17
Inspections on file
20
Deficiencies cited
8
Visits with none
0
Substandard care
0
Immediate jeopardy

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

Ohio license number
#2265R
County
Cuyahoga
Administrator
Chasity Davis
Phone
(216) 321-6331
Ownership
For Profit - Limited Liability Company

Inspections

17 on file · 20 deficiencies
November 6, 2025Licensure survey4 deficiencies
R-0339Administered meds - given only to and as prescribedOhio citation
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0349Medication record for administered medicationsOhio citation
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0391Resident incidents and log; identify resident upon requestOhio citation
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0615Fire drill requirementsOhio citation
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
October 6, 2025Complaint survey1 deficiency
R-0711Free from abuseOhio citation · correction confirmed 11/06/2025
What the surveyor found

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

Rule
Ohio Administrative Code - residential care rules
July 21, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
January 15, 2025Complaint survey4 deficiencies
R-0338Administered meds - MD ordersOhio citation · correction confirmed 11/06/2025
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0339Administered meds - given only to and as prescribedOhio citation
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0744Voice grievances and access to advocatesOhio citation · correction confirmed 11/06/2025
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
R-0745Deficiency R-0745Ohio citation · correction confirmed 11/06/2025
What the surveyor found

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.

Rule
Ohio Administrative Code - residential care rules
November 4, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
September 18, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
August 1, 2024Complaint survey1 deficiency
R-0712Adequate and appropriate treatment and careOhio citation
What the surveyor found

The facility failed to ensure appropriate communication with a contracted transportation company to ensure residents with severe cognitive impairment were safely escorted into the facility when using their services. This affected one of three residents reviewed who had cognitive impairment and resided on the memory care unit (Resident #244). The facility census was 86.

Findings include:

Review of the medical record for Resident #244 revealed an admission date of 05/16/24. Diagnoses included but were not limited to Alzheimer's dementia, peripheral vascular disease, end stage renal disease, dependence upon dialysis. Resident #244 resided on the locked memory unit.

Review of the 05/16/24 admission assessment for Resident #244 revealed severe cognitive impairment. Resident #244 was noted to require assistance of one staff for dressing, toileting, personal hygiene, bathing, and was independent for mobility.

Review of physician's orders for Resident #244 revealed an order dated 05/15/24 for dialysis Monday, Wednesday and Friday. Resident #244 was to be dressed at 6:00 A.M. for transportation.

Review of the 05/17/24 Brief Interview for Mental Status (BIMS) assessment for Resident #244 revealed severe cognitive impairment.

Review of Resident #244's service plan last reviewed on 05/23/24 revealed an activities of daily living self-care performance deficit related to cognitive impairment and diagnosis of dementia and required cueing, reorientation, supervision and assistance as needed. Resident #244 was on dialysis and had appointments on Monday, Wednesday and Friday.

Review of the 05/29/24 nursing progress note timed at 1:10 P.M. revealed Resident #244 was out to dialysis and when the transportation company dropped the resident off, the driver did not ensure Resident #244 entered the facility. Resident #244 was noted outside by the Maintenance Director and brought back into the facility. Resident #244 was assessed and found to be stable with no complaints of pain or discomfort. The transportation company was notified by supervisor that Resident #244 needed to be escorted into the building due to diagnosis of dementia. Resident #244's daughter was notified.

Review of the wandering risk assessments completed on 07/11/24 and 07/14/24 for Resident #244 revealed she was high risk for wandering.

Interview on 07/31/24 at 10:56 A.M. with the Resident Care Coordinator (RCC) revealed she was at lunch on 05/29/24 when Resident #244 was dropped off by the transportation vehicle after dialysis. RCC stated she was told by a staff member (could not remember which staff) the maintenance man found Resident #244 outside under the canopy of the facility entrance and brought her in. Resident #244 was taken back to the memory care unit, was assessed and did not have any observed concerns. The RCC stated she contacted the transportation company and Resident #244's daughter and notified them of the incident.

Interview on 07/31/24 at 12:02 P.M. with Maintenance Director #6 revealed he was walking by the facility entrance doors and saw Resident #244 outside the facility entrance under the canopy and went out to bring her back into the facility. Maintenance Director #6 stated Resident #244 went out to dialysis and had recently been dropped off at the facility entrance. Maintenance Director #6 thought she was outside for less than 10 minutes since she was usually dropped off around 10:30 A.M.

Interview on 07/31/24 at 12:20 P.M. with the Administrator revealed she was not working on 05/29/24 and was told the following day Resident #244 was brought back to the facility by the contracted transportation service and the driver was new and did not know Resident #244 needed to be escorted back into the building due to her dementia. The Administrator stated she was told by a staff person (could not remember which staff) Maintenance Director #6 saw Resident #244 outside at the facility entrance and brought her back inside and it was less than 10 minutes after being dropped off after dialysis.

Interview on 07/31/24 at 4:25 P.M. with Receptionist #12 revealed on 05/29/24 she was told by a staff person (could not remember name of staff) that Resident #244 was outside the facility on the street in front of the facility walking on the sidewalk. Receptionist #12 stated before she could alert staff, Maintenance Director #6 walked in the door with Resident #244 and took her back to the memory care unit.

Phone interview on 08/01/24 at 7:02 A.M. with contracted Transportation Scheduler #16 confirmed Resident #244 was dropped off at the facility following dialysis on 05/29/24 and was not walked into the facility. Scheduler #16 stated she was not aware Resident #244 had dementia and the driver needed to escort the resident back inside the facility prior to leaving. The facility notified the transportation company on 05/29/24 that Resident #244 needed to be escorted back into the facility when being dropped off.

Interview on 08/01/24 at 11:09 A.M. with Licensed Practical Nurse (LPN) #17 revealed she was on break when Resident #244 was brought back from dialysis and assessed Resident #244 when she returned to the unit and stated she did not find any injuries or concerns.

During a follow up interview on 08/01/24 at 12:20 P.M. with the Administrator, the Administrator confirmed Resident #244 was severely cognitively impaired and required supervision. The Administrator stated they called Transportation Scheduler #16 after the incident on 05/29/24 to ensure Resident #244 would be escorted back into the facility safely.

Follow up interview on 08/01/24 at 1:15 P.M. with the RCC confirmed residents residing in the memory care unit require supervision while on and off the unit.

Review of the undated facility policy The Aging Process revealed under the Consumer Service Plan Process; when moving into an assisted living setting, each resident is evaluated or assessed to determine how his or her need for services can best be met. A service plan is developed indicating services that will be delivered to meet particular needs based on the individual's physical, psychosocial and cognitive capabilities.

Review of the August 2024 facility resident agreement State of Ohio Residency Agreement-Memory Care revealed under Section B: Levels of Service stated the residence evaluates your needs using the attached Appendix B, Assessment/Service Level Determination, which is attached hereto and incorporated herein. These services offer a variety of personal care and nursing care assistance and/or behavioral interventions based upon Your personal preferences and needs. The costs for your care are included in your basic services fee.

This violation represents non-compliance investigated under Complaint Number OH00155852.

Rule
Ohio Administrative Code - residential care rules
May 16, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
April 19, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
February 13, 2024Licensure survey2 deficiencies
R-0338Administered meds - MD ordersOhio citation · correction confirmed 05/16/2024
What the surveyor found

Based on record review, interview, and review of the facility policy on medication management, the facility failed to provide all medications as ordered. This affected two residents (#87 and #92) of three residents reviewed for medication administration. The facility census was 97. Findings Include: 1. Review of the medical record for Resident #87 revealed a move-in date of 12/01/23. Diagnosis included Alzheimer's disease, peripheral vascular disease, diabetes, and hypertension. Review of the service plan dated 11/03/23 revealed Resident #87 was unable to self-administer medications. Review of physician's orders for February 2024 revealed Resident #87 had orders for escitalopram oxalate tablet 5 milligrams (mg) (used to treat depression and anxiety), multivitamins capsule, Timolol Maleate ophthalmic solution 0.5 % (used to treat high pressure inside the eye due to glaucoma or other eye diseases), instill one drop in both eyes in the morning, omega-3 fatty acids oral capsule 500 mg (supplement), aspirin EC tablet delayed release 81 mg, Carboxymethylcellulose sodium ophthalmic solution 1% (treats dry eyes), Latanoprost solution 0.005% (used to treat glaucoma), Lisinopril tablet 40 mg (used to treat high blood pressure and heart failure), Sennosides tablet 8.6 mg (used to treat constipation), Hydroxyzine HCl oral tablet 10 mg (antihistamine used to treat anxiety), Amlodipine Besylate oral tablet 5 mg (used to treat high blood pressure and chest pain), Cholecalciferol oral capsule 1.25 mg 50000 units (Vitamin D supplement) give one capsule by mouth one time a day every seven days, and Metoprolol Succinate oral capsule ER 24 hour sprinkle 25 mg (used to treat chest pain, heart failure, and high blood pressure). Review of the Medication Administration Record (MAR) for January 2024 revealed Latanoprost solution 0.005% was not given 01/29/24 at 7:30 P.M., and Timolol Maleate ophthalmic solution was not given 01/10/23, 01/14/23, 01/17/23, 01/25/23, and 01/30/23. 2. Review of the medical record for Resident #92 revealed a move-in date of 05/04/23. Diagnosis included dementia, atrial fibrillation, hyperlipidemia, and major depressive disorder. Review of the service plan dated 07/28/23 revealed Resident #92 was unable to self-administer medications. Review of physician orders for February 2024 revealed Resident #92 had orders for guaifenesin ER tablet extended release 12 hour 600 mg (cough medicine, expectorant), cyclosporine emulsion 0.05% (treatment for dry eye disease), betamethasone dipropionate external cream 0.05% (used to treat skin conditions), Lisinopril oral tablet 20 mg (used to treat high blood pressure and heart failure), Nitrostat sublingual tablet 0.4 mg (vasodilator to treat chest pain), Aspirin oral capsule 81 mg, Colace oral capsule 100 mg (stool softener), Levothyroxine sodium oral tablet 50 micrograms (mcg) (used to treat hypothyroidism), Amlodipine Besylate oral tablet 10 mg (used to treat high blood pressure and chest pain), Sotalol HCl tablet 120 mg (antiarrhythmic), Fluticasone Propionate nasal suspension 50 mcg (steroid), Ranolazine ER oral tablet 12 hour one tablet twice a day (used to treat chronic chest pain), Lasix oral tablet 20 mg (diuretic), Omeprazole oral tablet delayed release 20 mg (used to treat gastric reflux), Eliquis oral tablet 5 mg (anticoagulant) give one tablet by mouth two times a day, and Atorvastatin Calcium tablet 20 mg (used to treat high cholesterol). Review of the MAR for January and February 2024 revealed Levothyroxine 50 mcg, was not given on 01/15/24, 01/19/24, 01/24/24, 01/30/24, 02/7/24, and 02/11/24. Cyclosporine Emulsion was not given on 01/27/24 and 01/29/24. Eliquis was not given on 01/27/24 and 01/29/24. Ranolazine ER was not given on 01/27/24 and 01/29/24. Interview on 02/15/24 at 2:44 P.M. with the Administrator confirmed she could provide no documented evidence the above medications were administered for Residents #87 and #92. Review of the facility policy titled Medication AdministrationBased on record review, interview, and review of the facility policy on medication management, the facility failed to provide all medications as ordered. This affected two residents (#87 and #92) of three residents reviewed for medication administration. The facility census was 97.

Findings Include:

1. Review of the medical record for Resident #87 revealed a move-in date of 12/01/23. Diagnosis included Alzheimer's disease, peripheral vascular disease, diabetes, and hypertension.

Review of the service plan dated 11/03/23 revealed Resident #87 was unable to self-administer medications.

Review of physician's orders for February 2024 revealed Resident #87 had orders for escitalopram oxalate tablet 5 milligrams (mg) (used to treat depression and anxiety), multivitamins capsule, Timolol Maleate ophthalmic solution 0.5 % (used to treat high pressure inside the eye due to glaucoma or other eye diseases), instill one drop in both eyes in the morning, omega-3 fatty acids oral capsule 500 mg (supplement), aspirin EC tablet delayed release 81 mg, Carboxymethylcellulose sodium ophthalmic solution 1% (treats dry eyes), Latanoprost solution 0.005% (used to treat glaucoma), Lisinopril tablet 40 mg (used to treat high blood pressure and heart failure), Sennosides tablet 8.6 mg (used to treat constipation), Hydroxyzine HCl oral tablet 10 mg (antihistamine used to treat anxiety), Amlodipine Besylate oral tablet 5 mg (used to treat high blood pressure and chest pain), Cholecalciferol oral capsule 1.25 mg 50000 units (Vitamin D supplement) give one capsule by mouth one time a day every seven days, and Metoprolol Succinate oral capsule ER 24 hour sprinkle 25 mg (used to treat chest pain, heart failure, and high blood pressure).

Review of the Medication Administration Record (MAR) for January 2024 revealed Latanoprost solution 0.005% was not given 01/29/24 at 7:30 P.M., and Timolol Maleate ophthalmic solution was not given 01/10/23, 01/14/23, 01/17/23, 01/25/23, and 01/30/23.

2. Review of the medical record for Resident #92 revealed a move-in date of 05/04/23. Diagnosis included dementia, atrial fibrillation, hyperlipidemia, and major depressive disorder.

Review of the service plan dated 07/28/23 revealed Resident #92 was unable to self-administer medications.

Review of physician orders for February 2024 revealed Resident #92 had orders for guaifenesin ER tablet extended release 12 hour 600 mg (cough medicine, expectorant), cyclosporine emulsion 0.05% (treatment for dry eye disease), betamethasone dipropionate external cream 0.05% (used to treat skin conditions), Lisinopril oral tablet 20 mg (used to treat high blood pressure and heart failure), Nitrostat sublingual tablet 0.4 mg (vasodilator to treat chest pain), Aspirin oral capsule 81 mg, Colace oral capsule 100 mg (stool softener), Levothyroxine sodium oral tablet 50 micrograms (mcg) (used to treat hypothyroidism), Amlodipine Besylate oral tablet 10 mg (used to treat high blood pressure and chest pain), Sotalol HCl tablet 120 mg (antiarrhythmic), Fluticasone Propionate nasal suspension 50 mcg (steroid), Ranolazine ER oral tablet 12 hour one tablet twice a day (used to treat chronic chest pain), Lasix oral tablet 20 mg (diuretic), Omeprazole oral tablet delayed release 20 mg (used to treat gastric reflux), Eliquis oral tablet 5 mg (anticoagulant) give one tablet by mouth two times a day, and Atorvastatin Calcium tablet 20 mg (used to treat high cholesterol).

Review of the MAR for January and February 2024 revealed Levothyroxine 50 mcg, was not given on 01/15/24, 01/19/24, 01/24/24, 01/30/24, 02/7/24, and 02/11/24. Cyclosporine Emulsion was not given on 01/27/24 and 01/29/24. Eliquis was not given on 01/27/24 and 01/29/24. Ranolazine ER was not given on 01/27/24 and 01/29/24.

Interview on 02/15/24 at 2:44 P.M. with the Administrator confirmed she could provide no documented evidence the above medications were administered for Residents #87 and #92.

Review of the facility policy titled Medication Administration

Rule
Ohio Administrative Code - residential care rules
R-0399Water management program; legionella preventionOhio citation · correction confirmed 05/16/2024
What the surveyor found

Based on record review and interview the facility failed to have an Infection Control designee, and there was no infection control tracking documentation maintained after August 2023. This had the potential to affect all 97 residents residing in the facility.

Finding Include:

Review of the infection control logs revealed there were no tracking logs completed after 08/30/23.

Interview on 02/13/24 at 2:44 P.M. with the Administration revealed the previous Director of Nursing (DON) had been the infection preventionist and maintained the infection control log. No one has been maintaining the infection control log since the DON left in September 2023. The facility currently had no DON, and the Assistant Director of Nursing (ADON) was out on maternity leave. Antibiotics were reviewed daily. The nurses made sure there was a stop date.

Rule
Ohio Administrative Code - residential care rules
January 9, 2024Complaint survey2 deficiencies
R-0140Background check requiredOhio citation · correction confirmed 02/13/2024
What the surveyor found

Based on record review and interview the facility failed to ensure two of five employees whose personnel records were reviewed were checked for a finding of abuse, neglect, or misappropriation of the property on the Nurse Aide Registry (NAR). This had the potential to affect all 97 residents currently residing in the facility.

Findings Include:

Review of the personnel file for Resident Care Provider (RCP) #204 revealed a hire date of 06/06/23. There was no documented evidence that a NAR check was completed upon hire.

Review of the personnel file for Licensed Practical Nurse (LPN) #205 revealed a hire date of 12/20/23. There was no documented evidence that a NAR check was completed upon hire.

Interview on 01/09/24 at 1:31 P.M. with the Administrator confirmed there was no documented evidence RCP #204 and LPN #205 were checked against the NAR upon hire.

On 01/09/24 at 1:57 P.M. the Administrator confirmed checks against NAR for RCP #204 and LPN #205 were completed and no findings of abuse were identified.

This violation was an incidental finding identified during the complaint investigation.

Rule
Ohio Administrative Code - residential care rules
R-0338Administered meds - MD ordersOhio citation
What the surveyor found

Based on record review, interview, and review of the facility policy on medication management, the facility failed to provide all medications as ordered to Residents #28, #86 and #91. This affected three residents (#28, #86 and #91) of three residents reviewed for medication administration. The facility census was 97. Findings Include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/01/21. Diagnoses included Alzheimer's disease, hypertension, depression, arthritis, and dysphagia. Review of the physicians' progress note dated 10/05/21 revealed Resident #28 was unable to self-administer medications. Review of the physician's orders for December 2023 revealed orders for Amlodipine (a blood pressure medication) five milligrams (mg) by mouth (PO) once per day (QD), aspirin 81 mg PO QD, Escitalopram (used to treat depression) 10 mg PO QD, and Hydrochlorothiazide (used to lower blood pressure) 25 mg PO QD. Review of the Medication Administration Record (MAR) for December 2023 revealed no documented evidence Resident #28 received any of the above listed medications on 12/06/23. 2. Review of the medical record for Resident #86 revealed an admission date of 12/01/23. Diagnoses included hypertension, depression, glaucoma, and diabetes. Review of the physician's progress note dated 07/06/23 revealed Resident #28 was unable to self-administer medications. Review of the physician's orders for December 2023 revealed orders for Amlodipine 5 mg PO QD, Aspirin 81 mg PO QD, Escitalopram 5 mg PO QD, Latanoprost (used to treat glaucoma) 0.005% one drop in each eye QD, Lisinopril (used to treat low blood pressure) 40 mg PO QD, Metoprolol 25 mg PO QD, multivitamin one capsule PO QD, omega three fatty acids one capsule PO QD, Timolol Maleate (used to treat glaucoma) 0.5% one drop in each eye QD, and Sennosides (used to treat constipation) 8.6 mg PO twice per day (BID). Review of the MAR for December 2023 revealed no documented evidence Resident #86 received Amlodipine on 12/01/23 and 12/06/23, aspirin on 12/01/23 and 12/06/23, Escitalopram on 12/01/23 and 12/06/23, Latanoprost 12/02/23 and 12/30/23, Lisinopril on 12/01/23 and 12/06/23, Metoprolol on 12/01/23 and 12/06/23, multivitamin on 12/01/23 and 12/06/23, omega three fatty acids on 12/01/23 and 12/06/23, Timolol Maleate on 12/01/23, 12/03/23, 12/04/23/ 12/05/23, 12/24/23 and 12/31/23 and Sennosides one time each on 12/01/23, 12/02/23, 12/06/23 and 12/30/23. 3. Review of the medical record for Resident #91 revealed an admission date of 05/04/23. Diagnoses included atrial fibrillation, arthritis, hyperlipidemia, and constipation. Review of the physician's progress note dated 04/12/23 revealed Resident #91 was unable to self-administer medications. Review of the physician's orders for December 2023 revealed orders for aspirin 81 mg PO QD, Atorvastatin (used to treat high cholesterol) 10 mg PO QD, Fluticasone 50 micrograms (mcg) two sprays in each nostril QD, Lasix (diuretic) 20 mg PO QD, Levothyroxine Sodium (used to treat thyroid disorder) 50 mcg PO QD, Lisinopril 20 mg PO QD, Metamucil 0.52 grams two capsules PO QD with eight ounces of liquid, Omeprazole (used to treat gastro-esophogeal reflux disease) 20 mg PO QD, Sotalol (used to treat hypertension) 120 mg PO QD, Warfarin (anticoagulant) 3 mg PO QD, and Amlodipine 10 mg PO QD. Review of the MAR for December 2023 revealed no documented evidence Resident #91 received aspirin on 12/02/23 and 12/03/23, Atorvastatin on 12/02/23 and 12/03/23, Fluticasone on 12/02/23 and 12/03/23, Lasix on 12/02/23 and 12/03/23, Levothyroxine Sodium on 12/04/23, 12/05/23, 12/23/23, 12/26/23, 12/26/23 and 12/27/23, Lisinopril on 12/02/23 and 12/03/23, Omeprazole on 12/02/23 and 12/03/23, Sotalol on 12/02/23 and 12/03/23, Warfarin on 12/02/23, 12/03/23 and 12/11/23, and Amlodipine on 12/02/23 and 12/03/23. Interview on 01/09/23 at 1:31 P.M. with the Administrator confirmed she could provide no documented evidence the above medications were administered for Residents #28, #86 and #91. Review of the facility policy titled Medication AdministrationBased on record review, interview, and review of the facility policy on medication management, the facility failed to provide all medications as ordered to Residents #28, #86 and #91. This affected three residents (#28, #86 and #91) of three residents reviewed for medication administration. The facility census was 97.

Findings Include:

1. Review of the medical record for Resident #28 revealed an admission date of 11/01/21. Diagnoses included Alzheimer's disease, hypertension, depression, arthritis, and dysphagia.

Review of the physicians' progress note dated 10/05/21 revealed Resident #28 was unable to self-administer medications.

Review of the physician's orders for December 2023 revealed orders for Amlodipine (a blood pressure medication) five milligrams (mg) by mouth (PO) once per day (QD), aspirin 81 mg PO QD, Escitalopram (used to treat depression) 10 mg PO QD, and Hydrochlorothiazide (used to lower blood pressure) 25 mg PO QD.

Review of the Medication Administration Record (MAR) for December 2023 revealed no documented evidence Resident #28 received any of the above listed medications on 12/06/23.

2. Review of the medical record for Resident #86 revealed an admission date of 12/01/23. Diagnoses included hypertension, depression, glaucoma, and diabetes.

Review of the physician's progress note dated 07/06/23 revealed Resident #28 was unable to self-administer medications.

Review of the physician's orders for December 2023 revealed orders for Amlodipine 5 mg PO QD, Aspirin 81 mg PO QD, Escitalopram 5 mg PO QD, Latanoprost (used to treat glaucoma) 0.005% one drop in each eye QD, Lisinopril (used to treat low blood pressure) 40 mg PO QD, Metoprolol 25 mg PO QD, multivitamin one capsule PO QD, omega three fatty acids one capsule PO QD, Timolol Maleate (used to treat glaucoma) 0.5% one drop in each eye QD, and Sennosides (used to treat constipation) 8.6 mg PO twice per day (BID).

Review of the MAR for December 2023 revealed no documented evidence Resident #86 received Amlodipine on 12/01/23 and 12/06/23, aspirin on 12/01/23 and 12/06/23, Escitalopram on 12/01/23 and 12/06/23, Latanoprost 12/02/23 and 12/30/23, Lisinopril on 12/01/23 and 12/06/23, Metoprolol on 12/01/23 and 12/06/23, multivitamin on 12/01/23 and 12/06/23, omega three fatty acids on 12/01/23 and 12/06/23, Timolol Maleate on 12/01/23, 12/03/23, 12/04/23/ 12/05/23, 12/24/23 and 12/31/23 and Sennosides one time each on 12/01/23, 12/02/23, 12/06/23 and 12/30/23.

3. Review of the medical record for Resident #91 revealed an admission date of 05/04/23. Diagnoses included atrial fibrillation, arthritis, hyperlipidemia, and constipation.

Review of the physician's progress note dated 04/12/23 revealed Resident #91 was unable to self-administer medications.

Review of the physician's orders for December 2023 revealed orders for aspirin 81 mg PO QD, Atorvastatin (used to treat high cholesterol) 10 mg PO QD, Fluticasone 50 micrograms (mcg) two sprays in each nostril QD, Lasix (diuretic) 20 mg PO QD, Levothyroxine Sodium (used to treat thyroid disorder) 50 mcg PO QD, Lisinopril 20 mg PO QD, Metamucil 0.52 grams two capsules PO QD with eight ounces of liquid, Omeprazole (used to treat gastro-esophogeal reflux disease) 20 mg PO QD, Sotalol (used to treat hypertension) 120 mg PO QD, Warfarin (anticoagulant) 3 mg PO QD, and Amlodipine 10 mg PO QD.

Review of the MAR for December 2023 revealed no documented evidence Resident #91 received aspirin on 12/02/23 and 12/03/23, Atorvastatin on 12/02/23 and 12/03/23, Fluticasone on 12/02/23 and 12/03/23, Lasix on 12/02/23 and 12/03/23, Levothyroxine Sodium on 12/04/23, 12/05/23, 12/23/23, 12/26/23, 12/26/23 and 12/27/23, Lisinopril on 12/02/23 and 12/03/23, Omeprazole on 12/02/23 and 12/03/23, Sotalol on 12/02/23 and 12/03/23, Warfarin on 12/02/23, 12/03/23 and 12/11/23, and Amlodipine on 12/02/23 and 12/03/23.

Interview on 01/09/23 at 1:31 P.M. with the Administrator confirmed she could provide no documented evidence the above medications were administered for Residents #28, #86 and #91.

Review of the facility policy titled Medication Administration

Rule
Ohio Administrative Code - residential care rules
October 26, 2023Complaint survey2 deficiencies
R-0339Administered meds - given only to and as prescribedOhio citation · correction confirmed 02/13/2024
What the surveyor found

3. Review of the medical record for Resident #3 revealed an admission date of 09/08/23 with diagnoses of diabetes, hypertension, and schizophrenia.

Review of admission care plan for Resident #3 dated 08/25/23 completed by the attending physician revealed the resident was not able to self-administer his medications.

Review of September 2023 MAR for Resident #3 revealed a physician's order dated 09/08/23 for Metformin (oral diabetic medication) mg by mouth two times a day. Further review of the MAR revealed the 4:00 P.M. dose was blank indicating the medication was not documented as given on the following dates: 09/08/23, 09/14/23, 09/20/23, 09/21/23, 09/26/23, 09/28/23, 09/29/23, and 09/30/23.

Review of October 2023 MAR revealed Resident #3 had an order change dated 10/11/23 to receive Metformin 500 mg one table by mouth in the evening at 3:00 P.M. The MAR was blank on 10/11/23, 10/16/23, 10/20/23, and 10/24/23 indicating the medication was not given.

Review of nursing note for Resident #3 dated 10/02/23 timed at 8:34 A.M. and completed by LPN #600 revealed Resident #3 did not receive his Tradjenta as the medication needed to be ordered.

Review of nursing note for Resident #3 dated 10/03/23 timed at 8:19 A.M. and completed by LPN #600 revealed Resident #3 did not receive his Tradjenta as the medication needed to be ordered.

Review of nursing note for Resident #3 dated 10/04/23 timed at 9:12 A.M. and completed by RN #601 revealed Resident #3 did not receive his Tradjenta as the medication was not available.

Review of the nursing notes for Resident #3 dated 10/02/23 to 10/04/23 revealed they did not include documentation of physician notification regarding medications not being available for administration.

Review of service plan for Resident #3 dated 10/24/23 revealed under medication resident needed help with medications due to cognitive loss, required assistance with ordering medications, and required daily supervision of medications.

Interview on 10/26/23 at 11:21 A.M. with ADON/LPN #602 confirmed Resident #3 did not receive Metformin as ordered on the following dates: 09/08/23, 09/14/23, 09/20/23, 09/21/23, 09/26/23, 09/28/23, 09/29/23, 09/30/23, 10/11/23, 10/16/23, 10/20/23, and 10/24/23.

Review of facility policy titled Medication Administration dated 09/01/16 revealed medications were to be administered in accordance with physician order, state laws and assisted living regulations. If a resident had a physician order for a medication it was the responsibility of the facility to administer, and if there was a delay anticipated the staff should obtain an order to indicate the medication should be given when available.

This violation represents non-compliance investigated under Complaint Number OH00147284.

Rule
Ohio Administrative Code - residential care rules
R-0392Establish/implement written infection control P/P; infection prevention and control program and designee requirementsOhio citation · correction confirmed 02/13/2024
What the surveyor found

Based upon observation, staff interview, and policy review the facility failed to ensure employees properly washed their hands during medication administration. This affected three (Residents #23, #43, and #44) of six residents observed for proper handwashing during medication pass. The facility census was 90.

Findings include:

Observation on 10/26/23 at 8:17 A.M. with Med Tech (MT) #603 revealed the medication cart did not have any hand sanitizer. Further observation revealed MT #603 popped eight medications from each individual pill pack into a plastic cup and administered them to Resident #44. After giving the medication MT #603 did not wash her hands or use hand sanitizer. MT #603 then signed off the medications on the computer laptop.

Observation on 10/26/23 at 8:26 A.M. with MT #603 revealed she popped six medications from each individual pill pack into a plastic cup, and the seventh medication, a multi vitamin, fell out of the cup. MT #603 then picked up the medication with her bare hands and put it back in the cup. MT #603 then popped an additional four more medications in the cup and administered the medication to Resident #43. After giving the medication MT #603 did not wash her hands or use hand sanitizer. MT #603 then signed off the medications on the computer laptop.

Observation on 10/26/23 at 8:40 A.M. with MT #603 revealed she popped seven medications from each individual pill pack into a plastic cup and administered the medications to Resident #23. After giving the medication MT #603 did not wash her hands or use hand sanitizer. MT #603 then signed off the medications on the computer laptop.

Interview on 10/26/23 at 8:46 A.M. with MT #603 confirmed she did not wash her hands or use any hand sanitizer when completing the medication pass for Resident #23, #44 and #45.

Review of facility policy titled Handwashing dated 09/01/16 revealed handwashing should be completed when administering medications.

Rule
Ohio Administrative Code - residential care rules
June 21, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
March 24, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
January 5, 2023Complaint survey2 deficiencies
R-0349Medication record for administered medicationsOhio citation · correction confirmed 02/02/2023
What the surveyor found

Based on record review and interview, the facility failed to ensure medications were documented in the Medication Administration Record (MAR) when given. This affected three Residents (Resident #5, #30 and #78) of three Residents reviewed for medications. The facility census was 92.

Findings include:

1. Review of the medical record for Resident #5 revealed an admission date of 02/22/18. Diagnoses included type two diabetes mellitus, history of falling, hypertension, syncope and collapse, muscle weakness, and hyperlipidemia.

Review of the physician orders for Resident #5 revealed orders for atorvastatin calcium (a lipid lowering agent) tablet 40 milligrams (mg) to give one tablet by mouth at bedtime with a start date of 10/27/20.

Review of the Medication Administration Record (MAR) for Resident #5 for December 2022 revealed no documentation of the Atorvastatin Calcium tablet 40 mg being given on 12/07/22, 12/08/22, 12/09/22, 12/12/22, 12/15/22, 12/17/22, 12/18/22, 12/22/22, 12/23/22, and 12/31/22.

An interview on 01/03/23 at 2:35 P.M. with Resident #5 revealed he was receiving his medications as ordered.

2. Review of the medical record for Resident #30 revealed an admission date of 11/22/21. Diagnoses included epilepsy, human immunodeficiency virus (HIV) disease, dementia, and bradycardia.

Review of the physician orders for Resident #30 revealed orders for Fycompa (an anticonvulsant) tablet four mg by mouth at bedtime with a start date of 08/23/22, Keppra ( an anticonvulsant) tablet give 2000 mg by mouth at bedtime with a start date of 09/01/22, Depakote (an anticonvulsant) tablet delayed release 250 mg give three tablets by mouth two times a day at bedtime with a start date of 09/18/22, docusate sodium (a stool softener) liquid five milliliters (ml) by mouth two times a day with a start date of 08/23/22. and Eliquis (a blood thinner) tablet five mg by mouth two times a day with a start date of 08/23/22.

Review of the MAR for Resident #30 for December 2022 revealed no documentation of the medications being given on 12/07/22, 12/08/22, 12/09/22, 12/12/22, 12/15/22, 12/17/22, 12/18/22, 12/22/22, 12/23/22, and 12/31/22.

An interview on 01/03/23 at 10:25 A.M. with Resident #30 revealed he had no concerns with receiving his medications as ordered.

3. Review of the medical record for Resident #78 revealed an admission date of 08/06/22. Diagnoses included hypertension, vascular dementia with behavioral disturbance, and dementia.

Review of the physician orders revealed orders for atorvastatin calcium tablet 20 milligrams (mg) by mouth at bedtime every Monday, Wednesday, and Friday with a start date of 08/05/22, olanzapine (an antipsychotic) tablet 2.5 mg by mouth at bedtime with a start date of 11/15/22, quetiapine fumarate (an antipsychotic) tablet 25 mg by mouth at bedtime with a start date of 08/07/22, carvedilol (heart medication) tablet 12.5 mg one tablet by mouth two times a day with a start date of 11/15/22 and Eliquis tablet five milligrams by mouth two times a day with a start date of 08/04/22.

Review of the MAR for Resident #78 for December 2022 revealed no documentation of the atorvastatin calcium given on 12/09/22 and 12/12/22, the olanzapine 2.5 mg and quetiapine fumarate 25 mg was not documented as given on 12/03/22, 12/04/22, 12/09/22, 12/12/22, 12/13/22, 12/15/22, 12/17/22, 12/18/22, and 12/31/22, no carvedilol tablet 12.5 mg and Eliquis tablet five milligrams give on 12/03/22, 12/04/22, 12/09/22, 12/12/22, 12/13/22, 12/15/22, 12/17/22, 12/18/22, and 12/31/22 for the 7:00 P.M. shift.

An interview on 01/03/22 at 10:25 A.M. with Resident #78 revealed he had no concerns with receiving his medications as ordered.

Interview on 01/03/22 at 3:11 P.M. with the Director of Nursing (DON) revealed physician ordered medications should be signed off when they were given. The DON verified the missing documentation in the MARs and explained there had been problems with the facility electronic medical record system for the MAR not working properly.

Review of the facility policy Medication Documentation

Rule
Ohio Administrative Code - residential care rules
R-0710Safe and clean environmentOhio citation · correction confirmed 02/02/2023
What the surveyor found

Based on observation of the general facility environment and outside facility property, interviews with staff, family and friend of Resident #89, closed medical record review, review of a facility investigation, review of a police report, and review of government weather tracking information, the facility failed to maintain a safe environment and provide adequate supervision for Resident #89 to ensure the resident's whereabouts were known by staff. This resulted in Real and Present Danger on 12/24/22 at approximately 11:00 A.M. when Resident #89 was last seen in the facility by staff, Licensed Practical Nurse (LPN) #502, during Resident #89's medication administration. Actual harm occurred on 12/26/22 at approximately 8:20 A.M. when Resident #89 was found by the local fire department lying deceased in the snow on the side of the facility. This affected one resident (#89) of three residents reviewed for accidents. The facility census was 92.

On 12/29/22 at 12:20 P.M. the Administrator and Director of Nursing (DON) were notified Real and Present Danger began on 12/24/22 at 11:00 A.M. when Resident #89 was last seen in the facility, was thought to be on a leave of absence (LOA) with family and was subsequently found deceased on 12/26/22 outside on the facility grounds.

On 12/29/22 the Real and Present Danger was abated when the facility implemented the following corrective action:

From 12/26/22 to 12/29/22 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) in-serviced all staff currently within the facility on managing elopement and wandering behaviors. All staff were educated by 12/29/2022. Any employees who were not in the facility to be educated in person were emailed or called to be given the education. The education was documented on the in-service sign in sheet on 12/29/22.

On 12/26/22 an initial audit was conducted to ensure all residents were either in the building or on a leave of absence (LOA) by the DON and ADON.

On 12/26/22 the DON and/or ADON completed an elopement risk assessment upon initial assessment prior to admitting any resident to the Assisted Living Community. If the assessment triggered a resident was not appropriate for Assisted Living (AL), then admission would be denied. The DON and ADON identified no other recipients who had suffered or were likely to suffer a serious outcome because of noncompliance. Beginning on 12/29/2022 a plan for the DON and/or ADON to do quarterly Elopement Risk Assessments to ensure residents were appropriate for the AL was implemented. Quarterly assessments would be audited and maintained by both the DON and ADON on a quarterly basis continuously.

Beginning on 12/29/22 a plan for the DON and ADON to ensure the midnight census was run daily and the nursing staff ensured they knew where all residents were located was implemented. Any leave of absences (LOAs) would be confirmed and documented. This would be audited daily for four weeks, then once a week thereafter starting 12/29/22. A plan for the DON and ADON to educate all nursing staff on 12/29/22 on a new policy regarding census checking and LOA documentation was implemented.

On 12/29/22 the Administrator educated all residents on the process of signing out for LOAs. This was completed in the form of a letter. Should any resident be out longer than 24 hours the resident and/or Power of Attorney (POA) and/or emergency contact person would need to call the AL to inform them the resident would be gone for 24 hours or more. Should a resident not notify the AL, the nurses would contact the POA and/or emergency contact to confirm whereabouts then document LOA once confirmed. Nurses will be educated on this process by the DON and ADON by 12/29/22. DON and ADON will audit this process for four weeks daily then once a week continuously.

On 12/29/22 a plan for the Administrator to educate reception staff regarding the sign out policy was implemented. The Administrator will audit the sign out-and- in log daily and then once a week continuously.

Although the Real and Present Danger was abated on 12/29/22, the violation remains as the facility investigation of the incident was ongoing and the facility was in the process of implementing corrective action and completing audits.

Findings include:

Review of Resident #89's closed medical record revealed the resident was admitted to the facility on 02/23/21 with diagnoses including major depressive disorder, insomnia, anxiety disorder, and chronic kidney disease.

A neurology note, dated 02/07/22, revealed the resident had dementia.

A quarterly facility evaluation, dated 11/01/22, documented the resident had stable gait and was alert and oriented.

Record review revealed no progress notes from 12/23/22 to 12/26/22 except a progress note dated 12/25/22 at 8:35 P.M. authored by Licensed Practical Nurse (LPN) #501 which indicated the resident was on an LOA per report from a previous nurse.

Review of Resident #89's Medication Administration Record (MAR) revealed medications for 12/24/22 were documented as given on both day and night shift, and 12/25/22 medications were documented as away from home with meds meaning none of her medications were administered to her on 12/25/22 because she was not in the facility.

Review of police report, incident number 22-05180, revealed a fire department squad saw a body lying in the snow by the facility and found it to be a deceased elderly female. Police were dispatched to the scene on 12/26/22 at approximately 8:20 A.M. Facility staff identified the body to be Resident #89. It was unknown how long the resident was outside and there were no fresh footprints in the snow.

Review of local weather summaries from the weather.gov website revealed the temperature range on 12/24/22 was negative one-degree Fahrenheit (F) to 13 degrees F with a snow depth of approximately four inches. The temperature range on 12/25/22 was 11 to 14 degrees F with a snow depth of approximately four inches.

Review of facility staff assignments revealed LPN #502 was assigned to Resident #89's unit on the day shift (7:00 A.M. to 7:00 P.M.) on 12/24/22 and 12/25/22. Registered Nurse (RN) #505 was assigned to Resident #89's unit on the night shift (7:00 P.M. to 7:00 A.M.) on 12/24/22, and LPN #501 was assigned to Resident #89's unit on the night shift of 12/25/22.

Review of facility investigation witness statements revealed LPN #501 started her shift at 7:00 P.M. on 12/25/22 and was told by the off-going nurse during report Resident #89 was on a LOA. LPN #502 last saw the resident the morning of 12/24/22 and did not see her 12/25/22. Registered Nurse (RN) #505 did not see Resident #89 during her shift on 12/24/22. No other witness statement confirmed seeing the resident in the facility any time after the morning of 12/24/22.

On 12/27/22 at 3:54 P.M. interview with the Administrator verified Resident #89 was found deceased on the left side of the building on 12/26/22. The Administrator revealed facility staff believed Resident #89 had been out on a LOA with family.

Observation with the Administrator of the left side of the exterior building (where Resident #89's body was found) on 12/27/22 at 4:00 P.M. revealed an alley between the facility and a tree line, with a gas station on the other side. The nearest facility entrance was a locked stairwell door with no window. The administrator verified this area was where Resident #89 was found deceased on 12/26/22.

On 12/28/22 at 11:20 A.M. interview with Power of Attorney (POA) #601 revealed she was a close friend of Resident #89. She said Resident #89 had dementia but was alert and oriented and mobile. POA #601 revealed she last saw Resident #89 after coming for a visit on 12/23/22. She stated she did not take the resident from the facility and did not know of her to leave with any other family following this visit she had.

On 12/28/22 at 11:44 A.M. interview with Family Member #602 revealed she was Resident #89's sister. Family Member #602 revealed she had last seen the resident on approximately 12/15/22 when she took her out on a LOA to shop. The family member revealed Resident #89 was alert but sometimes had confused behavior such as forgetting what she ordered at a restaurant and eating produce in a grocery store. The resident was independently mobile but had a lot of falls and disliked using a cane. Family Member #602 denied knowledge of any other family members who would have taken the resident on an LOA on 12/24/22 or later.

On 12/28/22 at 11:56 A.M. interview with Receptionist #202 revealed Resident #89 left the building frequently without signing out, both for family LOAs and to walk to a nearby store.

On 12/28/22 at 12:20 P.M. interview with Resident Care Partner (RCP) #204 revealed she worked on 12/24/22 and 12/25/22 and did not see Resident #89 either day. RCP #204 revealed she was told the resident was out on a LOA.

On 12/28/22 at 1:15 P.M. interview with RCP #205 revealed she worked the night of 12/25/22. Resident #89's door was locked when RCP #205 rounded on her. RCP #205 revealed she did not see the resident all throughout her shift.

Interviews with Resident #35, #43, and #52 on 12/28/22 at 2:08 P.M. revealed they were friends with Resident #89. During the interviews, none of the residents indicated they saw Resident #89 on 12/24/22 or 12/25/22. The residents also indicated Resident #89 was stable when walking but fell often and sometimes the other residents helped her up.

On 12/28/22 at 2:45 P.M. interview with RCP #203 revealed she did not see Resident #89 when working on 12/25/22.

On 12/28/22 at 2:49 P.M. interview with LPN #501 revealed she got in report from LPN #502 on 12/25/22 that Resident #89 was on LOA. She stated she did not see Resident #89 during her shift on the night of 12/25/22.

On 12/28/22 at 3:36 P.M. interview with LPN #502 revealed she gave Resident #89 medication on 12/24/22 at approximately 11:00 A.M. She did not see the resident after that, including when she worked on 12/25/22. LPN #502 did not receive any report Resident #89 was on a LOA, however assumed so because the resident frequently left the building without notifying staff. She reported to the incoming nurse (LPN #501) the resident was on LOA.

On 12/29/22 at 8:47 A.M. interview with RCP #206 revealed she assisted passing meal trays on Resident #89's unit on 12/25/22 but did not see Resident #89 that day.

On 12/29/22 at 3:15 P.M. interview with LPN #207 revealed he did not see Resident #89 when he worked the evening of 12/24/22. He stated he passed medications on the resident's unit to assist the other night nurse assigned to the unit, however there was no answer when he knocked on Resident #89's door so he was unable to give her medications. He reported this to the resident's night nurse (RN #505). When asked by the surveyor why it was documented in the MAR on 12/24/22 that medications were given in the evening to Resident #89, LPN #207 explained his documentation was an error because he did not give Resident #89 any medication on 12/24/22 nor did he see her.

This violation represents non-compliance investigated under Complaint Number OH00138716.

Rule
Ohio Administrative Code - residential care rules
December 7, 2022Complaint survey2 deficiencies
R-0339Administered meds - given only to and as prescribedOhio citation · correction confirmed 02/02/2023
What the surveyor found

Based on observation, interview and record review, the facility failed to administer medications per the physician orders. This affected four residents, Resident #177, #136, #143, and #118 of six residents reviewed for medication administration. The facility census was 112

Findings include:

1. Review of the medical record for Resident #177 revealed an admission date of 01/03/21. Diagnosis included blindness in one eye, glaucoma, and low back pain.

Record review of the quarterly evaluation dated 9/27/22 at 8:00 A.M. completed by the Director of Nursing (DON) revealed Resident #177 was alert and oriented to person, place, time, and situation. Resident #177 was total dependents for bed mobility, transfers, locomotion, and used a wheelchair.

Record review of the physician orders for Resident #177 revealed resident had orders to receive refresh tears 0.5% one drop to both eyes three times a day related to glaucoma. Record review revealed the medication was to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Additional orders included tramadol 50 milligrams (mg) three times a day. Record review revealed the medication was to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M.

Record review of the Medication Administration Record (MAR) for December 2022 revealed Resident #177 did not receive the refresh tears or tramadol on 12/03/22 at 10:00 P.M., 12/04/22 AT 6:00 A.M. or 10:00 P.M., and 12/05/22 at 6:00 P.M.

Interview on 12/06/22 at 3:30 P.M. with the Director of Nursing (DON), revealed licensed nurses administer medications in accordance with physician orders. The DON revealed when medications were administered, the nurse administering the medication would sign off the medication administration record.

2. Record review for Resident #136 revealed an admission date of 05/01/2009. Diagnosis included heart failure and hypertension.

Record review of the December 2022 physician orders for Resident #136 revealed an order for lisinopril tablet 2.5 mg, give one tablet by mouth one time a day every Monday, Tuesday and Wednesday for hypertension.

Observation of medication administration on 12/05/22 at 9:55 A.M. revealed Licensed Practical Nurse (LPN) #307 did not have lisinopril tablet 2.5 mg available to administer to Resident #136.

Interview on 12/05/22 t 9:56 A.M. with LPN #307 confirmed Resident #136 did not receive the ordered lisinopril tablet 2.5 mg. LPN #307 revealed she would call pharmacy today and the medication would be available by the next morning for administration. LPN #307 confirmed Resident #136 ' s medication came from the pharmacy and should have been available for administration.

3. Record review for Resident #143 revealed an admission date of 07/01/21. Diagnosis included dementia.

Record review of the December 2022 physician orders for Resident #143 revealed orders for namenda five mg, give one tab by mouth two times a day related to unspecified dementia.

Observation of medication administration on 12/05/22 at 10:10 A.M. revealed LPN #307 did not have namenda five mg available to administer to Resident #143.

Interview on 12/05/22 t 10:11 A.M. with LPN #307 confirmed Resident #143 did not receive the ordered namenda five mg. LPN #307 revealed she would call pharmacy today and the medication would be available by the next morning for administration. LPN #307 confirmed Resident #143 ' s medication came from the pharmacy and should have been available for administration.

4. Record review for Resident #118 revealed an admission date of 07/03/21. Diagnosis included mood disturbance and anxiety.

Record review of the December 2022 physician orders for Resident #118 revealed orders for tylenol extra strength tablet 500 mg, give two tablets by mouth two times a day for shoulder pain.

Observation of medication administration on 12/05/22 at 10:15 A.M. revealed LPN #307 did not have tylenol extra strength tablet 500 mg available to administer to Resident #118.

Interview on 12/05/22 t 10:16 A.M. with LPN #307 confirmed Resident #118 did not receive the ordered tylenol extra strength tablet 500 mg. LPN #307 revealed she would call the family today and the medication would be available by the next morning for administration. LPN #307 confirmed Resident #118 ' s over the counter medication was provided by the family and it was the nurses responsibility to notify the family of the need to refill the medication prior to the resident running out of the medication.

Observations on 12/05/22 from 9:55 A.M. to 1:32 P.M., revealed Licensed Practical Nurse (LPN) #307 and #311 administered medications to Resident #136, #143, #118, #182, and #211. Three errors were observed during the medication administration.

The violation represents non compliance investigated under Complaint number OH00136228 and Complaint number OH00138093.

Rule
Ohio Administrative Code - residential care rules
R-0711Free from abuseOhio citation · correction confirmed 02/02/2023
What the surveyor found

Based on record review and interview, the facility failed to keep one resident, Resident #153, safe from physical abuse caused by another resident, Resident #172. This affected one resident, Resident #153 of two residents reviewed for abuse. The facility census was 112.

Findings include:

1. Record review for Specified Resident Resident #153 revealed an admission date of 04/15/22. Diagnosis included hypertension, seizures, and osteoarthritis.

Record review of the quarterly evaluation dated 10/11/22 completed by Director of Nursing (DON) revealed Resident #153 was alert and oriented to person, place, time, and situation. Resident #153 had no mood or behavior concerns. Resident #153 was independent with bed mobility, transfers, and ambulation.

Record review of the Open Area Flow Sheet for Resident #153 dated 11/21/22 at 1:30 P.M. completed by Assistant Director of Nursing (ADN) revealed on the left side upper lip approximately one-half inch laceration that was intact and well approximated with no redness or drainage. Resident #153 had no pain.

Record review of the hospital record for Resident #153 dated 11/21/22 at 12:43 P.M. revealed reason for visit was assault physical and diagnosis was facial laceration. Instructions included all cuts and wounds heal by forming a scar. The stitches/dermabond/steristrips that were placed at your visit are meant to minimize the scarring of your cut. Record review revealed no specific orders for further treatment.

Record review of the progress note dated 11/21/22 at 2:13 P.M. completed by DON revealed Resident #153 returned from the emergency room visit with no new orders.

Interview on 12/05/22 at 11:45 P.M. with Resident #153 revealed Resident #172 would want to start small arguments with him prior to the incident when he did not agree with him. Resident #153 revealed on 11/21/22 he was eating his breakfast in the dining room when Resident #172 came up to him yelling names at him. Resident #172 had a scraper in his hand and started swinging and cut him (Resident #153) in the face with the scraper. He stood up (Resident #153) and knocked Resident #172 onto the ground after he was cut. Resident #153 revealed they were immediately separated, the police and ambulance came, and he went to the hospital for treatment to the cut on his face.

2. Record review for Resident #172 revealed an admission date of 02/17/22. Diagnosis included cerebral infarction, mood disorder due to known physiological condition with major depressive like episode, and polyosteoarthritis.

Record review of the quarterly evaluation dated 11/15/22 completed by DON revealed Resident #172 was alert and oriented to person, place, time, and situation. Resident #172 had no mood or behavior concerns. Resident #172 was independent with bed mobility, transfers and ambulation with use of a rollator.

Review of the Self Reported Incident (SRI) dated 11/30/22 completed by Administrator revealed resident to resident physical abuse occurred on 11/21/22 at 9:00 A.M. at the facility in the dining room when Resident #172 entered the dining room at around 9:00 A.M. and approached Resident #153 that was sitting at his table and began to start an argument with him. Resident #153 got up to leave the dining room as he was done eating and that's when Resident #172 pulled an object out of his pocket and swung it at Resident #153 cutting his lip. Resident #153 then pushed Resident #172 to the floor. Residents were separated by the staff. Nurse assessed both residents and called EMS and police. Resident #153 went to the hospital and received a diagnosis a facial laceration and a steristrips were placed on his lip.

Record review of the SRI revealed Resident #204, #211, former specified resident (FSR) #217, and #218 witnessed the incident on 11/21/22 at 9:00 A.M. Resident #153 was cut by another resident with a metal object. Both residents were sent to the hospital. Record review of the facility investigation dated 11/21/22 completed by Dietary #305 revealed on 11/20/22 (Resident #172) and (Resident #153) had an altercation, they had words and was about to fight but (Receptionist #306) broke them up. Resident #172 was calling Resident #153 (described names) and how he would cut him. Dietary #305 revealed she told Resident #172 that she was going to put him out of the dining room if he didn't stop. At that time everything calmed down.

Interview with Administrator on 12/05/22 at 1:39 P.M. confirmed the date of occurrence of the altercation between Resident #153 and Resident #172 was 11/21/22 at 9:00 A.M. Administrator confirmed the date the SRI was initiated was 11/30/22. Administrator revealed the reason she did not initiate the SRI sooner was because she did not have a final disposition of the residents and it just slipped her mind. Administrator revealed Resident #172 had psych consults because he would escalade verbally. Administrator confirmed the witness statement completed by Dietary #305 revealed that Resident #172's threat to Resident #153 on 11/20/22 was never reported to her or she would have taken action at that time.

The violation represents noncompliance investigated under Complaint number OH00138056 and Complaint number OH00138023.

Rule
Ohio Administrative Code - residential care rules
September 8, 2022Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.