Ohio Living Rockynol

Based on medical record review and staff interview the facility failed to complete an annual fall risk assessment. This affected one resident (#34) of five residents reviewed for annual health assessments. The facility census was 57.

Findings include:

Review of the medical record for Resident #34 revealed admission to facility on 07/16/24 with diagnoses including congestive heart failure, high blood pressure, and osteoporosis. Further review revealed Resident #34 had an initial functional assessment completed by the facility on 07/16/24 which included a fall risk assessment. The initial fall risk assessment completed on 07/16/24 indicated that Resident #34 was a low fall risk.

Review of the medical record further revealed no other fall risk assessments completed until 10/01/25. The medical record indicated that Resident #34 had fallen at the facility on 07/21/25, 09/02/25, and again on 09/24/25. There were no post fall assessments completed after each fall that occurred. There were no interventions added to the service plan following the 07/21/25 fall. Further record review indicated on 08/17/25 interventions for fall risk were added to service plan to include, Resident to call for assistance with transfers

Based on medical record review and staff interview the facility failed to obtain authorized prescriber signatures on verbal and telephone orders within 14 days for residents. This affected two (#64, #65) of five residents reviewed for signing orders timely. The facility census was 57.

Findings include:

1. Review of the medical record for Resident #64 revealed admission to facility on 09/10/24 with diagnoses including early onset of Alzheimer's Disease, vitamin D deficiency, asthma, and osteoarthritis. On 08/13/25 diagnoses were updated to include severe dementia (impaired mental status with forgetfulness) with agitation.

Review of the medical record for Resident #64 revealed the following orders:

On 09/10/25 an order to discontinue Aricept (medication used for memory) 10 milligrams (mg) was entered by Licensed Practical Nurse (LPN) #22 as written order received by the Medical Doctor (MD) but there was no corresponding written order available to match.

On 04/16/25 an order to discontinue Seroquel (medication for psychotic behaviors and agitation) 25 mg twice a day was entered by Registered Nurse (RN) #23 as written order with no provider listed with no written/signed order to match.

On 02/11/25 an order to discontinue Seroquel 50 mg twice a day was entered by LPN #21 as written order from the nurse practitioner but unable to produce written order to match.

On 01/29/25 an order to start Ativan/Benadryl/Haldol (ABH) Gel (medication used for agitation) 0.5/25/1 mg topically every 12 hours as needed to area of choice was entered by by LPN #21 as written by Mind Care nurse practioner, no name provided. There was no written/signed order or to match.

Interview on 10/09/25 at 3:00 P.M. with the Assisted Living Director, LPN #20 revealed she could not find the matching orders signed by a authorized prescriber for the orders dated 09/10/25, 04/16/25, 02/11/25, or 01/29/25.

2. Review of the medical record for Resident #65 revealed admission to facility on 12/02/24 with diagnoses of dementia (mental impairment leading to forgetfulness). Further record review revealed an order dated 06/24/25 to discontinue dextromethorphan-guaifenesin syrup: 10-100 mg/5 milliliters (ml) administer 20 ml four times a day entered by LPN #24 as a telephone order from the MD. The order was not signed.

Interview on 10/09/25 at 3:00 P.M. with the Assisted Living Director, LPN #20 revealed verification of order not being signed by the MD with in 14 days.

Based on observation of medication carts and interview with staff the facility failed to properly store medications. This had the potential to affect 37 residents that utilize Medication Carts #01 and #03. The facility census was 57.

Findings Include:

Observation on 10/09/25 at 8:45 A.M. revealed Medication Cart #01 assigned to the first floor contained in the bottom drawer an open box of Lidocaine 4% Patches (topical pain relief medication). The contents of the box revealed silver packages containing the patches with no written information on the packages. Observation further revealed there was no expiration date on the box nor the individual packages. There was no resident identifier information or pharmacy label present on the box or individual packages.

Interview on 10/09/25 at 8:45 A.M. with Licensed Practical Nurse (LPN) #25 revealed she did not know which resident the Lidocaine patches belonged to. LPN #25 confirmed there was no expiration date or pharmacy label present on the box or individual packages in the box. LPN #25 removed the box of Lidocaine patches from the medication cart for disposal.

Observation on 10/09/25 at 8:55 A.M. revealed Medication Cart #03 assigned to the third floor had a stock bottle of Ibuprofen (medication to treat fever/pain) 200 milligrams (mg) tablets with manufacturer's expiration date of 08/2025 on the bottle.

Interview on 10/09/25 at 8:55 A.M. with LPN #22 revealed confirmation of the expiration date of 08/2025 on the bottle of Ibuprofen. LPN #22 removed the bottle from the medication cart for disposal.

Based on observation on the memory care unit and staff interview the facility failed to keep chemicals in a locked storage area. This had the potential to affect 14 cognitively impaired residents, (#27, #29, #38, #40, #51, #52, #62, #63, #64, #65, #66, #68, #69, and #70) residing on the memory care unit. The facility census was 57.

Findings Include:

Observation on 10/08/25 at 10:06 A.M. revealed the nurses' charting area by the common area on the memory care unit with unlocked cabinets. The area was open with no door or gated devices connecting the two areas. The cabinets contained two bottles of regular nail polish remover, one bottle of hydrogen peroxide, and one package of Tandill Laundry detergent pacs.

Interview on 10/08/25 at 10:06 A.M. interview with the Director of Environmental Services (DES) #26 revealed verification that the cabinets did not lock and should be locked if there are chemicals present. DES #26 verified there were two bottles of regular nail polish remover, one bottle of hydrogen peroxide, and one package of Tandill Laundry detergent pacs. The Assisted Living Director, Licensed Practical Nurse (LPN) #20 was notified and she removed the chemical products from the cabinet. LPN #20 verified that the first floor (memory care)was a locked unit and all residents residing on unit had cognitive (mental) impairments.

Observation 10/08/25 at 10:08 A.M. revealed the soiled utility room on the memory care unit locked with a key pad device. The code to unlock the key pad was taped on the key pad for easy entry. Inside of the soiled utility room was a half empty bottle of bleach and 1 spray bottle of Big Shot all purpose cleaner.

Interview on 10/08/25 at 10:09 A.M. with Personal Care Aide (PCA) #27 revealed verification of the key pad code taped on the key pad and easily visible. PCA #27 promptly removed the taped code from the key pad.

Interview on 10/08/25 at 10:09 A.M. with DES #26 revealed verification of code taped to key pad of soiled utility room and the presence of chemicals including bleach and multipurpose cleaner in the soiled utility room.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were given per physicians order. This affected one (#500) of three residents reviewed for medication administration. The facility census was 56.

Findings Include:

Review of Resident #500's medical record revealed the resident had a most recent admission to the facility on 03/28/25 with diagnoses including dementia and atrial fibrillation.

Review of the most recent functional assessment completed on 04/07/25 revealed Resident #500 was severely cognitively impaired and required extensive assistance from one staff member to complete activities of daily living (ADLs).

Review of Resident #500's physician orders revealed the resident was ordered a medication to help the heart beat at a normal rhythm, sotalol tablet, 120 milligrams (mg) twice daily orally on 03/27/24. Further review of the sotalol order revealed no ordered parameters or other instructions for withholding the medication.

Review of the medication administration record (MAR) for April 2025 revealed Resident #500's sotalol was held on 04/06/25 and 04/11/25 with no documentation of the reason for holding the medication.

Review of a nursing progress note dated 04/06/25 at 7:45 A.M. revealed Resident #500's sotalol was held due to low blood pressure. Further review of the medical record provided no evidence or reasoning for not administering Resident #500's sotalol on 04/11/25.

Interview with the Director of Nursing (DON) on 09/09/25 at 1:45 P.M. verified there was no documentation in the medical record supporting the withholding of Resident #500's sotalol on 04/06/25 and 04/11/25.

Review of the policy titled, Medication Administration

Based on closed medical record review, review of hospital records, and interview, the facility failed to provide adequate and timely care and medical intervention for Resident #55. This affected one resident (#55) of three residents reviewed for falls. The facility census was 58.

Actual harm occurred beginning on 06/25/24 at 1:07 A.M. when Resident #55 was found on the floor next to her bed after two previous falls within the previous 24 hours (06/24/24 at 3:33 A.M. and 06/24/24 at 6:44 A.M.) and the physician and/or certified nurse practitioner (CNP) were not notified. On 06/25/24 at 1:48 A.M. the neurological checks which were initiated for suspected head injury as a result of the falls indicated a change in condition including unclear speech with slurred and mumbled words and weakness and no action was taken. No neurological checks were documented again until 06/25/24 at 11:30 A.M. which indicated Resident #55's speech was clear, lower extremities were weak, and edema and bruising were noted around Resident #55's left eye. Again, no further action was taken including notification of the physician or certified nurse practitioner (CNP) until 06/25/24 at 1:00 P.M. when the family arrived and questioned Licensed Practical Nurse (LPN) #100 regarding extensive bruising, swollen eye and Resident #55's weakness. A neurological check on 06/25/24 at 1:00 P.M. revealed Resident #55's left eye was swollen shut and bilateral extremities were weak. LPN #100 told the family Resident #55 could be transferred to the emergency room; however, the family decided to take Resident #55 to a previously scheduled appointment with the resident's neurosurgeon. At the appointment the neurosurgeon encouraged Resident #55 to go to the emergency room given the extensive bruising after the fall. On 06/25/24 at 3:56 P.M. a family member notified the facility Resident #55 was taken to the emergency room and was being admitted to the hospital for overnight observation. On 06/28/24 at 10:28 A.M. the hospital called an update to the facility. Resident #55 was not doing well and was placed on hospice and was sent to a hospice center.

Findings include:

Review of the closed medical record revealed Resident #55 was admitted to the facility on 06/21/24 and discharged 06/25/24 with diagnoses that included fusion of cervical spine, hypertension, osteoporosis, syncope and collapse, delirium, and insomnia.

Review of the Assisted Living Admission Health and Functional Observation form dated 06/21/24 revealed Resident #55's decision making/cognitive functioning skills were reasonable and speech was clear. A Mini Mental State Exam dated 06/21/24 revealed Resident #55 had severe cognitive impairment.

Review of a progress note dated 06/24/24 timed 3:33 A.M. revealed Resident #55 was found on the floor. Resident #55 stated she had rolled out of bed. Resident #55 denied hitting her head and denied any pain. There was no written evidence the resident's physician or CNP was notified at this time.

Review of a progress note dated 06/24/24 timed 6:44 A.M. revealed Resident #55 was found on the floor. Resident #55 stated she heard a car. The note revealed Resident #55 denied any pain and was assisted to the toilet. While toileting Resident #55, a bump was observed to the posterior left side of Resident #55's head and a small bruise was noted to Resident #55's left shoulder. There was no written evidence the resident's physician or CNP was notified at this time.

Review of a neurological check dated 06/24/24 timed 6:50 A.M. revealed Resident #55's speech was clear and upper and lower extremities had strong movement.

Review of a progress note dated 06/24/24 timed 10:04 A.M. revealed the CNP was notified Resident #55 had two falls, had a bruise on the left shoulder and neurological checks were started. The documentation did not reveal the CNP was notified about the bump to the posterior left side of Resident #55's head.

Review of a progress note dated 06/25/24 timed 1:07 A.M. revealed Resident #55 was found lying flat on the floor next to the bed. Resident #55 could not say what happened. Resident #55 had an abrasion to the left inner knee. The abrasion was cleansed with normal saline and a bandage was applied. There was no written evidence the resident's physician or CNP was notified at this time.

Review of a neurological checks revealed on 06/25/24 at 1:48 A.M. Resident #55's speech was unclear with slurred and mumbled words and Resident #55 was weak. There was no written evidence the resident's physician or CNP was notified at this time or that the resident was transferred to the hospital for further assessment, evaluation or care following the repeated falls and identified change in condition (mumbled words and weakness).

No neurological checks were documented again until 06/25/24 at 11:30 A.M. The neurological check dated 06/25/24 at 11:30 A.M. revealed Resident #55's speech was clear, lower extremities were weak, and edema and bruising were noted around Resident #55's left eye. The neurological check completed on 06/25/24 at 1:00 P.M. revealed Resident #55's left eye was swollen shut and bilateral extremities were weak. There was no written evidence the resident's physician or CNP was notified at this time or that the resident was transferred to the hospital for further assessment, evaluation or care.

Review of a progress note dated 06/25/24 timed 1:00 P.M. revealed LPN #100 was called into Resident #55's room by the resident's daughter. Resident #55's eye was completely swollen shut with bruising noted around the eye and down the left side of Resident #55's face and neck. LPN #100 assisted Resident #55's daughter with transferring Resident #55 from a chair to wheelchair. Resident #55 was very tired, weak, and required a lot of assistance with the transfer. The note indicated LPN #100 suggested Resident #55 could be taken to the emergency department for evaluation due to Resident #55's current condition. The family decided to take Resident #55 to a scheduled neurosurgeon appointment stating it would be quicker, and the neurosurgeon could decide if Resident #55 needed to go to the hospital.

Review of a progress note dated 06/25/24 timed 2:15 P.M. revealed the CNP was updated Resident #55's condition had gotten worse. Resident #55's left eye was swollen shut with bruising around the left eye and down the side of the resident's face and neck. The CNP was notified Resident #55's family had transported Resident #55 to a neurosurgeon appointment and would let the neurosurgeon decide if Resident #55 should be sent to the emergency department.

Review of a progress note dated 06/25/24 timed 3:56 P.M. revealed a family member reported Resident #55 was taken to the emergency department and admitted for overnight observation. A progress note dated 06/28/24 at 10:28 A.M. revealed the hospital called an update to the facility. Resident #55 was not doing well. Resident #55 was placed on hospice and was sent to a hospice center and would not be returning to the facility.

Review of the hospital records dated 06/25/24 revealed Resident #55 had a past medical history of hypertension, urinary tract infection, and syncope and presented to the hospital with multiple falls in the past few weeks with head trauma. Resident #55 was at a follow up appointment on 06/25/24 when the physician encouraged Resident #55 to go to the emergency department for evaluation given extensive bruising after fall. Resident #55 reportedly had four falls over the past few days. Resident #55 was not on any oral anticoagulation.

An interview on 01/17/25 at 9:13 A.M. with the daughter of Resident #55 revealed when the family arrived at the facility to take Resident #55 to a scheduled appointment with neurosurgeon in June 2024, they discovered Resident #55's left eye was swollen closed and Resident #55 had extensive bruising to her face. The nurse stated they could transfer Resident #55 to the hospital if the family wanted. The resident's daughter stated the nurse did not seem concerned, so the family decided to take Resident #55 to the neurosurgeon. The daughter stated she felt the neurosurgeon would be more qualified to assess Resident #55 because of the head injury. When Resident #55 arrived at the neurosurgeon appointment, the neurosurgeon called an ambulance due to the terrible bruising and head trauma.

Interview on 01/17/25 at 2:16 P.M. with Licensed Practical Nurse (LPN) #100 revealed she received report the morning of 06/25/24 that Resident #55 had a fall. Neurological checks were done and LPN #100 kept Resident #55 within sight during her shift. The LPN stated Resident #55 did not have bruising at first and the bruising just appeared all of the sudden. LPN #100 stated she offered to send Resident #55 to the hospital after Resident #55's family arrived, and the bruising showed up. LPN #100 verified she had documented edema and bruising to Resident #55's eye and weakness to bilateral lower extremities on 06/25/24 at 11:30 A.M. (prior to the daughter's arrival). LPN #100 verified the CNP was not notified when LPN #100 noticed the edema and bruising at 11:30 A.M. or that Resident #55 had another fall the morning of 06/25/24. LPN #100 stated her shift started at 7:00 A.M. and verified she did not complete any neurological checks until 11:30 A.M. LPN #100 indicated she could not recall how much time had gone by since Resident #55 was within her sight and Resident #55's family called LPN #100 to the room to assess Resident #55 because of the bruising to Resident #55's face and her left eye being swollen shut.

Interview on 01/17/25 at 2:29 P.M. with Assisted Living Manager #101 revealed Resident #55 had light bruising when LPN #100 started her shift and the bruising worsened during the day. Assisted Living Manager #101 verified there was no documentation of the monitoring of the bump to Resident #55's head or the bruise to Resident #55's left shoulder after the assessment on 06/24/24 at 6:44 A.M. Assisted Living Manager #101 also verified documentation did not reveal neurological checks being completed every two hours, detailed information about how Resident #55 was lying (face up/face down/etc) after the falls on 06/24/24 at 6:44 A.M. and 06/25/24 at 1:07 A.M. when injuries were noted, and the CNP was not notified of changes discovered during neurological checks. A neurological check on 06/25/24 at 1:48 A.M. revealed changes in Resident #55's speech and weakness in lower extremities. Assisted Living Manager #101 verified there were no further neurological checks until 06/25/24 at 11:30 A.M.

During an interview on 01/21/25 at 2:15 P.M. the Director of Nursing (DON) verified neurological checks were not completed on 06/24/24 at 9:00 P.M. or 11:00 P.M. The DON also verified an agency nurse was working on 06/25/24 at 1:07 A.M. when Resident #55 had a fall and the agency nurse did not complete a fall event (incident report).

This violation represents non-compliance investigated under Complaint Number OH00160530.