Bloom at Rocky River

Based on interviews, record review and facility policy review, the facility failed to provide a qualified night shift caregiver on 06/28/25 for care delivery. This affected all residents residing in the facility. The facility census was 32.

Findings include:

Review of the staffing schedules from June 2025 to August 2025 revealed on 06/28/25, there were no licensed nurses or caregivers assigned to the facility for night shift.

Review of the time clock punch report dated 06/28/25 revealed there were no trained caregivers or licensed nurses working in the facility for the night shift, which was from 7:00 P.M. to 7:00 A.M.

Interview on 09/09/25 at 8:11 A.M. the Health and Wellness Director (HWD) confirmed the facility did not have a trained caregiver or licensed nurse working in the facility for the night shift on 06/28/25. HWD further confirmed the resident care needs on night shift included incontinence care, resident transfers, and first aid/cardiopulmonary resuscitation (CPR) in the event of an emergency.

Interview on 09/09/25 at 10:40 A.M. with the Divisional Director of Health and Wellness (DDHW) #70 revealed the facility had prior staffing challenges, turnover, and the need to temporarily use agency caregivers. In the evening on 06/28/25, DDHW #70 received a telephone call from the Executive Director (ED) who reported there being only one caregiver scheduled for the night shift on that night, so ED planned to stay in the facility during the night shift. However, the ED did not further communicate to DDHW #70 when the scheduled caregiver cancelled working. In addition, former Health and Wellness Director (HWD) #58 resigned on 06/28/25 at 6:21 P.M. without notice via a text message to DDHW #70.

Record review and interview on 09/09/25 at approximately 2:00 P.M. with the Divisional Director of Operations (DDO) #72 of ED's personnel file confirmed there was no evidence the ED had training on care delivery or first aid/CPR training.

Review of a document titled, Offer Letter signed on 02/12/25 by the ED, revealed an employment date of 03/24/25 and job requirement to obtain first aid/CPR training within 30 days of hire.

Review of a document titled, User Learning effective 09/09/25 which contained a list of training completed by the ED confirmed no training or competency to provide resident care or first aid/CPR.

Review of the ED's resume, undated, from the personnel file revealed no training on first aid/CPR, resident care or previous licensure or education for nursing.

Review of the ED's job description, undated, indicated first aid/CPR training was a requirement for the ED position.

Interview on 09/09/25 at 3:10 P.M. with ED verified being the only staff member present to provide resident care for night shift on 06/28/25 despite having no training in care delivery or first aid/CPR. ED stated although bonuses were offered to caregivers at the time to work on that shift, all refused. ED revealed being currently on medical leave as a result from providing care to residents during the night shift on 06/28/25. ED indicated once being licensed as a licensed practical nurse (LPN) until 2005 when it was inactivated and has been since then.

Review of the facility policy, Certification and Licensure

Based on interview, record review, and facility policy review, the facility failed to administer medications as ordered and as scheduled timely. This affected four residents (#4, #26, #28 and #32) out of four residents reviewed for medication administration. The facility census was 32.

Findings include:

1. Review of the medical record for Resident #4 revealed an admission date of 08/01/21 with diagnoses including central nervous system degenerative disease, depression, gastroesophageal reflux disease (GERD), and hyperlipidemia.

Review of the medication administration detail report (MADR) from June 2025 to July 2025 revealed on 06/28/25 and 07/05/25, Resident #4 was administered the ordered medications acetaminophen (for pain), cimetidine (for GERD), divalproex (an anticonvulsant), docusate sodium (for constipation), melatonin (a sleep aid), nystatin powder (an antifungal), pregabalin (for nerve pain), tamsulosin (for enlarged prostate), and trazodone (an antidepressant) at 6:01 P.M. which was earlier than the scheduled time of 8:00 P.M. On 07/27/25, the same medications were administered at 5:52 P.M., which was earlier than the scheduled time of 8:00 P.M.

2. Review of the medical record for Resident #26 revealed an admission date of 08/01/21 with diagnoses of dementia and depression.

Review of Resident #26's Medication Administration Records (MAR) for July 2025 and August 2025 revealed on 07/20/25 and 07/25/25 between 5:00 P.M. and 6:00 P.M., the ordered medication donepezil (for dementia) was not administered. On 08/25/25, diclofenac topical gel (for pain) was not applied as ordered between 6:00 P.M. and 8:00 P.M., and hydrocortisone cream (for inflammation) was not applied as ordered at 8:00 P.M.

Review of the MADR for June 2025 revealed on 06/28/25, Resident #26 was administered the medications ammonium lactate (for itching), donepezil and nystatin powder at 3:26 P.M. which was earlier than the ordered time of 5:00 P.M.

3. Review of the medical record for Resident #28 revealed an admission date of 05/09/22 with diagnoses including Alzheimer's dementia, hyperthyroidism, chronic obstructive pulmonary disease (COPD), and chronic bronchitis.

Review of Resident #28's MAR for July 2025 and August 2025 revealed on 07/19/25 at 8:00 A.M., the ordered medication buspirone (antianxiety) was not administered. On 07/25/25 between 5:00 P.M. to 6:00 P.M., dorzolamide eye drops (for eye pressure) were not administered. On 07/26/25 and 08/27/25 between 8:00 A.M. and 10:00 A.M. and on 08/27/25 between 8:00 P.M. and 10:00 P.M., lorazepam (for anxiety) was not administered. On 08/06/25, ipratropium/albuterol aerosol solution was not administered via nebulizer from 8:00 P.M. to 10:00 P.M.

Review of the MADR from June 2025 to July 2025 revealed on 06/28/25, Resident #28 was administered the medication divalproex at 6:05 P.M. which was earlier than the ordered time of 8:00 P.M. On 07/05/25, divalproex was administered at 5:24 P.M. which was earlier than the ordered time of 8:00 P.M. On 07/27/25, the medications divalproex and lorazepam were administered at 5:21 P.M. which was earlier than the ordered time of 8:00 P.M. On 07/31/25, the medications divalproex, doxycycline (antibiotic) and lorazepam were administered at 6:23 P.M. which was earlier than the ordered time of 8:00 P.M.

4. Review of the medical record for Resident #32 revealed an admission date of 07/17/23 with diagnoses including dementia, depression, glaucoma, and hyperlipidemia.

Review of Resident #32's MAR for July 2025 and August 2025 revealed on 07/16/25 and 08/06/25 at 8:00 P.M., risperidone (an antipsychotic) was not administered as ordered. On 07/25/25 and 08/26/25, dorzolamide timolol eye drops (for eye pressure) were not administered between 4:00 P.M. to 6:00 P.M.

Review of the MADR from June 2025 to July 2025 revealed on 06/28/25, Resident #32 was administered the medication risperidone at 5:58 P.M. which was earlier than the ordered time of 8:00 P.M. On 07/05/24 and 07/27/25, risperidone was administered at 5:14 P.M., which was earlier than the ordered time of 8:00 P.M. On 07/31/25, risperidone was administered at 6:12 P.M. which was earlier than the ordered time of 8:00 P.M.

Review of the facility payroll punch reports revealed on 06/28/25, 07/05/25, 07/27/25 and 07/31/25, there were no certified or licensed staff scheduled for medication administration from 7:00 P.M. until 7:30 A.M.

Interview on 09/10/25 at 11:00 A.M. with the Health and Wellness Director (HWD) verified the above findings.

Further interview on 09/10/25 at 1:50 P.M. with HWD confirmed the scheduled medication administration times were prescribed by the physician and documented as such in the MAR.

Review of facility policy, Medication Administration

Based on interview, record review, and facility policy review, the facility failed to report a fall, implement immediate fall interventions, conduct thorough fall investigations, and maintain an incident log separate from the resident medical records. This affected three residents (#26, #28 and #32) of three residents reviewed for falls and had the potential to affect all 32 residents residing in the facility.

Findings include:

1. Review of the medical record for Resident #26 revealed an admission date of 08/01/21 with diagnoses of dementia and depression.

Review of the nursing notes from June 2025 to July 2025 revealed Resident #26 fell on 06/18/25, twice on 07/10/25, and on 07/31/25.

Resident #26's medical record contained no post fall evaluations for the falls which occurred on 06/18/25, 07/10/25 and 07/31/25.

Interview on 09/09/25 at 2:55 P.M. with the Health and Wellness Director (HWD) confirmed there were no post fall evaluations completed for Resident #26's falls which occurred on 06/18/25, 07/10/25 and 07/31/25.

2. Review of the medical record for Resident #28 revealed an admission date of 05/09/22 with diagnoses of Alzheimer's dementia, hyperthyroidism, chronic obstructive pulmonary disease and chronic bronchitis.

Review of the nursing notes from May 2025 to July 2025 revealed Resident #28 fell on 05/09/25 and 07/28/25.

Review of a nursing note dated 07/28/25 at 4:22 P.M. by Licensed Practical Nurse (LPN) #34 revealed the nurse was informed around 4:00 P.M. of Resident #28's unwitnessed fall which reportedly occurred earlier in the day sometime between 6:00 A.M. and 6:30 A.M. and the nurse was not on duty at the time of the incident. After assessing Resident #28, there was complaint of right knee pain without visible swelling or bruising. The physician was notified, and a stat (urgent) x-ray was ordered.

Review of the x-ray report dated 07/28/25 revealed Resident #28 had no acute fractures of the of the right tibia/fibula, ankle, or knee.

Review of the staff punch reports for 07/27/25 revealed there were two Caregivers (CG) #19 and #33 working on the night shift.

Interview on 09/08/25 at 2:45 P.M. with LPN #34 verified there was no nurse present at the time of arrival to work on 07/28/25 at 7:00 A.M., only two CG #19 and #33 who had worked the previous night shift. The caregivers did not report any falls. It was the Executive Director (ED) who approached her around 4:00 P.M. on that day and notified the nurse of Resident #28's fall.

Interview on 09/09/25 at 8:11 A.M. with the HWD revealed a belief the ED had spoken with CG #19 and #33 about timely reporting of falls.

Review of the personnel files for CG #19 and #33 revealed no evidence of disciplinary action or education regarding the failure to report Resident #28's fall.

Interview on 09/09/25 at 2:50 P.M. with Resident #28's son revealed the son wrote a letter to the ED regarding concerns about the lack of reporting Resident #28's fall.

Interview on 09/09/25 at 2:55 P.M. with HWD verified there were no post fall evaluations or investigations completed for Resident #28's falls on 05/09/25 and 07/28/25, and confirmed Resident #28's fall on 07/28/25 was not communicated.

Interview on 09/09/25 at 3:10 P.M. with the ED verified becoming aware of the fall when Resident #28's son had inquired about it later in the day on 07/28/25 and was unable to recall speaking to LPN #34 about the fall.

Interview on 09/10/25 at 9:15 A.M. with the HWD verified the facility had no incident log which was separate from resident medical records.

Interview on 09/11/25 at 1:40 P.M. with the HWD confirmed there was no documentation regarding fall education or disciplinary action in the personnel files for CG #33 and CG #19.

3. Review of the medical record for Resident #32 revealed an admission date of 07/17/23 with diagnoses of dementia, depression, glaucoma, and hyperlipidemia.

Review of the nursing notes from May 2025 to August 2025 revealed Resident #32 fell on 05/07/25, 05/26/25, 06/05/25, 06/09/25, 06/18/25, 06/22/25 and 08/26/25.

Review of the post fall evaluation dated 06/05/25 revealed it was for a fall which occurred on 05/07/25. There were no post fall evaluations completed for the falls on 05/26/25, 06/05/25, 06/09/25, 06/18/25, 06/22/25 and 08/26/25.

Interview on 09/09/25 at 2:55 P.M. with the HWD confirmed there were no post fall evaluations completed for Resident #32's falls on 05/26/25, 06/05/25, 06/09/25, 06/18/25, 06/22/25 and 08/26/25, and the fall evaluation for Resident #32's fall on 05/07/25 was not completed until 06/05/25.

Review of the facility policy, Fall Policy

Based on record review, review of staff schedules and interviews the facility failed to ensure staff were monitoring and providing care to all residents as required. This affected one (Resident #27) of eight residents reviewed for staffing. This had the potential to affect 19 residents (#12, #13 #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) residing on the third floor of the facility. The facility census was 39.

Findings include:

Review of the medical record for Resident #27 revealed an admission date of 04/30/23. Diagnoses included but were not limited to adjustment disorder and insomnia.

Review of the 09/04/24 annual assessment revealed Resident #27 had a severe cognitive impairment. Resident #27 was noted to require maximum assistance of two for all activities of daily living.

Review of Resident #27's service plan which was last reviewed on 09/30/24 revealed she required full assistance from two staff for toileting, ambulation, had severe memory impairment and was a high fall risk with poor safety awareness who required safety checks four times per eight-hour shift.

Review of nursing progress note dated 03/07/25 timed at 1:47 P.M. written by Director of Nursing (DON) #201 stated she received a call from Executive Director (ED) #200 informing her that Resident #27's family observed her on video lying on the floor next to her bed for an ample amount of time. Upon arrival, DON #201 assessed Resident #27 and noted soreness/sensitivity to her leg. A red abrasion/bruise was noted to the resident's right outer knee, left inner knee, and right hip. Per family request, Resident #27 was to rest in bed for a few hours until lunch time.

No additional progress notes related to the fall were found.

Review of the post fall evaluation dated 03/12/25 for Resident #27 revealed the fall occurred on the morning of 03/07/25. The fall was an unwitnessed fall in Resident #27's room near the bed. Resident #27 stated she was sitting on the side of her bed with her legs hanging off and slid out of bed. Resident #27 was noted to be incontinent and have on regular socks. Resident #27 was noted to have signs of bruising and was able to move all extremities.

Interview on 03/12/25 at 9:21 A.M. with DON #201 revealed she was notified by ED #200 shortly before 6:00 A.M. on 3/07/25 that Resident #27's daughter saw on the room video camera that Resident #27 was on the floor next to her bed. DON #201 stated she quickly went to the facility to assess Resident #27 and found an abrasion with some bruising. Family declined to have Resident #27 sent out for evaluation. Upon talking with staff, DON #201 became aware that a nighttime agency caregiver did not report for her night shift and had not notified anyone. DON #201 stated she was also told by Agency Caregiver #110 that she thought she only had the residents for the second floor and had not checked on the residents from the 3rd floor during her shift starting on 03/06/25 at 11:00 P.M. until Resident #27's daughter requested help shortly after 6:00 A.M. on 03/07/25.

Interview on 03/12/25 at 10:36 A.M. with DON #201 confirmed that the fall assessment was started on 03/07/25 but not completed for Resident #27 until 03/12/25 after the surveyor had requested records related to Resident #27's fall.

Interview on 03/12/25 at 10:49 A.M. with ED #200 revealed Resident #27's daughter called her on the morning of 03/06/24 shortly before 6:00 A.M. stating she had been unable to reach any staff at the facility and needed help to get her mother off the floor since no one had checked on her. ED #200 stated when DON #201 arrived at the facility, DON #201 became aware that the agency caregiver did not report for her shift and had only monitored residents on the second floor and not residents on the third floor for the entire shift. ED #200 stated she was not notified that a caregiver did not show for their shift until the DON told her on 03/07/25. The other facility caregiver working the night of 3/06/25 was also found to have left her shift early around 6:00 A.M. without prior authorization and was terminated following the incident. ED #200 confirmed care was not provided during the night shift on 03/06/25 for any of the residents on the third floor.

Phone interview on 03/12/25 at 1:45 P.M. with Resident #27's daughter revealed shortly before 6:00 A.M. on 03/07/25 she observed on Resident #27's room camera that Resident #27 was on the floor next to her bed. Resident #27's daughter texted ED #200 at 5:49 A.M. on 03/07/25 and stated her mother was on the floor and no staff were answering the facility phone. At 6:13 A.M., Resident #27's daughter arrived at the facility and went to find a caregiver and asked for help to get her mother off the floor. Agency Caregiver #110 stated she was new at the facility and was unsure what she needed to do and would come in a minute. Resident #27's daughter went to Resident #27's room to wait until the Agency Caregiver #110 arrived about five minutes later. Resident #27's daughter stated she asked Caregiver #110 to find another staff member to assess Resident #27 before moving her. Agency Caregiver #110 returned a few minutes later with Caregiver #102. Caregiver #102 assessed Resident #27 and then assisted Agency Caregiver #110 to get Resident #27 back into bed. Since no major injuries were observed, the family declined to have Resident #27 sent out for evaluation. Resident #27's daughter stated per later review of the video footage of the night of 03/06/25, it revealed around 11:15 P.M. she observed Resident #27's legs hanging off the side of the bed. Around 1:07 A.M. she observed Resident #27 on the floor next to her bed and remained there until she arrived at the facility at 6:13 A.M.

Review of the staff schedule dated 03/06/25 revealed four caregivers were scheduled for the night shift of 03/06/25. Per review of the time punches, one scheduled agency caregiver, Agency Caregiver #112, did not call to cancel or report for her shift on the second and third floor. Caregiver #111 worked in the first-floor memory care unit from 11:00 P.M. and left around 6:00 A.M., which was an hour earlier than her scheduled end time. Caregiver #102 worked from 11:00 P.M. to 7:20 A.M. in the first-floor memory care unit. Agency Caregiver #110 worked from 11:00 P.M. to 7:20 A.M. on the second floor.

Review of the untimed phone statement given to ED #200 on 03/07/25 from Caregiver #102 given to ED #200 revealed she was working in the memory care unit downstairs and was unaware of the fall as she had not left the memory care unit until she was asked to assist Resident #27's following her fall shortly after 6:00 A.M.

Review of the untimed phone statement given to ED #200 on 03/07/25 from Caregiver #111 revealed she worked in the memory care unit on 03/06/25 from 11:00 P.M. until she left at 6:00 A.M. and was not aware of the fall.

Review of the undated witness statement Agency Caregiver #110 stated around 6:10 A.M. Resident #27's daughter approached her and stated she needed assistance to get her mother off the floor. Following going to Resident #27's room, she went to find another aide to assist her. Caregiver #102 assisted her to get Resident #27 up and then she left the room.

Interview on 03/12/25 at 3:33 P.M. with DON #201 confirmed the schedule for 03/06/25 showed Caregiver #111 reported for work at 11:00 P.M. and left an hour early at 6:00 A.M. from her scheduled time of 7:00 A.M. without permission. Caregiver #102 worked from 11:00 P.M. on 03/06/25 till 7:20 A.M. on 03/07/25 as scheduled but did not leave the memory care unit. Agency Caregiver #110 worked from 11:00 P.M. till 7:20 A.M. but only assisted residents on the second floor and did not go on the third floor during her shift. DON #201 confirmed she was not aware the agency caregiver did not report for her shift on 03/06/25 until she arrived at the facility the morning of 03/07/25 nor was she aware that Caregiver #111 left her shift an hour early without permission. DON #201 confirmed care was not provided for the third-floor residents from 11:00 P.M. on 03/06/25 till 7:00 A.M. on 03/07/25 when the day shift arrived.

Interview on 03/13/25 at 10:49 A.M. with ED #200 revealed Resident #27's daughter called her at 5:49 A.m. and informed her Resident #27 was on the floor in her room and she was unable to reach staff at the facility on the phone. ED #200 stated she called Caregiver #102 and told her Resident #27 was on the floor. Caregiver #102 stated she was working with a resident but would check on her when finished with care. ED #200 stated she called DON #201 and DON #201 stated she would head to the facility to assess Resident #27. ED #200 confirmed she was not aware prior to the morning of 03/07/25 that staff had left early, staff had not shown up for their shift or that staff were not assisting residents on the third floor during the night shift of 03/06/25.

This violation represents non-compliance investigated under Complaint Number OH00162724.

Based on record review and interview, the facility failed to ensure medications were given as ordered by the physician. This affected two residents (#14 and #18) of three residents reviewed for medication administration. No residents were identified as self-administering their prescribed medications. The facility census was 39.

Findings include:

1. Review of the medical record for Resident #14 revealed an admission date of 09/18/23. Diagnoses included but were not limited to acute respiratory failure with hypoxia, asthma, type II diabetes mellitus, hypertension, multiple sclerosis and obesity.

Review of 11/04/24 Resident Assessment for Resident #14 revealed she was cognitively intact and required staff to administer her medications.

a. Review of the physician order dated 11/04/24 for Resident #14 revealed an order for Atorvastatin (to reduce cholesterol) 40 milligram (mg) tablet to be given every night at bedtime. No diagnosis was listed.

Review of the Medication Administration Record (MAR) for February 2025 for Resident #14 revealed the 40 mg tablet of Atorvastatin was not recorded as being administered on 02/10/25, 02/17/25, 02/25/25, and 02/28/25.

b. Review of the physician order dated 10/31/24 for Resident #14 revealed an order for Baclofen (commonly used to treat muscle spasms) 20 mg one tablet to be given three times daily. No diagnosis was listed.

Review of the MAR for February 2025 for Resident #14 revealed the Baclofen was not indicated as being given during the 1:00 P.M. dose for 02/13/25 and 02/18/25 and not given during the 8:00 P.M. dose on 02/10/25, 02/17/25, 02/25/25 and 02/28/25.

c. Review of the physician order dated 10/31/24 for Resident #14 revealed a physician order for a Eliquis (an anticoagulant) 5 mg one tablet to be given twice daily. No diagnosis was listed.

Review of the MAR for February 2025 for Resident #14 revealed Eliquis 5 mg was not recorded as being given 2/10/25, and 2/17/25 during the 8:00 P.M. to 10:00 P.M. med pass as ordered.

. Review of the physician order dated 10/31/24 for Resident #14 revealed an order for ferrous glucose (iron supplement) 324 mg one tablet to be given twice daily. No diagnosis was listed.

Review of the MAR for February 2025 for Resident #14 revealed ferrous glucose 324 mg was not indicated as being given on 2/10/25, 2/25/25, and 2/28/25.

e. Review of the physician order dated 02/04/25 for Resident #14 revealed an order for Gabapentin (an anticonvulsant) 100 mg two capsules to be given by mouth three times daily. No diagnosis was listed.

Review of the MAR for February 2025 for Resident #14 revealed the 1:00 P.M. Gabapentin was not indicated as being given on 02/13/25, 02/18/25, and the 8:00 P.M. dose was not indicated as being given on 02/25/25, and 02/28/25.

f. Review of the physician order dated 11/06/24 for Resident #14 revealed an order for magnesium oxide (supplement) one tablet twice daily for hypomagnesemia (low magnesium levels).

Review of the MAR for February 2025 for Resident #14 revealed the 8:00 P.M. dose was not indicated as being given on 02/10/25, 02/17/25, 02/25/25, and 02/28/25.

g. Review of the physician order dated 02/20/25 for Resident #14 revealed an order for one capsule of Nitrofurantoin (an antibiotic) 100 mg by mouth twice daily for seven days for suspected urinary tract infection.

Review of the MAR for February 2025 for Resident #14 revealed the 8:00 P.M. dose of Nitrofurantoin 100 mg was not given on 02/25/25.

2. Review of the medical record for Resident #18 revealed an admission date of 01/07/24. Diagnoses included but were not limited to asthma, dementia, type II diabetes mellitus and osteoarthritis.

Review of Resident #18's assessment dated 01/21/25 revealed he was independent for self-care and required staff assistance with medication administration.

a. Review of the physician orders for Resident #18 revealed a 01/30/24 order for Hydroxyzine Pamoate (antihistamine which can also treat anxiety) 25 mg one tablet to be given at night for anxiety.

Review of the MARs dated February 2025 and March 2025 (to date, reviewed through 03/11/25) for Resident #18 revealed Hydroxyzine Pamoate was not indicated as being given on 02/04/25 and 03/05/25.

b. Review of the physician orders for Resident #18 revealed a 01/11/24 order for melatonin (supplement used to aid sleep) 5 mg to be given at night. No diagnosis was listed.

Review of the MARs dated February 2025 and March 2025 (to date, reviewed through 03/11/25) for Resident #18 revealed Melatonin was not indicated as being given on 02/04/25 and 03/05/25.

c. Review of the physician orders for Resident #18 revealed a 11/11/24 order for Memantine Hydrochloride (used to treat dementia) 10 mg to be given twice daily. No diagnosis was listed.

Review of the MARs dated February 2025 and March 2025 (to date, reviewed through 03/11/25) for Resident #18 revealed Memantine Hydrochloride was not indicated as being given on 02/04/25 and 03/05/25.

. Review of the physician orders for Resident #18 revealed a 01/07/24 order for Metformin (an oral medication used to lower blood glucose levels) 1000 mg to be given twice daily with meals for diabetes.

Review of the MARs dated February 2025 and March 2025 (to date, reviewed through 03/11/25) for Resident #18 revealed Metformin was not indicated as being given on 02/04/25 and 03/05/25 for the evening dose between 4:00 P.M. and 6:00 P.M.

Interview on 03/12/25 at 9:21 A.M. with the Director of Nursing #201 confirmed the MARs for Residents #14 and #18 did not reflect medications had been administered as ordered.

Review of the facility policy titled Medication Management revised 01/2021 revealed documentation shall be completed in the electronic medication administration record immediately after the resident has taken the medication. If the resident refuses to take the medication, the refusal shall be documented in the electronic medical record.

This violation represents non-compliance investigated under Complaint Number OH00162724 and is a recite from the survey dated 02/04/25.

Based on record review, interview and facility policy review, the facility failed to ensure residents were monitored to prevent falls and ensure medical treatment was provided timely following a fall as required. This affected two residents (#27 and #33) of three residents reviewed for falls. This had the potential to affect all 39 residents residing at the facility.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 04/30/23. Diagnoses included but were not limited to adjustment disorder and insomnia.

Review of the 09/04/24 annual assessment revealed severe cognitive impairment. Resident #27 was noted to require maximum assistance of two for all activities of daily living.

Review of Resident #27's service plan which was last reviewed on 09/30/24 revealed she required full assistance from two staff for toileting, ambulation, had severe memory impairment and was a high fall risk with poor safety awareness who required safety checks four times per eight-hour shift.

Review of nursing progress note dated 03/07/25 timed at 1:47 P.M. written by the Director of Nursing (DON) #201 revealed she received a call from Executive Director (ED) #200 informing her that Resident #27's family observed her on video lying on the floor next to her bed for an ample amount of time. Upon arrival, DON #201 assessed Resident #27 and noted soreness/sensitivity to her leg. A red abrasion/bruise was noted to right outer knee and left inner knee and right hip. Per family request Resident #27 was to rest in bed for a few hours until lunch time.

No additional progress notes related to the fall were found.

Review of the post fall evaluation dated 03/12/25 for Resident #27 revealed the fall occurred on 03/07/25. The fall was an unwitnessed fall in Resident #27's room near the bed. Resident #27 stated she was sitting on the side of her bed with her legs hanging off and slid out of bed. Resident #27 was noted to be incontinent and have on regular socks. Resident #27 was noted to have signs of bruising and able to move all extremities.

Interview on 03/12/25 at 9:21 A.M. with DON #201 revealed if there is a fall during the night shift, staff are to notify the DON or the ED. In regard to Resident #27, a fall occurred during the night on 03/06/25 but Resident #27 was not found until after 6:00 A.M. on 03/07/25. DON #201 was notified by ED #200 shortly before 6:00 A.M. on 03/07/25. Resident #27's daughter had called ED #200 after not being able to get a hold of staff at the facility. DON #201 came into the facility after being notified by ED #200. Upon arrival, DON #201 assessed Resident #27 and found bruising and an abrasion. Hospice was notified and following discussion with the family, declined to have Resident #27 sent out for treatment.

Interview on 03/12/25 at 10:36 A.M. with DON #201 confirmed that the fall assessment was started on 03/07/25 but not completed for Resident #27 until 03/12/25 following surveyor request for the assessment.

Interview on 03/12/25 at 10:49 A.M. with ED #200 confirmed staff had not checked on Resident #27 during the night shift on 03/06/25 from 11:00 P.M. till shortly after 6:00 A.M. on 03/07/25. ED #200 confirmed Resident #27 laid on the floor for a few hours prior Resident #27's daughter notifying her Resident #27 was on the floor in her room. Following being notified; ED #200 notified staff at the facility and the DON to go check on Resident #27.

Review of the undated phone statement from Caregiver #102 given to ED #200 revealed she was working in the memory care unit downstairs and was unaware of the fall as she had not left the memory care unit until she was asked to assist Resident #27's following her fall shortly after 6:00 A.M.

Review of the undated phone statement from Caregiver #111 revealed she worked in the memory care unit on 03/06/25 from 11:00 P.M. until she left at 6:00 A.M. and was not aware of the fall.

Review of the undated witness statement Agency caregiver #110 stated around 6:10 A.M. Resident #27's daughter approached her and stated she needed assistance to get her mother off the floor. Following going to Resident #27's room she went to find another aide to assist her. Caregiver #102 assisted her to get Resident #27 up and then she left the room.

Interview was attempted with Caregiver #102, but no return phone call was received. Interview with Caregiver #110 and #111 was unable to be obtained since they no longer work at the facility.

2. Review of the medical record for Resident #33 revealed an admission date of 09/20/24. Diagnoses included but were not limited to High blood pressure and reflux.

Review of 10/21/24 resident assessment for Resident #33 revealed severe cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #33 required moderate assistance with bathing, dressing, toileting, and transfers. Resident #33 was noted to require verbal reminder for mobility with her walker.

Review of Resident #33 service plan revealed it was last reviewed on 10/21/24. Resident #33 was noted to require staff assistance with toileting and transfers. Resident #33 was also noted to be a moderate fall risk and require reminders to use her walker.

Review of the nursing progress noted dated 01/01/25 timed at 4:41 A.M. revealed Resident #33 was found on the floor in her room at 4:20 A.M. leaning against the wall on her right side. Unknown caregiver stated she heard a big thud and then found the resident on the floor. Upon assessment resident was found to have two bumps on the right side of her head and was complaining of pain. Resident was noted to have full range of motion and was assisted up to standing position. Vitals were taken. Resident #33 walked to the bathroom with stand by assist. Resident #33 was noted at her baseline for neuros.

Review of the nursing progress note dated 01/01/25 timed at 5:19 A.M. revealed Resident #33's bump on her head remained the same and remained at baseline.

Review of the nursing progress note dated 01/02/25 timed at 10:46 A.M. revealed Resident # 33 was found lying on her back facing up in her room with her right leg extended forward. Resident #33 complained of right hip pain and was sent out for evaluation.

Review of the nursing progress note dated 01/02/25 timed at 11:27 A.M. revealed Resident #33 was admitted to the hospital with a displaced femur fracture.

Interview on 03/12/25 at 10:40 A.M. with ED #200 confirmed no fall assessment, investigation, or witness statements were completed following Resident #33's fall on 01/01/25 or 01/02/25. ED #200 also confirmed Resident #33 should have been sent out for evaluation following the first fall on 01/01/25 with the head injury.

Interview on 03/12/25 at 1:46 P.M. with DON #201 confirmed there was no fall assessment or fall evaluation completed after Resident #33's falls on 01/025 or 01/02/25 and the service plan had not been updated. DON #201 also confirmed that additional staff involved in both fall incidents no longer work for the facility and were unable to be contacted for surveyor interview related to the incidents.

Review of the 02/2025 revised facility policy called; Fall with Possible Head Injury revealed if a caregiver reports a fall the nurse will be notified immediately. For unwitnessed falls, if the resident is unable to tell you if they hit their head, inspect the head and neck for signs of trauma: bruising, swelling, redness, tenderness, pain with touch or bleeding. In circumstances where the resident appears to be unable to make a clear decision due to the injury the nurse will initiate transfer for emergency medical evaluation.

This violation represents non-compliance investigated under Complaint Number OH00162724.

Based on observation, interview, review of facility monitoring logs, and policy review, the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect all 39 residents residing at the facility. The facility census was 39.

Findings include:

Observation on 03/11/25 at 7:20 A.M. during the initial kitchen tour with Cook #109 revealed the meal temperature monitoring logs, refrigerator and freezer temperature monitoring logs, dish machine temperature monitoring log, and the three compartment chemical testing log for March 2025 (through 03/10/25) were not completed as required.

Observation on 03/11/25 at 7:27 A.M. of the walk-in refrigerator revealed:

- An undated 10-pound roll of ground beef thawing in a pan with visible blood in the bottom of the pan. The roll of ground beef was placed above of three cases of orange juice concentrate.

- An open, unlabeled, and undated partial roll of what appeared to be ground sausage.

- A gallon of whole milk with a sell-by date of 03/02/25.

- An unlabeled and undated gallon-size plastic bag of approximately 10 pancakes.

- An opened and undated 3-pound bag of feta cheese with best-by date of 11/25/24.

- An unlabeled and undated long metal pan of leftover pasta bake that was approximately half-full.

- An opened and undated container of leftover restaurant food from an employee.

Interview on 03/11/25 at 7:35 A.M. with Cook #109 confirmed the meal temperature monitoring logs, refrigerator, freezer, dish machine and three compartment sink logs were not completed daily as required. Cook #109 additionally confirmed the above listed food concerns found in the refrigerator.

Review of the undated facility policy titled Food Storage Labeling and Dating revealed it is the policy to wrap, cover, label, date and store all foods in a safe, appropriate manner. Each label must contain the following: product name, date of preparation/opening, and use by/expiration date.

Review of the facility policy titled Refrigerator and Freezer Temperature Log dated 10/2016 revealed temperatures of each refrigerator and freezer within the department and resident common area will be taken once per day and documented on the refrigerator-freezer log.

Review of the facility policy titled Food Receiving and Storage dated 07/2017 revealed raw meat must always be stored below ready to eat foods.

Review of the facility policy titled Food Temperatures during Preparation and Serving dated 07/2017 revealed food temperatures will be taken three times during the preparation and serving process and will be documented on the Production sheet. Temperatures will be taken when initially removed from the cooking surface, prior to being served and the temperature after the last resident is served.

Review of the facility policy titled Sanitizer Solution Log dated 01/2018 revealed all sanitizer solution must be tested each time it is changed to ensure effectiveness of sanitizer. Results of testing must be documented three times per day using the sanitizer solution log as required.

This violation represents non-compliance investigated under Complaint Number OH00162724 and is a recite from the survey dated 02/04/25.

Based on record review and staff interview the facility failed to ensure its grievance committee met at least annually as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.

Findings include:

During the entrance conference on 03/11/25 at 7:40 A.M. information regarding the facility grievance committee meetings and makeup was requested.

The facility was unable to provide information regarding its grievance committee make up or that any grievance committee had been held in the past year.

Interview on 03/11/25 at 2:43 P.M. with the Executive Director #200 verified she was unable to provide evidence that a grievance committee was held at least annually as required.

This violation is a recite from the surveys dated 07/10/24 and 09/05/24.

Based on medical record review, facility record review, policy review and interview, the facility failed to ensure reports of abuse were investigated and reported as required. This affected one resident (#27) of three residents reviewed for abuse and misappropriation. This had the potential to affect all 39 residents residing at the facility.

Findings include:

Review of the medical record for Resident #27 revealed an admission date of 04/30/23. Diagnoses included but were not limited to adjustment disorder and insomnia.

Review of the 09/04/24 annual assessment revealed severe cognitive impairment. Resident #27 was noted to require maximum assistance of two for all activities of daily living.

Review of Resident #27's service plan which was last reviewed on 09/30/24 revealed she required full assistance from two staff for toileting, ambulation, had severe memory impairment and was a high fall risk with poor safety awareness who required safety checks four times per eight-hour shift.

Phone interview on 03/12/25 at 1:45 P.M. with Resident #27's daughter revealed on 09/04/24 she observed on the room video camera in Resident #27's that an unnamed agency caregiver was being verbally abusive and rough with Resident #27 during care. Resident #27's daughter stated she went to talk with Executive Director #200 and a corporate person on 09/30/24 and showed them the videos of concern. Resident #27's daughter stated she was told the facility would investigate the alleged abuse but never received any follow up. Resident #27's daughter stated the caregiver has not cared for her mother since being reported.

Interview on 03/13/25 at 10:40 A.M. with ED #200 confirmed she was unable to provide evidence of investigation for the reported abuse concerns for Resident #27. ED #200 stated the alleged reported abuse to Resident #27 was reported to corporate and the agency the caregiver worked for was notified and was not allowed to return to the facility. ED #200 confirmed the alleged abuse was not reported to the State Agency.

Review of the 02/2025 facility policy called; Abuse and Neglect revealed facility health care professional who have reasonable cause to believe that a resident is being, or has been abused, neglected or exploited shall report the information immediately to the state licensure authority and branch support. The report must include the required information listed: name and address of the resident involved, any additional information that might be helpful in the protection of the resident. An internal investigation must be completed and documented on the investigation report. Reporting procedure will be to call the state licensure authority or state Ombudsmen. A report will be called to the state office within 24 hours by the Executive Director.

This violation represents non-compliance investigated under Complaint Number OH00163539.

Based on observation and interviews the facility failed to ensure resident medical records were available for review as required. This has the potential to affect all 39 residents residing at the facility.

Findings include:

During an interview on 03/12/25 at 9:21 A.M. with the Director of Nursing (DON) #201 surveyor resident requested the closed medical record for Resident #40.

Interview on 03/12/25 at 3:33 P.M. with DON #201 confirmed she was unable to provide the closed record for Resident #40.

This violation represents an incidental finding of non-compliance identified while investigating Master Complaint Number OH00163539 and Complaint Number OH00162724.

Based on record review, observation, and interview, the facility failed to ensure Resident #327 received medications as ordered. This affected one resident (Resident #327) of five resident reviewed for medication administration. The facility census was 37.

Findings include:

Review of the medical record for Resident #327 revealed an admission date of 03/24/23 with diagnoses of dementia.

Review of Resident #327's physician's orders revealed an order for morphine sulfate solution 100 milligrams (mg) per five milliliters (ml) give 0.25 ml (5mg) by mouth sublingually twice daily for pain dated 10/09/24.

Review of the medication administration records (MAR) dated February 2025 for Resident #327 revealed Resident #327 did not receive morphine sulfate as ordered on 02/01/25 and 02/02/25 on day shift.

Review of the progress notes for February 2025 for Resident #327 revealed no documentation about the missed doses of morphine sulfate on 02/01/25 and 02/02/25.

Interview on 02/04/25 at 9:43 A.M. with the Director of Nursing (DON) verified Resident #327 did not receive the morphine sulfate as ordered on 02/01/25 and 02/02/25 on day shift. The DON stated the medication was not available in the facility to give to Resident #327 on those days. The DON confirmed there was no progress note entry on those dates by nursing regarding the missed doses.

Review of the facility policy titled, Medication and Nursing revised 01/2021, stated medication errors include failure to administer a medication. A medication error shall be immediately reported to the Registered Nurse Coordinator (RNC), Resident, the Residents enacted POA, healthcare provider, and state entity if applicable. Documentation of medication errors and prescribers' responses shall be kept in the resident record.

Based on observation, record review, and interview the facility failed to ensure laundry services were provided to Resident #315 and #340 as required. This affected two residents (#315 and #340) of three residents reviewed for laundry services. The facility census was 37.

Findings include:

1. Review of the medical record for Resident #315 revealed an admission date of 05/19/23. Diagnoses included mild cognitive impairment and unspecified atrial fibrillation.

Review of the service plan for Resident #315, dated 09/24, revealed Resident #315 required assistance with laundry and housekeeping.

Observation on 02/03/25 at 9:22 A.M. of Resident #315 in her room revealed a laundry basket half full of dirty linen and the bathroom sink filled with water that had approximately four pairs of soiled underwear with visible evidence of stool in them. Resident #315 stated she has had loose stools for a few days and was attempting to clean her underwear by allowing them to soak first. A bar of wet soap was observed on the sink area. Resident #315 stated no one comes to her room when requested for help with her soiled underwear so she does the best that she can. Resident #315 stated her laundry was to be done by the staff on days she receives her showers.

Observation was conducted on 02/03/25 at 11:22 A.M. with Caregiver Assistant (CA) #32 of Resident #315 in her room, and CA #32 verified the laundry basket half full of dirty linen and bathroom sink filled with water that had approximately four pairs of soiled underwear with visible evidence of stool in them. CA #315 confirmed the staff were required to wash laundry for Resident #315.

2. Observation was conducted on 02/03/25 at 10:48 A.M. of Resident #340's room. There were clothes piled on the floor, and the pile of clothing reached waist high to the level of the countertop in the room.

On 02/03/25 at 11:04 A.M. an interview with CA #25 revealed laundry was behind all the time and night shift wasn't any help with resident assigned laundry. CA #25 stated the laundry was behind over the weekend so she was washing today what she could to ensure residents had clean bed linen and clothing. CA #25 stated it was difficult to get resident care completed during her shift if she also had to do the laundry.

On 02/03/25 at 4:40 P.M. observation with the Director of Nursing (DON) confirmed Resident #340 had clothes piled up in her room on the floor, and the DON stated she could not tell if the clothing was clean or dirty.

Review of the facility admission agreement, revised 03/2017, revealed the facility agreed to the following: provide designated services to the resident, as delineated in the service agreement. Services shall include laundry services. Linen laundry services should be provided, and personal laundry service should be available.

Review of the facility Housekeeping Laundry Policy, revised 07/12, revealed laundry shall be provided for residents as designated in their service plan.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 37 residents residing in the facility.

Findings include:

1. Observation was conducted on 02/03/25 at 8:06 A.M. of the facility main kitchen. The entire kitchen floor had a build-up of dried food and dried spillage of various liquids all over the floor area where staff would walk. Heavy build-up of food and crumbs was observed swept into corners and between counter and walls of the kitchen area.

Interview on 02/03/25 at 8:06 A.M. with Dietary Manager (DM) #2 verified the observed findings.

2. Observation was conducted on 02/03/25 at 8:11 A.M. of the second floor serving kitchen. The kitchen countertop had a build-up of dried liquids from the beverage dispenser, the floors were dirty with old, dried food and crumbs, and there was a puddle of backflow coming out of the floor drain onto the floor. Also, the walls behind a garbage can were splattered with food stains and dried on splatter from liquids.

Interview on 02/03/25 at 8:11 A.M. with Dietary Employee (DE) #34 and DM #2 verified the findings at the time of the observation.

Interview on 02/04/25 at 1:28 P.M. with the Director of Nursing and the Administrator revealed all dining staff were responsible to maintain a clean and sanitary kitchen. Both verified the facility kept no documentation to support the expectations of the dining staff, so there was no record on when the main kitchen and second floor serving kitchen were last cleaned.

Based on observation and interview, the facility failed to maintain a clean and safe living environment for the residents. This had the potential to affect all 37 residents in the facility.

Findings include:

1. Observation was conducted on 02/03/25 at 10:48 A.M. of the main dining area for resident meal service. There were two, portable space heaters plugged in and blowing heat in the main dining area.

Interview on 02/03/25 at 11:33 A.M. with the Maintenance Coordinator (MC) #31 verified two, portable space heaters were plugged in and being used as a source of heat in the main dining area.

2. Observation on 02/03/25 at 9:30 A.M. of the resident room for Resident #327 revealed a strong odor of urine and feces. In the bathroom there was a wet tile with an odorous brown substance on it sitting on the bathroom counter and the shower floor tiles were saturated with an odorous brown substance.

Interview and observation on 02/03/25 at 4:24 P.M. with the Director of Nursing (DON) confirmed the findings in the room and bathroom of Resident #327 were still there at the time of the observation with the DON.

Based on observation, record review and interview, the facility failed to ensure Resident #343, #324 and #334 received routine showers, and failed to ensure Resident #327 was provided wound care in accordance with acceptable standard of practice. This affected four residents (#343, #324, #327 and #334) of five residents reviewed for resident right to adequate nursing services. The facility census was 37.

Findings include:

1. Review of the medical record for Resident #343 revealed an admission date of 08/19/22 with diagnoses of coronary artery disease, chronic back pain, dementia, chronic diastolic congestive heart failure, and hypertension.

Review of the Service Plan dated 01/21/25 revealed Resident #343 had a memory impairment and poor safety awareness, and required full assistance with bathing and mobility support in the shower.

Further review of the medical records for Resident #343 revealed no evidence of showers being given for February 2025. For January 2025 there was one recorded shower for the month of January 2025.

Interview on 02/03/25 at 8:03 A.M. with Caregiver #18 revealed there was normally one aide assigned to each floor so resident showers did not always get done as required.

Interview on 02/04/25 at 11:44 A.M. with the Director of Nursing (DON) revealed she had implemented shower sheets for staff to document resident showers starting in January 2025 and prior to January documentation of showers was not required by the staff. The DON confirmed Resident #343 had no record of receiving showers in February 2025 and only one recorded shower in January 2025.

2. Interview was conducted on 02/03/25 at 9:36 A.M. with Resident #324 who revealed she needed help from staff to take a shower, and could not remember the last time she was showered.

Review of the medical record for Resident #324 revealed no evidence of showers being given during the month of January 2025 or February 2025.

Interview on 02/04/25 at 11:44 A.M. with the DON confirmed Resident #324 had no record of showers being given for the month of January 2025 and February 2025.

3. Observation on 02/03/25 at 10:57 A.M. of Caregiver #28 providing care to Resident #334 revealed the resident had body odor and oily hair. Caregiver #28 confirmed it did not look like Resident #334 had a shower recently so she would shower her today. Caregiver #28 stated Resident #334 was supposed to be showered yesterday.

Review of the medical record for Resident #334 revealed no evidence of showers being given during February 2025.

Interview on 02/04/25 at 11:44 A.M. with the DON confirmed Resident #334 had no record of showers being given for the month of February 2025.

4. Review of the medical record for Resident #327 revealed an admission date of 03/24/23 with diagnoses including dementia, benign prostatic hypertrophy, depression, neuropathy, musculoskeletal deformity, and peripheral vascular disease.

Review of the service plan dated 01/21/25 revealed Resident #327 had a memory impairment, disorientation to person, place, and time, required maximum assistance from staff with all Activities of Daily Living (ADL's), independent with meals, had active wounds, and chronic pain. Resident #327 required assistance with housekeeping, laundry, preparing meals, and financial affairs.

Review of the treatment orders for February 2025 for Resident #327 revealed an order for calmoseptine ointment 0.44/20.625 apply to skin abrasions on right knee, cover with ABD and wrap with kerlix once daily until resolved. There was no order for Resident #327 to have an air mattress.

Review of treatment administration records (TAR) for February 2025 for Resident #327 revealed the treatment had been signed off by Licensed Practical Nurse (LPN)#15 as treatment being completed on 02/03/25. There were no orders on the TAR to indicate Resident #327 had an air mattress.

Observation on 02/03/25 at 9:30 A.M. of Resident #327 revealed she was lying in bed and had just finished breakfast. Resident #327 had an air mattress in place and the equipment for the air mattress was not plugged in so it was not operating. There were no dressings applied to the right knee as ordered.

Interview and observation on 02/03/25 with the Director of Nursing (DON) of Resident #327 revealed the DON confirmed Resident #327 did not have a wound care dressing in place to right knee per order and that it had been signed off by LPN #15 as being completed. The DON also confirmed Resident #327 had a specialty air mattress in place, and the air mattress was not plugged in nor functioning at the time of the observation. The DON plugged in the air mattress and it began to operate. The DON confirmed they were not aware there was no order for the air mattress.