O'Neill Healthcare North Ridgeville

Based on observations, interviews with staff, pharmacist and a family member, record review and review of the facility policy, the facility failed to ensure the residents were administered medications per physician orders, failed to ensure residents were observed during medication administration, and failed to ensure the medications were administered before they were signed off in the Medication Administration Record. This affected three (#10, #16, and #23) of five residents reviewed for medication administration. The facility census was 43.

Findings include:

1. Review of Resident #23's medical record revealed an admission date of 05/26/23 and diagnoses included Parkinson's Disease, mild late onset Alzheimer's dementia with mood disturbance, major depressive disorder, chronic low back pain and sacroiliac pain.

Review of Resident #23's physician orders dated 02/18/25 revealed Percocet oral tablet 5-325 milligrams (mg), give one tablet three times a day for pain.

Review of Resident #23's Self-Administration of Medication Evaluation dated 07/02/25 included Resident #23 could not self-administer medications.

Review of Resident #23's Level of Care Evaluation Tool dated 10/01/25 included Resident #23 was independent for bathing, toileting, and mobility outside of suite and the facility administered Resident #23's oral medications.

Review of Resident #23's Medication Administration Record (MAR) dated 10/19/25 at 10:00 P.M., 10/20/25 at 6:00 A.M., 10/20/25 at 2:00 P.M. and 10/20/25 at 10:00 P.M. revealed the Percocet was not administered.

The progress notes dated 10/19/25 at 9:05 P.M. revealed Percocet was not on hand.

The progress notes dated 10/20/25 at 6:14 A.M. included Resident #23's Percocet was unavailable for administration; the nurse spoke with the pharmacy staff and Resident #23's Percocet would be delivered today.

The progress notes dated 10/20/25 revealed at 4:35 P.M., Percocet was on order. At 9:24 P.M. included Percocet was unable to be administered due to out-of-medication.

Interview on 10/23/25 at 11:52 A.M. with Resident #23's Family Member (FM) #350 revealed Resident #23 missed multiple doses of her Percocet and was told by the facility it was because the Nurse Practitioner did not send an order in for Percocet. FM #350 stated the medications were left in a cup on her bedside table for her to take later.

Observation on 10/27/25 at 8:54 A.M. of Certified Medication Assistant (CMA) #330 revealed she prepared Resident #23's medications including duloxetine oral capsule delayed release particles 60 mg, coenzyme Q10 oral capsule, aspirin 81 mg, magnesium oxide 400 mg, meloxicam 15 mg, amlodipine 5.0 mg, gabapentin 100 mg, potassium chloride ER oral tablet 20 milliequivalents (mEq) times two, buspirone oral tablet 7.5 mg, baclofen oral tablet 5.0 mg times three, chlorthalidone 25 mg, and placed them in a small plastic cup. CMA #330 picked up the cup which contained Resident #23's medications, walked into her room and placed the medications on Resident #23's bedside table. Resident #23 was sitting in a chair in her room. CMA #330 told Resident #23 her medications were on the bedside table. CMA #330 did not stay in the room and did not observe Resident #23 taking her medications and signed off the medications were administered before the medications were taken by Resident #23.

Interview on 10/27/25 at 12:06 P.M. of the Director of Nursing (DON) confirmed Resident #23 was not administered four doses of her Percocet on 10/19/25 and 10/20/25. The DON stated the nurse contacted Nurse Practitioner (NP) #352 on 10/17/25, but NP #352 did not send an order for Resident #23's Percocet until 10/19/25 at 9:28 P.M. The DON indicated the pharmacy delivered Resident #23's Percocet on 10/21/25 at 2:14 A.M. The DON stated she did not know why it took the pharmacy an extra day to send the Percocet. The DON confirmed she spoke with CMA #330 and CMA #330 confirmed she left Resident #23's medications at the bedside, did not observe her taking the medications, and signed the medications off they were administered before they were administered and without watching Resident #23 take them.

Interview on 10/27/25 at 1:09 P.M. with Pharmacist #353 revealed Resident #23 needed a new prescription for her Percocet and it was received on 10/19/25 at 9:18 P.M. Pharmacist #353 indicated the cut-off time for a medication, including Resident #23's Percocet to be delivered to the facility with the next delivery was 4:15 P.M. After 4:15 P.M., the medication would go into delivery the next day, but if it was needed sooner the facility could contact the pharmacy and a stat delivery would be made.

Interview on 10/27/25 at 2:15 P.M. with the DON confirmed the facility could have called the pharmacy for a stat delivery of Resident #23's Percocet and there was no evidence this was done.

2. Review of Resident #16's medical record revealed an admission date of 10/07/25 and diagnoses included benign paroxysmal vertigo, dizziness and trigeminal neuralgia.

Review of Resident #16's physician orders revealed on 10/08/25, an order for lamotrigine oral tablet, give 250 milligrams (mg) by mouth two times a day for anticonvulsant. On 10/15/25, lamotrigine 200 mg tablet was discontinued and a new order for lamotrigine 250 mg XR, 24 hours, take one tablet by mouth two times a day.

Observation on 10/27/25 at 8:30 A.M. of Certified Medication Assistant (CMA) #330 revealed she was preparing Resident #16's medications for administration. CMA #330 began preparing Resident #16's lamotrigine for administration but the dose on the bottle did not correspond to the Medication Administration Record (MAR). Resident #16's bottle which was found in the medication cart stated lamotrigine 200 mg, give one and a half pills to make 300 mg. Resident #16's MAR stated to give 250 mg two times a day. CMA #330 stated she found a second bottle in the cart, and it also said lamotrigine 200 mg, give one and a half pills to make 300 mg. CMA #330 stated she needed to clarify the lamotrigine dose and asked Regional Director of Clinical Services (RDCS) #354 about the discrepancy. RDCS #354 stated he would find out what the correct dose of Resident #23's lamotrigine was.

Interview on 10/27/25 at 9:40 A.M. with RDCS #354 confirmed Resident #16 had a physician order dated 10/15/25 for Lamictal (lamotrigine) 250 mg XR, take one tablet by mouth two times a day. RDCS #354 confirmed the physician order on 10/15/25 stated to discontinue lamotrigine 200 mg, and stated the lamotrigine order must have been transcribed incorrectly on 10/08/25 because it said 250 mg. RDCS #354 stated an order was not placed on 10/15/25 when the new order for lamotrigine 250 mg XR was given. RDCS #354 stated he contacted Nurse Practitioner (NP) #352 and she stated lamotrigine 250 mg XR should not be given twice a day because it was extended release and she changed the order to lamotrigine 250 mg XR, take one tablet one time a day.

Interview on 10/27/25 at 11:06 A.M. with the Director of Nursing (DON) confirmed Resident #16 was not getting lamotrigine per the physician order.

3. Review of Resident #10's medical record revealed an admission date of 12/19/22 and diagnoses included atrioventricular block, complete, sinus sick syndrome and Parkinson's disease.

Review of Resident #10's Self-Administration of Medication Evaluation dated 07/02/25 included Resident #10 could not self-administer medications.

Observation on 10/27/25 at 7:11 A.M. of Certified Medication Assistant (CMA) #330 revealed she prepared Resident #10's medications for administration including Carbidopa-Levodopa tablet 25-100 milligrams (mg) for Parkinson's disease, Lasix (furosemide) 20 mg times two for congestive heart failure, metoprolol tartrate 25 mg for hypertension, fludrocortisone acetate tablet 0.1 mg for low blood pressure. CMA #330 picked up the cup which contained Resident #10's medications, walked into his room and placed the medications on Resident #10's bedside table. Resident #10 was in bed sleeping. CMA #330 did not stay in the room and did not observe Resident #10 taking his medications. CMA #330 stated Resident #10 would take the medications when he woke up. CMA #330 signed off Resident #10's medications were administered before the medications were taken by Resident #10.

Interview on 10/27/25 at 12:06 P.M. with the Director of Nursing (DON) confirmed she spoke with CMA #330 and CMA #330 confirmed she left Resident #10's medications at the bedside, did not observe him taking the medications, and signed the medications off they were administered before they were administered and without watching Resident #10 take them. The DON stated CMA #330 was not aware that it needed to be care planned for her to do that.

Review of the facility policy titled Medication Administration Policy dated 02/2024 revealed the facility would ensure medications were administered in a safe manner. Residents would be observed during medication administration to ensure they have taken their medications. If a resident expresses the desire to self-administer medication, please refer to the Self-Administration of Medication Policy. Medications were administered to the right resident, the right dose, the right time, the right drug, the right route and the right documentation.

This violation represents non-compliance investigated under Complaint Number OH00168634.

Based on observation, staff interview, and review of a facility policy, the facility failed to prevent contamination of clean laundry. This has the potential to affect all 33 residents residing in the facility. Facility census was 33.

Findings include:

Observation on 11/06/23 at 8:40 A.M., revealed Housekeeper #1 was wearing plastic gloves while standing on the first floor to get into the elevator with her housekeeping cart in one hand and a vacuum cleaner in the other hand. As Housekeeper #1 pushed the elevator button with her gloved hand to get the elevator, Housekeeper #1 kept her plastic gloves on. Housekeeper #1 then pushed the second floor button in the elevator with her gloved hand. Continuous observation of Housekeeper #1 revealed she got off the elevator on the second floor while still wearing her plastic gloves, and proceeded to push the housekeeping cart to the side of the hallway, and plugged the vacuum cleaner into an outlet. While wearing the same plastic gloves, Housekeeper #1 started vacuuming the carpet. Housekeeper #1 then unplugged the vacuum cord from the outlet and touched the door handle while wearing the same plastic gloves to enter the laundry room on the second floor. Housekeeper #1 then grabbed a broom with her gloves on and started sweeping the floor in the laundry room. Housekeeper #1 then went to the trash can inside of the laundry room, and lifted the trash can lid off the trash can while continuing to wear the same plastic gloves. She removed a trash bag and replaced the trash can with a clean trash bag and placed the garbage can lid back onto the trash can while wearing her plastic gloves. Housekeeper #1 then touched the door handle to exit the laundry room, and touched the door handle to the garbage can to throw the trash bag away. Housekeeper #1 then touched the door handle to re-enter the laundry room while still wearing her plastic gloves. She then proceeded to move the curtain back from the clean linen cart which contained white clean folded towels and wash rags, while still wearing her plastic gloves, she began folding and organizing the towels and wash cloths on the clean linen cart.

On 11/06/23 at 8:50 A.M., interview with Housekeeper #1 verified she did not change her gloves or perform hand hygiene prior to touching the clean linens on the linen cart.

Review of the facility's hand washing policy revealed hands are to be washed before and after using personal protective equipment (PPE).