Wapakoneta Assisted Living

Based on observation, staff interviews, and review of the facility's medication administration policy, the facility failed to ensure medications were not pre-pulled prior to medication administration. This affected five Residents (#117, #120, #121, #123, and #124) of the six residents reviewed for medication administration. The census was 54.

Findings include:

Observation on 06/16/26 at 7:46 A.M. revealed Licensed Practical Nurse (LPN) #20 had five clear medication cups containing multiple unidentifiable pills, with only the residents' first names written on the cups. LPN #20 retrieved the cups from a desk in the nurse's station and placed them on top of the medication cart. LPN #20 went to hand a medication cup of unidentified pills to Resident #117 without verification of identity. As Resident #117 reached for the medication cup, LPN #20 realized the medication cup was for Resident #121. LPN #20 then explained these were Resident #121 medications.

During an interview on 06/16/26 at 7:47 A.M., LPN #20, verified five of the resident's medications were pre-pulled. LPN #20 stated medications were always pre-pulled for the residents that come to nurse's station. LPN #20 stated the residents did not want to wait for the nurses to pull them.

Review of the facility policy titled Administering Medications, dated 04/28/25 revealed the individual administering medications must verify the resident's identity before giving the resident his/her medications. methods of identifying the resident include checking photograph attached to medical record. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. Medication ordered for a particular resident may not be administered to another resident, unless permitted.

This violation represents non-compliance investigated under Complaint Number OH00170789.

Based on medical record review, review of the facility incident logs, staff interviews, and policy review, the facility failed to reassess residents for falls to determine changes in care needs. This affected one (#29) of two residents reviewed for change in condition. The facility census was 53.

Findings include:

Review of Resident #29's record revealed an admission date of 04/14/06 and re-admission date of 05/01/12. Diagnoses included osteoporosis, cardiac arrhythmia, hypertensive heart disease, diverticular disease of the intestine, and anxiety disorder. Further review revealed Resident #29 had eight falls within a four-month period.

Review of the facility's incident log revealed Resident #29 had falls on 04/06/25 in her room, between her bed and recliner; 05/11/25 in her room, between her bed and recliner; 05/20/25, with no details available; 06/16/25 in her room while getting dressed; 06/20/25 in her room, out of reach of her call light; 07/14/25 in her room, near her bathroom with untied shoes and not using her walker; and two falls on 07/29/25 in her bathroom.

Additional review of Resident #29's medical record revealed a fall risk assessment was completed on 11/13/24 with a score of 10, indicating the resident was at moderate risk for falls. Further review revealed no additional fall risk assessments had been completed since the 11/13/24 assessment, including after each of the eight fall events.

Interview on 07/31/25 at 2:13 P.M. with the Director of Nursing (DON) revealed fall risk assessments were to be completed every three months and after each fall event. The DON verified Resident #29 was not reassessed every three months, or after each of her eight fall events.

Review of the facility policy titled, Nursing Admission/Readmission/Annual Assessment Policy

Based on employee file review and staff interview, the facility failed to ensure staff had First Aid training within 60 days of hire. This affected three (#206, #208, and #210) employees of the four new employee files reviewed. The facility census was 41.

Findings include:

1. Review of the employee file for Resident Assistant (RA) #206 revealed a hire date of 08/24/23. Further review of the employee file revealed no documentation to support RA #206 had First Aide training within 60 days of hire.

2. Review of the employee file for RA #208 revealed a hire date of 05/13/24. Further review of the employee file revealed no documentation to support RA #208 had First Aide training within 60 days of hire.

3. Review of the employee file for RA #210 revealed a hire date of 04/09/24. Further review of the employee file revealed no documentation to support RA #210 had First Aide training within 60 days of hire.

Interview on 10/31/24 at 3:35 P.M., with Director of Nursing (DON) confirmed the employee files for RA #206, #208, and #210 contained no documentation to support First Aide training was completed within 60 days of hire.

Based on record review, staff interview, and policy review, the facility failed to complete tuberculosis (TB) risk assessment annually. This had the potential to affect all 41 residents. The facility census was 41.

Findings include:

Review of the facility TB risk assessment revealed it was dated 2023.

Interview on 10/31/24 at 11:24 A.M., with Director of Nursing (DON) confirmed the facility had not completed a TB risk assessment for 2024.

Review of the facility policy titled, Tuberculosis Control

Based on observation, staff interview, resident list review, and policy review, the facility failed to follow infection control procedures during medication administration. This affected two (#30 and #31) residents out of the two residents observed for medication administration. The facility also failed to ensure the glucometer was cleaned with a disinfectant after use. The facility identified eight residents (#04, #10, #14, #15, #19, #24, #30, and #32) who have staff check their fingerstick blood sugar levels with the glucometer. The facility census was 41.

Findings include:

1. Review of the medical record for Resident #31 revealed an admission date of 08/19/23, with medical diagnoses of atherosclerotic heart disease, gout, osteoporosis, dementia, hypertension, and Parkinson's disease.

Review of the medical record for Resident #31 revealed physician orders dated 08/08/24 for Zyloprim 100 milligram (mg) one tablet by mouth daily, meloxicam 7.5 mg one tablet by mouth daily, metoprolol 50 mg one tablet by mouth daily, probiotic capsule one by mouth daily, rasagiline 1 mg tablet by mouth daily, and Vitamin B12 one tablet by mouth daily.

Observation on 10/31/24 at 8:00 A.M., revealed Licensed Practical Nurse (LPN) #204 prepared medications for Resident #31. The observation revealed LPN #204 placed the Zyloprim, meloxicam, metoprolol, probiotic, rasagiline and Vitamin B12 tablets into her bare hands after removal from the medication cards. LPN #204 then placed the medications from her bare hands into the medication cup and administered the medications to Resident #31. The observation revealed LPN #204 did not perform hand hygiene before or after medication administration.

2. Review of the medical record for Resident #30 revealed an admission date of 07/08/24, with medical diagnoses of hypertension, gout, diabetes mellitus, and hypertensive heart disease with heart failure.

Review of the medical record for Resident #30 revealed physician orders dated 08/01/24 for acidophilus one capsule by mouth two times per day, Zyloprim 100 milligram (mg) by mouth daily, Buspar 10 mg tablet one by mouth daily, cetirizine 5 mg one tablet by mouth daily, Plavix 75 mg one tablet by mouth daily, cranberry capsule one by mouth daily, Cymbalta 60 mg one tablet by mouth daily, Eliquis 2.5 mg tablet one by mouth two times per day, Lasix 10 mg one tablet by mouth three times per week, metoprolol 50 mg one tablet by mouth daily, Imdur 30 mg one tablet by mouth daily, primidone 50 mg one tablet three times per day, Ranexa 500 mg one tablet by mouth daily, Vitamin B1 one tablet by mouth daily and Vitamin B12 one tablet by mouth five days per week.

Observation on 10/31/24 at 8:20 A.M., with LPN #204 revealed LPN #204 prepared the medications for Resident #30. The observation revealed LPN #204 place the acidophilus, Zyloprim, Buspar, cetirizine, Plavix, cranberry capsule, Cymbalta, Eliquis, Imdur, primidone, Ranexa, Vitamin B1 and Vitamin B12 into her bare hands after removal from the medication cards. LPN #204 placed the medications into a medication cup and administered the medications to Resident #30. The observation revealed LPN #204 did not perform hand hygiene prior to or after medication administration. The observation also revealed LPN #204 obtained Resident #30's finger stick blood sugar (FSBS) level by using a glucometer. LPN #204 was observed wiping the glucometer with an alcohol pad after she obtained Resident #30's FSBS.

Interview on 10/31/24 at 8:30 A.M., with LPN #204 confirmed she did not perform hand hygiene prior to or after administering medications to Resident #30 and #31. LPN #204 also confirmed she placed the medications for Resident #30 and #31 into her bare hands prior to placing them into a medication cup and administering the medications to the residents. LPN #204 also confirmed she used an alcohol pad to clean the glucometer after she obtained Resident #30's FSBS.

Review of facility provided list of residents revealed the facility identified eight residents (#04, #10, #14, #15, #19, #24, #30, and #32) who have staff check their fingerstick blood sugar levels with the glucometer. The facility census was 41.

Review of the undated policy titled, Medication Administration

Based on employee file reviews, staff interview, and policy review, the facility failed to ensure tuberculosis (TB) testing was completed upon hire. This affected one (#208) employee out of the three new employee files reviewed. This had the potential to affect all 41 residents. The facility census was 41.

Findings include:

Review of the employee file Resident Assistant (RA) #208 revealed a hire date of 05/13/24. Review of the employee file revealed no documentation to support the facility completed the two step TB testing upon hire.

Interview on 10/31/24 at 3:35 P.M., with Director of Nursing (DON) confirmed the employee file for RA #208 did not contain documentation to support the facility completed the two step TB testing upon hire for Resident #208.

Review of the undated policy titled, Tuberculosis Control

Based on observation, staff interview, and resident interview, the facility failed to ensure resident bathroom water temperatures did not exceed 120 degrees Fahrenheit. This affected two (#07 and #11) residents of the three residents reviewed for water temperatures. The facility census was 41.

Findings include:

1. Review of the medical record for Resident #07 revealed an admission date of 06/08/22, with medical diagnoses of hypertension, myocardial infarction, repeated falls, and syncope.

2. Review of the medical record for Resident #11 revealed an admission date of 03/20/24, with medical diagnoses of Parkinson's disease, schizoaffective disorder, chronic respiratory failure, and chronic obstructive pulmonary disease.

Observation and interview on 10/31/24 at 9:40 A.M., with Maintenance Director #202 revealed Maintenance Director #202 turned the hot water on in Resident #11's bathroom and obtained a hot water temperature of 125 degrees Fahrenheit. Interview with Maintenance Director #202 confirmed the hot water temperature in Resident #11's bathroom was 125 degrees Fahrenheit.

Observation and interview on 10/31/24 at 9:49 A.M., with Maintenance Director #202 revealed Maintenance Director #202 turned the hot water on in Resident #07's bathroom and obtained the water temperature with the facility thermometer. The observation revealed the hot water temperature for Resident #07 was 131 degrees Fahrenheit. Interview with Maintenance Director #202 confirmed the hot water temperature in Resident #07's bathroom was 131 degrees Fahrenheit.

Interview with Resident #11 stated her water in her bathroom gets pretty hot but stated she was able to adjust the temperature by turning on the cold water.