Inn at Whitewood Village The

Based on observation, facility policy review and staff interview, the facility failed to ensure medications were secured. This affected three residents (#21, #80, and #89). This had the potential to affect all 94 residents currently residing in the facility.

Findings include:

Observation on 03/05/25 at 8:32 A.M. revealed there were three medication cups filled with various amounts of pills on top of the medication cart. The pills were in the three medication cups and the empty pill packet for each resident was sitting on top of the cup.

Interview on 03/05/25 at 8:32 A.M. with Licensed Practical Nurse (LPN) #200 verified there were three medication cups with pills in them on top of the medicine cart for Residents #21, #80, and #89. LPN #200 stated he knew it was wrong to pre-pour the medications but he was not expecting anyone at the time of morning.

An interview on 03/05/25 at 9:15 A.M. with Executive Director (ED) #202 and Resident Care Coordinator (RCC) #203 stated LPN #200 knew better and the facility just had the re-licensed survey and had no citations.

Review of the facility policy titled Medication Policy dated 07/2024 revealed the person who administers the medication shall observe the resident taking medications.

This violation represents non-compliance investigated under Complaint Number OH00163159.

Based on observation, record review, facility policy review and staff interview, the facility failed to perform hand hygiene when administering medications. This affected one (#50) of three residents observed for medication administration. The facility census was 94.

Findings include:

Record review revealed Resident #50 was admitted on 08/26/24 with diagnoses including schizophrenia, major depressive disorder, and hypertension.

Review of the physician's orders for March 2025 revealed Resident #50 to have two tablets of acetaminophen 325 milligrams as needed for pain.

Observation on 03/05/25 at 8:42 AM. revealed Medication Technician (MT) #201 was at the nurse's station and Resident #50 came to the nurses' office and asked for Tylenol (acetaminophen). MT #20 did not perform hand hygiene and took the bottle of Tylenol and put two tablets into her bare hand then put the tablets into a medication cup, and then handed it to the resident. The residents took the Tylenol and left.

An interview on 03/05/25 at 8:44 A.M. with MT #201 verified she put the Tylenol in her bare hands without performing hand hygiene. MT #201 stated she knew it was wrong to put the medicine on her bare hand then into the cup, but stated it was easier to pour the tablets in her hand than tap them in a cup.

Review of the facility's policy titled Handwashing dated 11/13/14 revealed hands must be washed to reduce transmission of germs.

This violation represents non-compliance investigated under Complaint Number OH00163159.

Based on closed medical record review, observation of video footage, facility policy review and interview, the facility failed to immediately and thoroughly assess Resident #97 when there was a change in the resident's health status. This affected one resident (#97) of three residents reviewed for change in condition. The facility census was 94.

Findings include:

Review of the medical record revealed Resident #97 was admitted to the facility on 01/26/21 and discharged on 01/19/24. Resident #97 had diagnoses including hypertensive urgency, vascular dementia, malignant neoplasm of colon, chronic kidney disease Stage III, lumbar canal stenosis, hyperlipidemia, atrial fibrillation, emphysema, type 2 diabetes mellitus, polymyalgia rheumatic, history of cerebral vascular accident, and chronic anemia.

Review of a progress note dated 01/19/24 at 11:47 A.M. revealed Licensed Practical Nurse (LPN) #173 entered Resident #97's room to administer medication. Resident #97 stated she had to use the restroom. Resident #97 was unsteady and had many jerking movements. LPN #173 assisted Resident #97 to the toilet and then Resident Assistant (RA) #301 assisted Resident #97 with getting dressed. LPN #173 assessed Resident #97. Resident #97's blood glucose was 97 milligram/deciliter (mg/dL), temperature was 97.2 degrees Fahrenheit, pulse was 57 beats per minute, respirations were 16 breaths per minute, and blood pressure was 152/98 millimeter of mercury (mmHg). LPN #173 notified Resident #97's POA and physician of Resident #97's change in condition. The physician gave an order for Resident #97 to be evaluated at the hospital. Resident #97's POA arrived at the facility and transported Resident #97 to the hospital. On 01/19/24 at 7:33 P.M. the hospital notified LPN #173 that Resident #97 had been admitted to the hospital with new onset seizures.

Review of video footage of Resident #97's room revealed on 01/19/24 at 5:44 A.M. Resident Assistant (RA) #101 and RA #103 (training with RA #101) entered Resident #97's room. Resident #97 was not observed on camera at that time. At 5:49 A.M. RA #101 and RA #103 assisted Resident #97 from the bathroom to a recliner. Resident #97 was making jerking movements with arms. RA #101 stated she was texting Licensed Practical Nurse (LPN) #300. At 5:55 A.M. RA #102 entered the room. Resident #97 continued to make intermittent jerking movements with arms. At 5:56 A.M. LPN #300 entered the room. LPN #300 stood inside the doorway but did not approach Resident #97. LPN #300 left the room at 5:57 A.M. and returned at 5:58 A.M. and appeared to place a blood pressure cuff on Resident #97's left wrist. Resident #97 continued with intermittent jerking movements to arms. At 6:00 A.M. LPN #300 touched both of Resident #97's bare feet and then left the room. At 9:02 A.M. Resident #97 was observed walking unsteady with jerking movements to arms. Resident #97 also put hand around throat and rubbed along collar bone and upper mid chest. LPN #173 entered the room at this time. LPN #173 assisted Resident #97 to recliner. At 9:04 A.M. LPN #173 obtained a blood sample from a finger on Resident #97's right hand for blood glucose check. Resident #97 was observed with continued jerking movements to arms and rubbing throat area. At 9:05 A.M. LPN #173 assisted Resident #97 to the bathroom. Resident #97 stumbled and almost fell. Resident #97 put both hands up to throat. LPN #173 stayed with Resident #97 until RA #301 entered the room at 9:09 A.M. LPN #173 reentered the room at 9:25 A.M. and assisted RA #301 with transferring Resident #97 into a wheelchair. At 9:33 A.M. RA #301 and LPN #173 took Resident #97 out of the room in a wheelchair. At 10:39 A.M. Resident #97's husband entered Resident #97's room. At 10:44 A.M. Resident #97, power-of-attorney (POA), and RA #301 entered Resident #97's room. At 10:59 A.M. Resident #97, POA, and RA #301 leave the room.

Interview on 05/06/24 at 10:47 A.M. with the POA of Resident #97 revealed after being transported to the hospital on 01/19/24, Resident #97 had two grand mal seizures (involves loss of consciousness and violent muscle contractions) at the hospital. After the seizures, the doctors recommended Resident #97 be placed on hospice for comfort care. Resident #97 expired two days after being placed on hospice. The POA indicated they felt LPN #300 should have assessed Resident #97 when there was the initial change in condition. The POA also stated LPN #300 should have contacted the POA about the change.

Interview on 05/06/24 at 1:44 P.M. with RA #103 revealed (on 01/19/24) it probably took LPN #300 15 to 20 minutes to come to Resident #97's room. LPN #300 told RA #103 and RA #102 to leave the room so RA #103 was unsure if LPN #300 assessed Resident #97.

Interview on 05/06/24 at 2:07 P.M. RA #102 revealed on 01/19/24 RA #101 asked her to come see Resident #97. RA #102 stated she provided care for Resident #97 on a regular basis. RA #102 stated Resident #97 was not acting like Resident #97 normally did. LPN #300 entered the room and told RA #102 and RA #103 to leave the room. RA #102 stated LPN #300 was slow to respond to any requests by RA's for assistance.

Interview on 05/06/24 at 3:01 P.M. with LPN #173 revealed on 01/19/24, LPN #300 reported Resident #97 had an episode but was okay. RA #101 reported concerns about Resident #97 and stated they had given Resident #97 some orange juice. LPN #300 told LPN #173 she did not check Resident #97's blood glucose level at the time of the episode. LPN #173 stated she was not aware of LPN #300 doing any type of assessment of Resident #97. LPN #173 stated when she checked Resident #97's blood glucose it was in the 90's and Resident #97's blood pressure was slightly elevated. LPN #173 administered Resident #97's morning medications and called Resident #97's POA. LPN #173 told the RA staff to put Resident #97 in a wheelchair because Resident #97 was unsteady and had jerking movements. Resident #97 was taken out to the common area for an activity until the POA arrived. LPN #173 stated she notified the doctor of Resident #97's change in condition and LPN #173 recommended Resident #97 be transferred to the hospital for evaluation. The doctor said it was okay for Resident #97 to be evaluated at the hospital. The POA stated she would transport Resident #97 to the hospital. Staff assisted the POA with getting Resident #97 in the car.

Interview on 05/07/24 at 9:17 A.M. with RA #101 revealed on 01/19/24 Resident #97 was sitting on the toilet when RA #101 entered the room. Resident #97 was usually talkative in the morning but was not that morning. Resident #97 was jerking which was something new. RA #101 stated she text LPN #300 it was an emergency and told LPN #300 to come to Resident #97's room. LPN #300 did not arrive until probably five minutes later. LPN #300 did not assess Resident #97 but may have felt Resident #97 to see if Resident #97 felt hot (to touch). RA #101 stated something was wrong with Resident #97. RA #102, who provided care regularly for Resident #97, agreed there was a change in Resident #97's condition.

Interview on 05/07/24 at 11:07 A.M. with the Administrator revealed when LPN #300 was questioned about the incident with Resident #97 on 01/19/24, LPN #300 stated she would wait for the day shift nurse to assess Resident #300 because it was close to the time for day shift to come in. The Administrator verified there was no documentation of an assessment, vitals, or progress notes by LPN #300 regarding Resident #97's change in condition.

Interview on 05/08/24 at 12:07 P.M. with LPN #300 revealed on 01/19/24 it was almost shift change time when an aide asked LPN #300 to come to the room because Resident #97 was jittery and the resident's blood glucose was probably low. LPN #300 verified she did not assess Resident #97 because it was normal for Resident #97 to have jerking movements. LPN #300 stated if it had been something serious she would have assessed Resident #97. LPN #300 stated she told LPN #173 (the day shift nurse) Resident #97 had been jerking. LPN #300 asked if she was in trouble because she was 65 years old and wanted to keep working as a nurse. At 12:37 P.M. LPN #300 called back and stated she remembered that the aides said Resident #97 was doing better. LPN #300 verified she was called to Resident #97's room around 6:00 A.M. LPN #300 stated LPN #173 usually showed up to work around 6:40 A.M. for the 7:00 A.M. shift and LPN #300 assumed LPN #173 would go check Resident #97 as soon as she got report. LPN #300 stated she did not understand why LPN #173 would wait until around 9:00 A.M. to check Resident #97.

Review of the undated policy and procedure titled Responsibility: Licensed Nurse revealed all pertinent information to be documented which included a change in the residents physical or psychological condition.

Review of the undated policy and procedure titled Nurses Notes revealed it was the facility policy to document all physician and medically related examinations, treatments, interventions, pertinent information, changes in physical or mental status, and notification of all the previous information.

The admission packet provided to residents revised on 6/2018 revealed in the event of a medical emergency which constituted a significant adverse change in a resident's health status, the facility reserved the right to take immediate and proper steps to see that the resident received necessary medical attention by transporting the resident by squad or other emergency medical transportation to an appropriate emergency medical facility.

This violation represents non-compliance investigated under Complaint Number OH00152364.