Carriage Court of Grove City

Based on personnel record reviews and staff interviews, the facility failed to ensure new employees had physical exams completed 30 days before, or on the day of work. This affected three of six personnel files reviewed for qualifications and health of personnel. This had the potential to affect all 45 residents residing in the facility.

Findings include:

Review of Personal Care Aide (PCA) #130's personnel file revealed a start day of 06/05/25. A physical examination was not completed until 06/23/25.

Review of Executive Director (ED) #131's personnel file revealed a start day of 02/24/25. A physical examination was not completed until 03/12/25.

Review of PCA #133's personnel file revealed a start day of 11/12/24. A physical examination was not completed.

Interview with ED #131 on 07/23/25 at 10:50 A.M. confirmed PCA #130 and ED #131 had physical examinations completed after their hire dates, and PCA #133 did not have a physical examination.

Based on record review, resident and staff interviews and policy review, the facility failed to ensure medications were available and administered as physician ordered. This affected one (Resident #9) of five reviewed for medication administration. The facility census was 45.

Findings include:

Review of Resident #9's medical revealed an admission date of 07/21/25 with diagnoses including multiple sclerosis, chronic obstructive pulmonary disorder, and history of cerebrovascular accident with cognitive impairments.

Review of Resident #9's medication administration record (MAR) revealed on 07/22/25 at 8:00 A.M., Resident #9 was not administered Clopidogrel (blood thinner) 75 milligrams (mg), Fluoxetine 40 mg (depression), Furosemide 40 mg (diuretic), Metoprolol 25 mg (high blood pressure), and Omeprazole 40 mg (acid reflux) for the reason med unavailable.

During interview on 07/22/25 at 1:29 P.M., Resident #9 states she was admitted on the previous day (07/21/25), and her medications were not available yet. Resident #9 reported she brought her prescriptions with her upon admission but was told they could not be kept at the facility. Resident #9 stated she received some of her medications this morning but not others.

Interview with the Director of Nursing (DON) on 07/22/25 at 4:00 P.M. confirmed Resident #9's MAR was correct and Resident #9 was not administered some of her medications. The DON stated Resident #9's insurance was not covering some of her medications and they were working to get the prescriptions filled.

Review of the policy titled Medication Management, Administration, and Storage (Indiana and Ohio Only)

Based on observations, staff interviews, record review and review of the manufacturer's guide, facility failed to prime the insulin pen injector resulting in a significant medication error for three residents (#7, #8, and #34) of three reviewed for insulin administration. The facility identified four residents (#7, #8, #14, and #34) with orders for insulin The facility census was 45.

Findings include

1. Review of the medical record for Resident #7 revealed an admission date of 06/29/25. Diagnoses included diabetes mellitus.

Review of Resident #7's medication evaluation dated 05/10/25 revealed Resident #7 required assistance with medication.

Review of Resident #7's physician orders revealed an order for Humalog (insulin) 100 units per milliliters Kwik pen with instructions to inject subcutaneous per sliding scale three times daily before meals.

Observation and interview on 07/22/25 from 11:13 A.M. to 11:20 A.M. revealed Licensed Practical Nurse (LPN) #140's obtained Resident #7's blood sugar with result of 265. LPN #140 verified Resident #7 should be administered four units of insulin based on the physician order. LPN #140 placed needle on pen and dialed up four units, did not prime the pen, and administered four units of Humalog to Resident #7. LPN #140 verified she did not prime the insulin pen prior to administering four units of Humalog to Resident #7. LPN #140 stated she was unaware of what 'priming the pen' meant. LPN #140 verified priming of the insulin pens was not completed for Resident #7 prior to administration.

2. Review of the medical record for Resident #34 revealed an admission date of 10/09/24. Diagnoses included diabetes mellitus.

Review of the resident service evaluation dated 03/13/25 revealed Resident #34 required assistance with medication.

Review of Resident #34's physician orders revealed an order Humalog (insulin) 100 units per milliliter Kwik pen with instructions to inject subcutaneous per sliding scale three times daily. 201-250 = four units; 251-300 = eight units; 301-350 = 12 units; 351-400 = 16 units; over 400 = 20 units and call physician.

Observation and interview on 07/22/25 from 11:25 A.M. to 11:36 A.M. revealed Licensed Practical Nurse (LPN) #140 obtained Resident #34's blood sugar with result of 266. LPN #140 verified Resident #34 should be administered eight units of insulin based on the physician order. LPN #140 placed needle on pen and dialed up eight units, did not prime the pen, and administered eight units of Humalog to Resident #34. LPN #140 confirmed she did not prime the insulin pen prior to administering eight units of Humalog to Resident #34. LPN #140 stated she was unaware of what 'priming the pen' meant. LPN #140 verified priming of the insulin pens was not completed for Resident #34 prior to administration.

Review of the manufacturer's guide for Humalog and Humalog Kwikpen revealed instructions on priming your pen. It revealed priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The instructions state the user should turn the dose knob to select two units. Then states to hold the pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at the top. It states to continue holding the pen with needle pointing upwards and push the dose knob in until it stops and 0 is seen in the dose window Then hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin repeat priming steps six to eight no more than four times. If you still do not see insulin change the needle and repeat priming steps six to eight.

3. Review of the medical record for Resident #8 revealed an admission date of 05/31/23. Diagnoses included diabetes mellitus.

Review of the resident service evaluation dated 04/29/25 revealed Resident #8 required assistance with medication.

Review of the physician orders revealed an order for Novolog (insulin) 100 units per milliliter with instructions to inject subcutaneous per sliding scale before meals and at bedtime. 151-200 = two units; 201-250 = four units; 251-300 = six units; 301-350 = eight units; 351-400 = 10 units; over 400 call physician.

Observation and interview on 07/22/25 from 12:31 P.M. to 12:36 P.M. revealed Licensed Practical Nurse (LPN) #140 obtained Resident #8's blood sugar with result of 232. LPN #140 verified Resident #8 should be administered four units of insulin based on the physician order. LPN #140 placed needle on pen and dialed up four units, did not prime the needle and administered four units on Novolog to Resident #8. LPN #140 verified priming of the insulin pens was not completed for Resident #8 prior to administration.

Interview on 07/22/25 at 3:15 P.M. with the Wellness Director (WD) revealed to prime insulin you turn the pen upside down and turn to two units and push to see insulin drops come from the needle to ensure a full dose was given. The WD confirmed facility nursing staff were trained but agency staff did not receive the training. The WD confirmed LPN #140 was an agency nurse and was not trained after facility received previous citation (on 04/21/25).

Review of the manufacturer guide for Novolog revealed instructions for giving the airshot before each injection. It stated the user should turn the dose selector to two units and provides a diagram. Hold Novolog FlexPen with the needle pointing up and tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge and provide a second diagram. Keep the needle pointing upwards and press the push-button all the way in and provides a third diagram with the dose selector returning to 0 (zero). A drop of insulin should appear at the needle tip, if not change the needle and repeat the procedure no more than six times. If a drop of insulin was not seen after six times do not use the Novolog FlexPen.

This is an example of continued non-compliance from the survey dated 04/21/25.

Based on staff interviews, policy review, and record review, the facility failed to accurately document medication administration on the resident's medication administration records (MAR) for four (#7, #8, #13, and #34) of four residents reviewed for medication administration. The facility census was 45.

Findings include

1. Review of the medical record for Resident #7 revealed an admission date of 06/29/25. Diagnoses included dementia and diabetes.

Review of the physician orders revealed the following orders for Resident #7: acetaminophen 500 milligrams (mg) two tablets three times daily; Amlodipine 10 mg tablet once daily; Aspirin EC 81 mg tablet once daily; Atorvastatin 40 mg tablet once daily at bedtime; AZO Cranberry tablet one tablet once daily; Finasteride five mg tablet once daily; Gabapentin 100 mg capsule once daily at bedtime; Gabapentin 300 mg one capsule twice daily; Lantus Solostar 100 u/ml with instructions to inject 42 units subcutaneously at bedtime; Lidocaine 4% pain patch with instructions to apply one patch in the morning and remove in the evening; Multivitamin tablet once daily; Oxybutynin five mg tablet once daily; Polyethylene Gly 3350 powder with instructions to take 17 grams (gm) (one capful) by mouth in four to eight ounces of liquid daily; and Senna 8.6 mg tablet once daily.

Review of the MAR dated 06/2025 revealed the following medications were not documented as administered and/or provided reason why it was not administered: Acetaminophen three doses, Amlodipine, AZO Cranberry, Finasteride, multivitamin, Oxybutynin, Senna, and Aspirin on 06/03/25. Atorvastatin on 06/06/25, 06/08/25, and 06/28/25; Gabapentin on 06/06/25, 06/08/25, and 06/28/25; Humalog Kwik pen on three doses on 06/03/25, on two doses on 06/09/25, and 06/28/25; Lantus Solostar on 06/06/25, 06/07/25, 06/08/25, 06/26/25, and 06/28/25; and Lidocaine 4% pain patch on 06/03/25, 06/09/25, and 06/24/25;

Interview on 07/22/25 at 3:15 P.M. with the Wellness Director (WD) revealed confirmed Resident #7's MAR dated 06/2025 had several missing entries for reasons why medications were not administered to Resident #7. WD confirmed the MAR had options for entries to include if the medication was administered, refused, missed, away, suspended, and other with an option for a note to be left. The WD confirmed her expectation was for staff to document every entry on the MAR so facility would know if the medication was administered or not.

2. Review of the medical record for Resident #34 revealed an admission date of 10/09/24. Diagnoses included altered mental status, cerebrovascular accident, and diabetes.

Review of the resident service evaluation dated 03/13/25 revealed Resident #34 required assistance with medication.

Review of the physician orders revealed Resident #34 had the following orders: accu-check three times daily; 600 D3 400 international unit (IU) tablet take two tablets once daily; Clopidogrel 75 milligrams (mg) tablet once daily; Donepezil 10 mg once daily; Fluticasone prop 50 micrograms (mcg) nasal spray with instructions to instill two sprays in each nostril daily; Januvia 100 mg once daily; Levothyroxine 50 mcg once daily in the morning; Mirtazapine 7.5 mg once daily at bedtime; Multivitamin tablet once daily; Propranolol ER 80 caplet once daily; Pyridostigmine BR 60 mg tablet one tablet three times daily; Vitamin D3 25 mcg (1,000 IU) tablet once daily; Lantus Solostar 100 u/ml with instructions to inject 15 units subcutaneously daily; and Venlafaxine ER 75 mg caplet once daily.

Review of Resident #34's MAR dated 06/2025 revealed the following medications were not documented as administered and/or provided reason why it was not administered: accu-check once on 06/01/25, 06/07/25, 06/09/25, 06/10/25, 06/15/25, 06/21/25, and twice on 06/03/25, 06/04/25, 06/05/25, and 06/06/25; Calcium, Clopidogrel, Donepezil, Januvia, Multivitamin, Propranolol ER, Venlafaxine ER, and Vitamin D3 on 06/04/25 and 06/05/25; Fluticasone prop nasal spray on 06/04/25, 06/05/25, and 06/11/25; Blood glucose testing once on 06/03/25 and 06/23/25, twice on 06/04/25 and three times 06/05/25; Lantus Solostar on 06/04/25, 06/05/25, and 06/09/25; Levothyroxine on 06/08/25, 06/21/25 and 06/25/25; Mirtazapine on 06/06/25, 06/08/25, and 06/20/25; and Pyridostigmine BR once on 06/04/25, 06/06/25, 06/15/25, and twice on 06/05/25.

Interview on 07/22/25 at 3:15 P.M. with Wellness Director (WD) confirmed Resident #34's MAR dated 06/2025 had several missing entries for reasons why medications were not administered to Resident #34. WD confirmed the MAR had options for entries to include if the medication was administered, refused, missed, away, suspended, and other with an option for a note to be left. The WD confirmed her expectation was for staff to document every entry on the MAR so facility would know if the medication was administered or not.

3. Review of the medical record for Resident #8 revealed an admission date of 05/31/23. Diagnoses included atrial fibrillation, hepatitis A, diabetes, diabetic neuropathy, mild cognitive impairment and heart failure.

Review of the resident service evaluation dated 04/29/25 revealed Resident #8 required assistance with medication.

Review of the physician orders revealed Resident #8 had the following orders: Amlodipine five milligrams (mg) one tablet daily; Atorvastatin 40 mg tablet once daily; Diphenhydramine xtr 2% cream apply to affected area three times daily; Escitalopram 20 mg tablet once daily; Ferrous Sulfate 325 mg once daily; Gabapentin 300 mg capsule twice daily; Levothyroxine 25 microgram (mcg) tablet once daily; Methadone 10 mg tablet twice daily; Metoprolol tart 25 mg twice daily; Pantoprazole 40 mg once daily; Polyethylene gly 3350 powder with instructions to mix 17 gram (gm) with liquid once daily; Spironolactone 25 mg tablet once daily; Xarelto 20 mg tablet once daily; blood glucose testing four times daily; Novolog 100 units per milliliter (u/ml) Flex pen to inject subcutaneous per sliding scale before meals and at bedtime; Ropinirole 0.5 mg one tablet twice daily; and Doxycycline HYC 100 capsule twice daily.

Review of Resident #8's MAR dated 06/2025 revealed the following medications were not documented as administered and/or provided reason why it was not administered: Amlodipine, Escitalopram, Ferrous Sulfate, Pantoprazole, Polyethylene gly 3350 powder, Spironolactone, and Xarelto on 06/05/25; Atorvastatin on 06/06/25, 06/07/25 and 06/08/25; Diphenhydramine xtr 2% cream once on 06/04/25 and 06/08/25, twice on 06/03/25, and three times on 06/05/25; Doxycycline hyc once on 06/03/25 and 06/04/25, and twice on 06/01/25 and 06/05/25; Blood glucose test once on 06/07/25, 06/21/25, 06/22/25, 06/26/25, 06/27/25, twice on 06/03/25, 06/04/25 and 06/08/25, and three times on 06/05/25 and 06/06/25; Gabapentin once on 06/05/25, 06/06/25, 06/07/25, 06/08/25, and 06/27/25; Levothyroxine on 06/08/25; Methadone on 06/05/25, 06/06/25, 06/08/25, and 06/27/25; Metoprolol tart on 06/01/25, 06/05/25, 06/06/25, 06/08/25, 06/22/25 and 06/24/25. Novolog flex pen once on 06/01/25, 06/08/25, 06/11/25, 06/13/25, 06/26/25, 06/27/25, 06/30/25, and twice on 06/03/25, 06/04/25, 06/05/25, 06/06/25 and 06/09/25; Ropinirole once on 06/03/25, 06/04/25/25, and 06/08/25, and twice on 06/05/25.

Interview on 07/22/25 at 3:15 P.M. with Wellness Director (WD) confirmed Resident #8's MAR dated 06/2025 had several missing entries for reasons why medications were not administered to Resident #8. WD confirmed the MAR had options for entries to include if the medication was administered, refused, missed, away, suspended, and other with an option for a note to be left. The WD confirmed her expectation was for staff to document every entry on the MAR so facility would know if the medication was administered or not.

4. Review of the medical record for Resident #13 revealed an admission date of 09/28/22. Diagnoses included altered mental status, cerebrovascular accident, and diabetes.

Review of the resident service evaluation dated 04/30/25 revealed Resident #13 required assistance with medication.

Review of the physician orders revealed Resident #13 had the following orders: Albuterol HFA 90 micrograms (mcg) inhaler one puff daily; Atorvastatin 80 milligrams (mg) one tablet once daily; Eliquis five mg tablet once daily; and Metoprolol tart 25 mg half tablet once daily.

Review of Resident #13's MAR dated 06/2025 revealed the following medications were not documented as administered and/or provided reason why it was not administered: Albuterol, Atorvastatin, Eliquis, on 06/04/25, 06/05/25, 06/09/25 and 06/18/25; and Metoprolol tart on 06/04/25, 06/05/25, and 06/09/25.

Interview on 07/22/25 at 3:15 P.M. with Wellness Director (WD) confirmed Resident #13's MAR dated 06/2025 had several missing entries for reasons why medications were not administered to Resident #13. WD confirmed the MAR had options for entries to include if the medication was administered, refused, missed, away, suspended, and other with an option for a note to be left. The WD confirmed her expectation was for staff to document every entry on the MAR so facility would know if the medication was administered or not.

Review of facility training/memo dated 04/18/25 revealed all medications needs to be signed off. If medication was not given a reason needs to be documented in the medical record and a note created

Review of facility policy titled Medication Management, Administration and Storage

Based on observations, staff interviews and review of the activity calendar, the facility failed to ensure activities of interest were provided and offered at varied times for 10 residents currently residing on the memory care unit.

Findings include:

Observation on 07/22/25 at 10:18 A.M. of the memory care area found that no activities were going on. The Activity calendar was posted in the common area/dining room and was dated for June 2025. The calendar hanging up was dated June 2025. Four residents were observed sitting in the common area with a staff member with a television (TV) on. None of the residents were watching the television program that was on the TV.

Continuous observation dated 07/22/25 from 1:04 P.M. to 1:40 P.M. of the memory care unit revealed no activities were going on and no staff came to invite residents to activities.

Interview on 07/22/25 at 1:37 P.M. with Aide #115 confirmed the memory care unit typically does not have specific activities. Sometimes the therapy staff will do a workout and sometimes the activity staff from the main floor will come over and invite residents to activities in the main unit. Aide #115 confirmed BINGO was on the calendar for 1:00 P.M. and nails was on the calendar for 1:30 P.M. Aide #115 reported residents mainly stay in their rooms and acknowledged that could be exacerbated due to no other activities or options being available. Aide #115 confirmed the June Calendar was posted in memory care and not current month (July).

Interview on 07/22/25 at 1:55 P.M. with Executive Director (ED) confirmed the memory care director left several weeks ago with no notice and they had not yet replaced the position. The ED revealed the memory care director was also responsible for running activities on the memory care unit.

This is an example of continued non-compliance from the survey dated 04/21/25.

Based on staff interviews, policy review, and record review, facility failed to ensure thorough fall investigations were completed and take immediate and proper steps so the resident receives the necessary intervention to prevent further falls. This affected three (#10, #22, and #30) of three residents reviewed for falls. The facility census was 45.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 05/08/25. Diagnoses included tachycardia, dementia, and hypertension.

Review of the resident service evaluation dated 04/08/25 revealed Resident #10 required assistance with some activities of daily living.

Review of fall risk assessment dated 05/08/25 revealed Resident #10 was at a high falls risk with more than one fall in the six months prior to admission. No other questions were answered and no score was given to indicate risk for falls.

Review of initial service plan dated 05/08/25 revealed Resident #10 required staff assistance and used a walker and wheelchair to ambulate. It did not state Resident #10 was at risk of falls and had no mention of fall interventions.

Review of the progress note dated 05/20/25 revealed around 4:30 P.M., Resident #10 was found on the floor beside her bed. Resident #10 stated she was trying to go to bed. No fall specific interventions were documented in response to the fall.

The progress note dated 05/26/25 at 1:44 P.M. revealed Resident #10 was found on the floor sitting on her buttocks. Resident #10 stated she was trying to go to the bathroom. Resident #10 was brought to common area for closer supervision. No fall specific interventions were documented in response to the fall.

The progress note dated 06/14/25 at 6:20 A.M. revealed Resident #10 was found on the floor. Resident #10 reported falling and being too tired to get up. So she just laid down to take a nap. Resident #10 was educated to alert staff for help in the future.

The progress note dated 06/20/25 at 5:45 P.M. revealed Resident #10 was found sitting on her buttock on the floor in front of the recliner with her legs extended out in front of her. Resident #10 reported trying to get into her bed and slid from the recliner. No fall specific interventions were documented in response to the fall.

The progress note dated 06/30/25 revealed around 10:40 P.M., Resident #10 was found lying on the floor. Resident #10 educated on the importance of using call light and waiting for help.

The progress note dated 07/03/25 revealed around 3:15 A.M., Resident #10 was found laying in bed. Resident #10 was unsure the circumstances of a fall but had a small abrasion to wrist. No fall specific interventions were documented in response to the fall.

The progress note dated 07/22/25 revealed around 7:20 P.M., Resident #10 was found sitting on the floor with her back resting against the bed. Resident #10 was unsure the circumstances of the fall. Aide to assist the resident with toileting and activities for bedtime.

Resident #10's medical record found evidence of documentation of fall interventions including no evidence of fall service/care plan.

Review of incident and accident log dated 06/2025 to 07/2025 revealed interventions for recent falls included frequent checks and education on call light use times four.

Interview on 07/23/25 at 10:15 A.M. with the Wellness Director (WD) and Executive Director (ED) confirmed fall investigations were not thorough and it did indicate the immediate and appropriate actions to prevent Resident #10 from falling again. The ED and WD confirmed the fall investigations did contain specific details of the root cause of the fall and the fall investigations were not completed accurately with injury descriptions and intervention in place at the time of the fall. The ED and WD stated staff should find the fall interventions in the resident's service plan. The ED and WD confirmed education and reminding to use the call light over and over again for a resident with dementia was not appropriate.

Interview on 07/23/25 at 11:40 A.M. with WD confirmed Resident #10 had an initial service plan with no mention of falls or fall interventions and also had no service plan with interventions for falls/fall prevention.

2. Review of the medical record for Resident #30 revealed an admission date of 02/21/25. Diagnoses included dementia with behavioral disturbance, restless leg syndrome, heart disease, muscle weakness, dysphasia, and cognitive communication deficit.

Review of the resident service evaluation dated 03/15/25 revealed Resident #30 required assistance with some activities of daily living.

Review of the fall risk assessment dated 04/02/25 revealed Resident #30 was at a high fall risk.

Review of SLUMS (St Louis University Mental Exam Assessment) dated 04/07/25 revealed Resident #30 had a high school education and scored a four. The scoring indicated for a high school educated person a score one to 20 indicated dementia diagnosis.

Review of the progress note dated 05/18/25 at 1:25 A.M. revealed Resident #30 was found on the floor after attempting to get himself up in front of the recliner. No fall specific interventions were documented in response to the fall.

The progress note dated 06/05/25 revealed around 12:00 A.M., Resident #30 was observed sitting on his buttock with walker folded underneath him in the hallway to his bedroom. Resident #30 had increased agitation. Resident #30 refused vital signs and treatment to open area on his left middle finger and was assisted back to his room. Nurse trainee stayed in room to offer one-on-one visualization while resident calmed down.

The progress note dated 06/09/25 at 4:25 A.M. revealed Resident #30 was witnessed by staff losing his balance while attempting to get out of bed without assistance with roller walker. Resident #30 was sitting on his bottom on the floor in front of his bed with his legs extended. Resident #30 was reminded to use call pendant for assistance. Caregiver and nurse to implement more frequent checks to ensure safety.

The progress note dated 06/13/25 at 2:38 A.M. revealed Resident #30 was heard yelling and found by aide to be on the floor in front of his bed lying on his back. Caregiver instructed to sit near resident room. Resident #30 educated to use pendant for needed assistance.

The progress note dated 06/15/25 at 7:21 P.M. revealed Resident #30 was observed lying on the floor of his room by the nursing aide. No fall specific interventions were documented in response to the fall.

The progress note dated 06/16/25 revealed around 3:05 P.M., Resident #30 was observed lying on the floor beside his bed lying on the right side facing his bed. The walker was in the doorway to the bathroom and resident was unable to verbalize what occurred but thought he had possibly fallen out of bed. No fall specific interventions were documented in response to the fall.

The progress note dated 06/16/25 revealed around 8:15 P.M., Resident #30 was observed lying on his side in the dining room. No fall specific interventions were documented in response to the fall.

The progress note dated 06/16/25 revealed around 10:30 P.M., Resident #30 was observed lying on his right side in his bedroom. Resident #30 stated he was toileting and fell. Resident #30 stated he hit his head and had a laceration to right side of head. Hospice was contacted and no fall specific interventions were documented in response to the fall.

The progress notes dated 06/17/25, 06/18/25, and 06/19/25 revealed Resident #30 was status post fall day one. The medical record had no evidence or information related to the details of the fall and no fall specific interventions were documented in response to the fall.

The progress note dated 06/24/25 revealed around 8:00 P.M., Resident #30 was observed lying on his right side parallel with bed in bedroom. His wheeled walker was within reach. Resident #30 stated he was coming from the bathroom when he lost balance and fell. Hospice was contacted and no fall specific interventions were documented in response to the fall.

The progress note dated 06/29/25 at 11:30 P.M. revealed Resident #30 attempted to walk to the restroom without assistance and aide found the resident on the floor in front of the sink on his bottom. He complained of pain to his left hip. Pain medications provided. No fall interventions were documented in response to the fall.

The progress note dated 07/11/25 at 1:15 A.M. revealed Resident #30 was observed lying on the floor in front of his bed with legs extended . Resident #30 complained of elbow pain with no open areas or redness observed. No fall specific interventions were documented in response to the fall. The fall investigation dated 07/11/25 at 2:15 A.M. revealed intervention included assessment of resident skin and vital signs.

The progress notes dated 07/11/25 at 7:30 A.M. revealed Resident #30 was found on the floor before breakfast and complained to pain to right shoulder. No fall specific interventions were documented in response to the fall. The fall investigation dated 07/11/25 at 7:30 A.M. revealed contributing factors of flooring (slippery/wet/uneven) and intervention included assessment and hospice called.

The progress note dated 07/19/25 at 9:30 A.M. revealed Resident #30 was observed lying on the floor of his room by a table. Resident #30 reported he was trying to use the bathroom. Resident #30 educated on the importance of waiting for assistance.

The progress note dated 07/21/25 at 10:47 A.M. revealed Resident #30 was found on the floor. He stated he slipped out of bed. No fall specific interventions were documented in response to the fall.

Resident #30's medical record found no evidence of documentation of fall interventions including no evidence of fall service/care plan.

Review of incident and accident log dated 06/2025 to 07/2025 revealed interventions for recent falls included, assistance with toileting times two, one-on-one supervision, frequent checks times two, fall mat, ambulation assistance times two, and hospice visits times four.

Interview on 07/23/25 at 10:15 A.M. with the Wellness Director (WD) and Executive Director (ED) confirmed fall investigations were not thorough and it did indicate the immediate and appropriate actions to prevent Resident #30 from falling again. The ED and WD confirmed the fall investigations did contain specific details of the root cause of the fall and the fall investigations were not completed accurately with injury descriptions and intervention in place at the time of the fall. The ED and WD stated staff should find the fall interventions in the resident's service plan. The ED and WD confirmed fall investigation dated 07/11/25 mentioned a slippery/wet flooring but nowhere in the documentation did it state what the problem was or how it was fixed. The ED stated the air conditioner unit had leaked and Resident #30 slipped on the wet floor.

Interview on 07/23/25 at 11:40 A.M. with the WD confirmed Resident #30 had no service plan with interventions for falls/fall prevention.

3. Review of the medical record for Resident #22 revealed an admission date of 10/09/24. Diagnoses included dementia with behavioral disturbance and anemia.

Review of the fall risk assessment dated 03/04/25 revealed Resident #22 was at a moderate risk for falls.

Review of the resident service evaluation dated 03/13/25 revealed Resident #22 required assistance with some activities of daily living.

Review of SLUMS (St Louis University Mental Exam Assessment) dated 03/14/25 revealed Resident #22 had a high school education and scored a four. The scoring indicated for a high school educated person a score one to 20 indicated dementia diagnosis.

Review of the progress note dated 05/09/25 at 10:30 A.M. revealed the nurse was called by housekeeper and reported Resident #22 had a fall in the dining room. Resident #22 was unable to state what happened. Resident #22 was assessed and assisted back to her chair. No fall specific interventions were documented in response to the fall.

The progress note dated 06/19/25 revealed a fall occurred at 8:40 A.M. when the nurse was called to the memory care unit. The aide reported the previous aide was aware that Resident #22 was on the floor and asked for assistance in getting resident up. Aide had thought the resident was wanting to sleep on the floor and the nurse was notified. Dried blood was found above the left eyebrow trailing down to the ear. Swelling and bruising noted to left cheek and area surrounding left eye. Resident was unable to verbalize what had happened but stated it hurt. Resident #22 was sent to emergency department for evaluation. No fall specific interventions were documented in response to the fall. The fall investigation dated 06/19/25 at 8:40 A.M. revealed the vital sign section was left blank and pain level was left blank. The assessment was documented stating first aide was not administered and 911 was not contacted.

The progress note dated 06/30/25 at 12:30 P.M. revealed Resident #22 was sent to the emergency department following a fall. Resident #22 was unable to bear weight on right leg after the fall and displayed non verbal signs of pain. No fall specific interventions were documented in response to the fall.

The progress note dated 07/11/25 at 4:30 A.M. revealed Resident #22 was found on the floor in front of her bed on her bottom with legs extended out. No fall specific interventions were documented in response to the fall.

Resident #22's medical record found no evidence of documentation of fall interventions including no evidence of fall service/care plan.

Review of incident and accident log dated 06/2025 to 07/2025 revealed interventions for recent falls included frequent checks and hospital transfer. Resident #22's fall on 06/30/25 was not listed on the incident accident log.

Interview on 07/23/25 at 10:15 A.M. with the Wellness Director (WD) and Executive Director (ED) confirmed fall investigations were not thorough and it did indicate the immediate and appropriate actions to prevent Resident #22 from falling again. The ED and WD confirmed the fall investigations did contain specific details of the root cause of the fall and the fall investigations were not completed accurately with injury descriptions and intervention in place at the time of the fall. The ED and WD stated staff should find the fall interventions in the resident's service plan.

Interview on 07/23/25 at 11:40 A.M. with the WD confirmed Resident #22 had an initial service plan with no mention of falls or fall interventions and also had no service plan with interventions for falls/fall prevention.

Review of the facility's undated policy and procedure titled Fall Interventions Suggestions for Frequent Fallers revealed a list of fall interventions staff should use.

This is an example of continued non-compliance from the survey dated 04/21/25.

Based on review of the facility's fire and disaster drill records and staff interviews, the facility failed to ensure fire drills were completed once per shift per quarter. This had the potential to affect all residents. The facility census was 45.

Findings include:

Review of the facility's fire and disaster drills from 11/01/24 to 06/30/25 revealed the facility did not complete a fire drill on the second shift from the period of December 2024 to February 2025 and on the third shift from the period of March 2025 to May 2025.

On 07/23/25 at 10:57 A.M., an interview with the Executive Director (ED) confirmed the facility did not complete a fire drill on the second shift from December 2024 to February 2025 and on the third shift from March 2025 to May 2025.

Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure residents did not self-administer medications unless assessed as capable or ordered to self-administer medications. This affected one (#35) of five residents reviewed. The facility census was 44.

Findings Include:

Review of Resident 35's medical chart reveals admission date of 04/26/25 with diagnoses including type II diabetes mellitus with diabetic neuropathic arthropathy and essential tremor.

Review of Resident 35's service plan dated 04/26/25 revealed medication ill be administered by the nurse. Resident 35's self-administration medication assessment revealed the resident required medications to be stored and locked. Additional comments stated the power of attorney requested administration by licensed staff due to history of noncompliance.

Observation 06/10/25 at 8:37 A.M. revealed Resident #35 was sitting in a wheelchair in his doorway and asking someone to show him where his pills were. The Executive Director (ED) was walking toward Resident #35's room when Licensed Practical Nurse (LPN) #305 walked past ED and around Resident #35's wheelchair and into his room. LPN #305 picked up the medication cup which contained Resident #35's morning medications from the counter beside the sink. LPN #305 told Resident #35 I left them by the sink because you were brushing your teeth. Resident #35 told LPN #305 to put them on his desk, so he could take them. LPN #305 placed the medication cup with Resident #35's pills on the desk and Resident #35 wheeled over to the desk. Resident #35 put half of the pills from the medication cup into his left hand and took them. Resident #35 then placed the other half of the pills into his left hand and took the remaining pills.

Interview on 06/10/25 at 8:40 A.M. with LPN #305 and the ED verified the medication cup contained Resident 35's morning medications. LPN #305 said she didn't know if Resident #35 was self-administering his medications. The ED stated Resident #35 was not self-administering his his medication and told LPN #305 to watch Resident #35 take his medications and to make sure she watched all residents take their medications. LPN #35 stated she was an agency nurse and was told in report all residents along the front were self-administration of medications.

Interview on 06/10/25 at 8:41 A.M. with Resident #35 stated the nurses leave his medication cup on his desk every time he was due for medication. Resident #35 stated he was legally blind in both eyes, and the medication cup must be placed in specific place on his desk for him to see the medication cup.

Review of the facilities Medication Oversight, Assistance and Administration policy dated 10/2024 under the administration section states medication administration will be provided by a licensed nurse.

This was an incidental finding discovered during this complaint investigation completed on 06/10/25.

Based on record review, review of device activity times, and family and staff interviews, the facility failed to ensure residents were provided with adequate and timely care and services. This affected one (#44) of three residents reviewed for personal care. The facility census was 44.

Findings include:

Review of Resident 44's medical chart revealed an admission date of 05/05/23. Diagnoses included anxiety, chronic obstructive pulmonary disease, hypertension, and hypothyroid. Resident #44 was on oxygen via nasal cannula.

Review of the service plan revealed Resident #44 required reminders for personal grooming tasks to be initiated and reminders to bathe self.

Review of the facility's Device Alarm Activity revealed on 06/08/25, Resident #44's call light pendant was cleared after 178 minutes and 24 seconds.

Review of the facility maintenance request log dated from February 2025 to current revealed no requests for any damage or malfunctioning call light pendants.

Interview with Resident #44's family member on 06/10/25 at 8:27 A.M. stated Resident #44's call light does not get answered timely at times. The family member stated they have to go into the facility to assist Resident #44 at times because staff were no responding to Resident #44's call light.

Interview on 06/10/25 at 11:25 A.M. with Maintenance Director #130 confirmed no requests have been made regarding call light pendant system.

Interview on 06/10/25 at 1:10 P.M. with the Executive Director (ED) and the Director of Nursing (DON) verified the call light pendant data from the Device Alarm Activity report to be correct. ED stated she thinks the aides are answering the call light pendants but not clearing them until they were leaving the resident's room. The ED confirmed the expectation was for the call light pendants to be answered within 10 minutes.

This violation represents non-compliance investigated under Complaint Number OH00166098.

Based on interview and medical record review the facility failed to ensure Resident #21 was assessed following a change in condition. This affected one resident (#21) of three residents reviewed for change in condition. The facility census was 45.

Findings include:

Review of Resident #21's medical record revealed an admission date of 04/16/24 with diagnoses including dementia, hypertension, and hyperlipidemia.

Review of Resident #21's Resident Service Evaluation dated 01/14/25 revealed the resident required distant supervision with ambulation, dressed self with minimal assistance, and required no assistance with toileting or incontinence.

Review of Resident #21's progress note dated 04/03/25 revealed the resident had not been eating or getting out of bed. Resident #21 had been sleeping all day. The daughter planned on contacting hospice for resident due to a decline in health.

Review of Resident #21's progress note dated 04/06/25 revealed hospice was in to assess the resident and the resident was admitted to hospice.

Review of Resident #21's medical record revealed no further assessments or evaluations were documented in the medical record to reflect the change in condition Resident #21 had.

Interview on 04/16/25 at 2:30 P.M. with Resident #21's family revealed the resident had significantly declined recently, she was no longer able to walk independently, and rarely got out of bed.

Interview on 04/16/25 at 10:06 A.M. with the Executive Director (ED) verified Resident #21 had a change in condition and had not been assessed.

This violation represents noncompliance investigated under complaint OH00164605.

Based on interview and medical record review the facility failed to complete labs as ordered for Resident #21. This affected one resident (#21) of one resident reviewed for change in condition. The facility census was 45.

Findings include:

Review of Resident #21's medical record revealed an admission date of 04/16/24 with diagnoses including dementia, hypertension, and hyperlipidemia.

Review of Resident #21's physician note dated 02/12/25 revealed they were going to start an order for Depakote (anticonvulsant medication used as a mood stabilizer) due to increased altered mental status. The physician wanted a laboratory test completed in eight weeks.

Review of Resident #21's physician orders from 02/12/25 to 04/07/25 revealed an order for Divalproex (Depakote) 125 milligrams (mg) twice a day, and Depakote level in 8 weeks.

Review of Resident #21's physician order dated 04/07/25 revealed an order for Divalproex 125 mg one tablet at bedtime.

Review of Resident #21's medical record revealed no evidence laboratory test had been completed as ordered.

Interview on 04/21/25 at 9:20 A.M. with the Executive Director verified the laboratory test was not completed as ordered.

Based on medical record review, observation, staff interview, and manufacturer recommendations, the facility failed to correctly administer Humalog Insulin via pen injector to a resident, resulting in a significant medication error. This affected one (Resident #7) of four residents observed for medication administration. The census was 45.

Findings include:

Review of Resident #7's medical record revealed she was admitted to the facility on 05/31/23. Diagnoses included diabetes, high cholesterol, and high blood pressure. Further review revealed physician orders for 04/25 for Humalog sliding scale Insulin if FSBS (finger stick blood sugar) for 0-150- 0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, call the physician if above 400.

Observation of medication administration on 04/17/25 at 11:09 A.M. by Licensed Practical Nurse (LPN) #122 revealed she dialed up two units of Humalog Insulin for Resident #7 after obtaining her finger stick blood sugar of 181. LPN #122 then administered the two units in the Resident's abdomen. LPN #122 failed to prime the Insulin pen prior to administration of the insulin to the resident.

Interview of LPN #122 on 04/17/25 at 11:16 A.M. interview with LPN #122 verified she had not primed the Insulin pen prior to administering the two units of Insulin.

Review of manufacturer instructions for the Humalog KwikPen revealed it should be primed before each injection by dialing 2 units on the pen and injecting with the needle pointing up. If insulin is not seen coming out of the needle the pen should be reprimed.

This violation represents noncompliance investigated under complaint OH00164683 and OH00163929.

Based on medical record review and staff interview, the facility failed to ensure medication was documented as given. This affected three (Resident #26, #46 and #48) of three residents records reviewed. The census was 45.

Findings include:

1. Review of Resident #26's medical record revealed he was admitted to the facility on 04/12/25. Diagnoses included diabetes, hyperlipidemia, high blood pressure, mild cognitive impairment, cerebral infarction and fracture of the right acetabulum.

Further review of the medication administration record (MAR) for 04/25 revealed the facility failed to document the administration of medications on 04/13/25 the 8:00 P.M. dose for Atorvastatin (high cholesterol medication) 40 mg, Azelastine (antihistamine) 0.1 % nasal spray to each nostril twice a day, Basaglar Insulin 10 units, Lovenox (blood thinner) 40 mg, Famotidine (stomach medication) 40 mg, Lisinopril (blood pressure medication) 20 mg, Oxcarbazepine (anticonvulsant) 300 mg, and Verapamil 40 mg (blood pressure medication).

On 04/15/25 the facility failed to document the 8:00 A.M. dose of Azelastine 0.1 % nasal spray to each nostril twice a day, Basaglar insulin 10 units, Lovenox 40 mg, Famotidine 40 mg, Lisinopril 20 mg, and Novolog insulin sliding scale.

This lack of medication administration documentation was verified during interview on 04/17/25 at 11:40 A.M. with the Director of Nursing (DON).

2. Review of Resident #48's medical record revealed he was admitted to the facility on 12/16/24. Diagnoses included 12/16/24 Alzheimer's dementia, anxiety, anemia, chronic kidney disease, diabetes, and major depression.

Further review of the medication administration record (MAR) for 12/24 revealed no documentation for medications administered for the month of December.

Review of 01/25 MAR revealed the Docusate (stool softener) 100 mg was to be administered twice a day and was not documented as given 8:00 P.M. dose on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17 and 01/19 and 01/24. The Memantine HCL (used for dementia) 5 mg was to be administered twice a day and was not documented as given on 01/09, 01/10, 01/11, 01/12, 01, 14, 01/17, 01/19, 01/23, and 01/24. Refresh Optive Sensitive Ophthalmic solution two drops at bedtime and was not documented as given on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17, 01/19, 01/23 and 01/24.

Review of 02/25 MAR revealed the 8:00 A.M. doses were not documented as given on 02/13 Calcium (mineral)250 mg-400 units, Valium (antianxiety) 2 mg on 02/13, 02/19, Docusate 100 mg, Hydrochlorothiazide (diuretic) 25 mg, Lisinopril 10 mg, and on 02/13 Nova Ferrum (used to treat iron deficiency) 15 mg on 02/13. On 02/19, at 12:00 P.M. Quetiapine (antipsychotic) 25 mg on 02/13 and 02/18 and 4:00 P.M. doses of Quetiapine 50 mg on 02/07, 02/10 and 02/18. Refresh Optive Sensitive Ophthalmic solution two drops at bedtime and was not documented at 8:00 A.M. on 02/07 and 02/21.

3. Review of Resident #46 revealed he was admitted to the facility on 12/16/24. Diagnoses included Alzheimer's Dementia, high blood pressure, chronic obstructive pulmonary disease, and gastrointestinal reflux disease.

Further review of the medication administration record (MAR) for 12/24 revealed no documentation for medications administered for the month of December.

Review of the MAR for 01/25 revealed the 8:00 P.M. dose for Acetaminophen (analgesic) 650 mg was not documented on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17, 01/19, 01/23, and 01/24. Divalproex (anticonvulsant) 125 mg at bedtime dose was not documented on 01/16, 01/17, 01/19, 01/23 and 01/24. Eliquis (used to prevent blood clots) 5 mg at 8:00 P.M. dose was not documented on 01/09, 01/10, 01/12, 01/16, 01/17, 01/19, 01/23, and 01/24. Norco (opioid pain medication) 5-325 mg 8:00 P.M. dose was not documented on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17, 01/19, 01/23, and 01/24. Memantine 10 mg, 8:00 P.M. dose was not documented on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17, 01/19, 01/23, and 01/24. Mucinex (expectorant) 1200 mg, 8:00 P.M. dose was not documented on 01/09, 01/10, 01/11, 01/12, 01/16, 01/17, 01/19, 01/23, and 01/24.

Review of the MAR for 01/25 revealed the 8:00 A.M. dose for Acetaminophen 650 mg was not documented on 02/13 and 02/27. The 8:00 P.M. dose was not documented on 02/07, 02/21 and 02/22. Divalproex 125 mg at bedtime dose was not documented on 02/07, 02/21 and 02/22. Donepezil (used to treat dementia) 10 mg 8:00 A.M. dose was not documented on 02/07, 02/18, 02/19 and 02/22. Eliquis 5 mg at 8:00 A.M. dose was not documented on 02/13, 02/27 and the 8:00 P.M. on 02/07, 02/21 and 02/22. Norco 5-325 mg 8:00 A.M. dose was not documented on 02/13 and the 8:00 P.M. 02/07, 02/21, 02/22 and 02/24. Memantine 10 mg, 8:00 A.M. on 02/13 and 02/27 8:00 P.M. dose was not documented on 02/07, 02/21 and 02/22. Mucinex 1200 mg, 8:00 A.M. was not documented as given on 02/13 and 8:00 P.M. dose was not documented on 02/07, 02/21 and 02/22. Quetiapine 25 mg dose at 8:00 A.M. was not documented on 02/13 and 02/27. The 8:00 P.M. dose was not documented on 02/07, 02/18, 02/19, 02/21, 02/22 and 02/27.

On 04/17/25 at 12:45 P.M. the lack of medication administration documentation was verified during interview with the Administrator.

This violation represents noncompliance investigated under complaint OH00163929 and OH00164683.

Based on observation, interview, review of activities calendar and resident agreements, the facility failed to provide regular activities on the memory care unit. This affected 11 residents of 11 residents on the memory care unit. The facility census was 45.

Findings include:

Review of the April 2025 activity calendar for the memory care unit from 04/01/25 to 04/21/25 revealed no activities were scheduled before 10:00 A.M. Activities did not start until 2:00 P.M. on 04/06/25, 04/07/25, 04/12/25, 04/13/25, 04/14/25, 04/20/25, and 04/21/25. Only two activities were scheduled on 04/05/25, 04/06/26, 04/07/25, 04/13/25, 04/14/25, 04/19/25, 04/20/25, and 04/21/25. The activity calendar lacked variety, the scheduled for Sunday through Friday was the same week to week.

Review of the resident service agreement for the memory care unit revealed programming was to be on the seven dimensions of wellness and a variety of programs were to be chosen so that each day provided new opportunities. Mornings were noted to be the time when residents were the most active and had the greatest ability to focus. A variety of programs including small groups or one on ones would be available.

Observation on 04/16/25 at 9:00 A.M., 11:45 A.M., 2:12 P.M., and 2:30 P.M. revealed no activities taking place in the memory care unit. An activity was scheduled at 2:00 P.M., and was not observed to be taking place.

Observation on 04/17/25 at 10:15 A.M. and 2:05 P.M. revealed no activity taking place in the memory care unit. Activities were scheduled at 10:00 A.M. and 2:00 P.M. and were not observed to be taking place.

Interview on 04/16/25 at 2:30 P.M. with Resident #21's family revealed there were not enough activities on the unit. They did events around once a month but not a lot of activities day to day.

Interview on 04/17/25 at 2:05 P.M. with Personal Care Assistant (PCA) #111 verified there was no activity taking place on the unit at that time. She reported the aides were the only ones who did activities with the residents. PCA #111 reported the only scheduled activity was exercise on Tuesday's. Otherwise it was mostly providing the residents with independent activities like coloring books.

Interview on 04/17/25 at 2:30 P.M. with the Executive Director (ED) verified there was not a lot of activities on the calendar. She reported the memory care director was in charge of making the activity calendar and completing the activities on the unit.

Interview on 04/21/25 at 10:28 A.M. with PCA #105 revealed she had not witnessed any scheduled or structured activities take place on the unit. She reported the aides did exercise with the residents at times but that was it.

This violation represents noncompliance investigated under complaint OH00163929.

Based on interview, record review, and review of facility policy the facility failed to document and investigate Resident #21's elopement and ensure fall interventions were implemented for Resident #9 and #19. This affected three residents (#9, #19, #21) of 21 records reviewed. The facility census was 45.

Findings include:

1. Review of Resident #21's medical record revealed an admission date of 04/16/24 with diagnoses including dementia, hypertension, and hyperlipidemia.

Review of Resident #21's Saint Louis University Mental Status (SLUMS) examination dated 04/16/24 revealed the resident had dementia.

Review of Resident #21's progress note dated 02/10/25 revealed the resident had gotten off the locked memory care unit twice that day.

Review of Resident #21's medical record revealed no further documentation related to her 02/10/25 elopements.

Interview on 04/17/25 at 10:06 A.M. with the Executive Director (ED) revealed there was no additional documentation for Resident #21's elopements.

2. Review of Resident #9's medical record revealed an admission date of 09/23/22 with a diagnosis of cognitive disorder.

Review of Resident #9's fall risk assessment dated 09/11/24 revealed he was a moderate fall risk.

Review of Resident #9's progress note dated 03/30/25 revealed the resident was found laying on the floor in front of another residents bedroom. It was indicated the resident was walking to his bedroom and fell. No fall interventions were noted.

Review of Resident #9's progress note dated 04/07/25 revealed the resident had a fall when he was found on his bathroom floor. No fall interventions were noted.

Review of Resident #9's medical record revealed no evidence any interventions were in place for falls, he had no plan of care.

Interview on 04/21/25 at 11:10 A.M. with Resident #9's power of attorney (POA) revealed the resident had a couple of falls but the facility had been unable to identify how they are going to prevent him from falling.

Interview on 04/21/25 at 12:28 P.M. with the Director of Nursing (DON) revealed she was unable to find any fall interventions for Resident #9, he did not have a care or service plan in place.

Review of the policy 'Fall Reduction and Management Policy' revised February 2023 revealed following a fall any post fall interventions would be documented in the residents medical record. The residents service plan would be updated as necessary to include any additional fall reduction measures.

3. Review of Resident #19's medical record revealed an admission date of 03/07/22 with diagnoses including dementia, hyperlipidemia, and anemia.

Review of Resident #19's medical record revealed no evidence any interventions were in place for falls, she had no plan of care.

Review of Resident #19's progress note dated 03/01/25 revealed the resident was found lying on the floor in her bedroom. No fall interventions were indicated.

Review of Resident #19's progress note dated 03/11/25 revealed the resident was found sitting on the floor and a bump was noted on the right side of her head. No fall interventions were indicated.

Interview on 04/21/25 at 12:28 P.M. with the Director of Nursing (DON) revealed she was unable to find any fall interventions for Resident #19, she did not have a care or service plan in place.

Review of the policy 'Fall Reduction and Management Policy' revised February 2023 revealed following a fall any post fall interventions would be documented in the residents medical record. The residents service plan would be updated as necessary to include any additional fall reduction measures.

This violation represents noncompliance investigated under complaint OH00164747 and OH00164683.

Based on interview and record review the facility failed to maintain an infection control log. This had the potential to affect 45 of 45 residents residing in the facility.

Findings include:

Review of the infection control log revealed there was no data for March 2025.

Interview on 04/17/25 at 10:22 A.M. with the Director of Nursing (DON) verified there was no March 2025 infection control log. The DON verified there had been infections in March.

Based on review of Resident Council Minutes and staff interview, the facility failed to follow up on resident concerns. This had the potential to affect the 45 residents residing in the facility. The census was 45.

Findings include:

Review of the Resident Council Meeting Minutes for 01/30/25 revealed Resident #50's night medications are being delivered too late, around 10:30 P.M. to 11:00 P.M. and takes an injection every two weeks and must go and remind them. Resident #1 revealed he has had to go get his medication before.

Review of the Resident Council Meeting Minutes for 02/25/25 revealed Resident #24 had to wait till 11:00 P.M. the other day to get her medications and have been late the last two mornings. Resident #1 mentions when Licensed Practical Nurse (LPN) #120 and LPN #106 work, he must go get his meds from them.

Review of the Resident Council Minutes for 03/25/25 revealed Resident #24 revealed the new nurses don't come until around 10:00 P.M. to give night medications and some do not give her medications at all.

On 04/17/2025 at 1:48 P.M. interview with the Administrator verified no documentation on follow-up on Resident Council Concerns.

Based on interview and record review the facility failed to notify Resident #21's Power of Attorney (POA) of a change in the residents medication. This affected one resident (#21) of three residents reviewed for change in condition. The facility census was 45.

Findings include:

Review of Resident #21's medical record revealed an admission date of 04/16/24 with diagnoses including dementia, hypertension, and hyperlipidemia.

Review of Resident #21's Saint Louis University Mental Status (SLUMS) examination dated 04/16/24 revealed the resident had dementia.

Review of Resident #21's progress note dated 02/12/25 revealed there was a new order for Depakote (anticonvulsant used for mood stabilization), there was no indication the POA was notified.

Interview on 04/16/25 at 11:53 A.M. with Resident #21's POA revealed she had not been notified when the facility began Depakote for the resident. She reported she learned about the medication when hospice took over care for the resident.

Interview on 04/17/25 at 10:06 A.M. with the Executive Director (ED) verified there was no evidence Resident #21's POA had been notified of the addition of Depakote.

This violation represents noncompliance investigated under OH00164605.