Putnam Heritage

Based on observation, staff interview, and policy review, the facility failed to store medication safely. This deficient practice had the potential to affect two residents (Resident #42 and Resident #52) identified as cognitively impaired and independently mobile. The facility identified there were 17 residents who were cognitively impaired and independently mobile. The facility census is 33.

Findings Include:

Observation on 05/20/26 at 7:51 A.M. revealed two unattended medication carts in dining area, unlocked, and with a drawer ajar. There were two residents present, one eating and one getting up and ambulating with a walker past the medication carts.

Observation on 05/20/26 at 7:52 A.M. Licensed Practical Nurse (LPN) #1 entered the dining area and immediately left to get the Director of Nursing.

Interview on 05/20/26 at 7:53 A.M. with LPN #1 confirmed both medication carts were unlocked, and it was demonstrated that one of the drawers could not be shut at all and that it bounced back open.

Interview on 05/20/26 at 7:53 A.M. with the Director of Nursing confirmed the carts were not locked and that one drawer would not shut. The Director of Nursing verified Resident #42 and Resident #52 were in the area of the unlocked medication carts and were cognitively impaired and independently mobile.

Review of the undated policy named, Putnam Heritage Medication Storage

Based on staff interview and review of the Resident Funds Authorization Forms (RFAF), the facility failed to ensure a resident or resident representative signed the RFAF. This affected three residents (#16, #23, and #26) of four reviewed for resident funds. Additionally, the facility failed to ensure RFAF were witnessed by non-facility staff. This affected four (#16, #23, #26, and #34) of four records reviewed for resident funds. The facility census was 34.

Findings include:

1. Review of the medical record for Resident #16 revealed an admission date of 05/07/25.

Review of the RFAF for Resident #16 revealed a resident account was opened on 09/17/25. Further review of the RFAF for Resident #16 revealed the facility Administrator signed the document as a witness. The document was not signed by the resident or resident representative.

Interview on 02/02/26 at 12:50 P.M. with the Administrator verified Resident #16's RFAF was not signed by the resident or the resident representative. Further interview with the Administrator confirmed she signed the document as the witness.

2. Review of the medical record for Resident #23 revealed an admission date of 05/16/25.

Review of the RFAF for Resident #23 revealed a resident account was opened on 11/14/25. Further review of the RFAF for Resident #23 revealed the Administrator signed the document as a witness. The authorization was not signed by the resident or the resident's representative.

Interview on 02/02/26 at 12:50 P.M. with the Administrator verified Resident #23's RFAF was not signed by the resident or the resident representative. Further interview with the Administrator confirmed she signed the document as the witness.

3. Review of the medical record for Resident # 26 revealed an admission date of 05/23/24.

Review of the RFAF for Resident #26 revealed a resident account was opened on 10/16/25. Further review of the RFAF for Resident #26 revealed the Administrator signed the document as a witness. The authorization was not signed by the resident or the resident's representative.

Interview on 02/02/26 at 12:50 P.M. with the Administrator verified Resident #26's RFAF was not signed by the resident or the resident representative. Further interview with the Administrator confirmed she signed the document as the witness.

4. Review of the medical record for Resident #34 revealed an admission date of 06/06/25.

Review of the RFAF for Resident #34 revealed a resident account was opened on 08/21/25. Further review of the RFAF revealed the document was signed by the resident and witnessed by the Administrator.

Interview on 02/02/26 at 12:50 P.M. with the Administrator verified she witnessed Resident #34's RFAF.

Based on staff interview and review of resident funds records, the facility failed to ensure resident funds were in an interest bearing account. This affected four (#16, #23, #26, and #34) of four residents reviewed for resident accounts. The facility census was 34.

Findings include:

1. Review of Resident #16's medical record revealed an admission date of 05/07/25.

Review of the Resident Fund Log for Resident #16 revealed an opening account balance of $10.00 on 08/07/25. Further review of the Resident Fund Log revealed several transactions with deposits and withdrawals and a total balance as of 01/08/26 of $47.00.

2. Review of the medical record for Resident #23 revealed an admission date of 05/16/25.

Review of the Resident Fund Log for Resident #23 revealed an opening account balance of $20.00 on 11/13/25. Further review of the Resident Fund Log revealed there were not other transactions and the current balance was $20.00.

3. Review of the medical record for Resident #26 revealed an admission date of 05/23/24.

Review of the Resident Fund Log for Resident #26 revealed an opening account balance of $1.00 on 10/16/25. Further review of the Resident Fund Log revealed several transactions with deposits and withdrawals and a total balance as of 01/26/26 of $30.98.

4. Review of the medical record for Resident #34 revealed an admission date of 06/06/25.

Review of the Resident Fund Log for Resident #34 revealed an opening account balance of $1,700.00 on 08/21/25. Further review of the Resident Fund Log revealed several transactions of withdrawals and a total balance as of 01/02/26 of $700.00. The account for Resident #34 was closed on 02/02/26 with a balance of zero.

Interview on 02/02/26 at 12:50 P.M. with the Administrator verified Resident #16, Resident #23, Resident #26, and Resident #34 had resident fund accounts at the facility that were not in interest bearing accounts. The Administrator stated she maintained the residents' funds in a safe located in her office and maintained a log of deposits and withdrawals. The Administrator further stated there were no bank statements or other accounting that was sent to the residents or the resident representatives.

Based on review of personnel files, review of staff schedules, and staff interview, the facility failed to ensure resident care assistants (RCAs) had required first aid training. This had the potential to affect all 31 residents residing in the facility. The facility census was 31.

Findings include:

1. Review of the personnel file for RCA #162 revealed a hire date of 10/02/24. Review of the training documentation revealed RCA #162 did not have current first aid training.

Review of the staffing schedule revealed RCA #162 worked on 02/01/25, 02/02/25, and 02/20/25 from 6:00 A.M. to 2:00 P.M.

2. Review of the personnel file for RCA #156 revealed a hire date of 10/03/24. Review of the training documentation revealed RCA #156 did not have current first aid training.

Review of the staffing schedule revealed RCA #156 worked on 02/04/25, 02/07/25, and 02/19/25 from 6:00 A.M. to 2:00 P.M.

3. Review of the personnel file for RCA #240 revealed a hire date of 09/30/24. Review of the training documentation revealed RCA #240 did not have current first aid training.

Review of the staff schedule revealed RCA #240 worked on 02/03/25, 02/09/25, and 02/19/25 from 2:00 P.M. to 10:00 P.M.

Interview on 02/19/25 at 1:12 P.M. with the Administrator verified RCA #162, RCA #156, and RCA #240 did not have completed first aid training within 60 days of hire and were currently working in the facility.

This is a violation is a recite to the complaint survey completed 01/22/24.

Based on review of personnel files, review of staffing schedules, and staff interview, the facility failed to ensure resident care assistants (RCAs) received skills training or continuing education taught by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN prior to providing personal care services without supervision. This had the potential to affect all 31 residents residing. The facility census was 31.

Findings include:

1. Review of the personnel file for RCA #162 revealed a hire date of 10/02/24. Further review of the personnel file revealed no documentation RCA #162 completed skills training with an RN or LPN under the direction of an RN prior to providing resident care.

Review of the staffing schedule revealed RCA #162 worked on 02/01/25, 02/02/25, and 02/20/25 from 6:00 A.M. to 2:00 P.M.

2. Review of the personnel file for RCA #156 revealed a hire date of 10/03/24. Further review of the personnel file revealed no documentation RCA #156 completed skills training with an RN or LPN under the direction of an RN prior to providing resident care.

Review of the staffing schedule revealed RCA #156 worked on 02/04/25, 02/07/25, and 02/19/25 from 6:00 A.M. to 2:00 P.M.

3. Review of the personnel file for RCA #240 revealed a hire date of 09/30/24. Further review of the personnel file revealed no documentation RCA #240 completed skills training with an RN or LPN under the direction of an RN prior to providing resident care.

Review of the staff schedule revealed RCA #240 worked on 02/03/25, 02/09/25, and 02/19/25 from 2:00 P.M. to 10:00 P.M.

Interview on 02/20/25 at 8:01 A.M. with the Director of Nursing (DON) confirmed RCA #162, RCA #156, and RCA #240 had not completed a skills training with an RN or LPN under the direction of an RN prior to providing resident care. The DON revealed the RCAs train the newly hired RCAs and an LPN completes the initial orientation.

Interview on 02/20/25 at 10:07 A.M. with the Administrator revealed there were no RNs working at the facility.

Based on medical record review and staff interview, the facility failed to maintain a record of resident heights and weights as part of the initial assessment. This affected five (#17, #12, #19, #28, and #13) of five residents reviewed for assessments. The facility census was 31.

Findings include:

1. Record review of Resident #17 revealed an admission date of 05/30/23. Diagnoses include anemia, hypertension, heart failure, hyperglycemia. Review of Resident #17's chart revealed no evidence of height or weight maintained and monitored by the facility.

2. Review of Resident #12's medical record revealed an admission date of 12/06/22. Diagnoses included type II diabetes mellitus, hyperlipidemia, major depressive disorder, and fibromyalgia. Review of Resident #12's medical record revealed no evidence of a height or weight obtained since admission.

3. Review of Resident #19's medical record revealed an admission date of 10/25/24. Diagnoses include hyperlipidemia, epilepsy, hypertension, and anxiety disorder. Review of Resident #19's medical record revealed no evidence of a height or weight obtained since admission.

4. Review of Resident #28's medical record revealed an admission date of 09/05/24. Diagnoses include major depressive disorder, anxiety, and hypertension. Review of Resident #28's medical record revealed no evidence of a height or weight obtained since admission.

5. Review of Resident #13's medical record revealed an admission date of 12/06/22. Diagnoses include anxiety, autism, hypertension, myocardial infarction, and congestive heart failure. Review of Resident #13's medical record revealed no evidence of a height or weight obtained since admission.

Interview on 02/20/25 at 8:03 A.M. with the Director of Nursing (DON) revealed the facility did not record the height and weight of residents unless specified by a doctor's order and confirmed Resident #17, Resident #12, Resident #19, Resident #28, and Resident #13 did not have documented heights and weights in their medical records.

Based on observation, staff interview, and policy review, the facility failed to ensure food items were labeled and dated in a manner to prevent spoilage, and failed to ensure proper sanitation in the dish washing process. This had the potential to affect all 31 residents residing in the facility. The census was 31.

Findings include:

Observation of the kitchen dry storage area on 02/19/25 at 11:28 A.M. revealed two bottles of syrup which were opened and not dated. One bottle of syrup was approximately three-fourths used and the other bottle of syrup was approximately one-third used. Further observation revealed a container of potato pearls that were opened and not dated. Additionally, there was an unlabeled half-consumed bottle of water on the dry storage shelf.

Observation of the walk-in refrigerator on 02/19/25 at 11:31 A.M. revealed a bag of raw chicken that was opened and not dated along with a bag of hotdogs were opened and not dated.

Interview on 02/19/25 at 11:32 A.M. with Dietary Manager (DM) #107 verified the two bottles of syrup, potato pearls, raw chicken, and the hotdogs were opened and not dated. DM #107 verified the water bottle was a staff member's water bottle and removed it from the shelf.

Observation and interview during review of the dry food storage closet on 02/19/25 at 11:34 A.M. with DM #107 revealed a can of baked beans with a dent near the top of the can and a can of sweet potatoes with a dent on the middle of the can on the shelves. DM #107 verified the dents to the cans and removed the cans from the shelves.

Observation and interview on 02/19/25 at 11:42 A.M. revealed the three-compartment sink in use for dish sanitation. Further observation on 02/19/25 at 11:48 A.M. revealed DM #107 tested the sanitizer level in the sink and no sanitizer registered on the testing strip. Interview with DM #107 verified the sanitation level to be ineffective at the time of discovery.

Interview on 02/19/25 at 11:50 A.M. with Dietary Staff #70 verified the three-compartment sink was used instead of the dishwasher.

Review of the undated policy titled, Storage of Food in Refrigeration

Based on review of fire drill reports and staff interview, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the facility in at least two fire drills a year on each shift as required. This had the potential to affect all 31 residents residing in the facility. The facility census was 31.

Findings include:

Review of the facility's fire drill reports for the past year revealed third shift fire drills were completed on 05/24/24 and 08/25/24. There was no evidence residents were evacuated during these third shift fire drills.

Interview on 02/20/25 at 11:20 A.M. with the Administrator verified no residents were evacuated during third shift fire drills during the last year.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure No smoking signs were posted in the required areas of the facility. This directly affected one (#25) of one residents who used oxygen and one (#28) of one residents who smoked with potential to affect all 31 residents residing in the facility. The facility census was 31.

Findings include:

Review of Resident #25's record revealed an admission date of 05/01/23. Diagnoses include hyperlipidemia, anxiety disorder, chronic obstructive pulmonary disease, and chronic kidney disease.

Review of Resident #25's physician orders revealed an order dated 10/13/23 for oxygen at two liters continuous with instructions to adjust to keep saturation rates between 90 and 95 percent (%) as needed.

Observation on 02/19/25 from 8:12 A.M. to 8:36 A.M. revealed there were no No smoking signs posted in the facility. Further observation on 02/19/25 at 12:53 P.M. revealed there was not a No smoking sign posted on Resident #25's who used oxygen.

Interview on 02/19/25 at 12:55 P.M. with Resident Care Assistant (RCA) #152 verified a No smoking sign was not posted on Resident #25's door or in the required areas.

Review of the policy titled, Oxygen Administration dated October 2010, revealed equipment and supplies needed for oxygen use included a No smoking/oxygen in use sign to be placed on the outside of the door and over the resident's bed.

Interview with Licensed Practical Nurse (LPN) #48 on 02/20/25 at 11:18 A.M. verified there were no No smoking signs in the facility.

Based on observation, staff interview, and review of policy, the facility failed to ensure chemicals were stored in a safe and secure manner. This had the potential to affect four (#3, #22, #26, #19) of four residents who the facility identified as cognitively impaired and independently mobile. The facility census was 31.

Findings include:

1. Observation on 02/19/25 at 8:15 A.M. revealed the laundry room door across from Resident #2's room to be unlocked. Observed in the laundry room were three bottles of chemicals including a bottle of clean up disinfectant spray with a label that indicated to keep out of the reach of children, a half-full spray bottle of home bug spray with a label that indicated to keep out of the reach of children, and a three-fourths full bottle of concentrated laundry detergent with a label that indicated to keep out of the reach of children.

Interview on 02/19/25 at 8:24 A.M. with Housekeeping and Operations Manager (HOM) #103 verified the laundry room door across from Resident #2's room was unlocked and verified the chemicals inside the room were easily accessible.

2. Observation on 02/19/25 at 8:28 A.M. revealed antibacterial hand wash liquid and disinfectant wipes to be stored in a unlocked cabinet in the kitchenette across from Resident #4's room. Both bottles had labels that indicated to keep out of the reach of children.

Interview on 02/19/25 at 8:30 A.M. with HOM #103 verified the chemicals that were stored in the unlocked cabinet in the kitchenette across from Resident #4's room.

3. Observation on 02/19/25 at 8:32 A.M. revealed a bottle of disinfectant spray and antibacterial hand wash was revealed to be in a unlocked cabinet under the sink in an unlocked staff station. Review of the labels on the disinfectant spray and the antibacterial hand wash revealed to keep out of the reach of children.

Interview on 02/19/25 at 8:35 A.M. with Housekeeper #90 verified the staff station was unlocked and chemicals were stored in a unlocked cabinet under the sink.

4. Observation on 02/19/25 at 8:58 A.M. revealed food service surface sanitizer in an unlocked cabinet by the kitchen door in the main dining room. The label on the food service surface sanitizer revealed to keep out of the reach of children.

Interview on 02/19/25 at 9:00 A.M. with the Director of Nursing (DON) verified the food service surface sanitizer stored in an unlocked cabinet by the kitchen door of the main dining room.

Review of the undated facility policy for chemical and hazardous storage revealed all chemicals and hazardous materials are to be stored in a safe, locked area in the interior of the facility where only staff have access to these materials.

Based on record review, resident interview, staff interview, and review of the policy, the facility failed to administer medications per physician order to a resident. This affected one (Resident #1) of four residents reviewed for medication administration. The current census is 45

Findings include:

Record review of Resident #1 revealed the resident was admitted to the facility on 12/06/22. Diagnoses for Resident #1 included depression, diabetes type two, anxiety, seizures, and fibromyalgia. Review of Resident #1's service plan dated 01/2024 revealed the staff may leave medication with the resident after 10:00 P.M. for self-administration as needed. Resident #1 was capable of administering medications by herself with minimal assistance.

Review of Resident #1's physician orders revealed an order to discontinue Fluoxetine (antidepressant) 20 milligrams (mg) on 03/13/24. Further review revealed an order dated 03/19/24 for Fluoxetine 40 mg once a day in the morning.

Review of Resident #1's Medication Administration Record (MAR) dated 03/2024 revealed no documentation any anti-depressant medication, including the Fluoxetine, was administered from 03/13/24 to 03/20/24, indicating the medication was not administered. Further review revealed the resident received Fluoxetine 40 mg daily per order from 03/20/24 to 03/26/24.

Interview on 03/27/24 at 11:20 A.M. with Resident #1 revealed on 03/13/24, her primary physician increased her Fluoxetine from 20 mg to 40 mg a day due to her increased symptoms of depression. Resident #1 stated she notified the Administrator who also administers medications to Resident #1. Resident #1 stated it wasn't until 03/20/24 when she received the correct dosage of her Fluoxetine. Resident #1 stated she continued to ask the nurses and the Administrator about receiving her Fluoxetine 40 mg and was told the pharmacy had not supplied the new increased dosage pills to the facility.

Interview on 03/27/24 at 11:30 A.M. with Licensed Practical Nurse (LPN) #100 and the Administrator revealed on 03/13/24, Resident #1's physician increased her Fluoxetine from 20 mg a day to 40 mg and the order was sent from the physician to the facility's pharmacy. Per LPN #200, when the order came through the system, the staff nurse on duty did not acknowledge the order. LPN #200 stated Resident #1 continued to receive Fluoxetine 20 mg daily from 03/14/24 to 03/20/24 per the original order that had been discontinued on 03/13/24. LPN #200 verified there was no documentation stating the resident received the Fluoxetine 20 mg in the medical records. LPN #100 verified the staff administering the medication was not documenting the administration of the Fluoxetine medication. Per the Administrator, Resident #1's Fluoxetine 40 mg pills did not arrive to the facility from the pharmacy until 03/20/24. The Administrator verified Resident #1 had been reporting to the Administrator her physician had increased the medication from 20 mg to 40 mg on 03/13/24 and she was not receiving the appropriate dosage. The Administrator and LPN #100 verified the medication error was not recorded in the medication error log and not reported to Resident #1's physician.

Review of the undated policy titled, Prescription Medication Orders

Based on observation, medical record review, staff interview, facility concern documentation review, and medication administration policy review, the facility failed to ensure residents consumed medications at the time of administration. This affected four (#4, #5, #6, #7) of six sampled residents reviewed for medication administration in a facility census of 45. Findings include: 1. Review of the medical record of Resident #7 revealed an admission date of 12/06/22, with the diagnoses including: anemia, vitamin d disorder, hypomagnesemia, hypokalemia, major depression, acute embolism and thrombosis of deep veins right upper extremity, polyathritis, hydronephrosis, and chronic kidney disease. According to annual assessment dated 10/13/23, Resident #7 was assessed to require assistance with activities of daily living including bladder incontinence, independent with mobility utilizing walker. The most current medication administration assessment dated 12/19/22 Resident #7 requires staff to administer medications. Observations on 02/26/24 at 9:42 A.M., inside Resident #7's room revealed the resident in bed. Various medications including capsules were discovered contained inside a medication cup at the bedside. Interview on 02/26/24 at 10: 12 A.M., with Licensed Practical Nurse (LPN) #200 verified she placed the medications at the residents bedside earlier in the morning. LPN #200 was unaware if Resident #7 was independent with medication administration. 2. Review of the medical record of Resident #6 revealed an admission date of 12/06/22, with the diagnoses including: hypokalemia, dementia, mild neurocognitive disorder with behavior disturbance, depressive disorder, hypertension, and visual hallucinations. According to annual assessment dated 10/26/23 Resident #6 was assessed as independent with activities of daily living, independent with mobility utilizing walker and requires staff to administer medications. Observation on 02/26/24 at 9:47 A.M., revealed various medications contained in a medication cup located at Resident #6 bedside. Review of facility concern documentation revealed a family complaint Resident #6 was not taking medications. Interview on 02/26/24 at 10: 12 A.M., with Licensed Practical Nurse (LPN) #200 verified she placed the medications at the residents bedside earlier in the morning. LPN #200 was unaware if Resident #7 was independent with medication administration. 3. Review of the medical record of Resident #4 revealed an admission date of 12/06/22, with diagnoses including: hypothyroidism, fluid overload, peripheral neuropathy, traumatic subdural hemorrhage, hypertension, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, and urinary incontinence. According to the annual assessment dated 12/17/23 Resident #4 was assessed as independent with activities of daily living, and mobility. The assessment also indicated staff was to provide medication administration. Observation on 02/23/24 at 11:17 A.M., revealed the administrator to obtained medications including depakote 125 milligrams (mg), tramadol 50 mg, and sucrafate suspension 10 milliliters equaling one gram. The Administrator proceeded to Resident #4 room and handed the medications to Resident #4. The Administrator assisted the resident with consuming the sucrafate suspension and departed the room without verifying Resident #4 consumed the depakote 125 milligrams (mg), or tramadol 50 mg. Interview on 02/23/24 at 11:19 A.M., with the Administrator confirmed Resident #4 was not independent with medication administration and left the room before confirming the resident consumed the medications. 4. Review of the medical record of Resident #5 revealed an admission of 12/06/22, with diagnoses including: hypothyroidism, dementia, hypertension, atrial flutter, overactive bladder, and bradycardia. According to the annual assessment dated 12/17/23 Resident #5 was assessed as independent with activities of daily living, utilizes a walker for ambulation, medication management with staff to administer medications. Observation on 02/27/24 at 7:25 A.M., revealed Resident #5 standing inside the entrance of her room. The resident was confused and holding two medication cups containing various medication tablets. Interview with the resident at the time revealed she was unaware if she was instructed to take the medications this morning or if she had missed medications from the previous day. Interview on 02/27/24 at 7:30 A.M., with the Administrator confirmed medications are not to be left at the resident bedside and observed to be consumed at the time of administration. Review of the policy titled Preparation and General Guidelines for Medication AdministrationBased on observation, medical record review, staff interview, facility concern documentation review, and medication administration policy review, the facility failed to ensure residents consumed medications at the time of administration. This affected four (#4, #5, #6, #7) of six sampled residents reviewed for medication administration in a facility census of 45.

Findings include:

1. Review of the medical record of Resident #7 revealed an admission date of 12/06/22, with the diagnoses including: anemia, vitamin d disorder, hypomagnesemia, hypokalemia, major depression, acute embolism and thrombosis of deep veins right upper extremity, polyathritis, hydronephrosis, and chronic kidney disease. According to annual assessment dated 10/13/23, Resident #7 was assessed to require assistance with activities of daily living including bladder incontinence, independent with mobility utilizing walker. The most current medication administration assessment dated 12/19/22 Resident #7 requires staff to administer medications.

Observations on 02/26/24 at 9:42 A.M., inside Resident #7's room revealed the resident in bed. Various medications including capsules were discovered contained inside a medication cup at the bedside.

Interview on 02/26/24 at 10: 12 A.M., with Licensed Practical Nurse (LPN) #200 verified she placed the medications at the residents bedside earlier in the morning. LPN #200 was unaware if Resident #7 was independent with medication administration.

2. Review of the medical record of Resident #6 revealed an admission date of 12/06/22, with the diagnoses including: hypokalemia, dementia, mild neurocognitive disorder with behavior disturbance, depressive disorder, hypertension, and visual hallucinations. According to annual assessment dated 10/26/23 Resident #6 was assessed as independent with activities of daily living, independent with mobility utilizing walker and requires staff to administer medications.

Observation on 02/26/24 at 9:47 A.M., revealed various medications contained in a medication cup located at Resident #6 bedside.

Review of facility concern documentation revealed a family complaint Resident #6 was not taking medications.

Interview on 02/26/24 at 10: 12 A.M., with Licensed Practical Nurse (LPN) #200 verified she placed the medications at the residents bedside earlier in the morning. LPN #200 was unaware if Resident #7 was independent with medication administration.

3. Review of the medical record of Resident #4 revealed an admission date of 12/06/22, with diagnoses including: hypothyroidism, fluid overload, peripheral neuropathy, traumatic subdural hemorrhage, hypertension, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, and urinary incontinence. According to the annual assessment dated 12/17/23 Resident #4 was assessed as independent with activities of daily living, and mobility. The assessment also indicated staff was to provide medication administration.

Observation on 02/23/24 at 11:17 A.M., revealed the administrator to obtained medications including depakote 125 milligrams (mg), tramadol 50 mg, and sucrafate suspension 10 milliliters equaling one gram. The Administrator proceeded to Resident #4 room and handed the medications to Resident #4. The Administrator assisted the resident with consuming the sucrafate suspension and departed the room without verifying Resident #4 consumed the depakote 125 milligrams (mg), or tramadol 50 mg.

Interview on 02/23/24 at 11:19 A.M., with the Administrator confirmed Resident #4 was not independent with medication administration and left the room before confirming the resident consumed the medications.

4. Review of the medical record of Resident #5 revealed an admission of 12/06/22, with diagnoses including: hypothyroidism, dementia, hypertension, atrial flutter, overactive bladder, and bradycardia. According to the annual assessment dated 12/17/23 Resident #5 was assessed as independent with activities of daily living, utilizes a walker for ambulation, medication management with staff to administer medications.

Observation on 02/27/24 at 7:25 A.M., revealed Resident #5 standing inside the entrance of her room. The resident was confused and holding two medication cups containing various medication tablets. Interview with the resident at the time revealed she was unaware if she was instructed to take the medications this morning or if she had missed medications from the previous day.

Interview on 02/27/24 at 7:30 A.M., with the Administrator confirmed medications are not to be left at the resident bedside and observed to be consumed at the time of administration.

Review of the policy titled Preparation and General Guidelines for Medication Administration

Based on observation, record review, and staff interview, the facility failed to ensure the physician was informed regarding resident refusals of treatment application. This affected one (#5) of six sampled residents reviewed for the implementation and administration of physician orders in a facility census of 45.

Findings include:

Review of Resident #5's medical record revealed an admission date of 12/06/22, with diagnoses including: hypothyroidism, dementia, hypertension, atrial flutter, overactive bladder, and bradycardia. According to the annual assessment dated 12/17/23 Resident #5 was assessed as independent with activities of daily living, utilizes a walker for ambulation, medication management with staff to administer medications.

Review physician orders revealed on 02/14/24 the physician ordered the application of an ace wrap to the lower right leg. Applied in the morning (A.M.) and removed at bedtime (HS).

Review of the medication administration records revealed the Ace Wrap applied between 02/15/24-02/24/24. The resident was documented as refused on 02/25/24, and 02/26/24. No documentation contained in the record indicated the physician was notified of the resident refusals.

Observation on 02/26/24 at 9:19 A.M., 10:25 A.M., 11:30 A.M. and 02/27/24 at 7:25 A.M. and 9:35 A.M., revealed the resident dressed and without the ACE wrap applied.

Interview on 02/27/24 at 9:36 A.M., with Licensed Practical Nurse (LPN) #200 confirmed Resident #5 refused the application of the ACE wrap. LPN #200 also confirmed the physician had not been notified of the refusals. Observation at the time of interview assessed Resident #5 with three (3) plus pitting edema to the right lower extremity. Continued observation revealed Resident #5 to allow the application of the ACE wrap as ordered.

This violation represents non-compliance investigated under Complaint Number OH00151168.