Bickford of Worthington

Based on observations, staff interview, and facility policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner. This had the potential to affect all 67 residents residing in the facility. The facility census was 67.

Findings include:

1. Observations of the facility kitchen on 10/01/25 from 8:41 A.M. to 8:44 A.M. found the following items: frozen vegetable mix in plastic sack, opened and undated; frozen bread sticks in plastic sack, opened and undated; three pieces of fish wrapped in plastic wrap, opened and undated; one chicken breast in plastic wrap, opened and undated; two packages of crab meat in plastic wrap, opened and undated; five glass dishes of sherbet, unwrapped and undated; and an open package of blue cheese crumble with plastic wrap, an open date of 07/22, and another date written of 09/22.

Observations of the facility kitchen on 10/01/25 from 8:45 A.M. to 8:50 A.M. found the following items: mashed potatoes in small metal container covered with plastic wrap, opened and undated; plastic bag of spinach wrapped in plastic wrap, opened and undated; cheese slices wrapped in plastic wrap, opened and undated; bag of whipped cream with the opened end wrapped in plastic wrap, opened and undated; salad mix in a metal bowl wrapped in plastic wrap, opened and undated; metal bowl of strawberries wrapped in plastic wrap, opened and undated; and a plastic bag of hot dogs wrapped in plastic wrap, open and undated.

Interview with Cook #120 on 10/01/25 at 8:51 A.M. confirmed the items above that were opened and did not have dates, or the dates written on the food items were inconclusive as to when the items should be discarded.

Review of facility Food Storage Labeling and Dating policy, dated October 2024, revealed labels used to indicate the contents, date, use by, and other pertinent information related to stored food items. All food items stored in the branch must be labeled clearly and accurately. Labeling requirements revealed each label must include the following information: product name, date of preparation/opening, use by/expiration date, allergen information, and branch food manager's initials. Regularly check labeled items for expiration dates and freshness. 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 on the above.

2. Observations on 10/01/25 at 11:57 A.M. revealed Cook #120 taking the temperature of the food items on the tray line. Cook #120 did not have any alcohol swabs to cleanse the thermometer. Cook #120 took the temperature of pork, turkey, mixed vegetables, cauliflower, and sweet potatoes without cleansing the thermometer between food items. Between taking the temperature of each of the food items, Cook #120 wiped the thermometer probe with a red cloth towel. Cook #120 wiped the thermometer probe in the same spot after taking the temperature of each food item; she did not clean the cloth at any point.

Interview with Cook #120 on 10/01/25 at 12:20 P.M. confirmed the facility did not have any alcohol swabs to cleanse the thermometer. Cook #120 confirmed she was using the clean cloth to wipe the thermometer.

3. Observations on 10/01/25 from 12:06 P.M. to 12:20 P.M. revealed Cook #120 had a disposable glove on both hands. Cook #120 grabbed a piece of turkey with her gloved hand and placed it on the unclean tray line. Cook #120 held the piece of turkey with the gloved hand and cut the turkey. After cutting the turkey, Cook #120 placed the turkey on the resident's plate for service. After touching the turkey with the gloved hand, Cook #120 went on to touch the following items prior to changing her glove: tongs, serving spoon, paper meal ticket, plates, and the counter of the tray line. At 12:09 P.M., after changing her gloves, Cook #120 grabbed a bowl of prepared ground turkey, and scooped approximately half the bowl on to a resident's plate, with her gloved hand. Cook #120 did this two more times without changing her gloves. At 12:15 P.M., Cook #120 grabbed a piece of pork with the same gloved hand that she touched other items, cut it on the dirty tray line counter, and placed it on the resident's plate. By 12:20 P.M. Cook #120 had not changed her gloves, and had went on to touch the following items without changing her gloves: bread rolls, plates, tongs, serving spoon, tray line counter, red cloth, and paper meal tickets.

Interview with Cook #120 on 10/01/25 at 12:20 P.M. confirmed she touched multiple food items with her gloved hands. Cook #120 confirmed she did not change her gloves as often as she should have after touching food, and then went on to touch other items.

Review of facility Handwashing-Dining policy, dated March 2025, revealed facility members shall wash their hands before working with ready to eat food, between handling different types of foods, after handling trash or other contaminated objects, and after touched anything else that may contaminate hands, such as dirty equipment, work surfaces, or cloths.

Based on record review, review of facility policy, and staff interview, the facility failed to timely investigate a resident's fall and timely implement the interventions the facility identified to reduce the resident from falling. This affected one (Resident #51) of five residents reviewed for falls/accidents. The facility census was 64.

Findings include:

Review of Resident #51's medical record revealed the resident was admitted to the facility on 05/14/24. Diagnoses included dementia, vitamin deficiency, and major depressive disorder.

Review of the progress notes revealed Resident #51 was found on the floor in his room on 05/26/24, 06/05/24, 09/29/24, and 11/02/24. All four falls were without injuries. There was no post fall evaluation noted in Resident #51's medical record for his most recent fall on 11/02/24.

Interview with Director of Nursing (DON) on 11/20/24 at 2:37 P.M. revealed a care plan meeting occurred on 11/13/24 to discuss the resident's fall occurrences. The determination made was to rearrange some of the resident's furniture to mitigate some tripping hazards for him. The DON confirmed the furniture has not yet been moved as of 11/20/24.

Review of the facility's policy titled Fall Policy dated 10/2024 revealed post fall evaluation form should be completed after a resident fall and individualized interventions are considered. Interventions identified are implemented and documented in the resident's record.

Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner, and food items were labeled and dated. This had the potential to affect 64 residents who consumed food prepared in the kitchen. That facility census was 64.

Findings include:

1. Observation on 11/20/24 at 9:48 A.M. of the kitchen revealed the following concerns:

a. Refrigerator contained a carton of buttermilk with an expiration date of 11/12/2024.

b. Package of feta cheese with a good through date of 05/20/2024.

c. Tapioca pudding mix with an expiration date of 10/04/2023.

During a subsequent interview on 11/20/24 at 10:00 A.M.. Cook #11 confirmed the buttermilk, feta cheese, and tapioca pudding were expired and threw them away.

Review of the facility's policy titled Food Storage Labeling and Dating dated 10/2021 revealed to store food items should be regularly checked for expiration dates and freshness.

2. Observation and interviews on 11/20/24 at 12:08 P.M. revealed Dietary Employee #21 stated the facility was currently out of the test strips to check the concentration of the sanitizer solution. Cook #11 confirmed this information and added that she was unsure how long the facility had been out of the strips but they were currently on order.

Review of the policy titled Sanitizer Solution Log, Inspections, Nutrition and Food Service

Based on facility record review and staff interview, the facility failed to conduct fire drills as required. This had the potential to affect all 64 residents residing in the facility.

Findings include:

Review of facility fire drills documentation, dated November 2023 to October 2024, revealed the facility did not complete any fire drills between November 2023 and March 2024.

A subsequent interview with Regional Maintenance Director #11 on 11/20/24 at 10:32 A.M. confirmed the facility was missing fire drills from November 2023 and March 20204. He stated they now have a new maintenance director in-house, but the facility was unable to find documents created by and maintained by the previous facility maintenance director.

Based on record review and staff interview, the facility failed to ensure their central heating system was checked every two years by a heating contractor. This had the potential to affect all 64 residents residing in the facility.

Findings include:

Facility record review revealed the facility was unable to provide evidence of the central heating unit being checked within the last two years by a heating contractor.

Interview with Regional Maintenance Director #11 on 11/20/24 at 10:32 A.M. confirmed the facility did not have the required maintenance records to show the central heating unit was checked in the last two years. Regional Maintenance Director #11 stated the corporate office controls when the central heating was checked by a heating contractor.

Based on observation and staff interview, the facility failed to maintain a safe and clean living environment. This had the potential to affect 11 residents in the memory care unit who the facility identified who were cognitively impaired and independently mobile. The facility census was 64.

Findings include:

During an observation and interview of the memory care unit on 11/20/24 between 11:00 A.M. and 11:25 A.M. with Maintenance Director #11, two closet doors were left open with potentially hazardous materials inside. The first closet had furniture polish and disinfectant. The second closet had two containers of paint. Maintenance Director #11 confirmed the two closets were not locked and confirmed the closets should have been locked because of the hazardous materials in the closets and were accessible to the residents. Maintenance Director #11 stated a ticket would have to be opened to have the locks on the closets repaired.

Based on medical record review, observation, resident interview, staff interview, resident representative interview, and review of the facility work order log, the facility failed to ensure the central heating system for each resident's room was in good working condition. This affected one (Residents #10) of 12 residents reviewed for physical environment. The facility census was 73.

Findings include:

Review of the medical record for Resident #10 revealed an admission date of 09/19/23 with diagnoses including chronic kidney disease, type two diabetic, gout and hyponatremia.

Review of the service plan for Resident #10 dated 3/27/24 revealed the resident had memory loss and required one person assistance with bathing and activities of daily living (ADLs.)

Review of the functional assessment for Resident #10 dated 03/27/24 revealed the resident required a sit to stand lift device with one person assist to move from his recliner to a wheelchair and or to bed.

Observation on 04/22/24 at 10:00 A.M. revealed Resident #10 was in his recliner covered with a blanket. There was a portable space heater on the floor which was plugged in and blowing warm air into the room. The air temperature in the room was 74 degrees Fahrenheit (F.)

Interview on 04/22/24 at 10:00 A.M. with Resident #10 confirmed the heat in his room was not working and the facility had placed the portable space heater in his room. Resident #10 confirmed his room has cold since the heat has been out even with the space heater.

Interview on 04/22/24 at 10:05 A.M. with Licensed Practical Nurse (LPN) #100 confirmed the portable heater was plugged in and running in Resident #10's room. LPN #100 further confirmed the heat in Resident #10's room had not been working for at least two weeks and the portable space heater had been in the resident's room for at least two weeks.

Interview on 04/22/24 at 10:50 A.M. with Maintenance Director (MD) #120 confirmed the heater in Resident #10's room was nonfunctional and had been so for at least two weeks. MD #120 further confirmed Resident #10's heater had not been checked recently by a heating contractor to see if it could be repaired.

Interview on 04/22/24 at 11:00 A.M. with Resident #10's representative confirmed the resident's heat in the room was nonfunctional and had been so for at least three weeks. Further interview confirmed the facility had placed a portable space heater in Resident #10's room about three weeks ago and the facility had not offered the resident a room change until the heating was fixed.

Interview with the Executive Director on 4/22/24 at 4:00 P.M. confirmed the facility did not have a policy regarding the heating system.

Interview on 04/22/24 at 4:15 P.M. with the Director of Nursing (DON) confirmed that the heat as not been working in Resident #10's room and the facility placed a portable space heater in the room for the resident to keep warm. Further interview with the DON confirmed the facility did not ask Resident #10 if he would like to change rooms until the heating was fixed.

Observation on 04/22/24 at 1:00 P.M. of Resident #10's room revealed the air temperature in the room was 71 degrees F after staff had turned off the portable space heater in the room.

Review of the work order log for 2024 revealed there were no entries concerning Resident #10's heating system not working.

This violation represents noncompliance investigated under Complaint Number OH00153111 and Complaint Number OH00153071.

Based on medical record review, observation, resident interview, staff interview, resident representative interview, review of the facility work order log, and review of manufacturer's guidelines for portable space heaters, the facility failed to ensure a safe environment for the residents. This affected one (Residents #10) of 12 residents reviewed for physical environment. The facility census was 73.

Findings include:

Review of the medical record for Resident #10 revealed an admission date of 09/19/23 with diagnoses including chronic kidney disease, type two diabetic, gout and hyponatremia.

Review of the service plan for Resident #10 dated 3/27/24 revealed the resident had memory loss and required one person assistance with bathing and activities of daily living (ADLs.)

Review of the functional assessment for Resident #10 dated 03/27/24 revealed the resident required a sit to stand lift device with one person assist to move from his recliner to a wheelchair and or to bed.

Observation on 04/22/24 at 10:00 A.M. revealed Resident #10 was in his recliner covered with a blanket. There was a portable space heater on the floor which was plugged in and blowing warm air into the room. The air temperature in the room was 74 degrees Fahrenheit (F.)

Interview on 04/22/24 at 10:00 A.M. with Resident #10 confirmed the heat in his room was not working and the facility had placed the portable space heater in his room. Resident #10 confirmed his room was cold since the heat has been out even with the space heater. Resident #10 confirmed he did not have instructions regarding the use of the space heater.

Interview on 04/22/24 at 10:05 A.M. with Licensed Practical Nurse (LPN) #100 confirmed the portable heater was plugged in and running in Resident #10's room. LPN #100 further confirmed the heat in Resident #10's room had not been working for at least two weeks and the portable space heater had been in the resident's room for at least two weeks.

Interview on 04/22/24 at 10:50 A.M. with Maintenance Director (MD) #120 confirmed the heater in Resident #10's room was nonfunctional and had been so for at least two weeks. MD #120 further confirmed Resident #10's heater had not been checked recently by a heating contractor to see if it could be repaired.

Interview on 04/22/24 at 11:00 A.M. with Resident #10's representative confirmed the resident's heat in the room was nonfunctional and had been so for at least three weeks. Further interview confirmed the facility had placed a portable space heater in Resident #10's room about three weeks ago and the facility had not offered the resident a room change until the heating was fixed.

Interview with the Executive Director on 4/22/24 at 4:00 P.M. confirmed the facility did not have a policy regarding the use of portable space heaters.

Interview on 04/22/24 at 4:15 P.M. with the Director of Nursing (DON) confirmed that the heat as not been working in Resident #10's room and the facility placed a portable space heater in the room for the resident to keep warm. Further interview with the DON confirmed the facility did not ask Resident #10 if he would like to change rooms until the heating was fixed.

Observation on 04/22/24 at 1:00 P. M. of Resident #10's room revealed the air temperature in the room was 71 degrees F after staff had turned off the portable space heater in the room.

Review of the work order log for 2024 revealed there were no entries concerning Resident #10's heating system not working.

Review of the manufacturer's guidelines undated for the portable space heater the facility placed in Resident #10's room revealed extreme caution was necessary when the heater was used or near children or the disabled and or when the heater was left unattended.

This violation represents noncompliance investigated under Complaint Number OH0015311 and Complaint Number OH00153071.