Haven at Lakewood

Based on observation, interview, closed medical record review, review of pharmacy records, review of laboratory results, and facility policy review, the facility failed to ensure Resident #83's Trulicity (a once-weekly injectable medication to treat type two diabetes mellitus) was not erroneously discontinued and omitted from the resident's medication regimen. This affected one resident (#83) of three residents reviewed for medication administration. The facility census was 82.

Findings include:

Review of the closed medical record for Resident #83 revealed an admission date of 07/17/25. Diagnoses included type two diabetes mellitus, acute kidney failure, vascular dementia, and muscle weakness. Resident #83 was transferred to the hospital on 04/20/26 and did not return to the facility. Resident #83's recorded move-out date was 05/04/26.

Review of Resident #83's prior-to-admission laboratory results dated 05/19/25 revealed the resident had a Hemoglobin A1C (test that measures the average glucose levels over the previous three months; the result is reported as a percentage; the higher the percentage, the higher the average blood glucose levels) level of 6.9% (normal value 4.2-6.5%).

Review of the service plan dated 07/10/25 revealed Resident #83 required and received medication management services from the facility.

Review of the physician orders revealed Resident #83 had an order dated 09/27/25 for Trulicity 0.75 milligrams (mg) per 0.5 milliliter (ml) pen with instructions to administer 0.75 mg by subcutaneous route once weekly on Saturdays.

Review of Resident #83's Medication Administration Record (MAR) for January 2026 revealed the resident did not receive the ordered dosage of Trulicity on 01/03/26 and 01/17/26.

Review of the fax from the facility Pharmacy sent 01/23/26 at 7:53 A.M. revealed the pharmacy canceled the prescription order for Trulicity 0.75 mg/0.5 ml weekly injections.

Review of Resident #83's physician orders revealed the resident's Trulicity 0.75 mg/0.5 ml weekly injection was discontinued by the facility on 01/26/26.

Review of the MARs for the months of February 2026, March 2026, and April 2026 (through 04/20/26) revealed no indication the resident had an order for or received any weekly doses of Trulicity.

Review of Resident #83's progress notes from 01/26/26 through 04/20/26 revealed no indication the resident's family, Physician #400, or NP #325 had been notified the resident's Trulicity had been discontinued and was not being routinely administered.

Review of Resident #83's laboratory results from a local hospital system dated 04/20/26 revealed the resident's hemoglobin A1C level on 04/20/26 was recorded at 10.1% and on 04/27/26 the result was recorded at 10.3%.

Interview on 05/21/26 at 12:15 P.M. with Licensed Practical Nurse (LPN) #401 revealed the LPN recalled Resident #83's family had previously brought in at least five to six boxes of Trulicity injections, and they were not documented in the resident's record as received by the facility.

Interview with a family member of Resident #83 on 05/21/26 at 1:40 P.M. revealed the resident was participating in a special program through Local Hospital #700 to obtain Trulicity at a lower cost. The medication was delivered to the family member's home and brought into the facility once a month, including monthly between January 2026 and April 2026, and given directly to facility nursing staff. The family member reported the resident had been on Trulicity since admission to the facility in July 2025 and at no time was she aware or informed that the medication had been discontinued. Resident #83's family member stated upon moving the resident out of the facility, the family requested and was provided with the unused doses of Resident #83's Trulicity injections and was given five boxes, each containing four weekly single-use injectable pens.

Telephone interview on 05/21/26 at 2:20 P.M. with NP #325 revealed Resident #83 was a patient at the office. NP #325 verified Resident #83 was on Trulicity injections weekly, and it had not been discontinued. NP #325 confirmed Resident #83 was to take Trulicity once a week and denied knowledge of discontinuation of the medication on 01/26/26. NP #325 stated when they realized Resident #83 was not given her Trulicity injections weekly, they had to restart the medication on the lowest dose of Trulicity again due to her blood sugar levels being elevated, and that explained why Resident #83's Hemoglobin A1C level was elevated at 10.3%. NP #325 attributed elevated A1C directly to the medication gap. NP #325 stated Resident #83 was receiving medications from a different pharmacy in October 2025 through December 2025 but changed pharmacies because they could get it cheaper through Local Hospital #700's program. In January 2026, the new pharmacy (through Local Hospital #700's program) started filling the prescription, and Resident #83's family was delivering the medications to the facility. The facility staff did not update their pharmacy that the medication order remained active, but the facility's pharmacy would no longer be the supplier of the Trulicity. NP #325 verified the facility never called Physician #400 or NP #325 to confirm or inform them Resident #83's Trulicity had been discontinued. NP #325 attributed the resident's elevated A1C result directly to the medication gap and was required to restart Resident #83 on the lowest dose.

Interview on 05/21/26 at 2:30 P.M. with the Wellness Director (WD) verified Resident #83's order for weekly Trulicity injections had been discontinued by the facility on 01/26/26. The WD was unable to identify who discontinued the order. The WD confirmed on 01/23/26, the facility received a Cancel Prescription fax from the facility pharmacy. The WD verified she did not know how or why the Trulicity was discontinued and verified the order was discontinued and Resident #83 did not receive Trulicity from 01/23/26 through 04/20/26.

Review of the policy Medication Management dated 02/16/26 revealed the community offered medication and treatment management services to its assisted living residents which included administration of medications, documenting medication administration, coordination prescription refills, and communicating with the pharmacy, prescriber, and the resident and resident's legal representative regarding medication administration. The Health and Wellness Director was responsible for verifying the community's program was managed and executed within the scope of applicable law and company policy and procedure.

This violation represents non-compliance investigated under Complaint Number OH00170661.

Based on interview, observation, and record review the facility failed to administer medications as ordered. This affected one resident (Resident #49) of three residents reviewed for medication administration. The census was 75.

Findings include:

Review of the medical record for Resident #49 revealed an admission date of 05/26/23 with diagnoses of dementia, high blood pressure, and anxiety disorder

Review of the physician orders for 07/17/25 morning medication administration revealed orders for Fluticasone Propionate administer one spray into each nostril, Aspirin 81 milligrams (mg) give one tablet, Levothyroxine 75 micrograms (mcg) give one tablet , Metamine HCL 10 mg give one table , metoprolol ER 25 mg give three tablets, Sertraline HCL 100 mg give one tablet, Sertraline 25mg give 3 tablets, Vitamin B-12 250 mcg give one tablet, and Vitamin D-3 1000 units give one tablet.

An observation on 07/17/25 at 8:17 AM revealed LPN #505 administered fluticasone propionate nasal spray for Resident #49. LPN #505 administered two sprays into each of the resident's nostrils.

An interview on 07/17/25 at 8:18 A.M. with LPN #505 revealed they always administered two sprays for all nasal medications because sometimes the medication doesn't always come out of the bottle the first time the medication was sprayed into the nostril so dispersing two sprays (even if only one was ordered) would ensure the resident received the full dose of nasal medication. LPN #505 was unable to verify that administering two sprays was not equivalent to a double dose being administered.

Based on observation, record review, interview and policy review the facility failed to ensure medications were properly secured. This affected one resident (Resident #25) of three residents observed for medication administration.

Finding include:

Review of the medical record for Resident #25 revealed an admission date of 03/26/17 with diagnosis of vascular dementia with behavioral disturbances, psychosis, paranoid personality disorder, hemiplegia and hemiparesis.

A review of Resident #25's annual recertification medication regimen assessment dated 06/24/25 authored by Nurse Practitioner #545 revealed that Resident #25 required licensed staff to administer their medications.

An observation on 07/16/25 at 11:30 A.M. revealed Resident #25 sitting at the dining room table with three other residents. A medicine cup containing two large round orange pills was sitting on the dining room table beside her lunch plate. No staff members were seen in the area of their table

An interview on 07/16/25 at 11:02 A.M. with Resident #25 revealed that the unidentified pills were hers. She unable to identify the medication and further shared that the nurse left the pills there so that she could take them after she ate.

An interview on 07/16/25 at 11:10 AM with Licensed Practical Nurse (LPN) #507 revealed they left the medications on the table for Resident #25 to take. Further interview revealed they were aware that it was not the best practice to walk away and leave medications unattended. LPN #507 did not identify the medications left for Resident #25. Further interview revealed Resident #25 routinely took some of her medications before she ate and some of her medications after she ate. All medications were routinely left for Resident #25 to take when she chose because she would get very upset if some of her medications were not given. LPN #507 was unable to verify what medications Resident #25 consumed. The LPN shared there were other ways to ensure the resident's medication preferences were honored without leaving the medications unsecured and without appropriate staff supervision.

An interview with the Wellness Director on 07/17/25 at 10:00 A.M. verified that nurses must stay with the residents while administering medications to ensure medications were consumed per order and by the correct resident.

Review of facility policy titled Medication revealed that residents requiring medication administration assistance were to be monitored while taking medications, no medications were to be left unattended for Residents to take later, and that all medications and treatments were to be administered per the health care providers parameters.

Based on interview and observation the facility failed to ensure over the counter medications were properly labeled with dates when the multi-use containers were opened. This had the potential to affect all 75 residents in the facility.

Findings include:

An observation on 07/17/25 at 8:35 A.M. revealed over the counter medication were stored in a locked treatment cart located in the wellness center. Several multi-use containers of medication were open with no evidence of a date to indicate when the containers were opened. The opened undated containers were as follows; Tylenol 500 milligrams (mg) 1000 count bottle, Tylenol 325 mg 500 count bottle, generic liquid antiacid 355 milliliter (ml) bottle, and MiraLAX 26.9-ounce bottle

An interview on 07/17/25 at 8:37 A.M. with Licensed Practical Nurse (LPN) #505 revealed that they did not know that over the counter medications needed to be labeled when opened because they have expiration dates on them. LPN #505 verified the open multidose medications were not dated when opened.

An interview on 07/17/25 at 10:00 A.M. with the Wellness Director revealed that all opened medication needed to be dated upon opening.

Based on review of personnel files and interviews, the facility failed to ensure that the first step of the two-step process for tuberculosis testing known as Mantoux testing, was completed for new employees prior to their first day worked. This had the potential to affect all 75 residents in the facility.

Findings include:

Review of the personnel record for Resident Assistant #517 (RA) revealed their first day worked was 01/24/25. They received Mantoux testing step one on 01/24/25 and had those results read 01/26/25.

Review of the personnel record for RA #518 revealed their first day worked was 04/04/25. They received Mantoux testing step one 04/04/25 and had those results read 04/06/25.

Review of the personnel record for RA #519 revealed their first day worked was 04/18/25. They received Mantoux testing step one on 04/18/25.

Review of the personnel record for housekeeper #543 revealed their first day worked was 10/10/24. They received Mantoux testing step one on 10/10/24 and had those results read 10/12/24

An interview on 07/17/25 at 9:55 A.M. with Office Manager (OM) #502 revealed they thought the facility had always given the first step of the Mantoux test the employees first day worked. They were not aware that the first tuberculosis tests result needed to be known prior to contact with the residents.

An interview on 07/17/25 at 10:05 A.M. with the Wellness Director revealed that they are also the infection control designee for the facility. They confirmed that Mantoux test results were to be obtained prior to an employee's first day of work to minimize residents' exposure to known communicable disease. Further they shared that the facility does the two-step Mantoux process for all new hires, then annually a symptom review is completed for all active employees.

Based on record reviews, staff interviews, observation and policy review, the facility failed to ensure medications were administered following infection control guidelines. This affected one resident (Resident #49) of two reviewed for infection control with medication administration. The census was 75.

Findings include:

Review of medical records for Resident #49 revealed an admission date of 05/26/23 with diagnoses of dementia, high blood pressure, and anxiety disorder

Review of the physician orders for 07/17/25 morning medication administration revealed orders for Fluticasone Propionate administer one spray into each nostril, Aspirin 81 milligrams (mg) give one tablet, Levothyroxine 75 micrograms (mcg) give one tablet , Metamine HCL 10 mg give one table , metoprolol ER 25 mg give three tablets, Sertraline HCL 100 mg give one tablet, Sertraline 25mg give 3 tablets, Vitamin B-12 250 mcg give one tablet, Vitamin D-3 1000 units give one tablet.

An observation on 07/17/25 at 8:15 A.M. of the medication administration for Resident #49 revealed that Licensed Practical Nurse (LPN) #505 prepared medication for administration to Resident #49. LPN #505 removed each medication from the packaging, placed the tablet into her bare hand then placed the tablet into the medication cup.

An interview on 07/17/25 at 8:20 A.M. with LPN #505 revealed that she always placed the medication into her hand before putting it into the cup because pills often bounced and got dropped when you attempted to punch out of the medication cards supplied by pharmacy. LPN #505 further shared that they thought that if they performed hand hygiene that their hands were clean and they could touch the medications.

An interview on 07/17/25 at 10:00 A.M. with the Wellness Director revealed that touching medications with your bare hands was against basic infection control standards.

Review of undated facility policy titled Medications revealed that trained licensed personnel will administer medications following the CDC guidelines for infection control.

Based on observation, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents The census was 75.

Findings include:

An observation on 07/16/25 at 8:33 A.M. revealed Dietary Manager (DM) #503 wore a head scarf tied in a triangular pattern covering the top of her head with below her shoulder length hair exposed and not tied back. Further observation revealed two staff members were standing at the tray line requesting food items with out any type of hair covering.

An observation on 07/16/25 at 8:42 A.M. revealed DM #503 reached into all three reach-in coolers and two reach-in freezers, located thermometers and verified refrigeration temperatures. Further observation revealed a broken egg in the bottom of cooler #2. DM #503 reached in, moved items around and verified the broken egg. DM #503 continued to wear a head scarf that did not contain her long hair, allowing it to fall forward as she bent over.

An observation on 07/16/25 at 8:43 A.M. revealed DM #503 walked behind the tray line containing hot breakfast items in the steam table. Staff lifted the corners of the coverings on the pans in the steam table to show the breakfast items. DM #503 continued to wear the same head scarf with no other hair restraint.

An observation on 07/16/25 at 8:44 A.M. revealed an air conditioning vent located high on the wall at the end of the tray line and an air return vent located lower and to the right of the tray line that were very dusty and oily. The air conditioner vent was blowing cold air onto the food prep area and the tray line. DM #503 verified the vents needed to be cleaned.

An observation on 07/16/25 at 8:45 A.M. revealed Cook #432 with a cleaning bucket in her hand. Further observed Cook #432 check the sanitization level in the cleaning bucket and the test strip read zero. It was verified with cook #432 and DM #503 that the test strip results were zero.

An observation on 07/16/25 at 8:50 A.M. revealed beverages in a kitchenette cooler immediately outside of the kitchen door that contained two, one-gallon jugs of milk 3/4 full, one container of tomato juice 1/3 full and a pitcher of fruit punch with approximately 2 ounces of liquid. The beverages were opened but not dated. This finding was verified with DM #503 that these were not dated and should have dates on them.

An interview on 07/16/25 at 5 8:55 A.M. with DM #503 verified that everyone that comes into the kitchen should wear proper hair restraints. which could be a. hat, bandanna or a hairnet, and if their hair was long and exposed it should be tied back. DM #503 shared that their head scarf was a proper hair restraint as long as they weren't behind the tray line or preparing food. DM #503 identified the staff members that were in the kitchen at the beginning of the kitchen tours without hair restraints as Resident Assistant #521 and Resident Assistant #523.

An observation on 07/16/25 at 11:20 A.M. revealed Cook #527 prepared peanut butter sandwiches as an alternative lunch option. Cook #527 donned gloves, gathered supplies from multiple areas of the kitchen, such as utensils from under the food prep area, sandwich baggie, loaf of bread. They picked up a loaf of bread still in the plastic wrapping, removed two slices of bread and placed it on the food prep area without changing gloves. Cook #527 then reached above the prep area and retrieved a large can of peanut butter and three jelly packets. Cook #527 held a bread slice with their gloved left hand while spreading the peanut butter and jelly onto the bread. The sandwich was cut in half and placed into a baggy to be offered to residents during lunch as requested. Cook #527 verified they did not change their gloves during this process and should have gathered supplies before donning gloves and only touched food items once they had put on their gloves.

Review of undated facility policy titled Personal Hygiene revealed that hair must be restrained per state guidelines and that all exposed body hair must be covered.

Based on review of the Emergency Preparedness Plan (EPP) and staff interview, the facility failed to have a comprehensive EPP to address the evacuation of residents with impaired mobility and failed to implement the EPP to ensure resident safety during a power outage. This had the potential to affect all 84 residents of the facility. The facility census was 84.

Findings include:

Observation on 08/12/24 at approximately 1:30 P.M., upon entrance to the facility, revealed the building included eight floors.

Interview on 08/12/24 at 1:43 P.M. with the Administrator revealed the facility had no power, due to severe weather, from approximately 4:30 P.M. on 08/06/24 until 08/11/24 at approximately 1:20 P.M. The Administrator stated the facility did not have a back-up generator and intended to rent one; however, a large portion of the area was without power and there were no generators available. Once they found a generator to rent, the facility was unable to locate an electrician to connect it. The Administrator stated the facility was able to rent a smaller, 3500 kilowatt (kw), generator to run the ice machine, freezer and refrigerator. The Administrator verified the generator was not sufficient to power the fire alarm and fire pump.

Interviews on 08/12/24, between 3:15 P.M. and 4:23 P.M., with the Director of Nursing (DON) confirmed the facility did not attempt to evacuate residents during the power outage. The DON confirmed the facility scheduled staff per usual, with two Licensed Practical Nurses (LPN) and three to five Resident Assistants (RA) on first shift and one LPN and two RAs on night shift. The DON stated she and the Administrator rotated shifts to ensure one of them was present at all times. While the DON stated some department heads volunteered at different times to come in to help, the facility had no evidence of when additional support was present. The DON stated there were eight to ten residents who were brought to the first floor during the outage and slept on either a mattress or in a chair. The additional residents remained in their rooms on the second through eighth floors. The DON stated she did not know why the facility did not evacuate, noting it was not her call to make, and there was no place to evacuate to because power was out in the area and there was no phone service. The DON stated staff and residents were given flashlights and food was ordered out and brought in for each meal. The DON verified residents resided on floors two through eight and if there had been a fire or another emergency during the power outage, staff would not have been able to evacuate the residents from the upper floors of the facility. The DON further confirmed there were 52 residents (#3, #4, #6, #7, #8, #9, 11, #12, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #27, #29, #30, #33, #35, #38, #39, #41, #43, #45, #46, #48, #49, #50, #53, #54, #56, #57, #58, #60, #61, #62, #65, #66, #67, #69, #70, #71, #76, #77, #78, #80, #81, and #82) who would have required assistance down the stairs to evacuate the facility. Additionally, the DON verified seven of those residents (#20, #38, #49, #50, #60, #65, and #71) would have required the assistance of two staff members to go down the stairwell. The DON was unable to articulate the facility's plan to evacuate residents in an emergency situation.

Interview on 08/12/24 at 3:50 P.M. with RA #216 revealed the facility did not add extra staff during the power outage. RA #216 confirmed there were no lights or operational elevators during the power outage. RA #216 stated she did not know what they would have done if they needed to evacuate residents in an emergency situation, such as a fire. RA #216 further stated there were a number of heavy residents and residents in wheelchairs who resided on the upper floors of the facility and staff would not have been able to get them down.

Interview on 08/12/24 at 4:18 P.M. with RA #224 revealed several residents, who required more care, were moved to the first floor of the facility during the power outage. However, RA #224 stated they would not have been able to evacuate everyone if there had been an emergency, noting this would have been more challenging with the staffing levels at night.

Review of the EPP, revised 01/23/24, revealed in the event of a temporary power outage, the battery powered system or emergency operator (if applicable) will provide emergency power to critical areas. The plan identified a local rental company for a generator. Additionally, the plan did not address how to evacuate residents with impaired mobility. Lastly, the facility had an agreement for a shelter/host agreement with Facility #250.

Interview on 08/12/24 at 4:50 P.M. with the Administrator verified, during the power outage, the facility had no operational fire system, including the fire alarms and sprinkler system. The Administrator further confirmed there were eight floors to the facility, with all residents residing on floors two through eight. During the power outage, the facility elevators did not work, there was no hot water, no lights, and no phone service at the facility. The Administrator confirmed he did not attempt to evacuate the residents to a safer location. Additionally, the Administrator confirmed the facility identified in the EPP for emergency shelter, Facility #250, had a new owner and he was uncertain if the agreement was still valid. The Administrator verified he did not call the shelter/host facility regarding possible evacuation of residents during the power outage because the facility had no phone service. The Administrator stated the facility was focused on getting a generator and should have had one ready to be brought onsite, but that did not happen.

This violation represents non-compliance investigated under Complaint Number OH00156710.

Based on observation, staff interview and review of emergency preparedness documents, the facility failed to ensure policies and procedures were in place to address actions to be taken, and reporting requirements, when the fire detection, fire alarm, and sprinkler system was inoperable. In addition, the facility failed to ensure a fire watch was conducted during a power outage that affected the facility's fire detection and suppression system. This had the potential to affect all 84 residents in the facility. The facility census was 84.

Findings include:

Interview on 08/12/24 at 1:43 P.M. with the Administrator revealed the facility had no power from 08/06/24 at 4:30 P.M. until 08/11/24 at 1:20 P.M. The facility had no backup generator to run the fire suppression system. The Administrator stated their plan was to rent one, but a large portion of the surrounding area was without power and there were no generators available. Once the facility located a generator to rent, there was no electrician available to hook it up. The facility was able to rent a 3500 kilowatt (kw) generator to run the ice machine, freezer and refrigerator. However, the Administrator verified the fire alarm and fire pump were not powered. While the Administrator stated a fire watch was conducted, he verified the facility had no evidence the fire watch was completed.

Observation on 08/12/24 at 1:58 P.M. with Maintenance Director (MD) #900 revealed the facility's fire detection, fire alarm, and sprinkler system were all working now that the power was back on.

Review of the emergency preparedness records confirmed no evidence of a fire watch policy or any logs of a fire watch being completed from 08/06/24 through 08/11/24.

This violation represents non-compliance investigated under Complaint Number OH00156710.

Based on observation, record review and interview the facility failed to notify the director/Ohio Department of Health (ODH) when there was an interruption of normal business services at the facility due to a weather emergency in the facility from 08/06/24 through 08/11/24. This had the potential to affect all 84 residents residing at the facility. The facility census was 84.

Findings include:

Observation on 08/12/24 at approximately 1:30 P.M., upon entrance to the facility, revealed the building included eight floors. Residents resided on floors two through eight.

Review of the facility Emergency Preparedness Plan revised 01/23/24 revealed no documentation or direction to include the residential care facility would notify the director/Ohio Department of Health as required when there was an interruption of normal business services due to an emergency or a disaster involving the facility.

Interview on 08/12/24 between 1:43 P.M. and 4:50 P.M. with the Administrator revealed the facility had no power from 08/06/24 at 4:30 P.M. until 08/11/24 at 1:20 P.M. During this time, the facility had no back-up generator. The facility plan included to rent a generator, but with more than 70% of the area out of power there were no generators available. Once the facility found a generator to rent, there was no electrician available to hook it up. The facility was able to get a 3500-kw generator to run the ice machine, freezer and refrigerator. However, the fire alarm and fire pump were not powered. In addition, during this time period, the elevators were not working, there was no hot water, no lights, and no phone service at the facility.

This violation represents non-compliance investigated under Complaint Number OH00156710.

Based on review of the Emergency Preparedness Plan (EPP), shelter/host facility interview and staff interview, the facility failed to ensure a valid transfer agreement was in place for the evacuation of residents during an emergency situation. This had the potential to affect all 84 residents of the facility. The facility census was 84.

Findings include:

Review of the EPP, revised 01/23/24, revealed the facility had an agreement for a shelter/host (transfer) agreement with Facility #250.

Interview on 08/12/24 at 4:49 P.M. with Facility #251 revealed they used to be known as Facility #250; however, the facility was under new ownership. Facility #251 had no information related to the transfer agreement that existed between the facility and Facility #250.

Interview on 08/12/24 at 4:50 P.M. with the Administrator verified, during the power outage, the facility had no operational fire system, including the fire alarms and sprinkler system. The Administrator further confirmed there were eight floors to the facility, with all residents residing on floors two through eight. During the power outage, the facility elevators did not work, there was no hot water, no lights, and no phone service at the facility. The Administrator confirmed he did not attempt to evacuate the residents to a safer location. Additionally, the Administrator confirmed the facility identified in the EPP for emergency shelter, Facility #250, had a new owner and he was uncertain if the agreement was still valid, stating he would have to check on it.

This violation represents non-compliance investigated under Complaint Number OH00156710.