Ohio Living Llanfair

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review revealed the facility failed to ensure each resident receives adequate supervision to prevent accidents. This affected one Resident (#5) out of 5 residents reviewed for accidents. The facility also failed to document or implement immediate interventions for falls. This affected one Resident (#33) out of 5 residents reviewed for accidents. The facility census was 33.1. Medical record review for Resident #33 revealed she was admitted to the facility on [DATE]. Her diagnoses included myelodysplastic syndrome, psychotic disorder with delusions due to known physiological condition, anemia, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively impaired. Resident #33 was dependent on staff for medication administration, bathing, lower body dressing, putting on shoes, and toilet use. Resident #33 required set up assistance with meals, and oral hygiene. She required maximum assistance from staff with upper body dressing.
Review of the fall assessment dated [DATE] for Resident #33 revealed she scored a thirteen and this made her a moderate risk for falls.
Review of the progress notes for Resident #33 revealed she had a fall on 12/24/25 at 5:41 P.M. Resident #33 was found on the floor, lying sideways off the bed with legs on the floor mat. The bed was in the lowest position. Resident #33 sustained two skin tears one on hand and one on the index finger. No immediate intervention was listed. Resident #33 was found on the floor on 12/24/25 at 7:45 A.M. She was found on the her left side with her head under the bed. Resident sustained a skin tear to her right lower leg and sustained a bruise to her left back. Resident #33 also sustained a bruise to the left side of her head. No immediate intervention was listed for the fall. Resident #33 had a fall on 10/11/25 at 5:38 P.M. Resident #33 was found on the floor and sustained a skin tear on the side of her left leg. No immediate intervention was listed.
Review of fall investigation summary dated 12/14/25 at 7:45 A.M. revealed Resident #33 was observed on the floor mat in her room with her head under the bed. Resident sustained a right lower leg, left side of the back and bruising to the left side of the head. No immediate intervention was identified. Review of the follow up intervention revealed hospice reinstated Residents Ativan. Review of the fall investigation dated 12/24/25 at 7:41 P.M. for Resident #33 revealed she was found with her legs on the fall mat and upper body was on the bed. Resident #33 sustained skin tears to her left hand, left shin, and left index finger. The facility failed to list an immediate intervention. The follow up intervention was listed as padding was applied to the left side of the bed. Review of the fall investigation summary dated 10/11/25 revealed Resident #33 was found on the floor. She sustained a skin tear to her left leg. No immediate intervention was listed. The follow up intervention was listed as the hospice nurse came in and assessed Resident #33 post fall.
Interview with the Director of Nursing (DON) on 12/30/25 at 2:22 P.M. revealed if a resident has a fall the staff are to notify the nurse. The nurse will evaluate the resident and determine the next step. The nurse will notify the family and physician of the fall. The DON confirmed the nurse is expected to determine the immediate intervention and document the immediate intervention in the medical chart. The DON confirmed the facility failed to identify and document an immediate intervention for Resident #33's falls on 10/11/25, 12/14/25 and 12/24/25.
2. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: fracture of unspecified part of neck of right femur, unspecified atrial fibrillation, and chronic obstructive pulmonary disease.
Review of the MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, substantial/maximal assistance for toileting, partial/moderate assistance for showering/bathing, partial/moderate assistance for dressing, and partial/moderate assistance for personal hygiene. Resident is frequently incontinent of bowel and bladder.
Review of Resident #5's fall risk assessment dated on 10/20/25 at 5:47 P.M. revealed Resident #5 to be a high fall risk.
Review of the fall investigation for Resident #5 revealed on 12/22/25 at 8:57 P.M. revealed Resident #5 stood up in the shower and slid down the wall and was found sitting on her buttocks while Certified Nurse Assistant (CNA) #194 stepped out of the bathroom.
Review of CNA #194 witness statement revealed CNA #194 stepped out of the bathroom when Resident #5 fell in the shower.
Review of Licensed Practical Nurse (LPN) #172 revealed CNA #194 was standing outside the bathroom with the door cracked open when Resident #5 fell.
Review of the Witness statement from CNA #194 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell.
Review of the witness statement from LPN #172 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell.
Interview on 12/30/25 at 2:03 P.M. with DON confirmed CNA #194 should never have left Resident #5 alone in the bathroom.
Interview on 12/30/25 at 3:19 P.M. with CNA #194 confirmed they stepped out of the bathroom and had a hand on the bathroom door when Resident #5 fell in the shower. CNA #194 also stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed.
Interview on 12/30/25 at 4:47 P.M. with LPN #172 confirmed CNA #194 stepped out of the bathroom and had a hand on the bathroom doorknob when Resident #5 fell in the shower. LPN #172 stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed.
Review of the education form for CNA #194 dated on 12/23/25 revealed CNA #194 stepped away from a resident while the resident was in the shower. The education form states all staff must stay within reach of residents while they are in the shower.
Review of the facility policy titled, Fall Prevention and Management dated on 04/01/2003 and revised on 01/28/23 revealed at a time of a fall is the loss of an upright position that results in landing on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy revealed the facility failed to ensure medications are properly stored. This had the potential to affect one resident (#5) out of nine residents observed for medication storage. The facility also failed to ensure medications are labeled properly and not expired. This affected one (#3) of nine residents reviewed for medication labeling with the potential to affect all residents. The facility census was 33.1. Observation on [DATE] revealed Resident #5 was lying in bed asleep with her morning medications in a cup on the bedside table. Interview on [DATE] at 10:20 A.M with Licensed Practical Nursing (LPN) #8 confirmed medications were left on the bedside table. Review of Resident #5's Medication Administration Record (MAR) revealed in the medications in the cup there was Citalopram 20 milligrams (mg), cranberry tablet 450 mg, Eliquis 5 mg, famotidine 20 mg, Lisinopril 40 mg, Methenamine 1 gram, Senna-s 8.6 -50 mg, and acetaminophen 325 mg. 2. Observation on [DATE] at 4:37 P.M. of Rehab Medication Storage room with the Director of Nursing (DON) revealed an open tuberculin vial with no open date. Interview on [DATE] at 4:38 PM with the DON confirmed the open tuberculin vial did not have an open date and was supposed to. 3. Observation on [DATE] at 4:40 PM of the Rehab Medication Cart #2 revealed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Interview on [DATE] at 4:41 P.M. with Licensed Practical Nurse (LPN) #8 confirmed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Record Review for Resident #3 Medication Administration Record (MAR) revealed Resident #3 had an order, Humalog U-100 insulin (insulin Lispro) solution 100 units, dated for [DATE] - [DATE] and the same order dated [DATE] - [DATE]. The MAR also revealed the last date the Humalog U-100 insulin (insulin Lispro) solution 100 units was administered on [DATE]. Review of the facility policy titled, Medication Storage dated on [DATE] revealed all prescription medications shall be kept in locked storage areas and separate from materials that may contaminate the medicines and drugs. Review of the facility policy titled, Medication Administration dated on 01/2025 revealed Multi dose vials: Must have an open date for 28 days or per manufacturer's guidelines. The policy also stated the resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary kitchen in the main kitchen, failed to ensure the dishwasher properly sanitized the dishes on the Memory Care Unit, and failed to ensure the dietary staff utilize the use of hair nets. This had the potential to affect all residents who receive food from the kitchen. The facility identified all 33 residents receive food from the kitchen. The facility census was 33.1. Observation on 12/29/25 at 9:35 A.M. of Certified Nurse Assistant (CNA #178) revealed CNA #178 was hand washing the dishes in the Memory Care Unit kitchen with a regular household dish liquid and placed the dishes in the dishwasher. CNA #178 was not wearing a hair net. Continued observation of CNA #178 utilizes the dishwasher revealed neither the rinse or wash reached above 130 Fahrenheit (F) and the dishwasher was flashing add sanitizer.Interview on 12/29/25 at 9:35 A.M. with CNA #178 verified she was hand washing dishes in household detergent without a hair net. CNA #178 confirmed she does not utilize sanitizer in the sink because she utilizes the dishwasher. CNA #178 read the front of the dishwasher that confirmed the wash cycle should reach 160 degrees F and the rinse cycle should reach 180 degrees F if sanitizer is not used in the dishwasher. CNA #178 confirmed the dishwasher stated the temperature should reach 130 degrees F if sanitizer is being used. CNA #178 confirmed she ran the dishwasher a total of three times and each time the dishwasher continuously flashed add sanitizer. CNA #178 confirmed the dishwasher did not reach higher than 130 degrees F. CNA #178 confirmed the facility failed to maintain a dishwasher temperature log for the memory care unit. Interview on 12/29/25 at 11:22 A.M. with Dietary Manager (DM) #401 confirmed the dishwasher in the Memory Care Unit was flashing add sanitizer. DM #401 confirmed the facility failed to maintain a temperature log for the Memory Care Unit dishwasher. Review of the dishwasher temperature logs revealed the Memory Care kitchen did not have a dishwasher temperature log to review. 2. Observation on 12/30/25 at 11:45 A.M. with Registered Dietician (RD) #400 revealed the ceiling vents above the milk freezer near the food preparation table had dirt, and fuzzy debris hanging from it.Interview on 12/30/25 at 11:45 A.M. with RD #400 confirmed the kitchen vent had dirt, and fuzzy debris hanging from it. RD #400 confirmed the vent over milk freezer and food preparation area had dirt, fuzzy debris hanging from it.Review of the facility policy titled, Cleaning Dishes/Dish Machine, dated 2023, confirmed all flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning. Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough clearing products for the shift. Further review of the policy revealed the staff should check the dish machine gauges throughout the cycle to ensure proper temperatures for sanitation. Review of the facility policy titled, Employee Hygiene for Food Safety, dated 2023 confirmed the facility staff will wear hair restraints (hairnet or hat) to prevent hair from contacting exposed food. Review of the undated facility policy titled, General Sanitation of Kitchen, confirmed the cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Employees will be trained in how to perform cleaning tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to maintain record of pneumococcal vaccine administration and failed to offer pneumococcal vaccines to residents. This impacted two residents (#18 and #33) of five residents reviewed for pneumococcal vaccine administration. The facility census was 33. 1. Record review for Resident #18 revealed resident was admitted on [DATE] with diagnoses including need for assistance with personal care; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; other asthma; and respiratory disorders in diseases classified elsewhere. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Resident #18 had no behaviors, required setup assistance for eating and oral hygiene, substantial assistance for toileting, bathing, and upper and lower body dressing, and supervision assistance for personal hygiene, and resident refused mobility assessment.Further record review for Resident #18 revealed no documentation indicating the resident and/or resident's representative were offered a pneumococcal vaccine since admission. Record review also revealed no documentation of pneumococcal vaccine administration prior to admission.Interview on 12/31/2025 at 8:01 A.M. with Director of Nursing (DON) revealed the resident and/or resident's representative declined a pneumococcal vaccine in 2023. The DON further reported that a pneumococcal vaccine had not been offered to the resident and/or the resident's representative since declination in 2023.2. Record review for Resident #33 revealed resident was admitted on [DATE] with diagnoses that included repeat falls; psychotic disorder with delusions due to known physiological condition; transient cerebral ischemic attack, unspecified (history of); other asthma; muscle weakness (generalized); depression, unspecified; anxiety disorder, unspecified; delusional disorders; and respiratory disorders in diseases classified elsewhere. Review of the MDS dated [DATE] revealed Resident #33 was moderately cognitively impaired, and the MDS dated [DATE] revealed the resident rejected care four to six days a week. In addition, MDS dated [DATE] revealed Resident #33 required setup assistance for eating and oral hygiene, substantial assistance with upper body dressing and personal hygiene, was dependent for toileting, bathing, lower body dressing, sit to lying, lying to sitting, sit to stand, and transfers.Further record review for Resident #33 revealed resident received pneumococcal vaccine (PCV - 13) on 05/20/2015. Documentation review revealed no additional pneumococcal vaccines were offered to the resident and/or the resident's representative since admission.Interview on 12/31/2025 at 8:01 A.M. with DON revealed that the resident and/or resident's representative was not offered a pneumococcal vaccine since admission.Review of a document titled Influenza and Pneumococcal Vaccines with a revised date of 10/05/2025 revealed that Each resident is offered .pneumococcal immunization at least once, unless immunization is medically contraindicated, or the resident has already been immunized with pneumococcal vaccine within the past five years.

Based on review of Quality Assessment and Assurance (QAA) committee sign-in sheets and staff interview, the facility failed to ensure all required members of the QAA committee attended meetings at least quarterly. This had the potential to affect all 35 residents residing in the facility. The census was 35.
Findings include:
Review of the QAA committee meeting sign-in sheets for the last year revealed, for quarterly meetings held on 07/17/23 and 10/09/23, Medical Director (MD) #800 nor MD #800's designee attended the meetings as required.
Interview on 02/22/24 at 5:13 P.M. with the Administrator and Director of Nursing (DON) verified MD #800 nor a designee attended the quarterly QAA committee meetings on 07/17/23 and 10/09/23.

Based on record review, staff interview, and review of the facility's policy, the facility failed to administer insulin and intravenous (IV) antibiotics as ordered by the physician. This affected two (Resident #13 and #51) of six residents reviewed for unnecessary medications. The facility census was 57.
Findings include:
1. Review of the medical record for Resident #13 revealed an admission date of 02/11/16 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/18/21, revealed the resident was cognitively impaired.
Review of the resident's Medication Administration Record (MAR), dated April 2021, revealed an order for the IV antibiotic Cefazolin to be administered three times daily from 04/16/21 to 05/05/21 for treatment of a urinary tract infection (UTI). Review of the April 2021 MAR revealed the following doses were not administered and the MAR did not note a refusal or rationale for not administering the medication: 04/17/21 at 7:00 A.M., 2:00 P.M., and 6:00 P.M., 04/18/21 at 7:00 A.M. and 2:00 P.M., 04/25/21 at 7:00 A.M., 04/28/21 at 7:00 A.M., 2:00 P.M., and 6:00 P.M.
Review of the resident's MAR, dated May 2021, revealed the following doses were not administered and the MAR did not note a refusal or rationale for not administering the medication: 05/01/21 at 6:00 P.M., 05/05/21 at 2:00 P.M. Further review of the MAR revealed the medication was discontinued on 05/06/21.
Review of the nurse progress notes for Resident #13 dated 04/16/21 through 05/05/21 revealed the notes were silent regarding physician notification of the missed doses and/or refusals or rationale for missed doses.
Interview on 05/13/21 at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #13's medical record did not include physician notification of the missed doses and/or refusals or rationale for missed doses of IV antibiotics in April 2021 and May 2021.
Review of the facility's policy titled Medication Administration, dated 11/20/20, revealed the facility would ensure staff administered medications as ordered within two hours of the prescribed times and would monitor and document medication administration and the effectiveness of all medications administered.
2. Review of the medical record for Resident #51 revealed an admission date of 05/11/20 with a diagnosis of diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired.
Review of the care plan, dated 01/20/21, revealed the resident was at risk for hypo/hyperglycemia. Interventions included medications as ordered, monitor finger sticks as ordered, notify the physician of abnormal results, monitor for signs and symptoms of hypo/hyperglycemia and provide routine sliding scale insulin per orders.
Review of the resident's MAR, dated May 2021, revealed the resident did not receive nighttime dose of insulin on 05/01/21 and 05/02/21 or the morning dose of insulin per sliding scale on 05/11/21. There was not blood sugar recorded for the morning on 05/11/21
Interview on 05/13/21 at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #51's medical record did not include physician notification of the missed doses and/or refusals or rationale for missed doses of insulin in May 2021.
Review of the facility's policy titled Medication Administration, dated 11/20/20, revealed the facility would ensure staff administered medications as ordered within two hours of the prescribed times and would monitor and document medication administration and the effectiveness of all medications administered

Based on record review, observation, and staff interview, the facility failed to ensure dependent residents were shaved during provision of grooming and hygiene care. This affected one (Resident #51) of 17 residents reviewed for hygiene. The facility census was 57.
Findings include:
Review of the medical record for Resident #51 revealed an admission date of 05/11/20 with a diagnosis including dementia with behavioral disturbance, depression, and anxiety disorder.
Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with personal hygiene and grooming.
Review of the care plan, dated 05/18/20, revealed the resident had a self-care deficit related to dementia and decreased physical function. The goal was for the resident to have proper hygiene and grooming daily and as needed. Interventions included monitoring for any improvement/decline in self-participation, encourage to complete tasks on their own and assist as needed.
Observation of Resident #51 on 05/10/21 at 11:24 A.M. revealed the resident had long hairs (approximately one half inch) growing from her chin.
Interview on 05/10/21 at 11:26 A.M. with State Tested Nursing Assistant (STNA) #435 confirmed Resident #51 had long hairs growing from her chin and that shaving the resident should be done on shower days. STNA #435 further confirmed she was not sure when Resident #51 had last received a shower.
Interview on 05/10/21 at 11:28 A.M. with Licensed Practical Nurse (LPN) #395 confirmed Resident #51 had long hairs growing from her chin and the resident was not able to shave herself.
Interview on 05/13/21 at 11:00 A.M. with LPN #565 confirmed Resident #51's shower days were Wednesday (05/12/21) and Saturday on the evening shift and she should be shaved on those dates. LPN #565 confirmed the STNAs completed shower sheets with every shower but could not find any shower sheets for Resident #51 for the month of May 2021.
This deficiency substantiates Complaint Number OH00111766.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy, and staff interview, the facility failed to prevent a significant medication error when Resident #20 was given another resident's medications. This affected one resident (#20) of resident reviewed for medication administration. The facility census was 57.
Findings include:
Medical record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension unspecified heart failure, acute kidney injury, and unspecified dementia without behavioral disturbance.
Review of the Minimum Data Set (MDS) assessment, dated 03/03/21, revealed Resident #20 had moderately impaired cognition, did not wander, and did not reject care.
Review of the physician orders, for May 2021, revealed Resident #20 had active orders for acetaminophen (treats minor pain), acidophilus (probiotic), Albuterol sulfate (treats and prevents bronchospasm), calcium 500 milligrams (mg.) plus D, famotidine (treats gastroesophageal reflux disease), Levothyroxine (treats hypothyroidism), Metoprolol Succinate (treats high blood pressure), Miralax (stool softener), multivitamin with minerals, and Vitamin D3 (vitamin).
Review of the progress note, dated 05/06/21 at 9:50 A.M., revealed Licensed Practical Nurse (LPN) #55 reported to Registered Nurse (RN) #65 she had administered another resident's medication to Resident #20 by mistake. Medications administered included Tylenol (treats mild pain) 650 mg, Buspar (anti-anxiety medication) 10 mg., Lactulose (laxative) 30 mg., and Oxycodone (narcotic pain medication) 5.0 mg. RN #65 stated she notified the doctor and family.
Review of the facility's Medication Error Log, no date, revealed LPN #55 committed and reported a medication error on 05/06/21. The corrective action taken included staff education about the Five Rights of Medication Administration.
Interview on 05/11/21 at 03:07 P.M. revealed RN #65 stated on 05/06/21, the agency nurse (LPN #55) walked into the wrong room and gave medications to Resident #20 which belonged to another resident. The LPN #55 informed RN #65 immediately of what happened and what medications were given. The RN stated she looked at the medications given in error and made a list of potential side effects to monitor for before she explained to the doctor, in facility at the time of occurrence, what had happened. The doctor said the resident should be fine but recommended to monitor Resident #20 for diarrhea and drowsiness and hold routine medications. The agency nurse monitored Resident #20 frequently for vitals and adverse effects and passed on to continue monitoring in shift-to-shift report.
Review of the facility's policy titled Medication Error Report, dated 08/15/20, revealed in case of medication error, the nurse provides emergency care as needed, notifies the supervisor, physician, and resident's responsible party, assesses vital signs and adverse effects frequently, reported follow-up care in shift report, and documented each shift until the resident was stable.

Based on observation, staff interview, and review of the facility's policy, the facility failed to ensure staff performed appropriate hand hygiene during meals. This affected three (Residents #13, #23, and #36) of 14 residents on the Grove Unit. The facility census was 57.
Findings include:
Observation on 05/10/21 at 12:21 P.M. revealed State Tested Nursing Assistant (STNA) #455 entered the dining room after returning from a break off the floor, and did not perform hand hygiene before providing hands on assistance with eating to Residents #13, #23, and #36. STNA #455 did not sanitize her hands between assisting Residents #13, #23, and #36.
Interview on 05/10/21 at 12: 40 P.M. with STNA #455 confirmed she did not wash or sanitize her hands upon returning to the floor following her break and did not wash or sanitize hands in between providing hands on assistance with eating to Residents #13, #23 and #36.
Observation on 05/12/21 at 12:49 P.M. revealed STNA #455 was feeding Resident #13 her lunch and was wearing gloves. Then STNA #455 removed her gloves and discarded them, donned a pair of new gloves from her pocket and assisted Resident #36 with eating for approximately one minute. STNA then removed her gloves and discarded them, donned a new pair of gloves from her pocket and went back to provide additional hands-on assistance with feeding to Resident #13. The STNA was observed not to perform any hand hygiene between her glove changes from Resident #13 to Resident #36 and then Resident #36 to Resident #13.
Interview on 05/12/21 at 12:55 P.M. with STNA #455 confirmed she did not wash or sanitize her hands between residents, and she thought changing gloves between residents eliminated the need for her to perform hand hygiene.
Review of the facility's policy titled Hand Hygiene, dated 05/15/20, revealed hand hygiene should be performed before and after patient contact and glove use did not eliminate the need for hand hygiene.
This deficiency substantiates Complaint Number OH00111766.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the online Medscape resource, and review of the facility's policy, the facility failed to ensure antipsychotic medications were administered for appropriate clinical indications, monitored for target behavioral symptoms, and considered for gradual dosage reductions when indicated. This affected two (Residents #51 and #152) of six residents reviewed for unnecessary medications. The facility census was 57.
Findings include:
1. Review of the medical record for Resident #152 revealed an admission date of [DATE] with a diagnosis of Alzheimer's disease. Resident #152 had no diagnoses of psychosis or other specific medical conditions to justify the use of antipsychotic medications.
Review of the physician's order, dated [DATE], revealed the resident had an order for the antipsychotic medication Seroquel 75 milligrams (mg.) to be administered routinely three times daily.
Review of the resident's Medication Administration Record (MAR), dated [DATE], revealed it did not include monitoring of targeted behaviors associated with the use of Seroquel. The resident received Seroquel routinely three times daily as ordered.
Review of the medical record for Resident #152 revealed it did not include a baseline care plan regarding the use of Seroquel.
Interview on [DATE] at 12:40 P.M. with Licensed Practical Nurse (LPN) #565 confirmed Resident #152 received Seroquel three times daily and his record did not include targeted behaviors for the use of Seroquel or any kind of behavior monitoring or tracking.
Interview on [DATE] at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #152's medical record did not include the following: a diagnosis or specific medical condition related to Seroquel use, a baseline care plan regarding the use of Seroquel, or monitoring of targeted behavioral symptoms.
Review of the facility's policy titled Psychotropic Medications, dated [DATE]. revealed psychotropic medications will be administered pursuant to rule §483.45 in the Code of Federal Regulations (CFR).
Review of the online resource Medscape revealed Seroquel included a black box warning indicating the medication placed elderly patients with dementia related psychosis at increased risk of mortality and medication was not approved for the treatment of patients with dementia-related psychosis.
2. Review of the medical record for Resident #51 revealed an admission date of [DATE] with diagnoses including dementia with behavioral disturbance, depression, and anxiety disorder. Resident #51 had no diagnoses of psychosis or other specific medical conditions to justify the use of antipsychotic medications
Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively impaired, antipsychotics were received on seven out of seven days in the review period, no gradual dose reduction (GDR) had been attempted and the physician had not documented a GDR as clinically contraindicated.
Review of the resident's care plan, dated [DATE], revealed the resident had altered behavior related to diagnoses of dementia with behaviors and resident could become agitated when attempting to locate deceased husband. Interventions included to address inappropriate behavior consistently as it occurs, consult with psychiatrist/psychologist as needed, medications as ordered, monitor for effectiveness/adverse/side effects, consult with social worker as needed, educate family on diagnosis of dementia and not to remind resident of husband's passing.
Review of the physician's orders, dated [DATE], revealed an order for Zyprexa (an antipsychotic) to be administered routinely twice per day.
Review of the medical record for Resident #51 revealed it did not include an assessment of abnormal involuntary movements associated with long term antipsychotic use and it did not include monitoring of targeted behaviors associated with the use of Zyprexa.
Review of the MAR for [DATE] revealed the resident received Zyprexa twice daily routinely.
Interview on [DATE] at 12:40 P.M. with Licensed Practical Nurse (LPN) #565 confirmed Resident #51's record did not include targeted behaviors for the use of Zyprexa nor did the record include behavior monitoring.
Interview on [DATE] at 2:08 P.M. with Registered Nurse (RN) #835 confirmed Resident #51's medical record did not include the following: a diagnosis or specific medical condition related to Zyprexa use, an assessment of abnormal involuntary movements associated with long term antipsychotic use, attempted GDR and/or documentation of medical contraindication, or monitoring of targeted behavioral symptoms.
Review of the online resource Medscape revealed Zyprexa included a black box warning indicating the medication placed elderly patients with dementia related psychosis at increased risk of mortality and medication was not approved for the treatment of patients with dementia-related psychosis.

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure oxygen tubing was dated to indicate the date on which the tubing was changed/initiated. This affected one (Resident #51) of one resident reviewed for respiratory care. The facility identified eight residents on oxygen therapy. The census was 57.
Findings include:
Review of the medical record for Resident #51 revealed an admission date of 05/11/20 with a diagnosis including dementia with behavioral disturbance, depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 04/12/21, revealed the resident was cognitively impaired.
Review of the physician orders, dated May 2021, revealed an order for oxygen per nasal cannula up to five liters continuously to maintain oxygen saturation levels above 92 percent (%).
Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for May 2021 for Resident #51 revealed it was silent regarding administration of oxygen and regarding changing the oxygen tubing.
Observation on 05/10/21 at 11:17 A.M. revealed Resident #51 had oxygen in place per nasal cannula at five liters. The oxygen tubing was not dated.
Interview on 05/10/21 at 11:19 A.M. with Licensed Practical Nurse (LPN) #395 confirmed the oxygen tubing for Resident #51 was not dated and she was unsure when it had last been changed.
Observation on 05/12/21 at 12:31 P.M. revealed Resident #51 had oxygen in place per nasal cannula at five liters. The oxygen tubing was not dated.
Interview on 05/12/21 at 12:32 P.M. with LPN # 530 confirmed the oxygen tubing for Resident #51 was not dated and further confirmed the May 2021 MAR/TAR for the resident did not include documentation of oxygen administration or changing of tubing.
Review of the facility's policy titled Oxygen Administration and Handling, dated 10/10/20, revealed oxygen tubing should be dated when opened and should be changed at least weekly.

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to provide dining services in a dignified manner. This affected two (Residents #13 and #36) of five residents reviewed for nutrition. The facility census was 57.
Findings include:
1. Review of the medical record for Resident #13 revealed an admission date of 02/11/16 with a diagnosis of Alzheimer's disease.
Review of the Minimum Data Set (MDS) assessment, dated 02/18/21, revealed the resident was cognitively impaired and required extensive assistance of one staff with feeding.
Review of the care plan, last updated 05/11/21, revealed the resident was at nutritional risk due to diagnosis of dementia and need for need for mechanically altered diet due to pocketing foods. The resident could feed herself using her hands to eat and required staff assistance needed to finish and eat adequately. Interventions included the following: serve pureed diet as ordered, provide assistance to eat as needed for optimal meal intakes, offer cueing to clear pocketed foods from mouth as needed, monitor for choking, pocketing food, or drooling, monitor for signs and symptoms of self-feeding difficulties, and serve meals in the dining room.
Observation on 05/10/21 at 12:10 P.M. revealed Resident #13 was seated in the dining room with a plate of pureed food and utensils in front of her. Resident was using her fingers to eat the pureed food and was having difficulty feeding herself. There were no staff present in the dining room until 12:21 P.M. Further observation at 12:21 P.M. revealed State Tested Nursing Assistant (STNA) #455 entered the dining room and placed a spoon in Resident #13's hand and cued the resident so she was able to feed herself the pureed food with a spoon.
Interview on 05/10/21 at 12:22 P.M. with STNA #455 confirmed Resident #13 needed assistance and cueing to use a spoon when eating pureed food in order to provide a dignified dining experience.
2. Review of the medical record for Resident #36 revealed an admission date of 11/24/20 with a diagnosis of vascular dementia without behavioral disturbance.
Review of the MDS assessment, dated 04/10/21, revealed the resident was cognitively impaired and required supervision and set up help with eating.
Review of the care plan, dated 01/13/21, revealed the resident was at nutritional risk due to dementia. Interventions included the following: serve regular diet as ordered, supplements as ordered, assistance to eat, cueing as needed for optimal intakes, monitor for chewing/swallowing problems such as coughing, choking, pocketing, or drooling, monitor for signs and symptoms of self-feeding difficulties, and serve meals in the dining room.
Observation on 05/12/21 at 12:49 P.M. revealed STNA #455 was feeding Resident #13 her lunch when Resident #36 called for assistance. STNA #455 pushed Resident #13's plate out of the resident's reach and told the resident she would return soon. STNA #455 went to Resident #36 and fed her several bites of her food and remained standing over the resident as she did so. While STNA #455 was feeding/encouraging Resident #36 to eat, Resident #13 reached out for her plate of food but it was out of her reach. STNA #455 was the only staff person present in the dining room during the observation.
Interview on 05/12/21 at 12:55 P.M. with STNA #455 confirmed staff should sit down and be eye level when assisting residents with feeding to provide a dignified dining experience. STNA #455 further confirmed she had moved Resident #13's food out of her reach because while she tended to Resident #36. STNA #455 confirmed Resident #13 was reaching for her food while STNA was assisting Resident #36 but she had deliberately placed the resident's food out of reach because she didn't think resident would be able to feed herself as resident's ability to self-feed was variable from day to day.
Review of the facility's policy titled Dining and Meal Service, dated 2013, revealed the dining experience would be person-centered with the purpose of enhancing each individual patient's/resident's quality of life and would be supportive of each individuals' needs during dining and individuals would be assisted promptly and in a timely manner after the meal arrived.

Based on record review, staff interview, review of facility's Self-Reported Incidents (SRIs), and review of the facility's policy, the facility failed to report an allegation of physical abuse regarding a resident-to-resident altercation to the State Survey Agency, the Ohio Department of Health (ODH). This affected two (Residents #23 and #31) of two residents reviewed for abuse. The facility census was 58.
Findings include:
Review of the medical record for Resident #31 revealed an admission date of 09/05/18 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment revealed the resident was cognitively impaired.
Review of the nursing progress note for Resident #31, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. The nurse assessed the resident for injuries and none were noted.
Review of the medical record for Resident #23 revealed an admission date of 09/04/19 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the MDS assessment, dated 03/10/21, revealed the resident was cognitively impaired.
Review of the nursing progress note for Resident #23, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. Resident #23 confirmed she was slapped by another resident, but she was not injured.
Review of the facility's SRIs revealed there were no reports filed regarding Residents #23 and #31.
Interview on 05/12/21 at 2:45 P.M. with Executive Director (ED) #730 confirmed the facility did not report the resident-to-resident physical altercation between Residents #23 and #31 to the ODH.
Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed the facility would report all allegations of abuse including resident to resident abuse to ODH.

Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRIs), and review of the facility's policy, the facility failed to thoroughly investigate a resident-to-resident physical altercation. This affected two (Residents #23 and #31) of two residents reviewed for abuse. The facility census was 58.
Findings include:
Review of the medical record for Resident #31 revealed an admission date of 09/05/18 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment revealed the resident was cognitively impaired.
Review of the nursing progress note for Resident #31, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. The nurse assessed the resident for injuries and none were noted.
Review of the medical record for Resident #23 revealed an admission date of 09/04/19 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the MDS assessment, dated 03/10/21, revealed the resident was cognitively impaired.
Review of the nursing progress note for Resident #23, dated 04/09/20, revealed the nurse was called to the dining room due to resident being slapped by another resident. Resident #23 confirmed she was slapped by another resident, but she was not injured.
Review of the facility's SRIs revealed there were no reports filed regarding Residents #23 and #31.
Interview on 05/12/21 at 2:45 P.M. with Executive Director (ED) #730 confirmed the facility did not conduct an investigation regarding the resident to resident physical altercation between Residents #23 and #31.
Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed the facility would thoroughly investigate all allegations of abuse including resident-to-resident abuse.