Northwood Assisted Living

Based on observation, record review, and staff interview, the facility failed to ensure frozen meat was thawed in a manner to prevent foodborne illness. Additionally, the facility failed to ensure the walk in refrigerator was free of leaks and the kitchen was maintained in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 72. Findings include: 1. Observation of the kitchen on 03/27/24 at 8:01 A.M. revealed three large frozen tubes of ground beef sitting in the sink with cold water running from the facet. The water from the facet was only landing on two of the three packages and there was no standing water in the sink. Interview with Cook #600 on 03/27/24 at 8:01 A.M. verified there were three large frozen tubes of ground beef sitting in the sink with cold water running from the facet. Cook #600 verified the frozen tubes of ground beef were not submerged in water. Review of the United States Department of Agriculture Food Safety's article dated 06/15/13 and titled, Safe Defrosting MethodsBased on observation, record review, and staff interview, the facility failed to ensure frozen meat was thawed in a manner to prevent foodborne illness. Additionally, the facility failed to ensure the walk in refrigerator was free of leaks and the kitchen was maintained in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 72.

Findings include:

1. Observation of the kitchen on 03/27/24 at 8:01 A.M. revealed three large frozen tubes of ground beef sitting in the sink with cold water running from the facet. The water from the facet was only landing on two of the three packages and there was no standing water in the sink.

Interview with Cook #600 on 03/27/24 at 8:01 A.M. verified there were three large frozen tubes of ground beef sitting in the sink with cold water running from the facet. Cook #600 verified the frozen tubes of ground beef were not submerged in water.

Review of the United States Department of Agriculture Food Safety's article dated 06/15/13 and titled, Safe Defrosting Methods

Based on medical record review, review of the incident witness statements, review of facility policy and procedures, interviews with local emergency services, the County Coroner, and facility staff, the facility failed to maintain and ensure a resident's safety while being outside of the facility after dark, and facility staff not adequately monitoring his whereabouts. This resulted in Real and Present Danger and the potential for serious life-threatening injuries, negative health outcomes and/or death when on 02/16/24 Resident #01 was last seen between 4:00 A.M. and 4:30 A.M. when he went outside to smoke a cigarette and was not found until approximately 8:05 A.M. when Health and Wellness Director (HWD) #101 found him lying on his back, partially submerged in the facility pond, and unresponsive. Emergency services later confirmed he expired. This affected one (Resident #01) of three residents reviewed for environmental safety concerns and placed an additional 72 residents at risk for potential serious life-threatening harm, injuries, and/or death, who were identified by the facility as safe to exit the facility without staff supervision. The facility census was 75.

On 02/16/24 at 4:25 P.M., the facility's Executive Director (ED) and Vice President of Operations (VPO) #102 were notified Real and Present Danger began on 02/16/24 at approximately 4:30 A.M., when Resident #01 was last seen going outside to smoke a cigarette. Staff did not ensure he re-entered the facility. The resident was found on 02/16/24 at approximately 8:05 A.M., approximately three and one-half hours after he was last seen, when HWD #101 was notified by one of her nurses that a resident looked out the window and saw an empty wheelchair by the pond. HWD #101 found Resident #01 lying on his back, partially submerged in the facility pond, and unresponsive. Emergency services were immediately called, and it was determined he had expired. Interview with County Coroner Investigator #130 on 02/16/24 at 1:21 P.M. confirmed she was on-site and found Resident #01 expired. Parts of his legs were still in the pond, he was lying on his back, eyes open, and did not have any vital signs. There were no signs of blunt force trauma or injuries at the initial observation. She stated based on the information they have, they were not ruling out any cause of death at that point, which included drowning, health/cardiac incident, foul play, or anything else. They will be completing an autopsy with toxicology by 02/17/24. She further stated she would not speculate on a cause of death or what could have happened, but she confirmed his skin was cold to touch, his pants/lower body was wet/very cold, his upper body was not as wet as his lower body, both shoes were off and located on the right and left side of his body outside of the pond water, and his jacket was in his wheelchair, frozen as if it had gotten wet and froze.

The Real and Present Danger was abated on 02/20/24 when the facility took the following corrective actions:

On 02/16/24 from 7:59 A.M. to 8:07 A.M., Licensed Practical Nurse (LPN) #120 and LPN #121 ensured all residents were accounted for; all were except for Resident #01.

On 02/16/24 at 8:12 A.M., Emergency Services arrived at the facility and pronounced Resident #01 expired.

On 02/16/24 from 8:30 A.M. to 11:00 A.M., VPO #102 and Director of Clinical Services (DCS) #103 interviewed State Tested Nursing Assistant (STNA) #104 and Personal Care Assistant (PCA) #105, who worked during the time Resident #01 was outside of the facility. Both confirmed they saw Resident #01 go outside to smoke between 4:00 A.M. and 4:30 A.M. Their statements did not reveal whether they saw Resident #01 after he went outside to smoke at that time. They both left the facility on 02/16/24 at approximately 7:00 A.M. when their shift ended.

On 02/16/24 from 9:50 A.M. to 10:35 A.M., the facility contacted both of Resident #01's emergency contacts as well as the facility Medical Director to report Resident #01's death.

On 02/16/24 from 10:35 A.M. to 11:20 A.M., the facility investigation uncovered that residents would place a barrier (i.e., a rock) in the back door where the smoking area is located, so they could get back inside without having to ring the doorbell and notify staff. Environmental Director #106 audited all exterior doors for barriers/objects that could be used to prevent the doors from latching/locking and removed any that were near the doors.

On 02/16/24 from 11:00 A.M. to 11:15 A.M., VPO #102 verbally educated the Executive Director and HWD #101 regarding the following: A Red Stop Alarm was added to the smoking door, which will be alarmed/activated no less than between the hours of 7:00 P.M. to 7:00 A.M. This alarm will signal anytime the door is opened during these hours. Upon the alarm sounding staff are to report to the alerted area, confirm resident safety, and obtain a confirming head count of all residents in house. If any discrepancies are found, the staff will initiate missing resident procedures and notify facility administration. The smoking door will be locked at a minimum from 7:00 P.M. to 7:00 A.M. All smoking breaks between the hours of 7:00 P.M. to 7:00 A.M. will be supervised in their entirety by staff. Staff will ensure all residents and smoking materials are accounted for at the end of the supervised smoking break.

On 02/16/24 from 11:20 A.M. to 5:00 P.M., the Executive Director and Clinical Operations Specialist (COS) #107, educated all current facility staff on the above-mentioned new process and procedures. Total staff educated was 33 of 34; one staff remains uneducated due to a family emergency and will receive education prior to their next scheduled shift. The rest of the education was completed at 5:00 P.M.

On 02/16/24 from 3:20 P.M. to 4:00 P.M., Regional Quality Assurance Nurse (RQAN) #108, audited the completed smoking safety assessments of current facility smokers to ensure all residents who smoke were safe to smoke unsupervised, and had a service plan in place to ensure safety. There were no variances noted.

On 02/16/24 from 3:30 P.M. to 4:00 P.M., Maintenance Technician #109 installed an alarm on the exit door, leading to the resident smoking area, which requires the alarm to be manually shut off by a key. On 02/16/24 from 4:10 P.M. to 4:40 P.M., HWD #101 and the Executive Director interviewed 18/18 residents with the potential to be affected, currently residing in the facility. Those with potential to be affected include anyone who smokes. All residents with the potential to be affected deny experiencing any like incidents and were educated on the following process change: All resident smoke breaks from 7:00 P.M. to 7:00 A.M. will be directly supervised by staff. All residents will be required to re-enter the facility following their supervised smoking break and all smoking materials will be accounted for. The addition of the STOP alarm to the exit door to the smoking courtyard will ensure an alarm will sound with any exit, starting at 7:00 P.M. and the sound can only be deactivated by a key.

On 02/20/24 from 3:15 P.M. to 3:30 P.M., the Executive Director educated HWD #101, LPN #111, and COS #107 regarding the following: Residents identified as safe to exit the facility unsupervised will be re-educated that prior to doing so after-hours between (7:00 P.M. to 7:00 A.M.) they must notify a staff member and notify a staff member upon return. Staff members will be educated that it is their responsibility to ensure once a resident notifies them, they will be going outside afterhours, they must ensure the resident has re-entered the facility within the communicated time frame from the resident. If the resident has not checked in, at that time the staff member is to walk facility grounds to ensure resident safety. Any variances will be immediately reported to facility Executive Director and/or Wellness Director. Residents requiring supervision when they are on outside grounds will continue to be supervised when outside.

On 02/20/24 from 3:45 P.M. to 7:00 P.M., DCS #103 and RQAN #108 assessed all 75 residents in the facility for their ability to independently mobilize and completed a Brief Interview for Mental Status (BIMS) to ensure they were safe to exit the facility unsupervised, regardless of smoking preference. Of the 75 residents, 72 residents can exit the facility unsupervised. The following residents would require supervision if exiting the facility: Residents #13, #30, and #46. The service plans for those three current facility residents were also reviewed to ensure interventions are in place to ensure safety if exiting the facility.

On 02/20/24 from 4:00 P.M. to 7:15 P.M., COS #107 and LPN #111 educated 75/75 current facility residents on the following process change using the following education statement: Residents identified as safe to exit the facility unsupervised will be re-educated that prior to doing so after-hours (between 7:00 P.M. to 7:00 A.M.) they must notify a staff member and notify staff member upon return. Staff members will be educated that it is their responsibility to ensure once a resident notifies them, they will be going outside afterhours, they must ensure the resident has re-entered the facility within the communicated time frame from the resident. If the resident has not checked in at that time, the staff member is to walk facility grounds to ensure the resident's safety. Any variances will be immediately reported to facility Executive Director and/or Wellness Director. Residents requiring supervision when they are on outside grounds will continue to be supervised when outside.

On 02/20/24 from 4:00 P.M. to 7:15 P.M., HWD #101 educated 32 of 32 current staff members on the following process change using the following education statement: Residents identified as safe to exit the facility unsupervised will be re-educated that prior to doing so afterhours (between 7:00 P.M. to 7:00 A.M.) they must notify a staff member and notify the staff member upon return. Staff members will be educated that it is their responsibility to ensure once a resident notifies them, they will be going outside afterhours, they must ensure the resident has re-entered the facility within the communicated time frame from the resident. If the resident has not checked in at that time, the staff member is to walk the facility grounds to ensure the resident's safety. Any variances will be immediately reported to the facility Executive Director and/or Wellness Director #101. Residents requiring supervision when they are on outside grounds will continue to be supervised when outside.

Ongoing compliance includes the Executive Director or designee will provide education to new resident admissions who smoke and/or to current residents who become new smokers, and all newly hired employees to ensure they are aware of the current supervision and smoking guidelines. Also, the Executive Director/designee will audit to ensure the STOP alarm is activated on or by 7:00 P.M., five (5) times weekly for a period of four (4) weeks to ensure compliance with the process change. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary.

Executive Director or designee will interview five (5) resident smokers, each week, to ensure compliance and understanding of the process change, once (1) per week for a period of four (4) weeks. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary.

Executive Director or designee will audit, via observation; two (2) supervised smoking breaks a day, five (5) times per week for a period of one (1) week, and one (1) supervised smoking break a day five (5) times a week for a period of three (3) additional weeks thereafter. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary.

Vice President of Operations #102/designee will audit the completion of the above required audits, to ensure compliance; once (1) per week for a period of four (4) weeks. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary.

Residents identified as safe to exit the facility unsupervised during the hours of 7:00 A.M. to 7:00 P.M. who report to staff will be monitored to ensure they report their return to staff. If residents do not return at specified time, facility staff will walk the facility grounds to ensure resident safety and report any variances to the Executive Director or Wellness Director immediately. The Executive Director or designee will audit this process five (5) times weekly for four (4) weeks to ensure the process is followed.

Further continued ongoing compliance will be maintained through audits as dictated by the facility Executive Director, Wellness Director #101 and regional support team as deemed necessary.

Although the Real and Present Danger was abated on 02/20/24, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring for on-going compliance.

Findings include:

Review of the medical record for Resident #01 revealed he was admitted to the facility on 09/15/20. His diagnoses included hypertension, cerebral infarction, peripheral vascular disease, vascular dementia, hypo-osmolality and hyponatremia, Vitamin D deficiency, and Vitamin B12 deficiency anemia. Review of Resident #01's Brief Interview for Mental Status (BIMS) assessment, dated 02/01/24, revealed he was cognitively intact.

Review of Resident #01's basic level of care assessment, dated 11/30/23, revealed the resident's mental status was documented as mild impairment - some confusion, difficulty in remembering details in conversations, and forgetfulness. It also revealed he was independent with mobility but needed stand by assistance with bathing and hygiene.

Review of Resident #01's fall risk assessment, dated 02/01/24, revealed the resident scored a 54, which indicated a high risk for falls (score of 45 or higher is a high risk).

Review of Resident #01's current care plan revealed the resident had an activities of daily living (ADL) self-care performance deficit related to a cerebrovascular accident (CVA), limited mobility, short term memory deficit and visual deficit with interventions to educate the resident on wheelchair safety and the resident was able to self-propel in the wheelchair. The care plan revealed he was able to use tobacco products independently without adaptation or supervision with an intervention of the resident can smoke unsupervised.

Review of Resident #01's smoking assessment, dated 02/01/24, revealed he smokes 10+ times per day. He is to allow the facility to keep his lighter and cigarettes. He is to have a care plan for smoking.

Review of Resident #01's progress notes, dated 02/11/24, revealed he was found to be smoking tobacco in his room. His lighter was removed from his room, and he was re-educated about the facility smoking policy.

Review of Resident #01's progress notes, dated 02/16/24, confirmed he was found outside the facility without vital signs, and his legs partially submerged in the facility pond at 7:57 A.M. Emergency services was called to the facility and arrived at approximately 8:05 A.M. Emergency services, law enforcement, and the coroner's office took over the scene and started their investigation. At 10:50 A.M., Resident #01's body was released to the coroner.

Review of facility investigative statements, dated 02/16/24, revealed the statements were taken and typed by VPO #101 and DCS #103, who both signed the written statements. Within the statements, both STNA #104 and PCA #105 saw Resident #01 go outside to the smoking area between 4:00 A.M. and 4:30 A.M. Neither STNA #104 nor PCA #105 stated they saw Resident #01 after that time. There was nothing documented in the witness statements about walking outside to ensure Resident #01 had come back into the facility after smoking. Both statements also acknowledged knowing residents will utilize an object, such as a rock, to prop open the outside/locked door to the smoking area, so the residents could get back inside without having to use the doorbell to alert staff to open the door.

Interview with Resident #67 on 02/16/24 at 12:32 P.M. revealed staff will assist him outside to the smoking area when he wants to smoke. He can ask for one or two cigarettes, get his lighter from the receptionist or nurse (if he doesn't have one already), and go out to smoke. He confirmed that they will either put a rock in the smoking door to prop it open, or lightly close the door so the door doesn't close. This way, they can come back inside when they want and not have to wait for staff to let them back in. He confirmed staff do not go outside with him to smoke. He is not sure if they check on him occasionally when they are outside to smoke. He confirmed they have access to the facility grounds and the sidewalks around the facility when they go outside. He also confirmed that he does not always give back his lighter because he likes having it for himself.

Interview with County Coroner Investigator #130 on 02/16/24 at 1:21 P.M. confirmed she was on-site and found Resident #01 expired. Parts of his legs were still in the pond, he was lying on his back, eyes open, and did not have any vital signs. There were no signs of blunt force trauma or injuries at the initial observation. She stated based on the information they have, they were not ruling out any cause of death at that point, which included drowning, health/cardiac incident, foul play, or anything else. They will be completing an autopsy with toxicology by 02/17/24, and then completing the full coroner's report within the next 10 weeks. She would not speculate on a cause of death or what could have happened, but she confirmed his skin was cold to touch, his pants/lower body was wet/very cold, his upper body was not as wet as his lower body, both shoes were off and located on the right and left side of his body outside of the pond water, and his jacket was in his wheelchair, frozen as if it had gotten wet and froze.

Interview with Law Enforcement Officer #131 on 02/16/24 at 1:41 P.M. revealed she was on-site at the same time as the coroner. They took many pictures, did an initial scene investigation, and then collected his personal items before Resident #01 was taken away by the coroner's office. She also confirmed the same location and appearance of Resident #01 that County Coroner Investigator #130 found. She also confirmed they would not make a determination or speculate the cause of death, but they are not ruling anything out at this time.

Interview with Receptionist #110 on 02/16/24 at 1:50 P.M. revealed when she is at the receptionist desk, she is responsible for giving residents their smoking supplies. They are kept in a locked drawer at the receptionist desk, and a staff member has to get them for the residents. She confirmed that after hours (when a receptionist is not in the facility), the nursing staff (an aide or nurse) has the key to this drawer and will get the smoking materials for the residents. She confirmed that not all the residents bring their lighters back, including Resident #01, after they are done smoking. So, there are times she is not aware of when the residents come back in from smoking.

Interview with LPN #121, Activities Staff #123, and PCA #124 on 02/16/24 from 2:45 P.M. to 3:00 P.M. revealed the residents who smoke are to get their smoking items from the receptionist's desk, either from the receptionist, or from staff who have the key, when it's after hours. When they are done smoking, the residents are to take their lighter back to the receptionist's desk for safe keeping. They confirmed the door to the smoking area is never locked for them. They don't work the second/night shift that often, but even then, they don't believe the door to the smoking area was locked. They confirmed they have seen a barrier/object stuck in the smoking door to keep it propped open. When they see it, they will remove it so the door shuts. They do not have to sit outside with the residents who have been deemed safe to smoke. They can look in the resident's medical records to see if a resident needs supervision for smoking or not.

Interview with PCA #105 on 02/16/24 at 3:07 P.M. revealed she worked the night shift from 02/15/24 to 02/16/24. She arrived shortly before 7:00 P.M. on 02/15/24 and clocked out shortly after 7:00 A.M. on 02/16/24. She was not aware of what happened with Resident #01 when she left. She acknowledges that she assisted Resident #01 with getting his cigarettes between 4:00 A.M. and 4:30 A.M. Another resident went out with Resident #01 to smoke as well. She stated she went back to the smoking door around 4:50 A.M. and saw the rock in the door to prop it open. She stated she looked outside to the smoking area, didn't see anyone, so she removed the rock and shut the door. She confirmed she did not go outside to ensure all the residents came in. She confirmed it was a habit of residents to use a rock or object to prop the door open, so they did not have to use the doorbell to ask staff to open the locked door for them. She confirmed she assumed all residents were back inside and forgot to remove the rock. She confirmed she did not check to ensure Resident #01 (or the other resident) came back in the facility after she let them out to smoke.

Interview with HWD #101 on 02/16/24 at 3:25 P.M. revealed she arrived at the facility shortly before 8:00 A.M. on 02/16/24. When she walked into the facility, she was notified by one of her nurses that a resident looked out the window and saw an empty wheelchair by the pond. She instructed the nursing staff to count all the residents in the facility, while she ran outside to the pond. She confirmed she found Resident #01 on the bank of the pond, his legs partially in the water, lying on his back, hands on his chest, and eyes rolled back into his head. She stated she was confident he was not alive at that time. Their facility rule is not to touch a resident who appears to be deceased, so she did not check for vital signs, and they immediately called EMS. EMS arrived and confirmed he was deceased. She confirmed the process for residents to get their cigarettes was to go to the receptionist's desk, get their smoking materials, and then take their lighter back to the receptionist's desk when they were done. She also confirmed staff are to unlock the smoking door and assist them to the smoking area each time someone wants to smoke. She confirmed they do not go out with residents to smoke if they are deemed to be safe smokers, which all the residents that currently smoke were independent with smoking.

Interview with Resident #64 on 02/16/24 at 4:50 P.M. confirmed the facility staff do not always ask for his lighter back after he smokes. He confirmed he would go outside, smoke, and then not return his lighter. He confirmed he does not have to check in with the receptionist or nursing staff when he comes back inside from smoking unless he has to ring the doorbell for the smoking door to be unlocked. But he confirmed they use a rock or weight to prop the smoking door open, so they don't have to wait for staff to open the door.

Review of the undated facility policy titled, Missing Resident, revealed a resident is considered missing when staff has been unable to find them in their normal area of residence. When a resident is missing, staff should conduct a search of facility rooms. Check the closets, restrooms, laundry rooms. Look in vestibules of outside doors to see if the resident went outside and forgot their key and cannot re-enter the building. Call the Manager who may call in other staff to extend the search. If weather is severe, additional staff should be called to hasten the search. Once 20 minutes have passed, family should be notified and the police should be contacted. Once the resident is found, the resident should be checked. If needed, Emergency Medical Services (EMS) should be called. Complete an incident report. Follow state specific guidelines for reporting to regulatory agencies.

This violation represents non-compliance investigated under Complaint Number OH00151175.

Based on medical record review and staff interview, the facility failed to make a determination of a resident capability to self administer medications. This affected one (#21) resident of five residents reviewed. The facility census was 75.

Findings include:

Review of the medical record for Resident #21 revealed an admission on 10/03/23. Diagnosis include iron deficiency anemia.

Review of the basic level of care dated 10/03/23 for Resident #21 revealed the document contained no determination related to self administration of medication. Further review of Resident #21's medical record revealed there was no documentation regarding a determination of the residents ability to self administer medications.

Interview on 11/15/23 with Registered Nurse (RN) #30 verified the facility did not complete an assessment or determination on admission regarding Resident #21's capability self administration of medication. During the interview RN #30 verified there was no facility a policy regarding the concern.

This violation represents non-compliance investigated under Complaint Number OH00147573.

Based on medical record review, observation, staff interview and policy review, the facility failed to administer medication in sanitary manner. This affected one (#29) resident of two residents observed for medication administration. The facility census was 75.

Findings include:

Review of the medical record for resident #29 was admitted on 10/13/17. Diagnosis include depression.

Observation on 11/15/23 at 8:30 A.M. with Licensed Practical Nurse (LPN) #11 administered medications to Resident #29. LPN #11 did not complete hand hygiene prior to the initiation of the medication administration task. LPN #11 pushed two Tylenol 325 tablets thru the seal of the medication card with one falling onto the top of the medication cart. LPN #11 then picked up the Tylenol tablet and placed it into the medication administration cup without using gloves and/or without completing hand hygiene. LPN #11 continued to prepare amlodipine, citalopram, Lasix, lisinopril and potassium chloride. Once at the bedside, Resident #29 asked LPN #11 to break the potassium tablet in half. LPN #11 took the potassium tablet from the resident in her bare hands and broke it in two and handed it back to the resident to consume.

Interview on 11/15/23 at 8:42 A.M. with LPN #11 verified she did not complete hand hygiene prior to preparing the medication and again before handling the potassium to break it in half. Initially, LPN #11 was unable to locate any alcohol-based hand sanitizer but noted there was some on the side of the medication cart. LPN #11 stated she was unsure of the policy regarding handling medications.

Interview on 11/15/23 at 9:30 A.M. with Wellness Director #9 stated nurses should not handle medication with their bare hands.

Interview on 11/15/23 at 4:19 P.M. with LPN #11 approached surveyor and stated nurses are not to touch medications with their bare hands, and she was educated on the policy from the facility management.

Review of the facility policy titled Standard Precautions, undated revealed hands must be washed between any task which has the possibility of transferring bacteria from resident to resident.

Based on observation, staff interview and policy review, the facility failed to ensure hazardous chemicals were stored in a secure location. This had the potential to affect all 75 residents residing in the facility. The facility census was 75.

Findings include:

Observation on 11/15/23 at 8:53 A.M. of the kitchenette on the second floor revealed a bottle of Germicidal Ultra Bleach stored under the sink in a cabinet without a secure lock.

Interview on 11/15/23 at 8:55 A.M. with Housekeeping Supervisor #31 verified all chemicals should be stored in a secure and located location. Housekeeping Supervisor #31 verified the bottle of bleach was not secure and should not have been there. The facility confirmed all residents residing in the facility could access the unlocked/unsecured bottle of bleach.

Review of the facility policy titled Assisted Living Supplies and Equipment, Environmental Services undated, revealed hazardous chemicals will be stored in a secure location when not in use.

Based on medical record review, review of the incident report, interviews with local emergency services, residents and facility staff, the facility failed to ensure and maintain a safe environment to prevent a resident from getting stuck in the muddy bank of the pond on the facility's property in the dark without staff knowledge of him being outside at the time. This resulted in Real and Present Danger and the potential for serious life-threatening injuries, negative health outcomes and/or death when Resident #01 was last seen at 4:15 A.M. returning from smoking a cigarette outside and then was later found in the dark, in a body of water (pond) located on the facility's property approximately 45 minutes later when another resident (#61) was outside and heard someone calling for help. This affected one (#01) of three residents reviewed for environmental safety concerns and placed an additional 21 residents at risk for potential serious life-threatening harm, injuries, and/or death, who were identified by the facility as self-ambulatory with wheelchairs without assistance and who were considered safe to exit the facility without staff supervision. The facility census was 69.

On 09/07/23 at 3:17 P.M., the facility's Executive Director (ED), Regional Quality Assurance Nurse (RQAN) #155 and Wellness Director (WD) #60 were notified Real and Present Danger began on 08/31/23 at approximately 4:15 A.M., when Resident #01 was last seen returning from smoking a cigarette outside and then exited the facility without staff knowledge. The resident was found on 08/31/23 at approximately 5:00 A.M., stuck in the muddy bank of the pond located on the facility grounds. Resident #01 was heard by another resident (Resident #61), yelling out for help. Resident #61 informed staff that he had heard someone yelling. Staff went outside, and while using their phone flashlights to search the area because it was dark, they found Resident #01 stuck in the mud at the edge of the pond. Additionally, the facility was notified that there were non-functioning light fixtures on the exterior portion of the facility near the pond area.

The Real and Present Danger was abated on 09/13/23 when the facility took the following corrective actions:

On 08/31/23 at 6:20 A.M., Emergency Services transported Resident #01 to the hospital for evaluation after a fall and being outside wet in the elements. Resident #01 returned at 2:03 P.M. after evaluation in the emergency department. The resident had no abnormal findings or injuries related to the incident.

On 08/31/23 from 2:10 P.M. to 2:30 P.M., WD #60 interviewed Resident #01 about the incident and assessed him for injuries. The resident denied pain and injuries at that time. Resident #01 was educated to use caution when wheeling around the pond in his wheelchair including locking the wheelchair brakes and if the resident chose to leave the pathway, to avoid soft and muddy areas. Resident #01 verbalized understanding of the education.

On 09/07/23 from 3:17 P.M. to 9:45 P.M., the facility was informed of non-functioning light fixtures on the exterior portion of the facility near the pond area. Environmental Director #300 audited all external light fixtures surrounding the pond to ensure they were functioning as expected including six lampposts on the front walkway, two lampposts in the back of the pond area, two hanging lights by exit doors and two floodlights located on the pond-side of the facility. The audit found two of six lampposts needed new lightbulbs and a third was flickering and needed electrical contractor repair. The flood lights needed timer adjustments and one needed electrical contractor repair. The lampposts in the back of the facility at the pond needed timer adjustments and the hanging lights by the exits on the exterior of the door were in working order. Maintenance Director (MD) #305 dispatched Tiec Electric service to install replacement fixtures for the affected light fixtures located on the pond-side of the facility (one lamppost and one flood light). The Executive Director educated MD #305 and Maintenance Staff #185 on repairing light fixtures timely.

On 09/07/23 from 4:50 P.M. to 6:30 P.M., WD #60 interviewed 21 of 21 residents with potential to be affected (wheelchair bound residents who could be self-propelling near the pond). All residents interviewed denied concerns related to maneuvering in the facility and on the grounds including the pond area.

On 09/07/23 from 4:55 P.M. to 6:30 P.M., 71 of 74 residents were educated on using caution when wheeling around the pond in wheelchairs; including locking wheelchair brakes when sitting on uneven ground, and if choosing to leave the pathway, to avoid soft, muddy areas and were also educated to report any blown light bulbs to staff immediately. Three residents were out to the hospital and will be educated upon their return. All residents were provided with a handout with the information as well.

On 09/07/23 from 5:00 P.M. to 9:00 P.M., the ED and Community Liaison #295 educated all facility staff related to the exterior lighting policy and procedure related to reporting burnt out lights bulbs.

On 09/07/23 from 6:00 P.M. to 6:15 P.M., Regional Director of Operations #315 educated the ED on the process change related to maintenance performing facility exterior light rounds to ensure proper functioning and record in the TELS log (building management platform) at least once weekly.

On 09/07/23 from 7:15 P.M. to 7:30 P.M., the ED educated all maintenance staff on the change in procedure related to maintenance performing facility exterior light rounds to ensure proper functioning and record in the TELS log at least once weekly.

On 09/12/23 from 12:30 P.M. to 3:00 P.M., WD #60 educated 19 of 19 current residents with a written memo on safe wheelchair maneuverability including staying on the pathway and in well-lit areas to avoid muddy areas or where ground does not appear solid surrounding the pond. WD #60, RQAN #155, Clinical Operation Specialists #150 and #160 assessed 19 of 21 residents who use a wheelchair in the facility. Three residents previously noted were no longer residing in the facility. These residents also had wheelchair maneuverability observed as they navigated the path from the front door to the courtyard past the pond without any concerns noted.

On 09/13/23 from 10:30 A.M. to 2:00 P.M., all residents unable to mobilize independently were considered unsafe to exit the facility independently and would be accompanied outside by a staff member, family, or visitor, as appropriate. Residents who can mobilize without assistance were considered safe to exit the facility without staff supervision. Seventy-four of 74 residents were determined safe to exit the facility and were educated by the ED they were required to notify staff if exiting the facility when doors were locked from 7:00 P.M. to 7:00 A.M.

On 09/13/23 from 10:45 A.M. to 2:00 P.M., all current staff were educated by the ED that residents who can mobilize without any assistance are considered safe to exit the facility, but they are required to notify staff if exiting the facility from 7:00 P.M. to 7:00 A.M.

Ongoing compliance includes new admissions will be assessed for cognition and mobility if they are safe to be outside without staff at night and with safety in mobility around the pond area and will be educated on the new procedures in place related to informing staff when going outside at night. Audits will be completed and monitored that all interventions were in place.

Although the Real and Present Danger was abated on 09/13/23, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring for on-going compliance.

Findings include:

Review of the medical record for Resident #01 revealed an admission date of 09/15/20. Diagnoses included hypertension, respiratory insufficiency, urinary incontinence, vascular dementia, and muscle weakness.

Review of the falls risk assessment dated 07/09/23 revealed the resident scored a 41.0 which indicated a moderate risk for falls (score 25-44 was moderate).

Review of the care plan dated 08/31/23 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to a cerebrovascular accident (CVA), limited mobility, short term memory deficit and visual deficit with interventions to educate the resident on wheelchair safety and the resident was able to self-propel in the wheelchair. The care plan revealed the resident had memory loss dementia related to disease process (CVA) with interventions to present the resident with one thought, idea, or question at a time.

Review of a progress note dated 08/31/23 revealed the nurse was notified upon arrival to the facility for her shift that Resident #01 was sent to the emergency room because he was found out by the pond overnight. The note revealed Resident #01 was right on the edge of the pond with his feet in the pond. He was unable to free himself from the mud and paramedics were contacted to assist the resident out of the situation. The resident was transported to the hospital for evaluation. A progress note dated 08/31/23 revealed the resident returned from the hospital the same day with no injuries. A progress note dated 09/01/23 revealed the resident had an order placed for physical and occupational therapy for a wheelchair safety evaluation to be completed.

Review of the Emergency Medical Services (EMS) Report from the City of Springfield Fire and Rescue revealed EMS was contacted at 5:41:45 A.M. and arrived at the scene at 5:54:23 A.M. The report revealed the resident was alert and oriented to person, place, and event but not time and had a temperature of 97.7 degrees Fahrenheit with a slightly elevated blood pressure of 138/84. The narrative of the scene revealed Medic #04 was dispatched for a male on report of a fall. Upon arrival, EMS staff discovered Resident #01 in a pond on the property with staff present. The report documented the resident was sitting in about four to six inches of water near the edge of the pond. The report stated staff were unaware the resident had been outside and was discovered by another resident that happened to be outside. Resident #01 informed EMS staff that he took his wheelchair down to the area and fell from it. Resident #01 was removed from the water and was dressed in dry clothing. EMS reported the facility had no nursing staff onsite to assess the resident after the incident and for EMS to gather information from prior to hospital transfer. The report revealed EMS departed the facility with Resident #01 at 6:20:07 A.M.

Review of the incident investigation report dated 08/31/23 at 7:00 A.M. revealed Resident #01 was wheelchair bound for locomotion and had right sided hemiplegia related to a CVA. Resident was outside in soft mud visiting with another resident and was unable to free wheelchair from the mud. The investigation report form asked if the resident was taken to the hospital and was answered: no.

Staff Statements:

-The staff interview included in the investigation report revealed caregivers reported resident went outside with another resident around 4:00 A.M. Resident was sitting by the pond when his wheels got stuck in the mud. Resident was unable to free his own chair. Resident's friend returned inside to alert staff. Staff were unable to free the wheelchair themselves and emergency services needed to be contacted to assist.

Nursing Statement:

-Resident was taken to the emergency room prior to nurse arriving for her shift. Caregivers reported resident's wheelchair wheels were stuck/submerged in the soft ground by the water. Resident and staff were unable to pull the wheels from the mud and emergency services were contacted to assist. Resident was noticed to have right side weakness which was baseline for resident.

The immediate action taken:

-Case Manager and Physician were notified of the incident and transfer to the hospital

-Resident was evaluated and found to have no injuries

-Resident was educated on wheelchair safety and discouraged from sitting in the mud when feeding ducks

-A request was made for a therapy evaluation for wheelchair mobility

The Interdisciplinary Team (IDT) met and wrote a note dated 09/01/23

-Resident returned to the facility with no pain or injuries

-Resident had stated he was feeding the ducks by the pond and didn't realize the mud was soft. Resident was educated to use caution near the pond and discouraged from using his wheelchair in or around soft mud.

Review of the basic level of care assessment dated 09/04/23 and signed on 09/06/23 revealed the resident's cognition was marked as appropriately oriented with person, place, and time. All previous cognitive assessments completed quarterly since admission revealed the resident had mild or moderate impairment including confusion and difficulty remembering details and forgetfulness including the most recent cognitive assessment prior to the incident dated 06/06/23.

Interview on 09/06/23 at 9:00 A.M. with Resident #01 revealed he remembered going outside to smoke and remembered falling. Resident #01 did not remember if he fell in a puddle on the sidewalk or in the pond. The resident reported no injuries that he knew of and revealed I think I went to the hospital for either one day or four days. Resident #01 revealed he had right sided weakness and was unable to get himself up without assistance. He revealed he thought he was wearing shoes, a long sleeve shirt and sweatpants. He stated he was going outside to smoke and forgot where he should be smoking and was following along the trail around the backside of the facility toward the pond. The resident revealed he was alone at the time of the incident and revealed another resident helped find him.

Interview on 09/06/23 at 9:48 A.M. with Springfield Fire and Emergency Service staff (SFES) #100 revealed the incident occurred on 08/31/23 around 5:30 A.M. when the fire department and EMS were dispatched for a male in the pond. SFES #100 revealed she had also received a call from the hospital with concerns and requesting information related to the incident and run report.

Observation on 09/06/23 from 9:55 A.M. to 10:05 A.M. revealed the activity room door exited out to the smoking area which included several benches and a gazebo. A walking path flowed past the smoking areas toward the right of the building. The path eventually wrapped around to the front parking lot where the pond went along the side of the building with a steep drop from the sidewalk to the pond. The facility had lampposts along the curve from the back of the courtyard toward the pond.

Interview on 09/06/23 at 11:46 A.M. with Resident #61 revealed he went outside to feed the ducks at 5:00 A.M. which was his normal daily routine. Resident #61 heard someone yelling for help and revealed he was unable to see anything in the pond or around the pond due to it being dark outside still. Resident #61 revealed he went back inside the facility and informed two aides about someone yelling for help. Resident #61 revealed staff response was not very quick and revealed Resident #01 was found sitting on his bottom in the pond and was wet from the waist down.

Interview on 09/06/23 at 12:58 P.M. with the ED and WD #60 revealed the aides working 08/30/23 included Patient Care Aides (PCA) #70 and #73. Licensed Practical Nurse #65 worked the next morning and wrote up the incident report.

Interview on 09/06/23 at 1:02 P.M. with PCA #73 revealed Resident #61 was observed to come downstairs around 5:00 A.M. with a loaf of bread to feed the ducks. PCA #73 revealed Resident #61 typically came out at this time to feed the ducks near the pond. PCA #73 revealed Resident #61 came back inside after a few minutes and informed staff of someone outside calling for help. PCA #73 revealed she, along with the other aide on duty, found Resident #01 in the mud near the pond area. PCA #73 revealed she could not remember if the resident was in the water. She revealed Resident #01 was last seen about 2:00 A.M. during rounds and then Resident #01 came and got his smoking materials for the 4:00 A.M. smoke break. PCA #73 revealed staff did not check off or document anything when residents took their smoking materials, when they returned them, or when they go outside at night. She revealed she was unsure if the resident came back inside at any time between his smoking break at 4:00 A.M. and when he was found in the pond area. PCA #73 revealed she and PCA #70 attempted to get Resident #01 out of the pond/mud and revealed they contacted WD #60 and EMS for assistance. PCA #73 revealed when they found Resident #01, he informed staff he was trying to cross the water to not get his feet wet. PCA #73 revealed this comment did not make sense and when asked, the resident was unable to clarify. PCA #73 revealed the resident had a history of intermittent confusion. She revealed the resident was wet from the waist down and had mud on his chest and arms from grabbing at mud while trying to crawl out.

Interviews on 09/06/23 from 1:42 P.M. to 3:24 P.M. with LPN #65 revealed she came into work on 08/31/23 at 7:00 A.M. to work the day shift. LPN #65 revealed she was told by the night aides about Resident #01 being found in the pond area. She revealed she was informed the resident was found by another resident (#61) who had gone outside to feed the ducks early in the morning. LPN #65 revealed she had heard Resident #01's wheelchair was stuck in the mud close to the edge of the pond. She revealed the resident had transferred to the hospital out of an abundance of caution from cold exposure and to be evaluated after a fall. LPN #65 revealed the resident had already transferred to the hospital when she arrived and that she had no personal involvement with the situation. She revealed WD #60 informed her to complete the incident investigation report based on what the night PCA's told her. LPN #65 revealed Resident #01 had intermittent confusion and had difficulty with memory and recalling details. LPN #65 revealed WD #60 had requested she wait to document until they could decide on the story to put in the record. LPN #65 revealed there was a recent change to the smoking policy where residents were required to smoke in the designated smoking areas and had to return within 15 minutes. LPN #65 revealed staff did not inform her of the last time they saw the resident and she was not familiar with how long the resident was outside or stuck in the pond/mud.

Interview on 09/06/23 at 3:00 P.M. with WD #60 revealed she was unaware of who the other resident was in the incident investigation documents. She revealed she would need to check. WD #60 revealed the incident should say original on it if it had not been edited and confirmed the document did not say original. WD #60 revealed she was unsure what, if any, interventions were put in place after this incident of the resident being found in/near the pond.

Interviews on 09/06/23 from 1:20 P.M. to 3:15 P.M. with the ED, Clinical Operations Specialist (COS) #150 and WD #60 confirmed the incident report stated, other resident and confirmed there was no evidence of who this resident was. The ED, COS #150, and WD #60 revealed they did not know who this other resident was and revealed they would check statements. When asked for statements they revealed they did not have any additional statements from the incident. The ED revealed it was likely an assumption the staff made when writing the incident investigation report. COS #150 revealed the incident investigation report was a flowing document that can be adjusted, changed, and added to as needed. The ED and COS #150 were unable to provide any evidence of what staff changed and edited on the incident investigation report and when those changes were made. They revealed it was an interdisciplinary team that had discussed these changes and declined providing any information on where the report came from that the resident was with another resident when he got stuck, and the description and location of where the resident was found. The ED, COS #150 and WD #60 first revealed Resident #01 was found sitting in his wheelchair with his wheelchair wheels and his feet being stuck in the mud. Then the ED, COS #150, and WD #60 revealed the resident was found sitting at the edge of the mud and that the resident had lowered himself to sit in the mud. They stated the resident was alert and oriented and was able to make the choice if he wanted to go outside in the dark and to sit in the mud. The ED, COS #150 and WD #60 provided no evidence of interventions put in place to keep facility residents safe from maneuvering around the pond and pond safety after this incident occurred. They revealed Resident #01 had received education to not sit in the mud and a therapy consult was made for wheelchair maneuverability.

Interview on 09/06/23 at 4:36 P.M. with RQAN #155 revealed the facility was not required to put up a fence and asked what's the issue in relation to Resident #01 being found in the pond.

Interview on 09/07/23 at 8:45 A.M. with PCA #70 revealed she worked night shift on 08/30/23 and revealed she had given Resident #01 his smoking materials at 4:00 A.M. and observed Resident #01 return his smoking materials at the end of the smoking break at 4:15 A.M. PCA #70 revealed she heard a door alarm going off at the pond-side of the building at around 4:30 A.M. and went to the door to check it out. She stated she did not see any issues or concerns at that time. Around 5:00 A.M., Resident #61 was observed to go outside with a bag of bread to feed the ducks, which was his normal routine. PCA #70 revealed Resident #61 returned a few minutes later and reported he heard someone yelling for help outside by the pond but could not see in the dark. PCA #70 stated the lights were off and she had to turn them on but revealed the lights by the pond did not work. She stated it was still dark and she had to use her cell phone light to find Resident #01 who had fallen from his wheelchair in the pond. PCA #70 revealed the resident was found sitting in about one inch of water with his legs under him. She stated that she and the other PCA on duty found Resident #01 at around 5:15 A.M. to 5:20 A.M. and attempted to get him out of the water and mud but were unable so they contacted emergency services for assistance. PCA #70 revealed anytime a resident had a medical situation or fall at night, they send them to the hospital since the facility had no nurses to assess a resident after a fall. PCA #70 revealed she gave report to the day shift nurse and informed her Resident #01 was out to the hospital and reported the incident. PCA #70 revealed no other residents were outside when Resident #01 got stuck in the mud until Resident #61 went out at 5:00 A.M. and found him. PCA #70 revealed the resident had reported the reason he was in the pond was I was trying to get across to keep my feet from getting wet. PCA #70 revealed Resident #01 had intermittent confusion and revealed his cognition seemed off when he was found. PCA #70 revealed the resident was typically independent with maneuvering his wheelchair but needed assistance with transfers for showers and stumbled at times when trying to walk.

Interview on 09/07/23 at 9:00 A.M. with RQAN #155 revealed the resident was educated on smoking times and the new smoking policy prior to the incident with no evidence of additional education. She revealed the resident also had a therapy evaluation ordered and had education on wheelchair safety completed per the care plan on 09/05/23.

Interview on 09/07/23 at 9:20 A.M. with WD #60 revealed PCA #70 contacted her at 5:48 A.M. to inform her of the incident. WD #60 revealed staff had reported they had already called emergency services and were unable to get Resident #01 out of the pond area themselves. WD #60 revealed she could hear the emergency services arrive to the facility while she was still on the phone.

Interview and observation on 09/07/23 from 9:28 A.M. to 9:50 A.M. with Maintenance Staff #185 revealed he was recently informed three of the six lamp posts along the front of the building toward the pond were out and needed bulbs replaced. The facility had two parking lot lights and Maintenance Staff #185 revealed a company deals with those and was unable to say if they were working. Maintenance Staff #185 revealed he was unsure if the facility had lights outside and through observation found two flood lights on the side of the building facing the pond. Both lights had yellow and orange rusty tints. Maintenance Staff #185 revealed the lights were on a timer and he would adjust the timer to see if the lights worked properly. Maintenance Staff #185 returned after adjusting the timer and confirmed the two flood lights on the side of the building that faced the pond were not in working order. Maintenance Staff #185 walked toward the back of the building heading toward the smoking area from the pond area and found two additional lamp posts that were not working. Maintenance Staff #185 revealed he was informed that when they were working the lights were scheduled to turn off at 5:00 A.M. and revealed it was still dark at that time of day. Maintenance Staff #185 stated his plan was to adjust the times for lights to be on from 6:00 P.M. to 7:00 A.M. Maintenance Staff #185 revealed staff did not turn in timely work orders and revealed I can't fix something I don't know about. Maintenance Staff #185 observed some inner courtyard flood lights that were working and confirmed they did not illuminate much light to the area.

Interview on 09/11/23 at 10:48 A.M. with Lead Paramedic #125 revealed upon arrival to the facility on 08/31/23 around 5:45 A.M. the team was directed by staff to a pond on the property. He revealed Resident #01 was found sitting in the water in about four to five inches of water and was wet from the chest down and both arms were wet. He revealed the resident was covered in mud and was assisted up out of the mud and brought back inside the facility to get cleaned up and changed into warm clothes. He also revealed Resident #01's wheelchair was found sitting in the water and had mud on the wheels.

This violation represents non-compliance investigated under Complaint Number OH00146074.

Based on medical record review and staff interview, the facility failed to ensure residents received medications as ordered. This affected three (Residents #36, #45, and #50) of three residents review for medication administration. The facility census was 74.

Findings include:

1. Medical record review revealed Resident #36 was admitted to the facility 03/01/17. Diagnoses included depression, anemia, chronic kidney disease, hypertension, osteoarthritis coronary artery disease and anxiety.

Review of the Resident #36's physician orders and Medication Administration Record (MAR) for April 2023 revealed the following medications were ordered and not administered on the following dates:

Acidophilus Capsule give one capsule by mouth one time a day. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Atorvastatin Calcium F/C 40 milligram (MG) 1 tablet orally in the evening for hyperlipidemia. Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 4/28/23.

Baclofen 10 mg tablet give 1 tablet one time a day for muscle spasm. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Baclofen 10 mg tablet give 1 tablet orally in the afternoon for muscle spasm. Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Baclofen 10 mg tablet give 1 tablet orally in the evening for muscle spasm. Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23 and 4/28/23.

Clopidogrel F/C 75 MG tablet give 1 tablet orally one time a day for hyperlipidemia. Resident #36 did not receive the medication on 04/11/23.

Desvenlafaxine Succinate ER 100 mg tab ER 24 H give 1 tablet orally one time a day for depression. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Ferrous Sulfate 325 mg tablet give 1 tablet orally 1 time a day for anemia. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Fibercon Tablet give 625 mg by mouth 1 time a day for diarrhea. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Furosemide Oral Tablet 40 mg give 1 by mouth one time a day for edema. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Furosemide Oral Tablet 40 mg give 1 by mouth in the afternoon. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 04/24/23.

Hydrocodone-Acetaminophen tablet 5-325 MG give 1 tablet by mouth one time a day for pain. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/24/23.

Hydrocodone-Acetaminophen tablet 5-325 MG give 1 tablet by mouth in the afternoon for pain.

Resident #36 did not receive the medication on 4/28/23.

Hydrocodone-Acetaminophen tablet 5-325 MG give 1 tablet by mouth in the evening for pain. Resident #36 did not receive the medication on 04/25/23 and 04/28/23.

Lyrica Capsule 50 MG give 1 capsule by mouth in the evening for neuropathy.

Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Mupirocin Ointment 2% apply to crusty area on legs topically one time a day for wound.

The treatment was not completed on 04/11/23, 04/22/23, and 04/28/23.

Mupirocin Ointment 2% apply to crusty area on legs topically in the evening for wound.

The treatment was not completed on 04/11/23, 04/21/23,04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Omeprazole Capsule delayed Release 40 MG give 1 capsule by mouth one time a day.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Oscal 500/200 D-3 tablet 500-200 MG unit give 1 tablet by mouth one time a day.

Resident #36 did not receive the medication on 04/11/21 and 04/22/23.

Oxybutynin Chloride Oral Tablet 5 MG give 1 tablet by mouth in the morning.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 04/28/23.

Oxybutynin Chloride Oral Tablet 5 MG give 1 tablet by mouth in the evening.

Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 4/28/23.

Senna Oral tablet 8.6 MG give 1 tablet by mouth in the morning.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Senna Oral tablet 8.6 MG give 1 tablet by mouth in the evening.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Triamcinolone Acetonide Ointment 0.5% apply to reddened areas on legs topically 1 time a day for wound care mix with keto cream and then apply to legs. The treatment was not completed on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 4/28/23.

Triamcinolone Acetonide Ointment 0.5% apply to reddened areas on legs topically in the evening for wound care mix with keto cream and then apply to legs. The treatment was not completed on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Tylenol Oral Tablet 325 MG give 2 tablets by mouth one time a day for pain.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Tylenol Oral Tablet 325 MG give 2 tablets by mouth in the afternoon for pain.

Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Tylenol Oral Tablet 325 MG give 2 tablets by mouth in the evening for pain.

Resident #36 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 4/28/23.

Wellbutrin XL tablet extended Release 24-hour HCI ER (XL) give 150 mg by mouth one time a day. Resident #36 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

2. Medical record review revealed Resident #45 was admitted to the facility on 03/01/17. Diagnoses included depression, anemia, chronic kidney disease, hypertension, osteoarthritis coronary artery disease and anxiety.

Review of the Resident #45's physician orders and MAR for April 2023 revealed the following medications were ordered and not administered on the following dates:

Ativan 0.5 MG give one tablet by mouth in the morning for anxiety. Resident #45 did not receive the medication on 04/11/23, 04/22/23, and 4/28/23.

Ativan 0.5 MG give 1 tablet by mouth in the evening for anxiety. Resident #45 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Omeprazole Oral Capsule Delayed Release 40 MG give 1 capsule by mouth in the morning. Resident #45 did not receive the medication on 4/11/23 and 4/22/23.

Metoprolol Tartrate Oral Tablet 25 MG give 1 tablet by mouth in the morning. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Metoprolol Tartrate Oral Tablet 25 MG give 1 tablet by mouth in the evening. Resident #45 did not receive the medication on 04/11/23, 04/21/23, 04/22/23, 04/24/23, 04/25/23, and 4/28/23.

Metformin HCI Oral Tablet 1000 MG give 1 tablet by mouth one time a day. Resident #45 did not receive the medication on 04/22/23.

Metformin HCI Oral Tablet 1000 MG give 1 tablet by mouth in the evening. Resident #45 did not receive the medication on 04/24/23 and 04/25/23.

Levetiracetam oral tablet 1000 MG give 1 tablet by mouth in the morning for seizures. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Levetiracetam oral tablet 1000 MG give 1 tablet by mouth in the evening for seizures.

Resident #45 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/25/23 and 4/28/23.

Jardiance oral tablet 10 MG give 1 tablet by mouth in the morning. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Lactulose Oral Solution give 30 ml by mouth one time a day. Resident #45 did not receive the medication on 4/11/23.

Lactulose Oral Solution give 30 ml by mouth one time in the evening. Resident #45 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Levemir Subcutaneous Solution 100 unit/milliliters (ml) inject 12 units subcutaneously in the evening. Resident #45 did not receive the medication on 04/11/22, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Ipratroplum -Albuterol inhalation Solution 0.5-2.5 (3) mg/3 ml, 3 ml inhale orally one time a day. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Ipratroplum -Albuterol inhalation Solution 0.5-2.5 (3) mg/3 ml, 3 ml inhale orally in the afternoon. Resident #45 did not receive the medication on 04/11/23, 04/22/22, and 04/28/23.

Ipratroplum -Albuterol inhalation Solution 0.5-2.5 (3) mg/3 ml, 3 ml inhale orally in the evening.

Resident #45 did not receive the medication on 04/11/23, 04/22/22, 04/24/22, 04/25/23 and 04/28/23.

Rifaximin oral tablet 550 mg give 1 tablet by mouth in the morning. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Rifaximin oral tablet 550 mg give 1 tablet by mouth in the evening. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Sertraline HCI oral tablet 100 mg give 1 tablet by mouth in the morning. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Thiamine HCI Oral Tablet 100 mg give 1 tablet by mouth in the morning. Resident #45 did not receive the medication on 04/11/23 and 04/22/23.

Thiamine HCI Oral Tablet 100 mg give 1 tablet by mouth in the afternoon. Resident #45 did not receive the medication on 04/11/23, 04/22/23, and 04/22/23.

Thiamine HCI Oral Tablet 100 mg give 1 tablet by mouth in the evening. Resident #45 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Trazodone HCI oral tablet 100 mg give 1 tablet by mouth in the evening. Resident #45 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/25/23, and 04/28/23.

Novolog injection Solution 100 unit/ml inject as per listed sliding scale. Resident #45 did not have his blood sugar measured on 04/11/23 and 04/22/23 to determine dosage of insulin to administer or if the insulin was to be given.

3. Medical record review revealed Resident #50 was admitted to the facility on 08/04/22. Diagnoses included schizoaffective disorder, major depression disorder, repeated falls, and multiple sclerosis.

Benztropine Mesylate tablet one mg give 1 tablet by mouth in the morning. Resident #50 did not receive the medication on 04/11/23 and 04/22/23.

Benztropine Mesylate tablet one mg give 1 tablet by mouth in the afternoon. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/27/23 and 04/28/23.

Benztropine Mesylate tablet one mg give 1 tablet by mouth in the evening. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/27/23 and 04/28/23.

Docusate Sodium Capsule 100 mg give 1 capsule by mouth in the evening. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/27/23, and 04/28/23.

Klonopin Tablet one, give 1 tablet by mouth in the morning for anxiety. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Klonopin Tablet one, give 1 tablet by mouth in the evening for anxiety. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/27/23 and 04/28/23.

Multivitamin Tablet give 1 tablet by mouth in the morning. Resident #50 did not receive the medication on 04/11/23, 04/22/23, and 04/28/23.

Omeprazole Capsule delayed release 20 MG give one capsule by mouth in the morning. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Perphenazine Tablet 8MG give 1 tablet by mouth in the morning. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Perphenazine Tablet 8MG give 1 tablet by mouth in the evening. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/27/23 and 04/28/23.

Questran Packet 4 GM give 1 packet by mouth in the morning. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Questran Packet 4 GM give 1 packet by mouth in the evening. Resident #50 did not receive the medication on 04/11/23, 04/22/23, 04/24/23, 04/25/23, 04/27/23 and 04/28/23.

Spiriva Respimat Aerosol Solution 2.5 MCG/ACT 2 puff inhale orally in the morning. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Zoloft Oral Tablet Give 75mg by mouth one time a day. Resident #50 did not receive the medication on 04/11/23, 04/22/23 and 04/28/23.

Interview on 06/06/23 at 2:30 P.M. via e-mail with Quality Assurance Regional Nurse #120 verified missed medications for Residents #36, #45, and #50.

The facility did not provide a Medication Administration policy.

This violation represents non-compliance investigated under Complaint Number OH00142761.