Country Club Center II

Based on interview and record review, the facility failed to evacuate residents on at least two fire drills a year on each shift and failed to indicate how many residents were evacuated. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.

Findings include:

Review of the facility's fire drills from May 2024 to April 2025 revealed evacuations did not occur on at least two fire drills on each shift. Review of the first shift fire drills on 01/15/25, 04/08/25, and 10/02/24 revealed no residents were evacuated. Review of the second shift fire drills on 02/19/25, 08/16/25, and 11/21/24 revealed no residents evacuated.

Interview on 04/09/25 at 1:52 P.M. with Maintenance Director #111 revealed fire drills were completed on each shift every three months with evacuations one every six months. He additionally verified he did not have the evacuations noted with resident count for evacuations.

Based on record review, interview, and Ohio Administrative Code (OAC) review, the facility failed to ensure the written resident agreement/resident handbook was comprehensive to include all required information pertaining to resident equipment and supplies. This affected three residents (#1, #6, and #7) and had the potential to affect all 35 residents residing in the facility.

Findings Include:

1. Review of the medical record revealed Resident #1 was admitted on 03/31/24 with diagnoses that included chronic obstructive pulmonary disease, narcolepsy, paranoid personality disorder, schizoaffective disorder, major depressive disorder, and dementia. Record review revealed the Resident Agreement was signed by Resident #1 on 04/02/24.

2. Review of the medical record revealed Resident #6 was admitted on 07/02/24 with diagnoses that included chronic kidney disease, peripheral vascular diseases, type 2 diabetes mellitus, and glaucoma. Record review revealed the Resident Agreement was signed by Resident #6 on 07/03/24.

3. Review of the medical record revealed Resident #7 was admitted on 09/11/24 with diagnoses that included dementia and osteoporosis. Record review revealed the Resident Agreement was signed by Resident #7's responsible party on 09/12/24.

Review of the Residency Agreement revealed the assisted living apartments do not come furnished. The assisted living residents are encouraged to furnish their apartments as desired. The facility can assist with finding furniture to furnish the rooms, but currently the facility will only provide residents with two sets of bed linens, towels and wash cloths, and pillowcases.

There was no evidence that the Residency Agreement was specific to those bedroom furnishings and supplies included under OAC 3701-16-15 (C) (1) through 3701-16-15 (C) (6). This section of the OAC indicated that unless the resident chooses to bring his or her own or as specified in the resident agreement, the residential care facility shall provide the following bedroom furnishings and supplies including but not limited to:

3701-16-15 (C) (1) An individual bed equipped with springs and a clean comfortable flame-resistant mattress or a clean comfortable mattress with a flame-resistant mattress cover.

3701-16-15 (C) (2) Bed linen which shall include at least two sheets, a pillow and pillowcase, a bedspread, and one blanket that fit properly and are free of tears, holes and excessive fraying or wear.

3701-16-15 (C) (3) Closet or wardrobe space with a minimum width of twenty-two inches of hanging space sufficient in height and equipped for hanging full length garments and at least one shelf of adequate size within reach of the resident.

3701-16-15 (C) (4) A bedside table, personal reading lamp, adequate bureau, dresser or equivalent space, a mirror appropriate for grooming, and a chair with a padded back and seat, with arms for lateral support.

3701-16-15 (C) (5) Bath linen that includes at least two full towels, two face towels and two washcloths.

The Residency Agreement did not include information specific to these furnishings/supplies and/or who would provide or how they would be provided.

Interview on 12/06/24 at 11:19 A.M. with Corporate Clinical Director #53 verified the content of the facility Residency Agreement as noted above.

This violation represents non-compliance investigated under Complaint Number OH00153340.

Based on record review, interview, facility policy review and Self-Reported Incident (SRI) review, the facility failed to ensure Resident #3 was free of verbal abuse. This affected one resident (#3) of three residents reviewed for abuse/misappropriation. The facility census was 35.

Findings include:

Review of the medical record revealed Resident #3 was admitted on 02/06/15 with diagnoses that included obsessive-compulsive disorder, bipolar disorder, type 2 diabetes, attention-deficit hyperactivity disorder, anxiety disorder, and mild intellectual disabilities.

Review of SRI #250702 dated 08/12/24 revealed on 08/09/24 Resident #10 reported one day she overheard Resident Assistant (RA) #52 yell at Resident #3. Resident #3 stated earlier that week RA #52 entered Resident #3's apartment and asked Resident #3 about a shower. Resident #3 could not recall exactly what RA #52 said but said RA #52's voice was loud. Resident #3 stated she did not report the incident because RA #52 always yelled loudly at her to take a shower and Resident #3 did not want to report it. Resident #3 asked that RA #52 not be assigned to provide care for Resident #3.

A typed and signed statement (no date) by Resident #3 revealed RA #52 yelled at Resident #3 Tuesday through Friday to get a shower. Resident #3 stated RA #52's voice was loud but could not recall what specifically was said. Resident #3 stated she did not feel safe around RA #52. Resident #3 asked other RAs to assist her, would leave the dining room if RA #52 was there, and stayed in her room to avoid RA #52.

A typed statement (no date) by Office Coordinator #82 revealed Resident #10 reported hearing RA #52 yelling at Resident #3. Resident #10 reported it was something to the effect of 'shut up'. RA #52 was called and notified there was a complaint against RA #52 for speaking inappropriately to a resident. RA #52 stated it was about Resident #10 because Resident #10 tells other staff not to listen to RA #52. RA #52 denied telling any residents to shut up.

A handwritten statement dated 08/09/24 by Licensed Practical Nurse (LPN) #73 revealed Resident #3 said RA #52 yelled at Resident #3 all the time about showers. Resident #3 reported RA #52 yelled at Resident #3 on 08/08/24. On 08/08/24, RA #52 reported to the nurse Resident #3 refused to take a shower and smelled like yeast really bad. LPN #73 did not notice Resident #3 having an odor.

A typed statement obtained by Assistant Director of Nursing (ADON) #51 revealed Resident #10 stated she heard RA #52 yelling at Resident #3. RA #52 was treating Resident #3 like a dog and said something like, you will take a shower when I tell you, or something similar to that. Resident #10 asked Resident #3 if she was okay. Resident #3 said she was okay but looked tearful. Resident #10 reported RA #52 acted like she owned the place and stated the dining room was RA #52's and she would run it the way she wanted.

Review of employee change in status form revealed RA #52 was terminated by phone on 08/12/24 for speaking loudly to a resident and providing poor customer service.

Interview on 12/06/24 at 9:20 A.M. ADON #51 verified an investigation was completed and RA #52 was terminated for the way she talked to Resident #3.

Interview on 12/06/24 at 12:54 P.M. Resident #10 verified she reported verbal abuse by RA #52 when talking to Resident #3. Resident #10 stated Resident #3 was a good girl and did not deserve to be talked to that way. Resident #10 stated RA #52 left Resident #3 when she saw Resident #10 watching her. Resident #10 approached Resident #3 and asked if she was okay. Resident #3 looked like she was going to cry. Resident #10 stated she wanted to beat up RA #52 for the way she had talked to Resident #3.

Review of the Abuse policy revised on 01/31/20 revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse and mental abuse.

This violation represents an incidental finding identified while investigating Master Complaint Number OH00159357.

Based on record review, interview, facility policy review and review of facility Self-Reported Incidents (SRI), the facility failed to ensure Resident #3 had the right to maintain personal possessions and was free from misappropriation. This affected one resident (#3) of three residents reviewed for abuse/misappropriation. The facility census was 35.

Findings include:

Review of the medical record revealed Resident #3 was admitted on 02/06/15 with diagnoses that included obsessive-compulsive disorder, bipolar disorder, type 2 diabetes, attention-deficit hyperactivity disorder, anxiety disorder, and mild intellectual disabilities.

Review of SRI #253482 dated 10/28/24 revealed an allegation of misappropriation was investigated by the facility. On 10/26/24, LPN #57 requested Resident #3 to clean her apartment and instructed housekeepers to help facilitate. The Administrator had previously contacted Resident #3's guardian/mother to help with cleaning Resident #3's room. The plan was for Resident #3's mother to come into the facility on 10/26/24 and again on 10/29/24 to clear out a potential hoarding situation. Witness statements from housekeeping and aides revealed Resident #3 was involved in the process and agreed to throwing bags out, donating, or keeping items. Resident #3 stated she had not been agreeable to the discarding of the items from her apartment and had communicated her disapproval at the time of the alleged incident. LPN #57 was suspended pending investigation. Staff and residents were interviewed. During staff interviews, it was confirmed that the direction for the cleaning of Resident #3's room came from LPN #57 who stated the process had been coordinated by facility management. SRI #253482 was substantiated by the facility.

A typed summary of interviews with Resident #3 and Resident #3's mother, dated 10/30/24 and typed by SSD #80, revealed Resident #3 stated LPN #57 told Resident #3 she needed to clean her apartment or she would be evicted. Resident #3 stated she asked LPN #57 to leave. Right after that, two housekeepers and an aide came in and started putting Resident #3's things in a trash bag and told Resident #3 to clean her closet in the bedroom. Resident #3 stated they did not ask her what to throw out they just started putting things in garbage bags. Resident #3 stated it was between 5:30 P.M. and 7:00 P.M. Resident #3 said she was crying because they were taking her belongings. Resident #3 called her mother at 12:30 A.M. and let her mother know she was missing items. Resident #3's mother stated she had made plans to come to the facility and clean Resident #3's apartment. LPN #57 left Resident #3's mother a message that they were cleaning Resident #3's apartment or Resident #3 would be evicted. Resident #3's mother came to the facility on 10/27/24. Some of Resident #3's belongings were given to Resident #3's mother but not all the belongings.

A voicemail left by LPN #57 for Resident #3's mother on 10/26/24 was transcribed by LPN #64. The transcription was as follows: Hi my name is (LPN #57). I'm the nurse today at Country Club. Resident #3 was told in order to be able to continue staying here, her apartment needed to be cleaned out. We need to be able to see the couch. We need the whole floor, and it needs to be done this weekend. The transcription continued Two housekeepers came to help Resident #3 and Resident #3 was being very disrespectful and refusing to get rid of anything and refusing to do anything. If you can call me back, I am going to the room now to see if I can talk to her (Resident #3). Thank you.

A statement dated by Head of Housekeeping/Laundry #54 for the incident dated 10/26/24 revealed after an inspection by Head of Housekeeping/Laundry #54 and Maintenance #59 of Resident #3's apartment, the Administrator was notified of the need for the apartment to be cleaned. A resolution was put in place by the Administrator. On 10/26/24, a housekeeping staff member called Head of Housekeeping/Laundry #54 and asked if they were to clean Resident #3's apartment. Head of Housekeeping/Laundry #54 told the housekeeping staff not to clean Resident #3's apartment. On 10/27/24, staff called again and stated LPN #57 had contacted Maintenance #59 and Maintenance #59 said it was okay to clean Resident #3's apartment. Head of Housekeeping/Laundry #54 talked to LPN #57 who stated Maintenance #59 had said it was okay to clean Resident #3's apartment.

A statement by Housekeeping/Laundry #55 dated 10/28/24 revealed LPN #57 and RA #58 came to the laundry room and told Housekeeping/Laundry #55 and Housekeeping/Laundry #56 to clean Resident #3's apartment and get rid of stuff. Resident #3 was hesitant and appeared upset until LPN #57 threatened to call Resident #3's mother. Resident #3 started picking things up and said what could go and what could stay. LPN #57 told Housekeeping/Laundry #55 and Housekeeping/Laundry #56 that Maintenance #59 gave permission for Resident #3's apartment to be cleaned. Around 2:30 P.M. on 10/26/24 Housekeeping/Laundry #55 and Housekeeping/Laundry #56 called Head of Housekeeping/Laundry #54 and was told not to clean Resident #3's apartment. Later LPN #57 and RA #58 demanded that Housekeeping/Laundry #55 and Housekeeping/Laundry #56 clean Resident #3's apartment per Maintenance #59.

A statement by Housekeeping/Laundry #56 dated 10/28/24 revealed LPN #57 and RA #58 told the housekeepers Resident #3's apartment needed cleaned. Housekeeping/Laundry #55 and Housekeeping/Laundry #56 were to help and get rid of the trash. Resident #3 was hesitant until LPN #57 threatened to call Resident #3's mother. LPN #57 stated Maintenance #59 had said to clean Resident #3's apartment.

A statement by LPN #57 dated 10/19/24 revealed Housekeeping/Laundry #55 and Housekeeping/Laundry #56 came and said they were to clean Resident #3's apartment. LPN #57 told Housekeeping/Laundry #55 and Housekeeping/Laundry #56 to clean the apartment if that is what they were told to do. LPN #57 tried to reach Resident #3's mother several times. Housekeeping/Laundry #55 and Housekeeping/Laundry #56 stated they were told to have the couch and floor clear of clutter. Everything taken out of the room was at the nurse's station for donation. Resident #3 was never distressed or agitated and was proud of her apartment.

A statement by RA #58 dated 10/29/24 revealed housekeeping asked her to assist with cleaning Resident #3's room because Resident #3 was giving them problems when they went in Resident #3's room. Resident #3 asked RA #58 to go through things with her. Resident #3 would say bye-bye or keep to belongings.

A statement by LPN #81 dated 10/27/24 revealed when LPN #57 was making the housekeepers help clean Resident #3's apartment, LPN #81 told LPN #57 that management had made arrangements with Resident #3's mother to clean the room. On 10/27/24, LPN #57 was complaining Resident #3's mother was upset with staff for cleaning Resident #3's apartment. LPN #57 stated she was standing there when staff asked Resident #3 if she wanted items thrown in the trash, and Resident #3 had said yes. LPN #81 told LPN #57 that Resident #3 was in the facility for a reason and Resident #3's mother made all the important decisions.

A statement by Maintenance #59 dated 10/28/24 revealed he and Head of Housekeeping/Laundry #54 had inspected Resident #3's apartment on 10/25/24. The Administrator had a plan of action and instructed NO ONE to do anything. Maintenance #59 did not receive any calls from anyone at the facility over the weekend.

A statement by Staff #79 dated 10/29/24 revealed on 10/27/24 Housekeeping/Laundry #55 and Housekeeping/Laundry #56 cleaned Resident #3's apartment per LPN #57's orders. Later that afternoon, Housekeeping/Laundry #55 was in the laundry room wearing only a tank top. Housekeeping/Laundry #55 and Housekeeping/Laundry #56 stated they had to go dumpster diving to get everything they threw away and were afraid they were in trouble. Staff #79 called Head of Housekeeping/Laundry #54 and put Head of Housekeeping/Laundry #54 on speaker phone. Housekeeping/Laundry #55 and Housekeeping/Laundry #56 stated LPN #57 had told them to clean Resident #3's apartment. While still on the phone, Staff #79 went to talk with LPN #57. LPN #57 stated Resident #3's mother wanted everything back that had been taken out of Resident #3's apartment. LPN #57 stated Resident #3 helped organize everything by saying what to keep and what to put in the trash. LPN #57 stated she watched some of Resident #3's decision making. Head of Housekeeping/Laundry #54 told LPN #57 that Resident #3's mother was planning on coming in while Resident #3 was away from the facility so Resident #3's mother could clean the apartment on 10/29/24.

An interview on 12/06/24 at 10:33 A.M. SSD #80 revealed nursing and housekeeping had inspected Resident #3's room. SSD #80 stated she was not involved until after staff had removed items from Resident #3's room. Resident #3 told SSD #80 everything was fine. Resident #3's mother told Resident #3 to tell how she really felt. Resident #3 stated she felt staff intruded upon her and her apartment. SSD #80 verified Resident #3 had a hard time letting things go and Resident #3's mother usually cleaned Resident #3's apartment. SSD #80 stated Resident #3 was in her 30's but mentally was like a child and was agreeable with people and did not express true feelings except with her mother.

An interview on 12/06/24 at 10:50 A.M. LPN #64 revealed Resident #3 did not say much about her missing belongings to the staff at the facility. Resident #3 usually expressed her feelings to her mother. LPN #64 verified Resident #3's mother was Resident #3's guardian and was very involved in Resident #3's care. Resident #3's mother had come in the past to clean Resident #3's apartment when needed. Resident #3 was very childlike and was at the facility so she could live by herself. Resident #3's family was very involved and frequently visited and took Resident #3 on outings and vacations. LPN #64 stated Resident #3 would only allow two staff members to throw any items away now.

An interview on 12/06/24 at 11:09 A.M. with the Administrator verified arrangements had been previously made with Resident #3's mother to come clean Resident #3's apartment on 10/26/24 and 10/29/24. The Administrator stated the nurse working the weekend of 10/26/24 told Resident #3 her stuff had to be gotten rid of, or Resident #3 would be evicted. The Administrator stated on 12/06/24, Resident #3's mother had emailed a list of items Resident #3 was missing and the facility was going to replace the items.

An interview on 12/06/24 at 1:45 P.M. with Corporate Clinical Director #53 and the Administrator verified LPN #57 had been terminated. LPN #57 did not have permission to clean Resident #3's apartment or to get rid of any of Resident #3's belongings. The Administrator had talked with Resident #3's mother and there was a plan in place for Resident #3's mother to clean Resident #3' apartment and staff were not to be involved unless Resident #3's mother requested assistance.

Review of the undated policy Resident Personal Affects revealed the facility prohibits residents from accumulating unnecessary material objects for no certain purpose, creating a health and safety issue known as hoarding. Hoarding is defined as excessive acquisition of possessions (and failure to discard them), even if the items are worthless, hazardous or unsanitary. A living space sufficiently cluttered limiting activity. An accumulation of items that impeded normal movement and/or function throughout the living space. An accumulation of items that violates building and public safety codes by blocking access to exits, windows, and hallways or interfering with proper ventilation in the unit, which could result in injuries or fire. An accumulation of items that has the potential to encourage pest infestations. An accumulation of items that impedes the provision of care or response in an emergency situation. An accumulation of items that prohibit routine and nonroutine maintenance of the unit; creating a hazardous environment to the property, other residents, staff, and themselves. The policy indicated the Administrator, Social Service Director, Maintenance, or Environmental Supervisor reserve the right to inspect a resident's room/apartment at any time as long as it is arranged with the resident in advance prior to the inspection. The inspection will determine if all areas and components of housing are in compliance with health and safety requirements: free of garbage and debris, free of outdated or spoiled food/dry goods, free of infestation of pests, no evidence of fire hazard or electrical hazard, proper ventilation is maintained, and free of mold and/or odor. Residents or responsible parties will be notified in writing of any deficiencies at the time of the inspection and will be given seven days to correct the identified deficiencies. A follow up inspection will be scheduled and if the deficiencies are not corrected, the resident will be served a discharge notice in response to the danger to the health and safety presented to self and others.

Review of the Abuse policy revised on 01/31/20 revealed misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

This violation represents non-compliance investigated under Master Complaint Number OH00159357.