The most recent inspection on file for Forest Hills Place took place on November 6, 2025. Across the 17 inspections published by the Ohio Department of Health, surveyors cited 20 deficiencies.
A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.
This report reproduces what Ohio publishes and nothing else. Of the 17 inspections listed, the state publishes the surveyor's written findings for 9; for the other 8 it publishes only the date, the type of visit and the number of deficiencies - 8 of which found none.
Facility Details
Inspections
17 on file · 20 deficienciesNovember 6, 2025Licensure survey4 deficiencies▼
R-0339Administered meds - given only to and as prescribed▼
Based on record review, interview, and facility policy review, the facility failed to follow physician orders regarding notifying the physician of elevated blood sugar readings. This affected one resident (#51) of three reviewed for blood sugar orders. The facility census was 97.
Findings include:
Review of Resident #51's medical records revealed an admission date of 05/30/20. Diagnoses included diabetes and dementia.
Review of physician orders from October 2025 through November 2025 revealed Resident #51 was ordered Lantus (long acting insulin) 15 units at bedtime and to notify the physician if blood sugar readings were over 300 milligrams per deciliter (mg/dL) (normal range was between 60-100 mg/dL).
Review of Resident #51's blood sugar readings from October 2025 through November 2025 revealed the following: on 10/04/25 blood sugar was 371 mg/dL, on 10/09/25 blood sugar was 319 mg/dL, on 10/13/25 blood sugar was 390 mg/dL, on 10/14/25 blood sugar was 306 mg/dL, on 10/19/25 blood sugar was 323 mg/dL, and on 10/20/25 blood sugar was 309 mg/dL. Further review of Resident #51's medical records revealed no documented evidence the physician had been notified of the elevated blood sugars.
Interview on 11/05/25 at 12:25 P.M. with Licensed Practical Nurse (LPN) #262 confirmed Resident #51's physician orders stated to notify the physician for blood sugar readings above 300 mg/dL and LPN #262 further confirmed no documentation of physician notification related to the readings over 300 mg/dL.
Review of facility policy titled Blood Glucose Monitoring updated 09/01/16 revealed to report any pertinent observations to the Care Services Manager immediately that included blood sugars outside of routine ranges set by the physician.
This violation represents non-compliance investigated under Complaint number OH00168649.
R-0349Medication record for administered medications▼
Based on interview and record review, the facility failed to ensure accurate documentation regarding medication administration. This affected two residents (#8 and #98) of three reviewed for medication documentation.
Findings Include:
1. Review of Resident #8's medical record revealed an admission date of 03/03/25 with diagnoses that included asthma, schizoaffective disorder, fibromyalgia, gastro-esophageal reflux disease, atherosclerotic heart disease, major depressive disorder, peptic ulcer and secondary hypertension.
Review of Resident #8's physician orders revealed an order dated 03/03/25 for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 microgram (mcg) with instructions to inhale two puffs orally two times a day to prevent shortness of breath. Further review revealed an order dated 03/03/25 for Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) mcg/per actuation (act) with instructions to inhale two puffs orally every four hours as needed for shortness of breath.
Review of the facility communication log with the pharmacy revealed the Budesonide inhaler medication was ordered on 10/31/25 and delivered to facility on 11/04/25 at 7:29 P.M.
Review of Resident #8's Medication Administration Record (MAR) from 11/03/25 through 11/05/25 revealed Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 mcg had been administered on 11/03/25 and 11/04/25 at 7:00 A.M. and 7:00 P.M. and on 11/05/25 at 7:00 A.M. Further review revealed Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT was not marked as given on the MAR.
Interview on 11/05/25 at 12:02 P.M. with Licensed Practical Nurse (LPN) #236 revealed when she worked on 10/29/25, Resident #8's Budesonide inhaler had a few puffs left and she ordered a refill. LPN #236 revealed she had given Resident #8 the Budesonide inhaler today (11/05/25). When asked to see the Budesonide inhaler, LPN #236 provided the Albuterol inhaler. LPN #236 then looked for the Budesonide inhaler and could not find it. Further interview with LPN #236 revealed she was confused and gave Resident #8 the Albuterol inhaler and not the Budesonide inhaler as ordered.
2. Review of Resident #98's closed medical records revealed an admission date of 03/31/25 and a discharge date of 07/11/25. Diagnoses included diabetes, high blood pressure, and anxiety.
Review of various progress notes on 04/03/25 and from 05/05/25 through 05/11/25 for Resident #98 revealed medications were unavailable, however progress notes had not included which medications were unavailable.
Review of Resident #98's April 2025 and May 2025 Medication Administration Record (MAR) within the medical record revealed no documented evidence of which medications were not given due to unavailability.
Interview on 11/04/25 at 10:25 A.M. with LPN #262 confirmed progress notes and MAR's had not included which medications were unavailable or any information related to why the medications were unavailable. LPN #262 further stated documentation should have included rationale of why medications were unavailable as well as the medication names.
R-0391Resident incidents and log; identify resident upon request▼
Based on observation and interview, the facility failed to provide timely care following a fall. This affected one resident (#77) of two reviewed for falls. The facility census was 97.
Findings include:
Review of Resident #77's medical records revealed an admission date of 03/11/21. Diagnoses included dementia, anxiety and high blood pressure.
Review of the fall assessment dated 01/05/25 revealed Resident #77 had impaired gait and overestimated or forgot limits.
Review of the service plan revised 07/02/25 revealed Resident #77 required assistance with bed transfers and required reminders to call for assistance. Resident #77 had impaired cognition, displayed deficits in judgement and required cueing at times. Further review of the service plan revealed no documented evidence related to the residents falls or fall interventions.
Observation on 11/04/25 at 8:47 A.M. revealed Resident #77 was yelling out loudly. Upon entering Resident #77's room, Resident #77 was observed on her buttocks on the floor in front of a closet door. Resident #77 was unable to state what occurred and no obvious signs of injuries or pain were observed. At 9:02 A.M. Resident #77 had continued to loudly yell out and stated I'm on the floor. At 9:02 A.M. Licensed Practical Nurse (LPN) #263 had approached the nurses station located in close proximity to Resident #77's room. LPN #263 had then proceeded to walk away without having checked on Resident #77, who was still heard yelling out. At 9:09 A.M. Activities Aide (AA) #264 had approached the nurses station and had proceeded to walk away, Resident #77 was still yelling out and AA #264 then entered Resident #77's room and had observed Resident #77 on the floor. AA #264 had immediately exited Resident #77's room and proceeded to find a staff member. At 9:12 A.M., LPN #263 had entered Resident #77's room along with Resident Care Partner (RCP) #208 and the Executive Director, and they had observed Resident #77 on the floor. Interview with RCP #208 at time of observation revealed she had last seen Resident #77 at approximately 8:15 A.M. and she was in her bed. At 9:14 A.M., LPN #230 entered Resident #77's room and obtained vital signs. Interview with LPN #230 at time of observation revealed she had not provided any care for Resident #77 and was unaware how long she may have been on the floor. At 9:23 A.M. Resident #77 was placed back in bed via a mechanical lift. Resident #77 was confused and unable to state what had occurred.
Interview on 11/04/25 at 9:28 A.M. with LPN #263 revealed she had heard Resident #77 yelling out when she was at the nurses station previously, however LPN #263 stated Resident #77 had yelled out at times and she didn't think to she needed to go and check on her.
This violation represents non-compliance investigated under Complaint number OH00168649.
R-0615Fire drill requirements▼
Based on review of facility fire drills and staff interviews, the facility failed to complete fire drills on each shift every three months as required. This had the potential to affect all 97 residents currently residing in the facility.
Findings Include:
Review of the facility fire drills from 11/27/24 through 10/30/25 revealed from April 2025 through August 2025 (including quarter two for 2025) revealed no documented evidence of fire drills conducted on the night shift.
Interview on 11/04/25 at 10:00 A.M. with Maintenance Director #263 revealed he was following a chart that was in the fire and disaster drill binder when he started. He stated he was not aware that one drill needed to be completed on each shift every three months.
Interview on 11/05/25 at 12:40 P.M. with Licensed Practical Nurse (LPN) #262 and confirmed fire drills were not completed on each shift every three months.
October 6, 2025Complaint survey1 deficiency▼
R-0711Free from abuse▼
Based on record review, self-reported incident (SRI) review, staff interview, and facility policy review, the facility failed to prevent resident-to-resident abuse. This affected four residents (#7, #68, #83 and #96) of four residents reviewed for abuse. The facility census was 96.
Findings include:
1. Review of the medical record for Resident #7 revealed an admission date of 03/03/25. Diagnoses included moderate dementia with mood disturbance, anxiety disorder, major depressive disorder, schizoaffective disorder, and bipolar type.
Review of the 90 day/quarterly evaluation dated 06/17/25 revealed Resident #7 was alert and oriented to person, place, time, and situation. The evaluation also indicated Resident #7's mood included angry, withdrawn, and aggressive. Resident #7 was also noted to be independent for all activities of daily living (ADL).
Review of the progress note dated 07/9/25 at 1:48 A.M. revealed Resident #7 stated her next-door neighbor, Resident #68, was knocking on the wall and on her door, so when she went to tell him to stop, Resident #68 hit her. Medication Tech (MT) #404 called emergency services and had a full assessment done by paramedics. The resident refused to be sent to the emergency department (ED), so care was provided, the charge nurse was notified, and resident care partners from second shift wrote written statements.
Review of the medical record for Resident #68 revealed an admission date of 12/31/21. Diagnoses included mood disorder and schizophrenia.
Review of the 90 day/quarterly evaluation dated 04/14/25 revealed Resident #68 was alert and oriented to person, place, and situation. The evaluation indicated Resident #68's mood included withdrawn, flat affect, and disorganized thinking. Resident #68 was noted to be independent with all ADLs.
Review of the progress note dated 07/09/25 at 2:02 A.M. revealed Resident #68 admitted to hitting Resident #7 so Resident #68 was sent via squad to a local hospital for psychiatric evaluation, and the on-call manager was notified.
Review of the SRI #262590 investigation dated 07/08/25 revealed an incident and accident form dated 07/08/25 at 8:00 PM which reported Resident #68 punched Resident #7 in the face causing a large, raised area on the left side of forehead. Resident #7 made staff aware of the incident and refused to go to the hospital by emergency medical services.
Review of a handwritten statement by a former staff member, Resident Care Partner (RCP) #409 dated 07/08/25 revealed while performing last rounds in resident rooms, Resident #7 ran up to her as she was coming out of another resident's room and reported another resident (Resident #68) hit her. She did not know his name but identified the room. Resident #68 admitted to hitting Resident #7, so MT #404 was called to assist.
Review of the investigation interview and witness form dated 07/09/25 with Resident #68 revealed on 07/08/25 at approximately 8:30 P.M., a resident (unidentified) came up to him yelling and pointing a finger at his face. Resident #68 stated he got angry because the resident was in his face, so he hit her.
Review of the investigation and witness form dated 07/09/25 with Resident #7 revealed on 07/08/25 (no time indicated) Resident #7 was in her room when she noticed Resident #68 was going in and out of his own room, so she went to get a RCP to make Resident #68 stop. While walking past, Resident #68 punched her in the face. She kept walking and alerted a RCP (not named).
Interview on 10/06/25 at 11:42 A.M. with MT #404 via phone revealed she was called by one of the RCPs (not named) who reported Resident #7 was hit by Resident #68, so she went up to the unit. Resident #7 stated Resident #68 was making noises in his apartment and when she went to his door to stop the noise, he hit her. MT #404 asked Resident #68 what happened and if he had hit Resident #7 to which Resident #68 said yes. MT #404 called emergency services and sent Resident #68 out for evaluation and a squad came for Resident #7. MT #404 notified all responsible parties and management. Resident #7's room was moved away from Resident #68.
2. Review of the medical record for Resident #83 revealed an admission date of 10/24/22. Diagnoses included Alzheimer's disease, dementia, vascular dementia, and attention-deficit hyperactivity disorder.
Review of the 90 day/quarterly evaluation dated 07/10/25 revealed Resident #83 was alert and oriented to person, confused, and required assistance from staff only with dressing, toileting, and bathing.
Review of a late entry progress note dated 08/25/25 at 5:13 P.M. revealed Resident #83 was involved in an altercation with another resident (not identified). Resident #83 was hit in the head with a cane. Staff intervened immediately and separated the two residents. No visible signs of bruising or injury were noted at the time of incident. Power of attorney (POA) was notified of the incident and did not want to file charges against the other resident. Resident #83 was sent to a local hospital for further evaluation.
Review of the medical record for Resident #96 revealed an admission date of 02/28/25. Diagnoses included dementia with agitation and anxiety.
Review of a late entry progress note dated 08/25/25 at 5:31 P.M. revealed Resident #96 was involved in an altercation with another resident (not identified). Resident #96 hit another resident in the head with a cane. When asked what happened, Resident #96 stated because he did not want the other resident to sit next to him after sitting down, he hit him in the head with his cane. Resident #96 was sent to a local hospital for aggressive/violent behaviors. The POA was contacted and made aware of the incident.
Review of SRI #264542 dated 08/25/25 revealed an incident and accident investigation form dated 08/25/25 at 1:35 P.M. which indicated activities staff reported Resident #96 took his metal cane and hit Resident #83 on the head without provocation because Resident #96 did not want Resident #83 sitting in the chair next to him in the common area on the unit. Staff separated the two residents.
Review of the investigation interview and witness form with activities staff dated 08/25/25 at 1:35 P.M. revealed Resident #96 took his cane and hit Resident #83 on his head near the middle, close to the forehead on the right side. The incident happened quickly, and it was because Resident #96 did not want Resident #83 to sit in the chair next to him. The two were separated and no other altercation occurred. Resident #83 had no visible bruise at the time and was sent out for precaution.
Review of the investigation interview and witness form dated 08/25/25 with Resident #96 revealed Resident #83 was walking around following him, so he asked Resident #83 to leave him alone, but Resident #83 continued to follow him. When Resident #83 sat in the chair next to him, he tapped Resident #83 on the head with his cane. Resident #96 stated Resident #83 should not have sat next to him.
Review of the investigation interview and witness form dated 08/25/25 with Resident #83 revealed after being asked to explain what happened, the resident pointed at his forehead and stated it hurt badly. Resident #83 was unable to fully demonstrate due to dementia. The nurse asked the resident if he felt safe and Resident #83 responded yes and walked away.
Interview on 10/06/25 at 4:13 P.M. with the Administrator revealed the facility conducted thorough investigations and substantiated both incidents which affected Residents #7 and #83 as victims in the SRIs. The Administrator stated Resident #83's incident was witnessed without injuries, but in the other incident, Resident #7 resulted in a hematoma.
Review of the facility policy titled Abuse, Neglect, and Exploitation
July 21, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies▼
January 15, 2025Complaint survey4 deficiencies▼
R-0338Administered meds - MD orders▼
Based on record review, interview, and policy review, the facility failed to ensure accurate physician orders were in place regarding medications. This affected one resident (#110) of four residents reviewed for physician-ordered medications. The facility census was 104.
Findings include:
Review of Resident #110's closed medical records revealed an admission date of 06/19/24 and a discharge date of 11/26/24. Diagnoses included high blood pressure and dementia.
Review of Resident #110's closed medical records revealed physician orders dated 06/19/24-07/02/24 for senna (stool softener) twice a day and nifedipine (cardiac medication) 90 milligrams (mg) once a day from 06/20/24-08/24/24.
Review of Resident #110's preadmission paperwork dated 06/13/24 revealed medication list did not include senna or nifedipine.
Review of Resident #110's preadmission paperwork dated 06/13/24 with the Director of Wellness (DOW) on 01/02/25 at 10:39 A.M. confirmed the paperwork did not include Nifedipine or Senna. At time of interview DOW placed a call to Resident #110's Primary Care Physician (PCP) to clarify the orders. Telephone interview on 01/02/25 at 11:16 A.M. with PCP's Registered Nurse (RN) #301 revealed she had spoken with the PCP, however he was unavailable to a telephone interview. RN #301 stated the PCP had stated he not been aware Resident #110 had been receiving Nifedipine until 08/22/24 when Resident #110 was seen in his office. RN #301 stated the PCP had discontinued the Nifedipine at that time and RN #301 stated PCP had not ordered the medication. RN #301 stated the PCP had indicated he was unsure of who ordered the Nifedipine and it was likely the previous facility who had ordered the medication.
Telephone interview on 01/02/25 at 11:21 A.M. with Pharmacist #302 stated a medication list for Resident #110 was faxed to the pharmacy on 06/19/24 with LPN #303's signature, and that list included Nifedipine. Pharmacist #302 stated the medication list did not include a physician signature and stated the medication had been ordered according to the medication list.
Interview on 01/02/24 at 11:58 A.M. with DOW confirmed LPN #303 was a previous nurse at the facility and was likely the nurse who had sent the medication list to the pharmacy and stated the medication list was likely sent from Resident #110's previous facility.
Review of facility policy titled Medication Administration, dated 09/01/16 revealed medications were to be administered according to physician orders.
This violation represents non-compliance investigated under Complaint Number OH00160503.
R-0339Administered meds - given only to and as prescribed▼
Based on record review, staff interview, and policy review, the facility failed to ensure blood pressures were obtained prior to administering blood pressure medications according to physician orders. This affected two residents (#98 and #110) of four residents reviewed for blood pressure medication administration. The facility census was 104.
Findings include:
1. Review of Resident #98's medical records revealed an admission date of 12/21/21. Diagnoses included high blood pressure and dementia.
Review of Resident #98's physician orders for December 2024 revealed orders for Metoprolol (blood pressure medication) 25 milligrams (mg) one time a day and hold if blood pressure reading was less than 110 systolic.
Review of Resident #98's medical records revealed no documented blood pressure readings prior to administering medication.
Interview on 12/31/24 at 12:58 P.M. with the Director of Wellness (DOW) confirmed Resident #98's blood pressure was not checked prior to blood pressure medication administration.
2. Review of Resident #110's closed medical records revealed an admission date of 06/19/24 and a discharge date of 11/26/24. Diagnoses included high blood pressure and dementia.
Review of Resident #110's closed medical records revealed physician orders dated 07/04/24-09/02/24 for Norvasc (blood pressure medication) 5 mg one time a day and hold medication if blood pressure reading is less than 100 systolic and monitor blood pressure one time a day from 08/01/24-08/16/24.
Review of Resident #110's closed medical records revealed no documented blood pressure reading prior to 08/01/24.
Interview on 12/31/24 at 12:58 P.M. with DOW confirmed Resident #110's Norvasc had parameters that included to hold the medication if blood pressure reading was less than 100 systolic. Further review of Resident #110's medical records with DOW revealed no recorded blood pressure readings and medication was being administered without obtaining a blood pressure reading prior. DOW stated she had spoken with Resident #110's Power of Attorney (POA) and the POA had stated Resident #110's blood pressure was supposed to be checked daily. DOW stated she had contacted the physician and orders were received to monitor Resident #110's blood pressure daily for two weeks. DOW confirmed Resident #110's blood pressure should have been checked daily prior to administering the medication due to the parameters placed on the medication. DOW further confirmed Resident #98's blood pressure should have been checked prior to administering her blood pressure medications as well.
Review of facility policy titled Medication Administration, dated 09/01/16 revealed medications were to be administered according to physician orders.
This violation represents non-compliance investigated under Complaint Number OH00160503.
R-0744Voice grievances and access to advocates▼
Based on closed record review, staff interview, and review of facility policy, the facility failed to recognize and address grievances in an appropriate and timely manner. This affected one residents (#110) of three reviewed for grievances. The facility census was 104.
Findings include:
Review of Resident #110's closed medical records revealed an admission date of 06/19/24 and a discharge date of 11/26/24. Diagnoses included high blood pressure and vascular dementia. Upon admission, Resident #110 resided in the assisted living unit until 08/03/24, when the resident was moved to the secured memory care unit.
Review of Resident #110's progress notes revealed a progress note dated 06/28/24 authored by Director of Wellness (DOW) that stated a call was placed to Resident #110's Power of Attorney (POA) to discuss moving Resident #110 to the memory care unit.
Review of a progress note dated 07/01/24 authored by DOW revealed a follow up call was placed to the POA to discuss moving Resident #110 to the memory care. The note indicated Resident #110's POA was not understanding of the resident's required level of care and him being better suited for the memory care unit. The note stated the POA was very reluctant to agree to the resident's placement on the memory care unit.
Progress note dated 07/02/24 authored by DOW revealed the Executive Director (ED) had placed a call to Resident #110's Primary Care Physician (PCP) and was informed Resident #110's POA was very influential with requests to have Resident #110 remain in the assisted living unit. Progress note stated the ED explained to the PCP the POA lived out of state and was not understanding Resident #110's needs. DOW attempted to explain to the POA Resident #110's behaviors included wandering, confusion and being incontinent of bowel and bladder in inappropriate places which were not appropriate for an assisted living environment. The note stated the POA did not agree.
Progress note dated 07/03/24 authored by ED revealed she had spoken with Resident #110's PCP and the PCP had agreed that placement on the memory care unit was appropriate. PCP stated the POA was attempting to dictate care from out of state and had not noticed Resident #110's decline. The doctor stated he would send a notice to the facility outlining his agreement with Resident #110 being transferred to the memory care unit.
Review of Resident #110's physician note dated 07/03/24 revealed after discussion with facility staff on 07/02/24, the physician recommended Resident #110 be placed in the memory care unit of the facility for his best care and safety.
Review of Resident #110's progress notes between 07/03/24 and 08/03/24 revealed no evidence facility staff had attempted to further communicate with Resident #110's family or POA regarding transition to the memory care unit. There was no evidence of any notification the resident would be moving to the memory unit, nor a target date.
Review of Resident #110's progress note dated 08/03/24 revealed the resident was transferred to a room on the third floor (memory care unit). The note did not indicate the resident's family had been notified of the transfer.
Telephone interview on 01/15/25 at 10:27 A.M. with Family Member #150 revealed she was never offered an opportunity to file a formal grievance or concern. She confirmed she had not agreed to Resident #110 being transferred to the memory care unit and was not notified when he was transferred. She had discussed her concern on various occasions with facility staff and her concerns were not satisfactorily addressed.
Interview on 01/15/25 at 12:05 P.M. with ED revealed she had addressed Resident #110's POA's concerns as they had been brought up, and stated she had documented the issues in Resident #110's progress notes. ED stated she had not made the POA's concerns into an official grievance and attempted to handle the concerns as they were mentioned. ED stated the POA had not always returned calls and stated the POA had often called after hours when she was not present in the facility.
Review of facility policy titled Resident Concern (Grievance) Procedure undated revealed residents and/or families should report concerns and in response the facility would investigate in a prompt and thorough manner. It is the belief that most concerns can be resolved on an informal basis. If the concern cannot be resolved informally, the resident and/or the family will be encouraged to complete a Resident Concern (Grievance) Form. These forms are located in the front lobby. The Residence Director and/or designee shall initiate an investigation. Upon completion of the investigation, the Residence Director or Designee will complete the bottom portion of the form by providing a written summary. This summary shall include details about the concern, investigative findings, conclusions, and a response. A summary shall be provided to the person filing the Resident Concern (Grievance) Form. A copy of the completed form will be maintained by the facility.
This violation represents non-compliance investigated under Complaint Number OH00160503.
R-0745Deficiency R-0745▼
Based on closed record review, staff and family interview, and review of facility policy, the facility failed to ensure timely notification for a change in condition. This affected one resident (#110) of three reviewed for changes in condition. The facility census was 104.
Findings include:
Review of Resident #110's closed medical records revealed an admission date of 06/19/24 and a discharge date of 11/26/24. Diagnoses included high blood pressure and vascular dementia. Resident #110's record contained two individuals listed as his Power of Attorney (POA).
Review of Resident #110's hospital emergency department visit note, dated 08/29/24 at 8:57 P.M. revealed the resident presented to the emergency department with coffee ground emesis.
Review of Resident #110's progress notes revealed a note dated 08/30/24 timed 3:05 A.M., authored by Licensed Practical Nurse (LPN) #303 that stated upon arrival Resident #110 was observed with coffee ground emesis, and emergency services and the resident's POA were called. The note did not specify what time the resident experienced a change in condition, nor what time he was transferred to the hospital. Additionally, the note did not specify the name of the POA who was called, nor what time the notification occurred.
Review of LPN #303's time punches for LPN #303 revealed she clocked in for work on 08/29/24 at 6:54 P.M. and clocked out on 08/30/24 at 6:06 A.M.
Telephone interview on 01/15/25 at 10:27 A.M. with a Family Member #150 revealed she was one of Resident #110's POA and was his first emergency contact. Family Member #150 stated she had never been notified by the facility of Resident #110's 08/29/24 hospitalization. She recalled she had previously talked to Resident #110 on the phone on 08/29/24 at 5:04 P.M. and Resident #110 stated to her he had been feeling unwell. On 08/29/24, Family Member #150 placed a call to Family Member #155, who lived locally. She asked Family Member #155 to go to the facility to check on Resident #110, who agreed. On 08/29/24 at 8:20 P.M., Family Member #150 received a call from Family Member #155 stating Resident #110 was going to the hospital. Family Member #150 stated Resident #110 was hospitalized for over a week before subsequently being transferred to a skilled nursing facility (SNF) for rehabilitation. Family Member #150 stated she had not received a call from anyone at the facility regarding Resident #110's change of condition or hospitalization until she was contacted by the Director of Wellness (DOW) on 10/23/24 to inquire how Resident #110 was doing at the SNF and if he would be returning to the facility.
Interview on 01/15/25 at 2:05 P.M. with Executive Director (ED) confirmed LPN #303's progress note had been recorded on 08/30/24 at 3:05 A.M. and stated that was during the course of LPN #303's shift. ED stated the note may have been recorded at that time due to that is when LPN #303 had time to document it. ED confirmed LPN #303 was no longer employed by the facility.
Review of facility policy titled Change in Condition dated 09/01/16 revealed the Care Services Manager (CSM) or designee is responsible for responding to a resident's change of condition, making appropriate notifications, and implementing appropriate interventions. The CSM will notify the physician and responsible party, and document notifications. A change in condition assessment/evaluation will be completed timely and an updated care plan conference was to be held with the resident and/or responsible party.
This violation represents non-compliance investigated under Complaint Number OH00160503.