West Park Commons

Based on observation, review of the staff schedule, review of the resident handbook, and interview, the facility failed to provide a sufficient resident call light system on the ground floor and failed to administer medications as ordered for former Resident #74. This had the potential to affect 17 residents (Residents #18, #21, #6, #5, #37, #15, #69, #20, #59, #60, #26, #14, #39, #55, #41, #23 and #9) who resided on the ground floor and one (Resident #74) of three residents reviewed for medication administration. The census was 69.

Findings include:

1. Interview on 06/13/23 at 11:20 A.M. with Assisted Living Director (ALD) revealed residents resided on the first, second and third floor of the facility. Additionally, the ground floor of the attached skilled nursing facility (SNF) had been converted into residential care facility (RCF) resident rooms a couple years ago.

Another interview on 06/13/23 at 11:45 A.M. and 1:15 P.M. with the ALD revealed there were usually three Caregivers divided between the main RCF and the ground floor RCF from 7:00 A.M. to 3:00 P.M. and from 3:00 P.M. to 11:00 P.M. The facility also utilized Door Watchers on the ground floor RCF during that time. ALD #1 revealed there were no Caregivers, nurses, or Door Watchers in the main RCF or ground RCF from 11:00 P.M. to 7:00 A.M. since the RCF and attached SNF shared staff during the night specifically a night shift nurse manager from the SNF. After 11:00 P.M. the nurse manager carried a phone. If a resident, who resided on the main RCF, pulled their call light, the call light would notify the night shift nurse manager's phone then the night shift nurse manager would respond to the call light. ALD #1 verified the ground floor RCF call lights in resident rooms did not connect to the SNF's call light system to alert the staff if a resident needed assistance from 11:00 P.M. to 7:00 A.M.

Observation on 06/13/23 at 1:20 P.M. with Director of Maintenance (DM) #3 revealed to visit the ground floor RCF unit, the surveyor and DM #3 walked from the first floor of the main RCF, through the main shared RCF and SNF dining room, through the first floor SNF hallway, to the elevator then proceeded down one floor to the ground floor unit of the RCF. There was a call light switchboard directly in front of a nursing station by the front entrance of the ground RCF which was also the main entrance to the SNF. Caregiver #5 was sitting at the nursing station. DM #3 pulled the call light in Room #33 which audibly and visibly activated Room #33's light on the switchboard. Interview, during the observation, with DM #3 verified the resident call lights on the ground floor did not connect to the phone the night shift nurse manger carried nor did the resident call lights on the ground floor ring to the SNF nursing station to alert staff if residents' needed assistance. DM #3 also verified the call lights in resident rooms on the ground floor only rang at the switchboard near the ground floor nursing station/main entrance. DM #3 wasn't aware if a staff member was scheduled on the ground floor during the night to monitor the call lights.

A follow-up interview on 06/13/23 at 1:25 P.M. with the ALD verified the facility did not schedule a nurse, Caregiver or any other staff on the ground floor from 11:00 P.M. to 7:00 P.M. to monitor resident call lights. The ALD also verified if a resident residing on the ground floor used their call light during the night, a staff member would not know that resident needed assistance unless the nurse manager was rounding on the ground floor during that time.

Review of the nurse and Caregiver staff schedule from 06/09/13 through 06/13/23 revealed there wasn't a Caregiver or nurse assigned to the ground floor RCF from 11:00 P.M. to 7:00 A.M.

Review of the undated Resident Handbook revealed staffing: we have 24-hour staffing here at [facility name]. During the evening hours after 7:30 P.M., we utilize staff from the nursing home side of the building. These staff are trained and competent of completing the required job duties according to the State regulations for a residential care facility (RCF).

2. Review of the closed medical record for former Resident #74 revealed an admission date of 12/06/22, discharge date of 03/31/23 with diagnoses of multiple myeloma, anxiety disorder, depression, and chronic pain syndrome. Review of the admission note assessment dated 12/06/22 revealed Resident #74 was alert and oriented, was anxious as evidenced by yelling and calling staff names if she didn't get her way, and had chronic pain rated at a five out of 10 on the pain scale. Review of the assisted living facility evaluation assessment dated 12/06/22 revealed Resident #74 was independent with all her activities of daily living including mobility. Review of the medications service plan dated 12/09/22 revealed Resident #74 required daily supervision of medication with a goal of support to take all medications safely and as ordered.

Review of the nurse practitioner's progress note dated 12/16/22 revealed Resident #74 had chronic pain syndrome. Resident #74 recently transferred to the assisted living from another assisted living. Only acute concern/complaint from resident was that her pain medication was not ordered correctly. The order she came with was for Percocet three times a day as needed. She was insistent that it be given at 8:00 A.M., 4:00 P.M. and at bedtime. She previously had this regimen and had been working well for her for some time. Resident #74's regimen was changed for administration of Percocet at 8:00 A.M., 4:00 P.M. and 10:00 P.M. Resident #74 was agreeable to going to the skilled nursing facility (SNF) side of the facility for the 10:00 P.M. dose as there was no nurse available at the assisted living at this time.

Review of the physician order dated 12/16/22 revealed Resident #74 was ordered Percocet 5-325 milligram one tablet by mouth every night at 10:00 P.M. for pain.

Review of the health status progress note dated 01/02/23, timed 10:20 P.M. revealed Resident #74 called nurses station demanding a pain pill. Resident educated that per facility protocol she needed to come to the SNF nurses' station for medication. Resident became irate and stated, No, I can't, and it needs to be brought to me. Nurse brought medication to resident, Director of Nursing (DON) notified to address with resident facility protocol in assisted living.

Review of the health status note dated 01/03/23, timed 11:24 P.M. revealed Resident #74 called SNF first floor nurses' station at 9:35 P.M. This nurse spoke to resident. Resident requested pain medication. This nurse stated, unable to leave floor, if you would like a pain pill, you are in the assisted living and need to come to the SNF first floor nurses' station and I will get medication for you. Resident became verbally aggressive and yelling and name calling to this nurse. This nurse again explained that she could come to the nurses' station for medication after 7:00 P.M. Resident yelled profanities and slammed phone down. Resident did not come to nurses' station as of this time for pain medication.

Review of the January 2023's Medication Administration Record (MAR) for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 01/01/23, 01/02/23, 01/03/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/11/23, 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, 01/18/23, 01/19/23, 01/20/23, 01/21/23, 01/22/23, 01/23/23, 01/24/23, 01/25/23, 01/26/23, 01/27/23, 01/28/23, 01/29/23 and 01/31/23.

Review of the February 2023 MAR for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 02/01/23, 02/03/23, 02/04/23, 02/05/23, 02/07/23, 02/08/23, 02/10/23, 02/13/23, 02/14/23, 02/16/23, 02/18/23, 02/19/23, 02/21/23, 02/22/23, 02/23/23, 02/24/23, 02/27/23 and 02/28/23.

Review of the March 2023 MAR for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 03/09/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23, 03/18/23, 03/19/23, 03/21/23, 03/24/23, 03/27/23, 03/28/23, 03/29/23 and 03/31/23.

Review of the nurse staff schedule from 06/09/13 through 06/13/23 revealed a nurse was not assigned to the RCF from 7:30 P.M. to 7:00 A.M.

Interview on 06/14/23 at 9:32 A.M. with the complainant revealed former Resident #74 had complained of having to go from the assisted living to the SNF to get medications including scheduled and as needed medications at night.

Interview on 06/20/23 at 11:25 A.M. with the Director of Nursing (DON) verified Resident #74 was not administered several doses of Percocet at 10:00 P.M. during February 2023 and March 2023. The DON also verified the SNF nurses should have administered the Percocet as ordered to Resident #74. The DON also revealed the corresponding narcotic count sheets for the Percocet could not be located in the closed medical record.

Review of the facility's Assisted Living Medication Administration policy dated 05/11/21 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

This violation represents non-compliance investigated under Complaint Number OH00143329.

Based on closed medical record review, nurse staff schedule review, policy review and interview, the facility failed to administer medications as ordered for former Resident #74. This affected one (Resident #74) of three residents reviewed for medication administration.

Findings include:

Review of the closed medical record for former Resident #74 revealed an admission date of 12/06/22, discharge date of 03/31/23 with diagnoses of multiple myeloma, anxiety disorder, depression, and chronic pain syndrome.

Review of the admission note assessment dated 12/06/22 revealed Resident #74 was alert and oriented, was anxious as evidenced by yelling and calling staff names if she didn't get her way, and had chronic pain rated at a five out of 10 on the pain scale. Review of the assisted living facility evaluation assessment dated 12/06/22 revealed Resident #74 was independent with all her activities of daily living including mobility. Review of the medications service plan dated 12/09/22 revealed Resident #74 required daily supervision of medication with a goal of support to take all medications safely and as ordered.

Review of the nurse practitioner's progress note dated 12/16/22 revealed Resident #74 had chronic pain syndrome. Resident #74 recently transferred to the assisted living from another assisted living. Only acute concern/complaint from resident was that her pain medication was not ordered correctly. The order she came with was for Percocet three times a day as needed. She was insistent that it be given at 8:00 A.M., 4:00 P.M. and at bedtime. She previously had this regimen and had been working well for her for some time. Resident #74's regimen was changed for administration of Percocet at 8:00 A.M., 4:00 P.M. and 10:00 P.M. Resident #74 was agreeable to going to the skilled nursing facility (SNF) side of the facility for the 10:00 P.M. dose as there was no nurse available at the assisted living at this time.

Review of the physician order dated 12/16/22 revealed Resident #74 was ordered Percocet 5-325 milligram one tablet by mouth every night at 10:00 P.M. for pain.

Review of the health status progress note dated 01/02/23, timed 10:20 P.M. revealed Resident #74 called nurses station demanding a pain pill. Resident educated that per facility protocol she needed to come to the SNF nurses' station for medication. Resident became irate and stated, No, I can't, and it needs to be brought to me. Nurse brought medication to resident, Director of Nursing (DON) notified to address with resident facility protocol in assisted living.

Review of the health status note dated 01/03/23, timed 11:24 P.M. revealed Resident #74 called SNF first floor nurses' station at 9:35 P.M. This nurse spoke to resident. Resident requested pain medication. This nurse stated, unable to leave floor, if you would like a pain pill, you are in the assisted living and need to come to the SNF first floor nurses' station and I will get medication for you. Resident became verbally aggressive and yelling and name calling to this nurse. This nurse again explained that she could come to the nurses' station for medication after 7:00 P.M. Resident yelled profanities and slammed phone down. Resident did not come to nurses' station as of this time for pain medication.

Review of the January 2023's Medication Administration Record (MAR) for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 01/01/23, 01/02/23, 01/03/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/11/23, 01/12/23, 01/13/23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, 01/18/23, 01/19/23, 01/20/23, 01/21/23,

01/22/23, 01/23/23, 01/24/23, 01/25/23, 01/26/23, 01/27/23, 01/28/23, 01/29/23 and 01/31/23.

Review of the February 2023 MAR for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 02/01/23, 02/03/23, 02/04/23, 02/05/23, 02/07/23, 02/08/23, 02/10/23, 02/13/23, 02/14/23, 02/16/23, 02/18/23, 02/19/23, 02/21/23, 02/22/23, 02/23/23, 02/24/23, 02/27/23 and 02/28/23.

Review of the March 2023 MAR for Resident #74 revealed Percocet 5-325 milligram tablet was not administered at 10:00 P.M. to Resident #74 on the following dates: 03/09/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23, 03/18/23, 03/19/23, 03/21/23, 03/24/23, 03/27/23, 03/28/23, 03/29/23 and 03/31/23.

Review of the nurse staff schedule from 06/09/13 through 06/13/23 revealed a nurse was not assigned to the RCF from 7:30 P.M. to 7:00 A.M.

Interview on 06/14/23 at 9:32 A.M. with the complainant revealed former Resident #74 had complained of having to go from the assisted living to the SNF to get medications including scheduled and as needed medications at night.

Interview on 06/20/23 at 11:25 A.M. with the Director of Nursing (DON) verified Resident #74 was not administered several doses of Percocet at 10:00 P.M. during February 2023 and March 2023. The DON also verified the SNF nurses should have administered the Percocet as ordered to Resident #74. The DON also revealed the corresponding narcotic count sheets for the Percocet could not be located in the closed medical record.

Review of the facility's Assisted Living Medication Administration policy dated 05/11/21 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

This violation represents non-compliance investigated under Complaint Number OH00143329.

Based on observation, staff interview, resident interview, review of maintenance work orders, and review of facility policy, the facility failed to ensure a clean and sanitary environment was maintained for 14 residents (Resident #12, #16, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) of 14 residents reviewed for physical environment. The facility identified 13 residents (Resident #16, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) residing on the first floor of the main assisted living building. The facility census was 75.

Findings include:

Interview and observation on 04/26/23 at 2:17 P.M. with Resident #12 revealed the top right corner the inner window sill located in his room had chipping paint and water damage which had been there since his admission to the facility in September 2022. Resident #12 also reported his toilet did not seem as though it was properly secured to the wall.

On 04/27/23 beginning at approximately 11:40 A.M. a tour was conducted with the Director of Maintenance and Maintenance Worker #504. During the tour, the following was observed and verified by the Director of Maintenance and/or Maintenance Worker #504.

1. On the first floor of the main assisted living building, multiple ceiling tiles located outside of resident rooms in the common hallway and at the end of the 100-hall near the exit door contained rings indicative of water damage and black mold.

2. In the first-floor dining area, a ceiling tile located above a kitchenette had a large brown ring indicative of water damage and was sagging downward. The ceiling tile was dry at the time of observation.

3. Resident #12 had water damage along the upper and inner right corner of the sliding glass doors located in the main living area of his room. A grey substance was formed along the damage and drywall which had crumbled onto the floor and in the carpet below where the water damage was located.

4. Resident #12's bathroom toilet was secured to a steel beam located inside of the wall. There were areas of missing drywall where the inside of the wall could be seen. Below the toilet and along the bottom of the wall located behind the toilet contained a brown substance and water damage. The wall was chipping from this area and onto the floor behind the toilet.

During the tour, the Maintenance Director reported the water damage near Resident #12's window would be fixed and staff were just waiting for a span of warm days for the wall to dry out. The Maintenance Director also reported the water damage below the toilet in Resident #12's room was old and not new. The Maintenance Director and Resident #12 reported the bolts to the toilet were tightened and the water damage had been there for at least several months.

Review of maintenance work orders for 04/01/23 through 04/26/23 identified no work orders pertaining to mold, water damage, or Resident #12's toilet.

Review of the facility policy titled Policy; Resident Rights Policy