Provision Living at West Chester

Based on observation, staff interview, review of self-reported incident (SRI), review of witness statements, and record review, the facility failed to ensure a resident was free from staff to resident abuse. This affected one (#63) of the three residents reviewed for abuse. The facility census was 78.

Findings include:

Review of Resident #63's medical record revealed the resident was admitted to the facility on 11/30/22. Diagnoses included Alzheimer's disease and hyperlipidemia.

Review of Resident #63's Vital Signs Assessment dated 08/16/25 at 9:05 A.M. revealed Resident #63's blood pressure was 128 over 70 millimeters per mercury (mmHg), temperature was 97.9 degrees Fahrenheit, pulse was 78 beats per minute, respirations were 18 per minute and a pain level of zero (zero to 10 scale with zero being no pain and 10 being severe pain).

Review of Resident #63's progress note dated 08/16/25 at 6:30 A.M., revealed Licensed Practical Nurse (LPN) #244 assessed Resident #63 and the resident voiced no signs of pain or discomfort. Resident #63 showed no signs of any changes in behavior and no visible signs were noted to the skin from the incident. Resident #63's oxygen saturation was 98 percent and blood pressure was 110 over 74 millimeters per mercury (mmHg).

Review of the facility's infrared fall camera footage dated 08/16/25 at 6:50 A.M., revealed Resident Assistant (RA) #301 was observed pulling the covers off Resident #63. RA #301 then pulled the resident's legs off the side of the bed and continued holding the resident's legs as her legs are hanging off the side of the bed with her upper body still on the bed. Resident #63 appeared to be moving around in bed and trying to get RA #301 off her legs. Resident #63 then fell onto the floor and continued swinging her hands. RA #301 grabbed Resident #63 by the arms and pulled her into the bathroom dragging the resident across the ground. RA #301 was observed leaning over Resident #63 in the bathroom doorway. Resident #63 appeared to stand up in the bathroom doorway at 6:52 A.M. and Licensed Practical Nurse (LPN) #300 entered the room at 6:53 A.M.

Review of Resident #63's progress note dated 08/16/25 at 7:00 A.M., revealed LPN #300 responded to a fall alert detected by the fall alert system. LPN #300 found a caregiver in Resident #63's room and the resident was in a standing position in the doorway of the bathroom. LPN #300 tried to assess Resident #63's hands, but the resident pulled her hands away. LPN #300 helped Resident #63 put her pants and belt on and the resident returned to her bed and pulled the covers over herself. LPN #300 exited Resident #63's room with the caregiver. Memory Care Director (MCD) #224 was notified by LPN #300 of the situation and MCD #224 was sent the footage of the incident. MCD #224 communicated the incident to the physician on call, family members, the wellness leader, and Executive Director (ED).

Review of Resident #63's progress note dated 08/16/25 at 7:42 A.M., revealed MCD #224 notified the Nurse Practitioner (NP) on call, the ED and Resident #63's daughter of the incident.

Review of Resident #63's progress note dated 08/16/25 at 11:05 A.M., revealed LPN #300 completed a skin assessment on the resident after multiple attempts with no injuries noted. The resident's range of motion (ROM) was within normal limits, blood pressure was 128 over 70 mm/Hg, pulse was 78 beats per minute, respirations were 18 per minute, oxygen saturation was 97 percent, and temperature was 97.9 degrees Fahrenheit. MCD #224 was notified of the vitals and skin assessment.

Review of the facility's SRI created on 08/17/25 at 8:37 P.M. and completed 08/21/25, revealed RA) #301 handled Resident #63 inappropriately while attempting to provide care to her on 08/16/25. RA #301 removed the covers from Resident #63 and started to pull at Resident #63's feet at 6:50 A.M. Resident #63 was resisting care and was flailing her arms and kicking her feet. Resident #63 covered herself up with the blanket and fell on the floor during the interaction. Resident #63 was dragged by her feet to the bathroom by RA #301. RA #301 was suspended and then terminated. The SRI was substantiated for neglect and mistreatment.

Review of Resident #63's Wellness Evaluation dated 09/16/25, revealed the resident was cognitively impaired, was independent with transfers, mobility, and eating. Resident #63 required assistance with bathing, dressing, grooming, and toileting.

Observation of Resident #63 on 09/25/25 at 11:23 A.M., revealed Resident #63 was sitting in her recliner in her room with her husband. Resident #63 was clean and dressed appropriately.

Interview with Resident #63 and Resident #63's husband on 09/25/25 at 11:23 A.M. revealed Resident #63 denied being abused, falling, being dragged by staff, or being pulled out of bed by staff. Resident #63's husband denied Resident #63 being abused, falling, being dragged by staff, or being pulled out of bed by staff.

Interview via telephone with LPN #300 on 09/25/25 at 2:48 P.M., who stated she received a fall alert for Resident #63's room from the fall alert camera on 08/16/25 at approximately 6:50 A.M. LPN #300 stated she looked at the fall alert and saw what looked like someone dragging a resident by the arms. LPN #300 reported she went to Resident #63's room immediately and found RA #301 and Resident #63 in Resident #63's room when she entered the room. LPN #300 stated Resident #63 was standing in the doorway of the bathroom and RA #301 was helping Resident #63 get dressed. LPN #300 stated she helped get Resident #63 dressed and LPN #300 attempted to assess Resident #63's hands and arms, but the resident pulled her hands away and went to her bed. LPN #300 reported she did not see any marks on Resident #63. LPN #300 stated she and RA #301 left Resident #63's room after the resident went back to bed. LPN #300 stated she contacted MCD #224 about the incident. LPN #300 reported she was in the assisted living dining room after her shift when RA #301 approached her and said, if a resident was resisting, then what was she supposed to do. LPN #300 stated she told RA #301 that there should never be a reason why staff should forcefully drag or change a resident. LPN #300 reported RA #301 told LPN #300 that she had never seen her so upset. LPN #300 stated RA #301 was removed from the floor after the incident with Resident #63.

Interview with MCD #224 on 09/25/25 at 3:35 P.M. revealed MCD #224 and ED #302 interviewed RA #301 via phone after the incident and RA #301 admitted to dragging Resident #63 by her arms on the floor and forcing her to be changed. MCD #224 stated that she reviewed the video and observed RA #301 taking off Resident #63's covers and grab Resident #63's legs. MCD #224 reported Resident #63 appeared to be flailing around in bed as RA #301 continued to hold onto her legs. MCD #224 confirmed Resident #63 fell to the floor during the struggle and RA #301 grabbed Resident #63's arms and pulled her into the bathroom while Resident #63 was being dragged on the floor. MCD #224 reported the police were not called after the incident and Resident #63's daughter was notified by phone and in person. MCD #224 stated RA #301 was terminated and MCD #224 felt the action of dragging Resident #63 on the floor by her arms was considered abuse.

Interview via telephone on 09/25/25 at 3:55 P.M. with Resident #63's daughter, who stated the facility notified her of the incident where RA #301 dragged Resident #63 off the bed and on the floor two different times. Resident #63's daughter stated the facility informed her of the incident by phone and in person. Resident #63's daughter stated that she was very apologetic about the incident because Resident #63 was having increased behaviors at the time of the incident. Resident #63's daughter stated she could not recall discussing police involvement with the facility, but she did not wish to pursue any criminal charges.

Review of RA #301's personnel file on 09/25/25, revealed RA #301 was hired at the facility on 04/30/25 and was educated on the abuse policy on 05/07/25 and 06/04/25. The Bureau of Criminal Investigations (BCI) check was submitted on 04/23/25 and received on 04/29/25

Review of RA #301's timecard on 09/25/25, revealed on 08/15/25, RA #301 worked from 7:05 P.M. to 08/16/25 at 7:25 A.M.

Review of RA #301's employment history form on 09/25/25, revealed RA #301 was terminated on 08/18/25.

Review of RA #301's witness statement on 09/25/25 provided via phone to ED #302 and MCD #224 dated 08/18/25 at 11:01 A.M., revealed RA #301 went into Resident #63's room on 08/16/25 around 6:00 A.M. to do her last check. RA #301 told Resident #63 that she was taking her to the bathroom to get her ready for the day when the resident stated no. RA #301 went to Resident #63's closet to pull her clothing and brief out to show her intention. Resident #63 stated no and get out of her room right now then yelled a loud scream. RA #301 tried to take off her blanket and the resident got her hands and was moving her foot so hard, RA #301 was trying to protect her abdomen. RA #301 told the resident to stop and tried to hold her hands and legs to get her to stop so she could not hit RA #301 with her legs. RA #301 let go of Resident #63's legs and the resident got off the bed herself and then she sat up on the floor. RA #301 held her hands and asked if they could go now and the resident said no while screaming very loudly. RA #301 grabbed her hands and dragged the resident towards the bathroom. RA #301 did not get her to the bathroom and RA #301 left her there. RA #301 bent down nicely and calmly telling her that her daughter asked her to change her and she did not want the aides to blame her. RA #301 told her she had to keep her dry and clean. While talking to the resident, she was calm and was able to change everything. LPN #300 came in, and she zipped up her pants and RA #301 asked LPN #300 for help and then she left. RA #301 told Resident #63 she was doing her best to keep her clean and she took the trash out, thanked Resident #63 and said sorry. RA #301 went and talked to LPN #300. LPN #300 was sitting in the assisted living and RA #301 told her what happened. RA #301 told her these were challenges she faced when she went to Resident #63's room. RA #301 then told LPN #300 she dragged the resident and forced her to be changed. RA #301 asked LPN #300 if she thought she did the right thing, and LPN answered no, you do not have to drag or force her to do anything if she said no and that she could have left and called LPN #300. RA #301 said she made a big mistake. LPN #300 said that it was okay, and RA #301 asked if she needed to call someone right now. LPN #300 said MCD #224 was around, and LPN #300 said that she would text her. RA #301 said she would also text her. RA #301 texted MCD #224 and she texted back that there would be an investigation, and the facility would contact her on what happens next. RA #301 gave report and went outside and cried because she was so ashamed of herself. RA #301 went home and MCD #224 texted that RA #301 was on suspension until further notice and that the facility would contact her when the investigation was completed and when human resources (HR) reviewed everything. RA #301 responded back by saying she was so ashamed of herself and only God knows and how could she have done such a horrible thing. I didn't use my brain and only thought she was helping, and she thought it could be the best way to handle it right now. Please if you could all forgive me and give me another chance. I promise even in my next world I would never do such a thing again. The statement was signed by ED #302 and MCD #224.

Review of an email on 09/25/25 from LPN #300 to former ED #302 dated 08/22/25 at 3:46 A.M., revealed LPN #300 was alerted by the fall alert system to a fall notification in Resident #63's room on 08/16/25. Upon reviewing the alert footage, LPN #300 observed what appeared to be a staff member manually pulling a resident by the wrists in a manner inconsistent with safe patient handling practices. LPN #300 responded to Resident #63's room immediately. Upon entering the room, LPN #300 observed RA #301 standing in front of Resident #63's dresser while Resident #63 was positioned within the bathroom doorway. Resident #63's pants were visibly unfastened. LPN #300 approached Resident #63 to assess her for potential injury and reached for Resident #63's left hand and the resident retracted her arm. LPN #300 assisted Resident #63 in fastening her pants. During that time, Resident #63 displayed a flat affect, and appeared disengaged staring into space but not responding verbally beyond saying you are such a sweet lady. Resident #63 walked to her bed, laid down with her shoes on and covered herself with a blanket. LPN #300 attempted to clarify whether Resident #63 wished to rest but she did not respond. LPN #300 turned the room light off and exited with RA #301. LPN #300 recorded a copy of the fall footage and sent it directly to MCD #224 to review. This occurred during the shift change from night shift to day shift. LPN #300 proceeded to conduct a medication count with the oncoming medication technician and did not address the incident with RA #301 to maintain professional composure. After completing the medication count, LPN #300 relocated to the dining area on the first floor of the assisted living wing where RA #301 approached LPN there and expressed uncertainty about how she could have handled the situation differently. LPN #300 clearly stated at no point should a resident ever be physically dragged. LPN #300 informed her that she had chosen not to immediately address the matter earlier because LPN #300 needed time to maintain a professional and levelheaded demeanor. LPN #300 advised RA #301 that the appropriate course of action would be to report the incident directly to MCD #224. LPN #300 then excused herself from the dining room to avoid escalating the conversation.

Review of MCD #224's undated witness statement on 09/25/25, revealed MCD #224 was notified by LPN #300 about a fall alert on 08/16/25 at 6:56 A.M. LPN #300 stated that the alert involved RA #301 and Resident #63. Upon reviewing the footage, it appeared a staff member was pulling a resident by the arms across the floor between the bed and the bathroom. LPN #300 informed MCD #224 that Resident #63 was not on the floor when she entered the apartment and Resident #301 was standing. LPN #300 asked for guidance and stated that RA #301 came to her in the bistro area and LPN #300 advised RA #301 that she needed to talk with MCD #224. RA #301 reached out to MCD #224 and stated she made a big mistake that she regretted and that she had went to help change Resident #63 and the resident stated no and was yelling. RA #301 stated Resident #63 had put herself on the floor and stated she thought the best way was to drag and change her. RA #301 stated she realized it was a mistake and that she went to the nurse LPN #300 and told LPN #300 she made a big mistake. RA #301 then stated she did not want the other aides to keep complaining that she left the resident wet. RA #301 stated she did not actually mean harm. MCD #224 informed RA #301 that the facility would be investigating the incident and she was on suspension until further notice. MCD #224 informed former ED #302, Resident #63's daughter and the Nurse Practitioner (NP). MCD #224 followed up with the day nurse to monitor for injuries, vitals and a skin assessment.

Interview via phone with RA #301 on 09/29/25 at 11:55 A.M. who stated she was providing care for Resident #63 in the morning on 08/16/25. RA #301 stated Resident #63 was a tough resident and Resident #63 fell in her room. RA #301 reported Resident #63 was sitting on the edge of the bed and Resident #63 did not want to go to the bathroom. RA #301 stated she could not remember what happened but reported Resident #63 fell and she dragged the resident by her arms a few steps before RA #301 came to her senses. RA #301 reported Resident #63 was fighting RA #301 on the bed before her fall because she did not want to get up out of bed. RA #301 reported she already gave a statement to the facility about the incident.

Telephone interview with ED #302 on 09/29/25 at 3:58 P.M. revealed LPN #300 received an alert from the fall camera in Resident #63's room. ED #302 saw a person dragging another person in the fall camera footage and went to Resident #63's room and found Resident #63 in her room with RA #301. ED #302 stated that LPN #300 reported the incident to administration. ED #302 reported RA #301 also approached LPN #300 and stated she thought she did something wrong. ED #302 stated she investigated the incident and took RA #301's statement by telephone. ED #302 reported that she read RA #301's statement back to her after taking the statement and RA #301 admitted to dragging Resident #63 on the floor of her room. ED #302 reported she watched video and witnessed RA #301 dragging Resident #63 by the arms on the ground. ED #302 stated the family was notified but the facility did not contact the police because they left it up to the family to involve police. ED #302 stated she substantiated the SRI. ED #302 reported it was a judgement call, but she felt the incident was abuse.

Review of the facility's abuse, neglect or exploitation policy dated 02/08/18 revealed abuse of any resident will not be tolerated. All allegations, suspicions and incidents of abuse will be promptly investigated. If a staff member is accused or suspected of abuse, the staff member will be immediately removed from the community and work schedule pending the outcome of the investigation.

This violation represents non-compliance investigated under Complaint Number OH00168061.

Based on observation, record review and staff interviews, the facility failed to administer resident medications in accordance with the physician's orders. This affected one (#15) of the two residents observed and reviewed for medication administration. The facility census was 86.

Findings Include:

Review of Resident #15's record revealed the resident was admitted on 06/30/23. Diagnoses included unspecified dementia and seizures. Resident #15's was alert but not always oriented with fluctuations and dependent on staff for medication administration.

Review of the physician order for Resident #15 dated 07/11/25, revealed the resident's levetiracetam (for seizures) 250 milligrams (mgs) twice daily was to be discontinued and for Resident #15 to start Levetiracetam 500 mg twice daily.

Review of an additional physician order for Resident #15 dated 07/12/25, revealed the resident's Levetiracetam 250 mgs twice daily was to be discontinued.

Observation of the medication administration on 07/21/25 at 9:36 A.M. with Licensed Practical Nurse (LPN), revealed two different active orders of levetiracetam (for seizures) for Resident #15. One order was 250 mg twice daily and the second order was for 500 mg twice daily. LPN #129 stated the levetiracetam 500 mg twice daily order was the correct order and administered Resident #15 levetiracetam 500 mg. LPN #129 stated levetiracetam 250 mg should not be on the medication administration record (MAR). LPN #129 stated the pharmacy was responsible for updating the medications on the MAR and noted the pharmacy must not have updated the resident's MAR when the levetiracetam 250 mg was discontinued on 07/11/25.

Review of Resident #15's July 2025 Medication Administration Record (MAR) indicated the resident received levetiracetam 250 mg twice daily (8:00 A.M. and 5:00 P.M.) on 07/14/25, 07/15/2025, 07/16/25, 07/19/25, 07/20/25 and one time (8:00 A.M.) on 07/18/2025. The resident also received levetiracetam 500 mg twice daily on 07/12/25, 07/13/25, 07/14/25, 07/15/25, 07/16/25, 07/17/25, 07/18/2025, 07/19/25, 07/20/25, and one time (8:00 A.M.) on 07/21/25.

Interview with Director of Nursing (DON) on 07/21/25 at 4:25 P.M. verified documentation showing Resident #15 received levetiracetam 250 mg twice daily on 07/14/25, 07/15/2025, 07/16/25, 07/19/25, 07/20/25, and once daily on 07/18/25, and levetiracetam 500 mg twice daily on 07/12/25, 07/13/25, 07/14/25, 07/15/25, 07/16/25, 07/17/25, 07/18/2025, 07/19/25, 07/20/25, and one time on 07/21/25. The DON verified the two orders from NP showing levetiracetam 250 mg should have been discontinued on 07/11/25.

This violation represents non-compliance investigated under Complaints Number OH00167255 and OH00165762.

Based on record review and staff interview, the facility failed to evacuate residents during fire drills conducted over the past 12 months. This had the potential to affect all the residents in the facility. The facility census was 86.

Findings include:

Review of fire drill documentation dated 01/11/25, 01/30/25, 02/28/25, 03/31/25, 04/08/25, 04/16/25, 05/31/2025, 06/09/25, 06/26/25, 07/11/24, 08/29/24, 09/30/24, 09/30/24, 10/01/24, 10/07/24, 11/30/24, and 12/31/24 indicated that no resident evacuations were performed on each of these fire drill dates.

Interview on 07/21/25 at 1:24 P.M. with Maintenance Manager (MM) #124 confirmed that no resident evacuations were performed during the 16 documented fire drills over the past 12 months.

Based on interview and record review, the facility failed to implement their abuse and medication administration policies for reporting an allegation or suspicion of medication misappropriation to law enforcement and the nursing board. This affected three (#37, #42 and #43) residents out of 67 residents at the facility that required assistance with medication administration. The facility census was 76.

Findings include:

Review of Resident #37's chart revealed Resident #37 admitted to the facility on 06/03/24 with diagnoses including essential hypertension, malignant neoplasm, unspecified inflammatory spondylopathy, chronic kidney disease stage three and hypothyroidism.

Review of Resident #37's service plan dated 12/03/24 revealed Resident #37 had mild cognitive impairment and Resident #37 was independent with toileting, bathing, dressing, eating and transferring. Resident #37 required assistance with medication management.

Review of Resident #37's physician order dated 10/21/24 revealed Resident #37 was ordered Hydrocodone Acetaminophen (opioid analgesic) 7.5-325 milligram (mg) take one tablet by mouth every twelve hours.

Review of Resident #37's medication administration record dated 10/27/24 revealed Resident #37 received her Hydrocodone Acetaminophen 7.5-325 mg on 10/27/24 at 8:00 A.M.

Review of Resident #37's controlled drug log revealed Licensed Practical Nurse (LPN) #500 signed out one Hydrocodone Acetaminophen 7.5-325 mg tablet on 10/27/24 at 7:30 A.M. Resident #37 had one tablet of Hydrocodone Acetaminophen 7.5-325 mg on 10/27/24 that was missing from the card and not signed out.

Review of Resident #42's chart revealed Resident #42 admitted to the facility on 02/28/23 with diagnoses including multiple sclerosis, candidiasis of skin and nail, and chronic pain syndrome.

Review of Resident #42's service plan dated 09/04/24 revealed Resident #42 was cognitively intact, and Resident #42 required two person assistance with dressing, grooming, bathing, toileting and transfers. Resident #42 was independent with eating and required assistance with medication administration.

Review of Resident #42's physician order dated 07/01/24 revealed Resident #42 was ordered Tramadol (opioid analgesic) 50 mg take two tablets by mouth four times a day.

Review of Resident #42's physician order dated 09/16/24 revealed Resident #42 was ordered Pregabalin (anticonvulsant) 75 mg taken one capsule three times a day.

Review of Resident #42's medication administration record dated 10/27/24 revealed Resident #42 was given his Pregabalin 75 mg one capsule three times a day on 10/27/24 at 8:00 A.M. from LPN #500. Resident #42 also received his Tramadol 50 mg two tablets by mouth four times a day from LPN #500 on 10/27/24 at 12:00 P.M. and 6:00 P.M.

Review of Resident #42's controlled drug log revealed LPN #500 signed out one Pregabalin 75 mg capsule on 10/27/24 at 7:30 A.M. Resident #42 was also had one tablet of Pregabalin 75 mg capsule on 10/27/24 that was missing from the card and not signed out. LPN #500 signed out four Tramadol 50 mgs tablet on 10/27/24 with two tablets being signed out at 12:00 P.M. and two tablets being signed out at 6:00 P.M. The Tramadol 50 mgs tablets listed as being given on 10/27/24 at 6:00 P.M. were reported to still be in the medication card.

Review of Resident #43's chart revealed Resident #43 admitted to the facility on 09/29/23 with diagnoses including atrial fibrillation, congestive heart failure, cerebrovascular disease, and localized related symptomatic epilepsy and epileptic syndromes with complex partial seizures intractable with status epilepticus.

Review of Resident #43's service plan dated 11/12/24 revealed Resident #43 had occasional confusion and some difficulty recalling details and required occasional prompting and orientation. Resident #43 was independent with dressing, grooming, toileting, mobility, and eating. Resident #43 required stand by assistance with showering and Resident #43 required assistance with medication administration.

Review of Resident #43's physician order dated 10/23/24 revealed Resident #43 was ordered Oxycodone 5 mg take 0.5 to one tablet by mouth every six hours as needed for pain up to seven days.

Review of Resident #43's medication administration record dated 10/27/24 revealed Resident #43 was given her Oxycodone 5 mgs on 10/27/24 at 9:20 A.M. by LPN #500. LPN #500 reported the medication was effective.

Review of Resident #43's controlled drug log revealed LPN #500 signed out one Oxycodone 5 mgs tablets on 10/27/24 at 9:15 A.M. The Oxycodone 5 mgs tablet that was signed out by LPN #500 was noted to be in the medication card.

Review of the facility's self reported incident (SRI) dated 10/29/24 at 2:57 P.M. revealed the Director of Nursing (DON) was notified that the narcotic count had discrepancies on 10/27/24 at the end of the shift and three pills were missing. The exiting nurse, LPN #500 did not know where the medications went. LPN #500 was suspended pending investigation. Upon investigation, it was discovered that the Pregabalin and Hydrocodone were missing from two different residents. The pharmacy was notified, and the medications were replaced at the expense of the facility. LPN #500 reported that she did not know what happened to the medication and she did not recall giving medication to the incorrect resident. LPN #500 was no longer employed with the facility. The SRI stated that the incident was not reported to law enforcement or another state agency. The SRI was substantiated.

Review of LPN #500's separation check list dated 10/29/24 revealed LPN #500 was hired at the facility on 06/21/23. LPN #500's last day worked was on 10/27/24 and LPN #500 has a separation date of 10/29/24. LPN #500 was involuntary terminated for falsification of documentation, medication errors and missing medication.

Interview with Executive Director (ED) #200 and Memory Care Support Manager (MCSM) #18 on 01/24/25 at 1:00 P.M. revealed Director of Nursing (DON) #201 was contacted on 10/27/24 at shift change and was informed that the medication counts were off. MCSM #18 stated that Resident #37 was missing a Hydrocodone acetaminophen 7.5-325 mg and Resident #42 was missing a Pregabalin 75 mg capsule. MCSM #18 stated Resident #42 also had two Tramadol 50 mgs tablets that were signed out by LPN #500 but were still in the medication card. MCSM #18 reported that Resident #43 also had an Oxycodone 5 mgs that was signed out by LPN #500 but was still in the medication card. The Administrator reported that LPN #500 did not know what happened to the medications and denied possibly giving residents the wrong medications. The Administrator stated LPN #500 was terminated for falsification of documentation and medication errors. The Administrator reported the incident was reported as an SRI. The Administrator verified the facility did not contact law enforcement or the state board of nursing regarding the missing narcotics.

Review of the facility's abuse prevention program policy revised on 05/23/23 revealed the facility prohibits mistreatment, neglect or abuse of residents. The employee or agent that becomes aware of abuse or neglect including alleged misappropriation of resident property should immediately report the matter to their supervisor, the community administrator or designee and to the nurse supervisor or designee. The community administrator or designee that has reasonable cause to believe that any resident has been subjected to abuse or neglect shall immediately report the allegation to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner.

Review of the facility's medication administration and disposal policy revised 02/24/22 revealed any medication errors or omissions will be reported to the state per state regulations.

Based on record review, observation, resident interview, staff interview, review of facility policy, and review of online information per medication resource Medscape, the facility failed to ensure staff administered medications in accordance with the physician's order. This affected one (#6) of three residents reviewed for medications. The census was 30 residents.

Findings include:

Review of the medical record for Resident #6 revealed an admission date of 09/16/22 with diagnoses including lumbar disc degeneration, spinal stenosis, and hypothyroidism.

Review of the initial health assessment for Resident #6 dated 09/20/22 revealed the resident was cognitively intact and required supervision with activities of daily living (ADL's). Resident #6 was not capable of self-administration of medication.

Review of February 2023 monthly physician orders for Resident #6 revealed an order dated 09/16/22 for Synthroid 88 micrograms (mcg) take one tab by mouth once daily in the morning for hypothyroidism, take on an empty stomach.

Review of the February 2023 Medication Administration Record (MAR) for Resident #6 revealed medication was signed off as administered between 7:00 A.M. and 11:00 A.M.

Observation on 02/08/23 at 8:10 A.M. of Resident #6 revealed resident was in her room and it appeared she had consumed 100 percent (%) of her breakfast meal. Further observation revealed Licensed Practical Nurse (LPN) #50 administered an 80 mcg Synthroid tablet to resident.

Interview on 02/08/23 at 8:10 A.M. of Resident #6 confirmed she had just consumed 100% of her breakfast meal prior to taking Synthroid.

Interview on 02/08/23 at 8:13 A.M. of LPN #50 confirmed Resident #6's Synthroid order called for the medication to be administered on an empty stomach. LPN #50 confirmed the medication should be administered on night shift so resident could take the medicine before she ate breakfast.

Interview on 02/08/23 at 11:19 A.M. with the Director of Nursing (DON) confirmed Synthroid should not be given on an empty stomach.

Review of the facility policy titled Medication Administration and Disposal undated revealed residents should get medications at the right time and as ordered by the physician.

Review of online medication resource Medscape at https://reference.medscape.com/drug/synthroid-levoxyl-levothyroxine-342732#11 revealed Synthroid should be taken with a full glass of water preferably 30 min to 1 hour before breakfast on empty stomach.

This violation represents non-compliance investigated under Complaint Number OH00139204.

Based on record review, staff interview, review of manufacturer's information, and review of facility documents and policies, the facility failed to ensure residents were assessed promptly following a fall with injury. This affected one (#29) of three residents reviewed for falls. The census was 30 residents.

Findings include:

Review of the medical record for Resident #29 revealed an admission date of 06/24/22 with diagnoses including dementia with behavioral disturbance, hypothyroidism, and metabolic encephalopathy.

Review of the initial health assessment for Resident #29 dated 06/24/22 revealed resident was cognitively impaired and required staff assistance with activities of daily living (ADL's).

Review of the care conference note for Resident #29 dated 11/30/22 revealed the resident and resident's representative preferred that when staff checked on the resident during the night, they would not turn on the light or empty trash but should peek in on resident to make sure she is okay.

Review of the nurse progress notes for Resident #29 dated 01/17/23 timed at 5:30 A.M. revealed the nurse heard the resident yelling for help multiple times. The door was locked and when nurse entered the room the resident was found on the floor of her room next to her bed with covers under her and on top of her. Resident #29 had a laceration above her left eyebrow which had minimal bleeding. There was blood on the covers and on the floor. Resident complained of pain to her neck. Nurse called 911 and emergency medical personnel transported resident to the hospital.

Review of the hospital notes for Resident #29 dated 01/17/23 revealed resident was evaluated in the emergency room. She was treated for a facial contusion and laceration which was closed with steri strips. Computerized tomography (CT) scan of resident's head was negative. Resident #29 returned to the facility.

Interview on 02/08/23 at 11:19 A.M. with the Director of Nursing (DON) confirmed Licensed Practical Nurse (LPN) #80 was the sole staff person on duty on the memory care unit where Resident #29 resides for the night shift (7:00 P.M. to 7:00 A.M.) on 01/17/23. DON confirmed staff are to make rounds and do a visual safety check on all residents every two hours at a minimum. DON confirmed Resident #29's room is equipped with a fall detection system which detects resident movement and determines the time of falls. DON confirmed the facility's investigation of Resident #29's fall revealed resident fell at approximately 12:20 A.M. on 02/08/23, and the nurse did not check on the resident until 5:30 A.M. when she found resident on the floor. DON confirmed she also spoke with resident's representative who has cameras installed in the room, and representative confirmed the time of fall was sometime after midnight on 01/17/23. DON confirmed she gave LPN #80 a written warning because she did not check on resident every two hours per protocol, and resident laid on the floor for approximately five hours after her fall. DON confirmed when she interviewed LPN #80 the nurse said she checked resident at 11:00 P.M. on 01/16/23 but did not do any visual checks through the night. LPN #80 confirmed she did not enter Resident' #29's room until she heard the resident yelling for help on 01/17/23 at 5:30 A.M.

Review of the personnel file for LPN #80 revealed it included at written warning for the nurse per the DON dated 01/18/23. Review of written warning revealed this was a serious performance violation, and a fall occurred on 01/17/23 with the resident was noted on floor in her bedroom for hours after the initial fall and the nurse did not check on the resident.

Review of the manufacturer's information for the facility's fall detection system dated 2017 revealed the system tracks changes in resident movement helps detect for falls that occur at or near the bedside and determines time of the falls.

Review of the facility policy titled Change in Condition undated revealed the nurse should assess the resident immediately with any change in condition.

This violation represents non-compliance investigated under Complaint Number OH00139204.

Based on review of facility fire drill records and staff interview, the facility failed to ensure fire drills were held monthly and failed to ensure one fire drill was conducted on each shift at least every three months. This had the potential to affect all 30 residents residing in the facility. The census was 30 residents.

Findings include:

Review of fire drill records revealed fire drills were conducted on the following dates and times in 2022: 03/31/22 at 12:47 P.M. (day shift), 05/04/22 at 1:30 P.M. (day shift), 06/28/22 at 6:30 A.M. (night shift), 07/28/22 at 10:39 A.M. (day shift), 08/31/22 at 3:40 P.M. (evening shift), 09/30/22 at 6:35 P.M. (evening shift.) There was no fire drill held in April 2022.

Interview on 02/08/23 at 3:35 P.M. with the Executive Director (ED) confirmed the facility did not conduct a fire drill in April 2022 and the facility did not ensure one fire drill was conducted on each shift at least every three months.

Based on disaster drill records and staff interview, the facility failed to conduct a tornado drill as required. This had the potential to affect all 30 residents residing in the facility. The census was 30 residents.

Findings include:

Review of the facility disaster drill records dated March 2022 through February 2023 revealed a tornado drill was not conducted for the facility.

Interview on 02/08/23 at 1:28 P.M. with Maintenance Director (MD) #70 confirmed the facility had not conducted a tornado drill in 2022 or 2023.