Canton Regency Residential Care Facility

Based on observation, interview with staff, and review of the facility policy, the facility failed to ensure medications were locked and secure on the first-floor memory care unit. This had the potential to affect 14 residents (#98, #100, #101, #104, #105, #111, #115, #117, #118, #119, #121, #123, #127, and #129) on the first-floor memory care unit who were cognitively impaired and independently mobile. Findings included. Observations on 05/14/26 at 8:30 A.M. revealed the first-floor medication room door was open, the treatment cart was unlocked with numerous topical creams, wound cleansers and wound cleaning supplies in the medication room. There was one bottle of eye drops, three flex pens of insulin and three boxes of acetaminophen suppositories in the refrigerator in the unlocked medication room. On 05/14/26 at 8:35 A.M. an interview with Licensed Practical Nurse #244 verified she had not closed the medication room and any cognitively impaired and independently mobile residents had access. Review of the facility policy titled, Medication Storage of Centrally Stored MedicationsBased on observation, interview with staff, and review of the facility policy, the facility failed to ensure medications were locked and secure on the first-floor memory care unit. This had the potential to affect 14 residents (#98, #100, #101, #104, #105, #111, #115, #117, #118, #119, #121, #123, #127, and #129) on the first-floor memory care unit who were cognitively impaired and independently mobile.

Findings included.

Observations on 05/14/26 at 8:30 A.M. revealed the first-floor medication room door was open, the treatment cart was unlocked with numerous topical creams, wound cleansers and wound cleaning supplies in the medication room. There was one bottle of eye drops, three flex pens of insulin and three boxes of acetaminophen suppositories in the refrigerator in the unlocked medication room.

On 05/14/26 at 8:35 A.M. an interview with Licensed Practical Nurse #244 verified she had not closed the medication room and any cognitively impaired and independently mobile residents had access.

Review of the facility policy titled, Medication Storage of Centrally Stored Medications

Review of the medical record, review of the facility investigation, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to complete a thorough investigation of an abuse incident related to Resident #133, who was cognitively impaired and dependent on staff for care, and verbally abused by a staff member. This affected one resident (#133) out of four residents reviewed for abuse. Findings included: Review of the medical record revealed Resident #133 was admitted to the facility on 05/31/24. Diagnoses included pulmonary embolism, benign prostatic hyperplasia, depression, dementia with inappropriate sexual behaviors, meningioma, atrial fibrillation, and deep vein thrombosis. He expired at the facility on 12/30/25. Review of the Service Plan dated 10/16/25 revealed Resident #133 had moderately impaired cognition and was dependent on staff for activities of daily living. Review of Resident #133's progress notes from 07/22/25 to 07/30/25 revealed no documentation of any incidents related to abuse. Review of the incident report dated 07/24/25 revealed the nurse was notified Resident #133 was on the floor and had fallen out of bed. While being transferred he got two skin tears. There was a diagram on the report, and the right forearm was circled on the diagram. There were no other assessments, no measurements of the wounds, no pain assessments, and no psychosocial assessments completed. Review of the typed witness statement dated 07/25/25 revealed the Director of Nursing (DON) with Business Office Director #287 interviewed Resident Care Associate (RCA) #501 concerning what had happened on 07/24/25 with Resident #133. RCA #501 stated RCA #500 went into Resident #133's room to get him up for breakfast. She heard RCA #500 state to Resident #133 Are you going to get up, [expletive]? Are you going to stay in your [expletive] bed? Because if you do you aren't going to get any [expletive] breakfast. She stated RCA #500 did get Resident #133 up and bring him to breakfast, toileted him and put him in the reclining chair outside of the dining room. At lunch she heard RCA #500 getting upset because Resident #133 was yelling for coffee. RCA #500 said something about taking him to his room because Resident #133 was [Expletive] irritating. She stated she told him that Resident #133 was care planned that he would not go to his bed because of fall risks and RCA #500 said he did not care if he [expletive] falls and he was not dealing with him anymore. She indicated a couple hours or so later she was with the nurse when RCA #500 called and said that Resident #133 had fallen. She asked the nurse if she needed her help because she was starting another task. The nurse said no, she and RCA #500 could handle it. She said she saw RCA #500 later and he had blood on his pants. She stated she asked what happened and RCA #500 said That [expletive] idiot fell on me. Review of the handwritten witness statement from Licensed Practical Nurse (LPN) #502 dated 07/25/25 revealed on 07/24/25 she witnessed RCA #500 aggressively pulling Resident #133 away from the breakfast table due to him being mad the resident was yelling about coffee. He stated, I don't give a [expletive], I don't want to hear him. He's going to his room. She stated RCA #501 told RCA #500 that the resident was care planned to only be laid down at bedtime and during the day he was to be in the common area in the recliner. She stated she did see the resident in the common area in the recliner when she was going back downstairs. She stated later in the day around 1:00 P.M., RCA #501 let her know that RCA #500 had called her because Resident #133 had fallen out of bed. At that time, she went upstairs to the resident's room and RCA #500 had already stated on the telephone the resident was not hurt, however when she walked into the room the resident was sitting on the toilet and had blood all over him. She stated and RCA #500 also had blood all over him. She stated she asked RCA #500 what had happened because she thought the resident was not hurt and RCA #500 stated the resident fell out of the bed and when he went to get him off the floor, the resident fell on top of him. During that transfer, the resident got two skin tears to his right arm. When she asked the resident about his arm, the resident went to respond and RCA #500 cut him off and said straight to the resident, yea he got his arm cut cause he is a [expletive] idiot. Then the resident stated then see he always tells me I'm not allowed to talk! She stated RCA #500 continued to clean himself off and wiped the blood off of the resident. She stated she put a dressing on the wounds and RCA #501 stated RCA #500 always treated Resident #133 this way, management was aware and never addressed it. RCA #501 stated the hospice nurse stated she was concerned about the incident also because she made it very clear to not put the resident in his room and RCA #500 did it anyway. RCA #501 stated RCA #500 also talked about how much he could not stand Resident #133 right in front of Resident #133. She stated you could tell the resident understood and was hurt by how he talked about him. Review of the Self-Reported Incident dated 07/28/25 revealed on 07/24/25 at 2:00 P.M. a nurse witnessed an aide (RCA #500) aggressively pull a resident (Resident #133) in a wheelchair out of the dining room because the resident was yelling about coffee. In addition, this aide used profanity towards the resident as he was taking the resident out of the dining room. The aide told a co-worker, I don't give a [expletive], I don't want to hear him. Later that day, the same aide responded to this resident after he fell and used profanity toward a resident stating to another coworker yea, he got his arm cut cause he's a [expletive] idiot. The resident was present during both of these instances. RCA #500 was suspended on Friday [07/25/25] pending the investigation. He then sent the scheduler a text message stating that he quit. The investigation revealed RCA #500's comments could be seen as abusive towards the resident and he would have to be terminated. Review of the time sheets for RCA #500 revealed he worked from 7:00 A.M. to 3:04 P.M. on 07/24/25 (the day of the incident) and from 6:55 A.M. to 1:47 P.M. on 07/25/25 (the day after the incident). Further review of the facility investigation revealed no other residents on RCA #500's unit (the Memory Care Unit) were assessed for abuse and Resident #133 was not reassessed for abuse after the allegation of abuse was made. Additionally, review of the Abuse training dated 07/28/25, related to the abuse incident, revealed not all staff were included on the inservice. The topic of the training was recognizing and reporting verbal/mental abuse and not using profanity around or towards any resident, which could be considered verbal/mental abuse. On 05/13/26 at 4:16 P.M. an interview with the Executive Director revealed no skin assessments were completed of other residents in the Memory Care unit who worked with RCA #500. She stated the only skin assessment completed for Resident #133 was done on the incident report from 07/24/25 (before the abuse was reported). She stated the verbal abuse was directed at Resident #133 which was witnessed and substantiated. She stated they did not interview or assess any other residents as they immediately addressed the situation and removed RCA #500 from the facility. On 05/13/26 at 4:30 P.M. an interview with Director of Nursing revealed none of the residents in the Memory Care unit were able to be interviewed. On 05/14/26 at 10:08 A.M. an interview with the Director of Nursing revealed the facility only educated those staff members on the Abuse Training sheet dated 07/28/25. He stated he could not answer why they did not do an all-staff education. On 05/14/26 at 12:34 P.M. an interview with LPN #502 revealed there was a lot going on with how this aide treated the residents and the management were aware. He was verbally abusing numerous residents. She verified she had not reported his behavior, and she wished she would have. LPN #502 stated on 07/24/25 was she was passing out medication and was standing outside the doorway of the dining room and Resident #133 was yelling out that he wanted more coffee and he did it all the time, and instead of getting him more coffee, RCA #500 went over to Resident #133 and ripped his wheelchair backwards and started pulling him backwards so his feet would not drag, all the way back to the resident's room. RCA #500 was yelling, I'm tired of this [expletive]! and the other aide told him the resident was not to be in his room, but RCA #500 stated he did not care he was not listening to him. LPN #502 stated later that day, Resident #133 had fallen in his room, but she was not made aware of it until RCA #500 had already picked him up off the floor, and when he picked him up off the floor the resident did not help him and the resident fell on top of him. She stated of course he would not stand, they were using the mechanical lift half the time to get him up out of bed. She stated it was common knowledge that the aides were not to get anyone up off the floor by themselves. On 05/14/26 at 2:30 P.M. an interview with the Director of Nursing revealed he did not remember when RCA #501 actually told him about the incident, however he knew he started the investigation as soon as she told him about it. He stated it might have been the next day [07/25/25]. The Director of Nursing reviewed RCA #500's time sheets and verified RCA #500 continued to work after the incidents on 07/24/25. He also verified RCA #501 and LPN #502 should have reported the verbal abuse which occurred on 07/24/25 with RCA #500 and Resident #133, they were trained to immediately notify a manager of any incidents of abuse, and no staff members should get a resident up off the floor without the residents being assessed by a nurse. He stated RCA #500 only worked on the Memory Care unit. Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of PropertyReview of the medical record, review of the facility investigation, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to complete a thorough investigation of an abuse incident related to Resident #133, who was cognitively impaired and dependent on staff for care, and verbally abused by a staff member. This affected one resident (#133) out of four residents reviewed for abuse.

Findings included:

Review of the medical record revealed Resident #133 was admitted to the facility on 05/31/24. Diagnoses included pulmonary embolism, benign prostatic hyperplasia, depression, dementia with inappropriate sexual behaviors, meningioma, atrial fibrillation, and deep vein thrombosis. He expired at the facility on 12/30/25.

Review of the Service Plan dated 10/16/25 revealed Resident #133 had moderately impaired cognition and was dependent on staff for activities of daily living.

Review of Resident #133's progress notes from 07/22/25 to 07/30/25 revealed no documentation of any incidents related to abuse.

Review of the incident report dated 07/24/25 revealed the nurse was notified Resident #133 was on the floor and had fallen out of bed. While being transferred he got two skin tears. There was a diagram on the report, and the right forearm was circled on the diagram. There were no other assessments, no measurements of the wounds, no pain assessments, and no psychosocial assessments completed.

Review of the typed witness statement dated 07/25/25 revealed the Director of Nursing (DON) with Business Office Director #287 interviewed Resident Care Associate (RCA) #501 concerning what had happened on 07/24/25 with Resident #133. RCA #501 stated RCA #500 went into Resident #133's room to get him up for breakfast. She heard RCA #500 state to Resident #133 Are you going to get up, [expletive]? Are you going to stay in your [expletive] bed? Because if you do you aren't going to get any [expletive] breakfast. She stated RCA #500 did get Resident #133 up and bring him to breakfast, toileted him and put him in the reclining chair outside of the dining room. At lunch she heard RCA #500 getting upset because Resident #133 was yelling for coffee. RCA #500 said something about taking him to his room because Resident #133 was [Expletive] irritating. She stated she told him that Resident #133 was care planned that he would not go to his bed because of fall risks and RCA #500 said he did not care if he [expletive] falls and he was not dealing with him anymore. She indicated a couple hours or so later she was with the nurse when RCA #500 called and said that Resident #133 had fallen. She asked the nurse if she needed her help because she was starting another task. The nurse said no, she and RCA #500 could handle it. She said she saw RCA #500 later and he had blood on his pants. She stated she asked what happened and RCA #500 said That [expletive] idiot fell on me.

Review of the handwritten witness statement from Licensed Practical Nurse (LPN) #502 dated 07/25/25 revealed on 07/24/25 she witnessed RCA #500 aggressively pulling Resident #133 away from the breakfast table due to him being mad the resident was yelling about coffee. He stated, I don't give a [expletive], I don't want to hear him. He's going to his room. She stated RCA #501 told RCA #500 that the resident was care planned to only be laid down at bedtime and during the day he was to be in the common area in the recliner. She stated she did see the resident in the common area in the recliner when she was going back downstairs. She stated later in the day around 1:00 P.M., RCA #501 let her know that RCA #500 had called her because Resident #133 had fallen out of bed. At that time, she went upstairs to the resident's room and RCA #500 had already stated on the telephone the resident was not hurt, however when she walked into the room the resident was sitting on the toilet and had blood all over him. She stated and RCA #500 also had blood all over him. She stated she asked RCA #500 what had happened because she thought the resident was not hurt and RCA #500 stated the resident fell out of the bed and when he went to get him off the floor, the resident fell on top of him. During that transfer, the resident got two skin tears to his right arm. When she asked the resident about his arm, the resident went to respond and RCA #500 cut him off and said straight to the resident, yea he got his arm cut cause he is a [expletive] idiot. Then the resident stated then see he always tells me I'm not allowed to talk! She stated RCA #500 continued to clean himself off and wiped the blood off of the resident. She stated she put a dressing on the wounds and RCA #501 stated RCA #500 always treated Resident #133 this way, management was aware and never addressed it. RCA #501 stated the hospice nurse stated she was concerned about the incident also because she made it very clear to not put the resident in his room and RCA #500 did it anyway. RCA #501 stated RCA #500 also talked about how much he could not stand Resident #133 right in front of Resident #133. She stated you could tell the resident understood and was hurt by how he talked about him.

Review of the Self-Reported Incident dated 07/28/25 revealed on 07/24/25 at 2:00 P.M. a nurse witnessed an aide (RCA #500) aggressively pull a resident (Resident #133) in a wheelchair out of the dining room because the resident was yelling about coffee. In addition, this aide used profanity towards the resident as he was taking the resident out of the dining room. The aide told a co-worker, I don't give a [expletive], I don't want to hear him. Later that day, the same aide responded to this resident after he fell and used profanity toward a resident stating to another coworker yea, he got his arm cut cause he's a [expletive] idiot. The resident was present during both of these instances. RCA #500 was suspended on Friday [07/25/25] pending the investigation. He then sent the scheduler a text message stating that he quit. The investigation revealed RCA #500's comments could be seen as abusive towards the resident and he would have to be terminated.

Review of the time sheets for RCA #500 revealed he worked from 7:00 A.M. to 3:04 P.M. on 07/24/25 (the day of the incident) and from 6:55 A.M. to 1:47 P.M. on 07/25/25 (the day after the incident).

Further review of the facility investigation revealed no other residents on RCA #500's unit (the Memory Care Unit) were assessed for abuse and Resident #133 was not reassessed for abuse after the allegation of abuse was made. Additionally, review of the Abuse training dated 07/28/25, related to the abuse incident, revealed not all staff were included on the inservice. The topic of the training was recognizing and reporting verbal/mental abuse and not using profanity around or towards any resident, which could be considered verbal/mental abuse.

On 05/13/26 at 4:16 P.M. an interview with the Executive Director revealed no skin assessments were completed of other residents in the Memory Care unit who worked with RCA #500. She stated the only skin assessment completed for Resident #133 was done on the incident report from 07/24/25 (before the abuse was reported). She stated the verbal abuse was directed at Resident #133 which was witnessed and substantiated. She stated they did not interview or assess any other residents as they immediately addressed the situation and removed RCA #500 from the facility.

On 05/13/26 at 4:30 P.M. an interview with Director of Nursing revealed none of the residents in the Memory Care unit were able to be interviewed.

On 05/14/26 at 10:08 A.M. an interview with the Director of Nursing revealed the facility only educated those staff members on the Abuse Training sheet dated 07/28/25. He stated he could not answer why they did not do an all-staff education.

On 05/14/26 at 12:34 P.M. an interview with LPN #502 revealed there was a lot going on with how this aide treated the residents and the management were aware. He was verbally abusing numerous residents. She verified she had not reported his behavior, and she wished she would have. LPN #502 stated on 07/24/25 was she was passing out medication and was standing outside the doorway of the dining room and Resident #133 was yelling out that he wanted more coffee and he did it all the time, and instead of getting him more coffee, RCA #500 went over to Resident #133 and ripped his wheelchair backwards and started pulling him backwards so his feet would not drag, all the way back to the resident's room. RCA #500 was yelling, I'm tired of this [expletive]! and the other aide told him the resident was not to be in his room, but RCA #500 stated he did not care he was not listening to him. LPN #502 stated later that day, Resident #133 had fallen in his room, but she was not made aware of it until RCA #500 had already picked him up off the floor, and when he picked him up off the floor the resident did not help him and the resident fell on top of him. She stated of course he would not stand, they were using the mechanical lift half the time to get him up out of bed. She stated it was common knowledge that the aides were not to get anyone up off the floor by themselves.

On 05/14/26 at 2:30 P.M. an interview with the Director of Nursing revealed he did not remember when RCA #501 actually told him about the incident, however he knew he started the investigation as soon as she told him about it. He stated it might have been the next day [07/25/25]. The Director of Nursing reviewed RCA #500's time sheets and verified RCA #500 continued to work after the incidents on 07/24/25. He also verified RCA #501 and LPN #502 should have reported the verbal abuse which occurred on 07/24/25 with RCA #500 and Resident #133, they were trained to immediately notify a manager of any incidents of abuse, and no staff members should get a resident up off the floor without the residents being assessed by a nurse. He stated RCA #500 only worked on the Memory Care unit.

Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of Property

Based on observation, interview with staff, and review of facility policy, the facility failed to ensure chemicals were properly contained out of reach of residents on the memory care unit. This had the potential to affect 10 cognitively impaired and independently mobile residents (#97, #99, #106, #107, #110, #112, #114 #122, #126, #132) on the second-floor memory care unit.

Findings included:

Observations on the second floor Memory Care Unit on 05/13/26 at 9:30 A.M. revealed the door was open to the activity room and the cupboard underneath the sink was unlocked even though there was a lock on it. There were several bottles of cleaner in the cupboard, two bottles of multipurpose cleaner, one bottle of dish soap, one bottle of air freshener, one bottle of heavy-duty degreaser, one spray can of ant and roach spray, one bottle of glass cleaner, and one container of disinfectant wipes. There were no staff in the room. An interview at this time with Activity Aide #333 (who was walking a resident down the hallway) revealed the doors were usually closed to activity room and she did not know why they were open. She turned to the nurse and asked him if he had opened the doors and he stated he had not. An interview at this time verified the cleaning supplies were unlocked in the cupboard and accessible to any of the residents.

Review of the undated facility procedure for safely storing chemicals revealed they were to be locked up and away from where residents could get a hold of them.

This violation is an example of continued non compliance from the survey dated 04/30/25.

Review of the medical record, review of the facility investigation, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to timely report an abuse allegation and failed to ensure Resident #133, who was cognitively impaired and dependent on staff for care, was protected from verbal abuse by a staff member. This affected one resident (#133) out of four residents reviewed for abuse, and had the potential to affect 38 residents (#40, #76, #100, #101, #102, #105, #106, #107, #108, #109, #112, #113, #114, #115, #116, #117, #119, #121, #122, #124, #128, #129, #130, #131 #132, #133, #134, #135, #136, #137, #138, #139, #140, #142, #143, #144, #145, #146) in the memory care unit on 07/24/25. Findings included: Review of the medical record revealed Resident #133 was admitted to the facility on 05/31/24. Diagnoses included pulmonary embolism, benign prostatic hyperplasia, depression, dementia with inappropriate sexual behaviors, meningioma, atrial fibrillation, and deep vein thrombosis. He expired at the facility on 12/30/25. Review of the Service Plan dated 10/16/25 revealed Resident #133 had moderately impaired cognition and was dependent on staff for activities of daily living. Review of Resident #133's progress notes from 07/22/25 to 07/30/25 revealed no documentation of any incidents related to abuse. Review of the incident report dated 07/24/25 revealed the nurse was notified Resident #133 was on the floor and had fallen out of bed. While being transferred he got two skin tears. There was a diagram on the report, and the right forearm was circled on the diagram. There were no other assessments, no measurements of the wounds, no pain assessments, and no psychosocial assessments completed. Review of the typed witness statement dated 07/25/25 revealed the Director of Nursing (DON) with Business Office Director #287 interviewed Resident Care Associate (RCA) #501 concerning what had happened on 07/24/25 with Resident #133. RCA #501 stated RCA #500 went into Resident #133's room to get him up for breakfast. She heard RCA #500 state to Resident #133 Are you going to get up, [expletive]? Are you going to stay in your [expletive] bed? Because if you do you aren't going to get any [expletive] breakfast. She stated RCA #500 did get Resident #133 up and bring him to breakfast, toileted him and put him in the reclining chair outside of the dining room. At lunch she heard RCA #500 getting upset because Resident #133 was yelling for coffee. RCA #500 said something about taking him to his room because Resident #133 was [Expletive] irritating. She stated she told him that Resident #133 was care planned that he would not go to his bed because of fall risks and RCA #500 said he did not care if he [expletive] falls and he was not dealing with him anymore. She indicated a couple hours or so later she was with the nurse when RCA #500 called and said that Resident #133 had fallen. She asked the nurse if she needed her help because she was starting another task. The nurse said no, she and RCA #500 could handle it. She said she saw RCA #500 later and he had blood on his pants. She stated she asked what happened and RCA #500 said That [expletive] idiot fell on me. Review of the handwritten witness statement from Licensed Practical Nurse (LPN) #502 dated 07/25/25 revealed on 07/24/25 she witnessed RCA #500 aggressively pulling Resident #133 away from the breakfast table due to him being mad the resident was yelling about coffee. He stated, I don't give a [expletive], I don't want to hear him. He's going to his room. She stated RCA #501 told RCA #500 that the resident was care planned to only be laid down at bedtime and during the day he was to be in the common area in the recliner. She stated she did see the resident in the common area in the recliner when she was going back downstairs. She stated later in the day around 1:00 P.M., RCA #501 let her know that RCA #500 had called her because Resident #133 had fallen out of bed. At that time, she went upstairs to the resident's room and RCA #500 had already stated on the telephone the resident was not hurt, however when she walked into the room the resident was sitting on the toilet and had blood all over him. She stated and RCA #500 also had blood all over him. She stated she asked RCA #500 what had happened because she thought the resident was not hurt and RCA #500 stated the resident fell out of the bed and when he went to get him off the floor, the resident fell on top of him. During that transfer, the resident got two skin tears to his right arm. When she asked the resident about his arm, the resident went to respond and RCA #500 cut him off and said straight to the resident, yea he got his arm cut cause he is a [expletive] idiot. Then the resident stated then see he always tells me I'm not allowed to talk! She stated RCA #500 continued to clean himself off and wiped the blood off of the resident. She stated she put a dressing on the wounds and RCA #501 stated RCA #500 always treated Resident #133 this way, management was aware and never addressed it. RCA #501 stated the hospice nurse stated she was concerned about the incident also because she made it very clear to not put the resident in his room and RCA #500 did it anyway. RCA #501 stated RCA #500 also talked about how much he could not stand Resident #133 right in front of Resident #133. She stated you could tell the resident understood and was hurt by how he talked about him. Review of the Self-Reported Incident dated 07/28/25 revealed on 07/24/25 at 2:00 P.M. a nurse witnessed an aide (RCA #500) aggressively pull a resident (Resident #133) in a wheelchair out of the dining room because the resident was yelling about coffee. In addition, this aide used profanity towards the resident as he was taking the resident out of the dining room. The aide told a co-worker, I don't give a [expletive], I don't want to hear him. Later that day, the same aide responded to this resident after he fell and used profanity toward a resident stating to another coworker yea, he got his arm cut cause he's a [expletive] idiot. The resident was present during both of these instances. RCA #500 was suspended on Friday [07/25/25] pending the investigation. He then sent the scheduler a text message stating that he quit. The investigation revealed RCA #500's comments could be seen as abusive towards the resident and he would have to be terminated. Review of the time sheets for RCA #500 revealed he worked from 7:00 A.M. to 3:04 P.M. on 07/24/25 (the day of the incident) and from 6:55 A.M. to 1:47 P.M. on 07/25/25 (the day after the incident). Further review of the facility investigation revealed no other residents on RCA #500's unit (the Memory Care Unit) were assessed for abuse and Resident #133 was not reassessed for abuse after the allegation of abuse was made. Additionally, review of the Abuse training dated 07/28/25, related to the abuse incident, revealed not all staff were included on the inservice. The topic of the training was recognizing and reporting verbal/mental abuse and not using profanity around or towards any resident, which could be considered verbal/mental abuse. On 05/13/26 at 4:16 P.M. an interview with the Executive Director revealed no skin assessments were completed of other residents in the Memory Care unit who worked with RCA #500. She stated the only skin assessment completed for Resident #133 was done on the incident report from 07/24/25 (before the abuse was reported). She stated the verbal abuse was directed at Resident #133 which was witnessed and substantiated. She stated they did not interview or assess any other residents as they immediately addressed the situation and removed RCA #500 from the facility. On 05/13/26 at 4:30 P.M. an interview with Director of Nursing revealed none of the residents in the Memory Care unit were able to be interviewed. On 05/14/26 at 10:08 A.M. an interview with the Director of Nursing revealed the facility only educated those staff members on the Abuse Training sheet dated 07/28/25. He stated he could not answer why they did not do an all-staff education. On 05/14/26 at 12:34 P.M. an interview with LPN #502 revealed there was a lot going on with how this aide treated the residents and the management were aware. He was verbally abusing numerous residents. She verified she had not reported his behavior, and she wished she would have. LPN #502 stated on 07/24/25 was she was passing out medication and was standing outside the doorway of the dining room and Resident #133 was yelling out that he wanted more coffee and he did it all the time, and instead of getting him more coffee, RCA #500 went over to Resident #133 and ripped his wheelchair backwards and started pulling him backwards so his feet would not drag, all the way back to the resident's room. RCA #500 was yelling, I'm tired of this [expletive]! and the other aide told him the resident was not to be in his room, but RCA #500 stated he did not care he was not listening to him. LPN #502 stated later that day, Resident #133 had fallen in his room, but she was not made aware of it until RCA #500 had already picked him up off the floor, and when he picked him up off the floor the resident did not help him and the resident fell on top of him. She stated of course he would not stand, they were using the mechanical lift half the time to get him up out of bed. She stated it was common knowledge that the aides were not to get anyone up off the floor by themselves. On 05/14/26 at 2:30 P.M. an interview with the Director of Nursing revealed he did not remember when RCA #501 actually told him about the incident, however he knew he started the investigation as soon as she told him about it. He stated it might have been the next day [07/25/25]. The Director of Nursing reviewed RCA #500's time sheets and verified RCA #500 continued to work after the incidents on 07/24/25. He also verified RCA #501 and LPN #502 should have reported the verbal abuse which occurred on 07/24/25 with RCA #500 and Resident #133, they were trained to immediately notify a manager of any incidents of abuse, and no staff members should get a resident up off the floor without the residents being assessed by a nurse. He stated RCA #500 only worked on the Memory Care unit. Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of PropertyReview of the medical record, review of the facility investigation, review of the Self-Reported Incident, review of facility policy, and interview with staff, the facility failed to timely report an abuse allegation and failed to ensure Resident #133, who was cognitively impaired and dependent on staff for care, was protected from verbal abuse by a staff member. This affected one resident (#133) out of four residents reviewed for abuse, and had the potential to affect 38 residents (#40, #76, #100, #101, #102, #105, #106, #107, #108, #109, #112, #113, #114, #115, #116, #117, #119, #121, #122, #124, #128, #129, #130, #131 #132, #133, #134, #135, #136, #137, #138, #139, #140, #142, #143, #144, #145, #146) in the memory care unit on 07/24/25.

Findings included:

Review of the medical record revealed Resident #133 was admitted to the facility on 05/31/24. Diagnoses included pulmonary embolism, benign prostatic hyperplasia, depression, dementia with inappropriate sexual behaviors, meningioma, atrial fibrillation, and deep vein thrombosis. He expired at the facility on 12/30/25.

Review of the Service Plan dated 10/16/25 revealed Resident #133 had moderately impaired cognition and was dependent on staff for activities of daily living.

Review of Resident #133's progress notes from 07/22/25 to 07/30/25 revealed no documentation of any incidents related to abuse.

Review of the incident report dated 07/24/25 revealed the nurse was notified Resident #133 was on the floor and had fallen out of bed. While being transferred he got two skin tears. There was a diagram on the report, and the right forearm was circled on the diagram. There were no other assessments, no measurements of the wounds, no pain assessments, and no psychosocial assessments completed.

Review of the typed witness statement dated 07/25/25 revealed the Director of Nursing (DON) with Business Office Director #287 interviewed Resident Care Associate (RCA) #501 concerning what had happened on 07/24/25 with Resident #133. RCA #501 stated RCA #500 went into Resident #133's room to get him up for breakfast. She heard RCA #500 state to Resident #133 Are you going to get up, [expletive]? Are you going to stay in your [expletive] bed? Because if you do you aren't going to get any [expletive] breakfast. She stated RCA #500 did get Resident #133 up and bring him to breakfast, toileted him and put him in the reclining chair outside of the dining room. At lunch she heard RCA #500 getting upset because Resident #133 was yelling for coffee. RCA #500 said something about taking him to his room because Resident #133 was [Expletive] irritating. She stated she told him that Resident #133 was care planned that he would not go to his bed because of fall risks and RCA #500 said he did not care if he [expletive] falls and he was not dealing with him anymore. She indicated a couple hours or so later she was with the nurse when RCA #500 called and said that Resident #133 had fallen. She asked the nurse if she needed her help because she was starting another task. The nurse said no, she and RCA #500 could handle it. She said she saw RCA #500 later and he had blood on his pants. She stated she asked what happened and RCA #500 said That [expletive] idiot fell on me.

Review of the handwritten witness statement from Licensed Practical Nurse (LPN) #502 dated 07/25/25 revealed on 07/24/25 she witnessed RCA #500 aggressively pulling Resident #133 away from the breakfast table due to him being mad the resident was yelling about coffee. He stated, I don't give a [expletive], I don't want to hear him. He's going to his room. She stated RCA #501 told RCA #500 that the resident was care planned to only be laid down at bedtime and during the day he was to be in the common area in the recliner. She stated she did see the resident in the common area in the recliner when she was going back downstairs. She stated later in the day around 1:00 P.M., RCA #501 let her know that RCA #500 had called her because Resident #133 had fallen out of bed. At that time, she went upstairs to the resident's room and RCA #500 had already stated on the telephone the resident was not hurt, however when she walked into the room the resident was sitting on the toilet and had blood all over him. She stated and RCA #500 also had blood all over him. She stated she asked RCA #500 what had happened because she thought the resident was not hurt and RCA #500 stated the resident fell out of the bed and when he went to get him off the floor, the resident fell on top of him. During that transfer, the resident got two skin tears to his right arm. When she asked the resident about his arm, the resident went to respond and RCA #500 cut him off and said straight to the resident, yea he got his arm cut cause he is a [expletive] idiot. Then the resident stated then see he always tells me I'm not allowed to talk! She stated RCA #500 continued to clean himself off and wiped the blood off of the resident. She stated she put a dressing on the wounds and RCA #501 stated RCA #500 always treated Resident #133 this way, management was aware and never addressed it. RCA #501 stated the hospice nurse stated she was concerned about the incident also because she made it very clear to not put the resident in his room and RCA #500 did it anyway. RCA #501 stated RCA #500 also talked about how much he could not stand Resident #133 right in front of Resident #133. She stated you could tell the resident understood and was hurt by how he talked about him.

Review of the Self-Reported Incident dated 07/28/25 revealed on 07/24/25 at 2:00 P.M. a nurse witnessed an aide (RCA #500) aggressively pull a resident (Resident #133) in a wheelchair out of the dining room because the resident was yelling about coffee. In addition, this aide used profanity towards the resident as he was taking the resident out of the dining room. The aide told a co-worker, I don't give a [expletive], I don't want to hear him. Later that day, the same aide responded to this resident after he fell and used profanity toward a resident stating to another coworker yea, he got his arm cut cause he's a [expletive] idiot. The resident was present during both of these instances. RCA #500 was suspended on Friday [07/25/25] pending the investigation. He then sent the scheduler a text message stating that he quit. The investigation revealed RCA #500's comments could be seen as abusive towards the resident and he would have to be terminated.

Review of the time sheets for RCA #500 revealed he worked from 7:00 A.M. to 3:04 P.M. on 07/24/25 (the day of the incident) and from 6:55 A.M. to 1:47 P.M. on 07/25/25 (the day after the incident).

Further review of the facility investigation revealed no other residents on RCA #500's unit (the Memory Care Unit) were assessed for abuse and Resident #133 was not reassessed for abuse after the allegation of abuse was made. Additionally, review of the Abuse training dated 07/28/25, related to the abuse incident, revealed not all staff were included on the inservice. The topic of the training was recognizing and reporting verbal/mental abuse and not using profanity around or towards any resident, which could be considered verbal/mental abuse.

On 05/13/26 at 4:16 P.M. an interview with the Executive Director revealed no skin assessments were completed of other residents in the Memory Care unit who worked with RCA #500. She stated the only skin assessment completed for Resident #133 was done on the incident report from 07/24/25 (before the abuse was reported). She stated the verbal abuse was directed at Resident #133 which was witnessed and substantiated. She stated they did not interview or assess any other residents as they immediately addressed the situation and removed RCA #500 from the facility.

On 05/13/26 at 4:30 P.M. an interview with Director of Nursing revealed none of the residents in the Memory Care unit were able to be interviewed.

On 05/14/26 at 10:08 A.M. an interview with the Director of Nursing revealed the facility only educated those staff members on the Abuse Training sheet dated 07/28/25. He stated he could not answer why they did not do an all-staff education.

On 05/14/26 at 12:34 P.M. an interview with LPN #502 revealed there was a lot going on with how this aide treated the residents and the management were aware. He was verbally abusing numerous residents. She verified she had not reported his behavior, and she wished she would have. LPN #502 stated on 07/24/25 was she was passing out medication and was standing outside the doorway of the dining room and Resident #133 was yelling out that he wanted more coffee and he did it all the time, and instead of getting him more coffee, RCA #500 went over to Resident #133 and ripped his wheelchair backwards and started pulling him backwards so his feet would not drag, all the way back to the resident's room. RCA #500 was yelling, I'm tired of this [expletive]! and the other aide told him the resident was not to be in his room, but RCA #500 stated he did not care he was not listening to him. LPN #502 stated later that day, Resident #133 had fallen in his room, but she was not made aware of it until RCA #500 had already picked him up off the floor, and when he picked him up off the floor the resident did not help him and the resident fell on top of him. She stated of course he would not stand, they were using the mechanical lift half the time to get him up out of bed. She stated it was common knowledge that the aides were not to get anyone up off the floor by themselves.

On 05/14/26 at 2:30 P.M. an interview with the Director of Nursing revealed he did not remember when RCA #501 actually told him about the incident, however he knew he started the investigation as soon as she told him about it. He stated it might have been the next day [07/25/25]. The Director of Nursing reviewed RCA #500's time sheets and verified RCA #500 continued to work after the incidents on 07/24/25. He also verified RCA #501 and LPN #502 should have reported the verbal abuse which occurred on 07/24/25 with RCA #500 and Resident #133, they were trained to immediately notify a manager of any incidents of abuse, and no staff members should get a resident up off the floor without the residents being assessed by a nurse. He stated RCA #500 only worked on the Memory Care unit.

Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of Property

Based on observation, record review, and interviews, the facility failed to ensure care and services to address/manage behaviors for Resident #95 which caused delayed and/or inadequate personal care to the memory care unit residents. This affected one (Resident #95) of three residents reviewed for behavior management and had the potential to affect 33 (Residents #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #123, #124, #125, #126, and #128) identified by the facility as requiring hands on care on the memory care unit. The facility census is 126.

Findings include:

Review of the medical record for Resident #95 revealed an admission date of 07/03/23. Diagnoses included Alzheimer's disease, type II diabetes mellitus, agitation, confusion, edema, morbid obesity, and osteoarthritis.

Review of the nursing progress notes dated 08/14/25 at 9:24 P.M. revealed Resident #95 was on the room floor, requiring three staff assist. Three staff attempted to get resident up when he became combative and refused to stand. Another aide came and tried helping, making it four staff members. This was unsuccessful. At this time the resident started to try to hit staff and cursing at staff, calling them names and swinging his arms, refusing to bend his knees to stand. The nurse coordinator was called and instructed staff to call 9-1-1 to get him up and into the chair. Four policemen arrived to help. Four policemen and one staff member got the resident up to the chair.

Review of the nursing progress note dated 08/18/25 at 10:40 P.M. revealed Resident #95 was combative with care and required four staff assistance to get changed.

Review of the nursing schedules dated 08/18/25 to 09/01/25 revealed the memory care unit for the first shift (7:00 A.M. to 3:00 P.M.) and second shift (3:00 P.M. to 11:00 P.M.) had one nurse and four aides. The third shift (11:00 P.M. to 7:30 A.M.), had one nurse and two aides. Review of the schedule for 09/01/25 revealed the 11:00 P.M. to 7:30 A.M. shift had one nurse and two aides.

Review of the change in condition service plan dated 08/20/25 revealed Resident #95 required extensive multiple interventions for redirection, had occasional disruptive, aggressive or socially inappropriate behaviors, and often resisted care. Resident #95 required two staff assistance with mobility/ambulation, transfers, bathing, dressing, and toileting. Resident #95 also required frequent incontinent checks and/or changes daily both day and night.

Review of the handwritten nursing progress note in the paper medical record for Resident #95 dated 08/24/25 at 1:00 P.M. revealed three aides and one nurse assisted in changing the resident from a urine-soaked brief to a clean one.

Review of the handwritten nursing progress note dated 08/24/25 but not timed revealed Resident #95 required four staff members to assist with changing a soiled brief.

Further review of the handwritten nursing progress notes for Resident #95 dated 08/26/25 and untimed indicated during the 7:00 A.M. to 3:00 P.M. shift the resident was aggressive during care and required four staff assistance due to being combative, hitting, and pinching staff.

Interviews on 09/02/25 at 9:45 A.M. and at 2:19 P.M. with Certified Nursing Assistants (CNAs) #491 and #404 revealed it takes four staff to and at times a long time to provide care for Resident #95. Both stated timely care was not always provided during the later shifts. CNA #404 stated if there was not enough staff, Resident #95 did not receive the care needed. CNA #491 and #404 stated staffing levels included one nurse for the memory care unit with two aides on the second floor and one on the first floor during the first and second shift.

Observation on 09/02/25 at 11:37 A.M. of Resident #95 revealed the resident was in the room sitting in his recliner with a blanket covering his lower body and wearing no shirt. There was a strong smell of bowel movement.

Interview on 09/02/25 at 11:40 A.M. with Licensed Practical Nurse (LPN) #458 revealed Resident #95 had impaired cognition. Observation at this time of Resident #95 with LPN #458 verified the strong odor of bowel movement and the resident also had a dried, brown substance covering his left hand. LPN #458 confirmed the observation and indicated the staff would be gathered to clean the resident. LPN #458 stated it took four staff to provide care for Resident #95, two to transfer or stand him up and two to provide care. LPN #458 was unable to confirm there was sufficient staff to supervise the other residents during times when Resident #95 required the four staff for assistance due to behaviors, but it would only be for about 20 minutes.

Observations on 09/02/2025 from 12:07 P.M. to 12:25 P.M. of care provided to Resident #95 with four staff, Wellness Director (WD), LPN #458, CNA #491 and another unidentified aide. LPN #458 immediately closed the blinds, all four gathered supplies. LPN #458 requested the door to be closed. Observed Resident #95 was completely nude with his brief open and covered in feces from his lower abdomen to peri area. Three of the staff were required just to get the resident into a standing position. The aides guided him and lifted him to a standing position. WD was at his feet to prevent him from crossing them as the resident refused to uncross his legs. LPN #458 provided standby assist, filled the wash basin, got clean washcloth and soap, stood behind the resident while care was being performed for safety. The aides wiped and washed the resident while holding him upright. Resident #95 was agitated and required redirection multiple times. Resident #95 was cleaned first with wipes and then with soapy washcloths before a new brief was applied. He had difficulty following directions and required hands on care by three staff at all times while standing.

Follow-up interview on 09/02/25 at 12:22 P.M. with CNA #491 when she exited Resident #95's room stated he had dried bowel movement on his hands, and they were being soaked.

Interview on 09/03/25 at 8:36 A.M. with the WD confirmed it could take four staff to provide assistance to Resident #95 and about 20 minutes to get him in position to receive care. WD stated it was becoming more difficult and agreed there were concerns around Resident #95 requiring assistance from four staff due to behaviors.

Interview on 09/03/24 at 1:34 P.M. with Resident Care Associate (RCA) #489 revealed after arriving on shift on 09/02/25 at 8:00 A.M., Resident #95 was heavily soiled. RCA #489 stated he had not been changed since the afternoon of 09/01/25. RCA #489 stated they had to first serve breakfast and after they had attempted to change Resident #95, but he refused. RCA #489 stated Resident #95 was not changed until around noon on 09/02/25 making almost 24 hours since he was last changed. RCA #489 stated the staff on the night shift on 09/01/25 had two aides and a nurse. RCA #489 stated the one aide did not want to leave the second floor to come down to assist getting Resident #95 changed, that was why he was heavily soiled when she arrived at 8:00 A.M. on 09/02/25. RCA #489 stated it takes four sometime five staff to provide care for Resident #95 and often times it either leaves the other residents on the memory care unit unattended, or Resident #95 does not receive timely care.

Review of the memory care nurse's report revealed 35 residents resided on the memory care unit noting three (Residents #102, #115, and #116) of the 35 that did not require assistance from staff.

This violation represents non-compliance related to the allegation in Complaint Number OH00168072.

Based on observation and interview, the facility failed to maintain Resident #95's walls in good repair. This affected one (Resident #95) of three residents reviewed for environment. The facility census was 126.

Findings include:

Observation on 09/02/25 at 11:37 A.M. of Resident #95's room revealed on the wall behind the recliner was a large poorly patched hole on the right and a smaller, medium sized poorly patched hole with a smaller crumbling hole in the middle.

Interviews on 09/02/25 at 11:40 A.M. and at 12:22 P.M. with Licensed Practical Nurse (LPN) #458 and Certified Nursing Assistant (CNA) #491 verified and stated the wall was like that due to the recliner in Resident #95's room. Both LPN #458 and CNA #491 stated it had been that way for approximately six months.

Based on record review and interview, the facility failed to provide veterinary records of annual examinations including screening for internal and external parasites for pets residing in the facility. This had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 04/30/25 at 4:00 P.M., record review of the pet policy and individual pet records revealed a facility policy titled Appendix A Pet Agreement does not require annual examinations or screening for internal and external parasites for pets residing in the facility. Review of the pet record of a feline owned by Resident #37 revealed the last annual examination was on 03/08/24 and the screening for internal parasites for this feline was due on 01/03/24 and was not completed as of 04/30/25.

On 04/30/25 at 4:02 P.M., an interview with the Executive Director (ED) confirmed the form title Appendix A Pet Agreement was the facility's most current pet policy. She also confirmed the records for Resident #37's feline showed a due date of 01/03/24 for internal parasite screening, which had not been completed, and the last date of the pet annual examination was 03/08/24.

Based on observation and interview, the facility failed to store, prepare, distribute and serve all food in a manner that protects against contamination and spoilage. This had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 04/30/25 at 9:35 A.M., observation of the warming area of Memory Care two revealed an unlocked door which opened to a unit with all residents who were cognitively impaired. The warming area had a steam table which was dirty on the outside, with dirty, standing water in the wells which had food floating in it. The floor was dirty, with wrappers, plasticware and dried food stuck to it, as well as a broken red dish and the mechanism for the door handle and lock on the floor beside the door. There were no paper towels available at the hand washing sink, and the paper towel holder was found to be on the floor in the corner of the room. There was a 20-ounce bottle of Smucker's Sundae Syrup under the steam table that was open, and the label indicated refrigerate after opening. There was undated and partially wrapped cheese in the refrigerator. The cabinet above the countertop had loose potato chips on the shelf and two open pepper shakers with pepper spilled on the cabinet's shelves.

On 04/30/25 at 9:40 A.M., observation of the warming area of Memory Care one revealed a propped open door that was open to the dining area of a unit with all residents who were cognitively impaired. The warming area had a steam table with standing water, floating green beans that appeared to have been there for some time, and bits of foil and paper in the water. There was dried food and other scattered debris noted on the floor. There was a half full gallon of pancake syrup under the warming table with syrup all over the outside of the bottle and no lid on the bottle. Upon opening the dry storage cabinet, dirt and old papers, plasticware and sticky substances were found on the floor and doors of the cabinet.

On 04/30/25 at 9:50 A.M., an interview with the Director of Dining (DD) confirmed the findings of broken dish, components of the door, and dried food and dirt on the floor of the warming area of Memory Care two. He confirmed the wells of the steam tables of both the Memory Care one and Memory Care two warming areas held standing water, food, and other debris. He called these steam tables completely disgusting. He further confirmed there were no paper towels available in warming area one. He confirmed the open syrup bottle with no lid under the steam table on Memory Care one. He confirmed the 20-ounce open bottle was under the steam table in warming area two and had a label indicating it required refrigeration after opening. He confirmed the dry storage area was dirty, with sticky substances, dirt and debris on the floor and doors of the cabinet. He reported the responsibility of cleaning this area belonged to the caregivers on the memory care units. He indicated the kitchen only delivered the food and the kitchen staff only occasionally checked in on the condition of the materials and supplies in the warming rooms and the serving areas of the North unit kitchen.

On 04/30/25 at 11:40 A.M., observation of lunch service in the North Dining room revealed food was not served at the proper temperature. The salad temperature was noted to be 42 degrees Fahrenheit (F). There was no method to keep cold foods cold on the steam table area of the dining room. There were four staff members working in the kitchen serving food and none of them were wearing hair nets. A box of hair nets was noted in the small storage area beside the service area. The staff members serving food in the dining area were all caregivers, not kitchen staff.

On 04/03/25 at 11:45 A.M., interview with Wellness Coordinator, Licensed Practical Nurse (LPN) #2976 confirmed hairnets were available to the staff in the closet beside the service area. He confirmed the staff members in the service area were not wearing hairnets. He noted there was no way to maintain the temperature of the cold food in the service line which included shredded cheese, sour cream, and lettuce. LPN #2976 confirmed the staff plating and serving the food in North dining room were all caregivers and if there was a need for a patient outside of the dining area, they would have to stop service and attend to the needs of the patient before resuming food service.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least every three months on each shift as required. This had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 04/30/25 at 4:15 P.M., review of the facility's fire drill reports for the past 12 months revealed there was a fire drill completed on 06/13/24 dayshift and not again until 11/20/24. That exceeded the requirement of having a drill at least every three months on each of the three shifts. There was no fire drill conducted in February of 2025. Findings were verified by the Executive Director.

On 04/30/25 at 4:20 P.M., an interview with the Executive Director revealed the facility's maintenance department was responsible for conducting the facility's fire drills. She confirmed the fire drills had not been conducted on day shift at least every three months as required and that the fire drills conducted on day shift 06/13/24 and not again until 11/20/24 exceeded the every three-month requirement. She further confirmed there was no fire drill conducted in the month of February 2025.

This violation is a recite of the annual survey completed on 11/28/23 and was originally identified as tag R0614.

Based on observation and interview, the facility failed to post in a conspicuous place in each section a correctly oriented wall specific floor plan designating room use, location of alarm sending stations, evacuation routes and exits, fire alarms and fire extinguishers and flow of resident evacuation. This had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 04/30/25 between 9:45 A.M. and 10:30 A.M. during facility tour, observation revealed that none of the emergency evacuation signs on Memory Unit one and two were in proper orientation, nor did they contain evacuation routes that were location specific to the sign. There was no emergency evacuation sign in the hall containing rooms 20-29 on East wing.

On 04/30/25 at 10:30 A.M., interview with Licensed Practical Nurse (LPN) #2976 and Maintenance Director confirmed the emergency evacuation signs on Memory Unit one and two were not in proper orientation, nor did they contain evacuation routes that were location specific to the sign. LPN #2976 also confirmed the hall from rooms 20-29 did not contain an emergency evacuation sign.

Based on observation, record review and interview, the facility failed to conduct monthly fire safety inspections recorded on the self-inspection form. This had the potential to affect all residents of the facility. The facility had a census of 124.

Findings include:

On 04/30/25, during the facility tour, observation of the fire extinguishers on all units revealed a yellow tag that indicated the fire extinguishers had last been checked on 03/17/25. The Maintenance Assistant verified the date on the tags.

On 04/30/25 at 4:15 P.M., record review of fire safety monthly self-inspection forms indicated fire extinguishers had been checked on 04/18/25. These findings were verified by the Executive Director.

On 04/30/25 at 4:20 P.M., an interview with the Maintenance Supervisor revealed that as of 04/30/25, the fire extinguishers in the facility had not been checked. He confirms, however, that the self-inspection forms dated 04/18/25 indicated the fire extinguishers had been checked for the month of April, and they actually had last been checked on 03/17/25. The Executive Director confirmed the date on the yellow tags of the fire extinguishers was dated 03/17/25.

Based on observation, record review and interview, the facility failed to provide safe storage of poisonous and hazardous materials. This had the potential to affect all residents (#90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #120, #121, #122, #123, and #124) on both Memory care units. The facility census was 124.

Findings include:

On 04/30/25 at 9:35 A.M., observation of the Memory Unit two warming area revealed two one gallon containers of Liquid Bacogen bacteria culture plus deodorant. These were in the unlocked cabinet under the handwashing sink. The cabinet was noted to have a locking mechanism on it; however, there was no lock in place. There were seven residents unattended just outside this unlocked room who were ambulatory with cognitive deficits. At 10:00 A.M., observation of the Memory Unit one warming area revealed a spray bottle in an unlocked cabinet under the handwashing sink. This spray bottle had a handwritten sanitizer on the bottle with no chemical label. This unlocked room was accessible to all ambulatory patients on this unit. All patients on this unit were cognitively impaired. This was verified by Licensed Practical Nurse (LPN) #3350.

On 04/30/25 at 10:00 A.M., both the Executive Director (ED) and LPN #2976 confirmed the presence of Liquid Bacogen bacteria culture plus deodorant under the unlocked sink in the warming area of Memory Unit two. At 10:10 A.M., the ED and LPN #2976 confirmed the presence of the hand-labeled spray bottle of sanitizer under the unlocked sink in the warming area of Memory Unit one. They confirmed that all residents on Memory Unit one and Memory Unit two were cognitively impaired.

On 04/30/25 at 4:45 P.M., a review of Material Safety Data Sheet (MSDS) sheet for Liquid Bacogen bacteria culture plus deodorant revealed a hazard category for skin sensitization. The MSDS read If ingested, do NOT induce vomiting. If conscious, give a glass of water or milk to drink. Get medical attention. If ingested it may cause abdominal pain, nausea or vomiting. These MSDS indications were verified by ED.

Based on observation and interview, the facility failed to post a notice indicating the rules of the facility, Rules and Regulations for Residential Care Facilities or most recent licensure surveys are readily available to residents or may be requested at reasonable hours. This had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 4/30/25 at 9:32 A.M. observation during the facility tour revealed no required posting for availability of Rules and Regulations for Residential Care Facilities, nor was there a notice in place indicating the location of the results of the most recent licensure inspection survey.

On 4/30/25 at 11:10 A.M. an interview with the Executive Director confirmed that there were no notices in place indicating the availability of Rules and Regulations for Residential Care Facilities or the location of the most recent licensure inspection.

Based on observation and interview, the facility failed to protect the privacy of resident records. This affected two residents (#103 and #108) and had the potential to affect all residents of the facility. The facility census was 124.

Findings include:

On 04/20/25 at 11:31 A.M., an observation of medication administration revealed computerized medical record on top of the medication cart. During the medication observation, Licensed Practical Nurse (LPN) #3350 opened the Medication Administration Record (MAR) for Resident #103 and prepared medications. The medication cart was located in a dining area with eight residents and two staff members. Once the medication was prepared, LPN #3350 walked away from the medication cart to administer the medication, leaving the medical record open on the medication cart. This was repeated with the next medication administration for Resident #108.

On 04/30/25 at 11:34 A.M., an interview with LPN #3350 confirmed he had left the MAR open on the top of the medication cart. He further confirmed the MAR contained protected patient information and should be closed or minimized so that it could not be viewed by anyone in the area.

Based on interviews, record review, self-reported incident (SRI) review, police report review, facility investigation review, and policy review, the facility failed to ensure Resident #2 was free from misappropriation of personal funds. This affected one resident (Resident #2) of three residents reviewed for misappropriation.

Findings include:

Review of Resident #2's medical records revealed an admission date of 05/05/24 with diagnoses including but not limited to atrial fibrillation, heart failure, and chronic obstructive pulmonary disease (COPD).

Review of the Mini Mental State Exam assessment dated 02/05/24 revealed Resident #2 had mild impaired cognition.

Review of the facility self-reported incident (SRI), tracking number 254309, revealed on 11/21/24 at 8:46 A.M. the facility created an SRI for misappropriation towards Resident #2. The description of the allegation, which was substantiated by the facility, reported resident #2 gave her credit card to Housekeeper #210 to purchase panty liners for her. Housekeeper #210 reported she went to store and claimed she was unable buy items because the card declined. Housekeeper #210 returned the card to the resident. The facility had Resident #2's son review the transactions on her account and found the card was used on 11/18/24 for two purchases Resident #2 did not make nor authorize. Review of the facility SRI summary revealed on 11/18/24 at 2:00 P.M. Resident #2 gave Housekeeper #210 her debit card so she could go to the store to buy her panty liners. Housekeeper #210 went to store between 1:30 P.M. to 2:00 P.M. and claimed she was unable to buy the item and returned the card to Resident #2. This goes against the facility policy, so they contacted Resident #2's son/power of attorney (POA) to inform him of the incident and asked him to review her account as soon as possible. Review of Resident #2's bank statement revealed there were two purchases at Marathon Gas Station on 11/18/24 during the time Housekeeper #210 had Resident #2's debit card. Housekeeper #210 sent home on 11/19/24 and suspended pending police investigation. Housekeeper #210 denied using the debit card for personal use. Police report was filed and the facility was continuing the investigation.

Review of the facility investigation related to the SRI date 11/18/24 revealed the alleged incident occurred 11/18/24 two days prior to the SRI being submitted on 11/21/24.

Review of the facility document for Housekeeper #210 revealed she was terminated on 11/19/24.

Review of the Police Case Report, reported 11/20/24 for date of occurrence 11/18/24, revealed the police department obtained a copy of camera footage from the gas station Housekeeper #210 used the debit card as as well as two receipts showing the items purchased by the suspect. The receipt showed Resident #2's card was used to purchase alcoholic beverages, a cigarillo, and cigarettes. The report included Housekeeper #210 claimed Resident #2 gave her permission to purchase a drink and some cigarettes for going to get her pads. Housekeeper #210 stated when she attempted to purchase the pads she was not able to override the PIN number request, and was unable to purchase the pads. Housekeeper #210 revealed she was able to override the PIN at the gas station for the purchases. The report included Resident #2 did ask Housekeeper #210 to purchase pads for her, but could not recall how she went about giving Housekeeper her card and did not give permission to buy anything else. Resident # advised the officer she has previously loaned Housekeeper #210 twenty dollars and Housekeeper #210 never paid her the money back.

Interview on 12/06/24 at 12:06 P..M. with Wellness Coordinator (WC) #205 revealed Resident #2 reported she gave her credit card to Housekeeper #210 to buy her panty liners and was worried she hadn't returned. WC #205 reported she told Resident #2 staff are not permitted to take cash or credit cards to purchase items for residents.

Interview on 12/06/24 at 12:20 P. M. with Executive Director (ED) revealed she was notified by WC #205 on 11/18/24 Resident #2 had given Housekeeper #210 her credit card to purchase panty liners. ED confirmed staff are not permitted to take credit cards or money from residents and needed to be more specific in our policy. ED reported at first they didn't believe Housekeeper #210 did this but then through the investigation reported even though Housekeeper #210 denied making charges there were charges made during that time. ED reported we suspected she used the credit card without authorization of Resident #2 and substantiated the SRI. ED reported she refunded the credit card for the amount charged by Housekeeper #210 to Resident #2.

Interview on 12/06/24 at 12:59 P.M. with Housekeeping Director (HKD) 206 revealed on 11/18/24 at 3:38 P.M. she was notified by WD #205 via phone Resident #2 reported she gave her credit card to Housekeeper #210 to purchase panty liners for her and was concerned she hadn't returned yet. HKD #206 verified violation of policy to take anything to include credit card and money. HKD #206 reported she investigated the incident on 11/19/24 and spoke with Housekeeper #210. HKD #206 revealed once ED reported Resident #2's son confirmed the credit card was used on 11/18/24 for two purchases Housekeeper #210 was suspended pending investigation. HKD #206 reported Housekeeper #210 denied using the credit card and reported she didn't have the pin and it was declined. HKD #206 reported on 11/19/24 around 2:00 P.M. Housekeeper #210 was called to WD #205's office in the presence of HKD #206, WD #205, and Wellness Director (WD) informed Housekeeper #210 suspended pending investigation. HKD #206 reported she escorted Housekeeper #210 to her car.

Interview on 12/06/24 at 12:57 P.M. with Business Office Director (BOD) 207 revealed Housekeeper #210 was terminated on 11/19/24 due to the SRI being substantiated after the investigation determined she used Resident #2's credit card for purchases not authorized.

Review of facility policy, Prevention of Abuse, Neglect and Misappropriation, undated, revealed misappropriation of Resident's Property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

This violation represents non-compliance investigated under Complaint Number OH00160105.