New Dawn Retirement Center

Based on record review and interview, the facility failed to ensure three employees (#11, #41, and #34) of the four employee files reviewed did not have documented evidence that thorough pre-employment physicals were completed. This had the potential to affect all 11 residents residing in the facility.

Findings Include:

Review of the personnel file of personal care assistant (PCA) #11 revealed a physical form dated 08/27/24 was not completed in its entirety and did not have a legible medical provider's signature. The form listed PCA #11's date of birth, age, and address, height and weight and two squiggly lines on the examiner's signature space.

Review of the personnel file of Licensed Practical Nurse (LPN) #34 revealed a physical form dated 04/09/25 was not completed in its entirety and did not have a legible medical provider's signature. The form listed LPN #34's date of birth, age, and address, height and weight and two squiggly lines on the examiner's signature space.

Review of the personnel file of PCA #41 revealed a physical form dated 03/21/25 was not completed in its entirety and did not have a legible medical provider's signature. The form listed PCA #41's date of birth, age, and address and two squiggly lines on the examiner's signature space.

Interview on 06/05/25 at 5:15 P.M. with the Administrator #20 revealed the employee physical forms complete for PCAs #11 and #41 and LPN #34 were missing necessary information and legible signatures.

Based on record review and interview, the facility failed to obtain witnessed authorization forms with witnessed signatures by non-facility staff on three (Residents #201, #208, and #212) of five residents reviewed for resident funds. The facility census was 11.

Findings include:

Review of Resident #212's resident funds form titled Authorization and Agreement to Handle Resident Funds revealed the resident's signature dated 12/13/24 was witnessed by the facility Administrator only.

Review of Resident #208's resident funds form titled Authorization and Agreement to Handle Resident Funds revealed the resident's signature dated 04/22/2024 was witnessed by the facility Administrator and facility Licensed Social Worker (LSW) #19.

Review of Resident #201's resident funds form titled Authorization and Agreement to Handle Resident Funds revealed the resident's signature dated 01/28/2025 was witnessed by the facility Administrator and facility LSW #19.

Interview on 06/05/25 at 5:20 P.M. with the facility Administrator revealed she was not aware that facility staff or administration could not witness signatures on the Authorization and Agreement to Handle Resident Funds consent. The Administrator verified that the witness signatures on Residents #201, #208, and #212 Authorization and Agreement to Handle Resident Funds consent belonged to her and the facility LSW.

Based on record review, observation, review of the National Weather Service temperature history, interview and facility policy review, the facility did not monitor resident room temperatures after the heating, ventilation, and air conditioning (HVAC) heating and cooling system failed to ensure comfortable temperatures for the residents. This had the potential to affect all 11 residents residing in the facility.

Findings include:

Review of the facilities heating and cooling system on the 500, 600, and 700 halls failed to operate. As of 06/05/25, the system remains non-functioning. The facility rented five dual heater/air conditioning units from a local rentals company from 04/23/25 to 06/02/25. These units were placed in the 500, 600, and 700 resident hallways. Resident rooms were required to have doors open to receive heat or air from these units. On 06/02/25, invoices revealed the purchase of five portable air conditioning units to replace the prior rental units. The portable air condition units were placed in the hallways of 500, 600, and 700 halls and residents were required to leave their room doors open to receive cool air from the hallway.

Interview on 06/05/25 at 12:30 P.M. with the Administrator revealed the above findings were accurate. The Administrator reported the facility was going to repair the unit instead of replacing it due to the high cost. The Administrator also reported returning the heating and cooling units they rented due to the high cost and felt the purchase of five single cooling units would be sufficient until repairs to the whole system could be made.

Record review of temperature logs from 04/22/25 through 06/05/25 revealed temperatures were checked in the hallways of 500, 600, and 700 halls and dining room. There were no logs to confirm that resident room temperatures were checked or monitored.

Observation on 06/05/25 at 9:01 A.M. with Maintenance Technician (MT) #17 revealed Resident #210 sitting on couch wearing long sleeved shirt, jeans, and utilizing a throw blanket. The room temperature was 76 degrees Fahrenheit (F)

Interview on 06/05/25 at 9:01 A.M. with Resident #210 revealed she currently felt comfortable in her room, and she was okay with her door being left open.

Observation on 06/05/25 at 9:02 A.M. with MT #17 of Resident #202 revealed the resident was wearing shorts and short sleeved shirt. The room temperature was 75 degrees F.

Interview on 06/05/25 at 9:02 A.M. with Resident #202 revealed she currently felt comfortable in her room, and she was okay with her door being left open. Resident #202 also reported that it was a little warm in the evening last night, 06/04/25. The National Weather Service recorded outside temperatures in the Akron-Canton Ohio Region on 06/04/25 reaching a high of 86 degrees F.

Observation on 06/05/25 between 4:48 P.M. and 4:57 P.M. revealed resident room temperatures as follows: Residents #205 and #206 room was 79.8 degrees F, Resident #201's room was 79 degrees F, Resident #211's room was 79.7 degrees F.

Interview on 06/05/25 at 4:55 P.M. with Resident #201 revealed she currently felt comfortable with the room temperature because she turned the fan on and opened her window. Resident #201 reported that last week the facility was very cold at night. The facility did offer extra blankets, but Resident #201 reported it was still very cold. The National Weather Service recorded low temperatures between 05/25/25 through 05/31/25 ranging between 41-52 degrees F at night.

Interview on 06/05/25 at 5:30 P.M. with the Administrator revealed the policy related to heating and cooling system failure lacked procedures for frequency of temperature monitoring, location of temperature monitoring, and indications when to notify Resident physicians of health concerns. The Administrator confirmed there were no recordings of resident room temperatures on the temperature log.

Review of the cooling system failure policy revealed no specific procedures for monitoring ambient temperatures or the frequency to monitor temperatures or locations of temperatures to be monitored. There were no specified parameters for temperature monitoring. There were no indications of when to report resident health concerns to resident's physicians.

This violation represents non-compliance investigated under Master Complaint Number OH00166276.

The state published no narrative for this citation.

Based on record review, interviews, review of the facility self-reported incident (SRI) and review of the personnel file of Personal Care Aide (PCA) #37, the facility failed to prevent the loss of Resident #208's property. This affected one (Resident #208) of three residents reviewed for misappropriation of property. The facility census was 11.

Findings include:

Review of the medical record for Resident #208 revealed she was admitted to the facility on 03/05/25 with diagnoses including schizoaffective disorder, paranoid schizophrenia, dementia, incontinence, arthritis, morbid obesity heart failure, unspecified psychosis, anxiety, epilepsy, and major depression. Resident #208 utilizes a walker for assistance navigating the facility and requires some assistance with personal care and bathing.

Review of facility SRI tracking number 261005 created on 05/29/25 and completed on 06/04/25 by the Administrator revealed Resident #208 reported a red cash box missing from her room on 05/29/25. A signed statement by Licensed Social Worker (LSW) #19 revealed she had witnessed Resident #208 having the red cash box in her room. On 05/29/25, the facility staff, including the Administrator and LSW#19, assisted Resident #208 in searching her room for the red cash box with no results.

Interview on 06/05/25 at 9:30 A.M. with the facility Administrator revealed administration did interview all staff regarding the allegation of theft. The Administrator reported that the administration interviewed all residents regarding allegations of theft and safety. The Administrator reported she personally interviewed Resident #208, and the interview revealed that Resident #208 suspected PCA #37 of possibly taking the cash box. The Administrator reported there was no further investigation into PCA #37 since she no longer worked at the facility, and Resident #208 was insistent on not filing a police report.

Interview on 06/05/25 at 1:38 P.M. with Resident #208 revealed she reported to administration on 05/29/25 that a red cash box was missing from her room. Resident #208 reports that she had $390.00 and some valuable coins and sentimental jewelry belonging to her daughter in the box. Resident #208 reported that she last recalled seeing the box on 05/16/25 and it could have been taken or missing since then, but she did not realize until 05/29/25 that it was missing. Resident #208 reported that she suspected the night shift PCA (#37) may have taken cash box. Resident #208 reported that PCA #37 often acted weird and seemed like she may be on drugs. Resident #208 states she reported this to the Administrator but did not want to accuse anyone if she did not have evidence. Resident #208 reported that she does not want to file a police report. Resident #208 reported that several staff had knowledge of the red cash box in her room and that she kept cash and jewelry in it. Resident #208 reported that she often would ask staff to assist her in getting the box out of her dresser drawer where it was kept.

Record review on 06/05/25 of PCA #37's personnel file revealed a start date of 03/18/25. PCA #37 had both criminal background checks completed and review of the nurse aide registry (NAR) for history of abuse or misappropriations. Both records revealed no history of criminal activity or allegations of abuse or misappropriation of funds. Schedules revealed the last day PCA #37 worked was on 05/26/25, night shift. On 05/30/25 the Administrator made a phone call to PCA #37 to give notice of termination for unsatisfactory job performance. This was documented in PCA #37's personnel file dated for 05/30/25 at 11:30 A.M. There were no specifics given for the poor performance on the 5/30/25 document.

This violation represents non-compliance investigated under Complaint Number OH00166235.

Based on record review and interview, the facility failed to ensure all criminal record checks for employees were obtained within 30 days from the date the request was made. This affected one (Personal Care Assistant #870) of three new staff members reviewed for background checks. The facility census was 12.

Findings include:

Review of the personal file for Personal Care Assistant (PCA) #870 revealed she was hired on 05/28/24. There was no evidence of a criminal background check in her personal file.

Review of the facility's criminal background check log dated from 05/23/23 through 06/04/24 revealed PCA #870 was not listed as having her criminal background check performed by the facility. There were no entry dates after 06/04/24 listed on the log.

Interview on 07/03/24 at 8:49 A.M. with the Administrator revealed PCA #870's background check was completed on 05/23/24 and processed on 06/03/24. She stated the facility had never received the results as she believed it went to another facility. She stated PCA #870 was still employed with the facility.

Based on record review and interview, the facility failed to initially assess the resident's ability to self-administer medications and to their risk for falls. This affected one (Resident #2) of five residents reviewed for assessments. The facility census was 12.

Findings include:

Review of the medical record for Resident #2 revealed an admission date of 01/02/24 with diagnoses including congestive heart failure, difficulty walking, depression and anxiety.

Review of Resident #2's initial assessments revealed the facility did not assess her ability to self-administer medications or her risk for falls.

Interview on 07/03/24 at 4:09 P.M. with the Administrator verified Resident #2 did not have an initial assessment for her risk for falls or the ability to self-administrator medications.

3. Review of the medical record for Resident #10 revealed an admission date of 12/08/21 and diagnoses including schizoaffective disorder, recurrent major depressive disorder and anxiety disorder. There was no evidence an annual medication self-administration assessment was completed.

Interview on 07/03/24 at 4:07 P.M. with Administrator confirmed there was no evidence of an annual medication self-administration assessment for Resident #10.

4. Review of the medical record for Resident #12 revealed an admission date of 11/05/18 and diagnoses of adjustment disorder with depressed mood, disorientation, and age related osteoporosis. There was no evidence an annual medication self-administration assessment was completed.

Interview on 07/03/24 at 4:07 P.M. with Administrator confirmed there was no evidence of an annual medication self-administration assessment for Resident #12.

This violation is an example of continued non-compliance from the survey dated 03/03/21 and 03/20/23.

Based on record review and interview, the facility failed to ensure interest was applied in a reasonable amount of time to resident trust accounts. This affected four (Residents #1, #3, #4 and #8) of five resident trust fund accounts reviewed. The facility census was 12.

Findings include:

1. Review of the medical record for Resident #1 revealed an admission date of 12/16/20 with diagnoses including depression and diabetes mellitus.

Review of the quarterly Patient Trust Fund statement from 01/01/24 through 03/31/24 revealed Resident #1 had a balance of $926.01, showing the balance of $176.01 came forward on 01/01/24. There were service dates listed from 03/01/21 through 03/01/24. There was no interest noted on this quarterly statement.

Review of the current Patient Trust Fund statement dated from 03/01/24 through 06/30/24 for Resident #1 revealed interest was applied after the date of 05/01/24 with dates listed in only day and year. There was no month listed for when the interest was applied.

Interview on 07/03/24 at 3:20 P.M. with the Business Office Manager (BOM) #904 revealed he did not add interest monthly to resident accounts. He stated he had to add it manually to the account and he reviewed those periodically, preferably quarterly. He stated Resident #1 received a lump sum payment from social security and it was received on 03/26/24. The payment was dated back to 2023. BOM #904 stated there was no interest added to the account until 07/03/24 and it may have slipped under the radar. He verified the quarterly statement dated 03/01/24 through 06/30/24 did not list the month the interest was applied. BOM #904 also verified the facility received monthly statements from their bank indicating the amount of interest that was paid on the account.

2. Review of the medical record for Resident #3 revealed an admission date of 07/22/22 with diagnoses including depression and diabetes mellitus.

Review of the quarterly Patient Trust Fund statement from 01/01/24 through 03/31/24 revealed Resident #3 had a balance of $300.00, showing the balance came forward on 01/01/24. There was no interest noted on this quarterly statement.

Review of the current Patient Trust Fund statement dated from 03/01/24 through 06/30/24 for Resident #3 revealed interest was applied after the date of 05/01/24 with dates listed in only day and year. There was no month listed for when the interest was applied.

Interview on 07/03/24 at 3:20 P.M. with BOM #904 revealed he did not add interest monthly to resident accounts. He stated he had to add it manually to the account and he reviewed those periodically, preferably quarterly. BOM #904 stated there was no interest added to Resident #3's account until 06/01/24. He verified the quarterly statement dated 03/01/24 through 06/30/24 did not list the month the interest was applied. BOM #904 also verified the facility received monthly statements from their bank indicating the amount of interest that was paid on the account.

3. Review of the medical record for Resident #4 revealed an admission date of 07/22/22 with diagnoses including heart failure.

Review of the quarterly Patient Trust Fund statement from 01/01/24 through 03/31/24 revealed Resident #4 had a balance of $400.00, showing a balance of $350.00 that came forward on 01/01/24. There was no interest noted on this quarterly statement.

Review of the current Patient Trust Fund statement dated from 03/01/24 through 06/30/24 for Resident #4 revealed interest was applied after the date of 05/01/24 with dates listed in only day and year. There was no month listed for when the interest was applied.

Interview on 07/03/24 at 3:20 P.M. with BOM #904 revealed he did not add interest monthly to resident accounts. He stated he had to add it manually to the account and he reviewed those periodically, preferably quarterly. BOM #904 stated there was no interest added to Resident #4's account until 06/01/24. He verified the quarterly statement dated 03/01/24 through 06/30/24 did not list the month the interest was applied. BOM #904 also verified the facility received monthly statements from their bank indicating the amount of interest that was paid on the account.

4. Review of the medical record for Resident #8 revealed an admission date of 04/26/23 with diagnoses including heart failure, hypertension and diabetes mellitus.

Review of the quarterly Patient Trust Fund statement from 01/01/24 through 03/31/24 revealed Resident #8 had a balance of $1, 840.00, showing a balance of $1,720.00 that came forward on 01/01/24. There was no interest noted on this quarterly statement.

Review of the current Patient Trust Fund statement dated from 03/01/24 through 06/30/24 for Resident #8 revealed interest was applied after the date of 05/01/24 with dates listed in only day and year. There was no month listed for when the interest was applied.

Interview on 07/03/24 at 3:20 P.M. with BOM #904 revealed he did not add interest monthly to resident accounts. He stated he had to add it manually to the account and he reviewed those periodically, preferably quarterly. BOM #904 stated there was no interest added to Resident #8's account until 06/01/24. He verified the quarterly statement dated 03/01/24 through 06/30/24 did not list the month the interest was applied. BOM #904 also verified the facility received monthly statements from their bank indicating the amount of interest that was paid on the account.

Based on observations, record reviews and interviews the facility failed to ensure the dishwasher fuctioned at the proper temperature failed to ensure food was served at a palatable temperature. This had the potential to affect all 12 residents residing in the facility.

Findings include:

1. Interview on 07/01/24 at 8:30 A.M. with Cook #821 revealed the dish machine sanitized via high temperature. Cook #821 also said the kitchen staff noticed the water temperature to the dish machine was lower when the laundry washing machine was running at the same time the dish machine was being used. Laundry staff was to hold running the washing machine until late morning. The facility was waiting for the hot water tank to be replaced.

Observation of on 07/01/24 at 8:48 A.M. revealed a dietary aide rinsing and scrubbing dishes in a large grey colored bus tub filled with water and another tub labeled rinse prior to placing plates, cups and trays in a rack then sending the rack through the dish machine. Observation of the digital thermostat on the dish machine during the wash/rinse cycle revealed the temperature reached a high of 147 degrees Fahrenheit (F). Cook #821 placed another rack through the dish machine with similar results, temperature between 145-147 degrees F. The bus tubs did not include a sanitizing solution, just a rinse aid to prevent streaks and spots. Observation of the faceplate on the dish machine revealed the following:

AM-14 hot water sanitizing

Wash temperature of 150 degrees F minimum

Rinse temperature 180 degrees F minimum

Wash minimum 40 seconds

Dwell 13 seconds

Rinse minimum 9 seconds

Review of the label on the Advance Washing Solutions Rinse Additive container (the rinse aid utlized in the tub labeled rinse) revealed the product was effective at low use rates and provided sheeting to prevent hard water deposits and films, eliminated streaking and was effective in both low and high temperatures.

Interview on 07/01/24 at 9:00 A.M. with Maintenance #814 revealed the hot water tank was to be delivered this date. Maintenance #814 was uncertain how long the dish machine had not been reaching the appropriate temperature to sanitize but said it's been awhile.

Interview on 07/01/24 at 9:45 A.M. with the Administrator revealed the dish machine temperatures were inconsistent. The Administrator was informed by Dietary Manager #818 that after items were run through the dish machine the dietary staff sanitized the items. It was shared with the Administrator this was not observed and there were no bus tubs with water and sanitizer observed on the side of the dish machine where the dish racks exited.

Interview on 07/01/24 at 10:30 A.M. with Laundry aide #843 revealed she was not told until that morning (07/01/24) to hold off laundry from 10:00 A.M. to 12:30 P.M.

Interview on 07/01/24 at 2:58 P.M. with Dietary aide (DA) #833 revaled the temperature of the water in the dish machine was different everyday. DA #833 was not given any instructions on what to do when the water did not meet the proper temperature to sanitize.

Follow-up interview on 07/02/24 at 8:45 A.M. with the Administrator revealed she had a copy of what was posted on the dish machine regarding high and low temperatures along with what chemical to use. Review of the information revealed the information was not for sanitation but for appearances (spots and streaks).

Interview on 07/02/24 at 10:00 A.M. with Registered Dietitian (RD) #905 revealed when she spoke to the chemical supply technician he said they could use bleach if over 50 parts per million (PPM). Observation at this time revealed RD #905 using a test strip to test the chlorine level of the dish machine; however, the test strip being used was meant to be used for the 3 compartment sink, not the dish machine.

Follow-up interview on 07/02/24 at 2:30 P.M. with Cook #821 revealed kitchen staff started using bleach to sanitize dishes and cutlery on 07/02/24 when told to by RD #905.

Observation on 07/02/24 at approximately 2:30 P.M. revealed RD #905 had the proper chlorine test strip to be used for the dish machine.

Additional observation of the dish machine on 07/01/24 at 2:55 P.M. and 07/02/24 at 2:30 P.M. revealed temperatures on the dish machine ranged from 129 degrees to 165 degrees F.

Follow up interview with RD #905 on 07/03/24 at 9:00 A.M. revealed the kitchen staff started testing the chlorine levels of the dish machine on 06/08/24.

Review of the dish machine temperature logs for April, May and June 2024 revealed the temperatures were low and not hot enough to sanitize starting in May 2024.

Review of the chlorine testing log revealed the log was initiated on 06/08/24.

2. Observation on 07/02/24 at 11:15 A.M. revealed the food temperatures on the steam table for lunch service were above 165 degrees Fahrenheit. The kitchen prepared food for both the nursing and assisted living areas. The test tray was started at 12:22 P.M. and delivered to the floor by 12:31 P.M. The trays were passed out starting at 12:32 P.M. The test tray was tested at 12:43 P.M. and the BBQ ribs were 98 degrees Fahrenheit and the sweet potato fries were 94.3 degrees Fahrenheit.

Interview on 07/02/24 at 12:43 P.M. with Cook #821 revealed food should be served at 135 degrees Fahrenheit and confirmed the temperatures were below service temperature.

This violation is an example of continued non-compliance from the survey dated 03/20/23.

Based on record review and interviews the facility failed to evacuate residents who were capable of self-evacuation twice in the year for fire drills. This had the potential to affect all 12 residents.

Findings include:

Review of the fire drills revealed only one evacuation during the year for fire drills.

Interview on 07/03/24 at 2:40 P.M. with Maintenance #814 revealed only one evacuation was completed.

This violation is an example of continued non-compliance from the survey dated 03/20/23.

Based on review of the medical record and interviews with staff the facility failed to ensure self-administration evaluations were completed annually. This affected three residents (Resident #4, #6, and #12) of 12 residents residing in the facility.

Findings included:

1. Review of the medical record for Resident #4 revealed an admission date of 01/07/21. Diagnoses included hypothyroidism, diabetes, dementia, major depressive disorder, hypertension, atrial fibrillation, and bradycardia.

Review of the quarterly evaluation dated 03/15/23 revealed Resident #4 had intact cognition.

Further review of the medical record revealed the last completed self-administration of medication evaluation was completed on 01/24/22 for Resident #4 and she was not to self-administer her own medications.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual self-administration evaluation for Resident #4. She stated none of the residents in the assisted living were able to self-administer their own medications.

2. Review of the medical record for Resident #6 revealed an admission date of 09/19/19. Diagnoses included diabetes, atherosclerotic heart disease, tachycardia, congestive heart failure lymphedema, chronic kidney disease, and edema.

Review of the quarterly evaluation dated 11/10/22 revealed Resident #6 had intact cognition and there was not an annual self- administration of medications completed.

Further review of the medical record revealed the last completed self-administration of medication evaluation was completed on 09/19/19 for Resident #6 and he was not to self-administer his own medications.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual self-administration evaluation for Resident #6. She stated none of the residents in the assisted living were able to self-administer their own medications.

3. Review of the medical record revealed Resident #12 revealed an admission date of 11/05/19. Diagnoses included hemorrhagic disorder, hypothyroidism, diabetes, major depressive disorder, insomnia, chronic pain syndrome and atherosclerotic heart disease.

Review of the quarterly evaluation dated 02/03/23 revealed Resident #12 had intact cognition and there was not an annual self- administration of medications completed.

Further review of the medical record revealed the last completed self-administration of medication evaluation was completed on 01/31/22 for Resident #12 and she was not to self-administer her own medications.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual self-administration evaluation for Resident #12. She stated none of the residents in the assisted living were able to self-administer their own medications.

This deficiency is a recite to the annual survey completed 03/03/21.

Based on observation, and interview, the facility failed to ensure lint was removed from the dryer lint compartment. This had the potential to affect all 12 residents residing in the facility.

Findings include:

Interview on 03/16/23 at 1:18 P.M. with Personal Care Assistant (PCA) #125 revealed the assisted living had one industrial dryer. Observation of the lint compartment beneath the dryer revealed lint was removed from the front quarter of the lint compartment but the back three fourths of the lint compartment contained a large amount of lint. The back half of the lint compartment on the right side was covered in approximately six inches thick with lint. There was a sign on the dryer that said to clean lint after each use. PCA #125 got a broom and swept the lint into an approximately one foot by one foot ball. PCA #125 said she never saw it so full but was only there to fold towels and had not checked the lint compartment. PCA #125 said they do not log how often they clean out the lint compartment but verified should have been cleaned out.

Interview on 03/16/23 at 3:22 P.M. with the Administrator revealed the facility did not have a policy for cleaning the lint compartment. The administrator revealed they were going to institute the Dryer Lint Cleaning Log in the Assisted Living.

Based on observation, record review, interview and policy review, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect all 12 residents in the facility.

Findings include;

Initial tour of the kitchen on 03/13/23 9:04 A.M. revealed the following:

Five vents in the ceiling that were rusty colored, black in areas and covered in dust. There was black/brown dust collected around the vents on the ceiling itself.

The metal shelf over the length of the cooking area, grill and burners had grease and grime with crumbs and dust.

Both ovens were dirty with the floor, door, sides and back of the oven black. There were drops of food and assorted sizes of aluminum foil in the ovens.

Observation of the reach in refrigerator revealed the eggs were on the top shelf of the refrigerator in an open egg crate with other shelves and food items below.

Interview on 03/13/23 at the time of the observation with the Dietary Manager (DM) #119 revealed the ovens were not on the cleaning schedule so they were not cleaned.

Interview on 03/13/23 at 9:13 A.M. with Dishwasher #132 revealed he did not know what the wash and rinse temperatures were to be for the dishwasher.

Observation at the time of the interview revealed the Hobart dishwasher was to wash at 150 degrees Fahrenheit and rinse at 180 degrees Fahrenheit or above.

Review of the March 2023 Dishwasher Temperature log revealed the instructions included the wash temperature was to be 140 degrees Fahrenheit, instead of 150 degrees as per manufacturer guidelines, and the rinse temperature 180 degrees Fahrenheit.

Review of the dishwasher temperature log for March revealed the wash temperature was below 150 degrees on 03/01/23 for lunch at 149 degrees Fahrenheit (F), 03/03/23 for lunch at 143 degrees F, 03/04/23 for breakfast at 149 degrees F, 03/05/23 for breakfast at 148 degrees F, 03/06/23 lunch at 147 degrees F, 03/08/23 for lunch at 145 degrees F, and 03/10/23 for lunch at 149 degrees F. The rinse temperature was below 180 degrees F for the supper meals on 03/01/23 at 178 degrees F, 03/02/23 at 149 degrees F, 03/03/23 at 179 degrees F, 03/04/23 at 172 degrees F, 03/06/23 at 174 degrees F and 03/07/23 at 179 degrees F.

Spaghetti noodles were opened and undated in the dry pantry.

The walk in freezer contained condensation on the shelves that was in a thick waterfall fashion from the top shelf to the floor then spreading approximately four feet onto the floor of the walk in freezer.

The Salisbury steaks, fish fillets, and beef patties in the walk in freezer had their bags opened and exposed to the freezer air.

Interview on 03/13/23 at 9:23 A.M. with DM #119 verified the observations as stated above. The DM verified the dishwasher wash and rinse temperatures were lower than the recommended temperatures. He was unsure if staff were recording temperatures before the dishwasher reached maximum temperature.

Based on menu review, interview and policy review the facility failed to maintain records of food served or substitutions made for at least three months. This had the potential to affect all the residents in the facility. The census was 12.

Findings include:

1. Review of the menu for 03/13/23 revealed hushpuppies were to be served with the lunch meal.

Observations of the lunch meal on 03/13/23 at 12:16 P.M. revealed a roll was substituted for hushpuppies.

2. Review of the menu for 03/14/23 revealed wheat bread was to be served with the lunch meal.

Observation of the lunch meal on 03/14/23 at 12:43 P.M. revealed a roll was substituted for wheat bread.

3. Review of the menu for 03/15/23 revealed bacon wrapped chopped steak and silver white cake were part of the lunch meal to be served.

Observation of the tray line on 03/15/23 at 11:46 A.M. revealed the facility substituted Salisbury steak for bacon wrapped chopped steak, added mashed potatoes and served pound cake with whipped cream and chocolate instead of silver white cake.

The facility was unable to produce a substitution list for 2023.

Interview on 03/15/23 at 11:46 A.M. with Dietary Manager (DM) #119 revealed he was responsible for the substitution list. He verified there was not a list in the kitchen for staff to write on when they deviate from the menu. DM #119 did not provide any historical substitution list.

Review of the facility's Substitutions policy revised April 2007 included all substitutions are noted on the menu and filed in accordance with established dietary policies.

Based on observation and interview, the facility failed to evacuate residents during fire drills as required. This had the potential to affect all resident residing in the facility. The census was 12.

Findings include:

Review of fire drills revealed the previous 12 month fire drills completion forms showed no residents had been evacuated during the fire drills.

Interview with Maintenance Director #111 on 03/16/23 at 3:24 P.M. confirmed no residents had been evacuated during monthly fire drills for the past 12 months.

Based on review of the medical record and interviews with staff the facility failed to ensure annual fire education and assessments were completed for four residents (Resident #4, #6, #12 and #13) of 12 residents residing in the facility.

Findings included:

1. Review of the medical record for Resident #4 revealed an admission date of 01/07/21. Diagnoses included hypothyroidism, diabetes, dementia, major depressive disorder, hypertension, atrial fibrillation, and bradycardia.

Review of the quarterly evaluation dated 03/15/23 revealed Resident #4 had intact cognition.

Further review of the medical record revealed there was not an annual fire evaluation or assessment completed for Resident #4.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual fire evaluation and assessment completed for Resident #4.

2. Review of the medical record for Resident #6 revealed an admission date of 09/19/19. Diagnoses included diabetes, atherosclerotic heart disease, tachycardia, congestive heart failure lymphedema, chronic kidney disease, and edema.

Review of the quarterly evaluation dated 11/10/22 revealed Resident #6 had intact cognition.

Further review of the medical record revealed there was not an annual fire evaluation or assessment completed for Resident #6.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual fire evaluation and assessment completed for Resident #6.

3. Review of the medical record revealed Resident #12 was admitted to the facility on 11/05/19. Diagnoses included hemorrhagic disorder, hypothyroidism, diabetes, major depressive disorder, insomnia, chronic pain syndrome and atherosclerotic heart disease.

Review of the quarterly evaluation dated 02/03/23 revealed Resident #12 had intact cognition.

Further review of the medical record revealed there was not an annual fire evaluation or assessment completed for Resident #12.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual fire evaluation and assessment completed for Resident #12.

5. Review of the medical record revealed Resident #13 was admitted to the facility on 11/05/18. Diagnoses included glaucoma, adjustment disorder, disorientation, osteoarthritis, edema, anemia, myasthenia gravis, and osteoporosis.

Review of the quarterly evaluation dated 03/15/23 revealed Resident #13 had intact cognition.

Further review of the medical record revealed there was not an annual fire evaluation or assessment completed for Resident #13.

On 03/16/23 at 4:16 P.M. an interview with the Administrator revealed there was not an annual fire evaluation and assessment completed for Resident #13.

Based on observation and interview, the facility failed to complete a monthly self fire safety. This had the potential to affect all residents residing in the facility. The census was 12.

Findings include:

Review of the monthly Fire Safety - Self Inspection Form revealed was not completed for the past 12 months.

Interview with Maintenance Director #111 on 03/16/23 at 3:24 P.M. confirmed the monthly Fire Safety - Self Inspection Form was not completed for the past 12 months.

Based on observation and staff interview, the facility failed to maintain a functioning call system in the central shower/bathroom. This affected one resident (Resident #6) identified to use the central shower. The census was 12.

Findings include:

Observation on 03/13/23 at 1:33 P.M. of the common shower/bathroom next to the nurse station revealed it had three call lights. One by the toilet and one by each bathing area. Activation of the call lights revealed no light came on and no sound was audible. Licensed Practical Nurse #95 checked the nurse station and did not see or hear a call light signal.

Interview on 03/16/23 at 1:34 P.M. with LPN #95 verified the call lights in the common shower room were not working.

Interview on 03/16/23 at 1:36 P.M. with Personal Care Assistant (PCA) #179 revealed Resident #6 utilizes the central bathing/toilet room for showers since his apartment did not contain a bathtub or shower.