Shaker Gardens Care Community

Based on observation, interview, medical record review, and review of policy, the facility failed to ensure a resident call system was in place in restrooms used by residents. This affected one resident (Resident #29) and had the potential to affect all residents. The facility census was 101.

Findings include:

Review of the medical record for Resident #29 revealed an admission date of 12/13/23 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus with polyneuropathy, morbid obesity, chronic pancreatitis, muscle weakness, schizophrenia, major depressive disorder, unspecified intellectual disabilities, osteoarthritis bilateral knees, urinary incontinence, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.

Review of the COTTI: ALU Service/Functional Assessment completed on 09/25/24 revealed Resident #29 required an intermediate level of care with limited toileting assistance, which included stand-by partial assistance to get on and off the toilet. Review of the COTTI: ALU Service/Functional Assessment completed on 12/26/24 revealed Resident #29 required an intermediate level of care, toileting reminders or instruction, and extensive assistance for fall prevention.

Review of the Person-Centered Service Plan last updated 07/17/24 revealed Resident #29 was to receive assistance in all care areas of need provided by the assisted living facility staff 24 hours a day, seven days a week, in order to remain safe.

Observation of the first floor restroom on 01/02/25 at 9:40 A.M. revealed a resident wheelchair in the doorway of the accessible stall and Resident #29 sitting saying help me get up. When asked if there was a pull cord to request assistance, she replied no, just help me up. When informed the surveyor would find staff for assistance, she stated she didn't want to wait and attempted to pull herself up, but her legs wobbled, and she was unable to lift herself completely off the commode before dropping back down onto the toilet with a loud sigh. The surveyor went to the front desk to report a resident required assistance in the restroom.

Interview on 01/02/25 at 4:40 P.M. with the Assisted Living Director (ALD) confirmed there was no call light or pull cord in the first-floor restroom to alert staff if a resident needed assistance. During the interview, the ALD indicated residents had bathrooms in their bedrooms and the common area restrooms were not set-up for the residents, but there was nothing keeping the residents from using the restrooms in the common areas.

Interview on 01/02/25 at 4:42 P.M. with the Wellness Director revealed it was her belief Resident #29 could transfer herself but was just afraid to do so independently.

Observation and interview on 01/04/25 at 10:33 A.M. revealed Resident #62 entering the restroom on the second floor across from the main elevators. During the observation, Resident #62 confirmed the restrooms were for use for anybody, including residents, and that residents used that restroom regularly because it was closest to the nurse's station and the activity area, and some residents would have accidents if they had to go all the way back to their rooms. Resident #62 further confirmed none of the stalls in the restroom had a way for residents to alert staff if they needed help, and she thought it would be a good idea if there was a call button in the restrooms.

Observation of the second-floor women's restroom at 10:55 A.M. on 01/06/25 confirmed there were no pull cords in the restroom.

Review of the facility policy Call Lights last reviewed August 2023 revealed the objective of a resident call system was to provide a safe environment to meet resident care needs.

Based on observation, medical record review, review of fire report, review of police report, review of 15-minute checks documentation, smoking policy review, illegal drug use policy, and interview, the facility failed to ensure a safe environment free from accident hazards when smoking materials were not secured to prevent unsafe smoking in resident rooms. This resulted in Real and Present Danger and had the potential for life-threatening harm, injuries, negative health outcomes and/or death when on 12/13/24 at 7:37 P.M. a fire occurred in Resident #4's room resulting in smoke inhalation for Residents #4 and #20. Consequently, Residents #4 and #20 were transferred to the hospital and admitted for smoke inhalation and Licensed Practical Nurse (LPN) #3 was also treated in the hospital due smoke inhalation. In addition, the facility failed to implement their smoking policy for Residents #39, #41, #50 and #67 with known smoking and/or drug-use behaviors who engaged in smoking in non-designated smoking areas. This affected six residents (#4, #20, #39, #41, #50 and #67) and had to potential to affect all 101 facility residents.

On 12/16/24 at 4:30 P.M., the Administrator, Assisted Living Director (ALD) #1 and Regional Director of Operation (RDO) #7 were notified Real and Present Danger began on 12/13/24 at 7:37 P.M. when Resident #4, who was cognitively impaired and a known smoker of crack cocaine in his room, used a crack pipe in his room then placed the crack pipe and lighter inside a wicker basket on top of a wooden dresser resulting in the ignition of the wicker basket and wooden dresser and a fire spreading in the room. The sprinkler system activated containing the fire to Resident #4's room. The fire department arrived and investigated the fire, identifying the heat source of the fire was the smoking materials located inside the wicker basket.

The Real and Present Danger was abated on 01/06/25 when the facility implemented the following corrective actions:

On 12/13/24, Resident #4 was transported from the facility by Emergency Medical Services (EMS) and taken to the hospital where he remained until the evening of 12/15/24 at 8:23 P.M. when he returned to the facility and was placed on one-to-one supervision.

On 12/16/24 at approximately 2:30 P.M., Resident #4 was given a Notice of Immediate Discharge and would remain on one-to-one supervision until discharge.

By 12/16/24, all smokers were reassessed for smoking ability by ALD #1.

By 12/16/24, all residents were re-educated on the facility's smoking and non-prescription drug policy by Wellness Coordinator #8.

By 12/16/24, all residents' rooms were checked for lighters, contraband and any evidence of smoking in rooms by Business Office Manager (BOM) #2, Director of Maintenance (DM) #5 and Activities Director (AD) #25. Non-permitted items were removed. ALD #1 would be notified of any violations and would take appropriate action as outlined in the Smoking policy.

Beginning on 12/16/24, ALD #1/designee and nursing staff would continue to check smokers and residents with known active drug use daily for lighters, contraband, and any evidence of smoking in rooms for four weeks, then weekly until no evidence of smoking/drug policy violation observed, then as determined by the Quality Assurance Committee for ongoing compliance.

By 12/17/24, Human Resources Director #21 and Medical Records Director (MRD) #22 re-educated all current staff on the facility's smoking and illicit drug policy, and what to do, and to report to the director or any management staff evidence of non-compliance. This was confirmed via review of sign in sheet.

On 12/18/24, Resident #41 was given a 30-day Discharge Notice.

On 12/19/24, an interdisciplinary meeting consisting of ALD #1, Wellness Coordinator #8, Activities Director (AD) #25 and Steppingstones Drug Counselor #20 was conducted and would continue every Thursday at 4:00 P.M.

On 12/27/24, Resident #50 was given a 30-day Discharge Notice.

On 12/30/24, Residents #67 and #39 were given a 30-day Discharge Notice.

Beginning on 12/30/24, residents who were repeat offenders would be given a 30-day discharge notice, according to applicable regulations, and placed on 15-minute checks until discharged.

On 12/30/24 at 2:00 P.M., Residents #41, #50, #67 and #39 were placed on 15-minute checks. The staff were educated to check for lighters, smoking policy violations, illicit drugs or drug paraphernalia during the 15-minute checks.

On 12/30/24 and 01/03/25, Medical Director #27 approved that repeat offenders would have increased supervision and given a discharge notice, as appropriate.

Beginning on 12/30/24, prior to the admission of individuals with a history of alcohol and drug abuse, each would be required to sign a preadmission agreement outlining the conditions of admission.

On 12/31/24, the interdisciplinary team met with Assisted Living Waiver Case Managers regarding residents smoking in their rooms along with drug usage. The meetings would continue each month as appropriate.

On 12/31/24, ALD #1/designee conducted an in-service to staff on addiction. These in-services would continue on the third Thursday of every month.

On 12/31/24, ALD #1/designee conducted an in-service on addiction to residents. These in-services would continue the third Thursday of every month.

On 01/02/25, Resident #9 was placed on 15-minute checks.

On 01/03/25, Resident #41 discharged.

On 01/03/25, a new smoking policy was written by Regional Director of Clinical Services #28. The policy was reviewed and found to be comprehensive, and it provided clear direction to staff and residents.

On 01/03/25, residents and staff were educated on the new smoking policy by ALD #1, Wellness Coordinator #8 and MRD #22.

On 01/03/25, staff were educated on how to conduct a room sweep by ALD #1.

On 01/03/25, the Administrator, ALD #1 and RDO #7 met with Police Detective #26 for guidance on drug usage and paraphernalia. The police department advised to continue to call law enforcement, and the department would respond and take appropriate action.

On 01/06/25, Resident #50 was discharged.

Although the Real and Present Danger was abated on 01/06/25, the violation remained as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance.

Findings include:

1. Review of the medical record for Resident #4 revealed an admission date of 07/19/17 with diagnoses of dementia without behavior disturbances, catatonic schizophrenia, cocaine dependence with intoxication, diabetes and atrial fibrillation. Resident #4 was his own responsible party. Resident #4 signed the facility's Smoking policy on 07/19/17.

Review of the Service/Functional Assessment dated 07/24/24 revealed Resident #4 needed occasional reminders and needed supervision with some activities of daily living.

Review of the health status note dated 12/06/24 timed 8:22 A.M. authored by ALD #1 revealed Resident #4 was found in his room with another resident smoking crack cocaine. A crack pipe was confiscated by the nurse.

Review of the Smoke Evaluation Form dated 12/06/24 revealed Resident #4 smoked and utilized a lighter and a crack pipe. The evaluation revealed Resident #4 was reminded of the facility policy of no smoking in rooms and agreed not to smoke again.

Review of the Non-Prescribed/Illegal Drug or Alcohol Use policy revealed Resident #4 signed the policy on 12/06/24.

Review of the health status note dated 12/15/24 timed 6:55 P.M. authored by ALD #1 revealed on 12/13/24, there was a fire in the facility. Resident #4 started the fire in a waste basket in his room. The Fire Captain found a crack pipe along with a lighter in the burning waste basket. Resident #4 was assessed and noted to have wheezing and rhonchi (abnormal lung sounds) in his lower lung bases. Resident #4 was sent to the hospital for evaluation and was admitted for smoke inhalation. Family and the Waiver case manager were notified. The note indicated Resident #4 would be moving to a different room upon return to the facility.

Review of the hospital emergency physician progress note dated 12/13/24 timed 10:42 P.M. revealed Resident #4 presented with complaints of smoke inhalation. The note indicated Resident #4 had a fire in his apartment that evening at his assisted living and would be admitted for observation.

Review of the discharge summary dated 12/15/24 revealed Resident #4 was in the hospital for smoke inhalation.

Review of the medical record for Resident #20 revealed an admission date of 01/16/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and insomnia.

Review of the service/functional assessment dated 06/21/24 revealed Resident #20 walked independently and had occasional forgetfulness.

Review of the hospital emergency physician progress note dated 12/13/24 timed 10:49 P.M. revealed Resident #20 presented for apparent smoke inhalation. The note indicated Resident #20 was in his assisted living apartment when a fire occurred in the apartment next door. Resident #20 arrived complaining of smoking inhalation and was admitted.

Review of the discharge summary dated 12/15/24 revealed Resident #20 was admitted status post smoke inhalation and cleared per pulmonary.

Review of the Fire Department (FD) report dated 12/13/24 revealed there was an unintentional building fire from heat from undetermined smoking material in a bedroom with box, carton, bag, basket or barrel being the first item ignited by abandoned or discarded materials or products by a person possibly impaired by alcohol or drugs. There was $16,000 worth of property and content loss, 12 apparatus' and 29 personnel on scene and two injuries. The FD arrived on scene and reported nothing showing from two sides. On exiting the apparatus, the FD could smell smoke ...Dispatch and multiple residents stated it was on the second floor. The FD went to the second floor to find light haze and no heat. They entered Room 228 to find water coming from above, they identified smoke coming from the apartment above them. The FD went to the third floor to find significant dark smoke. The FD went to Resident #4's room ...found a desk/dresser on fire that was being kept in check by an activated sprinkler. The FD extinguished the fire with the water can ...The FD completed a primary search and checked on residents on the third floor. Resident #20 wanted to be seen due to smoke inhalation. The FD assisted the resident to the first floor to be treated and transported to the hospital ...The FD spoke to ALD #1 to find the resident from the fire unit (Resident #4). Resident #4 was in the lobby on the first floor. The FD and ALD #1 spoke to him to ensure he was alright and to figure out what occurred. Resident #4 stated he had been smoking, and his pipe was on the desk/dresser where the fire originated ...Resident #4 was not acting normal per staff so the FD treated and transported him to the hospital for possible smoke inhalation. The FD conducted an investigation to determine the origin and cause of the fire. Working from the least burned to the most burned in a systemic fashion they determined the area of origin to be the dresser. Smoking materials were located in a basket on top of the dresser including a lighter. A V-pattern was present on the wall behind and above the area of the origin. The basket had noted charring as well as mass loss further narrowing the area of origin to the area of the back of the basket. No other heat source was present in the area of origin. They determined that the cause of the fire was accidental, and the heat source was the smoking materials located inside the basket.

The surveyor placed a telephone call on 12/13/24 at approximately 10:30 P.M. to Shaker Heights Dispatcher #19 who verified an alarm dropped at 7:37 P.M. (on this date) and crews who worked on scene confirmed a working fire with sprinkler activation at 7:45 P.M. Shaker Heights Dispatcher #19 confirmed two residents were transported to the hospital for smoke inhalation and about an hour later, a staff member was also transported to the hospital for unknown reasons (later noted to be for evaluation of smoke inhalation).

Interview on 12/14/24 at 10:00 A.M. with the Administrator and Director of Maintenance (DM) #5 revealed there had been a fire on the third floor of the assisted living section, and it was in one (resident) room. The Administrator stated a resident was smoking something other than tobacco and caught the dresser on fire and the resident (Resident #4) had received smoke inhalation during the start of the fire.

Observation of the third floor on 12/14/24 at 10:00 A.M. revealed a heavy smoke smell in the corridor. In front of Resident #4's room was a large amount of standing water and some fire debris. Resident #4's door was broken from where the FD made a forcible entry. There was a burned bureau and a shattered mirror on the left wall and scorched paint approximately four feet by six feet. There was a burned wicker basket and some clothing materials on top of the dresser. The entire room was wet. Water had seeped into the carpeting on multiple other residents' units on the third floor. No other issues were noted in any of the adjacent or cross corridor rooms. A tour of the second floor found that water migrated to the units directly below the fire room. The corridor also had some ceiling tiles damaged with water which had fallen onto the carpet.

Interview on 12/16/24 at 9:00 A.M. with the Administrator revealed on 12/13/24, according to the FD, Resident #4's wicker basket caught on fire then caught his dresser on fire. The FD reported that they had found a crack pipe in the room. Resident #4 was sent to the emergency department as well as another resident (Resident #20) a couple of doors down. Resident #4 was back at the facility and was currently on one-to-one supervision.

Interview on 12/16/24 at 9:20 A.M. with ALD #1 revealed Resident #4 had resided at the facility for a long time and was sneaky and low-key. Resident #4 was not a cigarette smoker, but did smoke crack and had admitted to her that he had smoked crack on 12/13/24. The waste basket was sitting on top of his dresser, and a crack pipe was found inside the basket according to the Fire Chief. Resident #4 would solicit for money at the gas station across the street. ALD #1 revealed LPN #3 and LPN #4 were on duty at the time of the fire. Resident #4, Resident #20 and LPN #3 were sent to the hospital due to smoke inhalation on 12/13/24.

Interview on 12/16/24 at 9:55 A.M. with DM #5 revealed on 12/13/24, BOM #2 called him stating that the fire alarm was going off and the fire panel indicated a sprinkler head was activated. When DM #5 arrived at the facility at approximately 7:30 P.M., the FD was already engaged, and residents were in the lobby. According to the FD, it appeared a resident was smoking some substance in his room which caught a wicker basket and dresser on fire with fire damage to a wall. The sprinkler went off in the room which minimized fire damage. The sprinklers flooded the resident rooms to the right and left of Resident #4's room as well as three rooms on the second floor directly below Resident #4's room.

Observation on 12/16/24 at 10:10 A.M. with ALD #1 revealed a chair was outside Resident #4's temporary room with Certified Nurse Aide (CNA) #6 present. Resident #4 was lying in bed, in street clothes and shoes on, covered up by blankets. Resident #4 could not say how long he had resided at the facility. When asked what happened on Friday (12/13/24), Resident #4 responded a fire started. When asked how the fire started, Resident #4 replied I don't know.

Interview on 12/16/24 at 10:40 A.M. with BOM #2 revealed on 12/13/24 at 7:37 P.M., the fire alarm was sounding. BOM #2 called DM #5 to let him know the fire panel reported water board. LPN #3 stated she observed smoke on the second floor and a nurse aide said there was a fire on the third floor. The staff began knocking on resident doors and instructed residents to evacuate to the front lobby. The FD arrived and said the fire was confined to one room.

Interview on 12/16/24 at 12:15 P.M. with LPN #3 revealed on the evening of 12/13/24, LPN #3 was doing medication pass when LPN #3 received a phone call from Receptionist #11 indicating Resident #4 and Resident #41 were across the street soliciting money at the gas station. LPN #3 went to the gas station and the residents were not there, so LPN #3 returned to the facility and smelled smoke in the front lobby. A housekeeper and LPN #3 were notified the fire panel was lighting up and they went through all three floors, knocking on doors to evacuate the residents. When LPN #3 arrived on the third floor, the hallway was dark and filled with a cloud of smoke that she could not see through. LPN #3 was knocking on residents' doors and arrived at Resident #4's room. Resident #4 opened the door and was standing at the door when LPN #3 observed a fire behind him inside his room. LPN #3 evacuated Resident #4 from his room. Resident #4 appeared under the influence; his gait and response time was not at his baseline. Resident #4 would not tell LPN #3 what he was doing at the time of the fire. LPN #3 went to the emergency room on 12/13/24 due to the smoke inhalation.

Interview on 12/16/24 at 2:30 P.M. with ALD #1 revealed after Resident #4 was observed smoking crack cocaine in his room with a skilled nursing facility (SNF) resident on 12/06/24, Registered Nurse (RN) #12 confiscated the crack pipe, Resident #4 was reassessed using the facility's Safe Smoking Evaluation form, he was reeducated regarding smoking and drug use policies, and he signed the facility's Non-prescribed/Illegal Drug or Alcohol Use policy.

Interview on 12/16/24 at 3:35 P.M. with Receptionist #11 revealed on 12/13/24, the fire alarm went off. Housekeeper #23 and Receptionist #11 checked Room 126, but the fire was not there. Receptionist #11 notified BOM #2 who called DM #5. Housekeeper #23 went upstairs and saw smoke coming out of Resident #4's room and went to the front lobby to report, it's a real fire in Room [number provided]. Receptionist #11 called emergency medical services (911) and notified the dispatcher that there was a fire in Room [number provided].

Interview on 12/16/24 at 3:40 P.M. with RN #10 revealed on 12/06/24, Resident #84 (who resided in the facility SNF) could not be located within the SNF portion of the building. A little while later, a Certified Nursing Assistant (CNA) (unknown name) notified RN #12 of Resident #84's whereabouts in the assisted living. RN #12 knocked on Resident #4's door and observed Resident #84 sitting on her walker, within Resident #4's room, with a crack pipe in her hand. RN #12 confiscated the crack pipe and gave it to the Director of Nursing of the SNF.

Interview on 12/23/24 at 8:00 A.M. with Assistant Fire Chief for Shaker Heights #12 revealed he had concerns about resident's smoking inside this facility which was a non-smoking facility.

2. Review of the medical record of Resident #39 revealed an admission date of 09/22/23 with diagnoses of peripheral vascular disease, adult failure to thrive, major depressive disorder, hypertension, prediabetes and cardiomyopathy.

Review of the Service/Functional assessment dated 11/21/24 revealed Resident #39 used an assistive device to walk, needed occasional instruction or reminders and was oriented with occasional forgetfulness.

Review of the nursing note dated 12/06/24 timed 2:33 P.M. revealed that afternoon a call was placed to the nurse station from Resident #39's apartment. Resident #39 was not the caller, another resident (Resident #84) who resided on SNF placed the call. Resident #84's call was rerouted to the nurses' station because her attempt to contact another resident (Resident #94) was unsuccessful. When asked why she was placing a call from Resident #39's apartment phone when she should not be in his apartment because she was a skilled nursing home resident, Resident #84 disconnected the call. LPN #3 and LPN #24 then went down to Resident #39's apartment where he was not present but two other residents were. The residents were Residents #84 and #41. Upon opening the door, Resident #41 was behind the door. Upon assessment, Resident #41 showed signs and symptoms of substance abuse as evidenced by dilated pupils, disoriented to place stating she did not know where she was. LPN #3 instructed her to leave the apartment immediately. Walking further into the apartment, the smell of smoke was present, on the floor were two ash trays full of cigarette butts, marijuana paraphernalia and a crack stem. In the corner was another resident, Resident #84, sitting on her rollator, with a lethargic affect. Resident #84 was not an assisted living resident and was a SNF resident. LPN #3 and LPN #14 assisted Resident #84 back to her unit ...LPN #3 notified ALD #1 of the incident. LPN #3 was instructed by Administration to contact the police.

Review of the health status note dated 12/16/24 timed 2:39 P.M. revealed Resident #39 was letting another resident [Resident #41] smoke in his room. The aide threw out ashtrays and cigarette butts. The other resident [Resident #41] was told to leave.

Review of the smoking assessment dated 12/16/24 revealed Resident #39 was a smoker, five to 10 times a day, the resident could light his own cigarette, and the resident needed the facility to store lighter and cigarettes.

Review of the nursing note dated 12/27/24 timed 7:32 P.M. authored by LPN #3 revealed during hourly rounding, LPN #3 was on the second floor of the assisted living facility, the hallway had a strong smell of smoke. Walking down the hallway, LPN #3 stopped at Resident #39's room. The nurse entered the apartment, Resident #67 was behind the door, and would not allow the nurse access to the apartment. Resident #39 was Resident #67's boyfriend. A strong smell of controlled substance smoke was present, the room was foggy with gray smoke. LPN #3 asked Residents #67 and #39 to open the door. Resident #67 refused and closed the door. LPN #3 called the non-emergent police line for assistance in searching the apartment for controlled substances. The police arrived around 7:15 P.M. LPN #3 accessed Resident #39's apartment, Residents #67 and #39 were lying in bed engaging in sexual intercourse. LPN #3 asked Residents #67 and #39 if any controlled substances were present in the apartment. Residents #39 and #67 denied any controlled substances use in the apartment or any controlled substances being present in the apartment. LPN #3 noticed controlled substance drug paraphernalia on the dresser along with two lighters. LPN #3 asked for the rest of the controlled substances. Resident #39 handed over a pill bottle that contained a white, hard, rock-like substance. LPN #3 asked Resident #39 what the substance was. Resident #39 replied crack. LPN #3 exited the apartment and gave the drug paraphernalia to the officers. ALD #1 was notified of the incident.

Review of the 15-minute checks documentation for Resident #39 dated 12/30/24 revealed there was no documentation of Resident #39's whereabouts from 4:15 P.M. to 6:00 P.M. and Resident #39 was burning something in room at 9:00 P.M.

Review of the 15-minute checks documentation for Resident #39 dated 01/01/25 revealed Resident #39 was smoking in his room at 8:00 A.M. and I told him twice to stop smoking at 8:15 A.M. There was no documentation of Resident #39's whereabouts from 3:00 P.M. to 5:15 P.M. Resident #39 was in [Resident #41's] room smoking cigarettes at 5:30 P.M. There was no documentation of Resident #39's whereabouts at 5:45 P.M., 6:00 P.M., 6:30 P.M. through 7:15 P.M. and 11:15 P.M. to 11:45 P.M.

Review of the 15-minute checks documentation for Resident #39 dated 01/01/25 revealed there was no documentation of Resident #39's whereabouts from 12:00 A.M. to 6:45 A.M.

Interview on 12/16/24 at 11:20 A.M. with ALD #1 revealed on 12/16/24 (that morning), LPN #9 caught Residents #39 and #41 smoking in Resident #39's room with Resident #67 present.

Observation on 12/16/24 at 11:25 A.M. revealed Resident #39 self-propelling in his wheelchair from outside to inside the facility.

Interview on 12/16/24 at 12:00 P.M. with LPN #9 revealed on 12/16/24 (that day), LPN #9 walked into Resident #39's room and Resident #41 was holding a lit cigarette and there were liquor bottles in the room.

Interview on 01/02/25 at 10:58 A.M. with Resident #39 revealed he smoked cigarettes, weed and sometimes crack cocaine on his patio or outside in the smoking section. Resident #39 admitted to the occasional cigarette in his room. Resident #39 stated staff did not check on him and would only come in his room when they wanted to start [explicit].

3. Review of the closed medical record for Resident #41 revealed an admission date of 05/24/17 with diagnoses of diabetes, dizziness and giddiness, cocaine abuse, and legal blindness. Resident #41 discharged on 01/03/25.

Review of the Service/Functional assessment dated 11/21/23 revealed Resident #41 needed limited assistance with physical ability/ambulation, extensive assistance with bathing, grooming/dressing, toileting and needed occasional reminders. There were concerns with drug abuse.

Review of the health status note dated 08/22/24 revealed at approximately 7:30 A.M. while doing rounds, the nurse aide walked into Resident #41's room. Resident #41 was on top of a male resident having intercourse. The room was filled with marijuana smoke, and crack cocaine paraphernalia was found on the resident's dresser. Another female resident was standing in the room watching the event. A call was placed to Resident #41's case manager and a message was left for a call back. Family was notified.

Review of the nursing note dated 12/06/24 timed 2:57 P.M. revealed this afternoon a call was rerouted to the nurse's station from Resident #39's apartment phone from another resident, Resident #84. The call prompted the nurse, LPN #3 and LPN #14 to go down to Resident #39's apartment. Upon entering Resident #39's apartment, Resident #41 was present along with Resident #84. Resident #41 was behind the door and was assessed by the nurse. Resident #41 showed signs and symptoms of substance abuse intoxication as evidenced by dilated pupils, disorientation to place stating that she did not know where she was. The nurse instructed Resident #41 to leave the apartment. ALD #1 was notified of the incident. The nurse was instructed by Administration to contact the police.

Review of the nursing note dated 12/06/24 timed 7:23 P.M. revealed in passing during evening/bedtime medication pass, the nurse caught Resident #41 leaving Resident #39's apartment. The nurse asked Resident #41 to come to the nursing station for medication. The nurse noticed Resident #41's pupils were dilated, and she was disoriented wheeling into the hallway walls. The nurse asked Resident #41 if she had been using controlled substances. Resident #41's response time was delayed, and the resident began to stutter when responding. Resident #41 denied any controlled substance use, stated she would be down to receive medications. The nurse told her the nurses' station was in the opposite direction and to come down to receive insulin coverage. Resident #41 never showed up to the nurses' station, so the nurse went to Resident #41's apartment and Resident #41 was not present. The nurse aide then reported to the nurse and LPN #9 that Residents #41 and #67 were in Resident #39's apartment. The nurse aide walked in on Residents #39 and #67 engaging in sexual intercourse while Resident #41 was present in the apartment.

Review of the Non-Prescribed/Illegal Drug or Alcohol Use policy revealed Resident #41 signed the policy on 12/06/24.

Review of the health status note dated 12/16/24 revealed Resident #41 was in another resident's room [Resident #39's] smoking a cigarette holding the ashtray in her hand. Even though the nurse saw it, Resident #41 denied smoking. The nurse told her to leave Resident #39's room. The nurse notified ALD #1, the resident's case managers and emergency contact.

Review of the smoking assessment dated 12/16/24 revealed Resident #41 was a smoker, had visual deficit, smoked more than 10 times a day, required a smoking apron, and needed the facility to store lighters and cigarettes.

Review of Police Report #SHPD2024-002127 dated 12/18/24 revealed on 12/18/24 at 10:53 A.M., nursing staff found property at the facility. Nurse Aide (NA) #24 found a suspected crack pipe in Resident #41's room. ALD #1 advised that one of her staff members, NA #24, did rounds to check on residents within the facility. ALD #1 was told by NA #24 that she went into Resident #41's room which belonged to Resident #41 and found broken suspected crack pipe, multiple broken lighters, cigarette boxes, and a box of Narcan. The police officer collected the suspected crack pipe and took it back to the policy property room to be entered.

Review of the nursing note dated 12/26/24 revealed Resident #41 was given a 15-panel rapid urine drug screen by Drug Counselor #20. The drug screen showed positive results for cocaine, MDMA (ecstasy), barbiturates, amphetamines, methamphetamine, opiates, alcohol, oxycodone, and marijuana. The nurse held all pain, convulsion, and blood pressure medications for drug interactions.

Review of the nurse note dated 12/26/24 timed 8:59 P.M. revealed during rounding, the nurse intercepted Resident #41 leaving out of Resident #50's apartment. The nurse asked Resident #41 why she was leaving Resident #50's apartment. Resident #41's response time was delayed, pupils were dilated, and she was lethargic and disoriented. Resident #41 responded after the nurse asked a third time. Resident #41 indicated I was visiting a friend. The nurse asked Resident #41 if she had any alcohol or done any drugs because she did not look okay. Resident #41 did not respond. The nurse asked again, and Resident #41 responded, I only had weed I think, I swear, nothing else I don't think. The nurse took Resident #41 back to her apartment and got a set of vital signs. Resident #41's blood pressure was 140/75, heart rate was 129, and respirations were 14. The nurse practitioner was notified, and the nurse was instructed to send Resident #41 out to the hospital for possible substance abuse, alcohol intoxication and elevated heart rate.

Review of the 15-minute checks documentation for Resident #41 dated 12/31/24 revealed smoking in her room with [Resident #39] at 4:45 P.M.

Interview on 12/16/24 at 11:20 A.M. with ALD #1 revealed on 12/16/24 (that morning), LPN #9 caught Residents #39 and #41 smoking in Resident #39's room with Resident #67 present. ALD #1 verified Resident #41 had been a smoker of crack cocaine since high school and Resident #41 tagged along with Residents #39 and #4.

Observation on 12/16/24 at 11:25 A.M. revealed Resident #41 self-propelling in her wheelchair from outside to inside the facility.

Interview on 12/30/24 at 11:25 A.M. with LPN #3 revealed on 12/26/24, Resident #41 was drug tested by Drug Counselor #20 with positive results of cocaine, marijuana, methamphetamine among other substances. LPN #3 notified the nurse practitioner who advised her to hold some of the resident's medications due to drug interactions. While LPN #3 was conducting rounds that evening at approximately 8:00 P.M., LPN #3 observed Resident #41 leaving Resident #50's room. Resident #41's response was delayed, pupils were dilated, and the resident was disoriented. Resident #41 stated, I think it was weed but I don't know. Resident #41's heart rate was 129 beats per minute. LPN #3 notified the nurse practitioner and was advised to send the resident to the hospital via 911. EMS and the police arrived and questioned Resident #41. Resident #41 stated, she got the drugs from Resident #50. The police confiscated a lighter, crack pipe and marijuana. At the hospital, Resident #41 tested positive for cocaine, alcohol and marijuana and was sent back to the facility the morning of 12/27/24.

4. Review of the closed medical record for former Resident #50 revealed an admission date of 05/06/23 with diagnoses of alcohol abuse, psychotic disorder, bipolar disorder, and hypertension. Resident #50 discharged on 01/06/25.

Review of the Smoking Assessment dated 12/16/24 revealed Resident #50 was a smoker, smoked more than 10 times a day in the morning, afternoon, evenings and nights and the facility needed to store his lighters and cigarettes.

Review of the nursing note dated 12/23/24 timed 2:24 P.M. revealed during room check for noon, controlled substance drug paraphernalia was found. Resident #50 denied the drug paraphernalia belonged to him. Police intervened and issued a citation for paraphernalia. Management and corporate were aware of the incident. Resident #50 was placed on every 15-minute watch until further notice.

Review of the nursing note dated 12/26/24 timed 9:11 P.M. revealed during rounding, the nurse and nurse aide checked Resident #50's room after the nurse intercepted Resident #41 leaving from Resident #50's room exhibiting signs and symptoms of alcohol and/or controlled substances intoxication. During room sweep, marijuana, controlled substances and controlled substance drug paraphernalia were found. ALD #1 was notified. Police took drug items confiscated from Resident #50's room.

Review of the Service/Functional assessment dated 12/30/24 revealed Resident #50 was oriented with only occasional forgetfulness and was independent with physical ability/ambulation, bathing, grooming/dressing, and toileting.

Review of the 15-minute checks documentation for Resident #50 dated 12/31/24 revealed there was no documentation on Resident #50's whereabouts at 3:15 P.M., 3:30 P.M., 4:00 P.M., 4:15 P.M., 4:45 P.M., 5:15 P.M., 5:30 P.M., 6:00 P.M., 6:15 P.M., 6:45 P.M., 7:30 P.M., 8:00 P.M. through 9:00 P.M., 9:30 P.M. through 10:45 P.M.

Review of the 15-minutes checks documentation for Resident #50 dated 01/01/25 revealed Resident #50 was smoking in room (weed). I told him I was going to report it to the nurse. He said okay at 10:30 A.M. Resident #50 was smoking again. I told the nurse again at 1:45 P.M.

Interview on 12/30/24 at 11:25 A.M. with LPN #3 revealed on 12/26/24, during hourly rounding around 8:00 P.M., Resident #41 was observed leaving Resident #50's room. Police and EMS arrived and questioned where Resident #41 obtained drugs. Resident #41 replied, Resident #50. Police confiscated marijuana, a crack pipe and lighter from Resident #50's room. Resident #50 refused vital signs however admitted to drugs and paraphernalia.

Observation on 01/02/25 at 1:57 P.M. revealed Resident #50 was observed actively smoking a cigarette in his room. During the observation and interview, another gentleman (later determined to be Resident #8) was sitting in a chair in Resident #50's room who identified himself first as a friend, then like a relative. A green, black, and silver item resembling a vertical torch lighter was sitting on Resident #50's bedside table. When asked what the item was, Resident #50 replied, it is a torch. The item was said to have been a gift, and he stated he was allowed to keep it because it was a gift to him. Resident #50 stated he smoked cigarettes in his room and on his balcony and they checked on him a couple times a day, usually every two to three hours. Resident #50 also stated he smoked when he woke up, before and after meals, and before bed in his room and thought about 10 times per day he smoked in his room.

5. Review of the medical record for Resident #67 revealed an admission date of 10/25/23 with diagnoses of alcohol abuse, anxiety disorder, epilepsy, adjustment disorder, and migraines. Resident #67 discharged to the hospital on 01/04/25.

Review of the nursing note dated 12/19/24 timed 6:57 P.M. authored by LPN #3 revealed during evening medication pass, LPN #9 called Resident #39's room for Resident #39 when Resident #67 answered the phone. LPN #9 asked Resident #67 where Resident #39 was. Resident #67 stated that Resident #39 was not there. LPN #3 and LPN #9 went to Resident #39's room and the room was empty. Upon assessment of the room, in a cereal bowl on the dresser was cigarette buds and a white-rock substance on the floor the nurse stepped on and kicked. The apartment smelled of marijuana and cigarette smoke. Upon exiting the room, Resident #67 was walking down the hallway and LPN #3 questioned why she was walking the opposite direction of her room. Resident #67 appeared disoriented, her gait appeared unsteady, her pupils were dilated and her response time to questions was slow. Resident #67 stated, I wasn't doing anything, I don't smoke. LPN #3 searched Resident #67's room and there was no evidence of controlled substances or alcohol present. ALD #1 was contacted and informed of the incident.

Review of the nursing note dated 12/26/24 timed 12:38 P.M. revealed Resident #67 had a visit from the nurse practitioner. Resident #67 was found present in Resident #39's room. During the visit with the nurse practitioner, Resident #67 was lethargic, disoriented and pupils were dilated. Drug Counselor (DC) #20 assisted the nurse practitioner with providing a 15-panel rapid drug test. The 15-panel drug test was positive for amphetamines, barbiturates, buprenorphine, benzodiazepines, cocaine, ecstasy (MDMA), marijuana, methadone, methamphetamine, opioids, oxycodone, phencyclidine (PCP), propoxyphene and tricyclic antidepressant (TCA). DC #20 and the nurse practitioner confiscated one liter and one gallon of vodka from Resident #39's apartment. Resident #39 had supplied Resident #67 with the alcohol. When asked how Resident #67 received drugs, the resident refused to disclose where she got them from. Resident #67 admitted to using marijuana. When the nurse asked how Resident #67 consumed opioids since there were no prescribed narcotics for her, Resident #67 replied, what you mean, like fentanyl? I didn't do anything; I just smoked a joint. The nurse was instructed by the nurse practitioner to have Resident #67 transported to the hospital for intentional harm and to have a psychiatric evaluation for a potential hold. The nurse called EMS for transport.

Review of the nursing note dated 12/27/24 timed 7:32 P.M. authored by LPN #3 revealed during hourly rounding, LPN #3 was on the second floor of the assisted living facility, the hallway had a strong smell of smoke. Walking down the hallway, LPN #3 stopped at Resident #39's room. LPN #3 entered the apartment, Resident #67 was behind the door, and would not allow LPN #3 access to the apartment. Resident #39 was Resident #67's boyfriend. The strong smell of controlled substance smoke was present, the room was foggy with gray smoke. LPN #3 asked Residents #67 and #39 to open the door. Resident #67 refused and closed the door. LPN #3 called the non-emergent police line for assistance searching the apartment for controlled substances. The police arrived around 7:15 P.M. LPN #3 accessed Resident #39's apartment, Residents #67 and #39 were lying in bed engaging in sexual intercourse. LPN #3 asked Residents #67 and #39 if any controlled substances were present in the apartment. Residents #39 and #67 denied any controlled substances use in the apartment or any controlled substances being present in the apartment. LPN #3 noticed controlled substance drug paraphernalia on the dresser along with two lighters. LPN #3 asked for the rest of the controlled substances. Resident #39 handed over a pill bottle that contained a white, hard, rock-like substance. LPN #3 asked Resident #39 what the substance was. Resident #39 replied crack. LPN #3 exited the apartment and gave the drug paraphernalia to the officers. ALD #1 was notified of the incident.

Review of the Service/Functional assessment dated 12/30/24 revealed Resident #67 was oriented with only occasional forgetfulness and was independent of with ambulation, bathing, grooming/dressing, and toileting.

Review of the 15-minute checks documentation for Resident #67 dated 12/31/24 revealed there was no documentation of Resident #67's whereabouts at 3:00 P.M., 3:15 P.M., 3:30 P.M., 3:45 P.M., 4:00 P.M. 4:15 P.M., 4:30 P.M., 5:00 P.M., 5:15 P.M., 5:30 P.M., 5:45 P.M. 6:15 P.M. through 10:45 P.M.

Review of the 15-minute checks documentation for Resident #67 dated 01/01/25 revealed there was no documentation of Resident #67's whereabouts from 3:15 P.M. to 9:45 P.M.

Interview on 12/30/24 at 11:25 A.M. with LPN #3 revealed on 12/26/24, Resident #67 was sent to the hospital and returned during third shift on 12/26/24. On 12/27/24, Resident #67 was sent to the hospital for a seizure and was found to have controlled substances in her system. Later that day, LPN #3 could smell smoke which smelled like crack cocaine while at the nurses' station. A nurse aide knocked on the door and the resident would not allow the nurse aide to enter the room. The nurse went to the room and observed a gray cloud of smoke in the room and Resident #67 would not allow the nurse to enter the room. LPN #3 called the police for entry to the room. LPN #3 observed a thick cloud of gray smoke, crack cocaine, a crack cocaine pipe and two lighters which the police confiscated. Resident #67 was disoriented believing it was 10:00 A.M. not 10:00 P.M.

Review of the facility's Smoking policy dated May 2011 revealed residents, visitors, and staff were prohibited from smoking in any of the facility's buildings. Smoking by visitors and residents was only permitted outside the building in the designated smoking areas that was located off the dining room. Smoking was prohibited anywhere else on the premises. Smoking materials (lighters, matches and cigarettes) would be securely stored in a designated area; however, residents deemed to be independent could have their cigarettes in their possession when outside or on an leave of absence (LOA). Matches and lighter were not permitted to be kept by residents but were to be kept in the secure area designated. Residents who were determined to be safe with a lighter could have their lighter only when they were outside or on a LOA but were to return the lighter to staff upon entering the building. A resident who had been determined to be able to safely manage their cigarettes and lighter when outside was not permitted to give another resident a cigarette or lighter unless approved by a staff person because of that resident's potential for needing supervision of smoking. Violation of this was considered not following the smoking policy. The smoking policy would be monitored for compliance as needed. Upon encountering a resident that was not in compliance with the facility smoking policy, staff were to take the following actions:

Require the resident to immediately extinguish smoking materials (cigarettes, matches, etc.).

Take control of the smoking materials, provide a reminder to the resident of the smoking policy and procedure.

Notify the Administrator/Director of Nursing

Complete an incident report with witness statements and submit to the Director of Nursing.

The responsible party (if other than the resident) was to be notified of the incident and reminded of the facility's smoking policy.

A 30-day Discharge Notice could be issued; however, upon the approval of the Administrator discretion could be used for the first occurrence. In such case, the Administrator would determine what action would be taken:

(a)A letter about the incident would be issued to the resident/responsible party with a copy kept on file;

(b)Smoking privileges could be further restricted/controlled if appropriate; and

(c)Other steps taken as necessary to protect the other residents and staff (such as installation of smoke alarm in resident's room or bathroom)

An independent resident who did not comply with the smoking policy could have their status changed to a supervised smoker. A resident who continued to disregard the facility policy or caused unsafe conditions to other residents, would be assisted to make alternative living arrangements and would be issued a discharge notice.

Review of the facility's Non-Prescribed/Illegal Drug or Alcohol Use policy updated October 2023 revealed the possession or use of illegal drugs was not permitted in the facility or on the premises. Residents could not have or distribute illegal substances or alcohol in the building or on the premises. The facility reserved the right to conduct a room search if the facility had the suspicion that alcohol, prescribed medications, or illegal drugs could be stored in the room. If a resident did not agree with room search, the local police would be called to conduct a room search. The facility reserved the right to give a resident a discharge notice if they consumed, had, stored, sold or distributed prescribed medication, illegal drugs or alcohol in the building or the premises because of the potential risk to themselves or others.

This violation represents continued non-compliance investigated under Complaint Number OH00160705. The facility remains out of compliance from the surveys dated 01/04/24, 07/09/24, and 09/12/24.

Based on observation, record review, and interview the facility failed to ensure Resident #69 was free from an incident of resident to resident abuse. This affected one resident (#69) of three residents reviewed for abuse.

Actual harm occurred on 12/19/24 when Resident #69 was abused by Resident #58. Upon assessment on this date, an assessment identified Resident #69 was crying, shaking and rocking back and forth (in distress) with labored breathing. Around the resident's neck was visible redness, markings similar to a hand print, the resident's chest area was red in color, her left eye was swollen with a blood clot present in the corner of the left eye, and dried blood on the left forearm.

Findings include:

Review of the medical record for Resident #69 revealed an admission date of 11/26/18 with diagnoses of fibromyalgia, bariatric surgery status, diabetes, cellulitis, opioid dependence and hypertension.

Review of the service/functional assessment dated 03/27/24 revealed Resident #69 was oriented with only occasional forgetfulness, used a motorized wheelchair, and was independent with bathing, grooming and toileting. Resident #69 was her own responsible party.

Review of the incident note dated 12/19/24 timed 12:47 P.M. revealed Resident #69 stated to the nurse, I am scared for my life that Resident #58 hits me all the time. Today, [Resident #58] put his hands around my neck and choked me. The abuse has been happening for some months. I didn't report it because nobody here every does anything. I reported it today because I am scared and fed up. [Resident #58] takes my wheelchair and moves it so I can't leave or move. He pulls my hair. He never punches me. He always chokes me or pulls my hair. I'm scared and fed up this time. This is why I told. I am scared [Resident #58] will come into my room if I try to break up with him. My door doesn't lock. [Resident #58] will never stop hitting me no matter how much I love him, and he apologizes, he going to keep hitting me. The nurse assessed Resident #69's body. Upon assessment, Resident #69 was crying, shaking and rocking back and forth and appeared to be distress with labored breathing. Vital signs within normal. Around the resident's neck was visible redness, markings similar to a hand print, chest area red in color, left eye swollen bottom corner of left eye was a blood clot present. On left forearm, dried blood with old bruising.

Review of the health status note dated 12/29/24 timed 4:08 P.M. revealed due to Resident #69's injuries, the nurse practitioner gave orders to have Resident #69 seen in the emergency department; however, the resident refused medical attention.

Review of the closed medical record for Resident #58 revealed an admission date of 03/24/23 with diagnoses of diabetes, anxiety disorder, chronic obstructive pulmonary disease, hypertensive heart disease and major depressive disorder. Resident #58 discharged to the county jail on 12/19/24.

Review of the service/functional assessment dated 09/27/24 revealed Resident #58 was oriented with occasional forgetfulness and was independent with ambulation, grooming, bathing and toileting. Resident #58 was his own responsible party.

Review of the nursing note dated 12/19/24 timed 2:57 P.M. revealed Resident #58's sister/emergency contact was notified of the resident being arrested today.

Review of the Police Case Report SHPD2024-002132 dated 12/19/24 revealed an assault was reported and one male [Resident #58] was arrested. The report included Resident #69 had been strangled by her boyfriend, Resident #58.

Review of an undated witness statement authored by Resident #69 revealed, On 12/18/24, [Resident #58] got mad at me because I spent my money on cigarettes when he wanted me to give it to him. He put me in a choke hold with his elbow and when I started to scream for help, he put his other hand over my mouth and squeezed it to stop me from screaming until I could hardly breathe. Eventually, when I was quiet, he stopped. I got out of the room and staff told him I wanted him to leave. He told them I was delusional, but he did leave. This has been going on for some time and I haven't told because I am scared if I do, I will seriously get hurt once people in charge go home at night. He broke my door lock so I can't lock him from coming in about a month ago. I just need help to keep him away from me ...

Review of an undated witness statement authored by Receptionist #16 revealed, Resident #69 came to my desk and I asked her what was wrong with her left eye. She started crying and said I'm tired of him beating on me and was squeezing her until she turned red. She also stated I know he's going to get me when everyone leaves. She said she barricades herself in her room at night because he's trying to get in her room. So I text the Assisted Living Director with all the information she told me and it was handled from there.

On 12/23/24 at 10:05 A.M. Resident #69 was observed was using a motorized wheelchair to move throughout the facility. Resident #69 had several layers of clothes on. Resident #69's left eye was red with a small circular blood clot on the lower left area of the eye. Interview with Resident #69 at the time of the observation revealed herself and Resident #58 had been in a consented relationship for six months and he had physically choked her for months but had never punched her. Resident #69 stated she had not told any staff member because she was embarrassed.

Interviews on 12/23/24 with Assistant Living Director (ALD) #1 at 12:20 P.M., 2:40 P.M. and on 12/30/24 at 9:20 A.M. revealed Residents #69 and #58 were in a relationship; however, the facility staff had not been aware Resident #58 was physically abusive towards Resident #69 (until 12/19/24). ALD #1 stated the police arrested Resident #58 on 12/19/24, notified the facility that a restraining order was placed between Residents #69 and #58 and then the police returned that night to obtain the resident's medications. On 12/20/24, the jail notified the facility Resident #58 was going to be discharged from the jail to the Men's Homeless Shelter and could not return to the facility at that time due to the restraining order. ALD #1 stated Resident #58's Medicaid Case Manager and Ombudsman were notified, and Resident #58 was appealing his discharge. Resident #58 returned to the facility on 12/27/24 due there were no criminal charges or restraining order brought against him. ALD #1 had already notified Resident #69 of his arrival and indicated the resident was okay with it and Residents #69 and #58 were already speaking again.

A follow up interview on 12/30/24 at 10:10 A.M. with Resident #69 verified she was okay with Resident #58 returning the facility. The resident stated she felt safe and was knowledgeable about what to do if Resident #58 became abusive to her again.

This violation represents non-compliance investigated under Control Number OH00160940.

Based on record review, observation and interview the facility failed to maintain carpeted floors in good repair. This had the potential to affect all 89 residents living in the facility.

Findings include:

Observation on 09/12/24 at 8:30 A.M. revealed the carpet in the common areas of the first floor (hallways, common areas and dining room) were heavily worn and heavily stained.

Observations conducted on all three floors of the facility on 09/12/24 between 11:17 A.M. to 11:53 A.M. with Maintenance Director (MD) #550 revealed the carpet in the common areas throughout the facility on all three floors was stained, dirty-looking and worn. The carpet was taped to the floor in areas on the first, second and third floor hallways. The first-floor dining room carpet had rips in it. MD #550 verified the findings at the time of the observations and said a quote for carpet repair had been received, however, the repairs had not yet been scheduled.

Interview on 09/12/24 at 2:13 P.M. with the Assisted Living Director (ALD) #519 and the Executive Director (ED) verified the carpet throughout the building was heavily stained, heavily worn, ripped and taped in spots and there were plans to replace the carpet. Both verified the facility did not have a start date for the removal and installation of new carpet/flooring

Review of the carpet contractor quote dated 08/31/24 revealed the removal of carpet and the installation of new carpet and tiles would be $907.00. The dining room carpet was not included in the quote.

This violation is a recite to the annual survey conducted on 07/09/24 and complaint survey conducted on 01/04/24.

Based on record review, observation and interview the facility failed to ensure resident requests and inquiries were responded to promptly. This affected three residents (#27, #29 and #89) of five residents reviewed for resident rights. The facility census was 89.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 04/18/12 with diagnoses including paranoid schizophrenia, unspecified pain, unsteadiness on feet, gastro-esophageal reflux disease without esophagitis, and cocaine dependence. There was no evidence in her medical record regarding concerns with repairs including the hole in her ceiling in her bathroom.

Interview and observation with Maintenance Director (MD) #550 on 09/12/24 from 11:17 A.M. to 11:53 A.M. revealed the ceiling in Resident #27's bathroom had a hole in it that was approximately 30 inches in diameter with failing debris on the floor and toilet. The toilet was not secure to the floor and was covered in flaking debris from the ceiling. The toilet was able to be turned in place approximately 30 degrees but still flushed. The findings were verified with MD #550 at the time of the observation.

Interview on 09/12/24 at 12:35 P.M. with Resident #27 revealed it had been since June 2024 that she had the hole in her bathroom ceiling. She revealed a pipe in the hole leaked water and rust and debris also fell from the hole. She revealed she had communicated the concern to the facility including the Executive Director (ED) and the Maintenance Department (she was unable to identify a specific person). She revealed the maintenance department had told her I am in line and had to wait for the repairs to be made. She revealed she then communicated her concern to the Ombudsman.

Interview and observation on 09/12/24 at 2:13 P.M. with Assisted Living Director (ALD) #519 revealed she was not aware of the condition of Resident #27's ceiling needing to be repaired.

2. Review of the medical record for Resident #29 revealed an admission date of 03/07/24 and diagnoses including major depression, diabetes, and chronic kidney disorder. There was no evidence in his medical record regarding concerns with his bathroom vent needing repaired.

Observation was conducted during an environmental tour on 09/12/24 from 11:17 A.M. to 11:53 A.M. with MD #550 and revealed a vent that did not work when switched to the on position in Resident #29's room. There was also a hole around the vent in the drywall leaving a gap of about two inches from the edge of the vent. Rust and other small pieces of debris were present on the floor. This was verified with MD #550 at the time of the observation.

Interview on 09/12/24 at 12:20 P.M. with Resident #29 revealed he had a hole around his vent for months and months as well as the vent did not work. He revealed maintenance stated they would fix it but then they never did. He verified rust and debris fell from the hole all the time onto his floor.

Interview on 09/12/24 at 2:13 P.M. with the ALD #519 verified she had been aware of the vent needing repaired for quite a while, however, ALD #519 thought that maintenance had fixed it. She stated I guess I need to micromanage as maintenance said they fixed the concern so she assumed that it was fixed.

Review of the Maintenance Repair Log dated from 09/12/23 to 09/12/24 revealed there was nothing on the log regarding Resident #29's concern that his exhaust fan did not work.

3. Review of the medical record for Resident #89 revealed an admission date of 12/19/23 with diagnoses including cerebral infarction, epilepsy, gastro-esophageal reflux disease without esophagitis, major depressive disorder, essential hypertension, diabetes mellitus, and hypotension. There was no evidence in his medical record regarding concerns with repairs including his bathroom vent.

Interview and observation with MD #550 on 09/12/24 from 11:17 A.M. to 11:53 A.M. revealed the vent in Resident #89's restroom did not turn on when the switch was flipped.

Interview and observation on 09/12/24 at 12:33 P.M. with Resident #89 revealed he had an exhaust fan in his bathroom that did not work He revealed that it had been over a month since he had let the maintenance department know and they still had not fixed it. He revealed, they do not care and will not fix it.

Interview on 09/12/24 at 2:13 P.M. with the ALD #519 verified she had been aware of the vent needing repair for quite a while, however, she thought maintenance had fixed it. She stated I guess I need to micromanage as maintenance said they fixed the concern so she assumed it was fixed.

Interview on 09/12/24 at 2:52 P.M. with MD #550 revealed Resident #89 had stopped him in the hallway approximately one week ago and stated his exhaust fan was not working. He verified he had not filled out a work order for this request. He verified he had not fixed the exhaust fan.

Review of Maintenance Repair Log dated from 09/12/23 to 09/12/24 revealed there was nothing on the log regarding Resident #89's concern that his exhaust fan did not work.

This violation identified noncompliance during investigation of Complaint Number OH00157402.

Based on interview and record review, the facility failed to ensure the Ombudsman was permitted to attend a resident council meeting when invited by the residents. This affected three residents (#25, #40 and #67) out of five residents reviewed for resident rights. The facility census was 89.

Findings included:

Review of the Resident Council Meeting Minutes from 07/30/24 through 08/29/24 revealed the Ombudsman was not in attendance. The July minutes indicated the residents wanted their concerns to be conveyed to the Ombudsman. The August minutes indicated the residents wanted the Ombudsman to attend the next meeting.

Interview was conducted on 09/12/24 at 10:51 A.M. with the Ombudsman who stated the resident council president, Resident #84, asked her to attend the August 2024 resident council meeting and Resident #84 would be unable to attend that meeting due to illness. The Ombudsman revealed Activity Director (AD) #546 was present at the meeting and the other residents present wanted the Ombudsman to stay, however, AD #546 refused and told her to leave the meeting.

Interview on 09/12/24 at 12:13 P.M. with Resident #84 confirmed she was the resident council president and invited the Ombudsman to attend the August 2024 meeting. Resident #84 was informed by the other residents who were at that meeting that the Ombudsman was not permitted to attend.

Interview on 09/12/24 at 1:07 P.M. with AD #546 revealed she was responsible for running the resident council meetings.

AD #546 confirmed she did not let the Ombudsman attend the meeting in August 2024 because she did not know she was the Ombudsman.

Interview on 09/12/24 at 2:55 P.M. with Resident #67 revealed he attended the August 2024 resident council meeting and both he and the other residents were expecting the Ombudsman at the meeting because Resident #84 who was the council president told him due to illness Resident #84 would not attend but the Ombudsman was planning to attend the meeting. Resident #67 stated the council group was not asked if they wanted the Ombudsman to stay at the meeting, but instead AD #546 would not let her stay.

Interview on 09/12/24 at 3:28 P.M. with Resident #25 revealed he did attend the August 2024 resident council meeting and AD #546 did not ask him if the Ombudsman could stay at the meeting.

Interview on 09/12/24 at 3:45 P.M. with Resident #40 revealed she remembered attending the August 2024 resident council meeting and the Ombudsman was there, but AD #546 would not allow her to stay at the meeting. She revealed that all the residents wanted her to stay but AD #546 never asked them if she could stay.

Review of the facility policy Nursing Home Residents Bill of Rights revealed it did not specifically address resident council meetings, however, the policy did state that it is the facility's policy to abide by all resident rights.

Review of the facility document titled Resident and Family Council Toolkit stated on page five staff persons and long-term Ombudsmen attend council meetings if invited.

This violation identified noncompliance during investigation of Complaint Number OH00157402.

Based on observation and interview, the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect all 84 residents who received food from the kitchen. The census was 84.

Findings include:

Observation during tour of the kitchen on 07/08/24 at 4:30 P.M. with Dietary Manager (DM) #2 revealed the floor was wet in the walk-in refrigerator. There was dripping water from a rust stain within the walk-in refrigerator ceiling onto parchment paper covering deli sandwiches sitting on multiple racks of a metal cart. There was an unknown meat in a metal pan that was not labeled or dated, a plastic bag of what appeared to be chicken tenders that was not labeled or dated, and a plastic bag of what appeared to be diced chicken that was not labeled or dated. Interview, during the observation, with DM #2 revealed the walk-in refrigerator was brand new, the water had only started dripping and the Maintenance department would know more about why there was a drip from the ceiling. DM #2 verified the three food items were not labeled or dated.

Observation on 07/08/24 at 4:45 P.M. revealed Cook #1 removed the tray of deli sandwiches from the rack of the metal cart inside walk-in refrigerator with sitting water on the parchment paper to serve to the residents for dinner.

Interview on 07/09/24 at 8:40 A.M. with Maintenance Assistant (MA) #6, with the Executive Director present, revealed the walk-in refrigerator was installed in late 2023 or early 2024 and the reason there was a water drip from the ceiling was because the dietary employees kept the door of the walk-in refrigerator open for extended periods. MA #6 stated he had told the dietary employees repeatedly to keep the door closed.

Based on observation, review of contractor quote, and interview, the facility failed to ensure a sanitary, homelike environment for the residents. This had the potential to affect all 84 residents in the facility.

Findings include:

Observation on 07/08/24 at 5:00 P.M. revealed the carpet in the common areas of the first floor (hallways, common areas and dining room) were heavily worn and heavily stained.

Observation during a tour of the facility on 07/09/24 at 8:05 A.M. revealed the carpet in the common areas throughout the facility on all three floors was stained, dirty-looking and worn. The carpet was taped to the floor in areas on the first, second and third floor hallways. The first-floor dining room's carpet had rips in it.

Interview on 07/09/24 at 8:25 A.M. with the Assisted Living (AL) Executive Director and Administrator verified the carpet throughout the building was heavily stained and heavily worn however there were plans to replace the carpet.

Interview on 07/09/24 at 8:40 A.M. with Maintenance Assistant (MA) #6, with the AL Executive Director present, revealed the facility had received a quote to remove the common area carpet and replace it with flooring.

Interview on 07/09/24 at 1:05 P.M. with Resident #15 revealed the carpet was awful and dirty in the common areas.

Interview on 07/09/24 at 3:45 P.M. with the Administrator, with the AL Executive Director present, revealed the facility did not have a start date for the removal and installation of new carpet/flooring.

Review of the carpet contractor quote dated 04/05/24 revealed the removal of carpet in the first, second and third floor hallway and the installation of new carpet tiles would be $4,125. The dining room carpet was not included in the quote.

This violation is a recite to the complaint survey completed 01/04/24.

Based on medical record review, resident and staff interview, and policy review, the facility failed to timely notify resident representatives following hospitalizations. This affected two (#8 and #87) of four residents reviewed for hospital transfers. The facility census was 86.

Findings include:

1. Review of Resident #8's medical record revealed the resident was admitted to the facility on 11/21/23. Diagnoses included chronic respiratory failure, hypoxia, type II diabetes, hemiplegia and hemiparesis, anemia, and chronic fatigue.

Review of Resident #8's emergency contact list dated 11/21/23 revealed Resident #8 had a guardian and two other family members listed for emergency contacts with telephone numbers provided.

Review of a health assessment dated 01/11/24 revealed Resident #8 was a fall risk and needed assistance with mobility.

Review of a nursing progress note dated 03/07/24 revealed Resident #8 fell while in the facility and was sent to the emergency room (ER) for post-fall evaluation and treatment of pain. Further review of the medical record revealed no evidence any of Resident #8's emergency contacts were notified of the fall and subsequent transfer to the ER on 03/07/24.

Interview on 03/29/24 at 11:47 A.M. with Resident #8's guardian verified there was no notification from the facility when Resident #8 fell and was transferred to the ER on 03/07/24. Resident #8's guardian stated there was no notification made until 03/11/24 following Resident #8's return to the facility.

Interview with Licensed Practical Nurse (LPN) #66 on 03/29/24 at 1:10 P.M. confirmed on 03/07/24 she did not notify Resident #8's emergency contacts when the resident fell and was sent to the ER.

2. Review of Resident #87's medical record revealed the resident was admitted to facility on 10/04/21. Diagnoses included type II diabetes, hypertension, transient cerebral ischemic attack, and schizophrenia.

Review of Resident #87's emergency contact list dated 10/04/21 revealed Resident #87 had one family member and a case manager listed as emergency contacts with telephone numbers.

Review of nursing progress notes on 03/25/24 revealed Resident #87 was admitted to the hospital with intractable nausea and vomiting. Further review of the nursing progress notes revealed on 03/27/24 at 2:59 P.M. Resident #87 returned from the hospital and the resident's case manager was notified. Review of progress notes on 03/28/24 revealed Resident #87 was admitted to the hospital with intractable nausea and vomiting. There was no documentation of Resident #87's emergency contacts being notified of the hospitalizations.

Interview on 03/29/24 at 2:20 P.M. with Assisted Living Director #88 verified Resident #87's emergency contacts were not notified on 03/25/24 and 03/28/24 when Resident #87 had a change in condition and was transferred to the hospital.

Review of an undated policy titled, Notification of Changes Policy

Based on observation, interview, record review and review of facility policy the facility failed to ensure a sanitary, homelike environment for the residents. This had the potential to affect all 91 residents in the facility.

Findings include:

Review of Resident #87's medical record revealed an admission date of 11/21/23 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus, hemiplegia and hemiparesis following other cerebrovascular disease affecting the left non-dominant side.

Review of Resident #87's Nurse Practitioner progress notes dated 11/22/23 included Resident #87 was alert and oriented to time and place and was confused at times. Resident #87 used a wheelchair.

Interview on 01/04/24 at 1:41 P.M. of Family Member (FM) #300 revealed Resident #87 lived in the facility since 11/2023 and the facility was dirty. Resident #87 stated the staff did not always clean up the dining area after meals and left dirty dishes and food on the tables. Resident #87 stated the carpets were very dirty and stained.

Tour on 01/04/24 at 3:25 P.M. of the facility with Maintenance Director (MD) #301 revealed the door to the private dining area on the first floor was hanging crooked and could not be closed. Further observation of the door revealed the wood used for the door frame was cracked in a couple places. MD #301 stated the door needed to be repaired. The wall in the private dining room had pieces of dry wall and wall paper missing and MD #301 confirmed the dry wall and wall paper were missing and stated it looked like a wheelchair had scraped the wall and caused the damage. The tour revealed the carpet in the common areas throughout the facility on all three floors was stained, dirty looking and worn. The carpet was taped to the floor in areas on the first, second and third floor hallways. The first floor dining room's carpet had rips in it. MD #301 stated the carpets were cleaned weekly but the cleaning did not get the stains out and MD #301 confirmed the carpet was worn out and taped to the floor in areas. MD #301 confirmed the dining room carpet had rips in it. MD #301 did not know if there were plans to replace the carpet in the facility. Observation of the window on the first floor resident area revealed the window covering was very dirty all over and had multiple grayish drip marks tracking down the window blinds. The window sill was dirty and the window behind the blinds was very dirty and a build up of debris on the window was noted. MD #301 confirmed the dirty blinds, window and window sill. Observation of a few steps leading up to the first floor resident area revealed the steps were dirty and pieces of material put on the steps were coming loose and sticking up. MD #301 confirmed the steps were dirty and the pieces of material on the steps needed replaced. During the tour dirty dishes stacked on a table in the hall of the third floor resident area were noted.

Interview on 01/04/24 at 4:00 P.M. of Assisted Living Director (ALD) #302 revealed residents used the private dining area for events.

Interview on 01/04/24 at 6:00 P.M. of ALD #302 and the Administrator confirmed the above information. The Administrator stated there were plans to replace the worn out carpeting in the common areas in the spring, she had received estimates and the carpet replacement in the common areas was going to be done after the carpet in resident rooms was replaced. The Administrator stated it looked like the door to the private dining area needed replaced.

Review of the facility policy titled Resident Rights and Facility Responsibility Policy undated included residents have the right to a safe and clean living environment.

This violation represents non-compliance investigated under Complaint Number OH00149614.

Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #87's right to privacy. This affected one resident (Resident #87) out of three residents reviewed for privacy. The facility census was 91.

Findings include:

Review of Resident #87's medical record revealed an admission date of 11/21/23 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus, hemiplegia (paralysis) and hemiparesis (weakness) following other cerebrovascular disease affecting the left non-dominant side.

Review of Resident #87's Nurse Practitioner progress notes dated 11/22/23 included Resident #87 was alert and oriented to time and place and was confused at times. Resident #87 used a wheelchair.

Observation on 01/04/24 at 1:14 P.M. of Resident #87 revealed she was sitting in her room in a wheelchair. Further observation revealed one wall of her room was floor to ceiling windows with a sliding door. Resident #87's window curtains were hanging crooked and part of the curtains were not attached to the curtain rod and were hanging freely to the side of the curtain which was attached to the curtain rod. There was approximately a two foot area of the window from top to bottom not covered by the curtain. A concrete area with a railing could be seen where the window and door was not covered by the curtain.

Interview on 01/04/24 at 1:14 P.M. of Resident #87 revealed she had been in this room for about three weeks and had been trying to get something done about the curtains. Resident #87 stated people could be outside and walk by her room and look in the window. Resident #87 stated she did not have privacy.

Interview on 01/04/24 at 3:25 P.M. of Maintenance Director (MD) #301 confirmed Resident #87's curtains were hanging crooked and anyone on the outside could look in her room. MD #301 stated he would take care of the improperly hanging curtain immediately.

Review of the facility policy titled Resident Rights and Facility Responsibility Policy undated included residents have the right to privacy during medical examination, treatment and personal care.

This violation represents non-compliance investigated under Complaint Number OH00149614.

Based on policy review, kitchen audit review, observation and staff interview the facility failed to maintain its kitchen in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 77.

Findings Includes:

Observation of the facility's kitchen area on 07/05/23 between 6:20 A.M. and 7:15 A.M. revealed the following that was observed and verified at the time of observation with Cook #995.

In the walk-in fridge the following was noted.

1. A bottle of orange juice was noted in a plastic container with the container ripped and was undated.

2. A prepared bowl of salad was noted with plastic half cover it, had no date and noticeably brown lettuce.

3. A half of a white onion was wrapped in plastic and undated.

4. A plastic container of chopped chicken was undated.

5. An open bottle of barbeque sauce was undated.

6. A package of open turkey deli meat was undated.

7. A plastic container of pre-made sausage patties was undated.

8. A plastic container of chicken cutlets was undated.

9. A plastic container of rice pilaf was undated.

10. An open bottle of stir fry sauce was open and undated.

11. A package of cheddar cheese was open, undated and had noticeable green mold growth

12. A plastic container of tuna was undated, had white mold growth and produced a rancid smell when the lid of the container was taken off.

13. Multiple packages of chicken were observed defrosting on a baking sheet on sheet rank. The baking sheets the chicken were defrosting on were full of significant amount of blood that was nearly overflowing on to the floor.

14. A package of hotdogs was undated and had mold on the hot dogs.

15. A package of parmesan cheese had mold growth inside it

16. The fans circulating the air in the fridge were incased with dirt, dust and grime.

17. The walls and floors were full of significant splatter, debris and other unknown items.

In the walk-in freezer the following was observed

18. A bag of frozen chopped spinach was sitting on the floor.

19. An open plastic bag of corn was undated and exposed to the air.

20. An open box of puff pastry was undated and exposed to the air.

21. An open box of boneless skinless chicken breast was undated dated and exposed to the air.

22. An open package of cod filets was undated and exposed to the air.

23. Two open packages of crinkle cut fries were undated and exposed to the air.

24. An open plastic bag of lima beans was undated and exposed to the air.

25. A plastic container of breaded chicken filets was open and exposed to the air.

26. An open plastic bag of hamburger patties was exposed to the air and undated. Numerous patties showed significant freezer burn.

27. The floor was noted to full of food scraps, dirty and other unknown debris.

28. Significant ice build up was noted on the floor.

In the dry storage area the following was noted.

29. A plastic bag of egg noodles was open and undated.

30. A plastic bag of rigatoni was open and undated.

31. A plastic bag of tri-color rotini pasta was open and undated.

32. A plastic bag of sprinkles was open and undated.

33. A plastic cup was on a shelf with over two dozen dead fruit flies in it.

34. A cardboard box of hot dog buns with the keep frozen noted on the box was on a shelf. Upon opening the box, the hot dog buns were noted to be moldy.

35. A package of white cake mix was open and undated.

36. A package of fudge brownie mix was open and undated.

37. The light fixture was cracked and had three dead bugs in it.

38. Above the dry storage area was a large air vent that was nearly completely rusted and blowing area on to the food area.

In the direct food preparation area, the following was noted.

39. The six-burner stove had significant buildup of food, debris and other items.

40. The convection oven that was actively making biscuits for the morning meal was brown in color from grease and other build up and had noticeable food crust and build up on the bottom.

41. Numerous areas of the ceiling were noted to be water stained and other brown substances

42. The floor had numerous areas of food debris and other build up.

43. The air conditioning vent outside the walk-in freezer was incased in dirty, dust, grime and rust.

44. The microwave in the food preparation areas was extremely dirty with food debris and other items inside and had around of unknown substances on the outside of the microwave and key pad.

Interview with Nutrition Associate (NA) #770 at 10:50 A.M. revealed she conducts an audit once a month through her contract company of food temperatures, dinning room service and kitchen sanitation and shares findings with the facilities Executive Director and Dinning Services Manager via formal report. NA #770 revealed she conducted her last audit on 06/30/23 and shared significant concerns with the Executive Director.

Review of the audit conducted by NA #770 on 06/20/23 revealed concerns related to spare ribs thawing above cooked ham, Oven/stovetop are dirty with food residue, Steam table dirty and Microwave dirty, inside and out..

Review of the audit conducted by NA #770 on 05/26/23 revealed concerns related to undated items in cooler and fans in cooler dusty.

Review of the policy entitled Cleaning Instruction Refrigerators dated 05/27/13 revealed The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be cleaned as they are noticed

This violation represents non-compliance investigated under OH00143973.

Based observation and staff interview the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents. The facility census was 77.

Findings Include:

1. Observation of the facility's dumpster area on 07/05/23 between 6:20 A.M. and 7:15 A.M. revealed the following that was observed and verified at the time of discovery with Cook #995.

Multiple dumpsters were noted with their lids open and the trash bags over flowing.

Multiple food debris were noted on the ground in the dumpster areas.

Dozens of cigarette buts were noted around the dumpster area.

2. Observation of the laundry area on 07/05/23 between 1:25 P.M. and 1:45 P.M. with Maintenance Director (MD) #900 revealed the following that was observed and verified at the time of discovery.

The laundry room had a distinct potent musty smell.

The floor of the laundry room was in complete disrepair. Large cracks in the tile floor were noted along with various stains of different colors and numerous areas of significant dirt and debris.

Two local retail shopping carts were noted in the area and were extremely dirty

Two dryers were noted running. One of the dryers vents was completely disconnected and spewing lint on the floor

An outlet behind one of the dryers had lint all around the top of the plug

3. An environmental tour conducted on 07/06/23 between 10:00 A.M. and 10:19 A.M. with Housekeeping Supervisor (HS) #940 revealed the following that was observed and verified at the time of discovery.

Numerous dinning room chairs were noted with significant stains of various types

The carpeting and floor through out the facility were significantly stained and were sticky with unknown substances.

Numerous water stained ceiling tiles and areas were noted through out the facility.

An ice cooler used to pass ice water to residents had two noticeable bugs (appeared to be gnats) in the cooler.

The wheelchair being used by #4 had such significant buildup of what appeared to be lint and other debris the bottoms rungs of the wheelchair were completely unrecognizable to its original color.

This violation represents non-compliance investigated under OH00143073.

Based on observation and staff interview the facility failed to ensure the privacy and confidentially of resident records. This had the potential to affect all residents. The facility census was 77.

Findings Include:

Observation of the wellness center (main area used for medication administration and other medical needs) on 07/06/23 at 7:55 A.M. revealed a table outside of the wellness center. On this, with easy access to anyone in the area, was a book with title STNA (Stated Tested Nursing Assistant) report book. This book was noted contain multiple weeks of recent medical information including activities of daily living (ADL) assistance, refusals of care and treatment and other types of medical information.

Interview with Assisted Living Director (ALD) #990 on 07/06/23 at 8:00 A.M. verified the STNA report book should not have been in a publicly accessible area and contained sensitive medical information.

This violation was an incidental finding discovered during the complaint investigation.

Based on interview, record review, facility policy and procedure, the facility failed to administer medications as ordered. This affected two residents (Residents #56 and #64) of three residents reviewed for medication administration. The facility census was 77.

Findings include:

1. Review of the medical record for Specified Resident (SR) #56 revealed the resident was admitted to the facility on 08/02/21. Diagnoses included heart failure, peripheral vascular disease, hypertension, and morbid obesity.

Interview on 02/23/23 at 10:45 A.M., of the SR #56 revealed he did not receive his medication as ordered by the physician.

Review of the medication administration record (MAR) dated 02/02/23, revealed SR #56 did not receive his ordered medication as follows: Gabapentin 300 mg (milligram), give one capsule by mouth in the evening related to peripheral vascular disease; Pentoxifylline ER 400 mg, give one tablet by mouth three times a day related to atrial fibrillation.

2. Review of the medical record for Former Specified Resident (FSR) #64 revealed the resident was admitted to the facility on 02/13/22. Diagnoses included altered mental status, bipolar disorder, seizures, dementia, and depression.

Interview on 02/23/23 at 5:15 P.M., of the FSR #64 revealed he did not receive his medication as ordered by the physician.

Review of the medication administration record (MAR) dated 02/02/23, revealed FSR #64 did not receive his ordered medication as follows: Amlodipine 5 mg, give one tablet by mouth in the evening related to hypertension; Atorvastatin 80 mg, give one tablet by mouth at bedtime related to cholesterol; Quetiapine ER 400 mg, give one tablet by mouth at bedtime related to bipolar disorder; Ropinirole ER 2 mg, give one tablet by mouth at bedtime related to abnormalities of gait and mobility; Tamsulosin 0.4 mg, give two capsules by mouth at bedtime related to enlarged prostate.

Interview on 02/23/23 at 2:15 P.M., the Executive Director (ED) confirmed the above information was true and correct. No additional documentation was provided.

This violation represents non-compliance investigated under Complaint Numbers OH00140184 and OH00140078.

Based on observation and interview, the facility failed to maintain carpeting in good repair and maintain carpeting in a secured manner to prevent safety hazards. This had the potential to affect all residents and visitors who access the facility. The facility census was 77.

Findings include:

A tour of the facility was conducted on 02/22/23 at 3:10 P.M., the facility was clean, and appeared well-lived in. No pervasive orders were noted. The hallway carpet leading from the assisted living elevators to the main dining room was worn and taped with duct tape on the seams in multiple areas.

Observations on 02/23/23 at various times between 7:15 A.M. and 5:00 P.M., revealed a visitor had tripped on the taped seam and residents struggled with assistive devices to navigate the uneven carpet.

Further observations revealed the duct tape used to secure the carpet had become loose and rolled up on tape edges which caused the carpet to become sticky and uneven.

Interview on 02/23/23 at 10:15 A.M. with the Maintenance Director #700, confirmed the observations and verified the carpet was uneven and in need of replacement.

This violation represents non-compliance investigated under Complaint Number OH00139651.