Storypoint Shaker Heights

Based on interview, record review and review of facility policy the facility failed to maintain accurate documentation in the resident record for medication administration. This affected one Resident (#66) out of five residents reviewed for medication administration. The facility census was 83.

Findings included:

Review of the medical record for Resident #66 revealed an admission date of 03/16/26 with diagnoses including hypertension, osteoarthritis, right knee pain, and anemia.

Review of the Wellness Evaluation V5 dated 03/16/26 completed by Former Director of Nursing (DON) #900 revealed nursing staff were to administer Resident #66 her medications during two or less medication passes for routine oral medications and/or vitals less than daily. Resident #66 required assistance with her inhalers.

Review of the March 2026 Medication Administration Record (MAR) revealed Resident #66 had an order dated 03/16/26 for albuterol aerosol (bronchodilator) hydrofluoroalkane (HFA) inhale two puffs by mouth four times day to use as a rescue inhaler for respiratory difficulties. The MAR was blank on 03/17/26 at the 8:00 P.M. and nighttime doses, 03/18/26 at 8:00 A.M. and 11:00 A.M. doses, 03/20/26 at the 8:00 A.M. and 11:00 A.M. doses, and 03/28/26 at 8:00 A.M. and 11:00 A.M. doses. Resident #66 had an order dated 03/16/26 for allopurinol 100 milligram (mg) tablet give one tablet by mouth once daily used to treat gout. The MAR was blank on 03/20/26 and 03/28/26 for the A.M. doses. Resident #66 had an order dated 03/16/26 for amlodipine 10 mg give once tablet by mouth once daily for hypertension. The MAR was blank on 03/20/26 and 03/28/26 for the A.M. doses. For the order dated 03/16/26 for atorvastatin 40 mg give one tablet by mouth daily for cholesterol, the MAR was blank on 03/20/26 and 03/28/26 for the A.M. doses. For the order dated 03/16/26 for benzonatate 200 mg capsule by mouth three times a day for cough, the MAR was blank on 03/17/26 for the P.M. dose, and 03/18/26 for the noon dose. For the order dated 03/26/26 for cefdinir (antibiotic) 300 mg capsule by mouth twice a day for five days, the MAR was blank on 03/28/26 for A.M. dose. For the order dated 03/16/26 for Colace 100 mg tablet give one tablet by mouth twice a day for constipation, the MAR was blank on 03/17/26 8:00 P.M. dose, 03/18/26 8:00 A.M. dose, and 03/20/26 8:00 A.M. dose. For the order dated 03/16/26 for Eliquis (anticoagulant) 5 mg one tablet by mouth twice a day, the MAR was blank on 03/17/26 at 8:00 P.M. dose, 03/20/26 8:00 A.M. dose, and 03/28/26 8:00 A.M. dose. For the order dated 03/16/26 for Ferosul (iron supplement) 325 mg tablet give one tablet by mouth once daily, the MAR was blank on 03/18/26 and 03/20/26 at 8:00 A.M. doses. For the order dated 03/16/26 for lidocaine four percent apply one patch topically once a day (no location provided) for pain, the MAR was blank on 03/18/26, 03/20/26 and 03/28/26 for the A.M. doses. For the order dated 03/16/26 for lisinopril 40 mg give one tablet by mouth every day for hypertension, the MAR was blank on 03/18/26, 03/20/26, and 03/28/26 for the A.M. doses. For the order dated 03/26/26 for loratadine 10 mg tablet give one tablet by mouth daily for allergies, the MAR was blank on 03/18/26, 03/20/26, and 03/28/26 for the A.M. doses. For the order dated 03/16/26 for omeprazole 20 mg capsule give one capsule by mouth once daily for gastroesophageal reflux, the MAR was blank on 03/20/26, and 03/28/26 for the A.M. doses. For the order dated 03/16/26 for MiraLAX 17 grams by mouth daily mixed in four ounces of liquid for constipation, the MAR was blank on 03/20/26, and 03/28/26 for the A.M. dose. For the order dated 03/16/26 for senna 8.6 mg by mouth twice a day for constipation, the MAR was blank on 03/17/26 P.M. dose, 03/18/26 A.M. dose, and 03/20/26 A.M. dose. For the order dated 03/26/26 for Zoloft 50 mg tablet give one tablet by mouth once a day for depression, the MAR was blank on 03/20/26 and 03/28/26 for the A.M. doses. For the order dated 03/27/26 for voriconazole 200 mg tablet give one tablet four times a day for seven days for fungal/ yeast infection, the MAR was blank on 04/28/26 A.M. and noon dose, 04/29/26 P.M. dose, and 04/30/26 P.M. dose.

Review of the April 2026 MAR revealed Resident #66 had an order dated 03/16/26 for albuterol aerosol HFA inhale two puffs by mouth four times day. The MAR was blank on 04/01/26 8:00 A.M. dose, 04/06/26 at the 8:00 A.M. and 11:00 A.M. doses, 04/08/26 at the 8:00 A.M. dose, and 04/14/26 at the 8:00 A.M. dose. For the order dated 03/16/26 for allopurinol 100 mg tablet give one tablet by mouth once daily, the MAR was blank on 04/01/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for amlodipine 10 mg give once tablet by mouth once daily, the MAR was blank on 04/01/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for atorvastatin 40 mg give one tablet by mouth daily, the MAR was blank on 04/06/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for Colace 100 mg tablet give one tablet by mouth twice a day, the MAR was blank on 04/04/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for Eliquis 5 mg one tablet by mouth twice a day, the MAR was blank on 04/08/26 8:00 A.M. and 04/14/26 8:00 A.M. dose. For the order dated 03/16/26 for Ferosul 325 mg tablet give one tablet by mouth once daily, the MAR was blank on 04/04/26, 04/06/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for lidocaine four percent apply one patch topically once a day, the MAR was blank on 04/01/26, 04/04/26, 04/06/26, 04/08/26, and 04/14/26 for the A.M. doses. For the order dated 03/16/26 for lisinopril 40 mg give one tablet by mouth every day, the MAR was blank on 04/04/26, 04/06/26, 04/08/26, and 04/14/26. For the order dated 03/26/26 for loratadine 10 mg tablet give one tablet by mouth daily, the MAR was blank on 04/04/26, 04/06/26, 04/08/26, and 04/14/26. For the order dated 03/16/26 for omeprazole 20 mg capsule give one capsule by mouth once daily, the MAR was blank on 04/01/25, 04/08/26, and 04/14/26. For the order dated 03/16/26 for MiraLAX 17 grams by mouth daily mixed in four ounces of liquid, the MAR was blank on 04/01/25, 04/06/26, 04/08/26, and 04/14/26. For the order dated 03/16/26 for timolol maleate solution 0.5 percent one drop in both eyes twice a day for glaucoma, the MAR was blank on 04/06/26, 04/08/26, and 04/14/26 for the A.M. dose. For the order dated 03/16/26 tizanidine 2 mg tablet give one tablet by mouth three times daily, the MAR was blank on 04/01/26 at the 8:00 A.M. dose, 04/06/25 at the 11:00 A.M. dose, 04/08/26 at the 8:00 A.M. dose, and 04/14/26 at the 8:00 A.M. dose. For the order dated 03/26/26 for Zoloft 50 mg tablet give one tablet by mouth once a day, the MAR was blank on 04/01/26, 04/04/26, 04/06/26, 04/08/26, and 04/14/26.

Review of the Wellness Evaluation V5 dated 04/21/26 and completed by Former DON #900 revealed Resident #66 was able to self-administer her medications.

Review of the Saint Louis University Mental Status (SLUMS) evaluation dated 05/13/26 completed by Wellness Operations Specialist/ Licensed Practical Nurse (LPN) #950 revealed Resident #66 had intact cognition.

An interview on 06/04/26 at 10:45 A.M. with Resident #66 revealed she did not believe she was administered her medications as ordered from admission until she started to self-administer her medications on her own which was 04/21/26.

An interview on 06/08/26 at 9:45 A.M. with the DON and Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #200 verified the missing medication administration documentation for all the medications identified on the March and April 2026 MARs for Resident #66. They verified they were unable to determine if the above medications were offered, administered, refused or not given at all due to another reason because the MAR was blank and there was no other documented explanantion in the resident record to be able to determine. They verified a nurse was to administer Resident #66's medications from admission on 03/16/26 until when it was assessed she was able to self-administer her medications on 04/21/26. They revealed they were unable to provide any details as to why there were blanks in the MARS as they both had started at the facility after 04/20/26.

Review of the facility policy titled, General Medication Preparation, Assistance, Administration, and Observation dated 05/04/22 revealed the purpose of the policy was to prepare and administer medications in accordance with infection control principles and give per the medication rights. The policy revealed nothing about ensuring the nurse documented on the MAR after administration of the medication and/ or documented if the resident refused or if the medication was omitted for another reason.

This deficiency represents non-compliance investigated under Complaint Number OH00170621.

Based on observation, interview, review medication manufacturer guidelines, and review of facility policy the facility did not ensure eye drops were administered in accordance with prescription guidelines. This affected one Resident (#31) out of one observed for administration of eye drops. This had the potential to affect 17 additional Residents (#3, #16, #17, #20, #23, #26, #30, #1, #35, #37, #47, #60, #62, #66, #68, #73, and #81) identified by the facility with physician orders for eye drops. The facility census was 83.

Findings include:

Review of Resident #31's medical record revealed an admission date of 10/31/23 with diagnoses including glaucoma, chronic kidney disease, and cirrhosis of the liver.

Review of the service plan dated 02/21/25 revealed under the area of medications Resident #31 required assistance with medication administration. There was nothing in the service plan regarding his eye drops and Resident #31 refusing to wait between the drops at least five minutes per manufacturer guidelines.

Review of the After Visit Summary dated 10/07/25 and completed by Ophthalmologist #201 revealed Resident #31 had glaucoma and noted per her progress note that his right eye had severe open angle glaucoma and his left eye was staged at moderate open angle glaucoma. She recommended brimonidine 0.2 percent, one drop both eyes two times a day, and timolol maleate 0.5 percent ophthalmic solution, one drop in both eyes each morning.

Review of Drugs.com manufacturer's guidelines titled, Brimonidine and Timolol Ophthalmic dated 04/07/26 revealed the medications were used in combination to lower high pressure in the eye for patients with glaucoma or other eye pressure problems. If more than one topical ophthalmic drug was being used the eye drops should be instilled at least five minutes apart.

Review of the June 2026 Physician Orders revealed Resident #31 had the following physician orders: brimonidine solution 0.2 percent ophthalmic instill one drop in both eyes three times a day and timolol maleate solution 0.5 percent instill one drop in both eyes every morning.

Observation on 06/04/26 at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #144 prepared Resident #31's morning medications. LPN #144 applied gloves and administered his timolol maleate ophthalmic 0.5 percent one drop into each eye on 06/04/26 at 8:18 A.M.. LPN #144 then immediately followed those eyes drops by administering the brimodine tartrate solution two percent one drop into each eye on 06/04/26 at 8:19 A.M..

An interview on 06/04/26 at 8:23 A.M. with LPN #144 verified she administered Resident #31 his timolol maleate ophthalmic into each eye on 06/04/26 at 8:18 A.M. and then immediately administered his brimodine tartrate solution into each eye on 06/04/26 at 8:19 A.M. She revealed Resident #31 wanted his eye drops like that as he does not want the nurse to wait in between eye drops. She verified there was nothing in the physician order or service plan stating it was ok to give the eye drops without waiting five minutes between per manufacture guidelines. LPN #144 also verified she had not asked or educated Resident #31 to wait at least five minutes between his eye drops during observation.

An interview on 06/04/26 at 11:53 A.M. with Pharmacist #202 through facility contracted pharmacy revealed per manufactures guidelines the nurse should wait five minutes between all eye drops including Resident #31's brimonidine and timolol eye drops.

Review of the facility policy titled, General Medication Preparation, Assistance, Administration, and Observation dated 05/04/22 revealed the purpose of the policy was to prepare and administer medications in accordance with infection control principles and give per the medication rights. The policy revealed medication with special timing considerations shall have directions written on the MAR. There was nothing in the policy regarding ensuring at least five minutes between eye drops was followed. There was also no other policy in regards to eye drops.

This deficiency represents non-compliance investigated under Complaint Number OH00170621 and is a recite to the complaint survey completed 04/08/26.

Based on observation, interview, record review, review of medication manufacture guidelines and review of facility policy, the facility did not ensure Resident #81's insulin was dated when opened. This affected one Resident (#81) out of one resident observed for insulin administration. The facility identified one Resident (#81) as receiving insulin from the facility staff. The facility census was 83.

Findings include:

Review of the medical record for Resident #81 revealed an admission date of 02/10/25 with diagnoses including diabetes, chronic kidney disease, and anemia. She moved from the Assisted Living (AL) side of the facility to the memory care side on 06/02/26.

Review of the service plan dated 02/24/25 revealed Resident #81 required assistance with medication administration. Intervention included nurses to administer insulin per physician orders. There was nothing in the service plan regarding ensuring the insulin was dated when opened.

Review of the June 2026 Physician Orders revealed Resident #81 had an order dated 03/06/26 for lispro kwikpen 100 units per milliliter (ml) inject four units subcutaneously three times a day at 8:00 A.M., 12:00 P.M. and 4:00 P.M. due to diabetes.

Observation on 06/04/26 at 7:24 A.M. revealed Licensed Practical Nurse (LPN) #170 administered lispro kwikpen four units to Resident #81's right side of her abdomen. The insulin pen was not dated as to when it was opened.

An interview on 06/04/26 at 7:32 A.M. with LPN #170 verified the insulin pen was not dated as to when it was opened. She revealed Resident #81 had recently just moved onto the memory care unit so she was unsure when it was opened as it would have been opened by a nurse on the AL side.

An interview on 06/04/26 at 11:53 A.M. with Pharmacist #202 with facility contracted pharmacy verified insulin when opened should be dated and lispro kwikpen was good for 28 days after it was opened.

Review of the facility policy labeled, Medication Storage dated 06/10/22 revealed the purpose of the policy was to establish a procedure to be followed for safe, and consistent storage of medication. The policy revealed medication labels must include the resident's name, medication name, medication strength/ dose, frequency, route and expiration. There was nothing in the policy in regard to ensuring the medication was dated when opened including insulin.

Review of manufacture guidelines for Insulin Lispro dated 2023 revealed insulin lispro kwikpen was good for 28 days after it was opened.

Review of the facility guide labeled, Medication Expiration Guide dated 04/09/25 revealed to follow manufactures guidelines for how to store and when to dispose of medications. The guide revealed lispro kwiwpen was good for 28 days after the pen was opened.

This deficiency represents noncompliance as an incidental finding during investigation of Complaint Number OH00170621 and is a recite to the annual survey completed 11/03/25.

Based on interview, record review and review of facility policy the facility did not ensure appropriate notification as required for residents with change in condition. This affected two Residents (#32, #74) out of five residents reviewed for change in condition. The facility census was 83.

Findings include:

1. Review of the medical record for Resident #74 revealed an admission date of 05/02/23 with diagnoses including diabetes, glaucoma and asthma.

Review of the Wellness Evaluation V5 dated 12/04/25 and completed by Former Director of Nursing (DON) #900 revealed Resident #74 was cognitively intact, required assistance of one person with escorts and transfers, and was independent with her other activity of daily living (ADLs).

Review of Occupational Therapist (OT) #198's progress note dated 02/28/26 revealed she had seen Resident #74 at 9:00 A.M. to 9:45 A.M. and Resident #74 was blind and required a walking stick and close supervision to safely leave her apartment. The note revealed her vitals were obtained prior to the therapy session and her blood pressure was 181/83, pulse 62, respirations 15 and her oxygen saturation rate was 99 percent on room air. The note revealed Resident #74 reported feeling confusion and the back of her head hurting on the left side. OT #198 notified nursing of the elevated blood pressure and symptoms. During the therapy her blood pressure did improve to 150/80.

Review of nursing notes dated from 02/01/26 to 06/04/26 revealed there was no nurses note dated for 02/28/26 regarding a nursing assessment after OT #198 reported Resident #74 had an elevated blood pressure with confusion.

Review of the Blood Pressure Summary for Resident #74 dated from 02/01/26 to 06/04/26 revealed there was no blood pressure obtained by the nurse on 02/28/26.

An interview on 06/04/26 at 12:31 P.M. with OT #198 revealed on 02/28/26 Resident #74's blood pressure was elevated, and Resident #74 was acting different as she had confusion which was a change from her baseline. OT #198 revealed she contacted the nurse on duty but did not remember the nurse's name. OT #198 stated she then waited for the nurse to come to her room to assess Resident #74 and went down two different times to let the nurse know and the nurse never came up to assess Resident #74 while she was in the room over a 45-minute time frame.

An interview on 06/04/26 at 2:15 P.M. with Resident #74 revealed her blood pressure usually was not elevated. She revealed she remembered the time in February 2026 when it was elevated when OT #198 came to her room and she was having an off day, some confusion and feeling out of sorts. She verified OT #198 contacted the nurse because of her elevated blood pressure and that the nurse never came. She revealed that was usual as she did not feel the nurses at the facility responded when she had a change in condition and stated, I do not wait for them, I will just call 911 as they do not respond timely. She revealed everything turned out ok that day as she never had to go to the hospital and the confusion had gone away.

Interview on 06/08/26 at 11:15 A.M. with DON and Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #200 verified OT #198's progress note dated 02/28/26 revealed Resident #74 blood pressure was elevated at 181/83, she reported feeling confusion and the back of her head hurting on the left side. They verified per the therapy progress note the elevated blood pressure and symptoms were reported to nursing but there was nothing in the nursing notes regarding an assessment completed and/ or notification to a physician regarding the change in condition. They revealed they were not able to provide any details regarding the incident as they both had started at the facility after the incident on 04/20/25.

2. Review of the medical record for Resident #32 revealed an admission date of 04/09/26 with diagnoses including hypertension, muscle weakness, and hyperlipidemia.

Review of the service plan dated 04/13/26 revealed Resident #32 required staff assistance with bathing, dressing, and medication administration.

Review of OT #198's progress note dated 06/03/26, with time in of 12:15 P.M. and time out of 1:00 P.M. revealed prior to therapy Resident #32's blood pressure was 211/103 and nursing was notified. During therapy her blood pressure was 183/101 and post therapy her blood pressure was 154/84.

Review of Blood Pressure Summary dated from 04/09/26 to 06/09/26 revealed the last blood pressure obtained was on 04/14/26 and her blood pressure was 128/62. There was no blood pressure documented for 06/03/26.

Review of nursing notes dated 06/01/26 to 06/08/26 revealed there was no nursing note regarding an assessment for Resident #32's elevated blood pressure and complaint of lightheadedness during therapy on 06/03/26.

Review of Physical Therapy (PT) #901's progress note dated 06/03/26 with a time in of 1:00 P.M. and a time out of 1:45 P.M. revealed Resident #32's blood pressure prior to therapy was 154/84, pulse 82, respiration 12, and oxygen saturation level was 97 percent on room air.

An interview on 06/04/26 at 12:31 P.M. with OT #198 revealed on 06/03/26 Resident #32's blood pressure was elevated at 211/103, pulse was 71 and oxygen saturation rate was 97 on room air. OT #198 revealed she pushed the call light to get a nurse (LPN #109) and a caregiver had answered the call light. She revealed she asked the caregiver to get the nurse because her blood pressure was elevated. OT #198 revealed Resident #32 also complained that she was lightheaded. She revealed she took a second blood pressure, and it was 183/101. She revealed she waited in the room from 12:15 P.M. to 1:00 P.M. (45 minutes) and LPN #109 never came during that time frame to assess the resident.

An interview on 06/08/26 at 9:25 A.M. and 11:28 A.M. with LPN #109 revealed she was notified by the caregiver that Resident #32 was in her room with therapy and her blood pressure was elevated. She revealed she checked Resident #32's blood pressure as PT #901 was in the room at the time she went in. This surveyor reviewed progress note with LPN #109 regarding time frame as OT #198's progress note dated 06/03/26 recorded the time in was 12:15 P.M. and the time out was 1:00 P.M. and that Resident #32's blood pressure prior to OT therapy was 211/103 and PT #901's progress note dated 06/03/26 recorded the time in was 1:00 P.M. and the time out was 1:45 P.M. She verified she had not assessed Resident #32 while OT #198 was in the room from 12:15 P.M. to 1:00 P.M. and that it was when PT #901 was in the room after 1:00 P.M. She revealed she was in the dining room at the time, was unsure what time the caregiver actually had told her OT #198 needed her in Resident #32's room but verified by the notes it seemed there was a delay in assessing Resident #32's blood pressure. She verified she had not documented anything in the nursing notes regarding her elevated blood pressure (211/103) for OT #198, her assessment she completed and any notifications to a physician regarding change in condition.

An interview on 06/08/26 at 11:15 A.M. with the DON and ADON/ RN #200 revealed they were not aware of the concern Resident #32 displayed elevated blood pressure (211/103) and lightheadedness on 06/03/26 during therapy and verified there was nothing in the nursing notes regarding the change in condition, nursing assessment and/ or notification to a physician. They verified the physician should have been notified.

Review of facility policy labeled, Change in Residents Condition dated 02/27/23 revealed the purpose of the policy was to establish a process to evaluate, monitor, plan, and implement actions to meet resident needs and notify family and healthcare provider of changes in resident. Residents with unstable or potentially life threatening medical or mental health condition should be evaluated by a healthcare provider or sent to the emergency room (ER) as warranted by calling 911 immediately. The policy revealed the incident should be documented with the date and time of contacts on the communication notes in the resident chart and new orders should be directed to the pharmacy and placed in the resident's chart.

This deficiency represents non-compliance investigated under Complaint Number OH00170621 and is a recite to the annual survey completed 11/03/25.

Based on interview, record review and review of facility policy the facility did not ensure residents that displayed a change in condition were assessed in a timely manner. This affected three Residents (#32, #66, #74) out of five residents reviewed for change in condition. The facility census was 83.

Findings included:

1. Review of the medical record for Resident #74 revealed an admission date of 05/02/23 with diagnoses including diabetes, glaucoma and asthma.

Review of the Wellness Evaluation V5 dated 12/04/25 and completed by Former Director of Nursing (DON) #900 revealed Resident #74 was cognitively intact, required assistance of one person with escorts and transfers, and was independent with her other activity of daily living (ADLs).

Review of Occupation Therapist (OT) #198's progress note dated 02/28/26 revealed she saw Resident #74 at 9:00 A.M. to 9:45 A.M. and Resident #74 was blind and required a walking stick or close supervision to safely leave her apartment. The note revealed her vitals were obtained prior to the therapy session and her blood pressure was 181/83, pulse 62, respirations 15 and her oxygen saturation rate was 99 percent on room air. The note revealed Resident #74 reported feeling confusion and the back of her head hurting on the left side. OT #198 notified nursing of the elevated blood pressure and symptoms. During the therapy her blood pressure did improve to 150/80.

Review of nursing notes dated from 02/01/26 to 06/04/26 revealed there was no nurses note dated 02/28/26 regarding a nursing assessment after OT #198 reported Resident #74 had an elevated blood pressure with confusion.

Review of the Blood Pressure Summary for Resident #74 dated from 02/01/26 to 06/04/26 revealed there was no blood pressure obtained per the nurse on 02/28/26.

An interview on 06/04/26 at 12:31 P.M. with OT #198 revealed on 02/28/26 Resident #74's blood pressure was elevated, and Resident #74 was acting different as she had confusion which was a change from her baseline. She revealed she contacted the nurse on duty but did not remember the nurse's name. She revealed she then waited for the nurse to come to her room to assess Resident #74 and went down two different times to let the nurse know and the nurse never came up to assess Resident #74 while she was in the room over a 45-minute time frame.

An interview on 06/04/26 at 2:15 P.M. with Resident #74 revealed her blood pressure usually was not elevated. She revealed she remembered the time in February 2026 when it was elevated when OT #198 came to her room and she was having an off day, with some confussion and feeling out of sorts. She verified OT #198 contacted the nurse because of her elevated blood pressure and that the nurse never came. She revealed that was usual as she did not feel the nurses at the facility responded when she had a change in condition and stated, I do not wait for them, I will just call 911 as they do not respond timely. She revealed everything turned out ok that day as she never had to go to the hospital and the confusion had gone away.

An interview on 06/08/26 at 11:15 A.M. with DON and Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #200 verified OT #198's progress note dated 02/28/26 revealed Resident #74 blood pressure was elevated at 181/83, she reported feeling confusion and the back of her head hurting on the left side. They verified per the therapy progress note the elevated blood pressure and symptoms were reported to nursing but there was nothing in the nursing notes regarding an assessment completed and/ or notification to a physician regarding the change in condition. They revealed they were not able to provide any details regarding the incident as they both had started at the facility after the incident on 04/20/26.

2. Review of the medical record for Resident #66 revealed an admission date of 03/16/26 and her diagnoses included hypertension, osteoarthritis, right knee pain, and anemia.

Review of the service plan dated 03/16/26 revealed Resident #66 was oriented to person, time, and situation. She required assistance with her ADLs including transfers, dressing, toileting, and wheelchair mobility.

Review of the OT #198's progress note dated 04/16/26 revealed Resident #66 reported not feeling well and requested assistance in changing her incontinence product as it was soiled. Her blood pressure was 183/92, pulse 75, and oxygen saturation rate was 97. She notified the Former DON #900 and nurse on duty (Licensed Practical Nurse (LPN) #109) and sat with Resident #66 until their arrival. After five minutes of waiting, OT educated and initiated calming relaxation techniques including diaphragmatic breathing, guided imagery, and progressive muscle relation to reduce her elevated blood pressure. OT completed a second reading that measured 204/105 and then the Former DON #900 completed a third blood pressure: 189/101. Nursing contacted the EMS and she was sent to the hospital.

Review of the nursing note dated 04/16/26 at 5:12 P.M. and completed by LPN #109 revealed the nurse was informed by therapy that Resident #66's blood pressure was 189/101 at approximately 1:20 P.M. and the nurse rechecked her blood pressure and it was 205/106. The nurse instructed the resident to take deep breaths without talking and she notified EMS. The note revealed EMS arrived and her last blood pressure reading was 183/92 at 1:45 P.M.. She was transported to the hospital.

Review of a nursing note dated 04/17/26 at 7:27 A.M. and completed by LPN #156 revealed Resident #66 returned back to the facility from the hospital.

An interview on 06/04/26 at 10:45 A.M. with Resident #66 revealed there had been several times there had been a delay in assessment when she displayed a change in condition as she did not feel the nurses at the facility responded in a timely manner. She revealed there was one time that therapy (OT #198) was in her room and they had taken her blood pressure and it was elevated. She revealed OT #198 attempted to call the nurses and front desk but she was unable to get a hold of anyone for a period of time. She revealed OT #198 then took her blood pressure again, it was higher and she continued to try to get a hold of a nurse to come to the room. She revealed OT #198 finally was able to get Maintenance Director (MD) #185 to get the nurse. She revealed the nurse took her blood pressure, called EMS and she went to the hospital as her blood pressure was elevated.

An interview on 06/04/26 at 12:31 P.M. with OT #198 revealed on 04/16/26 at 1:15 P.M. she went to provide therapy services for Resident #66 and prior to starting the treatment she obtained her vitals including blood pressure 183/92, pulse 75 and oxygen saturation rate was 97 at room air. She revealed Resident #66 reported that she did not feel well as well as she felt Resident #66 did not look well displaying a change in condition from her baseline including she appeared weaker. She attempted to notify the nurse on duty (LPN #109), Former DON #900, and front desk receptionist by phone but neither answered their phones. She revealed after ten minutes she obtained a second blood pressure reading and her blood pressure was 204/105 but she stated nursing continued not to come to the room and she continued to not be able to reach them by phone. She revealed she was able to find MD #189 outside Resident #66's room and asked him to find a nurse. She revealed approximately five minutes later the Former DON #900 and LPN #109 came to the room as they stated they were in a meeting. She revealed the Former DON #900 obtained a third blood pressure: 189/101 and they called EMS to transport to the hospital. She revealed she felt there was a delay in treatment/ assessment as from the first blood pressure reading to the time the Former DON #900 and LPN #109 arrived was approximately 15 minutes. She revealed there had been other times that she was unable to get a hold of the nurse and/ or Former DON #900 as she stated they do not answer their phones which was the procedure set up by the facility was to call the nurse and/ or Former DON's phones when there was a change in condition/ emergency.

An interview on 06/08/26 at 9:25 A.M. and 11:28 A.M. with LPN #109 denied any time there was delay in assessment regarding Resident #66 as she felt she responded right away including on 04/16/26 when Resident #66's blood pressure was elevated. She revealed her blood pressure continued to be elevated, they contacted EMS and sent her to the hospital.

An interview on 06/08/26 at 11:49 A.M. with MD #185 verified he was outside Resident #66's room when therapy stated Resident #66's blood pressure was high and Resident #66 needed a nurse. He revealed he went to find the Former DON #900 and/ or a nurse. He revealed about five minutes later he found the Former DON #900 in the conference room and told her Resident #66 needed her in her room.

A interview on 06/08/26 at 11:15 A.M. with DON and ADON/ RN #200 verified OT #198's progress note dated 04/16/26 revealed Resident #66 reported not feeling well and her blood pressure was 183/92. They verified the note revealed she notified the Former DON #900 and nurse on duty (LPN #109) and sat with Resident #66 until their arrival. They verified the second blood pressure reading per the OT #198's progress note was 204/105. They revealed they were not able to provide any details regarding the incident as they both had started at the facility after the incident on 04/20/26 but did verify each nurse had a nurse's phone that staff were to utilize to notify of an emergency and/ or change in condition. They also verified the DON carried a phone as well. They were not aware of any current and/ or previous issues regarding staff including therapy not being able to get a hold of the nurse and/ or DON in a timely manner regarding a resident's change in condition.

3. Review of the medical record for Resident #32 revealed an admission date of 04/09/26 and her diagnoses included hypertension, muscle weakness, and hyperlipidemia.

Review of the service plan dated 04/13/26 revealed Resident #32 required staff assistance with bathing, dressing, and medication administration.

Review of OT #198's progress note dated 06/03/26 with a time in of 12:15 P.M. and a time out of 1:00 P.M. revealed prior to therapy her blood pressure was 211/103 and nursing was notified. During therapy her blood pressure was 183/101and post therapy her blood pressure was 154/84.

Review of Physical Therapy (PT) #901's progress note dated 06/03/26 with a time in of 1:00 P.M. and a time out of 1:45 P.M. revealed Resident #32's blood pressure prior to therapy was 154/84, pulse 82, respiration 12, and oxygen saturation level was 97 percent on room air.

Review of the Blood Pressure Summary dated from 04/09/26 to 06/09/26 revealed the last blood pressure obtained was on 04/14/26 and her blood pressure was 128/62. There was no blood pressure documented for 06/03/26.

Review of nursing notes dated 06/01/26 to 06/08/26 revealed there was no nursing note regarding an assessment for Resident #32's elevated blood pressure and complaint of lightheadedness during therapy on 06/03/26.

An interview on 06/04/26 at 12:31 P.M. with OT #198 revealed on 06/03/26 Resident #32's blood pressure was elevated at 211/103, pulse was 71 and oxygen saturation rate was 97 on room air. She revealed she pushed the call light to get a nurse (LPN #109) and a caregiver had answered the call light. She revealed she asked the caregiver to get the nurse because her blood pressure was elevated. She revealed Resident #32 also complained that she was lightheaded. She revealed she took a second blood pressure, and it was 183/101. She revealed she waited in the room from 12:15 P.M. to 1:00 P.M. (45 minutes) and LPN #109 never came during that time frame to assess.

An interview on 06/08/26 at 9:25 A.M. and 11:28 A.M. with LPN #109 revealed she was notified by the caregiver that Resident #32 was in her room with therapy and her blood pressure was elevated. She revealed she checked Resident #32's blood pressure as PT #901 was in the room at the time she went in. This surveyor reviewed progress note with LPN #109 regarding time frame as OT #198's progress note dated 06/03/26 recorded the time in was 12:15 P.M. and the time out was 1:00 P.M. and that Resident #32's blood pressure prior to OT therapy was 211/103 and PT #901's progress note dated 06/03/26 recorded the time in was 1:00 P.M. and the time out was 1:45 P.M. She verified she had not assessed Resident #32 while OT #198 was in the room from 12:15 P.M. to 1:00 P.M. and that it was when PT #901 was in the room after 1:00 P.M. She revealed she was in the dining room at the time, was unsure what time the caregiver actually had told her OT #198 needed her in Resident #32's room but verified by the notes it seems there was a delay in assessing Resident #32's blood pressure. She verified she had not documented anything in the nursing notes regarding her elevated blood pressure (211/103) for OT #198, her assessment she completed and any notifications to a physician regarding change in condition.

An interview on 06/08/26 at 11:15 A.M. with DON and ADON/ RN #200 revealed they were not aware of the concern Resident #32 displayed elevated blood pressure (211/103) and lightheadedness on 06/03/26 during therapy and that OT #198 notified the caregiver at the beginning of the therapy session at approximately 12:15 P.M. to get the nurse and per OT #198, LPN #109 never came to the room from 12:15 P.M. to 1:00 P.M to assess.

Review of the facility policy titled, Assist with Vital signs dated 10/17/22 revealed it was important to check the vitals signs of a resident and it was important to report any unusual findings to the director or designee.

Review of facility policy titled, Change in Residents Condition dated 02/27/23 revealed the purpose of the policy was to establish a process to evaluate, monitor, plan, and implement actions to meet resident needs and notify family and healthcare provider of changes in resident. Residents with unstable or potentially life threatening medical or mental health condition should be evaluated by a healthcare provider or sent to the emergency room (ER) as warranted by calling 911 immediately. When a resident displays a change in condition that is a priority the caregiver will notify the director by phone. The policy revealed the incident should be documented with the date and time of contacts on the communication notes in the resident chart and new orders should be directed to the pharmacy and placed in the resident's chart.

This deficiency represents non-compliance investigated under Complaint Number OH00170621 and is a recite to the complaint survey completed 02/05/26.

Based on record review and interview, the facility failed to ensure residents were fully informed of charges as required and accurately billed. This affected one resident (Resident #66) out of four residents reviewed for charges. The facility census was 83.

Findings include:

Review of the medical record for Resident #66 revealed an admission date of 03/16/26 with diagnoses including hypertension, osteoarthritis, right knee pain, and anemia. Resident #66 was her own responsible party for health care and for finances. Resident #66 managed her own funds and bank account. Resident #66 was assessed as Level of Care five as of 04/23/26.

Review of Saint Louis University Mental Status (SLUMS) evaluation dated 05/13/26 revealed Resident #66 had intact cognition.

Review of the resident billing account statement for Resident #66 for April 2026 revealed the resident was charged monthly 4,500.00 for rent and a monthly charge of 3,067.00 for the resident specific level of level of care five. The billing statement also revealed Resident #66 was not issued a level of care determination until 04/23/26 yet was billed for the whole month of level five level of care.

An interview on 06/04/26 at 2:07 P.M. with the Property/Business Manager (PBM) confirmed a mistake was made by the billing software and Resident #66 was overcharged for the full month of care in April 2026. The PBM confirmed the additional charges should not have occurred until the resident was actually assessed for level of care and prior informed of the additional charges. The PBM confirmed Resident #66 was not issued an official level of care until 04/23/26. The PBM stated she had corrected the mistake and went over the billing with Resident #66.

This deficiency represents non-compliance investigated under Complaint Number OH00170621.

Based on record review, resident interview, staff interview, observations and policy review, the administration failed to provide adequate oversight and ensure implementation of policies and procedures necessary for the safe and effective operation of the assisted living facility for 72 residents. This affected five (Residents #44, #70, #6, #65, and #33) and had the potential to affect all residents residing in the facility.

Findings include:

1. Review of the medical record for Resident #44 revealed an admission date of 09/26/24 with a diagnosis of Parkinson's disease. Resident #44 had intact cognition.

Review of the facility SPG Wellness Evaluation

Based on record review, resident interview, staff interview, observations and policy review, the facility failed to ensure sufficient staffing levels were met daily to provide care and meals in a timely manner for residents who required extensive and total assistance. This affected two (Residents #6 and #65) of eight residents who required extensive and total care and had the potential to affect all residents residing in the facility. The facility census was 72.

Findings include:

1. Review of the medical record for Resident #65 revealed an admission date of 05/02/23. Diagnoses included type one diabetes mellitus and glaucoma.

Interview on 03/30/26 at 10:01 A.M., Servers #519 and #522 stated they were always short staffed in the kitchen which made it difficult to feed residents who required assistance, take orders in the dining room and deliver meals to resident rooms.

Interview on 03/30/26 at 10:04 A.M., Licensed Practical Nurse (LPN) #574 stated they were always short staffed. The nurse must administer medications to 48 residents on three floors.

Interview on 03/30/26 at 12:06 P.M., Care Associate (CA) #555 stated, we don't have enough staff; residents don't always get showers as scheduled.

Interview on 03/30/26 at 2:30 P.M., Dining Room Manager (DRM) #509 stated we have been using the Styrofoam containers because we don't have enough staff to get the room trays delivered on time. Residents complain that meals were late and cold.

Observations from 03/30/26 through 04/01/26 noted kitchen staff delivering breakfast from 8:00 A.M. to 10:00 A.M. Review of the facility mealtimes noted breakfast would be provided between 7:30 A.M. and 9:30 A.M. Specific observations of Resident #65 were made on 03/31/26 from 9:00 A.M. to 10:05 A.M. Resident #65 received her breakfast at 10:05 A.M.

Interview immediately after Resident #65's breakfast was delivered, Kitchen Server #527 verified that the meal was late and stated he had no idea why it was so late, he does not usually deliver food to the apartments.

Interview on 03/31/26 at 8:42 A.M., Resident #65 stated her friend had prefilled the insulin syringes for the week, but she had difficulty administering the insulin in a timely manner because her meals were always late. Resident #65 stated her blood glucose levels had dropped significantly in the past due to administering the rapid-acting insulin and then having to wait for meals.

Interview on 03/31/26 at 9:00 A.M., CA #553 stated we are always short staffed, we have nine residents that require extensive assistance for washing, dressing, transfers, showering and one resident who required total care including transferring via a mechanical lift. Resident #6 who requires total care cannot activate her call light and was a risk for falls, so we must check on her frequently.

Interview on 03/31/26 at 9:15 A.M., CA #546 stated we have one nurse and two aides providing care for residents on three floors, plus delivering meal trays.

Interview on 03/31/26 at 9:40 A.M., Residents #4, #25, #37 and #49 were all seated at the same table in the dining room. All residents stated there were not enough direct-care staff or kitchen servers. Residents stated the food was served in Styrofoam and was always late and cold.

Interview on 03/31/26 at 10:04 A.M., LPN #579 stated there were not enough staff, staff are overwhelmed working extra hours to fill in. LPN #579 stated she worked as needed but worked 60 hours a week.

Interview on 03/31/26 at 11:15 A.M., Executive Chef (EC) #512 and Dining Room Manager (DRM) #509 stated the kitchen had challenges due to lack of staff in the morning; meals for residents eating in their apartments were late most of the time. EC #512 stated she had one cook to prepare meals and one server to take orders, fill beverages, deliver the meals to the dining room and manage the dining room. EC #512 stated the staff on second shift were to collect meal tickets from residents in the afternoon for breakfast the next morning. EC #512 stated the kitchen does not receive the breakfast tickets, so residents received the standing order of scrambled eggs and sausage. ECd#512 stated the food would be put on plates with warmers and placed on the cart. EC #512 stated the kitchen would call direct staff to take the plates to the rooms, and the staff would state they were too busy providing resident care, and the meals would get cold. EC #512 stated the kitchen staff took it upon themselves to deliver the meals, but they were short staffed as well, so one server could not take trays to three floors and serve the dining room at the same time.

Interview on 03/31/26 at 12:41 P.M., Wellness Director (WD) #582 stated the facility was not short staffed given the current census. WD #582 stated staff were scheduled according to the census. WD #582 could not state why Styrofoam containers were used, just that the containers have been used for months.

Interview on 03/31/26 at 2:18 P.M., Resident #33 stated he eats all his meals in his apartment, meals were always cold and served in a Styrofoam container.

Interview on 03/31/26 at 2:45 P.M., CA #560 stated they have one resident that required total care including use of a mechanical lift and at least nine residents that required extensive assistance with all activities of daily living.

Interview on 03/31/26 at 3:28 P.M., CA #552 who works on the memory care unit stated they used to have three aides for 19 residents but have two most days. CA #552 stated most residents on the memory care unit require extensive assistance, including assistance with feeding.

Interview on 04/03/26 at 2:30 P.M., CA #509 stated they worked 20 hours on 04/01/26 and 04/02/26. Review of the punch times verified CA #509 worked 7:01 A.M. to 11:37 P.M. on 04/01/26. CA#509 went home and returned to the facility 2.5 hours later and worked 04/02/26 from 2:08 A.M. to 7:18 A.M.

Interview on 04/06/26 at 11:40 A.M., Regional Director for Clinical Services (RDCS) #586 stated the expectation for answering calls was for staff to answer lights within 10 minutes. RDCS #586 stated it was not safe to have staff working 20 hours without a substantial break, RDCS #586 verified the punch times for CA#509.

Review of call light audits from 03/22/26 through 03/30/26 noted several days where call lights were answered after 50, 60, 88, and 120 minutes. This was verified by RDCS #586.

Review of facility policies titled Guideline Staffing and Call Light Guidance

Based on medical record review, interview, review of drugs.com and policy review, the facility failed to ensure timely administration of carbidopa/levodopa (time-sensitize) as ordered to manage symptoms of Parkinson's disease. This affected four (Residents #1, #23, #44 and #49) of five residents diagnosed with Parkinson's disease. The facility also failed to ensure residents requiring insulin received their insulin in a timely manner. This affected one (Resident #65) of two residents receiving insulin. The facility census was 72.

Findings include:

1. Review of medical record for Resident #1 noted an admission date of 06/30/23. Diagnosis included Parkinson's disease and mild cognitive impairment.

Review of physician orders noted Resident #1 was ordered carbidopa/levodopa (anti-Parkinson agent) 25-100 milligrams at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.

Review of administration history for February and March 2026 noted several days when the 8:00 A.M. dose was administered one, two, three and five hours past 8:00 A.M.

Review of medical record for Resident #23 noted an admission date of 12/03/25 with a diagnosis of Parkinson's disease.

Review of physician orders noted Resident #23 was ordered carbidopa/levodopa 25-100 milligrams at A.M., noon, P.M. and night.

Review of administration history for February and March 2026 noted staff were not consistent with administration times. The doses for A.M. varied between 8:16 A.M. and 10:52 A.M.

Review of medical record for Resident #44 noted an admission date of 09/26/24. Diagnosis included Parkinson's disease with dyskinesia which is a movement disorder characterized by involuntary erratic muscle movements.

Review of physician orders noted Resident #44 was ordered carbidopa/levodopa 25-100 milligrams at 7:00-9:00 A.M., noon and 5:00 P.M.-6:59 P.M.

Review of administration history for February and March 2026 noted all three doses were administered at different times throughout the week.

Review of medical record for Resident #49 noted an admission date of 10/21/25. Diagnosis included Parkinson's disease with dyskinesia which is a movement disorder characterized by involuntary erratic muscle movements.

Review of physician orders noted Resident #49 was ordered carbidopa/levodopa 25-100 milligrams at A.M., noon and P.M.

Review of administration history for February and March 2026 noted all three doses were administered at different times throughout the week.

Interview on 04/01/26 at 11:25 A.M., Wellness Director (WD) #582 stated medication times included early A.M. (12:00 A.M. to 6:59 A.M), A.M. (7:00 A.M.-10:59 A.M.), noon (11:00 A.M.-3:00 P.M.) and bedtime (4:00 P.M.- 11:59 P.M.). WD #582 was unable to state the importance of administering carbidopa/levodopa at the same time daily to ensure therapeutic effectiveness.

Interview on 04/03/26 at 8:58 A.M., Clinical Director of Medical House Calls #588 (outside company providing care) stated carbidopa/levodopa should be given at the same time every day to accomplish targeted outcomes. He stated he would educate staff at the facility on the importance of administering the medication in a timely manner.

Interview on 04/03/26 at 9:44 A.M., Certified Nurse Practitioner (CNP) #589 stated carbidopa/levodopa/levodopa was a time-sensitive medication that should be administered around the same time daily to be effective.

Review of information indicated on drugs.com noted levodopa should be taken at the same times every day to maintain consistent medication levels in the blood, minimizing wearing-off effects.

2. Review of the medical record for Resident #65 revealed an admission date of 05/02/23. Diagnoses included type one diabetes mellitus and glaucoma.

Interview on 03/31/26 at 8:42 A.M., Resident #65 stated her friend had prefilled the insulin syringes for the week, but she had difficulty administering the insulin in a timely manner because her meals were always late. Resident #65 stated her blood glucose levels had dropped significantly in the past due to administering the insulin and having to wait for her meals. Resident #65 stated she ate some leftovers around 9:30 A.M. so she could administer her insulin.

Review of physician orders for Resident #65 revealed the resident was ordered 14 units of Humalog (rapid-acting) insulin every morning at 8:00 A.M., every evening at 5:00 P.M. and 34 units of Lantus (slow-acting) at 10:00 P.M. Resident #65 was legally blind but administered her insulin herself. All orders for insulin were dated 11/21/24. Review of the medication administration record was not completed due to Resident #65 self-administering medications.

Observations throughout the week of survey noted kitchen staff delivering breakfast from 8:00 A.M. to 10:00 A.M. Review of the facility mealtimes noted breakfast was to be provided between 7:30 A.M. and 9:30 A.M. Specific observations of Resident #65 were made on 03/31/26 from 9:00 A.M. to 10:05 A.M.

Interview on 03/31/26 immediately after Resident #65's breakfast was delivered, Kitchen Server #527 verified that the meal was late and stated he had no idea why it was so late; he does not usually deliver food to the apartments.

Interview on 03/31/26 at 9:40 A.M., Residents #4, #25, #37 and #49 were all seated at the same table in the dining room. All residents stated there were not enough direct-care staff or kitchen servers. Residents stated the food was always late and cold.

Interview on 03/31/26 at 11:15 A.M., Executive Chef (EC) #512 and Dining Room Manager (DRM) #509 stated the kitchen had challenges due to lack of staff in the morning, and meals for residents eating in their apartments were late most of the time. EC #512 stated she had one cook to prepare meals and one server to take orders, fill beverages, deliver the meals to the dining room and manage the dining room. EC #512 stated the staff on second shift were to collect meal tickets from residents in the afternoon for breakfast the next morning. EC #512 stated the kitchen does not receive the breakfast tickets, so residents receive the standing order of scrambled eggs and sausage. EC #512 stated the food would be put on plates with warmers and placed on the cart. EC #512 stated the kitchen would call direct staff to take the plates to the rooms, the staff would state they were too busy providing resident care, and the meals would get cold. EC #512 stated the kitchen staff took it upon themselves to deliver the meals, but we were short staffed as well so one server could not take trays to three floors and serve the dining room at the same time.

Interview on 03/31/26 at 12:41 P.M., WD #582 stated the facility was not short staffed given the current census.

Interview on 03/31/26 at 2:18 P.M., Resident #33 stated he eats all his meals in his apartment, meals were always cold and served in a Styrofoam container.

Review of the facility policy titled Resident Room Trays

Based on observation, interview, and facility policy review, the facility failed to maintain a sanitary kitchen. This had the potential to affect all 72 residents residing in the facility.

Findings include:

Observations on 03/30/26 at 9:01 A.M. of the kitchen noted Line Cook (LC) #505 wearing gloves while plating food. LC #505 entered the refrigerator wearing gloves and touched shelving and the refrigerator door. LC #505 then continued to plate food including cutting up fruits without changing gloves. Interview immediately after the observation with LC #505 verified not changing gloves and stated he should have changed his gloves before touching the food.

Continued observations of the kitchen on 03/30/26 at 9:15 A.M. noted the refrigerator storage had expired and/or undated food, including a container of sesame seeds not dated or covered; applesauce not dated; beef soup not dated; queso dip with an end date of 03/28/26; coleslaw not dated; mashed potatoes not dated; tzatziki sauce which expired on 03/27/26. There was grilled chicken in a container not dated; raw chicken sitting on the bottom shelf not covered and leaking juices on the tray; fish filets sitting in a cardboard box on the second bottom shelf that were thawed out and leaking juices onto the bottom shelf and floor; tapioca pudding not dated; shredded chicken not dated; potato salad which expired on 03/26/26; a half of blueberry pie not dated; yams expired on 03/26/26; and a container of beets that expired on 03/26/26. Executive Chef (EC) #512 observed and verified all findings at the time of the observation.

Review of the facility policy titled, Sanitation Practices

Based on observation, interview and review of facility policy, the facility failed to ensure the area surrounding the dumpster was clean and free of miscellaneous debris. This had the potential to affect all 72 residents residing in the facility.

Findings include:

Observation on 03/30/26 at 9:35 A.M. of the dumpster with Executive Chef (EC) #512 noted the dumpster itself had garbage bags hanging out of the opened doors and lid. The ground area surrounding the dumpster had an opened foam container, latex gloves, plastic bottles, plastic ware, and soiled adult briefs and wipes.

Interview immediately after the observation with EC #512 verified the findings and stated, I am not sure who is responsible for maintaining the dumpster are.

Review of the facility policy titled, Trash Removal

Based on record review, resident interview, staff interview and facility policy review, the facility failed to ensure residents were free from staff-to-resident abuse and neglect and failed to ensure allegations of staff-to-resident abuse and neglect were investigated in a timely manner. This affected three (Residents #44, #70 and #6) of three reviewed for abuse. The facility census was 72.

Findings include:

1. Review of the medical record for Resident #44 revealed an admission date of 09/26/24 with a diagnosis of Parkinson's disease. Resident #44 had intact cognition.

Review of the facility SPG Wellness Evaluation

Based on observation, medical record review, resident and staff interview, hospital document review, and policy review, the facility failed to ensure Resident #10, who had a diagnosis of diabetes mellitus and was insulin dependent received adequate monitoring and care to prevent an acute change in condition. The facility failed to ensure insulin administration, blood glucose monitoring, and notification to the physician of levels outside of ordered values and changes in resident condition were completed timely and as ordered.

Actual Harm occurred on 11/30/25 at 8:41 A.M. when Resident #10 was assessed to be hyperglycemic with a blood sugar reading from the glucometer indicating the level was too high to register and the resident was diaphoretic, cold to touch, and had difficulty communicating her thoughts clearly. Resident #10 was transported to the local hospital emergency department (ED) via emergency medical services and admitted to the hospital with hyperglycemia and was placed on an insulin drip. Prior to the incident, on 11/29/25 at 5:53 P.M., Resident #10's blood glucose level was 56 milligrams per deciliter (mg/dL) (hypoglycemic) and the resident was provided with a snack. There was no evidence the facility notified the physician of the resident's low blood glucose reading or evidence of any additional monitoring being initiated to assess the resident for a change in condition. Resident #10's blood glucose level was not checked again until 11/30/25 as noted above. This affected one resident (#10) of three residents reviewed for change of condition and appropriate care and services. The facility census was 76.

Findings include:

Review of Resident #10's medical record revealed an admission date of 02/10/25 with diagnoses including type one diabetes mellitus, chronic kidney disease, and osteoarthritis.

Review of Resident #10's service plan report dated 02/24/25 revealed Resident #10 would meet medication needs with assistance. Interventions included the resident required (staff) assistance with medication administration.

Record review revealed a physician order dated 05/20/25 for Resident #10 to have blood glucose checks four times daily scheduled at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.

Review of Resident #10's medication administration record (MAR) revealed physician orders originally written on 07/08/25 for insulin lispro 100 units per milliliter (units/ml) with instructions to give insulin per sliding scale. The sliding scale included to inject two (2) units of insulin for blood glucose levels between 151 to 200 mg/dL, inject four (4) units of insulin for blood glucose levels between 201 to 250 mg/dL, inject six (6) units of insulin for blood glucose levels between 251 to 300 mg/dL, inject eight (8) units of insulin for blood glucose levels between 301 to 350 mg/dL, and inject 10 units of insulin for blood glucose levels greater than 350 mg/dL. The MAR noted blood glucose levels were scheduled to be checked between 8:00 A.M. to 10:59 A.M., 12:00 P.M. to 3:59 P.M., and 4:00 P.M. to 5:59 P.M.

Review of Resident #10's MAR revealed physician orders originally written on 08/09/25 for the resident to receive insulin lispro 100 units/ml with instructions to inject 6 units subcutaneously (SQ) before meals.

Review of Resident #10's MAR revealed physician orders originally written on 08/09/25 for the resident to receive Lantus Solostar injection 100 units/ml with instructions to inject 15 units SQ daily at bedtime.

Review of Resident #10's wellness evaluation dated 08/10/25 revealed Resident #10 was alert and oriented, but might have occasional confusion, forgetfulness, or memory loss. Resident #10 required reminders and cueing, and some set-up assistance for bathing. Resident #10 required three or more medication passes and daily vital sign and blood glucose checks.

Review of Resident #10's blood glucose level dated 11/29/25 at 9:04 A.M. revealed it was 526 mg/dL and Resident #10 was administered 10 units of insulin lispro. There was no evidence in Resident #10's medical record of the physician being notified of the high blood glucose level. There was no evidence Resident #10 was evaluated for an altered mental status, signs and symptoms of hyperglycemia, or weakness.

Review of Resident #10's blood glucose level dated 11/29/25 at 12:43 P.M. revealed a value of 360 mg/dL was obtained, and Resident #10 was administered 10 units of insulin lispro. There was no evidence Resident #10's physician was notified of the high blood glucose level.

Review of Resident #10's blood glucose level dated 11/29/25 at 5:53 P.M. revealed the level obtained was 56 mg/dL. The nurse gave Resident #10 food and no insulin was administered for meal coverage. Resident #10 had no additional blood glucose checks, including the blood glucose level ordered to be checked at 8:00 P.M. until 11/30/25 at 8:41 A.M. There was no evidence Resident #10's physician was notified of her low blood sugar.

Review of Resident #10's blood glucose level dated 11/30/25 at 8:41 A.M. revealed her blood glucose level was too high to be read and Resident #10 was sent to the emergency department.

Review of Resident #10's progress note dated 11/30/25 at 10:40 A.M. revealed Resident #10 presented with a significantly elevated blood glucose level as the glucometer was unable to register a value. Resident #10 was diaphoretic, cold to touch, and had difficulty communicating her thoughts clearly. Due to her hyperglycemia and altered mental status, Resident #10 was transferred to the local hospital ED for evaluation and management. Resident #10's son was notified. Resident #10 was not given insulin before her transfer to the ED because her blood sugar level did not register on the glucometer and the note indicated she might require a higher insulin dose that could be provided at the ED.

Review of Resident #10's pre-hospital care report summary dated 11/30/25 revealed a call from the facility was received at 8:27 A.M. and Emergency Medical Services (EMS) had resident contact at 8:31 A.M. Resident #10's blood pressure was 186/80 millimeters of mercury (mmHg), pulse was 88 beats per minute, respirations were 16 breaths per minute, oxygen saturation level 98 percent (%), and her blood glucose level was 582 mg/dL. Resident #10 was alert and oriented to person, place, time, and situation, and was transported to the local hospital ED.

Review of Resident #10's after visit summary for a hospital visit between 11/30/25 and 12/02/25 revealed Resident #10 was admitted to the hospital for hyperglycemia and was noted to be in diabetic ketoacidosis (DKA) without coma. Resident #10 was on an insulin drip, treated, and was stable to be discharged back to the facility. Resident #10 was ordered blood glucose level checks four times daily, insulin lispro 6 units SQ three times daily before meals, insulin glargine 15 units SQ daily at bedtime, and insulin lispro via sliding scale before meals. The sliding scale included for blood glucose levels below 110 mg/dL, given zero (0) units; for blood glucose levels between 111 and 150 mg/dL, give 0 units; for blood glucose levels between 151 and 200 mg/dL, give 2 units; for blood glucose levels between 201 and 250 mg/dL, give 4 units; for blood glucose levels between 251 and 300 mg/dL, give 6 units; for blood glucose levels between 301 and 350 mg/dL, give 8 units; for blood glucose levels between 351 and 400 mg/dL, give 10 units; and for blood glucose levels greater than 400 mg/dL, given 10 units and notify the provider.

Review of Resident #10's blood glucose levels obtained at the facility between 12/03/25 and 02/02/26 revealed blood glucose levels on 12/03/25, 12/04/25, 12/05/25, 12/14/25, 12/15/25, 12/22/25, 12/23/25, 12/24/25, 01/09/26, 01/16/26, 01/29/26, and 02/01/26 were not obtained four times a day as ordered.

Review of Resident #10's December 2025 MAR and related physician orders revealed an order dated 07/08/25, with no stop date, for insulin lispro to be administered via sliding scale. The sliding scale included to give 2 units for blood glucose levels between 151 and 200 mg/dL, give 4 units for blood glucose levels between 201 and 250 mg/dL, give 6 units for blood glucose levels between 251 and 300 mg/dL, give 8 units for blood glucose levels between 301 and 350 mg/dL, and give 10 units for blood glucose levels greater than 350 mg/dL. There was no evidence of the times Resident #10's blood glucose levels for sliding scale were ordered to be checked, but nurse documentation dated 12/03/25 through 12/31/25 revealed they were checked and insulin was administered per the sliding scale at 8:00 A.M. through 10:59 A.M., 12:00 P.M. to 3:59 P.M., and 4:00 P.M. to 5:59 P.M. Further review revealed an order dated 08/09/25, with a stop date of 12/14/25, for insulin lispro 6 units SQ before meals. Nurse documentation from 12/03/25 through 12/14/25 revealed insulin was administered in the morning, at noon, and in the evening. There was no evidence in Resident #10's medical record including progress notes why this order was stopped on 12/14/25.

Review of Resident #10's orders revealed an order dated 12/02/25, with a stop date of 12/27/25, for insulin lispro to inject 0 to 10 units per sliding scale three times daily before meals and notify the provider if blood glucose levels were greater than 400 mg/dL. There was no evidence of parameters for the sliding scale insulin. There was nurse documentation Resident #10 received insulin per the sliding scale and the documentation indicated a blood glucose level was recorded for morning, noon, and evening, but the documentation did not specify how many units of insulin Resident #10 received. There was no evidence in Resident #10's medical record, including progress notes, to explain why the insulin order was stopped on 12/27/25. Review of a physician order dated 12/05/25, with a stop date of 12/14/25, revealed Resident #10 was to receive 6 units SQ three times daily and 2 to 12 units per sliding scale three times daily. There was nurse documentation from 12/06/25 through 12/14/25 that Resident #10's insulin was administered in the morning, noon, and evening. There was no evidence blood glucose levels were checked for the sliding scale, and no clarification of the orders which indicated the sliding scale was 2 to 12 units which was different from the orders on 12/02/25 which indicated the sliding scale insulin was 0 to 10 units. There was no evidence in Resident #10's medical record including progress notes why this order was written and why it was discontinued.

Continued review of Resident #10's December 2025 MAR and physician orders revealed an order dated 08/09/25, with a stop date of 12/06/25, revealed Resident #10 was ordered Lantus Solostar 15 units SQ daily at bedtime. There was nurse documentation 12/02/25 through 12/05/25 that Resident #10 received the insulin. Review of an order dated 12/05/25, with a stop date of 12/22/25, revealed Resident #10 was ordered Lantus Solostar 15 units SQ at bedtime. There was no evidence in Resident #10's medical record as to why the order was initiated on 12/05/25 and there was no documentation of the insulin being administered on 12/14/25.

Review of Resident #10's physician orders and notes from Endocrinologist #505 dated 12/22/25 revealed Resident #10's main reason for the visit was to adjust her insulin and control of her type one diabetes mellitus. Endocrinologist #505 increased the resident's Lantus Solostar insulin to 20 units at bedtime, changed the mealtime Humalog (insulin lispro) to 4 units three times a day, and changed the sliding scale to 0 units for a blood glucose levels less than 150 mg/dL, give one (1) unit for a blood glucose levels between 151 to 200 mg/dL, give 2 units for blood glucose levels between of 251 to 300 mg/dL, give 3 units for a blood glucose level of 301 to 350 mg/dL, and 4 units for blood glucose levels greater than 350 mg/dL. Resident #10's blood glucose log was to be sent to Endocrinologist #505 via facsimile (fax) in one week.

Review of Resident #10's medical record and December 2025 MAR revealed no evidence the blood glucose log was faxed to Endocrinologist #505, there was no evidence the orders for sliding scale insulin were implemented, and there was no evidence the insulin lispro 4 units were administered before meals three times a day.

Further review of Resident #10's physician orders and December 2025 MAR revealed and order dated 12/22/25, with a stop date of 01/15/26, for the resident to receive insulin lispro 4 units SQ three times daily and 0 to 4 units per sliding scale three times daily. There was nurse documentation the insulin was administered in the morning, noon and evening. Resident #10's blood glucose levels were recorded but there was no evidence of the parameters used for the sliding scale of 0 to 4 units of insulin and no evidence of how many units of insulin Resident #10 was administered.

Review of Resident #10 blood glucose levels revealed on 12/04/25 at 8:56 A.M., Licensed Practical Nurse (LPN) #507 documented Resident #10's blood glucose level was 487 mg/dL and 10 units of insulin lispro were administered. There was no evidence that Resident #10's physician was notified as ordered.

Review of Resident #10's blood glucose levels revealed on 12/15/25 at 10:49 P.M., the resident's blood glucose level was 432 mg/dL. Review of Resident #10's December 2025 MAR and related progress notes revealed no evidence of the physician being notified as ordered.

Review of Resident #10's blood glucose levels revealed on 12/18/25 at 9:00 A.M., the resident's blood glucose level was 505 mg/dL. It was documented that 10 units of insulin lispro were administered, however, there was no evidence that Resident #10's physician was notified as ordered.

Review of Resident #10's blood glucose levels revealed on 12/21/25 at 12:38 P.M., the resident's blood glucose level was 434 mg/dL. It was documented that 10 units of insulin lispro were administered, however, there was no evidence that Resident #10's physician was notified as ordered.

Review of Resident #10's blood glucose levels revealed on 12/23/25 at 10:39 P.M., the resident's blood glucose level was 438 mg/dL. Further review of the medical record including progress notes and the December 2025 MAR revealed no evidence Resident #10 received insulin or the physician was notified as ordered.

Review of Resident #10's January 2026 MAR and physician orders revealed there was no evidence of the times the resident's blood glucose levels were obtained for the 07/08/25 insulin lispro sliding scale order. Further review of the nursing documentation revealed the blood glucose levels were obtained and insulin was administered per the sliding scale between 8:00 A.M. to 10:59 A.M, 12:00 P.M. to 3:59 P.M., and 4:00 P.M. to 5:59 P.M. Review of an order dated 12/05/25, with no stop date, revealed Resident #10 was ordered insulin lispro 6 units SQ three times daily between 2 to 12 units per sliding scale three times daily. There was nurse documentation from 01/14/26 through 01/31/26 that Resident #10's insulin was administered in the morning, noon, and evening. There was no evidence blood glucose levels were checked for the sliding scale and no clarification of the orders which indicated the sliding scale was 2 to 12 units. There was no evidence in Resident #10's medical record, including review of progress notes, to explain why the order dated 12/05/25 was initiated on 01/14/26. Review of Resident #10's January 2026 MAR and physician orders revealed an order dated 12/22/25, with a stop date of 01/15/26, for insulin lispro 4 units SQ three times daily and 0 to 4 units per sliding scale three times daily. The MAR had nurse documentation that Resident #10's insulin was administered daily in the morning, at noon, and in the evening. There was nurse documentation of Resident #10's blood glucose levels being checked, but there was no evidence Resident #10's insulin was administered per a sliding scale and there was no evidence of clarification of what the sliding scale was. There was no evidence in Resident #10's medical record indicating why the order was discontinued on 01/15/26.

Continued review of Resident #10's January 2026 MAR and physician orders revealed an order dated 12/05/25 with no stop date for Lantus Solostar 15 units SQ daily at bedtime was not documented it was administered from 01/01/26 through 01/26/26. On 01/27/26, 01/28/26, and 01/31/25 there was documentation Lantus 15 units was administered. Review of Resident #10's order dated 12/22/25, with a stop date of 01/31/26, revealed Lantus Solostar 20 units SQ daily at bedtime was discontinued on 01/31/26. There was no evidence in Resident #10's medical record why the Lantus was discontinued. Review of Resident #10's January 2026 MAR for 01/27/26 and 01/28/26 revealed there was documentation that Resident #10 received Lantus Solostar 15 units and Lantus Solostar insulin injection 20 units on both days at bedtime.

Review of Resident #10's February 2026 MAR and physician orders revealed there was no evidence of the times the resident's blood glucose levels were obtained for the 07/08/25 insulin lispro sliding scale order. Further review of the nursing documentation revealed the blood glucose levels were obtained and insulin was administered per the sliding scale between 8:00 A.M. to 10:59 A.M, 12:00 P.M. to 3:59 P.M., and 4:00 P.M. to 5:59 P.M. on 02/01/26 and 02/02/26.

Interview on 02/02/26 at 5:00 P.M. with Wellness Director (WD) #500 confirmed Resident #10's blood glucose levels were not routinely documented four times a day as ordered. WD #500 stated Resident #10's bedtime blood glucose order was not always implemented because the order for the bedtime blood glucose check did not get attached properly when the orders were verified from the pharmacy. WD #500 indicated the orders were now fixed and Resident #10's blood glucose level would be checked daily at bedtime.

On 02/03/26 at 11:03 A.M. Resident #10 was observed sitting in a chair in her room watching television. An interview with Resident #10 at the time of the observation revealed the facility was sometimes good and sometimes not good about checking her blood glucose levels. Resident #10 stated she had been to the hospital related to her blood glucose levels, and recently her level was so high EMS was called and she was transported to the ED and admitted to the hospital for treatment.

On 02/03/26 at 3:03 P.M. telephone interview with Nurse Practitioner (NP) #504, with WD #500, revealed Resident #10 had type one diabetes mellitus and her blood glucose levels were uncontrolled. NP #504 stated Resident #10 received Lantus Solostar 15 units at bedtime and was administered 6 units of insulin three times a day before meals with a sliding scale, and the sliding scale was in addition to the 6 units she was administered three times a day before meals. WD #500 asked NP #504 if a window of time from 8:00 A.M. to 10:59 A.M., 12:00 P.M. to 3:59 P.M., and 4:00 to 5:59 P.M. was appropriate for Resident #10's scheduled 6 units of insulin lispro and the sliding scale insulin. NP #504 stated the blood glucose levels should be checked before meals, and 7:30 A.M., 11:30 A.M., and 4:30 P.M. were more appropriate times for the levels to be checked and insulin administered. NP #504 stated he would review Resident #10's insulin orders with WD #500 the next time he visited the facility. NP #504 stated he expected the blood glucose levels to be checked before meals to have accurate levels, clarifying which times were best for accurate blood glucose readings, and again stated Resident #10's blood glucose should be checked before meals and to not use a timeframe. NP #504 stated he expected to be called if Resident #10's blood glucose level was less than 90 mg/dL and greater than 350 mg/dL. NP #504 indicated he was not aware if NP #503 was contacted by a nurse at the facility or if she adjusted Resident #10's insulin orders in January 2025. NP #504 stated he had not talked to Endocrinologist #505 regarding Resident #10's insulin orders. NP #504 indicated he managed Resident #10's insulin orders and only reached out to specialists such as Endocrinologist #505 if he had any difficulties.

Interview on 02/03/26 at 4:29 P.M. with WD #500 revealed she talked to the nurse (Licensed Practical Nurse (LPN) #506) who cared for Resident #10 on 11/29/25 and 11/30/25, and confirmed it was the same nurse both days. LPN #506 told WD #500 that on 11/29/25, Resident #10's blood glucose level was 526 mg/dL in the morning, and she gave the resident 10 units of insulin. LPN #506 gave an additional 10 units of insulin at lunchtime because Resident #10's blood glucose level was 360 mg/dL. On 11/29/25 at 4:30 P.M., Resident #10's blood glucose level was 56 mg/dL and LPN #506 stated she gave the resident a snack and her blood glucose level came up. WD #500 indicated LPN #506 told her she called Resident #10's physician on 11/29/25 and reported the high blood sugar of 526 mg/dL, but confirmed there was no evidence in Resident #10's medical record this was done. WD #500 confirmed there was no evidence additional blood glucose levels were checked after the blood sugar of 56 mg/dL until 11/30/25 at 8:41 A.M. when Resident #10's blood sugar did not register on the glucometer because it was too high, and the resident was transported to the local hospital ED and admitted with hyperglycemia.

Interview on 02/03/26 at 4:39 P.M. with WD #500 and Regional Wellness Director (RWD) #501 revealed it was unclear from Resident #10's medical record, but it appeared NP #503 was incorrectly called by a nurse regarding Resident #10's insulin orders in January 2025. RWD #501 stated in the past, NP #503 cared for Resident #10 and around October 2025 her care was switched to NP #504.

Interview on 02/04/26 at 9:05 A.M. with WD #500 and RWD #501 revealed WD #500 checked Resident #10's medical record, progress notes, and MARs for December 2025, January 2026, and February 2026 and could not find a sliding scale for 0 to 4 units insulin lispro or clarification of Resident #10's physician order written on 12/22/25. WD #500 confirmed physician orders for Resident #10's insulin administration were not followed. When asked about the discrepancies and lack of documentation regarding Resident #10's insulin orders in December 2025, and January and February 2026, WD #500 stated it was confusing and she could not tell what the nurses did. WD #500 indicated she was unable to determine why the nurses were documenting in all the insulin areas when it looked like it was the same thing, and she did not have a place to go in Resident #10's medical record to give an explanation. WD #500 stated sometimes there were duplicate orders and one had to be taken out. WD #500 revealed she was unsure why there were two orders in January 2026 for Lantus Solostar insulin, one for 15 units and one for 20 units to be administered at bedtime. WD #500 stated Resident #10's physician orders were not discontinued when she was admitted to the hospital, and the orders were continued after she came back to the facility. WD #500 stated that practice was typical, but going forward it was going to change, and orders would be discontinued when a resident was admitted to the hospital. WD #500 confirmed on 12/04/25, 12/15/25, 12/21/25, and 12/23/25 Resident #10's blood glucose levels were greater than 400 mg/dL, on 12/18/25 her blood glucose level was 505 mg/dL, and there was no evidence the high blood glucose readings were reported to Resident #10's physician as ordered.

Interview on 02/04/26 at 11:34 A.M. with NP #504 revealed he visited the facility once a month and if NP #503 was incorrectly called about Resident #10 and gave orders, he was not notified that it happened. NP #503 was Resident #10's old provider and he had no communication with her. NP #504 indicated Resident #10 was transported to the hospital on 11/30/25 for hyperglycemia and was followed by Endocrinologist #500. When asked about Resident #10's multiple orders for insulin lispro sliding scale, NP #504 stated there should only be one order for sliding scale insulin administration.

Interview on 02/04/26 at 2:56 P.M. with LPN #507 revealed Resident #10 had type one diabetes mellitus and her blood glucose levels were unstable. LPN #507 stated Resident #10's blood glucose levels were checked four times a day and she would notify the resident's physician if it was above 450 mg/dL. LPN #507 documented she checked Resident #10's blood glucose level on 12/04/25 at 8:56 A.M. and it was 487 mg/dL, and she administered 10 units of insulin lispro to the resident. There was no evidence LPN #507 contacted the physician to report the high blood sugar and when LPN #507 was asked about the lack of documentation that the physician was contacted LPN #507 stated she did not remember that day because it was almost two months ago. LPN #507 stated the documentation must have been a typo, (typographical error), because she would have called the physician.

Review of the facility policy titled, Change in Resident Condition

Based on record review and interview the facility failed to provide showers to residents that were dependent upon staff for assistance with activities of daily living. This affected three residents (Residents #47, #52, and #59) of five residents reviewed. The census was 58.

Finding include

1. Review of the medical record for Resident #47 revealed an admission date of 06/24/25 with diagnosis of dementia and hypertension. The resided on the secured memory care unit due to cognitive impairment and required staff assistance for all activities of daily living including bathing and hygiene

Review of the shower schedule and Care Associate documentation of showers given on shower sheets revealed Resident #47 was not on the shower schedule for staff. One shower sheet dated 10/22/25 was available and documented as shower refused. No other shower sheets were available since admission for Resident #47.

2. Review of the medical record for Resident #52 revealed an admission date of 09/25/25 with diagnosis of Alzheimer's disease, osteoarthritis, and hypertension. The resident required staff assistance for activities of daily living and communication related to cognitive impairment.

Review of the shower schedule and Care Associate documentation of showers given on shower sheets revealed Resident #52 was not on the shower schedule for staff. No documentation was available to support Resident #52 received a shower since admission.

3. Review of the medical record for Resident #59 revealed an admission date of 05/29/24 with diagnosis of dementia, diabetes, and hypertension. The resident was cognitively impaired and required staff assistance for activities of daily living and resided on the memory care unit.

Review of the shower schedule and Care Associate documentation of showers given on shower sheets revealed Resident #59 was not on the shower schedule for staff. Shower sheets documentation of shower given 09/30/25, 10/03/25 refused shower, 10/09/25 shower given. No other evidence of Resident #59 receiving a shower was available.

An interview on 10/23/25 at 11:00 A.M. with Corporate Wellness Director #683 verified the lack of shower documentation and there was no additional documentation to provide to verify showers were accepted by the resident

This violation represents non-compliance investigated under Complaint Number OH00168559.

Based on interview, observation, and policy review the facility failed to properly label prescription and over the counter medications. This had the potential to affect all residents. Facility census was 58.

Findings Include:

An observation on 10/22/25 at 9:45 AM of the medication cart located on the memory care unit with Licensed Practical Nurse (LPN) #674 revealed several bottles of opened medications without dates. Undated opened medications included one bottle of Cosopt eye drops, four bottles of Brimonidine eye drops, one bottle of Lumigan 0.1% eye drops, two bottles of liquid Haldol two milligrams per milliliter, four bottles of D3 tablets, two bottles of Senna plus tablets, one bottle of vitamin B12 tablets, and three bottles of Melatonin 5 milligram tablets.

An interview on 10/22/25 at 9:55 AM with LPN #674 revealed that these medication bottles were opened and undated. LPN #674 verified that all medications should be dated once opened.

A review of facility policy last revised 05/04/22 titled General Medication Preparation, Assistance, Administration and Observation stated that all multi-dose containers are to be dated when opened.

Based on record reviews, policy reviews, and interviews, the facility failed to complete appropriate notification for residents with condition changes. This affected one resident Resident #47 of five reviewed.

Findings include:

Review of the medical record for Resident #47 revealed an admission date of 06/24/25 with diagnosis of dementia and hypertension

Review of the wellness assessment dated 08/12/25 authored by the former wellness director revealed Resident #47 resided on the secured memory care unit due to cognitive impairment and required staff assistance for all activities of daily living and communication.

A review of Resident #47 medical record revealed a progress note dated 04/08/25 at 7:12 PM authored by Licensed Practical Nurse (LPN) # 673 that stated, caregiver alerted this nurse of bruise to resident's right lower abdomen. The resident had no complaints of pain or discomfort to that area. No noted falls. There was no documentation of notification to Resident #47's care provider, sponsor, or supervisor. No evidence of any follow-up documentation was available.

Further review of Resident #47 medical record revealed a progress note dated 06/18/25 at 2:59 P.M. authored by LPN #674 that stated, bruising noted to bilateral arms and left thumb. The caregiver stated that resident was kicking her and she grabbed her arms. There was no documentation of notification to Resident #47's care provider, sponsor, or supervisor. No evidence of any follow-up documentation was available.

An interview on 11/03/25 at 12 P.M. with Corporate Wellness Director #683 revealed that she was not aware of any incident of Resident #47 having any bruises or being grabbed by a caregiver. The expectation is that any resident with a change of condition, injury or any changes, the care provider, resident's sponsor, and any other appropriate party would be notified depending on the nature of the event. Further it is expected that the change and notifications were documented in the residents' medical record.

Review of the facility policy dated 2/27/23 titled Change in Resident Condition revealed that Resident healthcare provider and responsible party will be notified of change of condition and interventions implemented.

Based on record review and interview, the facility failed to perform 2 step Mantoux testing for new hire employees and annual retesting or tuberculosis symptom review for current employees. This had the potential to affect all residents. The census was 58.

Findings include:

Review of personnel files revealed three newly hired employees without documentation of receiving 2-step Mantoux testing.

1. Dietary Server #618 with a hire date of 09/16/25, received the first step Mantoux testing on 09/03, read 09/05/25 with no second step was completed.

2. Life Enrichment Lead #630 with a hire date of 09/16/25 received the first step Mantoux testing 09/03/25, read 09/05/25 with no second step completed.

3. Executive Chef #624 with a hire date of 08/05/25 received the first step Mantoux testing, not read and no second step was completed.

4. Dietary worker #623 with a hire date of 10/01/24 no evidence of annual testing or screening for symptoms of tuberculosis.

5. Dishwasher #606 with a hire date of 12/20/23 no evidence of annual testing or screen for symptoms of tuberculosis.

An interview on 10/21/25 at 3:22 P.M., with Property administrator #605, verified that there was no documentation to support that Mantoux testing had been completed. Further, I shared that Mantoux testing was usually the responsibility of the Wellness Director. The facility did not have a Wellness Director on cite and the corporate Wellness Director was covering the position until the newly hired facility Wellness Director could start.

Based on observation, and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents. The census was 58.

Findings include:

An observation on 10/21/25 at 11:20 A.M. revealed dietary server #607 pushed a cart out of the cooler stacked with multiple pans of food. These include one pan of marinara sauce dated 10/09/25, one pan of rice pudding dated 10/09/25, one large metal bowl of pasta salad without a date, and one-half pan of burritos without a date.

An observation on 10/21/25 at 11:23 AM with dietary server #607 revealed a second large tray cart sitting outside of the walk-in cooler with a pan of scallions dated 10/02.25, a pan of unidentified food without a lid or date, two pans of cabbage rolls without dates, a partial pan of mashed potatoes with a watery substance around the food without a date, a pan of chicken pot pie filling without a date, a pan of rice without a date. Sous Chef #622 verified the food was not dated and should be dated when placed in the cooler.

An observation on 10/21/25 at 11:26 AM with Sous Chef #622 of the walk in cooler revealed an unreadable date on a container of spaghetti noodles that were dark with a discolored liquid in bottom of container, a large container of unidentified food Sous Chef #622 believed it to be some type of soup, an undated pan of cooked bacon and sausage patties, a large container of cheese sauce without a lid or date with approximately 2 inches of water on top of cheese sauce. Verified by Sous Chef #622 that the food was not dated.

An interview on 10/21/25 at 11:28 AM with dietary server #607 revealed that the food was being cleared out of the cooler to make room for a food delivery that was coming and needed to be stored in the cooler. Further stated that outdated food was removed from the walk-in cooler daily. They were unable to explain why food with dates from 10/02 and 10/09 were still available in the cooler.

An interview on 10/21/25 at 11:30AM interview Executive Chef #624 stated that food was kept in the cooler for two to three days after it was prepared and then it was disposed of. When asked about the food that was dated 10/02 and 10/09, they stated that they kept the food for pureed diets. They were unable to explain why outdated food was kept for pureed diets instead of pureeing the food prepared at each meal. Further they stated that the pasta salad and burritos were just made for an event that was scheduled to take place on that day and that these food items were not being served to the public, not the residents. Was unable to explain why freshly made food was stacked on top of outdated food that was being disposed of.

An observation on 10/21/25 at 11:32 AM with Executive Chef #624 of dry goods storage revealed a bottle of Red-Hot brand sweet chili sauce opened on the shelf with a date of 9/15/25. The label on the hot sauce directions started to refrigerate after opening. Executive Chef #624 disposed of the container.

An observation on 10/21/24 at 12:10 PM of lunch service tray line revealed a container of chicken salad sitting in a large bowl of ice. The chicken salad temperature was checked with server #618. The temperature of the chicken salad was 80 degrees Fahrenheit.

An interview on 10/21/25 at 12:12 PM with server #618 revealed that they had just made the chicken salad and was cooling it with ice in the bowl. They stated that they were unaware that food prepared to be served cold must be cooled under refrigeration to less than 41 degrees and then placed on ice to hold food for service. They stated they would remake the chicken salad.

An observation on 10/21/25 at 12:25 PM revealed that the chicken salad temperature was checked when it arrived on the memory care unit for lunch service. The temperature was obtained by server #609 and was observed to be 50 degrees Fahrenheit. Server #609 stated that temperatures were not routinely taken once they reached the unit for service. Further reported that he and all the servers received food safe training via the Relias learning platform.

Based on observation, record review, policy review and interview, the facility failed to prepare an altered texture diet as ordered. This affected one resident (Resident #44). Resident #44 was the only resident in the facility with an order for a pureed diet at the time of the survey.

Findings include:

Review of the medical record for Resident #44 revealed an admission date of 09/15/25 with diagnosis of Alzheimer's disease, chronic kidney disease and hypertension.

Review of Resident #44 physician's orders revealed an order dated 02/06/25 for a pureed texture diet with thin liquids

An observation on 10/21/25 at 12:00 P.M. with server #618 of preparing a pureed enchilada for Resident #44's lunch revealed the server added water to the blender with the enchilada then added two scoops of thickener to the mixture to obtain pureed consistency.

An interview on 10/21/25 at 12:05 PM with Server #618 revealed they added approximately three fourths of a cup of water to the one enchilada to puree it. Then they added the thickener to it because it was too thin. Further stated they were unaware if the facility had recipe cards for pureed foods and they did not think they needed a recipe to put food into a blender and chop it up. The server verified they were unaware the facility policy stated to not use water when pureeing food.

Review of an undated facility policy titled Pureed revealed never use water as the liquid added to a pureed item, instead acceptable liquids to use were the drained juice from the food item, broth, gravy, juice, milk or butter.

Based on record review and interviews, the facility failed to conduct the required number of fire drills. This had the potential to affect all 58 residents residing in the facility.

Findings include:

A review of the facility fire safety drills revealed that a fire drill was not conducted during the month of September on any shift

An interview on 10/21/25 at 3:06 P.M. with Settings Lead #632 revealed they were unaware the mandatory fire prevention training completed in September could not be substituted for a fire drill for September and they did not do a fire drill in September.

This violation is a recite to the annual survey completed 07/09/24.

Based on record review and interview the facility failed to evacuate residents during fire drills. This had the potential to affect all 58 residents residing in the facility.

Findings include:

A review of the facility fire drill documentation for October, September, August, July, June, May, April, March, February, and January of 2025 and December 2024, November 2024, revealed no residents had been evacuated during those fire drills.

An interview on 10/21/25 with Settings Lead #632 revealed that the facility defends in place and that it would be too chaotic to move the Residents from one fire compartment to another due to the design of the facility. Further stated that he was unaware of where the residents were during fire drills.

Based on interview and record review the facility failed to honor resident preference and allow them to be involved in care decisions regarding medication administration. This affected one resident (Resident #39) of five residents reviewed. The census was 58.

Finding include:

A review of the medical record for Resident #39 revealed an admission date of 10/31/25 with diagnosis including hemiplegia, dysphagia, and hypertension. Resident #39 was cognitively intact and required staff assistance for mobility and transfers.

A review of Resident #39's risk agreement dated 02/21/25 revealed they were ordered a mechanical soft diet but preferred a regular texture diet, and they were aware of the risk of choking.

A review of Resident #39 physician's orders revealed no evidence of an order for crushed medication.

An interview on 10/23/25 at 9:00 A.M. with Resident #39 revealed Licensed Practical Nurse (LPN) #636 refused to give their medication whole in applesauce. Resident #39 shared when they were first admitted, they requested their medication be crushed but had since changed their mind. Further interview revealed they did not have an order for crushed medication and it was a matter of her preference. Resident #39 stated they had signed a risk agreement and the other nurses honored her preference.

An interview on 10/23/25 at 1:00 P.M. with LPN #636 revealed all residents that were ordered crushed medications were on the shift-to-shift report sheet and had physician's orders to have their medications crushed. LPN #636 independently mentioned Resident #39 and shared they got upset about having their medications crushed but LPN #636 refused to give them their medications whole. Further interview revealed the resident did not have an order for crushed medication

On 10/23/25 at 3:00 P.M. interview with the Executive Director revealed resident requests should be honored whenever possible and the Executive Director was unaware of the resident's request or the request not being honored.