urinary tract infection, morbid obesity, lymphedema,
pressure ulcer of sacral region, depression, anxiety disorder, type II diabetes, hypothyroidism, overactive
bladder, hyperlipidemia, bacteremia, rectal abscess, age related physical debility, weakness, and sepsis.
Review of her Minimum Data Set (MDS) assessment, dated 02/16/23, revealed she was cognitively intact.
Review of Resident #152's pressure ulcer skin logs and assessments, dated 02/16/23 and 02/17/23,
revealed she had three pressure ulcers documented (right buttock, left buttock, and coccyx). All three were
measured and documented as being unstageable (defined as full-thickness skin and tissue loss in which
the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by
slough or eschar).
Review of Resident #152's pressure ulcer skin logs, dated 02/23/23 to 03/07/23, revealed each wound was
measured weekly, but there was no assessment to the staging of each wound.
Review of Resident #152's progress notes, dated 03/11/23, revealed she was discharged home with her
sister due to her skilled nursing services coming to an end.
Review of Resident #152's progress notes, dated 03/28/23, revealed she returned/re-admitted to the facility
from the hospital.
Review of Resident #152's pressure ulcer skin logs and assessments, dated 03/31/23 to 04/04/23, revealed
she had two pressure ulcers (left buttock and coccyx). The assessments determined that depth could be
measured for each of these wounds, but the wounds were not staged.
Interview with the Director of Health Services (DHS) on 04/06/23 at 8:07 A.M. confirmed there was no
staging of Resident #152's wounds after 02/17/23 and when she returned back to the facility on [DATE].
The DHS stated they will stage the wound during the first assessment and then don't stage it unless there
is a change. However, the DHS also confirmed there should have been a staging of the wound when she
returned to the facility on [DATE].
Review of facility General Guidelines for Wound and Skin Care, dated 12/31/22, revealed the facility was to
document the type of wound, location, stage (if applicable), length, width, depth in centimeters, base,
drainage, peri-tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 10 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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
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.
Based on resident and staff interview, observation, and record review the facility failed to store drugs in
locked compartments when staff left an inhaler and nasal spray in a resident's room. This affected one
resident (#1) of five residents reviewed for medications. The facility census was 50.
Findings Include:
Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnoses of:
schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma,
hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified
dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary
incontinence.
Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was
cognitively intact and required physical help in bathing, supervision for personal hygiene and was
independent in all other activities of daily living. The resident used a walker to aid in mobility and was
frequently incontinent of bowel and bladder.
Observation of Resident #1's room on 04/03/23 at 10:14 A.M. revealed she had an albuterol sulfate inhaler
(asthma medication) and a fluticasone propionate (allergy medication) nasal spray on her bedside table in
her room.
Interview with Resident #1 on 04/03/23 at 10:15 A.M. revealed the inhaler and nasal spray had been in her
room for a few days and the nurse usually gives it to her and then takes it back to the med cart.
Interview and observation with Licensed Practical Nurse (LPN) #183 on 04/03/23 ay 11:30 A.M. verified
Resident #1 had an albuterol sulfate inhaler and a fluticasone propionate nasal spray on her bedside table
and she was not assessed to be able to self administer medications safely.
Review of Resident #1's medical record revealed no order for her to self administer medication. The
resident had an order dated 01/29/22 for fluticasone propionate nasal spray 50 micrograms (mcg) one
spray both nostrils twice a day at 6:00 A.M. and 6:00 P.M. Resident #1 had an order dated 01/29/22 for
albuterol sulfate inhaler 90 mcg one to two puffs for wheezing every six hours as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 11 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0791
Provide or obtain dental services for 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, interview, policy review, and record review the facility failed to provide emergency dental care.
This affected one resident (#6) of two residents reviewed for dental services. The facility census was 50.
Residents Affected - Few
Findings include:
Resident interview on 04/03/23 at 10:39 A.M. revealed Resident #6 complained of oral discomfort when
chewing meat. Resident #6 stated he had requested to see a dentist several times to staff.
Resident observation on 04/03/23 at 10:45 A.M. revealed Resident #6 had natural teeth with several broken
or missing, teeth were discolored. Gums were moist and pink in color with no bleeding observed. Tongue
was pink in color. No food particles were observed.
Resident observation on 04/05/23 at 8:35 A.M. revealed resident requested to see a dentist to Registered
Nurse (RN) #195 because of oral discomfort.
Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Parkinson's
disease, vascular dementia, weakness and depression disorder. The resident had a diet order for regular
textured foods with special instructions for mechanical soft foods on request by resident.
Record review revealed Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed
Resident #6 indicated oral pain and difficulty with chewing. The MDS revealed Resident #6 had obvious or
likely cavity or broken natural teeth.
Review of Resident #6's ancillary dental service progress note dated 01/12/23 revealed several teeth
fractured off or missing. The dental service progress note recommended to tell social services if pain
developed and dentist will come and remove offending teeth.
Review of Resident #6's monthly weights revealed the previous four months (January 2023 to April 2023)
Resident #6's weights were stable, ranging from 175.9 to 177.6 pounds.
Review of Resident #6's oral intakes revealed the previous four months (January 2023 to April 2023)
Resident #6's meal intake percentages ranged from 25% to 100% of consumed meal.
Review of Resident #6's dietary supplement intake revealed for the previous 14 days (03/22/23 to 04/05/23)
25% to 100% consumption of supplement.
Review of Resident #6's progress notes dated 04/03/23 to 04/06/23 revealed no complaint of oral pain or
difficulty chewing.
Interview on 04/05/23 at 12:33 P.M. with Minimum Data Set (MDS) Registered Nurse (RN) #151 revealed
clinical staff do not complete oral assessments for dental complaints.
Interview on 04/05/23 on 3:05 P.M. with Social Services #169 revealed process for requesting dentist visit
begins with staff reporting a resident experiencing oral pain or difficulty chewing. Social services will contact
ancillary dental services for an emergency visit to be scheduled.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 12 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0791
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 04/05/23 at 4:10 P.M. with Social Services #169 confirmed no staff had reported Resident #6
had complaint of oral discomfort or request to see a dentist.
Review of facility policy entitled, Dental Services Including Repair, Replacement (revised date 12/31/22),
revealed clinical staff will assess resident teeth and gums as needed to identify pain or broken teeth.
Facility staff will ensure delivery of emergency dental services to meet the resident needs.
Event ID:
Facility ID:
366480
If continuation sheet
Page 13 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interviews, and facility policy review the facility failed to properly store and
date opened food items and failed to have dietary staff secure loose hair in a hair restraint during food
preparation. This had the potential to affect all 50 residents in the facility. The facility census was 50.
Findings include:
During the initial tour of the kitchen on 04/03/23 from 8:20 A.M. to 9:15 A.M. the following was observed in
Freezer #1:
- A bag of frozen plant based meatballs was placed inside an opened cardboard box. The plant based
meatballs was exposed to the air. The meatballs were not dated. This was confirmed with Dietary
Supervisor (DS) #167 at 8:35 A.M.
- A bag of frozen plant based patties was placed inside an opened cardboard box. The plant based patties
were exposed to the air. The patties were not dated. This was confirmed with DS #167 at 8:35 A.M.
- A bag of frozen hamburger patties was placed inside an opened cardboard box. The hamburger patties
were exposed to the air. The patties were not dated. This was confirmed with DS #167 at 8:35 A.M.
- A bag of frozen breaded chicken patties was placed inside an opened cardboard box. The breaded
chicken patties were exposed to the air. The chicken patties were not dated. This was confirmed with DS
#167 at 8:35 A.M.
- A bag of frozen chicken breasts was placed inside an opened cardboard box. The chicken breasts were
exposed to the air. The chicken breasts were not dated. This was confirmed with DS #167 at 8:35 A.M.
The following observations were made in Cooler #1 during the initial tour:
- An opened bottle of Red Hot hot sauce was not dated. This was confirmed with Dietary Supervisor (DS)
#167 at 8:40 A.M.
- An opened bottle of prepared yellow Mustard with an expiration date of 03/15/23. This was confirmed and
was removed from Cooler #1 by Dietary Supervisor (DS) #167 at 8:40 A.M.
The following observations were made during lunch meal food preparations on 04/05/23 at 10:26 A.M.
- During preparation of pureed textured food, Dietary [NAME] #114 and Dietary Supervisor (DS) #167 were
observed wearing a hat with a long ponytail hanging out of the back, unrestrained.
- During lunch meal food tray preparations, Dietary Assistant #124 was observed rolling utensils in cloth
napkins with an unrestrained long ponytail hanging out the back of a hat.
Interview on 04/03/23 at 8:45 A.M. with Dietary Supervisor (DS) #167 confirmed kitchen policy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 14 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
states food is to be properly covered (not exposed to air) and a Date Code Genie is to be used to label food
products which includes: item name, date and time the food was labeled, use by date and initials of staff
member.
Review of kitchen policy, entitled Food Labeling and Dating Policy (dated 04/26/22), revealed food is to be
properly covered (not exposed to air) and a Date Code Genie is to be used to label food products which
includes: item name, date and time the food was labeled, use by date and initials of staff member.
Interview on 04/05/23 at 11:17 A.M. with the facility Administrator, confirmed kitchen policy states hair
restrained in a hat must be either in a bun style or tucked into the hat.
Review of facility kitchen policy entitled Hair Restraint (dated 11/30/21), revealed kitchen staff will wear a
hat that effectively keeps hair from contacting exposed food by securing hair that extrudes out of the hat by
wrapping in a bun style or tucked into the hat.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 15 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
Based on medical record review, staff interview, review of the hospice binder, and review of the hospice
contract, the facility failed to ensure continuity of care for a resident receiving hospice services when
hospice progress notes were not readily available to facility staff caring for a resident. This affected one
resident (#35) of one resident reviewed for hospice services. The facility census was 50.
Findings Include:
Review of the medical record for Resident #35 revealed an admission date on 02/01/22. Medical diagnoses
included encephalopathy (a brain disease), unspecified dementia, unspecified psychosis, developmental
disorder of scholastic skills, and other forms of scute ischemic heart disease.
Review of the physician orders dated March 2023 revealed Resident #35 had the following order dated
02/11/23:
admitted under hospice services related to other symptoms and signs involving cognitive functions
following cerebral infarction.
Review of the significant change Minimum Data Set (MDS) 3.0 assessment revealed Resident #35's
cognition was not assessed. However, pre staff assessment, revealed Resident #35 had severely impaired
cognition. Resident #35 required total dependence from one to two staff to complete Activities of Daily
Living (ADLs).
Review of the care plan dated 02/13/23 revealed Resident #35 required hospice care related to a terminal
diagnosis of other symptoms and signs involving cognitive functions following a cerebral infarction (stroke).
Interventions included: communicate with hospice when any changes are indicated to the plan of care,
coordinate care with hospice provider, and coordinate plan of care with hospice agency reflecting the
hospice philosophy.
Review of the hospice binder for Resident #35 revealed there were only the following notes in the binder:
Comprehensive assessment and plan of care update report dated 02/11/23, Routine Home Care note
dated 03/15/23 through 03/29/23, and a Facility Visit Checklist -Nurse dated 03/28/23. There were no
additional notes in the binder related to care provided by the hospice provider for Resident #35.
Interview on 04/05/23 at 12:20 P.M. with the Administrator confirmed Resident #35's hospice notes were
not kept on-site anywhere in the facility and they were not uploaded to the resident's electronic medical
record. The Administrator stated she had requested the notes from the provider but they were slow as
snails in responding to the request.
Interview on 04/05/23 at 12:49 P.M. with Registered Nurse (RN) #156 revealed she was aware Resident
#35 received hospice services. RN #156 stated if she was working when hospice visited Resident #35, she
received a verbal report from the hospice staff member regarding the resident. However, if she was not
working on the same day, it would be nice if they had the notes kept in a binder or something that we could
look at. RN #156 confirmed to her knowledge, there were not any hospice notes kept on site for any new
staff or agency staff or staff who were unfamiliar with Resident #35 that could be reviewed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 16 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0849
Level of Harm - Minimal harm
or potential for actual harm
Review of the hospice contract dated 11/20/20 revealed the contract stated, hospice and facility shall
communicate with each other regarding the hospice patient's condition through telephone, in-person verbal
communication, and if appropriate written communication in the hospice patient's medical record to ensure
that the hospice patient's needs are met 24 hours a day.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 17 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0881
Implement a program that monitors antibiotic use.
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, staff interview, and facility policy review, the facility failed to adequately follow
antibiotic stewardship procedures prior to the ordering and administering of antibiotics. This affected one
resident (#33) of two residents reviewed for antibiotic use. The census was 50.
Residents Affected - Few
Findings Include:
Record review revealed Resident #33 was admitted to the facility on [DATE]. Her diagnoses were
encephalopathy, sepsis, enterocolitis due to CDiff, acute respiratory failure, shock, pneumonia, dementia,
acute posthemorrhagic anemia, hyperlipidemia, hyperosmolality and hypernatremia, acute kidney failure,
major depressive disorder, insomnia, melena, hematemesis, hypertension, altered mental status, and
elevated white blood cell count.
Review of Minimum Data Set (MDS) assessment, dated 02/12/23, revealed she had a significant cognitive
impairment.
Review of Resident #33's progress note, dated 03/30/23, revealed Resident #33's family member was at
the facility and requested a urinalysis to be completed due to she thought that Resident #33 was more
confused than normal. The nurse documented that she did not notice any confusion out of Resident #33,
but reported the request to the nurse practitioner. The progress note revealed the nurse practitioner wanted
to monitor Resident #33 overnight, and if her condition did not change, they would order the urinalysis.
Review of Resident #33's progress note and physician orders, dated 04/01/23, revealed a new order to
have a urinalysis completed.
Review of Resident #33's progress note, dated 04/04/23, revealed a discussion with Resident #33 power of
attorney (POA)/family member regarding her condition. The laboratory results had not returned yet to
confirm/deny a UTI. Resident #33's family stated if the facility/physician does not start Resident #33 on an
antibiotic when the physician arrived at the facility later that day, she wanted Resident #33 sent to the
hospital.
Review of Resident #33's progress note, dated 04/04/23, revealed Resident #33 was seen by the physician.
The physician spoke with Resident #33's family and listened to the family's request about starting an
antibiotic, even prior to the urinalysis results returning. The physician decided to order Cipro 250 milligrams
(mg) twice daily for five days.
Review of Resident #33's progress notes, assessment forms, and medical documentation, dated 03/30/23
to 04/05/23, revealed the resident had no signs or symptoms documented to support she was confused or
having signs of a urinary tract infection.
Review of facility infection control log and infection control assessments revealed Resident #33's order for
Cipro 250 mg was placed on the infection control log, but it also confirmed the facility did not perform any
infection/antibiotic assessment, including a McGeer's assessment.
Interview with Director of Health Services (DHS) on 04/06/23 at 8:36 A.M. and 12:43 P.M. confirmed
Resident #33's order for Cipro 250 mg was ordered and administered prior to the facility completing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366480
If continuation sheet
Page 18 of 19
Printed: 05/15/2026
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
366480
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Taylor Springs Health Campus
748 Taylor 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 0881
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
a McGeer's assessment or the results of the urinalysis had returned. She confirmed that is typically not the
facility's procedure when an antibiotic is started/administered.
Review of facility Antibiotic Stewardship policy, dated 12/31/22, revealed the purpose of the policy was to
optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the
appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant
organisms, from unnecessary or inappropriate antibiotic use. Encompass a facility-wide system to monitor
the use of antibiotics. New orders for antibiotic usage will be reviewed during the campus Clinical Care
Manager on regular business days including antibiotics on new admissions from the community. Obtain and
review laboratory reports for campus trends of resistance. Include a separate report for the number of
residents on antibiotics that did not meet criteria (McGeer Criteria) for active infection. Pharmacy provider
will assist in review of all antibiotic usage for appropriateness.
Event ID:
Facility ID:
366480
If continuation sheet
Page 19 of 19
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F761 - Labeling of Drugs and Biologicals
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.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F646 - A nursing facility must notify the state mental health authority or state
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F791 - Dental Services
Provide or obtain dental services for each resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
FAQ · About this visit
Common questions about this visit
What happened during the April 6, 2023 survey of TAYLOR SPRINGS HEALTH CAMPUS?
This was a inspection survey of TAYLOR SPRINGS HEALTH CAMPUS on April 6, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TAYLOR SPRINGS HEALTH CAMPUS on April 6, 2023?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.