Meadow Falls of Finneytown

Based on interview and record review, the facility failed to ensure a newly hired Care Partner (CP) received first aid training within 60 days of hire. This affected one (CP #124) out of two newly hired employees reviewed for first aid training. This had the potential to affect the 46 residents residing in the facility. The facility census was 46.

Findings include:

Review of Care Partner (CP) #124's personnel file revealed CP #124 was hired at the facility on 01/28/25. Further review of CP #124's personnel file revealed CP #124 did not receive first aid training within 60 days of being employed by the facility.

Interview with Business Office Manager (BOM) #125 on 07/08/25 at 4:16 P.M. verified the facility had no documentation that CP #124 received first aid training within 60 days of being employed by the facility.

3. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on 04/05/2025 with diagnoses including Alzheimer's disease, dementia, and cognitive communication deficit.

Review of Resident #22's PSA dated 04/29/2025 revealed Resident #22 was alert and struggled with orientation to person, time, and place. Further review of PSA for Resident #22 indicated Resident #22 did not require assistance with transfers or toileting. Resident #22 required assistance with dressing, and utilized a walker and manual wheelchair as mobility aids. Additional review of Resident #22's PSA indicated need for assistance with managing medications including ordering and coordinating medications between family, health care providers, and pharmacy, as well as staff assistance with taking medication.

Review of Resident #22's Medication Administration Report (MAR) for April 2025 revealed the resident was not given Pravastatin sodium (used to lower cholesterol) 10 mg on 04/05/2025, Ascorbic acid tablet (antioxidant) 500 mg on 04/05/2025, 04/06/2025, 04/07/2025, 04/08/2025, 04/29/2025, and 04/30/2025, Folic acid (vitamin) 800 micrograms (mcg) on 04/05/2025, and 04/06/2025, probiotic daily oral capsule on 04/05/2025, 04/06/2025, and 04/07/2025, Sodium Chloride ophthalmic ointment 5% on 04/05/2025, 04/06/2025, and 04/07/2025, Omeprazole (proton pump inhibitor) 20 mg on 04/05/2025, Docuzen (laxative) 8.6-50 mg on 04/05/2025, 04/06/2025, 04/07/2025, and 04/09/2025, fish oil 800 mcg on 04/05/2025, 04/06/2025, 04/08/2025, 04/28/2025, 04/29/2025, and 04/30/2025, mighty shake (supplement) 6 ounce (oz) on 04/06/2025, and 04/09/2025, Lisinopril (used to treat high blood pressure) 20 mg on 04/05/2025; Magnesium (earth metal) 400 mg on 04/05/2025, Mirtazapine 15 mg on 04/05/2025, Multivitamin one table per day on 04/05/2025, and 04/06/2025; Pramipexole dihydrochloride (used to treat Parkinson's) 0.75 mg on 04/05/2025, Vitamin D3 on 04/05/2025, 04/06/2025, and 04/07/2025; Synthroid (hormone) oral 25 mcg was not administered on 04/15/2025, 04/16/2025, 04/19/2025, and 04/20/2025; Eliquis (anticoagulant) 2.5 mg was not administered on 04/05/2025, and Miralax oral powder (laxative) 17 gram (gm) was not administered on 04/05/2025, and 04/06/2025.

Review of Resident #22's MAR for May 2025 revealed the resident was not given Docuzen 8.6-50 mg on 05/02/2025, 05/03/2025, and 05/08/2025, fish oil 800 mcg on 05/25/2025, and mighty shake 6 oz on 05/18/25.

Review of Resident #22's MAR for June 2025 revealed the resident was not given Ascorbic acid tablet 500 mg on 06/03/2025, 06/22/2025, 06/24/2025, 06/26/2025, and 06/27/2025, occusoft lid scrub original external pad on 06/29/25, folic acid 800 mcg on 06/05/25, probiotic daily oral capsule on 06/05/25, Sodium Chloride ophthalmic ointment 5% on 06/05/25, Omeprazole 20 mg on 06/24/2025, and 06/27/2025, and Tylenol extra strength 500 mg on 06/03/2025.

Review of Resident #22's MAR for July 2025 revealed the resident was not given Pravastatin sodium 10 mg on 07/02/2025, 07/03/2025, 07/05/2025, 07/06/2025, and 07/07/2025, Megestrol acetate (progestins) 40 mg to be administered four times a day was not administered on 07/07/2025, and occusoft lid scrub original external pad on 07/01/2025, 07/02/2025, 07/03/2025, 07/04/2025, 07/05/2025, and 07/06/2025.

Review of the MARs from April 2025 through July 2025 for Resident #22 indicated that these medications were not administered due to the pharmacy not providing the prescribed medication to the facility.

Interview with HWC #127 on 07/08/2025 at 3:44 P.M. confirmed the facility experienced difficulty receiving timely refills of residents' prescribed medications. HWC #127 indicated the facility is engaging with a new pharmacy to start on 07/27/2025 due to medication refill challenges.

Review of the facility's medication policy dated November 2015 revealed all currently ordered medications will be available to residents.

Based on observation and interview, the facility failed to ensure medications in the medication cart were labeled and stored in the proper containers. This affected 23 (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23) out of 46 residents that resided in the facility. The facility census was 46.

Findings include:

Observation of medication cart on the memory care unit on 07/08/25 at 12:07 P.M. revealed there were three loose pills that were different shapes, colors and sizes located in the drawer of the medication cart.

Interview on with Licensed Practical Nurse (LPN) #128 on 07/08/25 at 12:07 P.M. verified there were three loose pills that were different shapes, colors and sizes located in the drawer of the memory care unit medication cart.

Review of the facility's census dated 07/08/25 revealed Resident #01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22 and #23 resided on the memory care unit.

Review of the facility's medication policy dated 03/31/22 revealed all medications should be labeled with necessary information to provide safe medication management and assistance.

Based on interview and record review, the facility failed to implement their tuberculosis control plan for tuberculosis testing of a newly hired employee. This affected one (Care Partner (CP) #124) out of five newly hired employees reviewed for tuberculosis testing. This had the potential to affect 46 out of 46 residents residing in the facility. The facility census was 46.

Findings include:

Review of Care Partner (CP) #124's personnel file revealed CP #124 was hired at the facility on 01/28/25. Further review of CP #124's personnel file revealed CP #124 did not have a two step tuberculosis (TB) skin test completed upon hire.

Interview with Business Office Manager (BOM) #125 on 07/08/25 at 4:16 P.M. verified the facility had no documentation that CP #124 received a two step TB test upon hire.

Review of the facility's TB control plan revised December 2022 revealed all associates will receive a baseline TB screening upon hire using a two step TB skin test.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the facility's call system was in working order. This affected two residents (#08 and #10) out of four residents on the memory care unit whose call lights were tested. The facility census was 46.

Findings Include:

1. Observation of the memory care unit on 07/08/2025 at 9:30 A.M. revealed call system pull cord in Resident #10's room did not activate the call system at the nurses' station when pulled.

Interview with Health and Wellness Coordinator (HWC) #127 on 07/08/2025 at 9:30 A.M. verified the call light in Resident #10's room did not function properly when pulled.

2. Observation on 07/08/2025 at 5:20 P.M. demonstrated that the call system pull cord in the bathroom of Resident #08's room did not activate the call system at the nurses' station when pulled.

Interview with HWC #127 on 07/08/25 at 5:20 P.M. verified the call light in Resident #08's bathroom did not function properly when pulled. HWC #127 indicated functioning call lights should register on the computer at the nurse's station. Once registered at the nurse's station staff should radio each other to communicate resident's need for assistance.

Review of an undated document titled In-house Testing of Nurse Call Systems

Based on interview and record review, the facility failed to provide and obtain written acknowledgements that staff received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program. This affected five (Housekeeper #117, Executive Director (ED) #150, Care Partner (CP) #124, CP #148 and Licensed Practical Nurse (LPN) #109) out of five newly hired employees reviewed for required written acknowledgements. The facility census was 46.

Findings include:

1. Review of Housekeeper #117's personnel file revealed Housekeeper #117 was hired at the facility on 07/17/24. Further review of Housekeeper #117's personnel file revealed no documentation that Housekeeper #117 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

2. Review of Executive Director (ED) #150's personnel file revealed ED #150 was hired at the facility on 07/29/24. Further review of ED #150's personnel file revealed no documentation that ED #150 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

3. Review of Care Partner (CP) #148's personnel file revealed CP #148 was hired at the facility on 01/14/25. Further review of CP #148's personnel file revealed no documentation that CP #148 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

4. Review of CP #124's personnel file revealed CP #124 was hired at the facility on 01/28/25. Further review of CP #124's personnel file revealed no documentation that CP #124 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

5. Review of Licensed Practical Nurse (LPN) #109's personnel file revealed LPN #109 was hired at the facility on 05/01/25. Further review of LPN #109's personnel file revealed no documentation that LPN #109 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

Interview with Business Office Manager (BOM) #125 on 07/08/25 at 3:54 P.M. verified Housekeeper #117, ED #150, CP #124, CP #148 and LPN #109 were not provided and did not sign a written acknowledgement that they received a copy of the addresses and telephone numbers of the county board of health, the county department of human services, the state departments of health and human services, the state and local offices of the department of aging, and the ombudsman program.

Based on record review, review of the facility's Self-Reported Incident (SRI), and staff interview, the facility failed to timely notify the physician and take immediate steps following a resident's x-ray results indicating a fracture of the wrist. This affected one (Resident #11) of three residents reviewed for accidents. The facility census was 42.

Findings include:

Record review for Resident #11 revealed the resident was admitted to the facility on 11/08/22. Diagnoses included Alzheimer's disease and muscle weakness. Review of the service plan and nursing assessment revealed Resident #11 was alert to name only, with severe cognitive impairments.

Review of the nursing notes dated 12/16/23 revealed Resident #11 was found to have a swollen left arm with slight discoloration on this date. The physician was notified and an order was received to obtain an x-ray and contact with the result. All responsible parties were documented as being notified.

Review of the x-ray results dated 12/16/23 revealed Resident #11 had a left wrist fracture. There was no evidence the physician was notified of the x-ray results until 12/29/23.

Review of the facility's SRI control number 242759 revealed an x-ray of the left wrist for Resident #11 was obtained and read as being positive for a left wrist fracture. This was not reported back to the physician or the nurse practitioner until 12/29/23.

Interview with the Executive Director (ED) on 01/11/24 at 2:40 P.M. verified that neither the physician or the nurse practitioner were not notified of Resident #11's left wrist fracture on 12/16/23. The ED verified the results were not relayed until 12/29/23 at which time an orthopedic consult was obtained.

This violation represents non-compliance investigated under Control Number OH00149833.

Based on open and closed medical record review, staff interviews, review of personnel files, review of the facility's Abuse policy, review of the Broda Chair Operations Manual, review of the staffing schedules, and review of the facility's Self-Reported Incident (SRI) and investigation, the facility failed to ensure a resident was free from neglect when Licensed Practical Nurse (LPN) #90, Caregiver #100, and Caregiver #110 failed to provide for the resident's care needs throughout the day including incontinence care and safe positioning in the Broda chair (chair that provides supportive positioning to enhance patient safety while facilitating safe, frequent repositioning throughout the day). This resulted in Real and Present Danger and the potential for serious life-threatening injuries, negative health outcomes, and/or death on 01/06/24 when Resident #50 was found to be completely saturated in urine because of lack of incontinence care and was found lying face down in a pool of her own blood because of her poor positioning in her Broda chair. Resident #50 sustained scattered small amount of subarachnoid hemorrhage (brain bleed) and a laceration to the right scalp requiring sutures. This affected one (Resident #50) of three residents reviewed for neglect and placed an additional two residents (Residents #01 and #08) at potential risk for neglect, as they were total care, utilized Broda chairs daily, and were on the same staff assignment as Resident #50 on 01/06/24. The facility census was 42.

On 01/12/24 at 1:40 P.M., the Executive Director (ED) was notified the Real and Present Danger began on 01/06/24 when Resident #50 was found by staff at approximately 7:20 P.M. with severely visible soiling from lack of incontinence care and laying in a pool of her own blood because of a fall from her Broda chair in her room. Resident #50 was dependent on staff for care needs which included toileting and repositioning. LPN #90, Caregiver #100, and Caregiver #110 worked on 01/06/24 from 7:00 A.M. to 7:00 P.M. and were assigned to provide care to Resident #50. LPN #90, Caregiver #100, and Caregiver #110 did not provide any incontinence care or repositioning to Resident #50 during the entire 12-hour shift. Caregiver #100 stated she brought Resident #50 to her room at 6:45 P.M. and left Resident #50 slightly reclined in her Broda chair in the middle of her room. At 7:20 P.M., Caregiver #100 found Resident #50 lying face down in a pool of her own blood. Resident #50 was left in poor condition and Resident #50's brief, clothing, Hoyer pad, and chuck pad were completely soaked through. Emergency Medical Services (EMS) were called to transport Resident #50 to the local hospital. In the hospital, Resident #50 received sutures for a laceration to her right scalp with a Computed Tomography (CT) scan of the head showing scattered small amount of subarachnoid hemorrhage within the left sylvian fissure and right posterior occipital lobe sulci. The neurotrauma discharge instructions from the hospital stated Resident #50 was diagnosed with a mild/moderate Traumatic Brain Injury.

The Real and Present Danger was abated on 01/15/24, when the facility implemented the following corrective actions:

On 01/06/24 at 7:37 P.M., EMS was called to transport Resident #50 to the local hospital.

On 01/09/24, LPN #90 was terminated as an employee of the facility for not completing care for Resident #50 on 01/06/24. Caregivers #100 and #110 were terminated as employees of the facility on 01/11/24 for not completing care for Resident #50 on 01/06/24.

On 01/10/24, following the facility's investigation into the neglect and fall of Resident #50, it was determined that education on Broda chairs and incontinence care needed to occur for the safety and standard of care for the residents at the facility.

On 01/10/24, the ED and/or designee-initiated education regarding the appropriate use of Broda chairs to all care associates (licensed nurses and caregivers). The education will be provided with the assistance of an outside provider. The training will be completed by 01/15/24. After 01/15/24, all care associates will not be permitted to work until training is completed.

By 01/15/24, the care associates will be educated by the ED and/or designee regarding incontinence care which will include checking and changing residents, and monitoring for care needs. Care associates who have not been trained by 01/15/24 will not be permitted to work until they are trained.

Beginning 01/15/24, training for new staff will be completed by the Health and Area Wellness Director #600 and Wellness Coordinator #700 before working independently. This education will be audited by the ED and/or designee weekly for new hires for four weeks after independent assignments are given.

By 01/15/24, current resident care plans will be audited for accuracy by Health and Area Wellness Director #600 and Wellness Coordinator #700. Personal Service Plans will be revised as needed to meet the needs of the residents. Going forward, residents will be assessed every six months and with a change of condition. This will be the responsibility of Health and Area Wellness Director #600 or Wellness Coordinator #700. Residents with like situations will be monitored for two weeks for proper use of transferring and equipment.

Beginning 01/15/24, the ED and/or designee will complete twice a week random audits of nursing documentation to verify alert charting is being completed for residents who meet the criteria for alert charting. Findings from the audits will be reported to the community's Safety Committee for their review and any additional action steps twice a week for four weeks.

Beginning 01/15/24, incontinence care will be checked daily by Health and Area Wellness Director #600 and/or Wellness Coordinator #700 for verification residents are being routinely checked and changed.

Observations on 01/11/24, 01/12/24, and 01/16/24 revealed residents were being provided routine incontinence care. Residents #01 and #08 were positioned correctly in their Broda chairs. There were no signs of resident neglect.

Although the Real and Present Danger was abated on 01/15/24, the violation continues as the facility is in the process of implementing their corrective action plan and monitoring for on-going compliance.

Findings include:

Closed medical record review revealed Resident #50 was admitted to the facility on 10/18/22. The resident had diagnoses including dementia, chronic kidney disease, anxiety, depression, and cataracts. Resident #50 resided in the memory care unit at the facility.

Review of the care plan dated 11/16/23 revealed Resident #50 had a history of falls, dependent on staff for personal care, chairfast with the use of a Broda chair, and incontinent of bowel and bladder.

Review of the progress note dated 01/06/24 at 7:35 P.M., written by LPN #90, documented Resident #50 was left in poor condition by an unspecified caregiver. Resident #50's brief, clothing, Hoyer pad, and chuck pad were completely soaked through. At 7:37 P.M., LPN #90 documented the resident fell from the Broda chair and was found by an unspecified caregiver (Caregiver #100) on the floor face down in a pool of blood in her bedroom. The resident was transferred to the hospital via EMS with all responsible parties being notified.

Review of the hospital paperwork revealed Resident #50 was admitted to the hospital on 01/06/24. The admission note stated the resident had an unwitnessed fall in the facility with a prolonged down time. Resident #50 received sutures to the laceration on the right scalp with a CT scan of the head showing scattered small amount of subarachnoid hemorrhage within the left sylvian fissure and right posterior occipital lobe sulci. The neurotrauma discharge instructions stated Resident #50 was diagnosed with a mild/moderate Traumatic Brain Injury.

Review of the staff schedules for 01/06/24 revealed LPN #90, Caregiver #100, and Caregiver #110 were scheduled to work for the day shift from 7:00 A.M. to 7:00 P.M. and were assigned to the memory care unit. The daily schedule reflected LPN #90 and Caregiver #110 were the assigned caregivers for Resident #50. Caregiver #100 was assigned to be on hand for two-person assists and other mobility tasks.

Review of the facility SRI revealed on 01/06/24, an investigation was conducted to determine if the caregivers and the nurse on shift attended to Resident #50 during their assigned shift. After completing interviews with LPN #90, Caregivers #100 and #110, they admitted there had been a miscommunication regarding who was assigned to Resident #50 on 01/06/24. This resulted in Resident #50 not being attended to throughout the entire shift. Resident #50 was present at all meals and activities throughout the day, but the checks and changes were not completed as needed.

The summary of the SRI revealed on 01/06/24, Resident #50 was in the dining room of the memory care unit, and was taken back to her apartment in her Broda chair at 6:45 P.M. On 01/06/24 at 7:20 P.M., Caregiver #100 yelled for a nurse to come to Resident #50's room as she was on the floor bleeding. Resident #50 was found lying face down in front of her Broda chair. All parties were notified, and Resident #50 was transported to the hospital and admitted with multiple lacerations and a small brain bleed.

Review of the facility's interview with LPN #90 on 01/08/24 revealed Resident #50 was last seen in the dining room between 6:00 and 6:30 P.M. LPN #90 had provided Resident #50 with prescribed Ativan (treats anxiety) as she was agitated at the time.

Review of the facility's interview with Caregiver #100 on 01/08/24 revealed Resident #50 was up in her Broda chair at 7:00 A.M. on 01/06/24. Resident #50 stayed up all day and was seen by staff in the common area and the dining room. Caregiver #100 stated she had taken Resident #50 to her room around 6:45 P.M. She stated there was another resident in Resident #50's bed so she removed that resident from the room while leaving Resident #50 slightly reclined in her Broda chair in the middle of her room.

Review of the facility's interview with Caregiver #110 on 01/08/24 revealed Resident #50 was on her assignment for the day (01/06/24), but she did not provide any type of care as she thought she had switched assignments with Caregiver #100.

Review of the personnel files revealed LPN #90 was terminated from employment on 01/09/24 and Caregivers #100 and #110 were terminated from employment on 01/11/24, following the results of the SRI investigation. The incident descriptions stated LPN #90 and Caregivers #100 and #110 were responsible for care of Resident #50, with the care not being completed.

Interview with the ED on 01/12/24 at 2:45 P.M. verified Caregivers #100 and #110 and LPN #90 did not provide appropriate care and services to Resident #50 on 01/06/24. The ED verified Resident #50 had not been provided with incontinence care for the duration of the 7:00 A.M. through 7:00 P.M. shift and was left in her chair the entire day. The ED also verified Resident #50 was not left in a safe situation in her room while seated in the Broda chair. All these factors had contributed to the resident's hospitalization and subsequent injuries.

Interviews with LPN #90, Caregiver #100, and Caregiver #110 were attempted during the survey with no answer.

Review of the facility's policy titled Abuse Policy, dated 10/2001, revealed the facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is most likely to occur. This policy defines neglect as failing to provide a resident with any treatment, care, goods, or service necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident.

Review of the Broda Chair Operations Manual dated 10/16/18 revealed the positioning of the chair should be determined by the caregiver responsible for seating which includes ensuring the chair is tilted sufficiently to prevent the resident from falling forward off the chair.

This was an incidental finding discovered during the course of this complaint investigation.

Based on review of resident medical records, staff and resident interviews, and review of facilities policy for medication administration, the facility failed to administer medication in accordance with physician orders. This affected one (Resident #11) of four residents reviewed for medication administration. The facility census was 55.

Findings include:

Review of the medical record for Resident #11 revealed an admission date of 06/30/21 with diagnoses that included: osteoarthritis, convulsions, polyneuropathy, macular degeneration, breast cancer, thrombocytopenia, ischemic cardiomyopathy, bilateral knee joint replacements, artificial left eye, celiac disease, hyperlipidemia, systolic congestive heart failure, vascular dementia with behavioral disturbances, cirrhosis of the liver, chronic kidney disease, recurrent depressive disorder, Diabetes Type 2, and cognitive communication deficit.

Review of June 2023 physician orders for Resident #11 revealed orders for Novolog (Insulin Aspart) 40 units subcutaneously before meals plus additional units per sliding scale before every meal, three times daily.

Review of the June 2023 Medication Administration Record (MAR) for Resident #11, revealed insulin Aspart was scheduled to be administered at 7:00 A.M., 11:00 A.M., and at 4:00 P.M. The sliding scale was scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Further review of the MAR revealed there was documentation for the doses of insulin administered late that were schedule for morning at breakfast time which included on 06/10/23 insulin was administered at 2:34 P.M., on 06/12/23 at 12:14 P.M., 06/13/23 at 10:33 A.M., and on 06/15/23 at 11:54 A.M.

Interview on 06/15/23 at 12:10 P.M. with Resident #10 revealed the resident recalled wife (Resident #11) did not receive breakfast dose of insulin before breakfast several times in the past week, but the resident was unable to recall specific dates.

Interview on 06/15/23 at 3:40 P.M. with the Regional Registered Nurse #44 verified Resident #11's morning dose of insulin was administered late on 06/10/23, 06/12/23, 06/13/23, and on 06/15/23.

Review of a policy titled, Administration of Medication last revised on 03/31/23, revealed medications shall be ordered by the attending physician and administered by a licensed nurse in accordance with applicable regulations and standards of practice.

This violation represents non-compliance investigated under Complaint Number OH00143333 and OH00143789.

Based on resident and staff interviews, observation, and review of facility policies, the facility failed to administer medication while providing privacy and protecting the modesty of a resident. This affected one (Resident #11) of four residents reviewed for medication administration. The facility census was 55.

Findings include:

Review of the medical record for Resident #11 revealed an admission date of 06/30/21 with diagnoses that included: osteoarthritis, convulsions, polyneuropathy, macular degeneration, breast cancer, thrombocytopenia, ischemic cardiomyopathy, bilateral knee joint replacements, artificial left eye, Celiac Disease, hyperlipidemia, systolic congestive heart failure, vascular dementia with behavioral disturbances, cirrhosis of the liver, chronic kidney disease, recurrent depressive disorder, Diabetes Type 2, and cognitive communication deficit.

Review of June 2023 physician orders for Resident #11 revealed orders for Novolog (Insulin Aspart) 40 units subcutaneously plus additional units per sliding scale before every meal, three times daily.

Observation on 06/15/23 at 9:11 A.M., revealed Licensed Practical Nurse (LPN) #39 administered insulin to Resident #11 out in the common hallway in the abdomen, LPN #39 apologized and stated she knew better, she then took Resident #10 to room for second injection.

Interview on 06/15/23 at 9:11 A.M. with Regional Registered Nurse #44 verified LPN #39 did not provide privacy to Resident #11 during insulin administration.

Interview on 6/15/23 at 12:10 P.M. with Resident #11 revealed the resident recalled wife ( Resident #11) receiving insulin injections being given in the hallway of the 2nd floor, but the resident was unable to recall specific dates.

Review of facilities policy titled, Administration of Medication with revision date of 03/31/22, revealed medications shall be ordered by the attending physician and administered by a licensed nurse in accordance with applicable regulations and standards of practice.

Review of facilities policy titled, Dignity with revision date of October 2022 revealed associates should promote, maintain, and protect resident privacy including bodily privacy during assistance with personal care and procedures.

This violation represents non-compliance with Complaint Number OH00143789.

Based on review of resident medical records, billing records, and staff interview, the facility failed to reasonably respond to family request of billing and care plan assessment to be corrected for a resident that was made in February 2023 and had not been adjusted and corrected until 06/22/23 resulting in concerns not being reasonably responded to in a timely manner. This affected one (Resident #13) of four residents reviewed for billing and assessments. The facility census was 55.

Findings include:

Review of the medical record for Resident #13 revealed an admission date of 01/12/23 with diagnoses that included Adjustment Disorder, hyperlipidemia, atrial fibrillation, Raynaud's Syndrome, hypothyroidism, Gastroesophageal Reflux, Vitamin B deficiency, Vitamin D deficiency, osteoarthritis, compression fractures- thoracic region, and cognitive function and awareness disorder.

Review of care plan assessment dated 01/12/13 for Resident #13 revealed she required staff assistance with activities of daily living including showers and laundry.

On 06/15/23, Resident #13's family ( daughter and son) was in facility and had requested for the Ohio Department of Health Surveyor and the Ombudsman to sit in on their care conference with the facility.

Observation of the care conference on 06/15/23 at 2:00 P.M. with Resident #13, family of resident, and facility staff revealed the family stated that the resident is independent with supervision for all activities of daily living (ADL), Resident #13 is frequently incontinent of urine and toilets herself and wore a brief. Resident #13's daughter provides showers and assists with laundry. Resident #13's family had concerns with extra care charges for Resident #13 that she is not receiving and had asked for them to be addressed and corrected in February 2023 and were not corrected at the time of the investigation.

Review of the billing record with Administrator revealed that the corrections to Resident #13's chart had not been made by the time of investigation and he had them corrected on 06/15/23 and would reimburse the family of Resident #13 for charges not rendered.

This violation represents non-compliance investigated under Complaint Number OH00143739.