Heritage of Lyndhurst LLC

Based on record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure proper medication administration. This affected one resident (#6) of three residents reviewed for narcotic medication administration. The facility census was 33.

Findings include:

Review of the medical record for Resident #6 revealed she was admitted to the facility on 12/29/23 with diagnoses including hypertensive chronic kidney disease, obesity, and major depressive disorder.

Review of the current physician orders dated 10/13/25 revealed an order for morphine sulfate oral solution 20 milligrams (mg) to be given 0.25 milliliters (ml) (narcotic pain medication) by mouth every two hours as needed for pain and/or shortness of breath.

Review of the progress note dated 10/13/25 at 9:59 A.M. revealed Resident #6 received a new order per hospice for morphine 20 mg per 5 ml to be given 0.25 ml by mouth every two hours as needed for pain and/or shortness of breath.

Review of the progress note dated 10/13/25 at 10:13 A.M. revealed Resident #6 received a dose of ordered morphine.

Review of the progress note dated 10/14/25 at 7:00 A.M. revealed Resident #6 was given a dose of morphine. Further review of the progress note revealed Resident #6 was given morphine dose on 10/13/25 at 12:00 P.M. and 7:00 P.M. by Certified Medication Technician (CMT) #812. CMT #812 signed off medication administration in narcotic book but was unable to come into the facility to sign-off in point click care (PCC) where her signature was omitted.

Review of the current physician orders dated 10/16/25 revealed an order for Resident #6 to be admitted to Amedisys Hospice (AH) with a diagnosis of Parkinson's disease with a prognosis of six months or less if the disease runs its course.

Review of the progress note dated 10/16/25 at 10:00 A.M. revealed Resident #6 received ordered dose of morphine.

Review of the progress note dated 10/21/25 at 2:00 P.M. revealed Resident #6 received ordered dose of morphine.

Review of the progress note dated 10/21/25 at 3:43 P.M. revealed Resident #6 complained of stomach pain to unknown AH staff nurse. AH staff nurse requested Licensed Practical Nurse (LPN) #801 to give Resident #6 dose of morphine. LPN #801 suggested Resident #6 use the restroom and let chili from lunch digest. Resident #6 requested to have dose of morphine.

Review of the controlled drug receipt, record, and disposition (CRD) form dated 10/09/25 revealed ineligible date and time for a dose of morphine given to Resident #6. Further review of the CRD form revealed Resident #6's order for morphine was administered on 10/13/25 at 12:00 P.M. and 7:00 P.M., 10/14/25 at 4:00 P.M., 10/16/25 at 10:00 A.M., and 10/21/25 at 2:00 P.M. with no other documented administration times. Review of the CRD form revealed signatures of staff who administrated the dose of morphine.

Review of the electronic medication administration record (EMAR) located in PCC for the month of October 2025 revealed Resident #6 received a dose of morphine on 10/13/25 at 10:13 A.M., a dose of morphine on 10/14/25 at 7:00 A.M. and 3:53 P.M., a dose of morphine on 10/16/25 at 10:00 A.M., and a dose of morphine on 10/21/25 at 2:00 P.M.

Reconciliation with Resident #6 EMAR located in PCC and the CRD form revealed the following:

Resident #6 received a dose of morphine prior to the first date of administering morphine on 10/13/25 which was not documented in the EMAR.

Resident #6 received three doses (10:13 A.M., 12:00 P.M., 7:00 P.M.) of morphine on 10/13/25 with two doses (12:00 P.M., 7:00 P.M.) not being documented on the EMAR.

Resident #6 received two doses (7:00 A.M., 3:53 P.M.) of morphine on 10/14/25 with one dose (7:00 A.M.) not being documented on the CRD.

Resident #6 received two doses (1:00 A.M.,10:00 A.M.) of morphine on 10/16/25 with only one dose (10:00 A.M.) documented on the EMAR and CRD.

Resident #6 received two doses (2:00 P.M., 3:43 P.M.) of morphine on 10/21/25 with the dose given at 3:43 P.M. per progress note dated 10/21/25 at 3:43 P.M. was not documented in EMAR or CRD.

Interview on 10/28/25 at 8:54 A.M. with LPN #801 during observation of medication administration, revealed all medications were given as ordered and on schedule. LPN #801 revealed all narcotics administered required a signature and sign-off on both the EMAR and CRD.

Interview on 10/28/25 at 11:59 A.M. with the Executive Director (ED) and Director of Wellness (DOW) revealed all narcotics administered were to be documented in PCC in the EMAR and CRD.

Interview on 10/28/25 at 12:15 P.M. with LPN #801 confirmed and verified she administered Resident #6, two doses of morphine on 10/16/25 and 10/21/25, and did not provide signatures and sign-offs for all administered doses of morphine.

Interview on 10/28/25 at 12:36 P.M. with the ED and DOW confirmed and verified the above findings at the time of the interview.

Review of the undated facility document titled Narcotic Administration Policy revealed the facility had a policy in place to ensure safe, accurate, and accountable administration or narcotic (controlled) medications by maintain strict procedures that included receipt, storage, administration, and documentation of controlled substances to prevent misuse, diversion, and medication errors. Review of the document revealed the facility did not implement the policy in regard to the allegation.

Review of the facility document titled Medication Management Individualized Plan dated 04/01/25, revealed the facility had a policy in place that all medications would be administered as prescribed, monitored to prevent possible complications or adverse reactions, reconciled, and documented. Review of the document revealed the facility did not implement the policy in regard to the allegation.

This violation represents non-compliance investigated under Complaint Number OH00168620.

Based on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure proper medication administration. This affected two residents (#6, #27) of three residents reviewed for medication administration. The facility census was 33. Findings include: Review of the medical record for Resident #6 revealed she was admitted to the facility on 12/29/23 with diagnoses including hypertensive chronic kidney disease, obesity, and major depressive disorder. Review of the current physician orders dated 10/13/25 revealed an order for morphine sulfate oral solution 20 milligrams (mg) to be given 0.25 milliliters (ml) (narcotic pain medication) by mouth every two hours as needed for pain and/or shortness of breath. Review of the progress note dated 10/13/25 at 9:59 A.M. revealed Resident #6 received a new order per hospice for morphine 20 mg per 5 ml to be given 0.25 ml by mouth every two hours as needed for pain and/or shortness of breath. Review of the progress note dated 10/13/25 at 10:13 A.M. revealed Resident #6 received a dose of ordered morphine. Review of the progress note dated 10/14/25 at 7:00 A.M. revealed Resident #6 was given a dose of morphine. Further review of the progress note revealed Resident #6 was given morphine dose on 10/13/25 at 12:00 P.M. and 7:00 P.M. by Certified Medication Technician (CMT) #812. CMT #812 signed off medication administration in narcotic book but was unable to come into the facility to sign-off in point click care (PCC) where her signature was omitted. Review of the current physician orders dated 10/16/25 revealed an order for Resident #6 to be admitted to Amedisys Hospice (AH) with a diagnosis of Parkinson's disease with a prognosis of six months or less if the disease runs its course. Review of the progress note dated 10/16/25 at 10:00 A.M. revealed Resident #6 received ordered dose of morphine. Review of the progress note dated 10/21/25 at 2:00 P.M. revealed Resident #6 received ordered dose of morphine. Review of the progress note dated 10/21/25 at 3:43 P.M. revealed Resident #6 complained of stomach pain to unknown AH staff nurse. AH staff nurse requested Licensed Practical Nurse (LPN) #801 to give Resident #6 dose of morphine. LPN #801 suggested Resident #6 use the restroom and let chili from lunch digest. Resident #6 requested to have dose of morphine. Review of the controlled drug receipt, record, and disposition (CRD) form dated 10/09/25 revealed ineligible date and time for a dose of morphine given to Resident #6. Further review of the CRD form revealed Resident #6's order for morphine was administered on 10/13/25 at 12:00 P.M. and 7:00 P.M., 10/14/25 at 4:00 P.M., 10/16/25 at 10:00 A.M., and 10/21/25 at 2:00 P.M. with no other documented administration times. Review of the CRD form revealed signatures of staff who administrated the dose of morphine. Review of the electronic medication administration record (EMAR) located in PCC for the month of October 2025 revealed Resident #6 received a dose of morphine on 10/13/25 at 10:13 A.M., a dose of morphine on 10/14/25 at 7:00 A.M. and 3:53 P.M., a dose of morphine on 10/16/25 at 10:00 A.M., and a dose of morphine on 10/21/25 at 2:00 P.M. Reconciliation with Resident #6 EMAR located in PCC and the CRD form revealed the following: Resident #6 received a dose of morphine prior to the first date of administering morphine on 10/13/25 which was not documented in the EMAR. Resident #6 received three doses (10:13 A.M., 12:00 P.M., 7:00 P.M.) of morphine on 10/13/25 with two doses (12:00 P.M., 7:00 P.M.) not being documented on the EMAR. Resident #6 received two doses (7:00 A.M., 3:53 P.M.) of morphine on 10/14/25 with one dose (7:00 A.M.) not being documented on the CRD. Resident #6 received two doses (1:00 A.M.,10:00 A.M.) of morphine on 10/16/25 with only one dose (10:00 A.M.) documented on the EMAR and CRD. Resident #6 received two doses (2:00 P.M., 3:43 P.M.) of morphine on 10/21/25 with the dose given at 3:43 P.M. per progress note dated 10/21/25 at 3:43 P.M. was not documented in EMAR or CRD. Interview on 10/28/25 at 8:54 A.M. with LPN #801 during observation of medication administration, revealed all medications were given as ordered and on schedule. LPN #801 revealed all narcotics administered required a signature and sign-off on both the EMAR and CRD. Interview on 10/28/25 at 11:59 A.M. with the Executive Director (ED) and Director of Wellness (DOW) revealed all narcotics administered were to be documented in PCC in the EMAR and CRD. Interview on 10/28/25 at 12:15 P.M. with LPN #801 confirmed and verified she administered Resident #6, two doses of morphine on 10/16/25 and 10/21/25, and did not provide signatures and sign-offs for all administered doses of morphine. Interview on 10/28/25 at 12:36 P.M. with the ED and DOW confirmed and verified the above findings at the time of the interview. 2. Review of the medical record for Resident #27 revealed she was admitted to the facility on 11/01/24 with diagnoses including type 2 diabetes, hypertension, and major depressive disorder. Review of the discontinued physician orders started on 11/01/24 and ended on 11/19/24 revealed an order for Zofran oral tablet 4 mg (medication to treat nausea and vomiting) to be given one tablet by mouth every six hours as needed for nausea and vomiting. Review of the current physician orders and current progress notes for the month of October 2025 revealed no physician's order for Zofran. Interview on 10/28/25 at 8:54 A.M. with LPN #801 during observation of medication administration, revealed all medications were given as ordered and on schedule. LPN #801 revealed all medications administered required a signature and sign-off on EMAR. Interview and observation on 10/28/25 at 12:15 P.M. with LPN #801 revealed two open boxes dated 10/14/25 and 10/16/25 of Zofran 4 mg to be given one tablet by mouth every three hours as needed for Resident #27. LPN #801 revealed Resident #27 was currently receiving Zofran as needed and she was required to alert staff if she required a dose. LPN #801 revealed Resident #27 last dose of Zofran was during morning medication administration on 10/28/25. LPN #801 was unable to produce the written order for Zofran, documentation of doses administered, and stated, It supposed to be in PCC. LPN #801 confirmed and verified the lack of an order for Zofran, documentation, and the current administering of Zofran as needed without an order. Interview on 10/28/25 at 12:45 P.M. with the DOW and Resident #27 revealed Resident #27 had been having symptoms of nausea daily. Resident #27 revealed the only thing that helped her nausea was Mylanta and Zofran. Resident #27 revealed she received at least one dose of Zofran daily, with her last dose being given this morning on 10/28/25 during the morning medication administration. Resident #27 revealed LPN #801 was pretty good at giving daily doses of Zofran as needed. Interview on 10/28/25 at 1:08 P.M. with the ED and DOW confirmed and verified the above findings at the time of the interview. Review of the facility document titled Medication Management Individualized PlanBased on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure proper medication administration. This affected two residents (#6, #27) of three residents reviewed for medication administration. The facility census was 33.

Findings include:

Review of the medical record for Resident #6 revealed she was admitted to the facility on 12/29/23 with diagnoses including hypertensive chronic kidney disease, obesity, and major depressive disorder.

Review of the current physician orders dated 10/13/25 revealed an order for morphine sulfate oral solution 20 milligrams (mg) to be given 0.25 milliliters (ml) (narcotic pain medication) by mouth every two hours as needed for pain and/or shortness of breath.

Review of the progress note dated 10/13/25 at 9:59 A.M. revealed Resident #6 received a new order per hospice for morphine 20 mg per 5 ml to be given 0.25 ml by mouth every two hours as needed for pain and/or shortness of breath.

Review of the progress note dated 10/13/25 at 10:13 A.M. revealed Resident #6 received a dose of ordered morphine.

Review of the progress note dated 10/14/25 at 7:00 A.M. revealed Resident #6 was given a dose of morphine. Further review of the progress note revealed Resident #6 was given morphine dose on 10/13/25 at 12:00 P.M. and 7:00 P.M. by Certified Medication Technician (CMT) #812. CMT #812 signed off medication administration in narcotic book but was unable to come into the facility to sign-off in point click care (PCC) where her signature was omitted.

Review of the current physician orders dated 10/16/25 revealed an order for Resident #6 to be admitted to Amedisys Hospice (AH) with a diagnosis of Parkinson's disease with a prognosis of six months or less if the disease runs its course.

Review of the progress note dated 10/16/25 at 10:00 A.M. revealed Resident #6 received ordered dose of morphine.

Review of the progress note dated 10/21/25 at 2:00 P.M. revealed Resident #6 received ordered dose of morphine.

Review of the progress note dated 10/21/25 at 3:43 P.M. revealed Resident #6 complained of stomach pain to unknown AH staff nurse. AH staff nurse requested Licensed Practical Nurse (LPN) #801 to give Resident #6 dose of morphine. LPN #801 suggested Resident #6 use the restroom and let chili from lunch digest. Resident #6 requested to have dose of morphine.

Review of the controlled drug receipt, record, and disposition (CRD) form dated 10/09/25 revealed ineligible date and time for a dose of morphine given to Resident #6. Further review of the CRD form revealed Resident #6's order for morphine was administered on 10/13/25 at 12:00 P.M. and 7:00 P.M., 10/14/25 at 4:00 P.M., 10/16/25 at 10:00 A.M., and 10/21/25 at 2:00 P.M. with no other documented administration times. Review of the CRD form revealed signatures of staff who administrated the dose of morphine.

Review of the electronic medication administration record (EMAR) located in PCC for the month of October 2025 revealed Resident #6 received a dose of morphine on 10/13/25 at 10:13 A.M., a dose of morphine on 10/14/25 at 7:00 A.M. and 3:53 P.M., a dose of morphine on 10/16/25 at 10:00 A.M., and a dose of morphine on 10/21/25 at 2:00 P.M.

Reconciliation with Resident #6 EMAR located in PCC and the CRD form revealed the following:

Resident #6 received a dose of morphine prior to the first date of administering morphine on 10/13/25 which was not documented in the EMAR.

Resident #6 received three doses (10:13 A.M., 12:00 P.M., 7:00 P.M.) of morphine on 10/13/25 with two doses (12:00 P.M., 7:00 P.M.) not being documented on the EMAR.

Resident #6 received two doses (7:00 A.M., 3:53 P.M.) of morphine on 10/14/25 with one dose (7:00 A.M.) not being documented on the CRD.

Resident #6 received two doses (1:00 A.M.,10:00 A.M.) of morphine on 10/16/25 with only one dose (10:00 A.M.) documented on the EMAR and CRD.

Resident #6 received two doses (2:00 P.M., 3:43 P.M.) of morphine on 10/21/25 with the dose given at 3:43 P.M. per progress note dated 10/21/25 at 3:43 P.M. was not documented in EMAR or CRD.

Interview on 10/28/25 at 8:54 A.M. with LPN #801 during observation of medication administration, revealed all medications were given as ordered and on schedule. LPN #801 revealed all narcotics administered required a signature and sign-off on both the EMAR and CRD.

Interview on 10/28/25 at 11:59 A.M. with the Executive Director (ED) and Director of Wellness (DOW) revealed all narcotics administered were to be documented in PCC in the EMAR and CRD.

Interview on 10/28/25 at 12:15 P.M. with LPN #801 confirmed and verified she administered Resident #6, two doses of morphine on 10/16/25 and 10/21/25, and did not provide signatures and sign-offs for all administered doses of morphine.

Interview on 10/28/25 at 12:36 P.M. with the ED and DOW confirmed and verified the above findings at the time of the interview.

2. Review of the medical record for Resident #27 revealed she was admitted to the facility on 11/01/24 with diagnoses including type 2 diabetes, hypertension, and major depressive disorder.

Review of the discontinued physician orders started on 11/01/24 and ended on 11/19/24 revealed an order for Zofran oral tablet 4 mg (medication to treat nausea and vomiting) to be given one tablet by mouth every six hours as needed for nausea and vomiting.

Review of the current physician orders and current progress notes for the month of October 2025 revealed no physician's order for Zofran.

Interview on 10/28/25 at 8:54 A.M. with LPN #801 during observation of medication administration, revealed all medications were given as ordered and on schedule. LPN #801 revealed all medications administered required a signature and sign-off on EMAR.

Interview and observation on 10/28/25 at 12:15 P.M. with LPN #801 revealed two open boxes dated 10/14/25 and 10/16/25 of Zofran 4 mg to be given one tablet by mouth every three hours as needed for Resident #27. LPN #801 revealed Resident #27 was currently receiving Zofran as needed and she was required to alert staff if she required a dose. LPN #801 revealed Resident #27 last dose of Zofran was during morning medication administration on 10/28/25. LPN #801 was unable to produce the written order for Zofran, documentation of doses administered, and stated, It supposed to be in PCC. LPN #801 confirmed and verified the lack of an order for Zofran, documentation, and the current administering of Zofran as needed without an order.

Interview on 10/28/25 at 12:45 P.M. with the DOW and Resident #27 revealed Resident #27 had been having symptoms of nausea daily. Resident #27 revealed the only thing that helped her nausea was Mylanta and Zofran. Resident #27 revealed she received at least one dose of Zofran daily, with her last dose being given this morning on 10/28/25 during the morning medication administration. Resident #27 revealed LPN #801 was pretty good at giving daily doses of Zofran as needed.

Interview on 10/28/25 at 1:08 P.M. with the ED and DOW confirmed and verified the above findings at the time of the interview.

Review of the facility document titled Medication Management Individualized Plan

Based on resident interviews, staff interviews, and record review, the facility failed to ensure meals were delivered in a timely manner in accordance with the posted mealtimes. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Findings include:

Interviews on 10/15/25 from 9:00 A.M. through 1:00 P.M. with Residents #2, #7, #13, and #22 revealed that meals are late frequently. Resident #7, who is Resident Council President, stated that meals being late had been brought up in resident council meetings and it had not been fixed yet. Resident #7 stated that on 10/11/25, there was no dinner until 7:00 P.M. when the Executive Director (ED) bought pizza for all the residents.

Interview on 10/16/25 from 7:00 A.M. through 11:30 A.M. with Resident Care Assistant (RCA) #205, RCA #208, and Licensed Practical Nurse (LPN) #206 revealed that meals are late, especially on the weekends.

Interview on 10/16/25 at 8:12 A.M. with Morning Dietary Aide (DA) #207 revealed meals are sometimes late. DA #207 stated that when she is working, meals are usually late due to the shift before her shift. She stated that she would come to work, and the pantry would be a mess, and she cannot serve food in a dirty pantry. She stated that she would have to take the dishes to the main kitchen and wash them before she would serve breakfast.

Interview on 10/16/25 at 9:15 A.M. with Activity Assistant (AA) #209 revealed that she started in Activities about a month ago. AA #209 stated she held one resident council meeting and the residents stated that the meals were late and that is why she started soup of the day.

Interview on 10/16/25 at 10:08 A.M. with the ED revealed that on Saturday 10/11/25 she received a call that the cook left, no one from dietary came to serve the assisted living residents, and the food was burnt because dietary left the food in the oven. The ED stated that she wanted to feed the residents, so she ordered pizza for them.

Telephone interview on 10/16/25 at 10:26 A.M. with Dietary Manager (DM) #211 revealed that meals were late because there were new cooks, and they did not realize that they must cook for assisted living as well as the skilled nursing facility. DM #211 stated that there had also been dietary staff call offs and she cannot be in the facility every day.

Review of the Resident Council minutes for August 2025 revealed that residents had a concern about meals being late. Review of the Resident Council minutes for September 2025 revealed that there were no new dietary concerns and made no mention of the mealtimes being corrected.

This violation represents non-compliance investigated under Complaint Number OH00168351.

Based on observation, staff interview, review of dish machine logs, and policy review, the facility failed to ensure food was stored and prepared in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all 35 residents. The facility census was 35. Findings include: Observation on 10/15/25 from 9:12 A.M. through 9:38 A.M. in the kitchen that prepares meals and cleans dishes is in the skilled nursing facility (SNF) with Cook #200 revealed that the dish machine was not registering the sanitation concentration of the low temp dish machine. Cook #200 ran five dish racks through the machine and tested it each time. The test strip did not measure any parts per million (ppm) for the sanitizer. Cook #200 did not know why the sanitizer was not registered. Observation of the grate on the floor near the dish machine revealed that there was dried food residue in it, the wall had food splatter on it and the tile on the bottom was broken and cove molding was bent. Observation in the cooking area revealed that the cover located at the bottom of the convection oven to protect the heating element was off and it was against the wall. The cover was dirty. Cook #200 stated that maintenance fixed the oven but did not put the cover back on. Interview on 10/15/25 at 10:23 A.M. with Administrator #201 brought the policies for kitchen sanitation and the low temp dish machine instructions and stated that there was a kink in the sanitation line and that is why it wasn't registering. She stated that it is now working, and the chemical company was called. Observation and interview on 10/15/25 at 2:09 P.M. with Regional Director of Operations (RDO) #204 revealed that dishes from breakfast were not washed yet but the low temperature dish machine was registering 50 ppm of the sanitizer concentration. Review of the undated policy titled, Dish Machine Temperature/Sanitizer RecordBased on observation, staff interview, review of dish machine logs, and policy review, the facility failed to ensure food was stored and prepared in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all 35 residents. The facility census was 35.

Findings include:

Observation on 10/15/25 from 9:12 A.M. through 9:38 A.M. in the kitchen that prepares meals and cleans dishes is in the skilled nursing facility (SNF) with Cook #200 revealed that the dish machine was not registering the sanitation concentration of the low temp dish machine. Cook #200 ran five dish racks through the machine and tested it each time. The test strip did not measure any parts per million (ppm) for the sanitizer. Cook #200 did not know why the sanitizer was not registered. Observation of the grate on the floor near the dish machine revealed that there was dried food residue in it, the wall had food splatter on it and the tile on the bottom was broken and cove molding was bent. Observation in the cooking area revealed that the cover located at the bottom of the convection oven to protect the heating element was off and it was against the wall. The cover was dirty. Cook #200 stated that maintenance fixed the oven but did not put the cover back on.

Interview on 10/15/25 at 10:23 A.M. with Administrator #201 brought the policies for kitchen sanitation and the low temp dish machine instructions and stated that there was a kink in the sanitation line and that is why it wasn't registering. She stated that it is now working, and the chemical company was called.

Observation and interview on 10/15/25 at 2:09 P.M. with Regional Director of Operations (RDO) #204 revealed that dishes from breakfast were not washed yet but the low temperature dish machine was registering 50 ppm of the sanitizer concentration.

Review of the undated policy titled, Dish Machine Temperature/Sanitizer Record

Based on record review and interview, the facility failed to ensure fire drills were conducted once a shift each quarter. This had the potential to affect all 35 residents currently residing in the facility. The facility census was 35.

Findings include:

Review of fire documentation for the previous twelve months, from September 2024 through September 2025, revealed fire drills had not been conducted once per quarter per shift. There was no evidence of fire drills conducted for the months of October 2024, November 2024, and December 2024.

Interview on 10/15/25 at 2:28 P.M. with Regional Director of Clinical (RDC) #202 verified that there were no other fire drills.

Based on record review and interview, the facility failed to ensure residents were evacuated during fire drills. This had the potential to affect all 35 residents currently residing in the facility. The facility census was 35.

Findings include:

Review of fire documentation for the previous twelve months, from September 2024 through September 2025, revealed there was no evidence that residents were evacuated during fire drills that were conducted and there was no evidence of fire drills conducted for the months of October 2024, November 2024, and December 2024.

Interview on 10/15/25 at 2:28 P.M. with Regional Director of Clinical (RDC) #202 verified that there was no evidence that residents were evacuated during fire drills and there was no other fire drills documented.

Based on review of the State Agency's Certification and Licensure System, observation, and staff interview, the facility failed to maintain an updated survey results book as required. This had the potential to affect all 35 residents in the facility. The facility census was 35.

Findings include:

Observation on 10/15/25 at 11:55 A.M. with Recptionist #212 revealed that the survey results were not available to residents without asking for them. In the glass cabinet in the lobby there was a sign that stated survey results and an arrow pointing down to a state form that stated the facility was in compliance on 01/19/20.

Review of the State Agency's Certification and Licensure System revealed the State Agency completed a complaint survey on 06/27/25 that resulted in two violations and the last recertification survey was completed on 09/10/24 that resulted in two violations.

Interview on 10/15/25 at 12:07 P.M. with Regional Director of Clinical (RDC) #202 revealed that she found the survey results in the Executive Director's office.

Based on review of facility Heating, Ventilation, and Air Conditioning (HVAC) inspection documentation, observations, interviews, and review of facility policy, the facility failed to ensure the central heating system was inspected every two years. This had the potential to affect all residents in the facility. The census was 32.

Findings Include:

Review of the facility documentation revealed there was no documented evidence of any HVAC inspections from the last two years.

Interview on 06/25/25 at 3:00 P.M. with the Executive Director (ED) revealed the air conditioning system had been malfunctioning on and off for a while, but new management was in the process of taking care of it.

Interview on 06/25/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #814 revealed the air conditioning had not been working since the prior summer (2024). LPN #814 revealed there were concerns with the hot temperatures amongst staff regarding some of the residents who walked through the halls and sat in the common areas. LPN #814 revealed there were currently four residents (#3, #7, #33, #34) residing on the third floor, but all residents were free to move about the facility freely. LPN #814 was observed with sweat dripping down the side of her face.

Interview on 06/25/25 at 3:25 P.M. with Certified Nurse Assistant (CNA) #802 revealed the facility was always hot on the second and third floors. CNA #802 revealed the air conditioning had been out of working order for at least two months.

Interview on 06/25/25 at 3:50 P.M. with the Maintenance Director (MD) #820 revealed the air conditioning system had been out of order since the previous year. MD #820 revealed last year, under previous management, the facility utilized portable standing air conditioning units. However, at this time, he had no knowledge of repairs through HVAC and was unaware of any work orders in place with invoices and/or receipts.

Interview on 06/27/25 at 9:40 A.M. with Family Member #830 revealed the air conditioning had not been working for over a year, he stated the residents on the second and third floor could not come out of their rooms to socialize because it was too hot.

Interview on 06/27/25 at 10:15 A.M. with Resident #10 revealed the heat was a problem. She stated it was a problem last year and now again this year.

Observations of air temperatures on 06/27/25 at 11:00 A.M. revealed MD #820 checked the air temperature on the second and third floor using the facility thermometer. The second floor was reading 81.2 to 82.4 degrees Fahrenheit, and the third floor was reading 86.1 to 87.4 degrees Fahrenheit.

Interview on 06/27/25 at 4:30 P.M. with the ED confirmed there was no evidence of a comprehensive HVAC inspection in the last two years.

Review of the facility document titled Heat and Humidity revised 04/01/25 revealed the facility had a policy in place to ensure precautionary and preventative measures for residents during the hot and humid summer months.

This violation represents non-compliance investigated under Complaint Number OH00166968.

Based on observation, staff interviews, family interview, resident interview, review of facility Heating, Ventilation, and Air Conditioning (HVAC) inspections, and facility policy review, the facility failed to maintain comfortable temperatures on the second and third floor. This affected 17 residents (#2, #5, #6, #8, #10, #16, #17, #18, #19, #20, #22, #24, #25, #27, #29, #31, #32) who reside on the second floor and four residents (#3, #7, #33, #34) who reside on the third floor. The facility census was 32.

Findings include:

Tour of the facility on 06/25/25 at 3:00 P.M. with the Executive Director (ED) revealed the third-floor common area was uncomfortable, hot, humid and muggy. There were multiple chairs lined up for leisurely lounging by residents and/or visitors. The thermostat located on the wall in the third-floor common area was inoperable and lacked display of the room temperature. The ED produced and utilized a digital hand thermometer to check the room temperature in the common area. The temperature read as 90.6 degrees Fahrenheit. Entry into the trird floor nursing station with the medication storage room attached revealed no thermostat. The nursing station and medication storage room was hot, humid and muggy. There were three medication carts located in the medication storage room. The temperature of the nursing station and medication storage room had a return reading of 94 degrees Fahrenheit, utilizing the digital hand thermometer. Observation of the second-floor common area revealed multiple chairs designated for leisurely lounging for residents and/or visitors. The common area was hot and uncomfortable. The thermostat on the wall located in the common area was in working condition and had a return reading of 80 degrees Fahrenheit.

Interview on 06/25/25 at 3:00 P.M. with the ED revealed all resident rooms were self-regulated. The ED revealed each room was equipped with their own heating and cooling units and individually controlled. The ED revealed the third-floor common area air conditioning system was out. The ED revealed the common areas were to be utilized by residents and/or their visitors. The ED revealed residents were currently not congregating in the second and third floor common areas due to the air conditioning system not in working order. The ED also revealed a Heating, Ventilation, and Air Conditioning (HVAC) company were contacted and due to service the air conditioning system in the facility the following week. The ED revealed the air conditioning system had been malfunctioning on and off for a while, but new management was in the process of taking care of it.

Interview on 06/25/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #814 revealed the air conditioning had not been working since the prior summer (2024). LPN #814 revealed there were concerns with the hot temperatures amongst staff regarding some of the residents who walked through the halls and sat in the common areas. LPN #814 revealed there were currently four residents (#3, #7, #33, #34) residing on the third floor, but all residents were free to move about the facility freely. LPN #814 was observed with sweat dripping down the side of her face.

Interview on 06/25/25 at 3:25 P.M. with Certified Nurse Assistant (CNA) #802 revealed the facility was always hot on the second and third floors. CNA #802 revealed the air conditioning had been out of working order for at least two months.

Interview on 06/25/25 at 3:50 P.M. with the Maintenance Director (MD) #820 revealed the air conditioning system had been out of order since the previous year. MD #820 revealed last year, under previous management, the facility utilized portable standing air conditioning units. However, at this time, he had no knowledge of repairs through HVAC and was unaware of any work orders in place with invoices and/or receipts.

Review of the facility document titled NAS Contractors dated 06/25/25 revealed an invoice for labor regarding the inspection of three HVAC units totaling $360.00 with the current balance still owed. The document had no additional information pertaining to the installation and/or the systems repaired during the service. There was no documented evidence of any other HVAC inspections from the last two years.

Interview on 06/27/25 at 9:40 A.M. with Family Member #830 revealed the air conditioning had not been working for over a year, he stated the residents on the second and third floor could not come out of their rooms to socialize because it was too hot.

Interview on 06/27/25 at 10:15 A.M. with Resident #10 revealed the heat was a problem. She stated it was a problem last year and now again this year. She stated last year they had units in the hallways, but they did not this year. She stated it was so hot, you could not go out of your room to visit with anyone in the hall. She stated she was able to adjust the air in her room and her room was cool and comfortable.

Observations of air temperatures on 06/27/25 at 11:00 A.M. revealed MD #820 checked the air temperature on the second and third floor using the facility thermometer. The second floor was reading 81.2 to 82.4 degrees Fahrenheit, and the third floor was reading 86.1 to 87.4 degrees Fahrenheit.

Interview on 06/27/25 at 4:30 P.M. with ED revealed there was no evidence of a comprehensive HVAC inspection in the last two years and the HVAC inspection document from NAS Contractors dated 06/25/25 was to determine what needed to be fixed.

Review of the facility document titled Heat and Humidity revised 04/01/25 revealed the facility had a policy in place to ensure precautionary and preventative measures for residents during the hot and humid summer months.

This violation represents non-compliance investigated under Complaint Number OH00166968.

Based on record review and interview, the facility failed to ensure fire drills were conducted once a shift each quarter. This had the potential to affect all 30 residents currently residing in the facility.

Findings include:

Review of the past 12 months of fire drills from August 2023 through August 2024 revealed fire drills had not been conducted once per quarter per shift. The dates were not readable and the times were also conflicting from what was documented.

Interview with Maintenance Director (MD) #100 on 09/10/24 at 3:00 P.M. revealed fire drills were managed by maintenance and he was unable to confirm the actual dates and times for the drills that were supplied during the survey visit. MD #100 was unable to provide confirmation receipts from the alarm company to distinguish dates and times.

Interview with Executive Director on 09/10/24 at 3:30 P.M. confirmed the fire drills were not completed as required and he would work with his maintenance staff.

Based on observation, interview, and record review the facility failed to ensure Resident #30 smoked only in designated smoking areas. This affected one resident (#30) of five residents reviewed for physical environment and potentially affected all 30 residents living in the facility.

Findings include:

Record review for Resident #30 revealed an admission date of 03/09/23. Diagnoses included essential hypertension and chronic obstructive pulmonary disease.

Review of the Health Service Evaluation assessment dated 11/26/23 revealed Resident #30 had normal cognition, had occasional disruptive verbal behaviors that were aggressive or socially inappropriate but was easily redirectable, ambulated independently but required cueing with or without assistive devices and planned to utilize flame lit or vaporized tobacco while in the community.

Review of the Smoking Assessment dated 11/26/23 revealed Resident #30 liked to smoke a flame lit cigarette in the morning and afternoon and was safe to smoke without limitations. Resident #30 was supplied with the community smoking rules.

Observation was conducted on 09/10/24 at 8:23 A.M. and revealed Resident #30's room to be filled with clouds of smoke and a smell of cigarette smoke filled the entire room. Three packs of cigarettes and one lighter were observed on her end table in the living room.

Interview with LPN #104 on 09/10/24 at 8:27 A.M. verified Resident #30 smoked in her room, and the Executive Director was aware of her smoking.

Interview with the Executive Director (ED) on 09/10/24 at 11:30 A.M. revealed the ED knew of resident #30 smoking in her room and feels bad to have to issue a 30 day notice however acknowledged that it had been going on since he's been here and he started in March 2024.

Interview with Maintenance Director #100 at 3:00 P.M. revealed he was aware of Resident #30 smoking in her room and notified the former Executive Director.

This violation represents non-compliance investigated under Complaint Number OH00157143

Based on record review and interview, the facility failed to ensure annual health assessments were completed. This affected one resident (#20) of three residents (#11, #20 and #22) reviewed who had been in the facility over 12 months. The facility census was 28.

Findings include:

Review of the medical record for Resident #20 revealed an admission date of 05/24/18. Diagnoses included but were not limited to diabetes mellitus and osteoarthritis. Further review revealed the health assessment that was dated 10/26/23 was not completed.

Interview on 04/15/24 at 9:41 A.M. with the Executive Director verified that an annual health assessment was not completed.

Review of the facility's undated policy Assessments and Documentation revealed that each resident's health was required to be assessed at least annually unless medically indicated sooner.

Based on resident council minutes, the facility concern log with resolutions, and interviews, the facility failed to timely address resident concerns. This affected Residents #4, #6, #11, #17, #22, #24, and #26 and had the potential to affect all 28 residents that resided in the facility.

Findings include:

Review of Resident Council Minutes from January 2024 through March 2024 revealed that concerns were brought up that food alternatives were not offered at mealtimes. There were no resolutions attached to the resident council meetings minutes.

Review of Concern forms dated 04/08/24 and 04/09/24 revealed concerns that food alternatives were not offered at meals over the weekend. Resolution was to discipline the employee.

Interview on 04/11/24 at 3:40 P.M. with Resident Council President, Resident #26, revealed that she invited Dietary Manager (DM) #203 to the resident council meeting in March to discuss food issues. DM #203 went over the process for ordering alternatives, but the process was not followed consistently. A resident was required to go to the receptionist the day before the meal was served and place the order with the receptionist. Resident #26 was told that she could not order the alternatives that were on the printed weekly menus because they were not available.

Interviews on 04/11/24 and 04/15/24 from 6:55 A.M. through 5:30 P.M. with Residents #4, #6, #11, #17, #22, #24, and #26 revealed that their concerns were not being addressed with regards to the food, especially regarding ordering an alternative during meals.

Interviews on 04/11/14 and 04/15/24 from 6:55 A.M. through 5:30 P.M. with Resident Care Assistant (RCA) #201, Licensed Practical Nurse (LPN) #204, RCA 206, and RCA 207 revealed that the residents brought up concerns about the food when it came to alternatives not being offered.

Interview on 04/11/24 at 4:00 P.M. with Executive Director (ED) #209 revealed that he could not find any written resolutions to the concerns that were brought up in resident council or regarding the concerns forms dated 04/08/24 and 04/09/24.

This violation represents non-compliance investigated under Complaint Number OH00151644.

Based on staff and resident interview and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure the privacy of all residents while obtaining laboratory specimens. This had the potential to affect all residents. Facility census was 28.

Findings include:

Interview on 04/11/24 at 2:40 P.M. with Resident #11 revealed that she was asked to be tested for Covid while in the dining room and she refused. She stated that the nurse took her out of the dining room and tested her in the hallway.

Interview on 04/15/24 at 9:10 A.M. with Licensed Practical Nurse (LPN) #204 revealed she did complete Covid testing in the dining room when there was an outbreak because it was hard to get the residents. LPN #204 stated that only Resident #11 requested that testing be done outside of the dining room, and she honored Resident #11's request.

Review of CDC Instructions for collecting an Nasopharyngeal (NP) specimen performed by a trained healthcare provider updated 07/15/22 revealed the following.

Tilt patient ' s head back 70 degrees.

Gently and slowly insert a minitip swab with a flexible shaft (wire or plastic) through the nostril parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient, indicating contact with the nasopharynx.

Gently rub and roll the swab.

Leave swab in place for several seconds to absorb secretions.

Slowly remove swab while rotating it. Specimens can be collected from both sides using the same swab, but it is not necessary to collect specimens from both sides if the minitip is saturated with fluid from the first collection.

If a deviated septum or blockage create difficulty in obtaining the specimen from one nostril, use the same swab to obtain the specimen from the other nostril.

Place swab, tip first, into the transport tube provided.

This violation represents non-compliance investigated under Complaint Number OH00151644.