Bickford of Scioto

Based on observations, staff interview, and review of facility policy, the facility failed to prepare food in a sanitary manner. This had the potential to affect all 41 residents residing in the facility who receive meals from from the kitchen. The facility census was 41 residents.

Findings include:

Observations from 11/03/25 from 11:40 A.M. to 11:47 A.M. revealed that while Cook #122 prepared the four cheese ziti and the pureed bread, she touched both clean and contaminated surfaces with the same single use pair of gloves on, without washing her hands. On 11/03/25 at 11:40 A.M., Cook #122 was observed touching the door to the steamer after pureeing the ziti, removing the dirty bowl from the food processor, going to the dirty side of the dishwasher, touching the sprayer with her gloved hand to rinse the inside of the food processor bowl, and then using the sprayer on the dirty side of the dishwashing machine to rinse her gloves before returning to the food processor to prepare pureed bread. Cook #122 did not wash her hands or change her gloves between touching contaminated items and touching clean items.

An interview with Cook #122 on 11/03/25 confirmed that the proper procedure to prevent cross contamination of food items was to wash her hands between touching unclean items and preparing food.

Review of a facility policy titled, Preventing Contamination from Hands

Based on observations, staff interviews, and review of facility policy, the facility failed to keep records of all menu items that had been substituted. This had the potential to affect all 41 residents who ate food from the facility. The facility census was 41 residents.

Findings include:

Observation of pureed meal preparation on 11/03/25 from 11:20 A.M. to 11:59 A.M. revealed that Cook #122 reviewed the recipe for the green salad and chose to substitute yogurt for the pureed diets instead of the green salad.

Review of the lunch menu for 11/03/25 revealed that a green salad was on the menu.

Review of the recipe for the green salad revealed that the modification for the pureed diet was to puree a cooked vegetable or soup of choice.

An interview with Cook #122 on 11/03/25 at 11:25 A.M. revealed that Cook #122 decided that she would make a menu substitution for the green salad puree option for lunch. Cook #122 revealed that she would substitute yogurt instead. Further interview confirmed that the facility did not keep a substitution log for items that had been substituted on the planned menus.

An interview with the Divisional Director of Operations #201 on 11/03/25 at 3:45 P.M. revealed that the facility does not keep records of menu substitutions, but that the facility would start to make record of the substitutions that were made.

Review of a facility policy titled, Menu Substitution

Based on observations, staff interview, and facility policy review, the facility failed to clearly label cleaning chemicals that were outside the original container, and failed to securely store hazardous chemicals. This had the potential to affect all 41 residents residing in the facility. The facility census was 41.

Findings include:

Observations on 11/03/25 at 9:30 A.M. and 3:00 P.M. revealed the chemical closet on the first floor of the facility was unlocked and unsecured. There was a bottle with an unknown chemical in it that was labeled floor and another bottle with an unknown chemical in it that as labeled bathroom. Also, observation during that time of a bottle of glass cleaner that was opened. On the side of the bottle, it stated that the storage must be in a locked area, which is was not. The following were chemicals were opened and in the unlocked chemical closet: bio brigade odor laser universal odor eliminator, cleaner degreaser, two bottles of bath and bowl cleaner, Goo Gone Caulk Remover, stainless steel cleaner and polish, 3 in 1 carpet cleaner and spot remover, Red Relief stain remover, Super HDQL10 Cleaner and Disinfectant, and Quick Defense disinfectant tabs. All the chemicals contained safety warnings indicating to avoid ingestion, protect skin/eyes during use and/or to store safely.

Observations on 11/03/25 at 9:40 A.M. and 3:10 P.M. found the chemical closet on the third floor of the facility was unlocked and unsecured. The following were chemicals was opened and in the unlocked chemical closet: one bottle of carpet cleaner. The chemical contained a safety warning indicating to avoid ingestion, protect skin/eyes during use and/or to store safely.

Observation on 11/04/25 at 7:15 A.M. revealed the same observations as 11/03/25 for the first and third floor chemical closets.

Interview with Caregiver #111 on 11/04/25 at 7:20 A.M. confirmed that the chemical room door should be locked when they are away from it. Caregiver #111 confirmed that it is typically locked. Caregiver #111 confirmed he was leaving the chemical room at that time and had not locked the door. Caregiver #111 confirmed there were two bottles of unknown chemicals in the storage closet. Caregiver #111 stated they were to be used on the floor and on the bathroom. Caregiver #111 also confirmed the glass cleaner stated it was to be stored in a locked area at all times.

Review of facility Hazardous Materials policy, dated July 2012, revealed all chemicals, poisons, or combustible material shall be stored and disposed of in accordance with the manufacturer's directions and all applicable regulations. All hazardous materials shall be properly labeled and stored in a locked storage area.

This violation is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure all residents had the following reviewed with them and provided a copy during the admission process: resident rights and a copy of the resident advocates. This affected three (#18, #33, and #40) of three resident medical records reviewed. The facility census was 41.

Findings include:

1. Resident #18 was admitted to the facility on 08/28/25. Diagnoses include metabolic encephalopathy, abnormalities of gait and mobility, cognitive communication deficit, antineoplastic chemotherapy-induced anemia, and thrombocytopenia.

Review of the facility mini-mental status exam (MMSE), dated 10/02/25, revealed Resident #18 had a mild cognitive impairment.

Review of Resident #18 resident admission agreement and handbook, dated 09/01/25, revealed there was no documentation to support the resident received a copy, or had the facility staff review the resident rights and the resident advocates with them upon admission.

2. Resident #33 was admitted to the facility on 03/19/25. Diagnoses include Alzheimer's disease and dementia.

Review of Resident #33's MMSE revealed it was not completed due to her having a severe cognitive impairment.

Review of Resident #33 resident admission agreement and handbook, dated 09/01/25, revealed there was no documentation to support the resident received a copy, or had the facility staff review the resident rights and the resident advocates with them upon admission.

3. Resident #40 was admitted to the facility on 05/31/25. Diagnoses include chronic pain of both shoulders, hypertension, type 2 diabetes with chronic kidney disease; stage 4.

Review of his MMSE, dated 10/09/25, revealed Resident #40 was cognitively intact.

Review of Resident #40 resident admission agreement and handbook, dated 09/01/25, revealed there was no documentation to support the resident received a copy, or had the facility staff review the resident rights and the resident advocates with them upon admission.

Interview with Divisional Director of Nursing #200 on 11/03/25 at 12:45 P.M. and 3:00 P.M. confirmed their admission packet is what they provide the residents and representatives. When asked about the signed receipt for advocates, rights, and transfer/discharge rights, he pointed to the same admission packet; specifically to the section on grievances and directing the residents and representatives to find the document, hanging on the facility wall, for the information related to the advocates. He stated, I've never been asked for that type of information before. He confirmed there was no section in the admission packet or handbook provided to the surveyors, in which the rights and/or advocates were discussed or provided to the residents.

Review of facility Resident Grievance policy, dated July 2012, revealed residents, or their responsible party, are encouraged to express their concerns freely. The facility is committed to operating under a philosophy that upholds the rights of all residents. The resident has a right to submit, at any time, a written complaint. Such communication shall first be submitted to the director. If a resident does not receive a written response from the director within 15 days, or wishes to appeal the director's decision, the resident may mail the grievance to the corporate office. Residents may also contact the state ombudsman or state licensure agency. These phone numbers are visibly posted in the branch, and have been made available to each resident and/or their legal representative upon move in.

Review of facility Move In policy, dated May 2014, revealed the following forms must be completed and returned prior to move in: admission agreement, service plan, and resident bill of rights.

This violation represents non-compliance investigated under Complaint Number OH00168670.

Based on observation, record review, staff interviews, and facility policy review, the facility failed to maintain a clean, sanitaty environment. This had the potential to affect all 44 residents residing in the facility.

Findings Include:

Observation on 10/22/25 at 12:00 P.M. made with the Director of Nursing (DON) revealed carpeting throughout the facility was stained and worn. Concurrent interview with the DON it was verified the carpet was worn and stained. The DON stated deep cleaning of the carpets had not been completed recently.

Observation and interview with Housekeeper #711 on 10/22/25 at 1:56 P.M. revealed air vents on the third floor with a black substance that was visible on the vent and the surrounding wall surface. Housekeeper #711 stated it was their responsibility to clean that area and confirmed it needed to be cleaned verifying the presence of a black substance on the vent and wall surface. Housekeeper #711 stated they are the only housekeeper on staff, and they worked Monday through Friday. Housekeeper #711 stated caregivers are responsible for cleaning on weekends. Continued observation revealed the entrance area on the first floor had two ceiling vents blowing onto decorative ceiling panels which were observed with thick dark dust accumulation. The Director of Nursing (DON) was present at this location at the time of the observation and stated vent cleaning is performed quarterly and did not respond when asked if staff should clean sooner when buildup is visible.

Observation on 10/22/25 at 2:20 P.M. of Resident #20's bathroom revealed the bathroom exhaust fan was covered with dust.

Interview with the DON and Family Advocate # 499 on 10/22/25 at 2:40 P.M. verified the exhaust fan in Resident's #20's bathroom had a buildup of dust, the DON stated vent cleaning occurs quarterly. When asked if staff should clean the vents sooner if they have an accumulation of dust on them the DON smiled but did not provide a verbal response.

Review of the Housekeeping and Laundry Policy, PP-50600, revised 07/2012 revealed the facility requires routine cleaning schedules and proper environmental maintenance.

This violation represents non-compliance investigated under Complaint Number OH00168577.

Based on observation, record review, staff interviews, the facility failed to ensure the facility was in good repair. This had the potential to affect all 44 residents residing in the facility.

Findings Include:

Review of the Maintenance Request forms from July 2025 through October 2025 revealed multiple unresolved work orders including leaks. The Maintenance Request forms did not contained completion dates or documented initials or signature of a staff member who had completed repair/task.

Review of the invoice provided by the facility for the roof repair dated 09/29/25 revealed it was for trim repair and not repairs to the roof structure.

Observation during the initial tour on 10/22/25 at 12:00 P.M. on the third-floor revealed multiple areas of staining and discoloration on the ceiling. The kitchenette area was observed and noted to have two ceiling tiles missing; and water dripped through another tile when touched.

Interview with Care Giver (CG) #703 on 10/22/25 at 12:23 P.M. confirmed the serving room on the third floor had been leaking for months and was leaking badly on 10/20/25.

Interview with CG #608 on 10/22/25 at 12:35 P.M. confirmed the water leaking from the ceiling had been happening for months maintenance worked on it last week, but it was obvious it was still leaking on Tuesday.

Interview with Family Advocate #499 on 10/22/25 at 3:00 P.M. confirmed the roof leak was active as of 10/20/25 and stated upper management acknowledged a roofing company should have been contacted for follow-up, but no documentation was available.

This violation represents non-compliance investigated under Complaint Number OH00168577.

Based on observation, interview, and record review, the facility failed to ensure residents were provided a safe and clean living environment free from hazards. This affected one resident (#8) of three residents reviewed. The facility census was 44 residents.

Findings Include:

Interview with Care Giver (CG) # 602 on 10/22/25 at 1:07 P.M. revealed Resident #8's refrigerator had a colored substance in the interior of the refrigerator. CG #602 stated staff were told the refrigerator would be removed a month ago, however it remained in the resident room.

Observation with the Director of Nursing (DON) of Resident #8's refrigerator on 10/22/25 at 2:30 P.M. revealed a black and green substance on the inner walls, shelves and door seal. Concurrent interview with the DON confirmed the black and green substance on the interior refrigerator surfaces, stating the refrigerator was unplugged and not being used for food storage currently, however the DON could not explain why the refrigerator remained in the resident's room.

Interview on 10/22/25 at 3:00 P.M. with Family Advocate #499 confirmed the facility was aware there was a delay the completion of maintenance request and verified there was no defined maintenance response time frame at the facility.

This violation represents non-compliance investigated under Complaint Number OH00168577.

Based on observation, staff interview, and review of hazardous materials policy, the facility failed to safely secure hazardous chemicals. This had the potential to affect six (Residents #32, #33, #36, #37, #40, #42). who were independently mobile and cognitively impaired and resided in the secured memory care unit. The facility census was 43.

Findings include:

Observations on 08/27/25 at 10:03 A.M. and 11:56 A.M. revealed the door to the bathtique room in the secured memory care unit was open. Inside this room was a large bathtub with a total of seven bottles of personal care products including body wash, shampoo, facewash, and lotions stored around the edge of the bathtub. Four of these products were found to have warning statements written on the back of the bottles.

Personal care products that were found unsecured in the bathtique with warning statements included the following:

Dr. Teals body wash: For external use only. Use only as directed. Keep out of reach of children.

CeraVe itch lotion: Warning- for external use only.

Equate body lotion: Warning- for external use only.

Nivea body lotion: Warning- for external use only.

Observation on 08/27/25 at 1:39 P.M. revealed that the door to the bathtique in the secured memory care unit had been closed, though the door was still unlocked. Upon entering the room, all personal care items that were observed earlier, including those with written warning statements, remained in the same location around the edge of the bathtub.

Interview on 08/27/25 at approximately 10:06 A.M. with housekeeper #86 revealed the door to the bathtique in the memory care unit is often kept open for residents to enter and use the facilities as needed, because there was a toilet and a sink inside another small room adjoining the room with the bathtub. Further interview revealed the bathtub had likely not been used for months, but the products around the bathtub were kept out and made accessible because they belonged to some of the residents on the unit. Housekeeper #86 added these products in the shared bathtique room are generally not kept in locked storage.

Interview on 08/27/25 at approximately 12:44 P.M. with the Executive Director, Health and Wellness Coordinator, and Regional Health and Wellness Director #99 revealed administrative staff were in the process of locating the facility policy for the storage of potentially hazardous materials.

Interview on 08/27/25 at approximately 5:20 P.M. with the Executive Director confirmed potentially hazardous materials in the secured memory care unit should be kept in locked storage.

Review of the Hazardous Materials Policy, PP-50400 revised July 2012 revealed all chemicals, poisons or combustible material shall be stored and disposed of in accordance with the manufacturer's directions and all applicable regulations. All hazardous materials shall be properly labeled and stored in a locked storage area.

This citation represents an incidental finding discovered during the complaint investigation conducted on 08/27/25 for Complaint Number OH00168045.

Based on record review and staff interviews, the facility failed to ensure unlicensed staff had competency checks off completed by a licensed nurse prior to independently working with residents. This affected one Caregivers (#102) of the four personnel files reviewed but had potential to affect all facility residents. The facility census was 53.

Findings include:

Review of personnel files for unlicensed Caregiver #102 who started on 04/28/25 revealed no documented evidence the Caregivers completed competency check-offs by a licensed nurse.

Interview on 06/03/25 at 3:57 P.M. with the Executive Director (ED), verified Caregivers #102 did not have competency check-offs prior to providing personal care to residents. ED stated they have delegation forms which are a form for tasks which the nurse picks a designated resident, and the caregiver performs the task. The delegation forms do not include all residents, just the name of one specific resident. Caregivers #102 had no competency list of skills taught or observed in their personnel file.

Requested facility policy regarding competency skills check off list but was not provided a policy by the facility.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on observation, resident and interview, medical record review, and review of the facility policy, the facility failed to ensure residents did not self-administer medications unless assessed as capable or ordered to self-administer medications. This affected one (#11) of five residents reviewed for self-medication administration. The facility census was 53.

Findings Include:

Review of Resident 11's medical chart reveals admission date of 03/26/25 with diagnoses listed as hypertension, type two diabetes mellitus, localized edema, urinary frequency, altered serum glucose, chronic pain, anxiety disorder, chronic renal disease, diarrhea, predominant irritable bowl syndrome, body mass index greater than or equal to 30 kilograms (kg)/meter (m) squared, left diastolic heart failure.

Review of Resident 11's service plan reveals under medication management supervision of self-administration, frequency as scheduled, and responsible med tech, nurse. Notes in Resident 11's service plan under medication management state Resident 11 will receive her medications from a licensed facility employee.

Observation 06/02/25 at 10:49 A.M. knocked and entered Resident #11's room. Resident #11 was sitting on the edge of the bed, and a white pill tablet was lying on the blue bedspread. Resident #11 says the nurse gave her the other pills and watched her take them, but the nurse didn't have applesauce, so they left the white pill for me to take with applesauce.

Interview on 06/02/25 at 10:54 A.M. Licensed Practical Nurse (LPN) #111 and Medication Technician (MT) #127 verified potassium pill as white pill sitting on Resident #11's blue bedspread. MT #127 picked up the white pill with bare, ungloved hands and gave Resident #11 the white pill in applesauce which was in Resident#11's room refrigerator. MT #127 says Resident #11 likes to take her medications with food, so they leave them for resident to take on her own. LPN #111 and MT #127 do not know if Resident #11 has assessment for self-administration of meds.

Review of Medication Management dated 01/2021 states prescription medication shall be administered by qualified and trained Bickford Family Member (BFM) on medication administration policies and procedures, pharmacy manual and electronic medication management software that meet state requirements.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on interviews, observation, record review, review of manufactures guide, and facility policy review, the facility failed to safely administer insulin to one (Resident #51) of one observed for insulin administration. This had the potential to affect eight residents who receive insulin at the facility. The census was 53.

Findings include:

Record review of Resident #51's medical record revealed diagnoses of Type II Diabetes Mellitus with hyperglycemia, pancytopenia, major depressive disorder, essential primary hypertension, alcohol dependence, and dementia.

Resident #51's service plan dated 4/2024 revealed Resident #51 required full staff assistance with medication administration management to include coordinate injections and glucometer checks.

Observation of medication administration for Resident #51 on 06/02/25 at 11:38 A.M., revealed Medication Technician (MT) #127 did not prime the insulin pen prior to administration of eight units of Novolog Flexpen 100 units per milliliter (ml) solution (regular insulin) and 14 units of Lantus Flexpen Solostar 100 units/milliliter solution via subcutaneous injection.

Interview on 06/02/25 at 11:53 A.M., MT #127 verified neither insulin pen was primed prior to dialing up the dose administered to the resident. MT #127 said priming is for intravenous tubing. MT #127 said she does not know how to prime insulin pens and has not been shown how to prime insulin pens.

Interview with the Health and Wellness Director (HWD) on 06/02/25 at 2:40 P.M., verified the expectation when administering insulin was to prime the pen with two units of insulin with every use. HWD confirmed the Nurse Delegation Form-Administration of Insulin does not include an instruction step to prime the insulin pen with two units of insulin with each use.

Review of NovoLog Flexpen prefilled pen (100 units/milliliter, U-100) manufacturer guide under giving the airshot before each injection stated: Before giving the injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select two units. Hold your Novolog Flexpen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to zero.

Review of the Lantus Solostar Pen manufacturer guide leaflet under step three stated: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that the pen and needle work properly and removing air bubbles. Select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way n. Check of insulin comes out of the needle tip. Check the dose window shows 0 following the safety test.

Review of MT #127's signed Nurse Delegation Form-Administration of Insulin dated 02/19/25 stated under additional instruction: Prime insulin pen with each needle. Dial to two units and hold pen upright, discard. Ensure there is no air bubble in pen. Then redial to ordered dose and administer.

Policy review of the facilities medication administration policy date 01/2021 stated Prescription medication shall be administered by qualified and trained Bickford Family Members (BFM's) on medication administration policies and procedures, pharmacy manual, and electronic medication management software that meet state requirements.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on record review, observation, and staff interview the facility failed to provide an individualized activity program designed to meet the interests and total care needs of the residents on the Memory Care unit. This had the potential to affect all the residents on the Memory Care unit. The census was 53.

Findings include:

Review of the June 2025 facility activity calendar revealed the calendar had meals listed as activities daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M., Monday through Friday there was exercise daily at 10:30 A.M., Coffee and Conv at 11:00 A.M. and Jeopardy at 7:00 P.M. There was an additional activity at 2:30 P.M. that was different each day. Saturday and Sunday had a different schedule for activities.

Observation on 06/02/25 at 10:30 A.M. revealed no exercise activity was occurring in Memory Care. The activity calendar stated exercise was scheduled to take place at 10:30 A.M.

Interview on 06/02/25 at 5:00 P.M., with Caregiver Assistant #103 verified there were not specific activities available for Resident's residing in Memory Care. There was an activity list posted but it was for the activities held on the other floors of the facility and those activities were not held in Memory Care.

Interview with Caregiver Assistant #103 on 06/03/25 at 8:25 A.M., revealed she is now the dedicated activities person for the Memory Care unit and she was interested in learning what types of music residents liked and discussed holding meetings with residents to discuss what activities they would be interested in.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on record review, interview and facility policy review the facility failed to ensure the resident's responsible party was notified of a change in condition in a timely manner for one (#51) of three reviewed. The census was 53.

Findings include:

Medical record review for Resident #51 revealed the resident was admitted to the facility on 04/27/24 with diagnoses of Type II Diabetes with hyperglycemia, alcohol induced persisting dementia and essential hypertension.

Record review of Resident 51's progress note dated 04/22/25 at 6:24 P.M. reveal Resident #51 was found on the floor next to the bed, I assume he tried to stand up, Resident has not been able to stand, had been in wheelchair all day, with redness noted to right hip and knee, still complaining of right sided pain in his groin or his foot, he yells in pain any time we try to make him sit. Notification of responsible person and Primary Care Provider (PCP) was not noted as completed.

Record review of Resident #51's progress notes revealed on 04/30/25 at 5:27 P.M., Resident #51's blood sugar checks read high after two finger sticks, Physician Assistant (PA) contacted, advised to resume previous insulin orders and recheck at 6:00 P.M.. Addendum to progress note at 5:48 P.M., revealed Resident's blood sugar recheck, 462. Physician Assistant (PA) and HWD notified, advised to continue hydrate with more water. Resident #51's record had no documentation present to indicate the responsible party was notified of this change in condition and the current plan of care.

Interview on 06/03/25 at 3:35 P.M. with the Health and Wellness Director (HWD) verified Resident #51's responsible party should have been notified after Resident #51's fall, stating I have been educating staff on the fall policy.

Interview on 06/03/25 at 3:36 P.M. with the HWD verified Resident #51's responsible party should have been notified of Resident #51's change in condition in regard to his elevated blood sugar and the current plan of care from the PA.

Review of facility policy Medication Administration with HWD on 06/03/25 at 3:37 P.M., confirmed the Medication Administration policy only discusses contacting HWD for a significant change in resident's health or behavior, nothing regarding contacting responsible party, but family should be notified.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on observation, record review and staff interview the facility failed to ensure infection control standards were maintained during administration of oral medications. This affected one residents (Resident #53) of five residents reviewed for medication administration. The facility census is 53.

Findings include:

Review of Resident #53's medical record reveals an admission date of 03/13/24 with diagnoses of hypertension, anemia, falling, bone fracture, hyperlipidemia, proximal femur fracture, anxiety disorder, dementia, rib fracture, fibromyalgia syndrome, recurrent major depressive disorder, joint prosthesis present, wanning short term memory and behavioral disturbance.

Review of Resident #53's service plan under medication management needs/details full assistance with medication administration management, assistance with crushed medications.

Observation on 06/03/25 during medication pass at 8:03 A.M. Medication Technician (MT) #127 did not wash her hands or use hand sanitizer. MT #127 did not wear gloves when removing oral medication, from one medication cup to a different medication cup. MT #127 picked up one of the Divalproex capsules with bare, ungloved hands and opened the capsule. MT #127 poured the Divalproex capsule into a cup of chocolate Ensure. MT#127, then picked up the second Divalproex capsule with bare, ungloved hands and poured the Divalproex capsule into the same cup of chocolate Ensure. MT#127 gave the chocolate Ensure with the Divalproex in it to Resident #53 who drank the chocolate Ensure.

Interview on 06/03/25 at 8:17 A.M. MT#127 verified she did not wear gloves to remove the Divalproex capsules from one medication cup to the other medication cup or have on gloves when she opened the Divalproex capsules and poured them into the chocolate Ensure. Further, MT#127 confirmed she should have worn gloves to touch the Divalproex capsules to open and pour them into the chocolate Ensure.

Review of facility Medication Management dated 01/2021 states Medication administration includes the following activities, based on the needs of the resident: (Personal Protective Equipment (PPE) to be worn, if indicated or while handling hazardous medications and wash hands).

Review of Medication Management dated 01/2021 states prescription medication shall be administered by qualified and trained Bickford Family Member (BFM) on medication administration policies and procedures, pharmacy manual and electronic medication management software that meet state requirements.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on observation, interview, and facility policy review, the facility failed to store food items in a safe and sanitary manner. This had the potential to affect all 53 residents receiving meals from the kitchen. The census was 53.

Findings include:

1. Observation of the main kitchen on 06/02/25 at 9:35 A.M., revealed an open bag of tomatoes and an uncovered container of applesauce in the reach-in refrigerator.

Interview on 06/02/25 at 9:35 A.M. with Cook #135 verified bag of tomatoes was open and the applesauce was uncovered.

Observation on 06/02/25 at 9:38 A.M. of the walk in refrigerator revealed three open containers of green beans, a container of onions, cranberries, chicken, onions and liver with red lids that were open and not properly closed.

Interview on 06/02/25 at 9:38 A.M., with Cook #135 verified the items in the walk-in refrigerator did not have the lids on properly.

Observation on 06/02/25 at 9:45 A.M. of the walk-in freezer revealed two containers of macaroni and cheese with a preparation date of 01/18/25 and an expiration date of 04/18/25.

Interview on 06/02/25 at 9:46 A.M., with Cook #135 verified the macaroni and cheese in the walk-in freezer was expired.

Observation on 06/02/25 at 9:46 A.M. of the bread storage area revealed one opened and one unopened package of hamburger buns with an expiration date of 05/08/25.

Interview on 06/02/25 at 9:48 A.M., with Cook #135 verified the hamburger buns were expired and were disposed of.

Observation on 06/02/25 at 9:50 A.M., of the dry storage area revealed an opened gallon sized bottle of Sweet Baby Ray's BBQ sauce, an opened undated gallon sized bottle of soy sauce, an opened undated gallon sized bottle of Teriyaki sauce all three bottles of sauce had manufacture labeling that stated refrigerate after opening.

Observation on 06/02/25 at 9:50 A.M., of the dry storage area revealed two unopened gallon sized bottles of unsulphured molasses with an expiration date of 07/18/20, an opened undated gallon bottle of light unsulphured molasses with an expiration dated of 07/18/20, an opened undated gallon of light corn syrup with an expiration date of 02/16/20, box of mustard bottles with an expiration date of 1/31/25, and an unopened gallon sized bottle of Karo Corn Syrup with an expiration date of 2019 that was used to hold the door open to the area of the dry storage, and walk in refrigerator and freezer.

Interview on 06/02/25 at 9:55 A.M., with Cook #135 verified the above expired items and the items were discarded in the garbage.

2. Observation on 06/02/25 at 10:30 A.M., of the Memory Care kitchen refrigerator revealed, an opened package of corn tortillas with an expiration date of 03/25, an opened undated gallon of milk, an opened, undated 16 oz container of parmesan cheese with an expiration date of 2022, an opened undated chocolate frosting container with an expiration date of 9/2024, a bottle of mustard with an expiration date of 01/2025, A Can't Believe it's Not Butter Spray with an expiration date of 2023, and an opened bag of cheese with no expiration date present.

Observation on 06/02/25 at 10:35 A.M., of the Memory Care Unit kitchen freezer revealed an uncovered freezer burned ice cream sundae.

Interview on 06/02/25 with Caregivers #102 and #106 verified the items in the memory care refrigerator and freezer were expired as listed above and would dispose of the items.

Review of the facilities Food Storage Labeling and Dating Policy verified, it is the policy for the Breadbasket Department to wrap, cover, label, date, and store all foods in a safe, appropriate manner. This is to prevent food-borne illness and retain food quality from becoming stale or dried out. All food items stores in the branch must be labeled clearly and accurately with: Product Name, Date of Preparation/ Opening, Use By/ Expiration Date, Allergen Information, and BFM's initials. Food should be discarded after 3 days and regularly check the labeled items for expiration dates and freshness, and discard items that are past their use-by date. All cooked foods, pre-packaged open containers, protein-based salads, and desserts are to be securely covered, labeled, and dated based in the above.

Based on observation, staff interview, and review of facility policies and housekeeper chores, the facility failed to maintain a clean homelike environment. This two ( resident #42 and #43 ) and had the potential to affected all residents. The facility census was 53.

Findings include:

Observation 06/02/25 at 7:40 A.M. entered the facility and was led to elevator. The elevator showed visible signs of dirt. Exited elevator to third floor hallway which also showed visible signs of dirt. Entered private dining room on third floor which showed dried food which looked like pieces of brown rice on table runner in the center of the table. Entered third floor public restroom which had pieces of white paper on the floor and around trash can, and no available toilet paper.

Observation 06/02/25 at 10:15 A.M. Resident #42's room on the second-floor revealed white paper on the floor and incontinent items cluttered on the floor.

Review of Resident #42's service plan stated under additional services requested assistance with housekeeping, frequency daily.

Observation 06/02/25 at 10:17 A.M. of the second floor revealed the common restroom had visible dirt and yellow liquid around the base of toilet, no toilet paper was on the toilet paper holder, no trash bags were in the trash cans, but trash was in the trash cans. No gloves were noted in second floor restroom where the resident spa tub was located. There was a strong urine odor in the second-floor dining room. The second floor hallways had visible dirt, pieces of white paper, and lint throughout hallway.

Interview on 06/02/25 at 10:30 A.M. with Caregiver assistant #106 who says there are gloves in the second-floor kitchen drawer which is labeled napkins. Caregiver Assistant verifies gloves are in the drawer labeled napkins. Caregiver Assistant #106 says she tells the nurse when she needs more gloves, and the nurse gets them for her.

Observation on 06/02/25 at 11:32 A.M. of the second floor revealed the common restroom had visible dirt and yellow liquid around the base of toilet, no toilet paper on the toilet paper holder, no trash bags in the trash cans, but trash was in the trash cans.

Interview on 06/02/25 at 11:35 A.M. with Housekeeper #125 revealed she is the only housekeeper and works Monday through Friday. Housekeeping is not available on weekends. She verified she cleans resident rooms once a week (vacuum, clean kitchenette, bathroom, fridge, and empties trash). If asked she will clean as needed. Caregivers should be emptying trash daily, changing soiled linen immediately and light cleaning and dusting. Housekeeper #125 cleans the second floor on Wednesdays. Bathtique in second floor restroom is deep cleaned on Wednesdays and caregivers should clean in between use. Adult diapers should be disposed of immediately outside and not left in rooms. Residents and families are responsible for providing toilet paper and trash bags for the residents.

Interview 06/02/25 at 12:04 P.M. with Caregiver Assistant #102 verified dirt and yellow liquid around the toilet base, no toilet paper, and no trash bags in cans with trash in them in the second floor common restroom. Caregiver assistant #102 says there are trash bags in the can for them to use and pulls one out to place it in one of the trash cans.

Observation 06/03/25 at 7:40 A.M. entered facility and noted visible white pieces of paper and dirt in elevator. The Third floor private dining area was observed and still had dried food like brown rice on center table runner. Third floor public restroom had more pieces of white paper on the floor around the trashcan, and no toilet paper. Third floor hallways exhibited visible dirt.

Observation 06/03/25 at 10:40 A.M. Resident #43's room had visible white pieces of paper and lint on the floor and visible soiled areas in the carpet.

Review of Resident #43's service plan states under additional services requested needs/details assistance with housekeeping, frequency as scheduled.

Interview on 06/03/25 at 8:18 A.M. interview with Medication Technician (MT) #127 revealed she has gloves in the bottom of her medication cart and produced a plastic bag with purple gloves in it. MT #127 says the gloves are ordered from pharmacy. MT #127 verified the families of the residents are required to provide gloves, trash bags, toilet paper, and trash bags for residents. MT #127 says if you move into an apartment, you have to provide those things, so the families provide it here. MT #127 says they like it when a resident goes on hospice, because hospice covers incontinent supplies and gloves. MT #127 says families must bring gloves in or have facility order from pharmacy at resident cost. MT #127 says the housekeeper gives them a roll of trash bags if they run out, but the families are supposed to provide. MT #127 says she doesn't know they schedule for the housekeeper, but the housekeeper's vacuums hallways.

Interview on 06/03/25 at 10:25 A.M. Power of Attorney (POA) #139 reveals he must buy gloves, trash bags, and incontinent supplies for Residents #1 and #2. He says when Resident #1 was on hospice, he didn't have to purchase those items as hospice purchased them for Resident #1. POA #139 reports as soon as the hospice discharged Resident #1, he had to start purchasing the supplies. POA #139 says he thinks it is a little excessive for him to purchase supplies, such as gloves and trash bags since he pays $13,000 a month for Resident #1 and #2 to live in facility.

Interview on 06/03/25 at 10:40 A.M. with Resident #43's spouse #140. Spouse #140 reports Resident #43 gets shower once or twice a week by hospice. Spouse #140 says the facility could be cleaner. He has brought in trash bags, but no gloves because she's on hospice which pays for Resident #43's gloves and incontinent supplies. Spouse #140 says the carpets need to be steam cleaned by professional companies.

Interview on 06/03/25 at 10:49 A.M. With Caregiver Assistant #126 who has worked at the facility for three years. Caregiver Assistant #125 revealed the families of the residents bring in gloves and trash bags for them to use with the residents. She says that's why we like hospice, because hospice pays for gloves and things. Caregiver Assistant #125 reports the caregivers have task sheets which should be printed and given to caregivers daily by the nurses, but she didn't get one on 06/03/25. Caregiver Assistant #125 reports she hasn't been given one in a long time. Additionally, she says the caregiver assistants can log in on their phones to see the task sheets, but the mobile app is not mobile friendly.

Interview 06/03/25 at 5:02 P.M. with Executive Director (ED) revealed resident families must provide gloves and trash bags. ED says it is in the Resident Agreement that residents and families must supply the gloves and trash bags. The ED reported the trash bags, gloves, and toilet paper are to be used in the resident's room. ED revealed the facility is to provide trash bags and toilet paper for common/public restrooms. The ED verified the resident agreement does not say the resident is responsible for providing gloves, trash bags, and toilet paper. The ED confirmed the facility Pre-Move-In Preparations document dated 01/2017 does not say residents must provide gloves and trash bags for their care.

Review of Resident Council Meeting Minutes dated 05/27/25 under items of concerns states housekeeping not great/just ok. Resident Council Meeting Minutes dated 04/29/25 under items of concern states cleanliness of elevator buttons and rails, register in resident's rooms are not cleaned, also, in resident's bathrooms Resident #11, #13, and #32 and other days rooms are not being cleaned once a week and under plan of action ask housekeeping to clean once a day.

Review of facility policy Housekeeping Safety dated 07/2012 revealed The Director shall schedule housekeeping and laundry services for residents and for common areas.

Review of facility policy Housekeeping Storage and Maintenance dated 07/2012 states Bickford Family Members shall notify the Director of the need to reorder housekeeping supplies.

Review of facility task sheet entitled Ten Step Weekly Apartment Cleaning Process dated 09/2014 under number four rotational cleaning week four vacuum cushions and backs of couches and chairs, pick up cushions and vacuum underneath where possible, remove PTAC filter and vacuum, and wash bathroom and kitchen rugs. Additionally, under number nine task sheet states vacuum carpets and rugs, spot clean carpet as needed with carpet cleaner, vacuum open spaces and inside closets, and move small furniture as necessary. Furthermore, the facility Housekeeper Chores dated 08/2016 states keep branch clean, tidy, and odor-free.

This violation represents non-compliance investigated under Complaint Number OH00165906.

Based on record review, interview, and policy review the facility failed to ensure a thorough investigation and/ or timely reporting of a fall. This had the potential to affect one of four residents reviewed in Memory Care unit. The census was 53.

Findings include:

Medical record review for Resident #51 revealed the resident was admitted to the facility on 04/27/24 with diagnoses of Type II Diabetes with hyperglycemia, alcohol induced persisting dementia and essential hypertension.

Review of Resident #51's service plan dated 12/04/24 revealed he required moderate assistance with dressing and grooming, minimal assistance with toileting and was independent with transfers and mobility. Resident #51 required safety checks twice a shift and required activity of daily living (ADL) assistance daily due to impaired cognition.

Record review of Resident 51's progress note on 04/22/25 at 6:24 P.M. reveal Resident #51 revealed the resident was found on the floor next to his bed, the staff got the resident up and the assisted the resident to the dining room. The resident had no post fall interventions implemented until 04/25/25 and no post fall evaluation was documented in the chart.

Record review of Resident #51's progress notes on 05/27/25 at 10:23 P.M. revealed Resident #51 was found on the floor in his room resident didn't look distressed or in pain, no injuries notes at this time, resident was directed to his wheelchair

Based on record review and interview the facility failed to provide evidence of a complete and accurate incident log. This had the potential to affect all 53 residents in the facility.

Findings include:

Request of review of the facility incident log revealed the facility had no incident log on the premises.

Interview with the Executive Director on 06/02/25 at 7:40 A.M. during entrance conference revealed the facility did not maintain an incident log, but rather had incidents documented in individual resident's medical charts.

Based on review of facility reported incidents, review of resident records, staff interviews, and review of facility policies, the facility failed to ensure evidence of a complete investigation and new interventions were initiated to promote safety after an injury of unknown injury occurred for Resident #41. Additionally, the facility failed to initiate new interventions after a fall for Resident #37. This affected two residents (#37 and #41) out of six residents reviewed for incidents and accidents. The facility census was 42.

Findings include:

1. Review of the medical record revealed Resident #41 was admitted to the facility on 11/05/18 with diagnoses that included dementia, cognitive communication deficit, and osteoarthritis.

Review of Resident #41's Global Deterioration Scale dated 09/20/24 revealed that she had a severe cognitive decline.

Review of Resident #41's service plan dated 04/10/25 revealed that she needed two person assistance with transferring. The plan was that the care team would monitor for changes in condition and conduct a reappraisal as appropriate. Resident #41 was noted to need moderate assistance for mobility.

Review of Resident #41's skin incident dated on 02/15/25 revealed that she was noted to have been sitting in the dining room eating her breakfast, when a large ecchymotic area was noted to her right eye and no fall had been reported. Resident #41 was monitored for pain and worsening of her condition over the course of three days, and her condition did not worsen, nor did she exhibit symptoms of pain.

Review of the Facility Reported Incident (FRI) #257898 revealed on 02/15/25, Medication Technician #98 reported to the Former Area Health and Wellness Director that she discovered an injury of unknown origin during her morning medication pass in the dining room. The Former Area Health and Wellness Director notified Resident #41's family, hospice, and the physician. The Former Area Health and Wellness Director interviewed the staff who worked the overnight shift leading into 02/15/25, but the investigation did not include formal interviews by the day shift staff from 02/14/25 or the day shift on 02/15/25. The conclusion reached by the facility was that abuse did not occur, but a root cause analysis as to what happened and how it happened was not completed. The facility concluded that if a fall had occurred, the resident would have hit her right eye. No new fall interventions were implemented, nor any action plan to prevent Resident #41 from sustaining another injury to her face.

Interview with Caregiver #83 on 04/16/25 at 2:25 P.M. revealed that she discovered the bruising on Resident #41's right eye on 02/15/25 sometime between 7:00 A.M. and 8:00 A.M. when she got Resident #41 up for breakfast. Caregiver #83 reported it to Medication Technician #98 immediately.

Interview with Medication Technician #98 on 04/16/25 at 10:45 A.M. revealed that she first noted the injury to Resident #41's right eye around 8:00 A.M. that morning when she was alerted by a Caregiver that Resident #41's right eye was bruised. Medication Technician #98 stated that she reported the incident immediately to the Former Area Health and Wellness Director. Medication Technician #98 stated that she continued to monitor Resident #41 for pain or a decline in her condition during the course of the shift and there were no negative findings.

Interview with Caregiver #85 on 04/16/25 at 11:23 A.M. revealed that she worked the overnight shift leading into 02/15/25 and had last visualized Resident #41's face when she was sleeping in bed around 4:30 A.M. and at that time, Resident #41 had no bruising. She stated that no falls or incidents occurred to Resident #41 to her knowledge.

Interview with the Executive Director on 04/16/25 at 2:22 P.M. revealed that she believed that the day shift that worked on 02/14/25 and the day shift that worked on 02/15/25 were interviewed by Family Advocate #108, however confirmed that the interviews were not formally documented in the facility investigation.

Interview with the Former Area Health and Wellness Director on 04/16/25 at 3:16 P.M. revealed that it was not conclusive if Resident #41 fell as no falls were witnessed and Resident #41 was not discovered out of bed. She further confirmed there were no new interventions placed after the injury of unknown origin occurred to prevent Resident #41 from having another injury occur.

Review of the facility policy titled Incident and Accident Report dated 12/2024 revealed that incidents and accidents can include resident falls or injuries. The Executive Director or Health and Wellness Director shall investigate incidents or accidents and document the investigation and corrective action regarding the incident or accident, and implement corrective action as appropriate.

2. Review of the medical record revealed Resident #37 was admitted to the facility on 10/15/22 with diagnoses that included anxiety, dementia, and seizures.

Review of Resident #37's Service Plan dated 12/23/24 revealed that she needed full assistance with toileting and bathing, but only needed minimal transferring and mobility assistance, such as cueing.

Review of Resident #37's fall incident dated 02/25/25 revealed on 02/25/25, Resident #37 had a fall while ambulating towards her room after dinner. The fall intervention that was documented on 02/26/25 by Former Area Health and Wellness Director was to monitor for pain. There was no documented evidence of any additional new fall interventions initiated for the 02/25/25 fall.

Interview with the Executive Director on 04/16/25 at 2:08 P.M. revealed that monitoring a resident for pain after a fall was not a new fall intervention for a resident who had experienced a new fall.

Interview with the Former Area Health and Wellness Director on 04/16/25 at 2:15 P.M. confirmed that a new fall intervention was not created for Resident #37 after her fall on 02/25/25.

Review of the facility policy titled Incident and Accident Report dated 12/2024 revealed that incidents and accidents can include resident falls or injuries. The Executive Director or Health and Wellness Director shall investigate incidents or accidents and document the investigation and corrective action regarding the incident or accident, and implement corrective action as appropriate.

This violation represents non-compliance investigated under Complaint Number OH00164288.

Based on record review and staff interviews, the facility failed to ensure staff completed physical examinations by a physician or other health care professional prior to or on the first day of employment. This had potential to affect all residents. The facility census was 48.

Findings include:

Review of personnel files for Licensed Practical Nurse (LPN) #105 with a start date of 01/31/25, LPN #112 with a start date of 01/13/25, and Caregiver #124 with a start date of 01/27/25 revealed no documented evidence of any physical exams being completed prior to or on the first day of hire.

Review of personnel file for LPN #130 with a start date of 09/11/24, revealed a physical dated 12/10/24.

Interview on 02/10/25 at 4:00 P.M. with the Executive Director (ED), verified the employee physicals were not completed prior to their start date. The ED stated the facility used the onsite Nurse Practitioner to complete physical assessments.

Review of facility policy titled Personnel Files dated 09/2016, revealed facility shall maintain employee files with pre-employment physicals.

Based on record review and staff interviews, the facility failed to ensure unlicensed staff had competency checks off completed by a licensed nurse prior to independently working with residents. This affected two Caregivers (#101 and #124) of the five personnel files reviewed but had potential to affect all facility residents. The facility census was 48.

Findings include:

Review of personnel files for unlicensed Caregiver #101 who started on 12/03/24, and unlicensed Caregiver #124 who started on 01/27/25, revealed no documented evidence the Caregivers completed competency check-offs by a licensed nurse.

Interview on 02/10/25 at 4:00 P.M. with the Executive Director (ED), verified Caregivers #101 and #124 did not have competency check-offs prior to providing personal care to residents.

Review of facility policy titled Personnel Files dated 09/2016, revealed facility shall maintain employee files with orientation checklists.

Based on record review and staff interview, the facility failed to ensure staff were checked on the nurse aide abuse registry prior to hire. This affected five personnel (Licensed Practical Nurses [LPNs]) #105, #112, #130, Caregivers #101, and #124) but had the potential to affect all facility residents. The facility census was 48.

Findings include:

Review of personnel files for Licensed Practical Nurse (LPN) #105, who started on 01/31/25, LPN #112, who started on 01/13/25, LPN #130, who started on 09/11/24, Caregiver #101, who started on 12/03/24, and Caregiver #124, who started on 01/27/25 revealed no documented evidence there staff were checked on the nurse aide abuse registry prior to being hired.

Interview on 02/10/25 at 4:00 P.M. with Executive Director (ED), verified the facility had no documeted evidence the staff were checked on the nurse aide abuse registry prior to starting employment.

Based on record review and staff interview, the facility failed to ensure new resident admissions were checked in the sex offender registry. This had the potential to affect all 48 residents. The facility census is 48. Findings include: Record review found no documented evidence the facility completed sex offender registry checks for new admission. Interview on 02/10/25 at 8:40 A.M. with the Executive Director, verified the facility had not completed inquiries on the sex offender registry for any new admissions. Review of a facility policy titled Sex Offender Screening of ResidentsBased on record review and staff interview, the facility failed to ensure new resident admissions were checked in the sex offender registry. This had the potential to affect all 48 residents. The facility census is 48.

Findings include:

Record review found no documented evidence the facility completed sex offender registry checks for new admission.

Interview on 02/10/25 at 8:40 A.M. with the Executive Director, verified the facility had not completed inquiries on the sex offender registry for any new admissions.

Review of a facility policy titled Sex Offender Screening of Residents

Based on observations, staff interview, and medical record review, the facility failed to ensure safe storage of medications. This affected one Resident (#12) during a medication cart review. The facility identified six Residents with orders for insulin (#12, #16, #19, #34, #47, and #48). The Facility census is 48. Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/23/23. Diagnoses included mild memory impairment, diabetes mellitus type II, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Review of a physician order for Resident #12 dated 11/04/24, revealed the resident was ordered Lantus Solostar Insulin Pen. The Lantus pen indicated to discard the used pen 28 days after first use. Review of the most recent physical examination for Resident #12 dated 12/10/24, revealed the resident was incapable of self-medicating. Observation of the medication cart being utilized for the dining room on 02/10/25 at 12:35 P.M. with Licensed Practical Nurse (LPN ) #112, revealed a Lantus Solostar insulin pen for Resident #12 was found to be opened and undated. The pen had instructions to dispose of 28 days after being opened. Interview with LPN #112 at the same time, verified the pen was opened and not dated. Review of facility policy titled, Medication ManagementBased on observations, staff interview, and medical record review, the facility failed to ensure safe storage of medications. This affected one Resident (#12) during a medication cart review. The facility identified six Residents with orders for insulin (#12, #16, #19, #34, #47, and #48). The Facility census is 48.

Findings include:

Review of the medical record for Resident #12 revealed an admission date of 12/23/23. Diagnoses included mild memory impairment, diabetes mellitus type II, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease (COPD).

Review of a physician order for Resident #12 dated 11/04/24, revealed the resident was ordered Lantus Solostar Insulin Pen. The Lantus pen indicated to discard the used pen 28 days after first use.

Review of the most recent physical examination for Resident #12 dated 12/10/24, revealed the resident was incapable of self-medicating.

Observation of the medication cart being utilized for the dining room on 02/10/25 at 12:35 P.M. with Licensed Practical Nurse (LPN ) #112, revealed a Lantus Solostar insulin pen for Resident #12 was found to be opened and undated. The pen had instructions to dispose of 28 days after being opened. Interview with LPN #112 at the same time, verified the pen was opened and not dated.

Review of facility policy titled, Medication Management

Based on record review and staff interview, the facility failed to ensure staff completed tuberculosis (TB) testing upon hire. This had potential to affect all facility residents. The facility was 48.

Findings include:

Review of personnel files for Licensed Practical Nurse (LPN) #105, who started on 01/31/25, LPN #112, who started on 01/13/25, LPN #130, who started on 09/11/24, Caregiver #101, who started on 12/03/24, and Caregiver #124, who started on 01/27/25 revealed no documented evidence of any tuberculosis (TB) two step testing being completed prior to or on the first day of hire.

Review of the facility's TB control plan dated 2024, revealed the facility staff shall complete a two step TB testing upon hire with the first step to be initiated prior to or on the first day of employment.

Interview on 02/10/25 at 4:00 P.M. with Executive Director (ED), verified LPNs #105, #112, #130, Caregivers #101 and #124 did not have TB testing initiated prior to their start date. The ED stated the facility was trying to catch up with all the TB testing for staff.

Review of facility policy titled Personnel Files dated 09/2016, revealed facility shall maintain employee files with tuberculosis testing.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on each shift every three months. The facility also failed to document fire alarm transmission and the receipt of the alarm by the alarm company for each drill. This had potential to affect all facility residents. The facility census was 48.

Findings include:

Review of fire drill documentation revealed no fire drills were conducted for January 2024 or February 2024.

Review of fire drill documentation dated 03/06/24, revealed fire drills were conducted at 1:35 P.M. (first shift), 2:00 P.M.(no shift identified), and 3:00 P.M. (second shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 04/30/24 at 3:00 A.M. (third shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 5/31/24 at 1:45 P.M. (first shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 06/27/24 at 10:00 P.M. (second shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 07/30/24 at 11:30 P.M. (third shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 08/30/24 at 10:30 A.M. (first shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 09/28/24 at 10:00 P.M. (second shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fired drill documentation revealed no fire drills were conducted October 2024.

Review of fire drill documentation dated 11/11/24 at 11:30 A.M. (first shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire drill documentation dated 12/11/24 at 11:00 A.M. (first shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Review of fire documentation dated 01/31/25 at 5:30 A.M. (third shift), revealed no documented evidence of verification of receipt of the fire alarm signal by the alarm company.

Interview on 02/10/25 on 11:14 A.M. with Maintenance Director (MD), #106 revealed the facility had no maintenance staff for 01/2024 and 02/2024 for fire drills and verified they were not done and he had no records. MD #106 stated he was unable to locate any fire drill from October 2024. MD #106 verified the shifts documented along with corresponding times showed the facility did not have a fire drill completed each shift each quarter. MD #106 verified the facility had no documented evidence of a second shift drill from October to December and no third shift drills from August to December. MD #106 also verified the facility does not have verification of receipt of the fire alarm either by the alarm company or 911 for any of the fire drills.

Review of the fire drill schedule, revealed fire drills shall be performed monthly and include each shift having a drill each quarter. The fire drills required staff signatures of those who participated in the drills. The facility shall use the fire drill report to document the drill.

Review of facility policy titled Disaster Policy and Procedure dated 07/2012 revealed facility shall conduct fire drills monthly, on alternating shifts.

Based on record review and staff interview, the facility failed to ensure fire drill evaluations included all required pieces of information including the method of activation, effectiveness of the drill, number of residents evacuated, weather conditions present at the time of the drill and any problems encountered and corrective actions taken. This had potential to affect all facility residents. The facility census was 48. Findings include: Review of fire drill documentation, revealed no fire drills were conducted January 2024, February 2024 and October 2024. Review of fire drill documentation dated 03/06/24, revealed fire drills were conducted at 1:35 P.M., 2:00 P.M., and 3:00 P.M., and the fire drill documentation did not include method of activation, effectiveness of the drill, number of residents evacuated, staff in attendance, weather conditions present at the time of the drill and any problems encountered and corrective actions taken. Review of fire drill documentation dated 04/30/24 at 3:00 A.M., revealed the fire drill documentation did not include effectiveness of the drill including any problems in encountered and corrective actions taken and only stated needs improvement. Fire drills also did not include the number of residents evacuated or weather conditions present at the time of the drill. Review of fire drill documentation dated 5/31/24 at 1:45 P.M., revealed the fire drill documentation did not include method of activation stated RaceBased on record review and staff interview, the facility failed to ensure fire drill evaluations included all required pieces of information including the method of activation, effectiveness of the drill, number of residents evacuated, weather conditions present at the time of the drill and any problems encountered and corrective actions taken. This had potential to affect all facility residents. The facility census was 48.

Findings include:

Review of fire drill documentation, revealed no fire drills were conducted January 2024, February 2024 and October 2024.

Review of fire drill documentation dated 03/06/24, revealed fire drills were conducted at 1:35 P.M., 2:00 P.M., and 3:00 P.M., and the fire drill documentation did not include method of activation, effectiveness of the drill, number of residents evacuated, staff in attendance, weather conditions present at the time of the drill and any problems encountered and corrective actions taken.

Review of fire drill documentation dated 04/30/24 at 3:00 A.M., revealed the fire drill documentation did not include effectiveness of the drill including any problems in encountered and corrective actions taken and only stated needs improvement. Fire drills also did not include the number of residents evacuated or weather conditions present at the time of the drill.

Review of fire drill documentation dated 5/31/24 at 1:45 P.M., revealed the fire drill documentation did not include method of activation stated Race

Based on record review and staff interview facility, the facility failed to ensure the central heating system had been checked by a heating contractor. This had potential to affect all facility residents. The facility census was 48.

Findings include:

Review of the maintenance paperwork, revealed no documented evidence of any inspections of the central heating system.

Interview on 02/10/25 at 11:14 A.M. with Maintenance Director #106, verified the facility had no record of any inspections of the central heating system.

Interview on 02/10/25 at 4:00 P.M. with Executive Director, revealed the facility had been using their in house maintenance staff to complete the inspections.

Based on observation and staff interview, the facility failed to ensure the state survey results were publicly available. This has the potential to affect 48 residents. The facility census is 48.

Findings include:

Observation of the facility on 02/10/25 at 8:10 A.M. with the Executive Director, revealed the survey results were unable to be located or a sign indicating where to locate the results. Interview at the same time with the Executive Director verified the facility did not have the past survey results posted. The Executive Director stated she did not have access to pull survey results from the Electronic Information Dissemination and Collection (EIDC) system.

Based on employee record reviews and staff interview, the facility failed to obtain physicals for new employees prior to starting work or on their first day. This had the potential to affect all 35 residents who received care from staff.

Findings include:

Review of the employee file for Certified Caregiver (CC) #134 revealed CC #134 was hired on 10/30/23 and did not have a physical in her file.

Review of the employee file for CC #135 revealed CC #135 was hired on 10/25/23 and did not have a physical in her file.

Review of the employee file for Caregiver Assistant (CA) #130 revealed CA #130 was hired on 11/20/23 and did not have a physical in her file.

Review of the employee file for CA #117 revealed CA #117 was hired on 09/09/21 and did not have a physical in her file.

Review of the employee file for CA #131 revealed CA #131 was hired on 11/15/23 and did not have a physical in her file.

During an interview, the Health and Wellness Director #121 on 12/27/23 at 2:30 P.M., confirmed the physicals were not available for newly hired staff, and stated the nurse practitioner had completed the physicals but did not have the proper paperwork at the time and she was coming in on 12/28/23 to finish the paperwork.

Based on resident record review and staff interviews, the facility failed to check the sex offender registry for newly admitted residents. This had the potential to affect all 35 residents residing in the facility.

Findings include:

Record review for Resident #19 revealed an admission date of 03/17/23. There was no evidence Resident #19 was checked on the sex offender registry prior to their admission.

Record review for Resident #3 revealed an admission date of 10/12/23. There was no evidence Resident #3 was checked on the sex offender registry prior to their admission.

Interview with the Executive Director (ED) on 12/27/23 at 9:15 A.M. confirmed the sex offender registry was not checked for Resident #19 and #3 prior to their admission to the facility.

Based on observations, record review, and staff interviews, the facility failed to provide medications as ordered. This affected one resident (Resident #19) of two residents reviewed for medication administration. The facility census was 35.

Findings include:

Medical record review for Resident #19 revealed an admission date of 03/17/23. Diagnoses included non-traumatic intracerebral hemorrhage, cerebral edema, pneumonia, cerebral infarction, compression of the brain, shingles right flank, acute kidney failure, acute anemia, acute neoplasm of the prostate, hyperlipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, idiopathic hypotension, muscle weakness, hematuria, and hemiplegia.

Review of the physician orders and Medication Administration Record (MAR) revealed Resident #19 received the following medications: Refresh 1.4-0.6% (polyvinyl alcohol-povidon) over the counter eye drops one drop in both eyes four times a day for dry eyes, lidocaine one patch every 12 hours for pain, buspirone 15 milligrams (mg) every eight hours for depression, famotidine 20 mg one tablet twice a day for heartburn, acetaminophen 325 mg two tablets every six hours as needed for pain, cholecalciferol (vitamin D) 1,250 micrograms (mcg) once a day on Mondays, methocarbamol 500 mg twice a day for pain, lisinopril 10 mg one tablet daily for hypertension, aripiprazole 2.0 mg one tablet for depression, escitalopram 10 mg one tablet for depression, doxazosin 2.0 mg one tablet once a day for urinary retention, Oxycodone 5.0 mg one tablet as needed for pain, and folic acid 400 microgram (mcg) one tab daily for supplement. The orders stated for medications to be crushed and administered by gastric tube (G-tube). During medication administration times, flush (clear the tubing) with 15 milliliters (mls) water before and after medications and five mls with each medication.

Observation of medication administration on 12/27/23 at 9:27 A.M. revealed Wellness Nurse #113 administered Resident #19 buspirone 15 mg one tablet, famotidine 20 mg one tablet, methocarbamol 500 mg one tablet, lisinopril 10 mg one tablet, aripiprazole 2.0 mg one tablet, escitalopram 10 mg one tablet, doxazosin 2.0 mg one tablet, Oxycodone 5.0 mg one tablet, and folic acid 400 mcg one tablet. Wellness Nurse #113 confirmed nine tablets were in the cup to administer to Resident #19. After placing the tablets in the cup, Nurse #113 poured all tablets into a small pouch and crushed them all together. Nurse #113 used a 50 ml syringe and administered the medications into the G-tube. Wellness Nurse #113 mixed a small amount of tap water with the crushed medications and used a cup filled with water from the sink to flush the tube before giving medication. He poured the tap water from the cup into the G-tube, allowed it to empty, poured in the medication mix, allowed it to empty, then poured in more tap water from the plastic cup. Wellness Nurse #113 did not administer eye drops or lidocaine patch.

Interview with Wellness Nurse #113 on 12/27/23 at 9:45 A.M. verified the physician orders said to give the medications one at a time. Wellness Nurse #113 said nursing staff mix them together all at once because there were no drug interactions and it was going in the G-tube. He said his flush amount was 50 mls because the syringe was 50 mls. Wellness Nurse #113 verified he didn't administer the eye drops or lidocaine patch to Resident #19.

Based on observation and staff interview, the facility failed to wear personal protective equipment (PPE) appropriately. This had the potential to affect all 35 residents residing in the facility.

Findings include:

During observations on 12/27/23 at 8:27 A.M., Wellness Nurse #136 was observed leaving room 132 wearing gloves and a mask that was falling down past her nose, carrying a basket full of laundry. Wellness Nurse #136 placed the basket of clothing on the ground outside of room 120 and then entered the room. She did not remove the gloves or perform hand hygiene prior to entering room 120 after exiting room 132. Wellness Nurse #136 was observed at 10:15 A.M. on 12/27/23 entering the elevator wearing gloves and a mask that was below the nose.

Interview with the Executive Director (ED) on 12/27/23 at 1:30 P.M. revealed staff should not be wearing gloves in the hallway. The ED stated staff can wear a mask if they want to, but it should not be below the nose.

Based on record reviews and staff interview, the facility failed to obtain baseline tuberculosis (TB)/Mantoux testing prior to staff working with residents. This had the potential to affect all 35 residents residing in the facility.

Findings include:

Review of the employee file for Certified Caregiver (CC) #134 revealed CC #134 was hired on 10/30/23. There was no evidence to indicate health screening, TB/Mantoux testing including a first and/or second step Mantoux test was completed for CC #134 prior to the start of their employment and/or during their employment.

Review of the employee file for CC #135 revealed CC #135 was hired on 10/25/23. There was no evidence to indicate health screening, TB/Mantoux testing including a first and/or second step Mantoux test was completed for CC #135 prior to the start of their employment and/or during their employment.

Review of the employee file for Caregiver Assistant (CA) #130 revealed CA #130 was hired on 11/20/23. There was no evidence to indicate health screening, TB/Mantoux testing including a first and/or second step Mantoux test was completed for CC #130 prior to the start of their employment and/or during their employment.

Review of the employee file for CA #117 revealed CA #117 was hired on 09/09/21. There was no evidence to indicate health screening, TB/Mantoux testing including a first and/or second step Mantoux test was completed for CC #1117 prior to the start of their employment and/or during their employment.

Review of the employee file for CA #131 revealed CA #131 was hired on 11/15/23. There was no evidence to indicate health screening, TB/Mantoux testing including a first and/or second step Mantoux test was completed for CC #131 prior to the start of their employment and/or during their employment.

Interview with the Executive Director (ED) on 12/27/23 at 4:00 P.M. verified there was no evidence to ensure health screening/TB/Mantoux testing was completed as required for CC #134, CC #135, CA #130, CA #117, and CA #131.

Review of the facility's TB Assessment revealed staff should have their first step of TB/Mantoux testing prior to the start of their employment.

Based on record review and staff interview, the facility failed to conduct monthly a fire drills as required. This had the potential to affect all 35 residents residing in the facility.

Findings include:

Review of the facility documents on 12/27/23 revealed there was no evidence of monthly fire drills for any of the months in 2023.

Interview on 12/27/23 at 5:00 P.M. with Executive Director (ED) confirmed they were unable to provide monthly fire drill reports. The ED reported the facility did not have a maintenance person and she was unsure where the reports were from the previous person in that role.

Based on record review and interview, the facility failed to conduct at least monthly a fire safety inspection as required. This had the potential to affect all 35 residents residing in the facility.

Findings include:

Review of the facility documents on 12/27/23 revealed there was no evidence of monthly fire safety inspection for any of the months in 2023.

Interview on 12/27/23 at 5:00 P.M. with Executive Director (ED) confirmed they were unable to the monthly fire inspection reports. She reported the facility currently does not have a maintenance person and she was unsure where the reports were from the previous person in that role.

Based on observation, policy review, and staff interviews, the facility failed to ensure hazardous materials were safely secured. This had the potential to affect 11 residents residing in the memory care unit.

Findings include:

Observation of the second floor memory care unit on 12/27/23 at 1:45 P.M. revealed unlocked cabinets in the bathette

Based on record review and staff interview, the facility failed to provide a grievance council comprised of two residents for every staff member. This had the potential to affect all 35 residents residing in the facility.

Findings include:

Review of the facilities grievance procedures on 12/27/23 revealed the facility did not have evidence of a grievance committee.

Interview on 12/17/23 at 2:00 P.M. with the Executive Director (ED) revealed the facility was unaware of the requirement to have a grievance committee and confirmed the facility did not have one.

Based on observations and resident and staff interview, the facility failed to maintain temperatures in residents areas that was safe and comfortable. This had the potential to affect all 27 residents residing in the facility. Facility census was 27.

Findings include:

Interview with Care Giver #40 on 10/20/22 at 7:33 A.M. revealed the facilities heating system is down and all the residents have heaters in their rooms. Care Giver #40 confirmed she was instructed to check on the residents frequently and they have additional blankets in the facility if needed.

Observation on 10/20/22 at 7:35 A.M., on the first floor, identified a common sitting area soda shop had a wall thermostat that read 58 degrees Fahrenheit (F). The first floor tour continued and identified there is a sitting room on the first floor just around the corner from a staircase. The room is observed with a gas powered fireplace. The sitting area with the fire place is 64 degrees F.

Interview with the facility Care Coordinator #9 on 10/20/22 at 7:33 A.M. confirmed the facilities heating system is currently down and they are in the process of getting it repaired. Care Coordinator #9 confirmed residents having space heaters in their rooms, are being offered additional clothing and or blankets as necessary. Care Coordinator #9 confirmed no residents have had any ill effects from the temperatures.

Observation of Resident #9's room was completed on 10/20/22 at 7:35 A.M. revealed an infrared heater sitting in the center of the floor of the room. The temperature in the room felt comfortable and Resident #9 was in bed, with her eyes closed with two thick blankets on.

On 10/20/22 at 7:41 A.M. observations of Resident #11's room revealed a heater sitting in the middle of the floor of the residents room and was blowing warm air out. The heater was touched and was warm to touch but not hot.

Observation of the third floor dining room was completed on 10/22/22 at 7:49 A.M. revealed the dinning area temperature was 62 degrees F, according to the thermostat on the wall. There were additional thermostats located in common hallway that were identified at 62 degrees F. The observation identified all resident apartment doors were closed.

Observation of Resident #18's room on 10/20/22 at 7:52 A.M. revealed there was a heater in the room that was blowing warm air. The heater was touched and was warm but not hot.

Observation of the second floor of the facility was completed on 10/20/22 at 7:59 A.M. revealed the thermostat outside of Room 205 is noted to be 67 degrees F.

Observation and interview with Resident #22 occurred on 10/20/22 at 8:01 A.M. Resident #22 was walking down the hallway heading towards the dining room. Resident #22 was fully dressed and had a light jacket on. Resident #22 was asked if he was staying warm and he identified yes. Resident #22 provided permission for me to look in his room and he stated he has a heater. Upon entering Resident #22 room the heater was turned off and unplugged. There was a thermostat outside of Resident #22 room which identified 62 degrees F.

Interview with the Executive Director on 10/20/22 at 8:44 A.M. confirmed he received a call on Saturday, October 8, 2022 that identified the staff thought there was a concern with the facilities heating, which is a boiler system. The facilities emergency heating contractor was called, came to the facility and identified there is something wrong with the actual boiler and his company could not repair this. The Executive Director confirmed an all staff meeting was completed on 10/08/22 to meet with caregivers, nursing staff and activities are to complete regular checks on all residents to ensure they are comfortable, windows were closed and heaters were being used safely. The Executive Director identified on 10/10/22 the boiler company came to the facility identified the mother board was out of the system and needed replaced. The company ordered the board and identified it would be in and installed on 10/24/22. The Executive Director confirmed the facility made sure that all resident rooms have the ceramic heaters. The Executive Director confirmed the heaters all have auto shut off if they tip over and or over heat. The Executive Director confirmed with observation of two of the units was completed. The units when moved did immediately turn off. The outside of the units were warm but not hot. The Executive Director confirmed the staff were all made aware to ensure the units were maintained away from the residents and items in their apartments in accordance with the manufactures instructions, which were provided for the units. The facility had a Building Emergency procedure that identified assess situation, protect the residents, protect property and re-establish order. The facility did not have a written policy for the events of temperatures outside of regulation range. The Executive Director confirmed the range is 71 to 81 degrees F and the temperatures readings in the building were not reaching the appropriate temperature.

This violation represents non-compliance investigated under Complaint Number OH00136740.