Ashford on Broad The

Based on medical record review, interview, and facility policy review, the facility failed to ensure residents were assessed when a change in condition and/or functional abilities warranted a change in services or equipment. This affected two residents (#34 and #94) of 11 sampled residents. The facility census was 102.

Findings Include:

1. Review of the medical record for Resident #34 revealed an admission date of 10/09/25. Diagnoses included orthostatic hypotension, hypoxic ischemic encephalopathy, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, hypertension, congestive heart failure, morbid obesity, hyperlipidemia, anxiety disorder, depression, chronic obstructive pulmonary disease and hypothyroidism.

Review of the resident's history and physical (H&P) dated 10/01/26 revealed the resident had no cognitive deficit.

Review of the hospital discharge summary dated 03/07/26 revealed the resident was admitted to the local acute care hospital on 03/04/26 for congestive heart failure and was being discharged. The resident was to start the medications Lasix, Prednisone, Trelegy Ellipta and wear oxygen at two liters per nasal cannula continuously.

Further review of the medical record revealed no documented evidence the resident required a portable oxygen tank or an oxygen concentrator, prior to his hospitalization on 03/04/26.

Review of the resident's progress note dated 03/07/26 at 3:41 P.M. revealed the resident returned to the facility via family transport from the hospital with new orders for Trelegy Ellipta twice daily, Lasix and Prednisone. The resident was also to keep his oxygen on at all times and the resident had a portable oxygen tank until oxygen concentrator was delivered to the facility. Further review of the medical record revealed no documented evidence the resident was reassessed upon readmission to the facility or the resident's service plan was reevaluated for any updated needs.

On 05/21/26 at 11:29 A.M., an interview with the Regional Director of Care (RDOC) verified the resident had no documented assessed when a change in condition and/or functional abilities occurred that warranted a change in services or equipment.

2. Review of the medical record for Resident #94 revealed an admission date of 05/13/24. Diagnoses include hypertension, epilepsy and diabetes mellitus.

Review of the resident's Mini-Mental exam dated 10/28/25 revealed a score of 26 indicating the resident had no cognitive impairment.

Review of the resident's self-medication administration evaluation dated 12/20/25 revealed the resident was not capable to administer her own medications.

Review of the progress note dated 03/10/26 at 2:02 P.M., revealed the resident was sent out to he hospital due to a change in condition. The progress note contained no assessment of the resident, vital signs or interventions implemented.

Review of the progress note dated 03/20/26 at 9:15 P.M. revealed the resident was readmitted to the facility at 5:30 P.M.

Review of the medical record revealed no evidence of a readmission assessment, full set of vital signs or readmission physician orders.

On 05/21/26 at 11:29 A.M., an interview with the Regional Director of Care (RDOC) verified the resident had no evidence of a readmission assessment, full set of vital signs, readmission physician orders or review of her service plan.

Review of the facility policy titled, Change in Condition

Based on medical record review, review of narcotic control sheets, and interview, the facility failed to ensure medication was not administered without a physician's order. This affected one resident (#94) of four residents reviewed for medication errors. The facility census was 102.

Findings Include:

Review of the medical record for Resident #94 revealed an admission date of 05/13/24. Diagnoses include hypertension, epilepsy and diabetes mellitus.

Review of the resident's March 2026 Medication Administration Record (MAR) and physician orders revealed the medication Eszopiclone (Lunesta) 1 milligram (mg) daily at bedtime was discontinued on 03/21/26.

Review of the resident's controlled drug receipt/record/disposition form for the Eszopiclone 1 mg by mouth daily at bedtime revealed the resident was administered a dose on 04/02/26 without a physician's order.

On 05/20/26 at 9:34 A.M., an interview with Licensed Practical Nurse (LPN) #260 verified the resident received the Eszopiclone 1 mg by mouth on 04/02/26 and had no physician order for the administration of the medication.

This violation represents non-compliance investigated under Master Complaint Number OH00170720, Complaint Number OH00170702, Complaint Number OH00170693, Complaint Number OH00170446, Complaint Number OH00170117, Complaint Number OH00170021, Complaint Number OH00169782, Complaint Number OH00166344, Complaint Number OH00163784, Complaint Number OH00163762, and Complaint Number OH00163731.

4. Review of the medical record for Resident #102 revealed an admission date of 04/05/24 and diagnoses including diabetes mellitus due to underlying condition with diabetic amyotrophy. Further review of the record indicated the resident was not able to self administer his medications.

Review of Resident #102's physician orders revealed orders for blood sugar checks four times a day, Basaglar Kwikpen 100 units per milliliter (u/ml) with instructions to administer 70 u subcutaneously two times daily, and Novolin Flexpen 100 u/ml with instructions to check blood sugar three times a day before meals per sliding scale and inject subcutaneously with additional sliding scale instructions for a blood sugar of 0-130 administer 0 u, 131-180 administer 6 u, 181-240 administer 8 u, 241-300 administer 12 u, 301-350 administer 16 u, 351-400 administer 18 u, and if greater than 401 call the physician.

Review of Resident #102's March 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following blood sugar checks and medications were not documented as completed/administered and had a dash through the recorded medication dates/times: blood sugar checks (due four times a day) were not completed on 03/05/25 in the evening and before bed, on 03/08/25 in the evening and before bed, on 03/18/25 midday, on 03/19/25 midday, and on 03/26/25 in the evening and before bed. The Basaglar Kwikpen 70 u twice daily was not given on 03/05/25 for the night dose, 03/06/25 for the morning dose, 03/08/25 for the night dose, and 03/26/25 night dose. The Novolin per sliding scale with instructions to check blood sugar three times a day before meals was not given on 03/05/25 for the evening dose, on 03/06/25 for the morning and midday doses, on 03/08/25 for the evening dose, on 03/18/25 for the midday dose, on 03/19/25 for the midday dose, and on 03/26/25 for the evening dose.

Interview with Regional Director of Care (RDOC) on 05/21/26 at 1:15 P.M. confirmed dashes on the MAR would indicate blood sugars checks were not completed or the medication was not given to the resident.

This violation represents non-compliance investigated under Master Complaint Number OH00170720, Complaint Number OH00170702, Complaint Number OH00170693, Complaint Number OH00170446, Complaint Number OH00170117, Complaint Number OH00170021, Complaint Number OH00169782, Complaint Number OH00166344, Complaint Number OH00163784, Complaint Number OH00163762, and Complaint Number OH00163731.

Based on observation, medical record review, review of narcotic control sheets, interview, and review of policy and procedure, the facility failed to ensure schedule four narcotic medications were destroyed in a timely manner leading to a medication error. This affected one resident (#94) of four residents reviewed for medication errors. The facility census was 102.

Findings Include:

Review of the medical record for Resident #94 revealed an admission date of 05/13/24. Diagnoses include hypertension, epilepsy and diabetes mellitus.

Review of the resident's March 2026 Medication Administration Record (MAR) and physician orders revealed the medication Eszopiclone (Lunesta) 1 milligram (mg) daily at bedtime was discontinued on 03/21/26.

Review of the resident's controlled drug receipt/record/disposition form for the Eszopiclone 1 mg by mouth daily at bedtime revealed the resident was administered a dose on 04/02/26 without a physician's order.

On 05/20/26 at 9:34 A.M., an interview and observation with Licensed Practical Nurse (LPN) #260 revealed Resident #94 had 43 tablets of Eszopiclone 1 mg locked in the narcotic lock box contained within the medication cart. LPN #260 revealed two staff nurses were able to destroy narcotic medication once the medication was discontinued. She further confirmed the medication error for the Eszopiclone 1 mg by mouth on 04/02/26.

On 05/20/26 at 9:47 A.M., interview with the Regional Director of Care (RDOC) verified discontinued medication should be destroyed as soon as possible and would expect the medication to be destroyed already.

Review of the policy titled Medication Loss or Spillage dated March 2026, revealed in the event of a need to destroy or discard a controlled substance, the disposal/discard will be witnessed and signed by two staff members qualified to pass and administer medications. In the event only one qualified person was available, a licensed nurse may request that another staff member witness the discard/destruction of the medication.

This violation represents non-compliance investigated under Complaint Number OH00170702 and Complaint Number OH00170446.

Based on medical record review, interviews and facility policy review, the facility failed to make a notation of a change in condition, including interventions taken, in the resident's medical record. This affected two residents (#34 and #94) of 11 sampled residents. The facility census was 102.

Findings Include:

1. Review of the medical record for Resident #34 revealed an admission date of 10/09/25. Diagnoses included orthostatic hypotension, hypoxic ischemic encephalopathy, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, hypertension, congestive heart failure, morbid obesity, hyperlipidemia, anxiety disorder, depression, chronic obstructive pulmonary disease and hypothyroidism.

Review of the hospital discharge summary dated 03/07/26 revealed the resident was admitted to the local acute care hospital on 03/04/26 for congestive heart failure and was being discharged. The resident was to start the medications Lasix, Prednisone, Trelegy Ellipta and wear oxygen at two liters per nasal cannula continuously.

Review of the resident's progress note dated 03/07/26 at 3:41 P.M. revealed the resident returned to the facility via family transport from the hospital with new orders for Trelegy Ellipta twice daily, Lasix and Prednisone. The resident was also to keep his oxygen on at all times and the resident had a portable oxygen tank until an oxygen concentrator was delivered to the facility.

Review of the medical record revealed no documentation related to the significant change causing the resident to be hospitalized from 03/04/26 to 03/07/26.

On 05/21/26 at 11:29 A.M., an interview with the Regional Director of Care (RDOC) verified the facility had not documented the significant change causing the resident to be hospitalized in the resident's medical record.

2. Review of the medical record for Resident #94 revealed an admission date of 05/13/24. Diagnoses include hypertension, epilepsy and diabetes mellitus.

Review of the progress note dated 03/10/26 at 2:02 P.M., revealed the resident was sent out to the hospital due to a change in condition.

Review of the progress note dated 03/20/26 at 9:15 P.M. revealed the resident was readmitted to the facility at 5:30 P.M.

Review of the medical record revealed no documentation related to the significant change causing the resident to be hospitalized from 03/10/26 to 03/20/26.

On 05/21/26 at 11:29 A.M., an interview with the Regional Director of Care (RDOC) verified the facility had not documented the significant change causing the resident to be hospitalized in the resident's medical record.

Review of the facility policy titled, Change in Condition

Based on medical record review, review of facility email communication, interviews, and review of the facility incident/accident log, the facility failed to ensure medication errors were recorded on the incident/accident log containing the time, place, and date of the occurrence, a general description of the incident and the care provided or action taken. This affected three residents (#34, #76 and #94) of four residents reviewed for medication errors. The facility census was 102.

Findings Include:

1. Review of the medical record for Resident #76 revealed an admission date of 12/30/25. Diagnoses included presbyopia, anxiety disorder, plasmacytosis, chronic kidney disease, cognitive communication deficit, dementia, moderate with anxiety, insomnia, pancytopenia, multiple myeloma not having achieved remission and major depressive disorder.

Review of the resident's discharge orders from a skilled nursing facility (SNF), given to the current facility upon admission, revealed an order dated 08/06/25 for Revlimid 15 milligrams (mg) (a medication used to treat multiple myeloma cancer) by mouth daily with the special instructions to give for seven days then off the medication for seven days and 08/07/25 there was an order for a complete blood count with differential (CBCD) every two weeks on Thursday and to fax the results to the oncologist (physician who diagnoses and treats cancer) before administering the Revlimid on Friday.

Review of the resident's admission orders dated 12/23/25 revealed the resident was admitted to the facility on Revlimid with instructions to give one capsule by mouth every morning for seven days, then off for seven days. Further review revealed the order for the Revlimid had no strength and the 15 mg dose was not transcribed. Additional review revealed the order for a complete blood count with differential (CBCD) every two weeks was not transcribed.

Review of the resident's January, February and March 2026 Medication Administration Records (MAR) revealed no evidence the resident had received the medication Revlimid 15 mg by mouth daily for seven days then off the medication for seven days. Further review revealed the medication was not listed on the MAR to be administered.

Review of the resident's April 2026 MAR revealed the resident received seven days of Lenalidomide (Revlimid) 10 mg by mouth on 04/14/26 through 04/20/26. Further review under the Revlimid 15 mg, also listed on the MAR, revealed she was also administered the medication on 04/21/26 when medication was discontinued as the dosage was reduced to 10 mg by mouth. Additional review of the MAR revealed the resident had only received seven days of the medication instead of the 14 total days per month.

Review of an email dated 04/28/26 from the Vice President (VP) to the Regional Director of Care (RDOC) and four other unknown employees of the facility revealed they where aware the resident had missed the Revlimid medication and referenced in the email, we have missed multiple doses. The VP instructed the staff they needed to put a plan in place to show they identified the medication concern and fixed it due to the facility expected the Ohio Department of Health any day.

Review of the Physician Assistant (PA) progress note dated 04/29/26 revealed the resident was being seen for an assessment due to missing medications. The assessment indicated the medication missed was Revlimid and was resumed on 04/13/26.

Review of the facility's incident/accident log from 11/01/26 to 05/19/26 revealed no incidents of medication errors.

On 05/21/26 at 10:48 A.M., interview with the Regional Director of Care (RDOC) verified the resident had not received the medication Revlimid as physician ordered. The RDOC revealed an incident report would be created and placed on the facility's incident/accident log.

2. Review of the medical record for Resident #94 revealed an admission date of 05/13/24. Diagnoses include hypertension, epilepsy and diabetes mellitus.

Review of the resident's Mini-Mental exam dated 10/28/25 revealed a score of 26 indicating the resident had no cognitive impairment.

Review of the resident's self-medication administration evaluation dated 12/20/25 revealed the resident was not capable to administer her own medications.

Review of the resident's March 2026 Medication Administration Record (MAR) and physician orders revealed the medication Eszopiclone (Lunesta) 1 milligram (mg) daily at bedtime was discontinued on 03/21/26.

Review of the resident's controlled drug receipt/record/disposition form for the Eszopiclone 1 mg by mouth daily at bedtime revealed the resident was administered a dose on 04/02/26 without a physician's order.

Review of the facility's incident/accident log from 11/01/26 to 05/19/26 revealed no incidents of medication errors.

On 05/21/26 at 10:48 A.M., interview with the RDOC verified the medication error involving the Eszopiclone 1 mg by mouth was not entered on the facility's incident/accident log.

3. Review of the medical record for Resident #34 revealed an admission date of 10/09/25. Diagnoses included orthostatic hypotension, hypoxic ischemic encephalopathy, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, hypertension, congestive heart failure, morbid obesity, hyperlipidemia, anxiety disorder, depression, chronic obstructive pulmonary disease and hypothyroidism.

Review of the resident's history and physical (H&P) with his active medication list dated 10/01/25 revealed an order for Trelegy Ellipta 200 micrograms (mcg)-6.2 mcg-25 mcg/inhalation powder with the special instructions to inhale one puff daily.

Review of the resident's my medication schedule form from the rehabilitation hospital dated 10/09/25 revealed the Trelegy Ellipta 200 mcg-6.2 mcg-25mcg inhale one puff daily was on the active medication list scheduled every morning.

Review of the resident's admission orders dated 10/09/25 revealed no evidence the medication Trelegy Ellipta 200 mcg-6.2 mcg-25 mcg inhalation powder was transcribed from the H&P to the admission orders.

Review of the resident's Medication Administration Record (MAR) for December 2025, January 2026, and February 2026, the medication Trelegy Ellipta 200 mcg-6.2 mcg-25 mcg inhalation powder was not listed on the MAR to administer.

Review of the resident's progress note dated 03/07/26 at 3:41 P.M. revealed the resident returned to the facility via family transport from hospital with new orders for Trelegy Ellipta twice daily, Lasix and Prednisone and changed his order for Metoprolol. The resident was also to keep his oxygen on at all times and the resident had a portable oxygen tank until the oxygen concentrator was delivered to the facility.

Review of the resident's March 2026 MAR revealed the resident received the first dose of Trelegy Ellipta 200 mcg-6.2 mcg-25 mcg inhalation powder on 03/10/26 since being admitted to the facility on 10/09/25.

Review of the facility's incident/accident log from 11/01/26 to 05/19/26 revealed no incidents of medication errors.

On 05/21/26 at 10:48 A.M., interview with the RDOC verified the medication error involving the Trelegy Ellipta 200 mcg-6.2 mcg-25 mcg inhalation powder was not entered on the facility's incident/accident log.

This violation represents non-compliance investigated under Complaint Number OH00170446.

Based on observation, staff interview and facility policy review, the facility failed to label and date food items. This had the potential to effect all residents who received meals from the facility kitchen. The facility census was 102.

Findings include:

An observation on 05/19/26 at 9:27 A.M., of the facility kitchen revealed the following concerns:

a. In the food storage there were three bags of pasta, garlic cloves, cannoli filling and peppers not dated or labeled.

b. In the refrigerator there were pepperoni, cheese slices, chicken salad, and island blend vegetables that were not dated, and five containers of what looked like turkey slices were dated 03/19 and not labeled and or disposed of.

An interview at the time of the observation with Executive Chef #102 confirmed the above findings.

Review of the facility policy titled Dining Services Health Standards of Practice revealed food items should be date marked.

Based on facility fire drill record review, facility policy review, and staff interview, the facility failed to conduct quarterly fire drills on each shift. This had the potential to affect all residents residing in the facility. The facility census was 102.

Findings include:

Review of the fire drill reports revealed no documented evidence of completed fire drills, including first and second shift fire drills, during the second quarter of 2025, during the months of May 2025 and June 2025.

Interview on 05/20/26 at 1:50 P.M. with the Vice President of Operations (VPO) confirmed there was no documented evidence of completed fire drills, including first and second shift fire drills, during the second quarter of 2025, during the months of May 2025 and June 2025.

Review of the facility policy titled Fire Emergency Plan Policy revealed monthly fire drills were to be completed on each shift quarterly.

Based on medical record review and interview, the facility failed to ensure physician ordered laboratory tests were completed as ordered. This affected two residents (#34 and #76) of 11 sampled residents. The facility census was 102.

Findings Include:

1. Review of the medical record for Resident #76 revealed an admission date of 12/30/25. Diagnoses included presbyopia, anxiety disorder, plasmacytosis, chronic kidney disease, cognitive communication deficit, dementia, moderate with anxiety, insomnia, pancytopenia, multiple myeloma not having achieved remission and major depressive disorder.

Review of the resident's discharge orders from a skilled nursing facility (SNF) revealed an order dated 08/06/25 for Revlimid 15 milligrams (mg) (a medication used to treat multiple myeloma cancer) by mouth daily with the special instructions to give for seven days then off the medication for seven days and 08/07/25 for a complete blood count with differential (CBCD) every two weeks on Thursday and fax results to the oncologist (physician who diagnoses and treats cancer) before administering the Revlimid on Friday.

Review of the resident's admission orders dated 12/23/25, prior to the resident's admission, revealed the order for the complete blood count with differential (CBCD) every two weeks on Thursday and fax results to the oncologist before administering the Revlimid on Friday was not transcribed.

Review of the resident's medical record revealed no evidence the CBCD was completed and sent to the oncologist every two weeks as ordered from January 2026 through April 2026.

On 05/20/26 at 10:40 A.M., an interview with Oncologist Licensed Practical Nurse (OLPN) #278 verified the resident was to receive Revlimid 15 mg by mouth with the special instructions to give every morning for seven days then off for seven days until the resident's appointment in February 2026 when the Oncologist decreased the dose to 10 mg by mouth with the special instructions to give every morning for seven days then off for seven days. The OLPN revealed the Oncologist was not aware the resident missed the doses of Revlimid until the resident's guardian notified the Oncologist when the guardian found the medication in the resident's apartment on 03/21/26 in the resident's purse. The OLPN revealed the resident had scheduled deliveries in January, February and March 2026 of the medication. The OLPN revealed the Oncologist was having communication issues with the facility regarding the labs ordered and the Calcium supplement the resident was to start receiving. The OLPN verified the laboratory test (CBCD) was a current order and should be completed prior to the start of each cycle of Revlimid.

On 05/20/26 at 2:10 P.M., an interview with Licensed Practical Nurse (LPN) #216 verified the CBCD was not obtained every two weeks as physician ordered.

2. Review of the medical record for Resident #34 revealed an admission date of 10/09/25. Diagnoses included orthostatic hypotension, hypoxic ischemic encephalopathy, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, atrial fibrillation, hypertension, congestive heart failure, morbid obesity, hyperlipidemia, anxiety disorder, depression, chronic obstructive pulmonary disease and hypothyroidism.

Review of the resident's telephone orders revealed an order dated 03/08/26 for a basic metabolic panel (BMP) and a B-type natriuretic peptide (BNP).

Review of the medical record revealed no documented evidence the BMP and BNP were completed as ordered.

On 05/20/26 at 2:10 P.M., an interview with Licensed Practical Nurse (LPN) #216 verified the BMP and the BNP were not completed as ordered.

This violation represents non-compliance investigated under Complaint Number OH00170446 and Complaint Number OH00170021.

Based on resident and staff interviews, medical record review, review of call light audits, and review of staff schedules, the facility failed to ensure sufficient and competent staffing on all shifts to meet resident needs. The affected four residents (#20, #30, #37 and #102) and had the potential to affect all 90 residents residing in the facility. The facility census was 90.

Findings Include:

1. Interviews on 01/22/25 at 3:05 P.M. and 01/23/25 at 8:30 A.M. with Personal Care Assistant (PCA) #205 and PCA #240 respectively revealed the facility was frequently staffed with only two aides during night shift and when they arrived for the start of their day shift at 7:00 A.M. residents were frequently found wet or soaked.

Interview on 01/27/25 at 7:25 A.M. with PCA #250 confirmed there were two aides who worked during nightshift on 01/26/25 from 11:00 P.M. to 7:00 A.M. on 01/27/25. PCA #250 stated her care assignment included the entire first floor, approximately 45 residents. PCA #250 reported there were three residents who required two person assistance, seven residents who required staff assistance with care all of the time

Based on closed record review and interview, the facility failed to ensure Resident #102's fall and subsequent unexpected death were included on the facility incident and accident log, failed to ensure an accurate investigation and accurate and timely communication of the circumstances of the resident's death were relayed to the resident's responsible party, physician and coroner and failed to ensure the local police were notified of the incident at the time of occurrence for possible further investigation. This affected one resident (#102) and had the potential to affect all 90 residents residing in the facility.

Findings include:

Review of the closed medical record for Resident #102 revealed an admission date of 04/14/23 with medical diagnoses including vascular dementia with psychotic disturbance, history of falling, cerebral aneurysm non-ruptured, cerebral atherosclerosis (plaque build up in the arteries of the brain), and diabetes mellitus with diabetic dermatitis. Resident #102 passed away at the facility on 01/03/25.

Review of the admission Mini-Mental State Examination Results and Service Plan dated 01/23/24 revealed Resident #102 scored 18 out of 30 on the exam, an indication of moderate cognitive impairment.

Review of a service plan dated 03/19/24 revealed Resident #102 had a behavior of wandering. Actions included: give resident instruction card with simple details (address and phone number) to keep in purse or wallet should they wander, have a picture and description of resident, have identification and contact numbers for the resident, offer resident support and listen to help the resident deal with his or her anger, improve the resident's safety by removing throw rugs, labeling rooms, and keeping the area well lit, notify other caregivers about resident's wandering behavior, and respond calmly and do not raise your voice. Resident #102 required assistance with toileting and nightly incontinence checks. The service plan revealed Resident #102 was forgetful and required safety checks every two hours.

Review of the staff schedules dated 01/02/25 revealed there were two aides, Personal Care Assistant (PCA) #210 and PCA #250 scheduled during night shift from 11:00 P.M. to 7:00 A.M. on 01/03/25. PCA #210 was assigned to care for Resident #102.

Review of the time punch for PCA #210 revealed the employee punched in on 01/02/25 at 11:03 P.M. and punched out on 01/03/25 at 7:07 A.M. Review of the time punch for PCA #250 revealed the employee punched in on 01/02/25 at 7:30 P.M. and punched out on 01/03/25 at 8:02 A.M.

Review of the facility incident and accident log revealed no documented incidents were included on the log involving Resident #102 on 01/02/25 or 01/03/25.

Review of the only progress note documented in Resident #102's medical record related to Resident #102's death was a progress note entered on 01/07/24 at 2:46 P.M. This note included on 01/03/25 at 2:45 P.M.,Director of Care (DOC) #221 was paged to Resident #102's room STAT (immediately). Upon entering the room, DOC #221 observed Resident #102 immediately off his concrete patio laying on the right side of his stomach, with slippers on and his walker overturned beside him on his left side. DOC #221 called Resident #102's name, then checked for a pulse. No pulse was found. DOC #221 instructed the staff to help roll Resident #102 over to check for respirations. At that time, there were not any respirations, and staff were unable to obtain vital signs. DOC #221 asked LPN #207 to also check for vital signs. LPN #207 confirmed Resident #102 did not have any vital signs. DOC #221 requested LPN #207 verify Resident #102's code status. LPN #207 confirmed Resident #102 was a Do Not Resuscitate Comfort Care (DNRCC). DOC #221 instructed staff to help Resident #102 off the ground and back into his bed. DOC #221 visualized redness to the right side of the cheek area and no other visible signs of injuries noted. Postmortem care was provided for family viewing. DOC #221 contacted Physician Assistant (PA) #410 via telephone. PA #410 gave a verbal order to release Resident #102's body to the funeral home of the family's choice. DOC #221 contacted Resident #102's Power of Attorney (POA) at approximately 10:50 A.M. The resident's family arrived for the viewing of Resident #102 at approximately 12:10 P.M. The resident's family inquired if an autopsy would be completed. DOC #221 contacted the funeral home to ask about an autopsy. The funeral home instructed DOC #221 to contact the Coroner's Office. DOC #221 spoke with Coroner Investigator (CI) #305. DOC #221 answered questions regarding Resident #102's past medical history, diagnosis, and date of last documented fall. CI #305 gave a verbal order to release the body to the funeral home. Resident #102's body was released to the funeral at approximately 1:10 P.M.

Review of a witness statement for PCA #250 completed by DOC #221 dated 01/10/25 revealed PCA #250 reporting last seeing Resident #102 at approximately 9:30 P.M. on 01/02/25 before she switched assignments to the second floor for the duration of night shift.

The facility had witness statements from direct care staff who worked on 01/03/25 and were involved with the situation, including PCA #240, LPN #207 and PCA #205.

A written statement provided by PCA #240 dated 01/03/25 (untimed) revealed she walked into Resident #102's room to pass a breakfast tray (no time noted) to the resident and observed the resident not to be in his bed or in the bathroom. PCA #240 observed Resident #102's back patio door to be cracked a little. PCA #240 looked outside and observed Resident #102's face in the concrete and legs in the snow/grass. PCA #240 called for assistance. DOC #221, PCA #232, PCA #205, and LPN #207 responded to the resident's room, assisted with putting the resident into his wheelchair and into bed then cleaned the resident.

Review of PCA #205's written statement dated 01/03/25 (untimed) revealed she responded to PCA #240's call for assistance in Resident #102's room. Upon arriving to the resident's room, PCA #205 observed Resident #102 outside of his room unalive and face down in the concrete. DOC #221 confirmed Resident #102 was deceased and insisted PCA #240, PCA #232, LPN #207, and herself assist to get Resident #102 off the ground and into his wheelchair and then placed the resident into his bed. PCA #205 assisted with cleaning Resident #102 for the family.

Review of LPN #207's written statement dated 01/04/25 at 5:23 P.M. revealed LPN #207 overheard PCA #240's call for a nurse STAT to Resident #102's room. Upon entering the room, she observed PCA #240, PCA #232, and PCA #205 and Resident #102's patio door was opened. As LPN #207 approached the patio door, she observed Resident #102's feet. LPN #207 continued outside and observed Resident #102 laying face down on his right side with his body on the neighboring patio. Resident #102 was not moving or breathing and did not have a pulse. DOC #221 arrived to the resident's room, stepped outside, and felt for a pulse. DOC #221 stated she did not feel a pulse. LPN #207 confirmed Resident #102 was a DNRCC. DOC #221 stated staff needed to move Resident #102 into his bed. LPN #207, Lead Personal Care Assistant (LPCA) #232, PCA #205, and PCA #240 transferred Resident #102 into his wheelchair and then into his bed. DOC #221 instructed the staff to clean Resident #102 up for the family.

Review of the facility investigation dated 01/10/25 (seven days after the incident) and completed by DOC #221 revealed an investigation template was completed related to Resident #102's unexpected death on 01/03/25. Resident #102 was noted to be independently mobile without capacity to make informed decisions. A PCA (identified as PCA #240) entered Resident #102's room and discovered the resident laying on the ground on his right side on his external patio. Resident #102 did not respond to verbal communication, no palpable pulse was found, and no respirations were visualized. Vital signs were attempted to be obtained by two LPNs, however, none were obtained. The resident's code status was verified as DNRCC. The Primary Care Physician (PCP) was notified and provided an order to release the resident's body to the funeral home. Resident #102's POA, the facility's Executive Director (ED), Regional Director of Care (RDOC) #302, Regional Vice President of Operations (RVPO) #304, and the Coroner's Officer were notified and an investigation was initiated. The facility's investigation revealed Resident #102 was last checked on by a PCA (identified as PCA #210) on 01/03/25 between 4:00 A.M. and 4:30 A.M. Resident #102 was discovered on 01/03/25 at 9:30 A.M. (five hours later) on his external patio without vital signs. PCA #210 was placed on administrative leave on 01/07/25 (four days after the incident) and in-service on two to three hour walking rounds being completed was first conducted with staff on 01/15/25 (12 days after the incident).

On 01/22/25 at 10:48 A.M. a telephone interview with Resident #102's responsible party, Responsible Party (RP) #307 revealed DOC #221 had contacted her on 01/03/25 and told her Resident #102 had a fall, was unresponsive and the funeral home came and got him. Then, DOC #221 stated the funeral home had not been to the facility yet and Resident #102 was still in his room for family viewing. The responsible party revealed she went to the facility and upon entering Resident #102's room, she observed fresh mud on the wheels of the resident's walker and there was also mud and a leaf stuck to the bottom of the resident's slippers. RP #307 stated she was told by another staff member that Resident #102 had been found outside. RP #307 stated Resident #102 wore a bracelet that was supposed to keep him from exiting doors to the outside. During the interview RP #307 stated DOC #221 indicated Resident #102 was found in his room, face down. RP #307 discussed having an autopsy completed with DOC #221. DOC #221 informed RP #307 she had called the Coroner's Office but no further information was provided.

On 01/22/25 at 3:05 P.M. an interview with PCA #205 revealed she and PCA #240 were the two PCA staff scheduled to work the day shift on 01/03/25 to provide direct resident care. (Review of time punches revealed both PCA #240 and PCA #205 punched in on 01/03/25 at 7:46 A.M.) PCA #205 revealed Resident #102 was assigned to PCA #240 on the day shift and the resident had been assigned to PCA #210 during night shift on 01/02/25. PCA #205 confirmed PCA #240 was the first staff person to locate Resident #102 (on 01/03/25). PCA #205 stated she responded to PCA #240's call for assistance via the walkie talkie. PCA #205 stated upon arriving at the resident's room, Resident #102 was observed outside, facedown, laying on the neighboring patio which was diagonal from the resident's outside patio with his walker beside him. PCA #205 stated, it was snowing outside and you could tell the resident had been out there for awhile because his walker was filled up with snow and his clothes were soaking wet when we found him. PCA #205 stated DOC #221 instructed the staff to lift Resident #102 off the ground, place him in his wheelchair, clean him up, and then place him in his bed with the covers over him before the family arrived at the facility. PCA #205 stated Resident #102's family was asking questions about what happened but DOC #221 had instructed the staff not to report anything to the family due to completing an investigation.

On 01/23/25 at 9:33 A.M. an interview with Coroner's Investigator (CI) #305 revealed on 01/03/25 DOC #221 called and informed their office Resident #102 was found on floor at approximately 9:30 A.M. with no signs of trauma. It was reported the resident was last known alive earlier that morning without any complaints. CI #305 stated had accurate information related to the incident been reported she probably would have asked a lot more questions to determine if further investigation needed to be completed. CI #305 confirmed the information including Resident #102 being found outside, deceased, with noted injuries to the right side of his face was pertinent information for the Coroner's Office to be made aware of to determine whether or not the office would pick the case up for further investigation.

On 01/23/25 at 11:59 A.M. an interview with DOC #221 revealed following the facility's investigation, it was determined PCA #210 failed to complete safety checks as required every two to three hours for Resident #102 during night shift. DOC #221 confirmed PCA #210 last peeked in on Resident #102 at approximately 4:00 A.M. on 01/03/25 and the resident was found deceased at approximately 9:30 A.M. (five hours later). DOC #221 confirmed Resident #102 required checks every two to three hours. DOC #221 was asked what information had been provided to the Coroner's Office and she initially stated she had informed the Coroner's Office that the resident had been found outside however, then she changed her response to I'm pretty sure I said he was found on the ground. DOC #221 stated she notified PA #410 that Resident #102 had fallen and was found outside. DOC #221 stated PA #410 was responsible for notifying Physician #306 of Resident #102's death.

On 01/27/25 at 8:20 A.M., the Coroner's Office was contacted by the ED who provided updated/accurate information of the incident on 01/03/25 involving Resident #102. The ED explained how Resident #102 was found lying outside his patio door on 01/03/25 and that 911 was not called at that time

On 01/27/25 at 4:19 P.M. an interview with Physician #306 via telephone revealed he did not recall being informed of any residents being found outside on their patio deceased at the facility and he stated he believed he would remember that if it occurred. Physician #306 stated if he was made aware of all of the information surrounding Resident #102's death, he would have asked more questions and considered the possibility of having the Coroner's Office look into the death.

On 01/29/25 at 12:30 P.M. an interview with PA #410 revealed she had been notified via text message by DOC #221 that Resident #102 was found partially inside and partially outside on his patio without vital signs and requested further instructions at approximately 10:00 A.M. on 01/03/25. PA #410 did not feel there were any unusual circumstances surrounding Resident #102's death from the information she received and gave the order to have Resident #102's body released to the funeral home.

On 01/29/25 at 2:00 P.M., the ED contacted Resident #102's family and provided details surrounding the resident's death, including that Resident #102 had been found lying outside his patio door.

On 01/29/25 at 5:32 P.M., Physician #306 was contacted by Licensed Nursing Home Administrator (LNHA) #405 and informed Resident #102 had been found (on 01/03/25) on the ground outside of his patio door.

Review of the facility policy, Incident Reporting

Based on observation, staff interview, and facility policy review, the facility failed to follow proper procedures when an exit door was alarming without a known cause. The had the potential to affect all 90 residents living in the facility. The facility census was 90.

Findings Include:

Observation on 01/27/25 at 7:42 A.M. revealed Personal Care Assistant (PCA) #247 responded to an alarming exit door at the end of the hallway by room 163. There was a door labeled Stairs to the left of the exit door that was not alarming. PCA #247 stated, someone with a wander guard set this alarm off. PCA #247 confirmed she did not see how the alarm was triggered. PCA #247 opened the exit door and stepped just outside onto the sidewalk and looked both ways. The aide returned inside the facility and stated, I don't see anyone. PCA #247 turned the alarm off and continued to a resident room to respond to a call light request for assistance. PCA #247 did not notify any other staff of the alarming exit door. The exit door was observed to lead out to a parking lot and then to a busy intersection.

Interview on 01/27/25 at 8:00 A.M. with Licensed Practical Nurse (LPN) #260 revealed when an exit door was alarming without a known cause, the alarm should be announced to all staff via the walkie talkie so staff can respond to the area to further investigate. LPN #260 confirmed there were no announcements about an alarming exit door on the walkie talkie made this morning and she was not aware of any alarming exit doors this morning.

Interview on 01/27/25 at 8:18 A.M. with the Executive Director (ED) confirmed the proper procedure for an alarming exit door with an unknown cause was to go outside and search the surrounding area first. Then, all residents in the facility were to be accounted for by the staff conducting visual checks. The ED confirmed she was not aware of any exit doors alarming this morning.

Review of the facility policy, Missing Resident Protocol & Code 999

Based on observation, closed medical record review, review of a facility investigation, review of online Columbus weather data, review of staff schedules, facility policy and procedure review, and interview, the facility failed to provide adequate supervision, intervention and routine safety checks to prevent Resident #102, who had a diagnosis of dementia, impaired decision making, and wore a wander guard, from exiting through his patio door to the outside courtyard. This resulted in Real and Present Danger and actual harm/resident death on 01/03/25 at 9:30 A.M. when Resident #102 was found outside lying on an adjacent patio on his right side in wet clothing with his head on the concrete patio. The resident's walker was found beside him filled with snow. Resident #102 was found with no palpable pulse, no respirations, and no obtainable vital signs confirmed by Director of Care (DOC) #221 and Licensed Practical Nurse (LPN) #207. After confirming Resident #102 had advance directives for Don Not Resuscitate Comfort Care (DNRCC), DOC #221 instructed Personal Care Aides (PCAs) #205 and #240, LPN #207, and Lead Personal Care Assistant (LPCA) #232 to transfer the resident inside and place him into his bed. DOC #221 then instructed the staff to provide postmortem care. The facility investigation revealed Resident #102 was last seen laying in his bed between 4:00 A.M. and 4:30 A.M. by PCA #210. Resident #102's service plan indicated the resident required safety checks every two hours. This affected one resident (#102) and had the potential to affect ten additional residents (#1, #8, #11, #16, #38, #45, #49, #61, #70, and #100) who were identified as having a diagnosis of dementia and resided in an apartment with a patio door leading directly to the outside. The facility census was 90.

On 01/23/25 at 4:30 P.M. the Executive Director (ED) and DOC #221 were notified Real and Present Danger occurred on 01/03/25 at 9:30 A.M. when facility staff failed to provide adequate supervision and/or safety interventions resulting in Resident #102 being found outside the facility lying on an adjacent concrete patio deceased.

The Real and Present Danger was abated on 01/29/25 when the facility implemented the following corrective actions:

On 01/03/25 at 3:00 P.M., DOC #221 assessed 43 residents with external patios and balconies for safety and determined all residents were safe at that time. Of the 43 residents with patio doors to the outside of the facility, ten residents, Resident #1, #8, #11, #16, #38, #45, #49, #61, #70, and #100 were identified who had a diagnosis of dementia. No changes were made for these ten residents at that time.

On 01/07/25 at 3:30 P.M., DOC #221 placed Personal Care Assistant (PCA) #210 on administrative leave pending the outcome of an investigation. PCA #210 was terminated effective 01/24/25 due to failure to perform a safety check as required (for Resident #102) and failure to wait for relief at the end of her shift on 01/03/25.

On 01/15/25 at 2:30 P.M., the Executive Director (ED) educated all clinical staff on walking rounds with the sign off on Activities of Daily Living (ADL) task sheet and change of condition policy. The PCA staff do not have access to the electronic health record system. The ADL task sheet is a condensed care plan with details of how the residents bathe, dress, groom, toilet and/or complete incontinence care, ambulate, transfer, cognition, participate in meals and activities, housekeeping needs and frequency, laundry days, and whether or not the resident required safety checks.

On 01/15/25 at 2:30 P.M., the ED educated all staff on Resident Rights. The in-service was titled, Ombudsman-The Nursing Home & Assisted Living Residents' Bill of Rights. All 32 resident rights were covered in the educational in-service, including the right to a clean and safe environment.

On 01/23/25 at 10:30 A.M., the ED educated Sales Director (SD) #223 regarding not admitting any resident with a dementia diagnosis, wandering behavior, and/or found to be at risk for elopement to an apartment with an outdoor patio or balcony.

On 01/23/25 at 5:30 P.M., Regional Director of Care (RDOC) #302 educated the ED on Resident Rights, Change in Condition, and not admitting any residents with a dementia diagnosis, wandering behavior, and/or at risk for elopement to an apartment with an outdoor patio or balcony.

On 01/24/25 at 1:30 P.M. the Regional Director of Maintenance (RDOM) #300 contacted the local State Fire Marshal to determine if a six-inch opening on an external patio door met fire code. On 01/27/25, the Fire Marshal approved a six-inch opening for all external patio and balcony doors that do not serve as fire exits. This width was determined to prevent resident egress. On 01/28/25 at 2:00 P.M. all patio doors were secured with six-inch opening by RDOM #300. On 01/29/25 at 6:00 P.M., the ED moved Resident #45 and Resident #49 to apartments which did not have a patio or a balcony due to the inability to ensure the resident's door to the outside opened no more than six inches and these residents' diagnosis of dementia.

On 01/24/25 at 4:00 P.M., the ED provided corrective action to DOC #221 related to the incident involving Resident #102 which included the failure to notify local police at the time of the incident.

On 01/24/25 at 4:16 P.M., the ED called the local police department to file a police report. Police Officer (PO) #412 arrived at the facility and obtained a statement about what occurred on 01/03/25. DOC #221 and the ED provided information about the incident. DOC #221 explained Resident #102 was found lying outside his patio door on the right side of his stomach. There was redness on the right side of the resident's cheek. DOC #221 checked for pulse and respirations and instructed the shift nurse (Licensed Practical Nurse (LPN) #207) to confirm the resident's code status (confirmed to be Do Not Resuscitate Comfort Care (DNRCC)). LPN #207 was asked to confirm Resident #102 did not have a pulse. DOC #221 instructed the staff to help lift Resident #102 off the ground and place him in his bed to provide postmortem care. DOC #221 informed PO #412 she had not called 911 at the time of the incident. PO #412 completed a police report and indicated it could take seven to ten days to complete. A report number was provided.

On 01/27/25 at 8:20 A.M., the Coroner's Office was contacted by the ED who provided updated/accurate information of the incident on 01/03/25 involving Resident #102. The ED explained how Resident #102 was found lying outside his patio door on 01/03/25 and that 911 was not called at that time.

On 01/27/25 at 11:00 A.M., the ED and designee provided staff re-education on the ADL task sheet, the resident Bill of Rights, fall policy, abuse and neglect policy, and proper protocol to follow in the event of a resident death. Any staff who were not re-educated by 01/29/25 at 3:00 P.M. were removed from the schedule immediately and would not return to work until the re-education was completed.

Beginning the week of 01/27/25 between 12:30 P.M. and 2:00 P.M., a weekly resident review meeting with the ED, Regional Director of Care (RDOC) #302, and/or Regional Vice President Of Operations (RVPO) #304 to discuss resident topics of ADL task sheets, new admissions, overall resident care, care concerns and interventions, new hire orientation review of the orientation checklist, and review of all 32 resident rights within the community ongoing until 07/31/25 and as needed thereafter.

Beginning the week of 01/27/25 between 7:00 A.M. and 11:59 A.M., the ED or designee would interview five random staff members on resident rights across all departments three times a week for 30 days, then once a week for 30 days then every two weeks for 30 days, then random as needed.

Beginning the week of 01/27/25 between 7:00 A.M. and 11:59 A.M. the ED or designee would audit signed ADL task sheets verifying care was completed every three days for 30 days, weekly for 30 days, biweekly for 30 days and then random thereafter. Any deficiencies would be investigated and corrected immediately by the DOC or designee.

On 01/28/25 at 12:00 P.M., DOC #221 was placed on administrative leave due to not cooperating with the State agency investigation involving Resident #102.

On 01/28/25 at 5:00 P.M., the 43 residents who resided in an apartment with a patio or balcony were reassessed by Licensed Practical Nurse (LPN) 400 and found to be safe to remain in their current apartments at this time.

The ED or designee would educate all new hire employees on all 32 resident rights to include the right to a safe and clean environment beginning in new hire weekly orientation class on 01/28/25 between 9:00 A.M. and 5:00 P.M.

The ED or designee would educate all new clinical employees (nurses, medication techs, and personal care assistants) on change in condition, what constitutes change of condition, who and when to notify, and completion of visual checks every two to three hours in new hire weekly orientation beginning on 01/28/25 between 9:00 A.M. and 5:00 P.M.

On 01/29/25 at 2:00 P.M., the ED contacted Resident #102's family and provided details surrounding the resident's death, including that Resident #102 had been found lying outside his patio door.

On 01/29/25 at 5:00 P.M., LPN #407 with oversight from the regional team (including RVPO #304 and RDOC #302) was designated to lead the clinical team.

On 01/29/25 at 5:32 P.M., Physician #306 was contacted by Licensed Nursing Home Administrator (LNHA) #405 and informed Resident #102 had been found (on 01/03/25) on the ground outside of his patio door.

On 01/30/25 at 2:30 P.M., all nursing staff were scheduled to receive training related to recognizing, responding, and documenting changes of condition and resident rights with Clinical Risk Management Consultant (CRMC) #303.

On 01/31/25 at 11:59 A.M., the ED or designee would complete Mini-Mental Status Assessments on all 87 residents who were residing in the facility on 01/31/25.

By 01/31/25 between 11:00 A.M. and 11:30 A.M. Regional Sales Advisor (RSA) #301 would modify the admission checklist and educate all Senior Living Advisors that no resident with a dementia diagnosis would be moved into an apartment with a patio or balcony.

The ED or designee would address any trends identified with Quality Assurance Performance Improvement Committee quarterly and as needed. An action plan would be developed and implemented to ensure compliance.

Although Real and Present Danger was abated on 01/29/25, the facility remained out of compliance as the facility was in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings Include:

Review of the closed medical record for Resident #102 revealed an admission date of 04/14/23 with medical diagnoses including vascular dementia with psychotic disturbance, history of falling, cerebral aneurysm non-ruptured, cerebral atherosclerosis (plaque build up in the arteries of the brain), and diabetes mellitus with diabetic dermatitis. Resident #102 passed away at the facility on 01/03/25.

Review of the admission Mini-Mental State Examination Results and Service Plan dated 01/23/24 revealed Resident #102 scored 18 out of 30 on the exam, an indication of moderate cognitive impairment.

Review of a service plan dated 03/19/24 revealed Resident #102 had a behavior of wandering. Actions included: give resident instruction card with simple details (address and phone number) to keep in purse or wallet should they wander, have a picture and description of resident, have identification and contact numbers for the resident, offer resident support and listen to help the resident deal with his or her anger, improve the resident's safety by removing throw rugs, labeling rooms, and keeping the area well lit, notify other caregivers about resident's wandering behavior, and respond calmly and do not raise your voice. Resident #102 required assistance with toileting and nightly incontinence checks. The service plan revealed Resident #102 was forgetful and required safety checks every two hours.

Review of the semi-annual Elopement Results and Service Plan assessment dated 03/19/24 revealed Resident #102 had a wander guard (an alarm system that is used to monitor residents who are at risk from wandering) placed upon admission due to the resident voicing his dislike of having to move into a facility. When Resident #102 had a positive urinary tract infection the resident had a history of demonstrating exit seeking behavior.

Review of the staff schedules dated 01/02/25 revealed there were two aides, PCA #210 and PCA #250 scheduled during night shift from 11:00 P.M. to 7:00 A.M. on 01/03/25. PCA #210 was assigned to care for Resident #102.

Review of the time punch for PCA #210 revealed the employee punched in on 01/02/25 at 11:03 P.M. and punched out on 01/03/25 at 7:07 A.M. Review of the time punch for PCA #250 revealed the employee punched in on 01/02/25 at 7:30 P.M. and punched out on 01/03/25 at 8:02 A.M.

Review of online weather data for Columbus, Ohio at https://www.timeanddate.com/weather/usa/columbus/historic?month=1&year=2025 revealed on 01/03/25 between 6:00 A.M. and 12:00 P.M. a high temperature of 27 to 30 degrees Fahrenheit (F) with a low of 25 to 27 degrees F, light snow and 14 to 21 mile per hour (mph) winds.

Review of the facility incident and accident log revealed no documented incidents were included on the log involving Resident #102 on 01/02/25 or 01/03/25.

Review of the only progress note documented in Resident #102's medical record related to Resident #102's death was a progress note entered on 01/07/24 at 2:46 P.M. This note included on 01/03/25 at 2:45 P.M., DOC #221 was paged to Resident #102's room STAT (immediately). Upon entering the room, DOC #221 observed Resident #102 immediately off his concrete patio laying on the right side of his stomach, with slippers on and his walker overturned beside him on his left side. DOC #221 called Resident #102's name, then checked for a pulse. No pulse was found. DOC #221 instructed the staff to help roll Resident #102 over to check for respirations. At that time, there were not any respirations, and staff were unable to obtain vital signs. DOC #221 asked LPN #207 to also check for vital signs. LPN #207 confirmed Resident #102 did not have any vital signs. DOC #221 requested LPN #207 verify Resident #102's code status. LPN #207 confirmed Resident #102 was a DNRCC. DOC #221 instructed staff to help Resident #102 off the ground and back into his bed. DOC #221 visualized redness to the right side of the cheek area and no other visible signs of injuries noted. Postmortem care was provided for family viewing. DOC #221 contacted Physician Assistant (PA) #410 via telephone. PA #410 gave a verbal order to release Resident #102's body to the funeral home of the family's choice. DOC #221 contacted Resident #102's Power of Attorney (POA) at approximately 10:50 A.M. The resident's family arrived for the viewing of Resident #102 at approximately 12:10 P.M. The resident's family inquired if an autopsy would be completed. DOC #221 contacted the funeral home to ask about an autopsy. The funeral home instructed DOC #221 to contact the Coroner's Office. DOC #221 spoke with Coroner Investigator (CI) #305. DOC #221 answered questions regarding Resident #102's past medical history, diagnosis, and date of last documented fall. CI #305 gave a verbal order to release the body to the funeral home. Resident #102's body was released to the funeral at approximately 1:10 P.M.

Review of a witness statement for PCA #250 completed by DOC #221 dated 01/10/25 revealed PCA #250 reporting last seeing Resident #102 at approximately 9:30 P.M. on 01/02/25 before she switched assignments to the second floor for the duration of night shift.

A written statement provided by PCA #240 dated 01/03/25 (untimed) revealed she walked into Resident #102's room to pass a breakfast tray (no time noted) to the resident and observed the resident not to be in his bed or in the bathroom. PCA #240 observed Resident #102's back patio door to be cracked a little. PCA #240 looked outside and observed Resident #102's face in the concrete and legs in the snow/grass. PCA #240 called for assistance. DOC #221, PCA #232, PCA #205, and LPN #207 responded to the resident's room, assisted with putting the resident into his wheelchair and into bed then cleaned the resident.

Review of PCA #205's written statement dated 01/03/25 (untimed) revealed she responded to PCA #240's call for assistance in Resident #102's room. Upon arriving to the resident's room, PCA #205 observed Resident #102 outside of his room unalive and face down in the concrete. DOC #221 confirmed Resident #102 was deceased and insisted PCA #240, PCA #232, LPN #207, and herself assist to get Resident #102 off the ground and into his wheelchair and then placed the resident into his bed. PCA #205 assisted with cleaning Resident #102 for the family.

Review of LPN #207's written statement dated 01/04/25 at 5:23 P.M. revealed LPN #207 overheard PCA #240's call for a nurse STAT to Resident #102's room. Upon entering the room, she observed PCA #240, PCA #232, and PCA #205 and Resident #102's patio door was opened. As LPN #207 approached the patio door, she observed Resident #102's feet. LPN #207 continued outside and observed Resident #102 laying face down on his right side with his body on the neighboring patio. Resident #102 was not moving or breathing and did not have a pulse. DOC #221 arrived to the resident's room, stepped outside, and felt for a pulse. DOC #221 stated she did not feel a pulse. LPN #207 confirmed Resident #102 was a DNRCC. DOC #221 stated staff needed to move Resident #102 into his bed. LPN #207, LPCA #232, PCA #205, and PCA #240 transferred Resident #102 into his wheelchair and then into his bed. DOC #221 instructed the staff to clean Resident #102 up for the family.

While there was no written statement from PCA #210 as part of the facility investigation, the facility provided text message communication between DOC #221 and PCA #210. Review of text messages communicated between DOC #221 and PCA #210 dated and signed on 01/09/25 revealed PCA #210 was not aware Resident #102 required check and changes throughout the night. PCA #210 stated I just kind of peeked in to Resident #102's room at approximately 4:00 A.M. (on 01/03/25) and the resident was in bed from what she could tell. PCA #210 stated she was aware of what a resident care plan was but had never seen one for Resident #102. DOC #221 asked PCA #210 if she knew to check the resident care board. PCA #210 stated she was told the board was outdated and she did not know Resident #102 required check and changes. DOC #221 informed PCA #210 that Resident #102 required safety checks every two to three hours and required assistance to the bathroom.

Review of the facility investigation dated 01/10/25 (seven days after the incident) and completed by DOC #221 revealed an investigation template was completed related to Resident #102's unexpected death on 01/03/25. Resident #102 was noted to be independently mobile without capacity to make informed decisions. A PCA (identified as PCA #240) entered Resident #102's room and discovered the resident laying on the ground on his right side on his external patio. Resident #102 did not respond to verbal communication, no palpable pulse was found, and no respirations were visualized. Vital signs were attempted to be obtained by two LPNs, however, none were obtained. The resident's code status was verified as DNRCC. The Primary Care Physician (PCP) was notified and provided an order to release the resident's body to the funeral home. Resident #102's POA, the facility's ED, RDOC #302, RVPO #304, and the Coroner's Officer were notified and an investigation was initiated. The facility's investigation revealed Resident #102 was last checked on by a PCA (identified as PCA #210) on 01/03/25 between 4:00 A.M. and 4:30 A.M. Resident #102 was discovered on 01/03/25 at 9:30 A.M. (five hours later) on his external patio without vital signs. Additional staff identified as witnesses to the incident included PCA #210, PCA #205, PCA #240, PCA #250, PCA #500, and LPCA #232. Review of the facility schedule and additional investigation information revealed PCA #500 worked on 01/02/25 from 6:56 A.M. to 3:08 P.M. and no witness statement was obtained from this PCA. There were not any LPNs listed as a witness to the incident. The investigation revealed DOC #221 assessed additional residents who resided in apartments with patios for risks on 01/03/25. PCA #210 was placed on administrative leave on 01/07/25 (four days after the incident) and in-service on two to three hour walking rounds being completed was first conducted with staff on 01/15/25 (12 days after the incident).

On 01/22/25 at 10:48 A.M. a telephone interview with Resident #102's responsible party, Responsible Party (RP) #307 revealed DOC #221 had contacted her on 01/03/25 and told her Resident #102 had a fall, was unresponsive and the funeral home came and got him. Then, DOC #221 stated the funeral home had not been to the facility yet and Resident #102 was still in his room for family viewing. The responsible party revealed she went to the facility and upon entering Resident #102's room, she observed fresh mud on the wheels of the resident's walker and there was also mud and a leaf stuck to the bottom of the resident's slippers. RP #307 stated she was told by another staff member that Resident #102 had been found outside. RP #307 stated Resident #102 wore a bracelet that was supposed to keep him from exiting doors to the outside. During the interview RP #307 stated DOC #221 indicated Resident #102 was found in his room, face down. RP #307 discussed having an autopsy completed with DOC #221. DOC #221 informed RP #307 she had called the Coroner's Office but no further information was provided.

On 01/22/25 at 2:49 P.M. an interview with LPN #207 (who worked on 01/03/25 from 6:59 A.M. until 3:21 P.M.) revealed she responded to PCA #240's request for assistance in Resident #102's room on 01/03/25. LPN #207 confirmed Resident #102 was found outside on a patio laying facedown and was unresponsive at approximately 9:30 A.M. LPN #207 stated Resident #102 was already deceased when he was found outside. LPN #207 stated Resident #102 was able to ambulate to and from the bathroom inside his room but typically used a wheelchair for longer distances. LPN #207 stated at the time the resident was found, he did not feel stiff but was very cold to the touch and the resident's skin was mottled at the time he was found. LPN #207 stated it had been snowing that night.

On 01/22/25 at 3:05 P.M. an interview with PCA #205 revealed she and PCA #240 were the two PCA staff scheduled to work the day shift on 01/03/25 to provide direct resident care. (Review of time punches revealed both PCA #240 and PCA #205 punched in on 01/03/25 at 7:46 A.M.) PCA #205 revealed Resident #102 was assigned to PCA #240 on the day shift and the resident had been assigned to PCA #210 during night shift on 01/02/25. PCA #205 confirmed PCA #240 was the first staff person to locate Resident #102 (on 01/03/25). PCA #205 stated she responded to PCA #240's call for assistance via the walkie talkie. PCA #205 stated upon arriving at the resident's room, Resident #102 was observed outside, facedown, laying on the neighboring patio which was diagonal from the resident's outside patio with his walker beside him. PCA #205 stated, it was snowing outside and you could tell the resident had been out there for awhile because his walker was filled up with snow and his clothes were soaking wet when we found him. PCA #205 stated DOC #221 instructed the staff to lift Resident #102 off the ground, place him in his wheelchair, clean him up, and then place him in his bed with the covers over him before the family arrived at the facility. PCA #205 stated Resident #102's family was asking questions about what happened but DOC #221 had instructed the staff not to report anything to the family due to completing an investigation. PCA #205 confirmed Resident #102 required safety checks and was a check and change every two to three hours throughout the day and night.

On 01/23/25 at 8:30 A.M. an interview with PCA #240 revealed she was the assigned aide to care for Resident #102 during day shift on 01/03/25. PCA #240 stated she arrived at Resident #102's room to deliver his breakfast meal tray (actual time not given), but did not see the resident in his bed or in the bathroom or anywhere in his room. PCA #240 observed the resident's patio door to be slightly open and it was snowing outside. PCA #240 stated she observed Resident #102 outside on a neighboring patio. The resident was lying on his right side with his walker next to him. The walker was upright. PCA #240 stated Resident #102's skin was turning blue and appeared like frost bite. PCA #240 stated when she assisted with picking Resident #102 up off the ground, the resident's body was limp. There were cuts to Resident #102's face and eyebrow and his hand had a scratch on it. PCA #240 stated Resident #102 was normally ambulatory in his room with a walker and required safety and check and change checks every two to three hours.

On 01/23/25 at 9:10 A.M. an interview with the Executive Director (ED) verified on 01/07/25 PCA #210 had been placed on administrative leave pending further investigation.

Attempts to reach PCA #210 via telephone during the investigation were unsuccessful as the phone number provided had been disconnected.

On 01/23/25 at 9:33 A.M. an interview with Coroner's Investigator (CI) #305 revealed on 01/03/25 DOC #221 called and informed their office Resident #102 was found on floor at approximately 9:30 A.M. with no signs of trauma. It was reported the resident was last known alive earlier that morning without any complaints. CI #305 stated had accurate information related to the incident been reported she probably would have asked a lot more questions to determine if further investigation needed to be completed. CI #305 confirmed the information including Resident #102 being found outside, deceased, with noted injuries to the right side of his face was pertinent information for the Coroner's Office to be made aware of to determine whether or not the office would pick the case up for further investigation.

On 01/23/25 at 10:30 A.M. an interview with LPCA #232 revealed she worked as Lead PCA on 01/03/25 (the employee clocked in on 01/03/25 at 8:01 A.M. and out at 4:52 P.M.) and was present in the facility but not assigned to provide direct resident. LPCA #232 revealed she had however responded to PCA #240's call for immediate assistance in Resident #102's room on the morning of 01/03/25. LPCA #232 stated Resident #102 was found with his head face down on the neighboring concrete patio and his feet on his own outdoor patio. The resident's walker was beside him and was upright. The resident was dressed in a t-shirt and had jogging pants on. Resident #102 had one slipper in place, and one was off of his foot. The resident's clothing was wet. Resident #102 had a gash to his right eye lid, a mark on his forehead, and scratches on the tops of his hands and arm. She stated she assisted with placing Resident #102 into his wheelchair from the ground and cleaning the resident up with PCA #205. LPCA #232 confirmed PCA #210 was assigned to care for Resident #102 during night shift on 01/02/25. LPCA #232 stated she was the Lead PCA and confirmed Resident #102 had dementia and required safety checks as well as check and change every two to three hours. LPCA #232 confirmed there was no documentation of any safety checks or check and changes being completed for any resident (including Resident #102) in the facility.

On 01/23/25 at 11:59 A.M. an interview with DOC #221 revealed following the facility's investigation, it was determined PCA #210 failed to complete safety checks as required every two to three hours for Resident #102 during night shift. DOC #221 confirmed PCA #210 last peeked in on Resident #102 at approximately 4:00 A.M. on 01/03/25 and the resident was found deceased at approximately 9:30 A.M. (five hours later). DOC #221 confirmed Resident #102 required checks every two to three hours. DOC #221 was asked what information had been provided to the Coroner's Office and she initially stated she had informed the Coroner's Office that the resident had been found outside however, then she changed her response to I'm pretty sure I said he was found on the ground. DOC #221 stated she notified PA #410 that Resident #102 had fallen and was found outside. DOC #221 stated PA #410 was responsible for notifying Physician #306 of Resident #102's death.

Information provided during the investigation revealed PCA #210 was terminated effective 01/24/25 due to failure to perform a safety check as required (for Resident #102) and failure to wait for relief at the end of her shift on 01/03/25.

On 01/27/25 at 4:19 P.M. an interview with Physician #306 via telephone revealed he did not recall being informed of any residents being found outside on their patio deceased at the facility and he stated he believed he would remember that if it occurred. Physician #306 stated if he was made aware of all of the information surrounding Resident #102's death, he would have asked more questions and considered the possibility of having the Coroner's Office look into the death.

On 01/29/25 at 12:30 P.M. an interview with PA #410 revealed she had been notified via text message by DOC #221 that Resident #102 was found partially inside and partially outside on his patio without vital signs and requested further instructions at approximately 10:00 A.M. on 01/03/25. PA #410 did not feel there were any unusual circumstances surrounding Resident #102's death from the information she received and gave the order to have Resident #102's body released to the funeral home.

On 02/03/25 at 10:36 A.M. information provided from the ED via email revealed the Lead Personal Care Assistant (LPCA) does not have a resident care assignment and only assists if needed with resident care.

Review of the facility policy, Change of Condition

Based on closed medical record review, review of hospital records, review of the facility incident log, review of call light reports, facility policy review and interview, the facility failed to provide timely, adequate and necessary care and treatment to Resident #2 following a fall with injury. This affected one resident (#2) of four sampled residents.

Actual harm occurred on 11/21/24 (between 3:30 A.M. and 5:44 A.M.) when Resident #2 experienced an unwitnessed fall, and an on-duty unlicensed staff failed to provide adequate and timely care/treatment. Personal Care Assistant (PCA) #240, who found Resident #2 sitting on the floor with blood on the left side of her face moved Resident #2 twice, from the floor to a chair, and then from the chair to her couch prior to the resident being evaluated by a nurse. PCA #240 did not notify Resident #2's daughter as requested by Resident #2. The resident was making groaning noises and verbally complained of severe pain following the incident. Prior the incident, the resident had last been seen by staff at approximately 12:30 A.M. The resident's daughter was notified of the incident (at approximately 7:00 A.M.) and the resident was subsequently transferred to the hospital. Resident #2 was diagnosed with a closed displaced comminuted (shattered into more than two pieces) fracture of the left patella (knee cap) which required surgical intervention and a left eyebrow laceration requiring treatment with Dermabond.

Findings Include:

Review of Resident #2's closed medical record revealed an admission date on 03/18/23. Medical diagnoses included dementia, hypertension, and insomnia. A diagnosis of osteoporosis was noted in the resident's hospital records.

Review of the annual Physician History and Physical assessment dated 04/13/24 revealed Resident #2 had abnormal cognitive status with evidence of a cognitive decline. Resident #2 had a diagnosis of Alzheimer's Disease and required assistance with medication administration.

Review of the resident's undated (current) service plan revealed Resident #2 required assistance with ambulation and stand by assistance with transfers. Resident #2 repeated she lost glasses

Based on medical record review, review of hospital records, review of the facility incident log, review of call light reports, facility policy review and interview, the facility failed to provide adequate supervision and assistance to prevent a fall with injury for Resident #2. Additionally, the facility failed to timely respond to call lights for Resident #5, #24, and #47. This affected four residents (#2, #5, #24 and #47) for four residents reviewed for falls and call light responses. The facility census was 90.

Actual harm occurred on 11/21/24 when staff failed to provide safety checks for Resident #2, a resident with dementia who required staff assistance with ambulation as per the resident's service plan to prevent a fall with injury. On 11/21/24 the resident was seen by staff at approximately 12:30 A.M. The resident was next seen, after staff responded to her call pendant on 11/21/24 at 5:48 A.M. at which time she was on the floor. The resident complained of pain and was subsequently transferred to the hospital where she was diagnosed with a closed displaced comminuted (shattered into more than two pieces) fracture of the left patella (knee cap) which required surgical intervention and a left eyebrow laceration requiring treatment with Dermabond.

Findings Include:

1. Review of Resident #2's medical record revealed an admission date on 03/18/23. Medical diagnoses included dementia, hypertension, and insomnia. A diagnosis of osteoporosis was noted in the resident's hospital records.

Review of the annual Physician History and Physical assessment dated 04/13/24 revealed Resident #2 had abnormal cognitive status with evidence of a cognitive decline. Resident #2 had a diagnosis of Alzheimer's Disease and required assistance with medication administration.

Review of the resident's undated (current) service plan revealed Resident #2 required assistance with ambulation and stand by assistance with transfers. Resident #2 repeated she lost glasses

Based on medical record review, Power of Attorney (POA) and staff interviews and review of the Resident Agreement, the facility failed to provide a thirty-day discharge notice to Resident #99's POA and further failed to notify the POA of discharge plans and the subsequent transfer of the resident to another facility. This affected one resident (#99) of two residents reviewed for discharge. The facility census was 96.

Findings include:

Review of Resident #99 medical record revealed an admission date of 05/09/24. Diagnoses included bipolar disorder.

Review of the nursing progress note dated 07/31/24 revealed Resident #99's POA wrote an electronic mail (e-mail) to the facility explaining her plans to move the resident to a facility with a locked unit. Resident #99's POA requested the facility find an appropriate facility for the resident to discharge to.

Review of the nursing progress note dated 09/11/24 at 10:34 A.M. revealed the Ombudsman was notified via e-mail about Resident #99's transfer to another facility.

Further review of the medical record revealed Resident #99 was discharged from the facility on 09/12/24 at 12:00 P.M. There was no evidence the facility provided a thirty-day notice of discharge to Resident #99 or the POA or communicated the discharge plans for the resident.

Interview on 10/09/24 at 3:21 P.M. with Resident #99's POA revealed she received notification from the facility via text message that Resident #99 was accepted by a facility. The POA stated she replied to the text message and stated she wanted to investigate the facility before her mother was moved to that facility. Resident #99's POA stated on 09/13/24, she was contacted by the admissions coordinator from a different facility stating she needed to sign consent forms for the resident to receive care. The POA stated she was unaware of any plans for the resident to discharge to that facility and she was unaware the facility had discharged the resident on 09/12/24.

Interview on 10/09/24 at 1:23 P.M. with the Executive Director (ED) confirmed the facility did not issue a discharge notice to Resident #99 or her POA and further verified the POA was not notified of the resident's transfer to another facility on 09/12/24.

Review of the facility's Resident Agreement revealed the facility will present a thirty-day notice to a resident if the resident is to be discharged from the community.

This violation represents non-compliance investigated under Master Complaint Number OH00158725 and is a recite to the complaint survey completed 08/05/24.

Based on closed medical record review, review of hospital documents, family and staff interview, review of a facility investigation and review of facility policy, the facility failed to ensure medications were properly secured for Resident #100, who had been assessed to be unsafe to self-administer medications and failed to provide adequate supervision to prevent a medication overdose. This resulted in Real and Present Danger and subsequent death beginning on 09/20/24, when Licensed Practical Nurse (LPN) #123 discovered Resident #100 had a bottle of Sevelamer (prescription medication to control blood levels of phosphorus for people on dialysis) in his room. At the time of discovery, LPN #123 failed to remove the medication from Resident #100 ' s room, failed to determine if Resident #100 had any additional prescription or over-the-counter medications and failed to report her findings to additional staff or administration. On 09/23/24 at 11:00 A.M., LPN #123 administered Resident #100 ' s (scheduled) noon medications. Facility staff did not provide any supervision or check on Resident #100 again on 09/23/24 until 4:00 P.M. (five hours after the last time he was seen) at which time he was found unresponsive in his room by Personal Care Assistant (PCA) #156. At the time the resident was found unresponsive, a bottle of acetaminophen was observed in his room, with pills on the resident's body and the floor. Resident #100 was transferred to the hospital where he subsequently passed away on 09/26/24 from an overdose of acetaminophen due to profound shock with multiorgan failure. This affected one resident (#100) of five residents reviewed for medication storage, with the potential to affect 89 additional residents identified by the facility who were assessed to be unsafe to self-administer medications. The facility census was 96.

On 10/28/24 at 1:01 P.M., the Executive Director (ED) and Regional Director of Care (RDC) #200 were notified Real and Present Danger began on 09/20/24 when LPN #123 discovered Resident #100 had prescribed medication in his room and did not remove the medication, did not report the resident had the medication and further failed to ensure the resident did not have additional prescription or over-the-counter medications in his room. On 09/23/24 at 4:00 P.M. PCA #156 found Resident #100 unresponsive in his room. The resident had last been seen on this date at 11:00 A.M. The resident passed away on 09/26/24 with the cause of death documented as an acetaminophen overdose.

The Real and Present Danger was abated on 10/29/24 when the facility implemented the following corrective actions:

- On 09/23/24, Resident #100 was transferred to the hospital for evaluation and treatment. Resident #100 did not return to the facility and expired in the hospital on 09/26/24.

- On 10/04/24, Director of Care (DOC) #131 initiated staff education on notifying the DOC or designee if medications were discovered in a resident ' s room. Licensed nursing staff would remove and secure medications unless there was an active order for the resident to be able to safely self-administer medications. DOC #131 or designee would ensure any medications were removed from resident rooms. As of 10/28/24 51 of 67 facility staff had received the education. On 10/28/24 DOC #131/designee implemented a plan for the remaining 16 staff still needing the education to receive it prior to working their next scheduled shift.

- On 10/08/24 DOC #131/designee completed a full community apartment sweep/check to ensure no unsecured medications were in resident rooms. Any medications found were secured immediately.

- On 10/28/24, RDC #200 reeducated Assistant Director of Care (ADOC) #167 on ensuring all medications were properly secured.

- On 10/28/24, LPN #123 was placed on administrative leave pending the outcome of the facility investigation.

- Beginning 10/28/24, Activity Director (AD) #132/designee would provide monthly education for three months to residents and families present at Resident Council meetings on outside pharmacy use and to give all medications, including over-the-counter medications, to nursing staff immediately, unless the resident had been assessed to safely self-administer medications.

- Beginning on 10/28/24, DOC #131/designee would ensure all new hires were educated on securing medications and the removal of any medications found in a resident ' s room for those resident ' s who did not have an active order to self-administer medications.

- On 10/29/24, ADOC #167 reassessed 11 residents (#7, #15, #16, #19, #48, #49, #59, #63, #75, #79 and #91) identified as being able to self-administer medications to ensure accuracy of assessments, orders and care plans.

- Beginning on 10/29/24, DOC #131/designee would complete weekly audits on all resident rooms for any medications within visual sight for four weeks, then every two weeks for four weeks and then monthly for 90 days. Any concerns would be immediately addressed, and trends would be reviewed by the Quality Assurance Performance Improvement (QAPI) committee quarterly and as needed. An action plan would be developed and implemented as needed to address any identified areas of concern.

- By 10/31/24, the ED/designee would ensure residents and families were educated on outside pharmacy use and all medications must be given to nursing staff immediately unless there was an active order for the resident to self-administer medications. This education was being provided through letters mailed and/or provided to residents and families.

- On 10/31/24, the QAPI Committee would meet to review the facility investigation, corrective action, outcome of current audits and review policies and procedures related to medication storage. Any areas of concern would be addressed.

- Beginning on 11/04/24, DOC #131/designee would provide continued education during the monthly all staff meeting for three months on the removal of medications discovered in a resident ' s room who has been assessed as unsafe to self-administer medications.

- Beginning on 11/05/24, the ED/designee would randomly interview five staff members every two weeks for three months to assess the knowledge of medication storage. Any concerns would be addressed immediately. Any identified trends would be reviewed by the QAPI Committee, and an action plan developed and implemented as needed.

- The facility implemented a plan that by 11/06/24, RDC #200 would provide reeducation to DOC #131 on ensuring all medications were secured (upon DOC #131 ' s return from leave).

- Interviews on 10/28/24 from 4:35 P.M. through 4:48 P.M. with PCA #164, Activities Assistant (AA) #113, LPN #168, LPN #126 and Office Staff (OS) #119 verified the facility provided education related to medication storage.

- Review of four (#15, #38, #61 and #99) additional open resident records revealed no concerns.

Although the Real and Present Danger was abated on 10/29/24, the violation remains as the facility remained in the process of implementing additional corrective actions and monitoring for compliance.

Findings include:

Review of Resident #100 ' s closed medical record revealed an admission date of 08/16/24 with diagnoses including hypertension, transient ischemia attack and end stage renal disease. Further review revealed Resident #100 received hemodialysis (treatment that filters waste and excess fluids from the blood when the kidneys do no function properly) every Tuesday, Thursday and Saturday.

Review of the hospital after visit summary, dated 09/05/24, revealed Resident #100 had outpatient surgery and returned to the facility with orders for Cephalexin (antibiotic) 500 milligrams (mg) one capsule two times daily for three days, Oxycodone-acetaminophen 5-325 mg one tablet every four hours as needed (PRN) for pain and Sevelamer HCI 800 mg three tablets three times daily with meals.

Review of self-medication assessment dated 09/07/24 revealed Resident #100 was unable to safely self-administer medications. The assessment indicated the resident was unable to verbalize what medications he took, why he took the medications, the correct dosage or how often he was to take the medication.

Review of the nursing assessment dated 09/07/24 revealed Resident #100 was capable of making his own daily decisions, needed safety checks every two to three hours due to the resident's identified fall risk and required nursing administration of medication and/or treatments.

Review of Resident #100's service plan dated 09/07/24 revealed the resident needed safety checks every two to three hours due to fall risk and required nursing administration of medication and/or treatments.

Review of the Medication Administration Record (MAR) for September 2024 revealed the resident had an order (dated 08/22/24) for acetaminophen 325 mg, two tablets every four hours as needed for pain (daily dose not to exceed 3000 mg daily). One administration of acetaminophen was documented on 09/09/24.

Review of a progress note dated 09/20/24 at 2:02 P.M., and completed by LPN #123, revealed the pharmacy was called to hold Sevelamer HCl 800 mg until further notice due to the resident having the bottle. Further review of the medical record revealed no evidence the bottle of Sevelamer HCI was removed from the resident's room, or any interventions were implemented to secure medications or to ensure the resident did not have any additional prescription or over-the-counter medications in his room at this time.

Record review revealed the next progress note entry, dated 09/23/24 at 4:33 P.M., and completed by LPN #154, revealed LPN #154 documented Resident #100 was found in a chair, sitting with a bottle of Sevelamer HCl by his chair and pills on the floor and not responsive. The LPN documented the resident was taken to the hospital.

Review of the facility investigation dated 09/24/24 revealed PCA #156 found Resident #100 unresponsive (on 09/23/24) at 4:00 P.M. in his room. LPN #154 entered the room at 4:04 P.M. LPN #123 was the last known staff to see Resident #100, when she administered his noon medications at 11:00 A.M.

Review of a written statement from DOC #131, dated 09/25/24, confirmed a bottle of Sevelamer was found in Resident #100's room on a table by the door. DOC #131's statement also included a bottle of acetaminophen was found in Resident #100's room on a bed side table, with the lid off, and five to six pills were observed on the floor.

Review of hospital records revealed on 09/23/24, Resident #100 was seen through the emergency department (ED) for an acetaminophen overdose. The resident was admitted to the intensive care unit (ICU), where he expired on 09/26/24 from an acetaminophen overdose due to profound shock with multiorgan failure.

Interview on 10/09/24 at 12:24 P.M. with Case Manager (CM) #225 revealed she received information from Resident #100 ' s family regarding the resident ' s overdose in the facility. CM #225 stated the family was concerned this had occurred and had no knowledge of where the resident had gotten the acetaminophen.

Interview on 10/09/24 at 2:00 P.M. with LPN #123 confirmed the last time she saw Resident #100 on 09/23/24 was around 11:00 A.M., when she administered his noon medications.

A telephone interview on 10/09/24 at 1:48 P.M. with LPN #154 revealed on 09/23/24, she received a verbal alert on her walkie talkie from PCA #156 to go to Resident #100's room as he was unresponsive. LPN #154 stated the resident was naked in his chair. She observed the bottle of Sevelamer HCl by the resident ' s chair and saw pills on the floor and on the resident's body. LPN #154 stated Resident #100 was sent to the hospital for further evaluation and treatment.

A telephone interview on 10/15/24 at 10:07 A.M. with Family Member (FM) #230, and Resident #100's Power of Attorney (POA), revealed she lived out of state. FM #230 stated she had concerns related to the resident having access to medications in his room, including over-the-counter acetaminophen, due to safety concerns. FM #230 denied knowledge of how Resident #100 obtained the Sevelamer or acetaminophen that were found in his room.

A telephone interview on 10/15/24 at 10:41 A.M. with FM #235 revealed she lived local to the resident and visited him at the facility. FM #235 denied bringing the resident Sevelamer or acetaminophen and had no knowledge of who would have brought the medications to him.

Interview on 10/15/24 at 10:56 A.M. with DOC #131 confirmed Resident #100 was unable to safely self-administer medications. A follow-up interview at 12:00 P.M. confirmed Sevelamer HCI and acetaminophen were found in Resident #100 ' s room on 09/23/24 following the overdose. DOC #131 stated the acetaminophen was a store brand. The dose was 325 mg and was a 1000 count bottle. DOC #131 stated there were 183 acetaminophen pills left following the incident on 09/23/24. Additionally, the Sevelamer bottle indicated it was refilled on 09/17/24 with a total of 810 tablets. Resident #100 was ordered nine Sevelamer tablets daily and there were 759 pills remaining. The Sevelamer was filled at a private pharmacy, which was not the same as the store brand of acetaminophen found in the resident ' s room.

Interview on 10/15/24 at 11:00 A.M. with the ED confirmed Resident #100's medications should have been secured once they were first discovered in his room (on 09/20/24) since he was unable to safely self-administer medication. The ED stated she was unaware Resident #100 had the Sevelamer and acetaminophen in his room until the resident overdosed on 09/23/24.

Interview on 10/15/24 at 2:32 P.M. with DOC #131 revealed the facility maintained no documentation of when residents were checked on. DOC #131 confirmed Resident #100 was to be checked on every two to three hours (safety checks) and further verified on 09/23/24, the last known time Resident #100 was seen was at 11:00 A.M., five hours before he was found unresponsive in his room.

Interview on 10/15/24 at 2:49 P.M. with PCA #163 revealed she was assigned to provide care for Resident #100 during the day shift on 09/23/24. PCA #163 stated she could not recall the last time she saw the resident on that date and further added she only provided care to the resident if he requested it. The PCA was unsure if the resident had eaten lunch on this date.

Interview on 10/28/24 at 8:25 A.M. with LPN #123 revealed she observed Sevelamer in Resident #100 ' s room on 09/20/24 but did not remove it. LPN #123 stated she was uncertain if the resident was able to self-administer medications. LPN #123 confirmed she did not investigate whether Resident #100 was able to have the medication in his room and stated she informed the on-coming nurse the resident had the medication.

Interview on 10/28/24 at 8:38 A.M. with LPN #154 revealed she was the on-coming nurse on 09/20/24, the date LPN #123 discovered medication in Resident #100 ' s room. LPN #154 denied receiving in report the resident had unsecured medication in his room.

Review of the facility policy titled Medications Policy, revised March 2024, revealed medications were to be administered by a nurse unless the resident was able to self-administer medications with a written physician's order. If a resident does self-administer medications, they must be stored safely within their apartment.

This violation represents non-compliance investigated under Complaint Number OH00158373.