Burton'S Ridge

Based on record review, interview, and policy review, the facility failed to ensure guardians signed consents for immunizations. This affected one (#18) of three residents reviewed for immunizations. The facility census was 33. Findings include: Review of medical record for Resident #18 revealed an admission date of 07/14/21 with diagnoses including but not limited to epilepsy, bipolar disorder, and diabetes. Review of Guardianship paperwork dated 2017 revealed Resident #18 was deemed incompetent and a guardian was appointed for an indefinite time period related to bipolar disorder, anxiety disorder, and post traumatic stress disorder. Review of immunization records from the Local Health Department (LHD) revealed Resident #18 received the influenza and COVID vaccine on 11/05/25 per the clinic held at the facility. Review of the consent form for Resident #18, for the LHD, revealed the resident signed the consent form on 10/20/25 and the influenza and COVID vaccines were administered on 11/05/25. Further review revealed the resident's Guardian did not sign the consent form. Interview on 02/02/26 at 8:56 A.M. with the Director of Nursing (DON) and the Administrator revealed the facility offers vaccines for influenza, COVID, and pneumonia. Both stated they are to contact the responsible parties if the residents are unable to consent to the vaccines. Interview on 02/02/26 at 10:54 A.M. with the DON revealed the if a resident had a legal guardian, the guardian would have to sign the vaccination consent forms for the residents. Interview on 02/02/26 at 1:32 P.M. with the LHD DON #127 via phone revealed the LHD sent the consents to the facility for the staff to obtain consents for vaccines, billing the insurance, and the vaccine education sheets. Interview on 02/02/26 at 1:36 P.M. with Guardian via phone for Resident #18 revealed they were not notified of the resident signing consent for the COVID and influenza vaccines. Family member stated that she would have consented to the influenza vaccine but not the COVID vaccine. Review of policy titled, Infection Control PlanBased on record review, interview, and policy review, the facility failed to ensure guardians signed consents for immunizations. This affected one (#18) of three residents reviewed for immunizations. The facility census was 33.

Findings include:

Review of medical record for Resident #18 revealed an admission date of 07/14/21 with diagnoses including but not limited to epilepsy, bipolar disorder, and diabetes.

Review of Guardianship paperwork dated 2017 revealed Resident #18 was deemed incompetent and a guardian was appointed for an indefinite time period related to bipolar disorder, anxiety disorder, and post traumatic stress disorder.

Review of immunization records from the Local Health Department (LHD) revealed Resident #18 received the influenza and COVID vaccine on 11/05/25 per the clinic held at the facility.

Review of the consent form for Resident #18, for the LHD, revealed the resident signed the consent form on 10/20/25 and the influenza and COVID vaccines were administered on 11/05/25. Further review revealed the resident's Guardian did not sign the consent form.

Interview on 02/02/26 at 8:56 A.M. with the Director of Nursing (DON) and the Administrator revealed the facility offers vaccines for influenza, COVID, and pneumonia. Both stated they are to contact the responsible parties if the residents are unable to consent to the vaccines.

Interview on 02/02/26 at 10:54 A.M. with the DON revealed the if a resident had a legal guardian, the guardian would have to sign the vaccination consent forms for the residents.

Interview on 02/02/26 at 1:32 P.M. with the LHD DON #127 via phone revealed the LHD sent the consents to the facility for the staff to obtain consents for vaccines, billing the insurance, and the vaccine education sheets.

Interview on 02/02/26 at 1:36 P.M. with Guardian via phone for Resident #18 revealed they were not notified of the resident signing consent for the COVID and influenza vaccines. Family member stated that she would have consented to the influenza vaccine but not the COVID vaccine.

Review of policy titled, Infection Control Plan

Review of review of personnel files, observations and staff interview, the facility failed to ensure staff members serving a special population (locked/secured memory care unit) received four hours of continuing education annually as required. This affected three (#100, #113 and #124) out of six personnel files reviewed and had the potential to affect 13 (#10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21 and #22) residents residing on the locked/secured memory care unit. The facility census was 37.

Findings include:

Review of State Tested Nursing Assistant (STNA) #100 personnel file revealed the staff members hire date was 08/27/24. STNA #100 received two hours of special training for dementia care at time of hire on 08/27/24 but did not receive four hours of relevant continuing education annually.

Review of Licensed Nurse Practical (LPN) #113 personal file revealed the staff members hire date was 06/22/23. LPN #113 received two hours of special training for dementia care at time of hire on 06/22/23 but did not receive four hours of relevant continuing education annually.

Review of Resident Assistant (RA) #124's personnel file revealed the staff member received two hours of special training for dementia care at time of hire on 07/24/24 but did not receive four hours of relevant continuing education annually.

Observations and interview on 10/09/25 at 11:56 A.M. with Administrator confirmed the facility had a locked/secured memory care unit serving 13 (#10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21 and #22) residents with dementia. The Administrator confirmed STNA #100, LPN #113 and RA #124 provide care in the locked/secured memory care unit and these staff have not completed four hours of continuing education related to dementia care annually as required.

Based on record review and staff interview, the facility failed to timely close and return remain funds to a resident upon discharge. This affected one (#50) out five residents reviewed for personal fund accounts. The facility census was 37.

Findings include:

Review of Resident #50 medical record revealed the resident was admitted on 12/13/24. Diagnoses include dementia, Alzheimer's disease and wedge compression fracture of T11-T12 vertebra. Resident #50 was transferred to a geriatric psychiatric unit on 07/04/25 and discharged from assisted living facility on 07/17/25.

Review of Resident #50's personal fund account revealed the facility issued a check for the amount of $35.00 on 07/31/25, which was sent to the resident's power of attorney. Review of Resident #50's personal funds account revealed the resident still had a balance of $0.66 with the facility with the most recent statement dated 09/30/25. Further review of the balance revealed it is from interest 01/01/25 - 03/31/25 of $0.15 and interest 04/01/25 - 06/30/25 of $0.51.

Interview on 10/08/25 at 9:58 A.M. with Administrator confirmed Resident #50 discharged on 07/17/25. The Administrator stated checks are distributed to close resident funds accounts by the facility corporate office. The Administrator stated she did not noticed Resident #50 still had an account balance and she would contact corporate to refund money.

Based on observation, staff interview and review of the facility policy, the facility failed to dispose of out dated/expired food items. This had the potential to affect all 36 residents residing in the facility. The facility census was 36.

Findings include:

Observation and interview was conducted on 07/17/25 at 9:06 A.M. with Wellness Director (WD) #119 revealed one, twelve ounce, Kraft Mayo bottle with use by dated/expired of 03/29/25 and one, twelve ounce, Kraft Mayo bottle with use by dated/expired of 05/04/25 were observed in a condiment caddy place on a table in the activities room where residents eat their meals. WD #119 verified at time of find of out dated/expired food. The facility confirmed all 36 residents residing in the facility receive meals/food from the facility kitchen.

Review of the facility policy titled Storage of Perishable Foods dated February 2018 perishable food items may be served until manufacture's use by date.

This violation represents non-compliance investigated under Complaint Number OH00167634.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored and served in a safe and sanitary manner. This had the potential to affect all 44 residents. The census was 44.

Findings include:

1. Observation of the kitchen on 11/14/24 at 8:53 A.M. revealed Dietary Cook #100 was in the kitchen and was not wearing a hair or beard net.

Observation on 11/14/24 at 8:55 A.M. revealed the walk-in refrigerator contained numerous food items including an undated gallon of ranch dressing, one quart of French dressing with a best use by date of 09/30/24, an undated gallon of honey mustard, seven pounds of undated strawberry topping, 33 ounces of crushed garlic with a best use by date of December 2023, 32 ounces of low calorie Italian dressing with a best use by date of 08/31/24, a jar of pepperoncinis opened on 03/26/24 with a round thick black and gray substance on the outside of the bottle, five ounces of undated soy sauce, undated bourbon style sauce, undated pizza sauce in a facility storage container, apricots in a facility storage container with a use by date of 11/11/24, a nearly empty undated five gallon bucket of pickle strips with the lid cracked open, and an undated full five gallon bucket of pickles with the lid cracked open. There was also raw meat stored above a box of red onions and the two buckets of pickles. Observation of the dry storage area revealed a bucket of chocolate frosting opened on 06/19/24 with a best use by date of 11/10/24. Continued observation of the kitchen revealed a singular bag of hamburger buns in the serving area with a green substance on the buns.

Interview on 11/14/24 at 9:03 A.M. with Dietary Manager #101 verified all of the walk-in refrigerator and dry storage food concerns observed on 11/14/24 at 8:55 A.M.

Interview on 11/14/24 at 9:05 A.M. with Dietary Cook #100 verified he was not wearing a hair or beard net while in the kitchen.

2. Observation of the refrigerator and freezer in the memory care kitchenette on 11/14/24 at 10:40 A.M. revealed a Boston cream pie was opened and undated and a can of sparkling water was opened, undated, and uncovered in the refrigerator. Observation of the freezer revealed three undated one gallon tubs of ice cream and an handled cup stored inside a container of cubed ice.

Interview on 11/14/24 at 10:45 A.M. with Licensed Practical Nurse #200 verified the Boston cream pie, sparkling water, tubs of ice cream, and the ice cubes were not stored properly in the memory care kitchenette.

3. Observation on 11/14/24 at 11:30 A.M. of the lunch meal service revealed Dietary Cook #100 was not wearing a hair net, but was wearing a beard net.

Interview on 11/14/24 at 11:31 A.M. with Dietary Cook #100 verified he was not wearing a hair net during lunch meal service.

Review of a policy for food storage, dated January 2018, verified all packaged food, canned foods, or food items stored will be dated, kept clean, and dry at all times.

Based on review of fire drill records and staff interview, the facility failed to ensure fire drills were conducted as required. This had the potential to affect all 44 residents in the facility. The census was 44.

Findings include:

Review of fire drill records dated November 2023 to October 2024 revealed the facility did not complete fire drills on each shift at least every three months as required. There was no documentation of the facility completing a third shift fire drill for the months of November and December 2023 and January and February 2024. Additionally, the facility complete first shift fire drills on 01/31/24 and 06/19/24 which resulted in four months between first shift fire drills.

Interview on 11/14/24 at approximately 4:00 P.M. with the Executive Director verified the facility did not complete fire drills as required.