The Village of Westerville

Based on observation, record review, and staff interview, the facility failed to ensure safe and sanitary storage of food items. This had the potential to affect all residents residing in the facility. The facility census was 32.

Findings include:

Observation on 07/26/24 at 12:47 P.M. revealed the walk in freezer had an undated open bag of sweet potatoes on a shelf.

The ansel system above the deep fryer and cook top had four pipes. All pipes were greasy with dust covering the outer surface making a fuzzy appearance. The pipe to the far right had dust hanging off about an inch in length.

Both oven doors and handles were darkened, sticky and dusty.

The dry storage had a scoop stored in the sugar bin and in the flour bin.

The reach in sandwich and juice refrigerator contained:

A black bean burger use by date 06/24/24.

Romaine lettuce and yellow onion in an undated styrofoam container with the lid open.

Provolone cheese undated and open.

Three salads use by date 07/25/24.

Review of the dishwasher temperature log revealed the dishwasher temperature was not logged at each meal. There was not a temperature logged for washing of the breakfast dishes 07/26/24 or 07/13/24. The lunch and supper meals had not had a temperature logged since 07/17/24. There was not a lunch temperature logged 07/02/24, 07/03/24, 07/05/24, 07/13/24, 07/14/24 or 07/16/24. Only 11 of 26 days were recorded. There was not a supper dishwasher temperature logged 07/13/24, 07/15/24, 07/16/24 and none since 07/17/24. Only 14 of 26 days were recorded.

Review of the three compartment sink sanitizer concentration log revealed the sanitation level of the water was not documented for breakfast on 07/02/24, 07/03/24, 07/15/24, 07/16/24, 07/25/24 and 07/26/24. Only 20 of 26 days had a recorded sanitation level. For the lunch meal a sanitation level was not logged since 07/17/24. There was not a lunch sanitation level logged 07/01/24, 07/14/24, 07/16/24, and since 07/17/24. For the dinner meal, there was not a dinner sanitation level logged 07/13/24, 07/15/24, 07/16/24 and none since 07/17/24. Only 14 of 26 days were recorded.

There was dirt/debris behind the table holding the steamer. There were missing baseboard tiles.

There were damaged metal baseboards between the walk in refrigerator and the walk in freezer. The baseboards were gapping away from the wall.

The right chute of the ice machine was leaking.

Observations and interview on 07/26/24 between 12:47 P.M. and 1:26 P.M. with Cook #101 verified the dishwasher and three compartment sink and sanitation cleaning water were not consistently logged to measure sanitization levels and water temperatures. Cook #101 verified the undated, outdated, and uncovered food items in the reach in refrigerator. Cook #101 verified the undated open bag of sweet potatoes on a shelf in the walk in freezer. Cook #101 also verified the dirty oven doors.

Observation on 07/26/24 at 1:52 P.M. with the Executive Director verified the dirty oven doors, ansel system, leaking ice chute, missing floor tiles and dirty activity oven.

Review of the facility's undated Food and Nutrition and Dishwashing Practices included:

-Cleaning and sanitation practices keep food safe.

-Dirty equipment and surfaces are a breeding ground for bacteria that may cause food borne illness or infection.

-Keep a clean and tidy work space.

-Cleaning includes use of an approved detergent to wash the designated area.

-Sanitizing means that an approved sanitizing chemical in solution, such as Oasis 146, is used after the surface is cleaned.

-Use and follow weekly and monthly cleaning schedules to make sure all areas of the kitchen are given a deep cleaning on a routine basis.

-The food service director, assistant food service director or dietitian makes rounds to spot check for cleanliness.

-Items are dated with delivery date on the case or container and stored to ensure first in,first out (FIFO) method.

-Labels include the name of the item, date it was prepared or opened and a date the item should be used by.

-The manufacturer's expiration date, when available is the use-by date for unopened items

-Foods placed in the refrigerator are to be labeled with name of item, date item is placed and date it is to be used.

-Foods prepared, cooled and held below 41 degrees F without contamination may be held up to 7 days from date of preparation (day of preparation is counted as Day 1).

-Ready-to-eat, potentially hazardous foods from processing plants are marked when opened and dated with manufacturer's Use by date or 7 days, whichever is first.

-Confirm wash and rinse temperatures are within acceptable ranges before washing dishes.

This violation represents non-compliance investigated under Complaint Number OH00155538.

This violation is evidence of continued non-compliance from the surveys dated 03/17/24 and 04/18/24.

Based on record review, observation, and staff interview the facility failed to maintain a record of food substitutions from the menu. This had the potential to affect all residents residing in the facility. The facility census was 32.

Findings include:

Review of the Week 1 menu revealed the Friday lunch meal was Apricot chicken, couscous, green beans, wheat roll and a lemon bar.

Observation on 07/26/24 at 12:59 P.M. of the tray line revealed the meal included a red wine chicken instead of Apricot chicken and a white roll instead of wheat.

Dietary/Kitchen record review revealed no evidence of a food substitute log.

Interview on 07/26/24 at 5:05 P.M. with Cook #109 revealed they do not have anyplace to write when there is a change to an item on the menu. Cook #109 verified they do not write down when they change menu items.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00155538.

This violation is evidence of continued non-compliance from the survey dated 03/27/24.

Based on medical record review, review of the incident/accident log, and staff interviews, the facility failed to ensure the time, place, date of occurrence, and general description as well as the care provided for resident falls was included on the incident log. This affected three (Residents #18, #28, and #39) out of four residents reviewed for falls. The census was 38.

Findings include:

1. Review of Resident #18's medical record revealed Resident #18 was admitted on 07/23/21 with diagnoses which included chronic kidney disease stage three, dementia, depression, and hypertension.

Review of Resident #18's progress note dated 04/25/24 at 10:10 P.M. revealed Resident #18 got up from the chair in the hallway and began walking to her room with a rollator walker and the walker got away from her. Resident #18 fell and hit the side of her head on a nearby wheelchair. The nurse on duty called the Hospice nurse who came to the facility to assess Resident #18 and requested Resident #18 be sent to the emergency room for evaluation. Resident #18 went to the emergency room on 04/25/24, received two staples to the side of the head, and returned to the facility on 04/26/24 at 4:20 A.M.

Review of the Incident/Accident Log, dated April 2024 through May 2024, revealed there was no information related to Resident #18's fall on 04/25/24 was included on the incident/accident log.

Interview with Director of Nursing (DON) on 05/15/24 at 3:00 P.M. confirmed Resident #18's fall with injury on 04/28/24 at 10:10 P.M. was not included on the facilities incident/accident log.

2. Review of Resident #28's medical record revealed Resident #28 was admitted on 11/26/20 with diagnoses which included dementia, hypertension, tremor, hemiplegia and hemiparesis, type two diabetes, and malignant neoplasm of prostate.

Review of Resident #28's progress note on 04/18/24 at 10:24 A.M. revealed the aide reported Resident #28 was found on the floor. Staff entered the room and Resident #28 was lying on the floor on his left side perpendicular to the bed with a pillow under his head. Resident #28 was alert with confusion and denied pain. The nurse practitioner and Resident #28's daughter were notified of the fall.

Review of Resident #28's progress note on 04/28/24 at 10:09 A.M. revealed the nurse gave in report that Resident #28 slipped off his bed that morning. Resident #28 had an abrasion to the left forehead and scrape to the left elbow.

Review of the Incident/Accident Log, dated April 2024 through May 2024, revealed there was no information related to Resident #28's falls on 04/18/24 and 04/28/24 included on the incident/accident log.

Interview with the DON on 05/15/24 at 3:00 P.M. confirmed Resident #28's falls on 04/18/24 and 04/28/24 were not included on the facilities incident/accident log.

3. Review of Resident #39's medical record revealed Resident #39 was admitted on 05/20/23 with diagnoses which included dementia, cognitive communication deficit, and history of falling.

Review of Resident #39's progress note, dated 04/23/24 at 11:15 A.M., revealed Resident #39 stood up from her chair in the activities room and went to sit back down and sat on the floor. The fall was witnessed and Resident #39 was assessed to have no injuries.

Review of the Incident/Accident Log, dated April 2024 through May 2024, revealed there was no information related to Resident #39's fall on 04/23/24 included on the incident/accident log.

Interview on 05/15/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #430 revealed the facility had no fall policy. LPN #430 stated the nurses know to assess residents for injuries, notify the family and physician, and assess for ways the fall could have been prevented as well as educate the resident on how to prevent falls in the future.

Interview with the DON on 05/15/24 at 3:00 P.M. confirmed Resident #39's fall without injury on 04/23/24 at 11:15 A.M. was not included on the facilities incident/accident log.

This violation is an example of continued non-compliance from the survey dated 10/18/23.

Based on resident and staff interview, observation, and review of Resident Council Meeting Minutes, the facility failed to ensure meals were palatable and appetizing. This had the potential to affect all 38 residents residing in the facility who received meals from the kitchen. The census was 38.

Findings include:

Interview on 05/14/24 at 9:40 A.M. with Resident #38 revealed the food is okay but was very bland and often cold. Resident #38 indicated he mainly goes to the dining hall and the food seems to be warmer when he eats in the dining hall.

Interview on 05/15/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #39 and her daughter shared the sandwich being served with the meat and bun separately on the plate and not made as a sandwich was unappetizing.

Interview with Nurse Aide #400, Nurse Aide #420 and LPN #430 on 05/15/24 between 9:30 A.M. and 9:35 A.M. revealed they all stated the food was unappetizing in appearance and did not taste good. They indicated they would not choose to eat at the facility if there were other options.

Interview with Resident #39's daughter on 05/15/24 at 9:56 A.M. revealed Resident #39 was on a regular diet. Resident #39's daughter indicated Resident #39 refused dinner last evening and stated the food looked and tasted terrible. Resident #39's daughter stated she was present for Resident #39's dinner last evening and agreed the food looked terrible. Resident #39's daughter stated I got mother a Snickers Bar for dinner.

Observation of the lunch food temperatures on the tray line on 05/15/24 at 11:50 A.M. revealed the salmon was 152.2 degrees Fahrenheit, the rice was 186.6 degrees Fahrenheit, the peas were 167.2 degrees Fahrenheit. At 12:10 P.M., the cabbage temperature was obtained and measured 171.3 degrees Fahrenheit. At 12:35 P.M., the perogies temperature was obtained and measured 180.5 degrees Fahrenheit. The food was ready to be served at 12:35 P.M.

Observation and completion of a test lunch tray with the Director of Nursing (DON) on 05/15/24 at 12:55 P.M. revealed the perogies were 122.3 degrees Fahrenheit, the peas were 114.4 degrees Fahrenheit, and the cabbage was 107.6 degrees Fahrenheit. The perogies tasted bland and were chewy. The cabbage was greasy, crunchy, and at times difficult to chew. The peas were cool in temperature.

Interview with the DON on 05/15/24 at 1:07 P.M. revealed the food was cool in temperature. The DON stated they use an open cart as opposed to a closed tray cart to deliver the trays to the resident rooms. The DON agreed the perogies were chewy and bland, and the cabbage was greasy and crunchy.

Interview on 05/15/23 at 1:30 P.M. with Resident #32 revealed Resident #32 had the salmon, peas, rice, and cabbage. Resident #32 indicated the salmon was dry and the cabbage still had the core in it and was too tough to chew.

Interview on 05/15/24 at 1:40 P.M. with Resident #18 revealed the lunch meal on 05/15/24 was bland and unappealing. Resident #18 stated I hope the food is addressed at resident council.

Review of the Resident Council Meeting Minutes, dated 02/09/24, revealed residents voiced concerns that there needed to be more variety of ice cream flavors and food was sometimes over cooked.

Review of the Resident Council Meeting Minutes, dated 03/13/24, revealed the food could be hotter.

The Resident Council Meeting Minutes for April 2024 were requested during the survey however they were not provided to the state surveyor prior to the end of the survey.

Interview with the DON on 05/15/24 around 3:30 P.M. revealed she could not find the April 2024 Resident Council Meeting Minutes.

This violation represents non-compliance investigated under Complaint Number OH00153223.

Based on review of photographic images, policy review and interviews, the facility failed to employ a sufficient number of qualified and trained dietary staff to provide timely, adequate and proper nutrition services. This had the potential to affect all 40 facility residents as they all received meals from the kitchen. The facility census was 40.

Findings include

Interview on 04/17/24 at 9:04 A.M. with Kitchen Manager (KM) #92 revealed facility had only hired one staff member since he started and revealed facility was still short staffed after several kitchen staff resigned. KM revealed he was working just about every day and the facility had two cooks on staff to make all the food for the residents in the assisted living and independent living (a total of approximately 90 residents in both settings).

Interviews on 04/17/24 from 9:15 A.M. to 9:22 A.M. with Dietary Staff (DS) #83 and DS #89 revealed KM #92's daughter had been working at the facility. They revealed she was only about 11 years old and had been working on the tray line as well as passing out food to residents as a dietary staff member would. Staff provided a photograph and confirmed the young girl was behind the kitchen tray line area with food in the tray line warmers. The young girl had no hair net on, no gloves on and was wearing crock shoes instead of slip-resistant safe shoes. They revealed the photo was of KM #92's daughter, who was brought in to help due to low staffing and revealed she was assisting with the breakfast meal in this photograph.

Interview on 04/17/24 at 9:35 A.M. with Executive Director and Health and Wellness Director revealed facility had no new volunteer applications completed in the previous 90 days besides the mother of the Executive Director.

Interviews on 04/17/24 from 2:00 P.M. to 2:10 P.M. with Dietary Staff #83, DS #68 and DS #98 revealed concerns related to a minor child working in the kitchen. They revealed she had been present in the kitchen numerous days and had been handling resident food without proper training and without using hygienic practices. They also revealed she had not gone through proper health screenings that all employees have to go through including physicals and tuberculosis screenings.

Interview on 04/17/24 at 2:09 P.M. with Licensed Practical Nurse (LPN) #95 revealed to her knowledge the facility did not have any events for bringing your child to work day. They had a solar eclipse watch event and an easter egg hunt, but revealed kids would have been outside or sitting in the common areas with their families, not working and providing services to residents.

Interview on 04/17/24 3:20 P.M. with the Health and Wellness Director (HWD) revealed the facility had a solar eclipse party where families were invited to watch outside and an easter egg hunt was held which was also an outside activity with snacks provided. HWD revealed KM #92 had asked permission about a resident's daughter being at the facility over spring break due to child care concerns which was allowed. HWD revealed KM was instructed his daughter should remain in the common area/lobby, the activity room or in his office at all times and should not be in the kitchen or handling food. HWD confirmed the photograph of a child around age 11 working in their facility kitchen and handling resident food was in fact KM#92's daughter. HWD revealed facility management did not give permission for this and had not been informed. HWD revealed facility always had a manager on call if the kitchen needed assistance and revealed she was not aware of a request for assistance. HWD contact the Executive Director on speaker phone during the interview who also confirmed she was not aware of KM #92's daughter handling food especially without safety protocols in place. HWD confirmed photo had a timestamp of 03/30/24 at 6:25 A.M. and confirmed it was the morning of the easter egg hunt, but that activity wound not explain why a child was handling food around breakfast time. Executive Director and HWD were visibly upset and confirmed this was against their facility hiring rules and labor laws. They revealed if he (KM #92) needed assistance he should have contacted the manager on call who would have come in to assist.

Interview on 04/17/24 at 3:30 P.M. with Kitchen Manager #92 confirmed his daughter was at the facility on 03/30/24 and was handling food. He revealed she was traying up cookies, wrapped apples and made a fruit bowl. KM revealed he was the only cook in the facility when this occurred. KM revealed he did not get permission to have his daughter in the kitchen handling food. KM revealed no education was provided to his daughter about safe handling of food and sanitation at this time as she understood more about kitchens than many staff do.

Review of facility policy titled, Employment of Minors dated 12/24/23 revealed minors under 16 shall not be employed unless prior approval from HR Operations Vice President. Signed authorizations must be obtained prior to submitting for health screenings including TB testing, drug screens, physicals and hepatitis B Vaccines and any background check. The policy stated all state and federal child labor law would be maintained and all documentation related to the employment of minors would be retained in accordance of state and federal guidelines.

This violation represents non-compliance investigated under Complaint Number OH00152871.

Based on observation, interview and policy review, facility failed to ensure safe and sanitary condition of kitchen equipment and also failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 40 facility residents as they all received food from the kitchen. The facility census was 40.

Findings include

On 04/17/24 beginning at 9:04 A.M. observation of the facility kitchen, with Kitchen Manager (KM) #92 revealed in the freezer there were small sausage pieces that were undated and a large box of lima beans that were open to air and undated. KM #92 voiced he was unaware of frozen food needing dated after being opened. He also stated facility did not date items upon arrival/delivery.

In the refrigerator, a package of hot dogs was observed to be open to air and undated, a tray of corned beef had an unknown liquid substance pooled on the foil covering, a bag of raw chunks of meat (cut into skewer or kabob size) was dated 04/09/24. At the time of the observation, KM #92 revealed the food dated 04/09/24 was old and threw it out. Old lunch meat ham was dated 04/07/24 and KM #92 revealed it should be discarded after seven days, a cottage cheese container had a use by dated of 04/16/24. Mozzarella cheese was found open to air and dated 03/19/24 with a discard date of 04/19/24. KM #92 revealed this was misdated and should be discarded after seven days. Two packages of lunch meat were found to be open to air. The refrigerator also had two open staff drinks mixed in with resident food.

In the dry storage area there was one bag of white cake mix dated 8/20 with a discard date of 11/30, a bag of cane sugar and a bag of powdered sugar both were undated and a box of rice was uncovered and open to air. KM #92 confirmed the findings at the time of the observation, revealed he was getting a container for the rice and indicated he had not baked since starting a month ago.

On 04/17/24 at 9:12 A.M. observation of the fryer revealed it appeared dirty with thick layer of back dried grease on the edges with about 10 dried and some blackened fries on the interior lip of the machine. The grease appeared dark and had chunks of food in it.

Interview with Kitchen Manager #92 confirmed breakfast (on 04/17/24) included bacon, eggs, pancakes, sausage but stated none of it was made in the fryer. He observed the grime and the food residue left in the fryer and stated it should be cleaned after each meal it was used and confirmed it was dirty.

Interview on 04/17/24 at 9:15 A.M. with Dietary Staff (DS) #83 revealed she comes into work after the kitchen manager and revealed the kitchen was always dirty with items from the previous days meals on the floors, countertops and cooking services.

Interview on 04/17/24 at 9:22 A.M. with Dietary Staff #89 revealed staff did not use the fryer much but did reveal it had been used to make resident food in the previous few days. DS #89 revealed it did not look like the fryer had been cleaned and confirmed using it for resident meals without cleaning it or changing out the oil. DS #89 revealed when she arrived to work she saw a dirty kitchen with food scraps and residue on counters and cooking equipment.

Review of facility procedure titled, Food and Nutrition Services - Cleaning and Cleaning schedule dated 07/2018 revealed food safety was at risk when the kitchen was not kept clean and the population of medical facility's includes resident already at risk of getting sick. Dirty equipment was a breeding ground for bacteria. Kitchen and cooking equipment should be cleaned and sanitized as they are used and the food service director should be rounding to ensure cleanliness.

Review of facility procedure titled, Food and Nutrition Services - labeling and dating foods dated 07/2018 revealed food items would be labeled for food safety. Items shall be labeled with delivery date, the labels should include the name of the item and date it was prepared or opened and the date the item should be used by. Ready to eat food from processing plant should be marked when opened and held for no more than seven days.

Review of facility procedure titled, Food Storage Main Kitchen Section III - Production and Controls dated 06/2020 revealed food shall be stored in a safe and sanitary manner including be labeled and dated. Food should be stored in sanitary storage containers with lids or in a food quality plastic bag and label contents and date as appropriate. Frozen food should also be dated and sealed and food should be discarded after when it exceeded the expiration date or use by date.

This violation represents non-compliance investigated under Complaint Number OH00152871. This violation is also an example of continued non-compliance from the survey dated 03/27/24.

Based on record review and staff interview, facility failed to ensure background checks were completed for staff upon hire. This had the potential to affect all residents residing in the facility. The facility census was 38.

Findings include:

Review of the personnel files for Caregivers (CG) #105 and #123 and Licensed Practical Nurse (LPN) #42 revealed they did not include evidence of criminal background checks being completed.

Interview 03/27/24 at 11:00 A.M. with Human Resources Director (HRD) #43 confirmed the facility had no record of background checks being completed for CG #105 hired August 2000, CG #123 hired July 2023, and LPN #42 hired February 2006. HRD #43 confirmed all staff are required to have background checks completed prior to hire before they can begin working.

Review of facility policy titled Criminal History Check dated 01/14/13 revealed facility should conduct criminal background checks within the guidelines of specific state laws. All applicants offered employment should undergo a criminal background check and employment would be contingent upon the results.

This violation represents non-compliance investigated under Complaint Number OH00152339.

Based on observation and staff interview, the facility failed to ensure safe and sanitary storage of food items. The facility also failed to ensure the kitchen equipment was maintained in a sanitary manner including cooking surfaces, cooking and serving utensils and the food thermometer. This had the potential to affect all residents residing in the facility. The facility census was 38.

Findings include:

Observation on 03/25/24 at 11:00 A.M. revealed the refrigerator contained the following undated items: French toast, smoked sausage, a block of cream cheese, a large bag of shredded cheese, a zip lock bag of bacon. Further observation revealed there were several trays of raw fish thawing directly over cooked food. Observation revealed the freezer contained a large box of vegetables that was also left open to air and several individual bags of vegetables removed from their box and not dated. Observation of the flat top grill revealed it was still dirty from breakfast with quarter-sized chunks of egg on top of the grill and on the sides of the cooking surface. There was a spatula on the grill covered with chunks of egg and leftover breakfast food.

Interview on 03/25/24 at 11:05 A.M. with Kitchen Manager (KM) #73 confirmed the observations of the refrigerator, the freezer and the grill. KM #73 confirmed the staff had not been properly trained on storing food including labeling, dated, sealing open container, and safe storage practices.

Observation on 03/25/24 at 12:05 P.M. revealed KM #73 began taking food temperatures. KM #73 placed the thermometer in the veal parmesan and then wiped the thermometer off with a dry rag and placed the thermometer in the spaghetti noodles. KM #73 then wiped the thermometer with the same rag and placed the thermometer in the chicken alfredo sauce.

Interview on 12:15 P.M. with KM #73 confirmed he had not used sanitation wipes or solution to clean the thermometer between each food item.

Observation of tray line on 03/25/24 at 12:25 P.M. revealed KM #73 was preparing hamburgers for lunch and used the dirty spatula on the flat top grill which still had egg residue from the breakfast meal.

Interview on 03/25/24 at 12:25 P.M. with KM #73 confirmed he used the spatula which had egg residue from breakfast to flip the hamburgers for the lunch meal. KM #73 confirmed the grill and equipment should be cleaned after each meal.

Interview on 03/26/24 at 12:34 P.M. with Administrator confirmed the facility had no policies regarding food storage, sanitation, or kitchen cleanliness.

This violation represents noncompliance investigated under Complaint Number OH00152131.

Based on record review, observation, and staff interview the facility failed to ensure menus and spreadsheets were created and followed to ensure proper nutrition and serving sizes. This had the potential to affect all residents residing in the facility. The facility census was 38.

Findings include:

Review of the menu dated March 2024 revealed it included a weekly rotation of meals and had been signed off by a dietitian in January 2024. The menu did not indicate serving sizes of the items. There were no spreadsheets to accompany the menu.

Observation of tray line on 03/25/24 at 12:00 P.M. revealed Cook #44 was plating the lunch meal which included veal parmesan, chicken alfredo with spaghetti noodles, broccoli, fried cabbage, dinner roll and pumpkin pie. Cook #44 was using tongs to plate the broccoli and some servings looked to be about one-half cup in size while other plates got only one broccoli floret.

Interview on 03/25/24 at 12:15 P.M. with Cook #44 confirmed he did not know the proper serving sizes for the food items, so he was just some of each item on the plate and doing a visual check of the amounts.

Interview on 03/25/24 at 2:00 P.M. with Kitchen Manager #73 confirmed the facility was not following the menu. KM #73 confirmed he started about a week ago and he had made meals looking at what he had available. KM #73 confirmed the lunch meal on 03/25/24 was not on the current menu and the staff were not using spreadsheets to determine appropriate portion sizes.

Interview on 03/26/24 at 12:34 P.M. with Administrator confirmed the facility had no policies regarding meals, spreadsheets, menus, or serving sizes.

This violation represents non-compliance investigated under Complaint Number OH00152065.

Based on record review and staff interview, the facility failed to ensure a resident received the full course of an antibiotic for the treatment of a urinary tract infection (UTI) as ordered by the physician. This affected one resident (#37) of three residents reviewed for infections.

Findings include:

A review of Resident #37's medical record revealed she was admitted to the facility on 02/21/20. Her diagnoses included a history of urinary tract infections, congestive heart failure, and adult onset diabetes mellitus.

A review of a nurse practitioner visit note dated 12/21/23 revealed Resident #37 was seen at the request of the nursing staff and the resident for a suspected UTI. The resident was indicated to be symptomatic for a UTI with urinary urgency and frequency. A urinalysis (U/A) with reflex culture had been previously ordered and was indicated to be pending.

A review of Resident #37's physician's orders revealed a U/A with culture and sensitivity (C&S) was re-ordered by the nurse practitioner. The order was dated 12/21/23.

A review of a laboratory report for a U/A with a culture if indicated that was collected on 12/22/23 revealed it was positive for a UTI. The culture indicated the resident had greater than 100,000 CFU/milliliters (ml) of Escherichia Coli (bacteria that was normally present in the intestines of healthy people) and between 10,000 to 15,000 CFU/ml of Enterococcus Faecalis.

Further review of Resident #37's physician's orders revealed the resident was ordered to receive Bactrim DS one tablet by mouth twice a day for three days and Cipro 250 milligrams (mg) by mouth every 12 hours for ten days for the treatment of a UTI. The order was written on 12/26/23.

A review of Resident #37's medication administration record (MAR) for December 2023 revealed the resident was to receive Bactrim DS one tablet by mouth twice a day for three days beginning on 12/27/23. The antibiotic was to be given through 12/29/23 and the times for administration was at 8:00 A.M. and 8:00 P.M. The MAR was not documented on to reflect the resident was given the evening doses of the Bactrim DS for any of the three days it was supposed to be given. According to the documentation on the MAR only half of the doses were given over that three day period. Findings were verified by the Director of Nursing (DON).

On 01/24/24 at 11:00 A.M., an interview with the DON confirmed Resident #37's MAR for December 2023 showed she only received half of the doses of Bactrim DS between 12/27/23 and 12/29/23 that was ordered for the resident to treat a UTI. She verified the MAR did not show any evidence of the evening doses of the antibiotic being given as there were no nurses' initials entered to signify the medication had been given. She acknowledged without the medication being signed off on the MAR there was no evidence it was given to the resident as ordered.

This violation represents non-compliance investigated under Master Complaint Number OH00150394 and Complaint Number OH00150205.

Based on record review and staff interview, the facility failed to conduct 12 fire exit drills, one conducted on each shift at least every three months and under varied time and conditions, failed to include movement of residents capable of self-evacuation to safe areas or to the exterior of the structure on at least two fire drills per year on each shift, and failed to complete an evaluation of the fire exit drill. This had the potential to affect all 43 residents.

Findings include:

1. Review of the facility's 2023 fire exit drills, revealed the facility conducted one evacuation drill and ten fire drills in 12 months.

2. None of the fire exit drills moved residents capable of self-evacuation to safe areas during each drill.

3. The ten fire exit drills for 2023 did not have an evaluation of the drill.

Interview with Building Services Coordinator (BSC) #6 at 10:25 A.M. on 01/25/24, confirmed there were no fire exit drills done for the months of November 2023 and January 2024. BSC #6 verified the drill conducted in January 2024 was a general evacuation drill.

This violation represents non-compliance investigated under Complaint Number OH00150191.

Based on record review and staff interview, the facility failed to ensure a resident's urinary tract infection (UTI) was identified timely and was adequately treated to resolve her infection. This affected one resident (#37) of three residents reviewed for infections.

Findings include:

A review of Resident #37's medical record revealed she was admitted to the facility on 02/21/20. Her diagnoses included a history of UTI's, congestive heart failure, and adult onset diabetes mellitus.

A review of a nurse practitioner visit note dated 12/05/23 revealed Resident #37 was seen on that date for having symptoms consistent with a UTI. A urinalysis (U/A) with reflex to culture was ordered to rule out a UTI.

A review of Resident #37's physician's orders revealed there was an order for a U/A with reflex to culture to be done. The order was received on 12/05/23.

A review of Resident #37's laboratory reports revealed a U/A had been collected on 12/06/23 at 6:04 A.M. The lab report indicated it was for a Urinalysis with microscopic (final results). It was resulted on 12/06/23 at 8:50 P.M. The urine had many bacteria in it. There was no evidence of a culture being done.

A review of a nurse practitioner visit note dated 12/21/23 revealed Resident #37 was seen again for a suspected UTI. The nurse practitioner gave an order for another U/A and C&S to be done.

A review of Resident #37's laboratory report for the U/A with culture revealed the second urine specimen was collected on 12/22/23 at 11:32 A.M. A culture had been performed with that test and the results were reported on 12/26/23 at 8:13 A.M. The culture report showed the resident's urine contained greater than 100,000 CFU/milliliters (ml) of Escherichia Coli and 10,000 to 15,000 CFU/ml of Enterococcus Faecalis.

A review of a nurse practitioner visit note dated 12/26/23 revealed Resident #37 was seen on that date for a UTI. The visit note indicated the resident was suspected as having had a UTI as she was known to be symptomatic and a U/A with reflex to culture had been previously ordered and was pending as of 12/21/23. Another U/A was ordered and the results were noted to be positive on 12/26/23 with that visit. The nurse practitioner indicated she was going to start the resident on Cipro and Bactrim for a total of three days.

A physician's order dated 12/26/23 confirmed Resident #37 was ordered to receive Bactrim DS one tablet by mouth (po) twice a day (BID) for three days. She was also ordered to receive Cipro 250 milligrams (mg) po every 12 hours for three days.

A review of Resident #37's medication administration record (MAR's) for December 2023 revealed the Bactrim DS was scheduled to be given at 8:00 A.M. and 8:00 P.M. beginning on 12/27/23 and was to continue through 12/29/23 for a total of three days. The MAR did not show documented evidence of the Bactrim DS being given twice a day as ordered during that three day period. Doses were not documented as having been given for the evening doses due 12/27/23, 12/28/23, or 12/29/23.

A review of a nurse practitioner visit note dated 01/04/24 revealed Resident #37 was seen on that date for continued urinary symptoms. The note indicated the resident had antibiotics ordered and had completed the course of the antibiotic treatment, but continued to have symptoms of a UTI. The physician indicated the Bactrim DS would be extended for two more days. A physician's order dated 01/04/24 confirmed Bactrim DS had been ordered to be given BID for two more days for the continued treatment of a UTI.

A review of Resident #37's MAR for January 2024 revealed there was no documented evidence of the resident receiving Bactrim DS BID for two more days, after being ordered on 01/04/24 for the continued treatment of a UTI. The MAR had a blue squiggly line through it and a hand written note to see new order. The MAR did not have another order that pertained to Bactrim DS and there was no evidence of any additional doses being given for two more days as was ordered by the nurse practitioner.

On 01/24/24 at 11:00 A.M., an interview with the Director of Nursing (DON) confirmed the U/A that was done on 12/06/23 did not have a culture done with it to identify any organisms that were present when Resident #37 was symptomatic for a UTI. She had contacted the nurse practitioner that visited the resident in the facility and confirmed another U/A and C&S had been ordered on 12/21/23, as the previous U/A completed on 12/06/23 did not include a reflex culture as was intended. She stated the need for a reflex culture was not included on the lab slip when it was sent to be processed by the lab. She acknowledged Resident #37 had a delay in the identification and treatment of her UTI as a result. Her UTI was not treated until 12/26/23 (20 days after the initial lab test was ordered). She further acknowledged the MAR's for December 2023 and January 2024 revealed the resident was not given the full course of her antibiotic treatment that was to be given twice a day for a total of three days. She acknowledged the evening doses of the Bactrim DS had not been signed off as having been given with the 8:00 P.M. doses on 12/27/23 through 12/29/23. She was also not able to show two additional days of Bactrim DS had been given to the resident when ordered on 01/04/24.

This violation represents non-compliance investigated under Master Complaint Number OH00150394 and Complaint Number OH00150205.

Based on observations, resident, family, and staff interviews, medical record review, and facility policy review, the facility failed to ensure the elevator was maintained in good working condition. The deficiency affected two residents (Residents #28 and #39) and had the potential to affect four additional residents (#30, #36, #38, and #47) identified by the facility to require assistance to get from the second floor to the first floor. The facility census was 46.

Findings include:

Observation on 01/02/24 at 9:20 A.M. revealed the facility's elevator was not working and had an Out of Order sign posted to cover the elevator buttons.

Review of the medical record for Resident #28 revealed an admission date on 01/15/23. Medical diagnoses included Alzheimer's Disease, muscle weakness, anxiety disorder, and heart disease.

Review of the Nursing Admission Evaluation dated 02/26/23 revealed Resident #28 was alert to person only and had a recent change in cognitive status. Resident #28 had unstageable bilateral heel ulcers and was noted as bedfast. The resident required one person assistance with ambulation and transfers, required limited assistance with all Activities of Daily Living (ADLs), and had impaired safety awareness, impaired balance, and unsteady gait.

Interview and observation on 01/02/24 at 12:05 P.M. of Resident #28 and the resident's daughter (Daughter (DTR) #140) revealed the resident was sitting in a broda chair in her room with DTR #140 sitting beside her. Resident #28 and DTR #140 stated when the facility's elevator worked, the resident went downstairs to eat dinner sometimes, and attended church and various other activities offered in the afternoons and evenings. However, since the elevator has not been working, Resident #28 had not attempted to go downstairs because it would require two to three staff to assist the resident to use the chair lift. DTR #140 stated she did not want Resident #28 to be isolated in her room but it was difficult without a working elevator for the resident to safely be able to leave her room to go downstairs.

Review of the medical record for Resident #39 revealed an admission date on 10/22/21. Medical diagnoses included Systemic Inflammatory Response Syndrome (SIRS), hypo-osmolality and hyponatremia, atrial fibrillation, chronic pain syndrome, and cognitive communication deficit.

Review of the annual Nursing Admission Evaluation dated 12/12/22 revealed Resident #39 was alert and oriented to person, place, and situation. Resident #39 used a wheelchair for mobility, required one person assistance with ambulation and transfers, and required limited assistance with bed mobility and dressing and extensive assistance for toileting and bathing.

Interview on 01/02/24 at 12:10 P.M. with Resident #39 revealed she had not attempted to go downstairs since the elevator broke down because she needed a walker or wheelchair and staff to assist her. Resident #39 stated she enjoyed engaging in activities downstairs and missed the activities. Resident #39 stated, if the elevator was working, I would go downstairs more often.

Interview on 01/02/24 at 10:05 A.M. with Licensed Practical Nurse (LPN) #70 revealed the facility's elevator had been out of service since 12/23/23. There were residents on the second floor who needed extensive assistance from two or more staff in order to use the chair lift to get downstairs. LPN #70 stated initially the elevator was supposed to be fixed by 12/26/23 but now the staff had been told it would take at least 30 days.

Interview on 01/02/24 at 10:50 A.M. with Maintenance Director (MD) #112 confirmed the facility's elevator had been out of service since 12/23/23. MD #112 contacted the contractor who assessed the elevator for repair and determined the elevator repairs would take 30 days once the facility's corporate office approved a proposal. MD #112 stated the elevator was old and outdated and has needed multiple repairs since 2021.

Review of the Service and Repair Order dated 12/26/23 revealed a repair proposal with estimated cost had been provided to the facility. However, the proposal was pending approval at the time of the survey investigation.

A facility policy was requested at the time of the survey but no policy was provided.

This violation represents non-compliance investigated under Complaint Number OH00149490.

Based on medical record review, review of a police report, review of the resident sign-out sheet, review of resident two-hour check logs, review of the incident log, review of the facility incident report, resident interview, staff interview, and facility policy review, the facility failed to ensure Resident #27 was provided a safe environment and adequate supervision to prevent elopement. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death, when Resident #27, who was independently mobile and maintained a personal vehicle at the facility, signed himself out of the facility on 12/18/23 at 12:35 P.M. to go to the grocery store and did not return to the facility. Resident #27's Health Care Power of Attorney (HCPOA)/Daughter was not notified the resident was missing until 12/19/23 at 9:00 A.M. (approximately 18 hours later). Resident #27's HCPOA filed a missing person report with the local police station on 12/19/23 at 12:16 P.M. (approximately 24 hours later) when she was unable to locate Resident #27 and a Silver Alert (an endangered missing adult alert) was initiated. Resident #27 was located by the police at an unknown home approximately 25 minutes away from the facility on 12/19/23 at approximately 6:00 P.M. Resident #27 reported being cold and that he had slept in his car overnight on 12/18/23. Resident #27 and his HCPOA were transported by the police to a local hospital where he was evaluated and admitted until 12/20/23 due to missed prescription medications for over 36 hours and considerable pain. This affected one resident (#27) of three residents reviewed for accidents and had the potential to affect four additional residents (#1, #14, #38, and #40) identified by the facility as having the ability to leave the center. The facility census was 46.

On 12/27/23 at 4:10 P.M., the Executive Director and Regional Director of Operations (RDOO) #135 were notified Real and Present Danger began on 12/18/23 at 12:35 P.M. when Resident #27 signed out of the facility to go to the grocery store and did not return. Resident #27's HCPOA was notified the resident was missing on 12/19/23 at 9:00 A.M. (approximately 18 hours later). A missing person report was filed with the local police department by Resident #27's POA on 12/19/23 at 12:16 P.M. (approximately 24 hours after the resident signed out). The police located Resident #27 approximately 25 minutes away from the facility where the resident reported being cold and that he had slept in his car overnight on 12/18/23. The police transported Resident #27 and Resident #27's HCPOA to a local hospital where the resident was admitted until 12/20/23.

The Real and Present Danger was abated on 12/30/23 when the facility implemented the following corrective actions:

Between 12/26/23 and 12/30/23 the Executive Director/designee initiated missing persons education with Assisted Living caregivers and licensed staff.

Between 12/26/23 and 12/30/23 the Executive Director/designee-initiated education with Assisted Living caregivers and licensed staff regarding residents' two-hour checks and accurate documentation.

Between 12/26/23 and 12/30/23 the Executive Director/designee-initiated education regarding the resident sign out process with the Assisted Living caregivers and licensed staff.

On 12/28/23 the Executive Director/designee reviewed the Resident Handbook with Resident #27 regarding the responsibilities of the resident while residing in the assisted living center. On 12/28/23 Resident #27's face sheet was updated to include a new cell phone number. The sign-out process was reviewed as part of the Resident Handbook individually with Resident #27 on 12/28/23 and a signature obtained. The center has updated the primary care physician regarding the resident's current condition. On 12/29/23 the physician ordered an emergent psychological evaluation (date of which is pending) with the service provider. The center has spoken with the Power of Attorney (POA)/Resident Representative (RR) regarding the previous Leave of Absence (LOA) concern(s). The POA/RR is reviewing the continued need to have a vehicle at the center and other possible living arrangements.

On 12/28/23 the facility reviewed current residents to determine who had the ability to independently leave the center. There were four (4) additional residents, Resident #1, #14, #38, and #40, not including Resident #27, who had the ability to leave the center. The facility implemented a plan to have these four (4) residents (#1, #14, #38, and #40) assessed on or within 12 days of 12/28/23 by a licensed nurse to determine their cognitive ability to leave the facility independently. The assessments will be documented on Monthly Wellness Visit sheets for each resident. In addition, the Executive Director/designee would review the Assisted Living sign-out log for the last 30 days to ensure Assisted Living residents were following the process for signing out. Current resident face sheets were reviewed to validate emergency contact information was available.

By 12/30/23 the Executive Director/designee would revise its current sign-out log to include Anticipated Time of Return and Name/Contact Number. The current sign-out book for Assisted Living would be moved from the main entrance reception area to the nursing station(s) so the nursing staff could validate when an Assisted Living resident had signed out, when they anticipate returning, and a contact number while they were away from the center. The facility identified this process reduced the opportunity of both Assisted Living and Independent Living residents utilizing the same sign-out log. The Assisted Living center has 24-hour nursing staff to assist with the sign-out process whereas the reception area is open select hours of the day. Education would be provided to current residents and/or POA/RR on the revised process by 12/30/23 by the Executive Director/designee. The Assisted Living center nursing staff would also be educated on the revised sign-out process by 12/30/23 by the Executive Director/designee. In addition, the Assisted Living center nursing staff would receive education on the resident two-hour check process and documentation. Licensed nurses would be educated on the process placing and documenting a resident who was on alert charting. Staff members who were not active on the schedule would be in serviced via phone or educational packet prior to their return to work by the Executive Director/designee. As of 12/30/23 30 assisted living employees out of 34 assisted living employees would be educated. The remaining four employees would be provided with education via educational packet. New Assisted Living staff would be in-serviced on these changes as part of their new hire orientation.

The facility developed a plan for twice a week random audits to be conducted by the Executive Director/Designee for the next 30 days on the resident 2-hour check compliance to validate staff were accurately completing the forms. Findings from the audits would be reported to the community's Safety Committee for review and any additional action steps.

The facility developed a plan for twice a week random missing resident drills to be conducted by the Executive Director/Designee for the next 30 days to validate staff understanding of the missing resident procedure. Findings from the missing resident drills would be reported to the community's Safety Committee for their review and any additional action steps.

The facility developed a plan for the sign-out process to be audited randomly twice a week by the Executive Director/designee for the next 30 days to validate assisted living residents signed out of the center in accordance with the new process. Findings from the audits would be reported to the community's Safety Committee for their review and any additional action steps.

The facility developed a plan for twice a week random audits of alert charting documentation to be conducted by the Executive Director/designee to validate alert charting was being completed for residents who met the criteria for alert charting. Findings from the audits would be reported to the community's Safety Committee for their review and any additional action steps.

Although the Real and Present Danger was abated on 12/30/23, the violation remains as the facility was in the process of monitoring and implementing their correction actions.

Findings include:

Review of the medical record for Resident #27 revealed an original admission date on 06/12/21 and a readmission date on 06/20/22. Medical diagnoses included type II diabetes mellitus, asthma, chronic systolic heart failure, hypertension (high blood pressure), hypotension (low blood pressure), major neurocognitive disorder (characterized by the progressive and persistent deterioration of cognitive function), adjustment disorder with mild anxiety and depressed mood, chronic pain syndrome, and cocaine abuse.

Review of Resident #27's Health Care Power of Attorney (HCPOA) dated 10/04/16 revealed the resident appointed his daughter, (DTR) #150 to be his POA.

Review of the annual Nursing Admission Evaluation dated 06/14/23 revealed Resident #27 was alert and oriented to person, place, and situation. Resident #27 had an implanted pain pump for chronic pain. Resident #27 used a walker/cane/crutch to assist with mobility, was independent with completing activities of daily living (ADLs), was on prescribed antipsychotic and antidepressant medications and had chronic skin lesions on both lower legs.

Review of physician's orders dated December 2023 revealed Resident #27 had the following orders: Carvedilol (for high blood pressure and heart failure) 6.25 milligrams (mg) tablet with instructions to give one tablet twice daily at 7:00 A.M. and 9:00 P.M. dated 08/03/23, Gabapentin (for nerve pain) 800 mg tablet with instructions to give one tablet three times daily for chronic pain at 7:00 A.M., 12:00 P.M., and 9:00 P.M. dated 08/03/23, Januvia 50 mg tablet with instructions to give one tablet daily for diabetes mellitus (DM) at 7:00 A.M. dated 08/03/23, Losartan Potassium 50 mg tablet with instructions to give two tablets every morning at 7:00 A.M. for hypertension (HTN) dated 08/03/23, Quetiapine 25 mg tablet with instructions to give one tablet at bedtime at 9:00 P.M. for depressive disorder dated 08/03/23, Quetiapine 50 mg tablet with instructions to give one tablet daily at bedtime at 9:00 P.M. for depressive disorder dated 08/03/23, Trazodone 150 mg tablet with instructions to give one tablet daily at bedtime for insomnia at 9:00 P.M. dated 08/03/23, Novolog insulin with instructions to inject subcutaneously per a sliding scale three times daily with meals dated 08/03/23, Novolog insulin with instructions to inject 18 units subcutaneously three times daily before meals at 7:00 A.M., 11:00 A.M., and 4:00 P.M. dated 08/03/23, and Lantus insulin with instructions to inject 50 units subcutaneously daily at bedtime at 8:00 P.M. dated 09/17/23.

Review of the undated Individualized Service Plan revealed Resident #27's mental status was cooperative and forgetful. Resident #27 was independent with ADLs and mobility. Resident #27 liked his independence and frequently refused care. There was no further information included on the service plan.

Review of the incident log dated from 10/10/23 to 12/25/23 revealed Resident #27 was on the log for an elopement incident on 12/20/23.

Review of the resident sign-out sheet revealed Resident #27 signed out of the facility on 12/18/23 at 12:35 P.M. to go to a local grocery store. There was no evidence Resident #27 returned to the facility.

Review of the Resident Two Hour Check sheet dated 12/18/23 revealed State Tested Nurse Aide (STNA) #80 noted Resident #27 was observed in his living room at 2:00 P.M. and bathroom at 4:00 P.M. on 12/18/23.

Review of the Medication Administration Record (MAR) on 12/18/23 revealed Resident #27 received morning medications and was marked as being on a Leave of Absence (LOA) for evening and bedtime medications.

Review of the Resident Two Hour Check sheet dated 12/19/23 revealed STNA #151 noted Resident #27 was observed in his bedroom at 10:00 P.M., 12:00 A.M., 2:00 A.M., and 4:00 A.M. on 12/19/23.

Review of the MAR on 12/19/23 and 12/20/23 revealed Resident #27 continued to be marked as LOA on 12/19/23 for all medications. Resident #27 was marked as hospital on 12/20/23 for morning, afternoon, and evening medications. Resident #27 received bedtime medications as ordered on 12/20/23.

Review of the nursing progress note for Resident #27 revealed on 12/19/23 (untimed), Licensed Practical Nurse (LPN) #70 noted she was informed in the morning on 12/19/23 by the night shift nurse that Resident #27 was not in his room all evening. LPN #70 went to the resident's room and searched for Resident #27 but was unsuccessful. LPN #70 called DTR #150 and notified her that Resident #27 had not been in his room or the facility during night shift on 12/18/23. DTR #150 attempted to locate Resident #27 as well but was unsuccessful and informed LPN #70 she was filing a missing person report. There was no further contact with DTR #150. LPN #70 noted she attempted to follow-up with DTR #150 on 12/20/23 and left a voicemail message with no return contact received. An additional note dated 12/19/23 (date appears to be an error) at 7:00 P.M. by an unknown nurse stated Resident #27 was not feeling well and ended up in the hospital. The resident was not able to recall how he arrived there but Resident #27 was admitted and discharged on 12/20/23. Resident #27 returned to the facility on 12/20/23 at 7:00 P.M. from the hospital with complaints of back pain. Resident #27 had a morphine pump inserted to the right-side of his abdomen. On 12/21/23 (untimed), an unknown nurse noted Certified Nurse Practitioner (CNP) #105 visited Resident #27. New orders for labs were received and a referral for wound care. There were no other notes related to the incident on 12/18/23.

Review of the Incident Management Report dated 12/20/23 at 11:11 A.M. revealed Resident #27 signed himself out of the facility on 12/18/23 at 12:35 P.M. The behavior was not unusual for the resident because he was ambulatory and still drove a personal vehicle. Later in the evening, dining staff noticed Resident #27 was not in his room when his meal tray was delivered. The following morning on 12/19/23, the floor nurse reached out to DTR #150 and was able to make contact. DTR #150 agreed to attempt to locate Resident #27 before contacting the police. Later in the afternoon on 12/19/23, DTR #150 notified the facility she was not able to locate Resident #27 and would be contacting the local police department to report Resident #27 missing. A Silver Alert went out on 12/19/23 at 4:00 P.M. Resident #27 was found unharmed, but the police transported Resident #27 to a local hospital for observation due to not receiving prescription medications for more than 24 hours. There were no written statements from any staff or residents included with the incident report investigation.

Interview on 12/26/23 at 10:27 A.M. with Resident #27 revealed the resident was hesitant to speak with this surveyor regarding the events on 12/18/23 and 12/19/23. Resident #27 stated he did drive himself in his own vehicle that was kept at the facility to run errands. Resident #27 stated he left the facility on 12/18/23 to get a battery for his watch and became confused. Resident #27 stated, that was really rough on me. Resident #27 indicated he could not recall where he was found, who found him, or how long he had been gone from the facility but remembered he did go to the hospital for observation and to receive prescription medications. Resident #27 became agitated and strongly requested this surveyor not contact DTR #150 regarding the incident and stated, that's my business.

Interview on 12/26/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #70 revealed she worked day shift on 12/19/23 and was the first staff person to be in contact with Resident #27's HCPOA/DTR #150 about the resident missing. LPN #70 arrived at the facility on 12/19/23 at 6:00 A.M. and was informed by LPN #72 that Resident #27 was not in his room or that he had been seen in the facility during night shift on 12/18/23. LPN #72 stated Resident #27 was marked as being on a LOA on the MAR but did not report exactly what time Resident #27 left on 12/18/23. LPN #70 checked Resident #27's room to search for the resident but was not able to locate him. LPN #70 contacted DTR #150 on 12/19/23 at approximately 9:00 A.M. (approximately 18 hours after the resident signed out) and notified her Resident #27 had not returned to the facility after signing out on 12/18/23. DTR #150 stated she was aware Resident #27 planned to go to the bank, the grocery store, and going to buy a new cell phone on 12/18/23 but she had not seen or spoken to the resident recently. DTR #150 agreed to try to locate Resident #27. On 12/19/23 at approximately 12:00 P.M., DTR #150 contacted LPN #70 to inform she was not able to find Resident #27 and planned to file a missing person report with the police department. LPN #70 stated there was an alert that was sent out on the local news and the resident was found around 6:00 P.M. on 12/19/23. Resident #27 was taken to the hospital and returned to the facility on 12/20/23. LPN #70 stated Resident #27 was typically alert and oriented and left the facility frequently. The resident would be gone for two or three hours and then return. LPN #70 stated Resident #27 never stayed away from the facility overnight. LPN #70 stated Resident #27 had displayed some abnormal behaviors including hiding in the closet and bathroom, hoarding items, and increased agitation prior to this incident, but stated she had not documented anything in the resident's record or reported any of the behaviors to any other staff for follow-up.

Interview via telephone on 12/26/23 at 1:56 P.M. with LPN #71 revealed she worked during day shift on 12/18/23 and was assigned to care for Resident #27. LPN #71 stated Resident #27 was not in his room when she attempted to check the resident's blood glucose levels at approximately 12:00 P.M. or 4:45 P.M. LPN #71 stated Resident #27 frequently left his room as well as the facility, but she was not aware Resident #27 had signed himself out of the facility on 12/18/23. LPN #71 stated the staff did not usually check the sign out sheets at the front desk. Resident #27 would typically leave the facility for four to five hours but always returned to the facility and had not stayed gone overnight before. LPN #71 stated she reported to the night shift nurse (LPN #72) that Resident #27 was not in his room around 5:00 P.M. when she last checked but did not report the resident had left the facility. LPN #71's shift ended around 6:15 P.M. on 12/18/23 and she did not work again until 12/20/23.

Interview via telephone on 12/26/23 at 3:35 P.M. with LPN #72 revealed he was Resident #27's nurse during night shift on 12/18/23. LPN #72 stated Resident #27 was not in his room or seen in the facility during his shift from 6:00 P.M. to 6:00 A.M. on 12/19/23. LPN #72 stated LPN #71 reported to him that Resident #27 was not in his room and assumed the resident had left with family or something. LPN #72 stated he marked Resident #27 as being on LOA on the MAR. LPN #72 stated he had not notified any administrative staff, physician, or Resident #27's HCPOA/DTR #150 because he did not think he should be concerned, and the resident did not leave during his shift.

Interview via telephone on 12/27/23 at 9:40 A.M. with Certified Nurse Practitioner (CNP) #105 revealed she had only seen Resident #27 once prior to 12/18/23 but had been told by the previous CNP that the resident did leave the facility on his own and had some cognitive deficits. CNP #105 stated she was not aware of any changes in Resident #27's behavior or cognition prior to 12/18/23. CNP #105 stated it would have been abnormal for Resident #27 to stay gone from the facility overnight and this should have alerted staff as being concerning.

Interview on 12/27/23 at 10:05 A.M. with the Executive Director (ED) confirmed she was not notified Resident #27 was missing until the morning of 12/19/23. The ED confirmed the documentation on the two-hour resident check sheet dated 12/19/23 was inaccurate because Resident #27 was in the hospital until 12/20/23.

Interview via telephone on 12/27/23 at 11:30 A.M. with State Tested Nurse Aide (STNA) #80 revealed she was the aide assigned to care for Resident #27 during second shift from 2:00 P.M. to 10:00 P.M. on 12/18/23. STNA #80 stated she thought she saw Resident #27 in the front lobby area at the beginning of her shift around 2:00 P.M. but she was not able to say for certain whether she had seen him or not. STNA #80 confirmed she had checked Resident #27's room around 3:45 P.M., 5:10 P.M., and between 6:00 P.M. and 7:00 P.M. and Resident #27 was not observed in his room. STNA #80 stated she had noticed Resident #27 had been more antsy and impatient than usual prior to 12/18/23 but had not reported the changes to the nurse or any other staff because she did not think it was big deal.

Review of the police report dated 12/27/23 at 12:56 P.M. revealed a missing person report was opened for Resident #27 on 12/19/23 at 12:16 P.M. by DTR #150. DTR #150 reported Resident #27 had the beginning stages of dementia and an addiction to cocaine but had been clean for four years. DTR #150 last spoke to Resident #27 on 12/18/23 at 1:30 P.M. via telephone. The facility notified DTR #150 in the morning on 12/19/23 that Resident #27 had not returned on 12/18/23. Resident #27 was allowed to leave the facility but had always returned by 8:00 P.M. which was his curfew (later identified 8:00 P.M. to be the time when the front door was locked). A Silver Alert was entered. The police were able to track Resident #27's cell phone and found the resident on 12/19/23 at an unknown time leaving a residence on foot. When approached, Resident #27 reported being cold and stated he had slept in his car overnight. The police notified DTR #150. When DTR #150 arrived, the police transported her and Resident #27 to the hospital for evaluation. A follow-up call with DTR #150 was made on 12/20/23 who confirmed Resident #27 was admitted to the hospital due to complaints of pain and missing prescription medications for over 36 hours but would be discharged back to the facility on 12/20/23.

The facility identified four additional residents, Resident #1, #14, #38, and #40 who had the ability to leave the center independently and who would be at risk to become missing without proper systems in place to ensure for the proper supervision and accounting for residents.

Review of the Resident Caregiver job description revealed the caregiver would be compliant with monitoring and documenting mandatory two-hour checks as per facility protocol and monitor and communicate residents' changes in condition and service requirements to Supervisor, as appropriate.

Review of the Resident Handbook revealed the facility would provide care including notification of change in condition to the primary care physician when needed and round-the-clock wellness checks.

Review of the facility policy titled, Missing Patients

Based on observations, resident and staff interviews, record review, review of fall investigations and facility policy review, the facility failed to complete mandatory two-hour checks for one resident (Resident #80) and failed to timely implement appropriate fall interventions for one resident (Resident #4). The deficient practices affected two (Residents #4 and #80) of five residents reviewed for accidents. The facility census was 49.

Findings Include:

1. Review of the medical record for Resident #4 revealed a move-in date on 02/02/23. Medical diagnoses included closed fracture of pelvis, fall, spine fracture (compression fracture of L1 vertebra), and closed fracture of fifth thoracic vertebra.

Review of the nursing admission evaluation dated 05/02/23 revealed Resident #4 was alert and oriented to person and time only. The resident was wheelchair bound and required assistance from one staff for transfers and ambulation. Resident #4 required extensive assistance with bed mobility, dressing, and eating and was totally dependent on staff for toileting and bathing. The resident was noted to have had a fall in the last thirty days. Resident #4 had impaired safety awareness, impaired balance, was unable and/or unwilling to ask for assistance and had an unsteady gait.

Review of the nurse's note dated 07/10/23 at an unknown time, 07/31/23 at 7:00 A.M., 08/15/23 at an unknown time, 09/12/23 at 5:05 A.M., and 09/13/23 at 5:15 A.M., revealed Resident #4 had falls on each of those dates.

Review of the nurse's note dated 07/10/23 at an unknown time revealed the note was a late entry. Resident #4 was found on the floor on 07/05/23 at an unknown time (five days earlier) at bedside by the attending aide. No injuries were noted when the resident was assessed by the nurse. Resident #4 stated she put herself on the floor because she felt more comfortable laying on the floor than in her bed. On 07/10/23 at 1:30 P.M. (five days after the resident's fall), Resident #4 was educated on the risk of injury due to putting self on the floor.

Review of the nurse's note dated 07/31/23 at 7:00 A.M. revealed Resident #4 was found on the floor in front of her bed. The resident stated, I just rolled out of this bed. There were no injuries noted upon assessment. A floor mat and possible body pillow were suggested to the family. There was no further follow up noted related to whether or not the family supplied the body pillow for Resident #4. On 08/07/23 at 3:30 P.M. (seven days after the fall), Resident #4 was educated on positioning in the bed to help prevent rolling out of bed, and the facility staff reached out to home health agency to request an evaluation to see if the resident would benefit from a bariatric bed. There was no additional documentation related to the outcome of the evaluation or if the evaluation was completed.

Review of the nurse's note dated 08/15/23 at an unknown time revealed Resident #4 was found on the floor in the sitting area by the first-floor nurse's station. Resident #4 was noted to have a small bruise to her right eyebrow, occipital bone area. Resident #4 stated she was trying to go to her room. On 08/17/23, Resident #4 had purple coloring around the occipital area of her left eye as well. Resident #4 denied having another fall. On 08/21/23 at 10:00 A.M. (six days after the fall), Resident #4 was educated to reinforce the need to call for assistance for transfers.

Review of the nurse's note dated 09/12/23 at 5:05 A.M. revealed Resident #4 was found on the floor by the sink area in her room in a supine position. No visible injuries were noted. Resident #4 was unable to recall what happened. The resident was brought to the couch by the nurse's station for closer observation and checked on frequently by the staff. There was no indication of a new fall prevention intervention being implemented following the fall.

Review of the nurse's note dated 09/13/23 at 5:15 A.M. revealed Resident #4 was found on the floor. No injuries were noted, and the resident denied hitting her head. The resident denied any pain. Report was given to the oncoming nurse for follow-up. At 09/13/23 at 11:15 P.M., no injuries were noted. There was no indication of a new fall prevention intervention being implemented following the fall.

Review of the incident reports for Resident #4's falls revealed there was no incident report completed for Resident #4's falls on 07/05/23 or 09/13/23. The incident reports completed for Resident #4's falls on 07/31/23, 08/15/23, and 09/12/23 did not indicate what fall prevention interventions had been implemented to attempt to reduce the resident's frequent falls.

Review of the Quality Indicator Logs dated July 2023 and August 2023 revealed Resident #4 was on the logs for falls on 07/05/23, 07/31/23, and 08/15/23. The logs indicated the resident was provided with education as the intervention for each occurrence with no additional fall prevention interventions implemented.

Observation and interview on 08/17/23 at 3:28 P.M. with Resident #4 in her room revealed the resident was sitting in her recliner chair with feet propped up. The resident did not have a bariatric bed, floor mat, or body pillow in place. Resident #4 confirmed she did have frequent falls and stated she lost her balance sometimes and did sometimes get up without assistance. Resident #4 stated she forgot to ask for help sometimes. Resident #4 stated she did not know of anything the facility had done to try to prevent or reduce the amount of falls the resident endured.

Interview on 10/18/23 at 4:38 P.M. with the Director of Nursing (DON) confirmed Resident #4's cognition was questionable and the resident had periods of confusion. DON confirmed there were no other fall prevention interventions attempted for Resident #4 other than education. The DON confirmed additional fall prevention interventions should have been implemented in order to attempt to reduce the amount of falls Resident #4 endured. The DON also confirmed there was also a delay in reviewing the resident's falls.

2. Review of the closed medical record for Resident #80 revealed a move-in date on 08/01/23 and a discharge date due to death on 09/25/23. Medical diagnoses included type II diabetes mellitus, coronary artery disease, cognitive impairment, and metastatic squamous cell carcinoma of the scalp and neck.

Review of the nursing admission evaluation dated 08/04/23 revealed Resident #80's admitting diagnosis was general weakness. The resident was alert and oriented to person, place, and situation. The resident used a walker for ambulation. Resident #80 was independent with ambulation, transfers, bed mobility, eating, and toileting and required limited assistance from staff for dressing and bathing. No falls were indicated in the last 180 days.

Review of the nurse's note dated 08/16/23 with unknown time revealed Resident #80 was admitted to hospice with the diagnosis of senile degeneration of the brain.

Review of nurse's note dated 09/25/23 with an unknown time revealed Resident #80 expired at 5:50 A.M. The resident was found face down approximately two feet from the door with an abrasion to the left side of his forehead and skin tears to his left elbow and left knuckle.

Review of the witness statement dated 09/25/23 with unknown time completed by Resident Care Assistant (RCA) #91 revealed the aide was doing rounds at approximately 4:35 A.M. on 09/25/23 when she found Resident #80 laying on the floor near the door. RCA #91 notified the nurse immediately. Resident #80 was unresponsive. RCA #91 reported the last time she saw Resident #80 alive was at midnight (12:00 A.M.) (approximately four and a half hours earlier).

Interview on 10/17/23 at 3:49 P.M. with the Executive Director (ED) revealed she completed an internal investigation of the incident involving Resident #80 on 09/25/23 because she was not able to follow a good timeline of the events after reviewing the documentation in the resident's record. The ED confirmed there was no record of when the assigned aide (RCA #91) had checked on Resident #80. The ED confirmed the facility's policy was that the aides were required to check on all residents at least every two hours. The ED stated the previous ED did not enforce the two-hour checks. The ED confirmed RCA #91 did not complete checks every two hours on Resident #80 as required.

An interview via telephone with RCA #91 was attempted on 10/18/23 at 10:19 A.M. but was unsuccessful. No return contact was received during the survey period from the aide.

Interview on 10/17/23 at 5:39 P.M. with the ED revealed Resident #80 slept in a recliner chair and would have had to have ambulated from his recliner chair and fell where he was found on the floor.

Review of the facility policy, Falls Prevention

Based on observation, interview, policy review, and record review, the facility failed to administer medications to Resident #22 as ordered by the physician. This affected one resident (#22) of two residents observed for medication administration. The facility census was 51.

Findings included:

Record review revealed Resident #22 was admitted to the facility on 09/25/21 with diagnoses including left femoral neck fracture, hyponatremia, hypothyroidism, osteoporosis, essential hypertension, spinal stenosis of lumbar region, and anxiety.

Observation on 09/22/23 at 9:36 A.M. revealed Licensed Practical Nurse (LPN) #106 administering morning medications to Resident #22, including furosemide (Lasix) 40 milligrams (mg) one tablet every morning and afternoon and levothyroxine 25 micrograms (mcg) one tablet by mouth every morning before breakfast. During observation of medication administration, the surveyor observed a breakfast tray sitting in front of Resident #22.

Interview on 09/22/23 at 9:47 A.M. with LPN #106 confirmed Resident #22 had already eaten her breakfast and the order for levothyroxine stated medication should be administered prior to breakfast.

Record review revealed Resident #22's morning medications were ordered to be given at 7:00 A.M. Further review of orders for medication revealed an order from 09/16/23 for Lasix 20 mg tablet, two tablets by mouth daily.

Interview on 09/22/23 at 4:20 P.M. with LPN #106 confirmed the medications for Resident #22's morning administration was ordered for 7 A.M. and the order for Lasix administered was incorrect.

Review of a policy titled Medication Administration: Medication Pass revealed nursing staff should open the medication administration record and review physician orders against the medication label and review for accuracy prior to administration.

This violation represents non-compliance investigated under Complaint Number OH00133120.

Based on observation and interview, facility failed to keep the floors in good repair which caused safety hazards to residents. This had the potential to affect all 51 residents. The facility census was 51.

Findings included:

Observation of the facility during the initial tour on 09/22/23 at 9:48 A.M. revealed areas of broken concrete consistently throughout the hallways on the second floor of the facility on the A hall. Once stepping off the elevator, an area to the carpet was buckled. Continuing down the A hallway and turning to the right at the double doors was an unlevel floor which rose up, then back down and had duct tape holding the carpet down. At the end of this hallway was an area of flooring that was soft and slightly caving in next to a window.

Interview on 09/22/23 at 4:02 P.M. during an additional tour of the facility with Administrator and Maintenance Director #60 confirmed there were multiple spots in the floor that could be a tripping hazard due to buckled carpet, broken concrete under the carpet, or soft spots in the facility.

This violation represents non-compliance investigated under Complaint Number OH00146131 and Complaint Number OH00133120.

Based on observation and interview the facility failed to establish a grievance committee. This had the potential to affect all 51 residents in the facility. The facility census was 51.

Findings included:

Observation of the facility on the initial tour on 09/22/23 at 9:48 A.M. revealed no evidence of a grievance committee being posted.

Interview with Administrator revealed the facility does not have a grievance committee.

This violation is cited as an incidental finding to Master Complaint Number OH00146131.

Based on observation and interview, facility failed to ensure residents had a homelike environment. This had the potential to affect all 51 residents. The facility census was 51.

Findings included:

Observation of the facility during the initial tour on 09/22/23 at 9:48 A.M. revealed the second floor of the assisted living had peeling wallpaper throughout the hallway and several areas of the floor had buckled carpet, cracked concrete underneath the carpet, or soft spots in the floor.

Interview on 09/22/23 at 4:02 P.M. during an additional tour of the facility with the Administrator and Maintenance Director #60 confirmed the wallpaper was peeling from the walls and there were multiple spots in the floor that could be a tripping hazard due to buckled carpet, broken concrete under the carpet, or soft spots in the facility.

This violation represents non-compliance investigated under Complaint Number OH00146131 and Complaint Number OH00133120.