Ohio Living Lake Vista

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and interviews, the facility failed to ensure resident medical records were documented accurately. This affected one Resident (#39) out of two residents reviewed for closed record review. The facility census was 39.Findings include:Review of the closed medical record for Resident #39 revealed an admission date of 12/21/25. Admitting diagnosis included cardiomegaly, urinary tract infection, acute vaginitis, bradycardia, edema, hypokalemia, and chronic obstructive pulmonary disease (COPD).Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition.Review of the progress note dated 01/03/26 timed 2:15 P. M. by Registered Nurse (RN) #503 revealed Resident #39 was having weakness, lethargy, and confusion along with having a hard time holding object and staying awake. Resident #39's husband was at bedside and requested resident to be seen at emergency room. Nurse practitioner (NP) on call was contacted and provided authorization to send the resident to the emergency room for evaluation and treatment.Further review of the medical record revealed a discharge date of 01/03/26. There was no evidence Resident #39 had returned to the facility or was available for medication/treatment administration on 01/05/26.Review of the Medication Administration Record (MAR) for Resident #39 revealed on 01/05/26 medications were signed off as administered for Alvesco HFA Aerosol Inhaler 80 mcg/Actuation, Calcium with Vitamin D 600 mg-10 mcg tablet, Cholecalciferol 25 mcg capsule, Eliquis 5 mg tablet, Flecainide 100 mg tablet, Miconazorb AF 2% powder, multivitamin tablet, Prevacid 24hr 15 mg capsule and, saline mist aerosol spray 0.65% on day shift (7:00 A.M.-7:00 P.M,) by RN# 410.Review of the Treatment Administration Record (TAR) for Resident #39 revealed on 01/05/26 the following treatments were signed off as completed applied ted hose to bilateral lower leg (BLE) in A.M., bilateral assist bars available, pressure reduction cushion to wheelchair was in place, head of bed (HOB) elevated, obtained full set of vital signs, monitored for signs and symptoms of dehydration, change in electrolytes, acute kidney injury, monitored for signs and symptoms of bleeding related to anticoagulation therapy, completion of oral care, and ensured protective barrier after each incontinence episode on day shift (7:00 A.M.-7:00 P.M.) by RN #410.Interview with Interim Director of Nursing (DON) #494 on 01/22/26 at 11:05 A.M. confirmed Resident #39 was discharged on 01/03/25 without readmission to facility, DON #494 also confirmed RN #410 as the initials listed on MAR and TAR dated 01/05/26 as administering medications and treatments for Resident #39 listed above.Review of facility policy titled Electronic Clinical Documentation revised date 05/20/22 revealed when a medication was not administered to a resident, the administering individual would indicate not administered and document the reason the medication was not administered in MAR.Review of facility policy titled Medication Administration General Guidelines dated 2007 revealed the individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. The policy also revealed if a dose of regularly scheduled medication was withheld the nurse shall document in the electronic medication administration record that the dose was withheld and enter and explanatory note.Review of MAR and TAR information key revealed correct documentation for a missed medication and missed treatment administering individual's initials were to be in parentheses with explanation directly below each missed individual medication and treatment missed.

Based on observation, interview, and facility policy review, the facility failed to maintain proper infection control practices during medication administration. This affected one Resident (Resident #17) out of four residents observed for medication administration. The facility census was 39. Finding include: Review of Resident #17's medical record revealed an admission date of 12/02/25. Diagnosis included congestive heart failure, cystitis, anemia, anxiety disorder, unspecified pain, vitamin deficiency, and chronic respiratory issues. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 dated 12/02/25 revealed he was cognitively intact, required assistance by at least one staff member for all Activities of Daily Living (ADLs) including bed mobility, medication administration, dressing, showering, toileting and ambulation. Observation made during medication administration on 01/21/26 at 8:53 A.M. while preparing medications for Resident #17, Registered Nurse (RN) #410 sanitized her hands with liquid hand sanitizer, she then proceeded to touch the keys to the medication cart, the medication cards, computer screen and the medication cup. RN #410 then while checking the medications to the orders she popped each the pills one by one directly into her bare hand without re-sanitizing them, she then proceeded to place all the medications in the a medication cup, then dumped the cup into a pouch in order to crush the medications and placed them into apple sauce and administered them to Resident #17. Interview on 01/21/26 at 9:00 A.M. with RN #410 confirmed she did not perform proper hand hygiene when administering medications to Resident #17. Review of facility policy titled Medication Administration General Guidelines, last revised January 2025 revealed proper hand hygiene is to be used including washing your hands with soap and water, or use hand sanitizer and allow for dry time as well as when handling all medications gloves are to be worn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored appropriately and not left at the bed side. This affected two residents (Residents #8 and Resident #44) out of two residents reviewed for medication storage. The facility census was 39. Finding include:1.Review of Resident #8's medical record revealed an admission date of 11/22/24. Diagnosis include unspecified dementia, need for assistance with personal care, cerebral infarction, hypo-osmolality, hyponatremia and cognitive communication deficit.Review of Resident #8's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed at the time of the assessment the resident had intact cognition. They required assistance with Activities of Daily Living (ADLs) including dressing, bed mobility, and medication administration. Review of Resident #8's physician orders dated January 2026 revealed she was not ordered Tylenol Arthritis, or artificial tears. Further review of Resident #8's physician orders revealed she was ordered Tylenol 650 milligrams (mg) every six hours as needed for pain.Observation on 01/21/26 at 8:33 A.M. of Resident #8's over bed table revealed there was four Tylenol with Arthritis pills left in a medication cup and there were three bottles of artificial tears left on the night stand.Interview on 01/21/26 at 8:52 A.M. with Registered Nurse (RN) #410 confirmed the medications were left on the over bed table and on the nightstand, however RN #410 denied putting those medications on Resident #8's over bed table or on her night stand. RN #410 confirmed Resident #8 was not on Tylenol with Arthritis or artificial tears. RN #410 stated there were no residents in the facility who were responsible for giving their own medications. RN #410 stated all medications were administered by nursing staff.Interview on 01/21/26 at 11:46 A.M. with Resident #8 revealed she takes the Tylenol in her room when ever she wants to and does not inform the nurse, and she stated she will use the artificial tears when ever she wants to and does not notify the nurse.2. Review of Resident #44's medical record revealed an admission date of 01/16/26. Diagnosis include malignant neoplasm of rectum, muscle weakness, need for assistance with personal care, hyperlipidemia, hypertension, and benign prostatic hyperplasia without lower urinary tract symptoms.Review of Resident #44's physician orders dated January 2026 revealed there were no orders present allowing Resident #44 to leave medication at bedside.Review of Resident #44's progress notes dated 01/21/26 at 12:27 A.M. authored by RN #458 revealed resident was alert and oriented to person, place and time. He was able to make needs known, denied any pain or discomfort. Resident #44 his used wheeled walker with limited assist by one staff member. He required assistance with dressing, and activities of daily living.Observation on 01/20/26 at 12:17 P.M. revealed Resident #44 had two pills in a cup on bedside table. Resident #44 revealed they bring a medication for his bladder and a medication for cholesterol between 4:00 and 5:00 A.M. and that was too early. The nurses leave them in the cup on table, and when he feels more awake he will take them.Interview on 01/20/26 at 12:19 P.M. with RN #458 confirmed the medications were left at bed side and should not of been.Review of facility policy titled Medication Storage, last revised 09/14/25 revealed, the nursing home shall assure safe storage of medications. Staff shall ensure all prescription medications and drugs, except those that are authorized to be kept at the bedside for self-administration in accordance with Resident Rights, shall be kept in locked storage areas and separate from materials that may contaminate the medicines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policies the facility failed to ensure appropriate and consistent communication regarding dialysis treatment provided and the resident's response, complications, reactions, or recommendations. This affected Resident #15 who was identified as the only resident receiving dialysis in the facility. The facility census was 39.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 02/16/21. Diagnoses included end stage renal disease, acute and chronic respiratory failure with hypoxia, and congestive heart failure.
Review of the physician's order dated 02/16/21 revealed Resident #15 was to receive dialysis every Monday, Wednesday, and Friday from 10:00 A.M. to 1:15 P.M. at an outside dialysis center.
Review of the care plan dated 06/28/22 revealed Resident #15 had end stage renal disease and received dialysis every Monday, Wednesday, and Friday at an outside dialysis center. Interventions included to have no trauma to the access site, Resident #15 would maintain her dry weight, and the facility was to communicate with dialysis facility as needed regarding resident dialysis care issues.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition and required assistance with all activities of daily living.
Review of the nursing progress note dated 08/28/24 at 2:30 P.M. revealed Resident #15's son called the facility to notify them that Resident #15 had issues at dialysis and was returning to the facility. He reported the dialysis center scheduled a treatment for the next day and the family would provide the transportation. The nurse notified the physician.
Interview on 09/04/24 at 10:00 A.M. with the Director of Nursing (DON) revealed the facility communicated with the dialysis center on an as needed basis. They did not communicate with every treatment and maybe only monthly if a problem arose. The DON confirmed on 08/28/24 the family notified the facility of Resident #15's trouble at dialysis and the added treatment not the dialysis center.
Review of the facility's policies and procedures related to dialysis revealed the policies did not address a communication process with the dialysis providers to include how the communication would occur, who was responsible for communication, and where the communication and responses would be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on interview, record review, review of facility policy, review of the Ohio Board of Nursing Registered Nurse scope of practice, and review of facility investigation the facility failed to ensure staff provided care and services according to professional standards of practice/within their scope of practice. This affected one (#146) of five residents (#8, #15, #46, #142, #145) reviewed for medication errors. The facility census was 39.
Findings include:
Review of the medical record for Resident #146 revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #146 was receiving hospice services and expired in the facility. Diagnoses included chronic obstructive pulmonary disease, bipolar disorder, and dysphagia (difficulty swallowing). Resident #146 had no known allergies.
Review of the care plan dated [DATE] revealed Resident #146 was at risk for cardiovascular complications related to her disease process. Interventions included to administer medications as ordered and to monitor vital signs.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 had severe cognitive impairment and required extensive assistance with all activities of daily living.
Review of nursing progress notes dated [DATE] timed at 4:56 A.M. authored by Registered Nurse (RN) #500 revealed the following.
•
On [DATE] at 7:45 P.M. Resident #146 took pills with whole thin liquids. Resident #146 was conversant.
•
On [DATE] at 8:45 P.M. the aide informed the nurse Resident #146 could not breathe, and her lips were blue.
•
On [DATE] at 8:46 P.M. the aide obtain equipment to obtain vital signs and the nurse stayed with Resident #146.
•
On [DATE] at 8:50 P.M. vital signs were Blood pressure 150/83, Oxygen level 92% on six liters of oxygen, respirations 33, pulse 112. RN #500 attempted to contact Resident #146's family because Resident #146 had an advance directive of Do Not Resuscitate Comfort Care (DNRCC).
•
On [DATE] at 8:55 P.M., RN #500 called Resident #146's son with no answer.
•
On [DATE] at 9:00 P.M., RN #500 called emergency services (911). Resident #146 was struggling more to breath and had hemoptysis (spitting up blood or blood stained mucous). RN #500 made a clinical decision to administer 1 milligram of Morphine. RN #146 obtained the Morphine that was prescribed for another resident, Resident #145.
•
On [DATE] at 9:05 P.M., RN #500 called the daughter who asked RN #500 to hold off sending Resident #146 to the hospital until speaking with her brother the power of attorney (POA). The daughter successfully called her brother on three way conference call. The son was notified of Resident #146's condition and that Morphine was given because RN #500 had no other options to keep Resident #146 comfortable. The ambulance squad spoke to the son, and he decided Resident #146 should be sent to the hospital. Resident #146 was sent to the emergency room via squad and admitted to the hospital intensive care unit with a diagnosis of hypoxia related to pneumonia.
Review of Self-Reported Incident (SRI) dated [DATE] revealed Resident #145's Morphine was administered to another resident (Resident #146). Review of the controlled medication flowsheet confirmed that on [DATE], one milligram of Morphine was taken from Resident #145 and administered to another resident.
Review of the witness statement dated [DATE] timed 9:00 P.M. from RN #500 confirmed RN #500 gave Resident #146 Morphine that belonged to Resident #145 without checking Resident #146's orders or calling the physician. RN #146 indicated she was called to Resident #146's room and found Resident #146 with blue lips struggling to breath. RN #500 assessed Resident #146's vital signs and placed her on six liters of oxygen via nasal cannula. Resident #146's vital signs were stable, but she was struggling to breath. They assessed her code status and learned she was a DNRCC. RN #500 assumed this meant the resident was receiving hospice services so she was unsure if she should call the medics. RN #500 attempted to reach Resident #146's son with no answer. RN #500 then decided to call 911 and made the independent clinical decision to administer Morphine 1 mg by mouth to Resident #146 to help with her breathing because she was a DNRCC, and she assumed the resident had an order for medication. Resident #146 began coughing up blood, so she administered the dose sublingually. The family did reach back out at the time the emergency squad arrived, and RN #500 informed the family of the situation and that she administered Morphine without an order. The family decided to send Resident #146 to the hospital. Later, that evening she received a call from the hospital informing her Resident #146 was pleasantly confused and being admitted to the hospital for hypoxia.
Review of the hospital Discharge summary dated [DATE] revealed Resident #146 was discharged with a diagnosis of hypoxia related to pneumonia and an order for a palliative care consult was placed.
Review of the nursing progress note dated [DATE] revealed Resident #146's family decided to place Resident #146 under hospice care and an order for Morphine was obtained at that time.
Interview on [DATE] at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #146 was administered Morphine without a physician's order. The DON said the incident was investigated and reported to the State Agency and RN #500, who was an agency nurse, was reported the Board of Nursing and placed on the do not return list. All staff were educated regarding misappropriation, following physician orders and not administering medications without a physician order. In addition follow up auditing was completed to ensure no medication was administered without a valid physician order.
Review of the employee file for RN #500 confirmed she was employed by a staffing agency contracted by the facility. RN #500 had a current nursing license at the time of the incident and background screening had been completed. Documentation validated RN #500 received training on abuse and neglect and medication administration.
Review of the Ohio Department of Health Scopes of Practice: Registered Nurses (RN) and Licensed Practical Nurses (LPN) dated [DATE] revealed the following.
Registered Nurses Section 4723.01(B), ORC, defines the scope of RN practice as: Providing to individuals and groups nursing care requiring specialized knowledge, judgment, and skill derived from the principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes: (1) Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen; (2) Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions; (3) Assessing health status for the purpose of providing nursing care; (4) Providing health counseling and health teaching; (5) Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice; (6) Teaching, administering, supervising, delegating, and evaluating nursing practice. RNs have independent licensed authority to engage in all aspects of practice specified in Section 4723.01(B), ORC, except that, when providing nursing care pursuant to Section 4723.01(B)(5), ORC, the RN must have an order from an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice for administration of medication or treatments or for the regimen that is to be executed. Rule 4723-4-03(D), OAC.
Review of the facility's undated Safe Medication Administration Practices, Long-Term Care policy revealed you must check the resident's medical record to make sure that all required documents, medication information, sensitivities, history and physical examination findings, diagnoses, and laboratory results are present and current.
The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions:
•
On [DATE] all medication carts were audited for any missing narcotic medications.
•
On [DATE] the DON reported the incident to the contracted staffing agency and RN #500 was placed on the do not return list.
•
On [DATE] the DON reported RN #500 to the Ohio Board of Nursing.
•
On [DATE] all staff were educated on the abuse and misappropriation policies and procedures.
•
On [DATE] Resident #145's Morphine was replaced.
•
On [DATE] and [DATE] all staff were educated on medication administration and that there was on call physician coverage 24-hours a day and they were not to administer medications without an order.
•
Audits were completed twice weekly regarding change of condition and calling the physician as appropriate for direction/orders and to ensure there was no misappropriation of resident medication for the weeks of [DATE] and [DATE], then monthly for three months on [DATE], [DATE], and [DATE]. No additional concerns were noted.
•
Review of the quality assurance and performance improvement (QAPI) during the annual survey revealed the committee was involved in the development of the corrective action plan and ongoing compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy and procedure review the facility failed to ensure Resident #22 was free from an incident of staff to resident verbal abuse. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 39.
Findings include:
Review of the medical record for Resident #22 revealed an admission date of 06/10/22. Diagnoses included dementia, anxiety, and vitamin deficiency.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had moderately impaired cognition. She required extensive assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. She had no behaviors noted.
Review of the facility SRI tracking number 230485 dated 12/26/22 and timed 1:52 P.M. revealed Resident #22 reported State Tested Nurse's Aide (STNA) #204 told her to shut up.
Review of the facility investigation completed on 12/27/23 revealed STNA #204 was suspended pending investigation. Staff working at the time of the incident were interviewed and confirmed hearing STNA #204 telling Resident #22 to shut up. STNA #20 was terminated from her employment.
Interview on 05/02/23 at 12:21 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #205 confirmed the investigation led to finding of verbal abuse by STNA #204 and her subsequent termination.
Review of the facility policy titled Abuse, Neglect, Misappropriation, and Crime Reporting, dated 01/18/21, revealed the facility would take measures to prevent abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Ombudsman was notified of resident transfers and discharges to the hospital. This affected three (Residents #45, #46, and #10) of four residents reviewed for transfer and discharge to the hospital. The facility census was 54.
Findings include:
1. Resident #45 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure. Resident #45 was hospitalized from [DATE] through 03/22/22.
Review of physicians orders dated April 2022 revealed orders for nursing staff to obtain a full set of vitals including pulse, respirations, blood pressure, temperature, and blood oxygen level twice a day and as needed, oxygen at three liters per min (LPM) via nasal cannula (NC) continuously, and the head of her bed was to be elevated to alleviate shortness of breath.
Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact.
Review of the care plan dated 03/23/22 revealed she was at cardiopulmonary risk related to a diagnosis of acute and chronic respiratory failure. Nursing staff were to encourage the resident to cough and deep breath frequently, monitor respiratory rate, blood oxygen saturation, and lungs sounds every shift. The resident was to wear her oxygen at 3 LPM continuously.
Review of nurses notes dated 03/13/22 at 8:59 P.M. revealed Resident #45 was in respiratory distress with a blood oxygen level of 79 percent (%) on 3 LPM, a non-rebreather oxygen mask was applied, and her oxygen was increased to 4 LPM, her blood oxygen level increased to 89%. Resident #45's daughter was at the bedside and kept informed of the resident's condition. Resident #45's physician was updated and gave an order to send the resident to the emergency room where she was admitted for respiratory failure.
Review of nurses notes dated 03/14/22 revealed Social Worker (SW) #143 mailed out the resident's bed hold letter to the representative but did not notify or document notification to the Ombudsman.
2. Resident #46 was admitted to the facility on [DATE] with diagnoses which included Coronavirus 19 infection, generalized muscle weakness, atrial fibrillation and chronic obstructive pulmonary disease.
Review of the admission MDS dated [DATE] revealed Resident #46 was cognitively intact and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing. The MDS assessment dated [DATE] revealed Resident #46 was discharged , return not anticipated.
Review of nurses notes revealed Resident #46 was sent to the hospital on [DATE] per physician orders due to a change in mental status and being short of breath. Resident #46 was admitted to the hospital with diagnoses of hypotension and peripheral edema and did not return to the facility after hospitalization.
3. Resident #10 was admitted to the facility on [DATE] with diagnoses including subarachnoid hemorrhage secondary to a fall at home, left sixth rib fracture, right distal radius fracture, hypertension and hypothyroidism.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 was severely cognitively impaired and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing.
Review of nurses notes revealed Resident #10 was sent to the hospital on [DATE] per physician orders for evaluation and treatment after a fall and was admitted with a left femur fracture.
Nurses notes dated 03/07/22 revealed SW #143 mailed out the resident's bed hold letter to the representative but was absent documentation of any notification to the Ombudsman.
Nurses notes dated 03/08/22 revealed Resident #10 returned to the facility.
Interview on 05/04/22 at 2:00 P.M. with the Administrator confirmed the facility did not notify the Ombudsman of transfers or discharges of residents. The Administrator stated he was aware that the facility had to notify the Ombudsman of resident transfers/discharges to the hospital but could not say why it was not being done. He stated one years' worth of discharge notifications had been sent to the Ombudsman as of today 05/04/22.
Interview on 05/04/22 at 2:01 P.M. with the Director of Nursing (DON) also confirmed they did not notify the Ombudsman of resident transfers or discharges.
Interview on 05/05/22 at 9:43 A.M. with the Ombudsman confirmed the office had not received notifications of resident transfers or discharges from the facility. The Ombudsman confirmed she received emails last night (05/04/22) and this morning (05/05/22) of all the transfers and discharges for March, April and May 2022.
Review of facility policy titled Discharge, Transfer of Resident dated 05/03 revealed the facility was to in situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility must send a notice of discharge to the resident and resident representative and must also send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice to the Office of the State Long Term Care (LTC) Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the ombudsman only needed to occur as soon as practicable as described below. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative.