Oakleaf Village (Columbus)

Based on medical record review and staff interview, the facility failed to ensure self administration of medication assessment was completed. This affected one resident (#132) of seven resident records reviewed. The census was 136.

Findings included:

Review of Resident #132's medical record revealed she was admitted to the facility on 12/27/21. Diagnoses included mild cognitive impairment, hyperlipidemia, CAD, high blood pressure, major depression, osteopenia, hyperglycemia, herpes and follicular non-Hodgkin Lymphoma.

Further review revealed no evidence an annual determination by a physician or other licensed healthcare professional working within their scope of practice, as to whether or not the resident is capable of self-administering medications was completed.

On 07/22/25 at 10:59 A.M. interview with the Assistant Director of Care #110 verified during interview the self-medication assessment was not completed.

2. Medical record review for Resident #128 revealed one set of telephone orders dated 03/28/25 contained orders for six medications that were not signed by the prescribing healthcare provider.

3. Medical record review for Resident #67 revealed one set of telephone orders for labs dated 01/14/25 that contained orders for three separate labs that were not signed by the prescribing healthcare provider.

Interview with Executive Director on 07/22/25 at 3:30 P.M. verified that there was no provider signature on the identified telephone orders for Residents #128 and #67.

Based on observation, staff interview, and review of facility policy, the facility failed to provide clean and sanitary eating and drinking utensils for residents in the memory care unit. This affected 29 of 29 residents in the memory care unit. The facility census was 136.

Findings Include:

Observations on 07/21/25 between 9:35 A.M. and 9:40 A.M. revealed multiple dining utensils including plastic plates and cups soaking in sinks filled with soapy water in each of the four serveries in the four wings of the memory care unit.

Interview with Cook #117 on 07/21/25 at 9:40 A.M. revealed the dining utensils observed soaking in the sinks were for resident use. Cook #117 stated that the dishwashing units in these serveries had been out of order for around six months or longer. Further interview with Cook #117 at this time revealed that the facility staff had been washing the residents' cups and plates by hand which including rinsing with water in the servery sinks and then washing the dishes and cups in a soap solution labeled for cleaning pots and pans.

Interview with Program Director #145 on 07/21/25 at 9:45 A.M. verified that staff were handwashing resident utensils and cups in the sinks of the memory care serveries. Program Director #145 stated that the mechanical dishwashers in memory care serveries have been out of order over the last six months, and that around two weeks prior to the day of the survey other dishwashing units had arrived but were too large to fit in the designated space for the units. Program Director #145 verified that the facility was still waiting for new dishwashing units to arrive. At this time, further interview with Program Director #145 revealed that pots and pans for food preparation in the memory care unit are still run through the dishwasher in the memory care kitchen, but the dishes and cups were being washed by hand.

Interview on 07/21/25 at 2:25 P.M. with the Executive Director verified that staff had not been following facility policy regarding proper cleaning and sanitization of resident utensils in the memory care unit. The Executive Director stated that staff were not following the required steps of wash/rinse/sanitize while dishwasher units were out of order. Executive Director also stated that Program Director #145 and Executive Chef #159 had been notified of this deviation from facility policy and further educated on 07/21/25.

Review of facility policy titled 2027 Dining Services Health Standards of Practice, section six regarding ware washing, revealed that facility staff are to follow the appropriate procedures for washing, rinsing, and sanitizing dining utensils if not using a dishwashing machine.

Based on review of fire drills and staff interview, the facility failed to verify transmission/receipt of the signal of the fire alarm. This had the potential to affect the 136 of 136 residents in the facility.

Findings include:

Review of the fire drills from 07/24 to 07/25 revealed no documented evidence the facility verified receipt of the transmission/receipt of the fire alarm signal.

This was verified during interview with Maintenance Director #203.

Based on observation and staff interview, the facility failed to ensure signs were posted in areas oxygen was in use. This affected two rooms in the 300 hallway of the memory care unit. The census was 136.

Findings include:

Observation on 07/22/25 at 9:52 A.M. revealed Room 303 and Room 307 had oxygen in use in the resident rooms with no signs alerting to the use of oxygen.

On 07/22/25 at 9:57 A.M. interview with Director of Care #193 verified there were no oxygen in use signs in place.

Based on observation and staff interview, the facility failed to ensure call systems were provided in toilet facilities used by residents. This had the potential to affect 136 of 136 residents residing in the facility.

Findings include:

Tour of the facility between 10:11 A.M. to 10:30 A.M. revealed in the men and women's bathroom by the private dining room there were no call systems provided for transmission of calls from the toilet facilities by the residents.

This was verified during interview with the Executive Director on 07/22/25 at 2:00 P.M.

Based on observation and staff interview, the facility failed to present any documentation of inspection reports of the heating, ventilation, and air conditioning (HVAC) system from within the past two years. This had the potential to affect all residents residing in the facility. The census was 136.

Findings Include:

Interview on 07/21/25 at 1:25 P.M. with Director of Maintenance #203 revealed that records of facility HVAC inspections were not readily available, though he would try to locate the records.

Observation at the end of the annual survey on 07/22/25 at 3:55 P.M. revealed that the facility could not produce any record of HVAC inspections over the last two years.

Interview with the Executive Director on 07/22/25 at 4:05 P.M. verified that records of facility HVAC inspections from within the past two years were still unavailable.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect the 136 of 136 residents residing in the facility.

Findings include:

On 07/22/25 tour of the facility between 10:11 A.M. to 10:30 A.M. revealed the following:

a) A chair by Room 119 upholstery ripped in three places.

b) Carpet stained in front of Room 121 and Room 143

c) Carpet stained entering hall to Room 102) The wall by the lounge area on hall 140-156 with multiple places with the drywall missing and needing patched.

e) The women bathroom by the private dining with the baseboard missing in the bathroom stall and the wall paper is loose on the wall.

g) Ceiling tile stained by Room 119 and in lobby near private dining room.

This was verified during interview with the Executive Director on 07/22/25 at 2:00 P.M.

Based on medical record review, observation and staff interview, the facility failed to ensure residents were treated with respect and dignity. This affected one resident (#99) of 136 residents residing in the facility. The census was 136.

Findings include:

Review of Resident #99's medical record revealed he was admitted to the facility on 10/29/24. Diagnoses included anxiety, depression, dementia with behaviors, constipation, chronic obstructive pulmonary disease, pain, fractured pubis, and severe protein calorie malnutrition.

On 07/22/25 at 10:03 A.M., observation of Resident #99 sitting in the lobby of the memory care unit with his catheter urinary drainage bag hanging on his walker. The bag was uncovered with urine observed in the drainage bag. This was verified during interview at the time of the observation with Director of Care #193.

Based on interviews, record reviews and facility policy, the facility failed to ensure the correct dosage of a medication was administered. This affected one (Resident #21) out of three residents reviewed. The facility census was 91.

Findings include:

Review of the medical record for Resident #21, revealed an admission date of 12/17/24. Diagnoses included: chronic obstructive pulmonary disease, depression, hypertension, type 2 diabetes mellitus and mixed stress and urge incontinence.

Review of the History and Physical that included a medication administration list dated 12/12/24 for Resident #21 revealed Bupropion 150 milligrams (mg) oral every morning for depression.

Review of a telephone order dated 03/03/25 for Resident #21 revealed a refill for Bupropion 450 mg one tablet orally every morning.

Review of the Medication Administration Record for Resident #21 revealed for the dates of 03/04/25, 03/05/25 and 03/06/25 the resident received Bupropion 450 mg one tablet orally every morning.

Review of the progress notes for Resident #21 dated 03/06/25 at 5:18 P.M. authored by the Director of Care revealed the resident had been administered Bupropion 450 mg instead of 150 mg due to a medication prescription error.

Interview on 04/03/25 at 2:05 P.M. with the Director of Care verified Resident #21 received Bupropion 450 mg instead of the correct dose of Bupropion 150 mg for the dates of: 03/04/25, 03/05/25, and 03/06/35.

Review of the facility policy titled Medications last revised on 10/2024 revealed the nurse, or designee, must refer to the Medication Administration Record to obtain the correct medication, time, dosage and route of administration as ordered by the physician for each individual resident.

This violation represents non-compliance investigated under Master Complaint Number OH00163720 and Complaint Number OH00163495.

Based on interview and record review, the facility failed to monitor change of condition for one resident (#21) out of three residents reviewed. The facility census was 91.

Findings include:

Review of the medical record for Resident #21, revealed an admission date of 12/17/24. Diagnoses included: chronic obstructive pulmonary disease, depression, hypertension, type 2 diabetes mellitus and mixed stress and urge incontinence.

Review of the Medication Administration Record for Resident #21 revealed for the dates of 03/04/25, 03/05/25 and 03/06/25 the resident received Bupropion 450 mg one tablet orally every morning.

Review of the progress notes for Resident #21 dated 03/06/25 at 3:20 P.M. revealed the resident complained that the Bupropion 450 mg ordered on 03/03/25 was making her feel palpitated, nervous and shaky.

Review of the progress notes for Resident #21 dated 03/06/25 at 5:18 P.M. authored by the Director of Care revealed the resident had been administered Bupropion 450 mg instead of 150 mg due to a medication prescription error. The resident was a little jittering, but alert and oriented. Will continue to monitor the residents' progress.

Further review of Resident #21's medical record revealed no documentation of follow up for the residents change of condition for over twenty-four hours.

Interview on 04/03/25 at 3:54 P.M. with the Executive Director verified no documentation of change of condition follow-up was completed on Resident #21 for over twenty-four hours.

This violation represents an incident finding when investigating Complaint Number OH00163495.

Based on observations, interviews, and policy review, the facility failed to ensure all hazardous waste was disposed of properly to prevent the spread of infectious diseases. This had the potential to affect all 84 residents residing in the facility.

Findings include:

Observation on 11/16/24 at 10:10 A.M. revealed Resident #66 had a cart of personal protective equipment (PPE) outside the door and there was a red hazardous waste bag hanging next to the door in the hallway which had used PPE in it and was not tied.

Observation on 11/16/24 at 1:41 P.M. revealed the red hazardous waste bag was still hanging in the hallway outside Resident #66's room and was not tied.

Observation and interview on 11/16/24 at 2:30 P.M. with Director of Nursing (DON) confirmed the red bag was a hazardous waste bag and should not be kept in the hallway or be open. DON stated Resident #66 was on transmission based precautions for c-diff (a bacteria which can cause infectious diarrhea).

Review of the policy Infection Control - Universal Precautions, revised 03/2020, revealed universal precautions were a required practice for helping protect associates from bloodborne pathogens or contagious germs that are carried through the blood and other body fluid. The policy further specified to treat all blood and body fluid as if infectious for bloodborne pathogens.

This violation represents an incidental finding of noncompliance identified during Complaint Number OH00158826.

Based on observation and interview the facility failed to maintain facility common areas at a comfortable temperature level. This had the potential to affect the 75 residents (#1 through #75) living in the assisted living building. The facility census was 102.

Findings included:

Interview on 01/17/24 at 3:06 P.M. with the Executive Director (ED) revealed on 01/16/24 they noted the heat was not running as it should have been. It was determined that one of the boilers needed a part that was immediately ordered.

Interview on 01/17/24 at 3:14 P.M. and from 4:40 P.M. to 5:00 P.M. with Regional Maintenance #366 revealed the primary boiler was down and they were relying on the second boiler. He reported they had expected the part for the boiler to be in on 01/17/24, however, it was determined a second part was needed. They were then expecting the boiler to be fixed on 01/18/24. He noted residents that complained of the cold were provided a space heater and they had put space heaters in some of the hallways on the second floor due to them running colder. Regional Maintenance #366 reported the second-floor hallways likely ran colder due to the elevator shafts.

During a tour on 01/17/24 from 4:40 P.M. to 5:00 P.M. with Regional Maintenance #366 the temperature of various rooms and hallways were obtained. The hallway on the first floor containing rooms 127 to 139 and providing access to rooms 140 to 155 was found to be 70.5 degrees Fahrenheit (F). Observation of the second-floor hallway containing rooms 217 to 232 revealed the temperature was 64 degrees F, the hallway containing rooms 233 to 246 and providing access to rooms 247 to 263 revealed the temperature was 66.9 degrees F. Review of the last hallway on the second floor containing rooms 200 to 216 revealed the temperature was 60.4 degrees. Observation of the activities room revealed it was 62.8 degrees F. Regional Maintenance #366 verified the above temperatures were below the expected range of 71 degrees to 81 degrees F.

Interview on 01/18/24 at 2:30 P.M. with Personal Care Assistant (PCA) #358 reported the upstairs hallways had been chilly, she reported the space heaters they added on that day had helped.

Interview on 01/18/24 at 3:50 P.M. with Licensed Practical Nurse (LPN) #264 revealed the hallways had been cooler than resident rooms.

This violation represents non-compliance investigated under Complaint Number OH00150101.

Based on record review and staff interview, the facility failed to ensure laboratory testing was completed as ordered and fall assessments were completed per protocol. This affected two (Residents #33 and #56) receiving laboratory services and three (Resident's #7, #54 and #81) of three residents reviewed for falls. The census was 96.

Findings include:

1. Interview 02/10/23 at 1:48 P.M. with the Director of Nursing (DON) and Administrator revealed on 12/22/22 the facility switched laboratories due to results taking extremely long to report. The new lab drew blood on Thursday 12/22/22 (facility was unable to provide a list of residents who had laboratory testing 12/22/22) for laboratory testing. The DON affirmed there were glitches when the new company took over. The new company was to come to the facility every Monday and Wednesday to draw labs. The DON revealed the new provider informed the facility they would have lab results in 48 hours.

On 02/13/23 at 4:03 P.M. the DON identified two residents she could remember that had a delay in their laboratory testing.

Review of Resident #33's record revealed an admission on 07/26/21 with diagnoses including hypertension, esophageal reflux disease, hypothyroidism, left and right sided lumbago with sciatica and osteoporosis. Resident #33 had a Complete blood count with differential drawn on 12/22/22. Review of the lab result revealed the sample was received 01/04/23 with the results reported the same day, 13 days later.

Review of Resident #56's record revealed an admission on 12/04/21 with diagnoses including anxiety disorder, heart disease, and coronary artery disease (CAD). Resident #56 had a Chemistry 7 drawn on 12/22/22. Review of the lab result revealed the sample was received 01/03/23 with the results reported 01/04/23, 13 days later.

On 02/13/23 at 4:51 P.M. Regional Director of Care #116 revealed when nursing management returned from Christmas holiday 12/27/22 they noted the laboratory results of 12/22/22 were not on the fax machine. They attempted to review the portal on 12/27/22 and attempted to narrow down some labs that remained outstanding. Regional Director of Care #116 did not know of any correspondence from the laboratory to alert the facility of an issue with the testing. Inquiry from the facility to the lab included the lab samples were accidentally sent to a lab possibly in Tennessee instead of local. The weather and the holiday threw the receipt of the results off. Regional Director of Care #116 could not say if the lab was open on Monday 12/26/22 but no lab draws were completed that day at the facility. The lab came on 12/28/22 for ordered draws and on 01/04/23. There was no information of them being at the facility 01/02/23 for their Monday and Wednesday draw dates. They had a meeting with the lab on 01/05/23 because the portal was still not reflecting accurately and requested assistance with understanding and cleaning up the portal. The lab test due 12/22/23 not redrawn on 12/28/22 or 01/04/23 were recollected on 01/06/23. With it being a new lab company, the facility reviewed collection protocol again to make sure they knew the process and the lab knew the process. There was no explanation as to why the laboratory test were not redrawn on 12/28/22 when the comply was in the facility.

On 02/13/23 at 5:04 P.M. Regional Director of Care #116 included the floor nurses did not have access to the portal to check for lab results. The nurses did not contact management to let them know no lab test results were faxed to the facility. Regional Director of Care #116 verified it was dependent on management to check for the laboratory test results. There was no evidence management checked on 12/23/22, 12/24/22, 12/25/22 or 12/26/22 for lab results.

2. Review of the medical record revealed Resident #81 was admitted 08/16/18 and readmitted 01/25/23 with diagnoses including paroxysmal atrial fibrillation, sleep apnea, hyperlipidemia, unspecified muscle weakness (generalized), and difficulty in walking reduced mobility. Resident #81 had falls on 05/25/22 at 3:25 A.M. in room without injury, 12/02/22 at 4:18 A.M. in bathroom without injury, 12/18/22 at 10:18 P.M. in room without injury, 01/27/23 at 5:40 A.M. in room without injury, and 01/27/23 at 12:00 P.M. in room, son present, bruised knee.

Review of the fall assessments revealed the last fall assessment was completed 08/21/21 which scored the resident at low risk for falls. There was no evidence of a fall assessment being completed after the 05/25/22, 12/02/2, 12/18/22 or 01/27/22 falls as per protocol.

Review of the activity of daily living (ADL) sheet provided to staff revealed Resident #81 was to be checked every two hours due to falls.

Review of an email dated 01/27/23 and timed 10:43 A.M. to the DON from Resident #81's son included a concern his mother indicated when she fell she was on the floor from 10:30 P.M. until the morning of 01/27/23. The resident's son asked for an investigation. There was no evidence the concern was investigated.

Review of the incident report for 01/27/23 included Resident #81 pulled the call bell and said she was on the floor for a while.

The resident was admitted to the hospital and currently not in the facility.

Interview 02/10/23 at 7:17 P.M. with the Administrator verified there were not any fall assessments since August 2021.

Interview 02/10/23 at 7:42 P.M. with the DON revealed a fall assessment was to be completed with each fall incident report.

Review of the facility's Falls Risk Assessment and Care Plan policy included a Falls Risk Assessment would be completed for all new residents and quarterly upon a change in the resident's condition. The policy indicated to See the Falls Risk Assessment and Care Plan form. Upon the assessment and identification of a resident who had a risk of falls, the Falls Risk Assessment and Care Plan form would be added to the resident's Personal Service Plan. The Falls Risk Assessment and Care Plan form included the assessment of factors that may have contributed to fall risk, and interventions designed to reduce the possibility of falls.

On 02/13/23 at 2:27 P.M. the DON revealed the facility did not do service plans in their computer system. The assignment sheets equaled what services were to be provided. Personal Service Plans were not developed as the facility policy indicated.

3. Review of Resident #54's record included a 08/06/21 admission with diagnoses including Barrett's esophagus, insomnia, chronic obstructive pulmonary disease, depression,

hypertension, chronic kidney disease (CKD), emphysema, dementia, hyperlipidemia, osteoarthritis, and mood [affective] disorder. Record review included falls 11/21/21 at 7:30 P.M., the resident was on the floor with liquid feces over her and the bathroom floor. A 01/14/22 2:00 A.M. fall resulted in a skin tear to left leg. A fall 03/23/22 at 10:44 P.M. reported to the fire department by the resident resulted in a laceration to the right lower leg, knee and left arm; she was trying to put on her bedroom light when she fell by her bed and then crawled out to her living room to call the squad. On 07/16/22 at 10:28 A.M. during medication administration the resident was found on the floor covered with a comforter with a skin tear to the back of the left arm. On 02/04/23 at 11:59 A.M. during medication administration the resident was on the floor with a skin tear to right leg and a swollen or fractured wrist. The resident was admitted to the hospital with a fractured wrist and was not at the facility.

The annual fall assessment dated 02/06/22 revealed Resident #54 was a high risk for falls.

Review of ADL sheet revealed Resident #54 was to be checked on every two hours.

There was no evidence of a fall assessment since 02/06/22.

On 02/13/23 at 6:25 P.M. Regional Director of Care #116 verified Resident #54 had falls without a fall assessment completed since 02/06/22.

4. Review of Resident #7's records revealed a 04/05/21 admission with diagnoses including depression, overactive bladder, abnormalities of gait and mobility and malaise. The resident was under hospice care. The resident had falls on 10/03/22, 10/24,22, 11/20/22, 12/15/22 and 12/15/22. The resident's last fall assessment was 10/03/22.

Review of the staff ADL sheet revealed Resident #7 was a check on every two hours due to hospice and being weak.

Observation 02/10/23 at 3:21 P.M. revealed Resident #7 in her room in her chair sleeping with oxygen per nasal cannula at four liters per minute.

On 02/13/23 at 1:17 P.M. the DON revealed Resident #7 was to be checked every two hours. Other interventions like therapy could not be ordered since she was hospice.

On 02/13/23 at 6:25 P.M. Regional Director of Care #116 verified Resident #7 had falls without a fall assessment completed since 10/03/22.

This violation represents non-compliance investigated under Complaint Number OH00140133 and OH00140000.

Based on record review, interview, facility investigation and policy review, the facility failed to administer medications as ordered to Resident #81. This affected one resident (#81) out of four residents reviewed for medication administration. Facility census was 96.

Findings include:

Review of the medical record revealed Resident #81 was readmitted 01/25/23 with diagnoses including paroxysmal atrial fibrillation, sleep apnea, hyperlipidemia, unspecified muscle weakness (generalized), and difficulty in walking reduced mobility. Resident #81 was admitted to the hospital 12/20/22 and readmitted to the facility from skilled care 01/25/23.

Review of progress notes included Resident #81's son informed the facility of a 01/25/23 anticipated return to the facility from rehabilitation and he would have a new medication list and clinical notes. The progress notes included Resident #81 was readmitted around 3:00 P.M. and medication administered.

Review of an email dated 01/27/23 and timed 10:43 A.M. to the Director of Nursing (DON) from Resident #81's son included a concern his mother was not administered any medication until the morning of 01/27/23. He said Licensed Practical Nurse (LPN) #117 handed him the unopened medication packages he brought to the facility 01/25/23 from the rehabilitation facility for his mom to be administered until her medication arrived. He asked for a formal inquiry about why the medications were not administered from Wednesday through Thursday considering the work undertaken to hand over the discharged packet from the transferring facility that included the update medication list, the discharge notice and actual medications handed to LPN #117 and a conversation with LPN #118.

Review of the investigation included LPN #117 administered the medication the evening of 01/25/23 and placed the remainder of medications in her slot in the medication cart. The medications were not signed on the medication administration record (MAR) electronically or on paper. The readmission orders were not entered into the MAR nor was a paper MAR initiated. On 01/26/23 all medications were not administered. On 01/27/23 morning medications were administered, the resident went to a doctor appointment and was admitted to the hospital for observation.

Interview 02/10/23 at 6:01 P.M. with the DON included she had not entered the medication orders into the electronic MAR and wrote a handwritten MAR for LPN #117 to sign what medications he administered 01/25/23. Review of the handwritten MAR revealed Lantus insulin 8 units at bedtime was not administered 01/25/23. Gabapentin, an anticonvulsant, 300 milligrams (mg) three times a day, Lantus insulin 8 units at bedtime, magnesium oxide 240 mg, metformin, 1000 mg twice a day, mirtazapine, an antidepressant, 7.5 mg, a multivitamin daily, norvasc, an antihypertensive, 10 mg daily, pravachol, for hyperlipidemia, 40 mg at bedtime, and tapazole, hyperthyroid medication, 5 mg each morning were not administered 01/26/23.

Review of the MAR for 01/27/23 revealed Gabapentin 300 mg, magnesium oxide 240 mg, metformin 1000 mg, mirtazapine 7.5 mg, a multivitamin daily, norvasc 10 mg daily, and tapazole 5 mg each morning were not administered as ordered.

Review of Medication Administration policy and procedure, dated March 2020, included it was the policy of the community to supervise or administer all medications that the residents received an ordered by their physician. All medications were administered by a nurse, or designee, or self-administered with a written physician's order. The nurse, or designee, must refer to the medication administration record to obtain correct medication, time, dosage, and route of administration. Each dose administered was to be properly recorded on the MAR as indicated by nurse, or designee's, initials in the appropriate block.

This violation represents non-compliance investigated under Complaint Number OH00140133 and OH00140000.

Based on record review, facility investigation review and interview, the facility failed to ensure medication errors were included on the incident log. This affected one (Resident #81) of 10 residents reviewed. The facility census was 96.

Findings include:

1. Review of the medical record revealed Resident #81 was readmitted 01/25/23 with diagnoses including paroxysmal atrial fibrillation, sleep apnea, hyperlipidemia, unspecified muscle weakness (generalized), and difficulty in walking reduced mobility.

Review of an email dated 01/27/23 and timed 10:43 A.M. to the Director of Nursing (DON) from Resident #81's son included concern his mother was not administered medication as ordered.

Review of the investigation included Licensed Practical Nurse (LPN) #117 administered the medication the evening of 01/25/23 and placed the remainder in her slot in the medication cart. The medications were not signed on the medication administration record (MAR) electronically or on paper. The readmission orders were not entered into the MAR nor was a paper MAR initiated. On 01/26/23 all medications were not administered. On 01/27/23 morning medications were administered, the resident went to a doctor appointment and was admitted to the hospital for observation.

Interview 02/10/23 at 6:01 P.M. with the DON revealed she learned the medications were not entered onto an electric or paper MAR. She wrote a handwritten MAR for LPN #117 to sign what medications he administered 01/25/23. Review of the handwritten MAR revealed Lantus insulin 8 units at bedtime was not administered 01/25/23. Review of the electronic MAR included Gabapentin, an anticonvulsant, 300 milligrams (mg) three times a day, Lantus insulin 8 units at bedtime, magnesium oxide 240 mg, metformin, 1000 mg twice a day, mirtazapine, an antidepressant, 7.5 mg, a multivitamin daily, norvasc, an antihypertensive, 10 mg daily, pravachol, for hyperlipidemia, 40 mg at bedtime, and tapazole, hyperthyroid medication, 5 mg each morning were not administered 01/26/23.

Review of the MAR for 01/27/23 revealed Gabapentin 300 mg, magnesium oxide 240 mg, metformin 1000 mg, mirtazapine 7.5 mg, a multivitamin daily, norvasc 10 mg daily, and tapazole 5 mg each morning were not administered as ordered.

Review of the January 2023 incident log revealed the medication error was not included on the log.

Interview 02/10/23 at 7:32 P.M. with the DON verified she had not entered the medications errors on the incident log.

This violation represents non-compliance investigated under Complaint Number OH00140133 and OH00140000.

Based on record review, interview, and policy review, the facility failed to administer medications as ordered to Resident #6. This affected one resident (#6) out of three residents reviewed for medication administration. Facility census was 98.

Findings include:

1. Review of the medical record revealed Resident #6 was admitted 11/27/21 with diagnoses including type II diabetes, atrial fibrillation, hypertension, and congestive heart failure.

Review of physician orders revealed Resident #6 was ordered Warfarin (anticoagulant) 2.5 milligram (mg) by mouth once a day on Monday, Tuesday, Wednesday, Thursday, and Friday.

Review of the medication administration record (MAR) revealed Resident #6 was not administered Warfarin 2.5 mg on 01/02/23, 01/04/23, and 01/05/23.

Interview on 02/03/23 at 3:30 P.M. Director of Nursing verified Warfarin was not administered to Resident #6 on 01/02/23, 01/04/23, and 01/05/23.

2. Review of the medical record revealed Resident #6 was admitted 11/27/21 with diagnoses including type II diabetes, atrial fibrillation, hypertension, and congestive heart failure.

Review of after visit summary dated 12/24/22 revealed Resident #6 was ordered sodium chloride (to replace sodium lost from the body) one gram by mouth twice a day on Sunday, Tuesday, Thursday, and Saturday.

Review of the MAR revealed Resident #6 sodium chloride two grams by mouth daily from 12/24/22 until 01/28/23.

Interview on 02/03/23 at 3:00 P.M. Director of Nursing verified sodium chloride two grams was administered twice a day instead of one gram twice a day on Sunday, Tuesday, Thursday, and Saturday.

Review of Medication Administration policy and procedure, dated March 2020, revealed all medications are administered by a nurse, or designee, or self-administered with a written physician's order. The nurse, or designee, must refer to the medication administration record to obtain correct medication, time, dosage, and route of administration. Each dose administered is properly recorded on the MAR as indicated by nurse, or designee's, initials in the appropriate block.

This violation represents non-compliance investigated under Master Complaint Number OH00139409 and Complaint Number OH00139339.

Based on medical record review, staff interview, and Resident Agreement review, this facility failed to complete health assessments on new residents to ensure their care needs. This affected one (Resident #500) of the 7 residents reviewed for care assessments. The facility census was 81.

Findings include:

Review of the medical record for Resident #500 revealed an admission date of 05/31/22 and a discharge date of 06/14/22. Diagnosis was not identified in medical record during review.

Continued review of Resident #500's medical record revealed no current or up to date health care assessments to review.

Interview on 10/26/22 at 2:30 P.M. with the Assistant Director of Nursing (ADON) #82 revealed that she had completed a virtual assessment of Resident #500 prior to coming to the facility for respite care. Due to this being an virtual assessment, not all of the questions could be completed fully but the questions that were answered were done so by Resident #500 herself and were appropriate answers. Resident #500's daughter provided additional information regarding care needs. ADON #82 claimed that once Resident #500 admitted to the facility, the admitting nurse should have completed the new admission assessments.

Interview on 10/26/22 at 3:30 P.M. with the Director of Nursing conformed when a resident is newly admitted to the facility there are seven different assessments that are to be completed which include a Mini Mental Assessment, Medication Self-Administration Assessment, Functional Assessment, Elopement Assessment, Fall Assessment, and Braden Assessment. The DON confirmed that this assessments has not been completed for Resident #500.

Review of the facility's Resident Agreement, no date noted revealed on page 3 under section C. Resident Health Assessments. In accordance with state law governing residential care facilities, the Resident's health will be assessed by the Community upon admission and at least annually thereafter, unless medically indicated sooner. If, as a result of any health assessment, it is determined that Residents requires services or accommodations beyond that which the Community provides the Resident shall be transferred to an appropriate location, in accordance with state law.

This violation substantiates complaint number OH00135741.