Ridge at Lancaster The

Based on observation, review of Material Safety Data Sheets (MSDS), and staff interview, the facility failed to ensure hazardous chemicals were properly stored when not in use. This had the potential to affect 14 residents (#2, #5, #7, #8, #12, #13, #16, #18, #29, #21, #24, #27, #28, and #32), who the facility identified as having had cognitive impairment, and was also independent in ambulation or wheelchair mobility. The facility's census was 32.

Findings include:

On 02/03/26 at 9:29 A.M., an observation during the initial tour of the facility revealed there were unsecured chemicals that were found in a lower cabinet below the sink in the facility's main dining room. The cabinet had a lock, but it was unlocked and the cabinet door was able to be opened. Inside that cabinet was a 67.6 ounce bottle of Clean On The Go All Purpose Hydrogen Peroxide Based Cleaner. There was also a 1 quart sized bottle of Solv 20% Phos Gel Thickened Bowl and Tile Cleaner. Findings were verified by Licensed Practical Nurse (LPN) #75.

On 02/03/26 at 9:31 A.M., an interview with LPN #75 revealed hazardous chemicals, such as those found under the sink in the main dining room, were not to be stored in that cabinet. She immediately notified the maintenance director and had the hazardous chemicals removed from the cabinet below the sink and he secured them so residents did not have access to them.

Review of the MSDS for Clean On The Go Super HDQL 10 revealed it's recommended use was as a disinfectant. Hazard statements on the MSDS indicated it was harmful if swallowed, harmful in contact with skin, and caused severe skin burns and serious eye damage. Recommendations for response to exposure included immediately calling a poison center or physician. Storage recommendations indicated it should be stored locked up.

Review of the MSDS for Solv 20% Phos Gel revealed it's recommended use was for a bowl cleaner and deodorizer. Hazard statements on the MSDS indicated it caused severe skin burns and eye damage and could be corrosive to metals. Precautionary statements (prevention) included instructions to not breathe dust/ fume/ gas/ mist/ vapors/ or spray. It recommended wearing protective gloves/ protective clothing/ eye protection/ and face protection when using. They were to store the hazardous chemical locked up. Most important symptoms and effects revealed it was corrosive to eyes. Contact would cause irritation and redness to exposed areas. Prolonged contact may cause severe skin irritation or mild burn.

Based on observation and staff interview, the facility failed to ensure that food was appropriately stored and dated. This had the potential to affect all of the residents residing in the facility. The facility census was 42 residents.

Findings include:

Observation on 02/25/25 at 7:55A.M. of the reach-in freezer revealed the following opened and undated items: a large bag of corn kernels, a large bag of mixed vegetables, a large bag of capri vegetables, a large bag of broccoli, a large bag of unknown white chopped meat, a large bag of frozen hamburger patties, a large bag of corn fritters and two large bags of frozen biscuits.

Interview on 02/25/25 at 8:00 A.M. with Cook #104 confirmed the reach-in freezer contained multiple opened and undated items.

Observation on 2/25/25 at 8:05A.M. of the reach-in refrigerator revealed the following opened and undated items: a plate of six cooked hamburger patties, a large pack of sausage patties, a large pack of bacon, a large bag of diced potatoes.

Interview on 02/25/25 at 8:10 A.M. with Cook #104 confirmed the reach in refrigerator contained multiple opened and undated items.

Based on personnel record review, review of tuberculosis test results, staff interview, and facility policy review, the facility failed to ensure a two-step tuberculosis test was obtained for two facility staff (Resident Assistant (RA) #66 and RA #69). This had the potential to affect all 36 residents who resided in the facility.

Findings Include:

Review of the personnel file for Resident Assistant (RA) #66 revealed the RAs first day worked was 02/08/24.

Review of the Tuberculosis (TB) Test Placement and Read results dated 02/05/24 revealed RA #66 received an initial TB test on 02/05/24 at 5:05 P.M. Results were negative and read on 02/07/24 at 5:58 P.M. There was no evidence of the second step to the TB test being completed.

Review of the personnel file for Resident Assistant (RA) #69 revealed the RAs first day worked was 02/08/24.

Review of the TB Test Placement and Read results dated 02/01/24 revealed RA #69 received an initial TB test on 02/01/24 at 3:12 P.M. RA #69 was instructed to return to the same clinic that provided the injection 48-72 hours after injection to have the test read and must have the test read between 02/03/24 at 3:12 P.M. and 02/04/24 at 3:12 P.M. Failure to return for the test read during the specified time may require a new test. There was no evidence RA #69 returned to have the initial test read or completed a new two-step TB test.

Interview on 04/22/24 at 3:45 P.M. with the Executive Director (ED) confirmed there was not any evidence the two-step TB tests had been completed for RA #66 or RA #69.

Review of the facility undated policy, M. Tuberculosis Screening for Employees

Based on observations, menu review, staff interview, and facility policy review, the facility failed to ensure a dinner meal was served in a sanitary manner. This had the potential to affect all 36 residents who resided in the facility.

Findings Include:

Review of the menu for the dinner meal service on 04/22/24 revealed the planned meal included chicken parmesan, buttered spaghetti, tossed salad, wheat bread, margarine, dressing choice, parsley garnish, and chilled mandarin oranges.

Observations on 04/22/24 from 4:40 P.M. to 4:55 P.M. of dinner meal service with Cook #64 revealed the cook had gloves on at the time of the start of the observation. Cook #64 used her gloved hands to grab a handful of salad from a plastic container and placed it on the residents' plates. Then, Cook #64, with the same gloves on, grabbed a handful of parmesan cheese from an opened large plastic bag and sprinkled it over the top of the chicken parmesan on the residents' plates. Finally, Cook #64, with the same gloves on, grabbed a dinner roll from a plastic bag and placed on residents' plates. Cook #64 was observed on multiple occasions to handle paper meal tickets and a ballpoint pen in between plating food items with the same gloves on. Cook #64 did not change her gloves or wash her hands with soap and water during the duration of the observation. Cook #64 did not use any serving utensils to plate the above food items and used her gloved hands.

Interview on 04/22/24 at 4:55 P.M. with Cook #64 confirmed she had handled the above food items with the same gloves on. Cook #64 confirmed she had not changed her gloves or completed any hand hygiene during the meal service observation. Cook #64 confirmed she had not used any serving utensils to plate salad, parmesan cheese, or a dinner roll on the residents' plates. Cook #64 stated, I didn't even think about it. I just did what I was taught to do.

Review of the facility undated policy, titled Service of Foods revealed during meal service, food was protected from contamination and growth of pathogenic organism. To help eliminate factors that contribute to food borne illness, suitable utensils were used to handle foods.

Review of the facility undated policy titled Handwashing

Based on record review and interview, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift as required. This had the potential to affect all 36 residents that resided at the facility.

Findings Include:

Review of the monthly fire drill records from May 2023 to April 22, 2024 revealed one resident was evacuated during the second shift fire drill on 06/07/23, one resident was evacuated during the third shift fire drill on 10/09/23 and one resident was evacuated during the first shift fire drill on 02/02/24.

Record review revealed no evidence all residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift as required.

On 04/22/24 at 2:15 P.M. interview with the Executive Director (ED) and Maintenance Director (MD) #56 confirmed only one resident was evacuated during the three fire drills listed above between May 2023 and April 22, 2024.

This violation is a recite to the survey completed on 12/16/20 and 01/24/23.

Based on record review, review of a fire investigation, review of a fire report, and staff interview, the facility failed to report a fire incident to the Ohio Department of Health (ODH). The affected one reident (#27) and had the potential to affect all 36 residents in the facility.

Findings Include:

Review of the medical record for Resident #27 revealed an admission date on 10/01/18 with medical diagnoses including dementia, type II diabetes mellitus, and hypertension.

Review of the quarterly Brief Interview for Mental Status (BIMS) assessment dated 10/23/23 revealed Resident #27 had severe cognitive impairment and scored three out of 15 on the assessment.

Review of the Assisted Living Quarterly Assessment dated 10/23/23 revealed Resident #27 was independent with mobility and transfers. Resident #27 was alert and oriented with periods of forgetfulness. Resident #27 required assistance with bathing, toileting, grooming, and dressing.

Review of the Risk Occurrence Incident Report Form dated 12/27/23 at 12:40 A.M. revealed staff heard an alarm and went to investigate. The staff smelled smoke near Resident #27's room. The resident had a small candle-looking lamp that was knocked over onto a sweatshirt. Resident #27's room was full of smoke. The staff called 911 and removed Resident #27 from the room. The fire department came and put out the fire. Resident #27's nephew was notified as well as the local Area Agency on Aging (AAA). Resident #27 did not sustain any injuries and was assessed by the paramedics who denied the need for the resident to be transported to the hospital.

Review of the Fire Report dated 12/27/23 revealed a small flame was started by a bedside light in Resident #27's room. Resident #27 had taken off her sweatshirt and accidentally laid it over the lamp, knocking off the lampshade. The sweatshirt started smoldering and smoking and set off the smoke detector. The fire department was notified and arrived on scene to put out the flame and assisted to ensure everyone was safe. Maintenance Director (MD) #56 cleaned up Resident #27's room and discarded the sweatshirt and lamp.

There was no evidence the fire incident had been reported to the Ohio Department of Health (ODH).

Interview on 04/23/24 at 12:45 P.M. with Maintenance Director (MD) #56 confirmed the fire incident was not reported to ODH. MD #56 stated he contacted the local county health department but did not contact ODH because he was not aware ODH should have been contacted.

A facility policy was requested related to reporting fire incidents but none was provided for review.

Based on record review and interview, the facility failed to evacuate residents capable of self-evacuation for at least two fire drills a year on each shift. This had the potential to affect all 31 residents that reside at the facility.

Findings include:

Review of the monthly fire drill records for the year 2022 revealed the facility had only evacuated residents for the fire drill conducted in February 2022. There were no residents evacuated during the fire drills conducted for the remaining months of the year.

Interview with Facility Administrator on 01/24/23 at 2:00 P.M. confirmed the only fire drill where residents were evacuated was conducted in February 2022 and during the remaining months of the year 2022 there were no residents evacuated during the conducted fire drills.

This violation is a recite to annual survey completed 12/16/20.