Inn at University Village The

Based on record review, interview and policy review, the facility failed to ensure medication orders were transcribed correctly upon admission. This affected one resident (#90) of three residents sampled for medication errors. The facility census was 87.

Findings include:

Resident #90 was admitted to the facility on 10/23/25 and discharged home on 12/05/25. Diagnoses included Parkinson's disease, hyperparathyroidism, hypothyroidism, anxiety disorder, dementia, and depression.

Review of the Senior Living Standard Level of Care and Service Plan dated 10/22/25 revealed Resident #90 was mildly confused and needed reminders for redirection and orientation. She required assistance due to moderate dementia with significant short-term memory loss. She was not independent in decision making. Level of care determination revealed Resident #90 required facility staff to administer medications.

Review of the physician orders revealed the medication Cinacalcet HCl (a medication used to treat hyperparathyroidism) oral tablet 30 milligrams (mg) to be given one time a day starting 10/24/25 and a discontinue date of 11/13/25.

Review of a Medication Error Form dated 11/13/25 revealed Resident #90 was noted to have a medication error related to Cinacalcet Hcl 30 milligrams. The form noted the medication was scheduled as daily and should be twice daily (BID). The error was discovered by family. The order was changed, the family and the physician were notified. Listed corrective action noted to receive clarification and verify with medication list. The form was signed by the Director of Nursing (DON).

Review of the November 2025 Medication Administration Record (MAR) revealed the medication Cinacalcet HCl oral tablet 30 mg was given once a day until 11/14/25 when a new order revealed Cinacalcet HCl oral tablet 30 mg was to be given twice a day which started 11/14/25 and was discontinued 12/05/25 when Resident #90 was discharged home.

Interview on 04/29/26 at 9:06 A.M. with a family member of Resident #90 revealed she inquired how many times daily Resident #90 was receiving Cinacalcet HCl, and was told the resident was receiving Cinacalcet HCl 30 mg once daily in the morning. She informed the DON this medication should be given twice a day in the morning and the evening.

Interview with the DON on 04/29/26 at 4:10 P.M. revealed she transcribed the daily dosage wrong for Resident #90's medication Cinacalcet HCl oral tablet 30 mg upon admission. It was ordered to be administered twice a day from admission through discharge for Resident #90 but was only administered once daily until 11/14/25.

Review of the National Institutes of Health's Nursing Rights of Medication Administration dated 2023 revealed administering medications safely requires following the rights of medication administration and includes the right patient, right drug, right dose, right route, right time and right documentation to ensure efficacy and safety.

This violation represents non-compliance investigated under Complaint Number OH00170152.

Based on observation, medical record review, review of medication error reports, and interview, the facility failed to ensure medications were administered in accordance with physician orders. This affected one (Resident #24) of three residents observed for medication administration and one (Resident #25) of three residents whose records were reviewed for medication administration.

Findings include:

Review of Resident #25's medical record revealed diagnoses including chronic kidney disease (CKD), congestive heart failure (CHF), diabetes mellitus, lymphedema of the legs, hyperlipidemia, hypertension, gout and asthma. A History and Physical dated 09/11/25 indicated nurses were responsible for all medications.

a. A nursing note dated 09/28/25 at 8:17 A.M. indicated Resident #25 received Eliquis (anticoagulant) 2.5 milligrams (mg) during breakfast. The power of attorney, physician and case manager were notified. No new orders were received.

Resident #25 did not have an order for Eliquis (anticoagulant) and no listed allergy of Eliquis.

Review of progress notes between 09/28/25 and 10/08/25 revealed no adverse effects experienced by Resident #25 related to administration of the Eliquis.

Review of a medication error form dated 09/28/25 revealed Resident #25 received Eliquis 2.5 mg. Licensed Practical Nurse (LPN) #100 was educated regarding medication administration. Neurological checks and vital signs were monitored every shift for three days.

On 10/08/25 at 3:33 P.M., the Executive Director verified the administration of Eliquis to Resident #25 had been identified as a medication error.

b. On 10/08/25 at 3:10 P.M. LPN #100 was observed preparing medications for Resident #24. While preparing polyethylene glycol (laxative), the medication was measured in a cap to the 17 gram line then placed in a cup (the cap is provided with the medication and is marked specifically to indicated 17 grams). LPN #100 was asked how she measured the amount of polyethylene glycol to administer and stated she used the line on the cap to measure it, verifying she poured 17 grams. It was brought to the attention of LPN #100 the order on the electronic Medication Administration Record (MAR) indicated one gram was ordered to be administered every evening.

On 10/08/25 at 3:10 P.M., LPN #100 verified the discrepancy between the label on the polyethylene glycol which indicated to administer 17 grams and the order to administer 1 gram. LPN #100 verified there needed to be a clarification, stating she would fix it and proceeded to administer polyethylene glycol 17 grams.

Review of Resident #24's physician orders revealed polyethylene glycol one gram in the evening for constipation was ordered 03/27/25.

On 10/08/25 at 3:33 P.M., the Executive Director verified best practice was to clarify discrepancies in medication orders prior to administration of a medication.

This violation represents continued non-compliance investigated under Complaint Number OH00168434.

Based on medical record review, review of the facility's medication error list, and staff interview, the facility failed to ensure residents received their medications as physician ordered. This affected two (#39 and #64) of three residents reviewed for medication administration. The facility census was 88.

Findings include:

1. Medical record review for Resident #64 revealed an admission date of 06/06/23. Diagnoses included chronic obstructive pulmonary disease and essential hypertension (HTN).

Review of facility's medication error list dated 08/11/25 revealed Resident #64 had been administered 12.5 milligrams (mg) Metoprolol tartrate (treats HTN).

Review of Resident #64's physician orders for August 2025 revealed Resident #64 did not have an order for Metoprolol tartrate 12.5 mg.

Interview on 08/25/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #64 was found to be administered Metoprolol tartrate 12.5 mg by Medication Technician (MT) #225 on 08/09/25. MT #2335 was a new hire on 07/10/25, was in training, was not familiar with the residents and handed the medication cup to Resident #64 in error.

2. Medical record review for Resident #39 revealed an admission date of 03/03/25 Diagnoses included cerebrovascular disease, vascular dementia, and congenital stenosis of aortic valve.

Review of facility's medication error list dated 07/12/25 revealed Resident #39 had been administered medications in error which included Metoprolol 25 milligrams (mg) (treats hypertension), furosemide 20 mg (reduces fluid retention), Coumadin five mg (used to prevent and treat blood clots), Digoxin 62.5 micrograms (mcg) (treats heart failure and atrial fibrillation).

Review of Resident #39's physician orders for July 2025 revealed Resident #39 did not have an order for Metoprolol, furosemide, Coumadin, and Digoxin.

Interview on 08/25/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #39 received Metoprolol 25 mg, furosemide 20 mg, Coumadin five mg, and Digoxin 62.5 mcg in error. Licensed Practical Nurse (LPN) #226 administered the medications to Resident #39 that were meant for another resident.

Review of facility's medication policy dated 07/20/24 revealed all medications shall be given only to the individual resident for whom they are prescribed. No medication shall be given to any resident unless ordered by a physician.

This violation represents non-compliance investigated under Complaint Number OH00167914.

Based on record review, review of police report, review of the facilities self-reported incident (SRI), and interview, the facility failed to ensure residents were free from misappropriation. This affected one (Resident #82) of one resident reviewed for misappropriation. The facility census was 88.

Findings include:

Review of the medical record for Resident #82 revealed an admission date of 08/29/19. Diagnoses included Alzheimer's Disease, dementia, chronic kidney disease and depression.

Review of the Senior Living Standard Level of Care and Service Plan dated 10/02/24 revealed Resident #82 resided on the memory care unit, was mostly confused and needed reminders, needed assistance with activities of daily living and was independent with management of his finances.

Review of the facility SRI number 261924 submitted to the State Survey Agency on 06/13/25, revealed the facility investigated misappropriation of Resident #82's credit card due to a concern from his power-of-attorney (POA). On 06/13/25 at 1:17 P.M., the facility was notified by Resident #82's POA there were transactions on his bank account statement that were not normal. The POA had called the businesses from the transactions listed but was unable to get the information on who charged the credit card. Resident #82's POA then contacted the police department on 06/13/25 at 3:51 P.M. The police department spoke to the business that had charged the credit card and confirmed Assisted Living Aide (ALA) #224 had used the credit card to pay her rent. On 06/14/25 at 7:00 A.M., ALA #224 was suspended prior to her shift while the facility completed their investigation. On 06/14/25 at 2:08 P.M., the Administrator spoke to the police department and it was confirmed that ALA #224 was suspected of using Resident #82's credit card to pay her utilities and rent. They stated it would be turned over to the detective bureau at their police department. On 06/15/25, ALA #224 sent a text to the facility stating that she resigned. On 07/01/25 at 10:10 A.M., the detective from the police department stated he was unable to speak to ALA #224 but the department would be filing charges of theft from the elderly and fraud.

Review of the Police Report #25-15292, dated 06/13/25 at 3:35 P.M., revealed Resident #82's POA had called the police department due to theft of Resident #82's credit card.

Review of Massillon Municipal Court docket case #2025CRA01516 revealed ALA #224 had been charged on 07/09/25 with theft from a person in a protected class and telecommunications fraud. An arrest warrant was issued on 07/09/25.

Interview on 08/25/25 at 12:32 P.M. with the Administrator revealed the facility had been cooperating with the police department and had not heard any other information since 07/01/25 related to the theft of Resident #82's credit card. She stated the facility substantiated the SRI for misappropriation of Resident #82's credit card due to the above findings. The Administrator stated she believed the amount that was misappropriated was $1,100.00.

Review of the facility's undated policy titled Abuse and Neglect revealed the facility was to provide an environment free from physical, verbal, mental and emotional abuse or misappropriation.

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

Based on observation and interview, the facility did not label and date foods in the refrigerator in the resident kitchen of the memory care unit. This had the potential to affect all 24 residents (#71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #93, #94, #95, and #96) currently residing on the memory care unit. The facility census was 93.

Findings Include:

Observation of the resident kitchen in the common area of the Memory Care unit on 04/30/25 between 1:00 P.M and 1:45 P.M with Environmental Director (ED) #1 revealed a red, approximate four-inch, boundary/rope like device pulled across the entrance and exits to the open style kitchen. Several residents were sitting in the common area with two caregivers. Resident #80 was sweeping the kitchen floor with a broom. ED #1 stated, Resident #80 likes to help out, and it keeps him occupied. The refrigerator had several expired items and items not labeled with dates and times. This included: a Styrofoam box dated 04/23/25 with an employee name. There was a Styrofoam container with the date 4/20/25 with a resident's name on it containing leftover food. There was a metal square container with plastic wrap covering it with no label or date. ED #1 stated it was ranch dressing. There were two pitchers with large open tops uncovered, one with orange juice and another with strawberry kiwi drink mix. There were no labels or dates on either pitcher. ED #1stated they were drinks prepared for residents and verified there were no labels or dates on them, and they were not covered. There was a gallon of milk open with about two-thirds of the milk remaining in container. There was no date to confirm when the milk was open. The manufacture sell-by date was 04/23/35. ED #1 verified the milk's sell-by date was 4/23/25. ED #1 immediately had the caregivers remove the unlabeled foods and drinks and expired items from the refrigerator.

Interview on 04/30/25 at 2:10 P.M. with Assistant Director of Nursing (ADON) #2 verified all residents on the memory care unit were independently mobile.

On 05/01/25 at 9:15 A.M. an interview with Executive Director #3 verified it was possible for residents to easily cross the four-inch barrier to the kitchen if caregivers were not supervising them. Executive Director #3 verified all residents on the memory care unit were independently mobile.

Based on observation and interviews, the facility did not provide safe and secure storage of chemicals in the resident kitchen of the memory care unit. This had the potential to affect all 24 residents (#71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #93, #94, #95, and #96) currently residing on the memory care unit. The facility census was 93.

Findings Include:

Observation on 04/30/25 between 1:00 P.M and 1:45 P.M of the kitchen in the main common area of the Memory Care unit with Environmental Director (ED) #1 revealed a red, approximately four-inch, boundary/rope like device pulled across the entrance and exits to the open style kitchen. Several residents were sitting in the common area with two caregivers. Resident #80 was sweeping the kitchen floor with a broom. ED #1 stated, Resident #80 likes to help out, it keeps him occupied. The cabinet below the sink was unlocked containing chemicals including a bottle of Dawn dishwashing soap, a spray bottle of clear sanitizer spray, and a bottle of kitchen cleaner.

Interview with ED #1 on 04/30/25 at 1:10 P.M. verified the cabinet was unlocked, and chemicals were present.

Interview on 04/30/25 at 2:10 P.M. with Assistant Director of Nursing (ADON) #2 verified all residents on the memory care unit were independently mobile.

On 05/01/25 at 9:15 A.M. an interview with Executive Director #3 verified it was possible for residents to easily cross the four-inch barrier to the kitchen if caregivers were not supervising them. Executive Director #3 verified all residents on the memory care unit were independently mobile.