Majestic Care Middletown Assisted Living

Based on record review and staff interviews, the facility failed to notify a resident in writing regarding what is provided by the facility upon move into the facility. This affected one (#82) resident of the three residents reviewed. The facility census was 108.

Findings include:

Review of the medical record for Resident #82 revealed the resident was admitted to the facility on 08/21/24. Diagnoses included, hemiplegia and hemiparesis, congestive heart failure, dysphagia, diabetes mellitus, anemia, and spinal stenosis.

Review of a Functional Assessment, for Resident #82 dated 08/15/24, revealed the resident was cognitively intact. Resident #82 was independent with walking, toileting, eating and dependent on staff for medication administration and transportation.

Review of the Resident Agreement, for Resident #82 dated 08/15/24, revealed no documented evidence the facility provided in writing what was being provided by the facility upon the resident moving into the facility.

Interview with General Manager (GM) 500 on 09/18/24 at 12:29 P.M.. revealed the facility was aware of the new regulations requiring a facility to notify a resident / resident's sponsor in writing of what is provided by the facility. GM #500 verified Resident #82 was not provided with resident agreement that detailed what the facility provided.

This violation represents non-compliance investigated under Master Complaint Number OH00157425.

Based on observation, staff interview, record review, and facility policy review, the facility failed to administer medication as ordered by a physician. This affected two (69, and #92) residents of three residents reviewed for medication administration. The facility census was 108.

Findings include:

1) Review of medical record for Resident #92 revealed the resident was admitted to the facility on 06/01/11. Diagnoses included dementia, anxiety, post cholecystectomy syndrome, anemia, anemia, major depressive disorder, gastro-esophageal reflux disease (GERD), and cellulitis.

Review of the Functional Assessment, for Resident #92 dated 11/30/23, revealed the resident had some mild cognitive deficits and was dependent on staff to administer medications.

Review of the active physician orders for Resident #92 revealed the resident was ordered the following morning medications: Aldactone 50 milligrams (mg) for edema, Anastrozole Tablet one mg for breast cancer, Calcium Carbonate Antacid tablet for (GERD), Aricept five mg for alcohol induced dementia, calcium tablet 500 mg give two tablet for supplement, Carafate one gram (gm) for antacid, Cymbalta 90 mg delayed release particles mg by mouth for depression, Folic Acid one mg for supplement, Klor-Con sprinkle capsule 10 milliequivalent (mEq) for a supplement, Lasix tablet 20 mg for edema, Levothyroxine 50 mg related to hypothyroidism, Loratadine 10 mg for allergies, Lyrica oral capsule 300 mg for pain, Namenda Tablet 10 mg for dementia, Oxycodone 10 mg for pain, Pentoxifylline 400 mg for muscle aches, Protonix 20 mg for GERD, Therems-M for Supplement, Thiamine 100 mg related to alcohol dependence, vitamin-D 1000 units for supplement, and Zoloft 100 mg for major depressive disorder.

2) Review of the medical record for Resident #69 revealed the resident was admitted to the facility on 12/05/23. Diagnoses included bariatric surgery, essential primary hypertension, anxiety disorder, history of suicidal behavior, hyperlipidemia, bipolar disorder, and obstructive sleep apnea.

Review of the Functional Assessment, for Resident #69 dated 12/04/23, revealed the resident was cognitively intact and dependent on staff for Medication Administration.

Review of the active physician orders for Resident #69 revealed the resident was ordered the following morning medication. Amiodarone 200 mg for abnormal heart rhythm, aripiprazole tablet 10 mg for depression, bupropion 300 mg for depression, Calcium Carbonate tablet 600 mg for supplement, Carvedilol 6.25 mg for hypertension, vitamin-D tablet 1000 unit for supplement, Eliquis tablet 2.5 mg for prevention of blood clots, Farxiga tablet 10 mg for diabetes, Gabapentin Capsule 300 mg for nerve pain, Lisinopril 10 mg for hypertension, Loperamide 2 mg for diarrhea, Potassium 40 mEq health maintenance, and Torsemide 40 time a day for fluid retention.

Observation of Resident #92 on 09/18/24 at 7:48 A.M., revealed the resident was seated in the dining room with a clear plastic cup of medications next to her on the table. Interview with Resident #92 at the same time, indicated the cup of medications were her morning medications and she would take them with her meal. A nurse was not in the dining room.

Observation of Resident #69 on 09/18/24 at 7:50 A.M., revealed the resident was seated in the dining room with a clear plastic cup of medications next to him on the table. A nurse was not in the dining room.

Interview with Licensed Practical Nurse (LPN) #204 on 09/18/24 at 8:00 A.M., revealed she placed the medications for Resident #92 and Resident #69 in the medicine cups and placed the cups next to the residents because they would take medications until they were eating. LPN #204 verified Resident #69, and Resident #92 were seated in the dining room and had all of their morning medications in a medication cup beside their plate and she was not in the room to observe them take their medications.

Interview with Clinical Director (CD) #601 on 09/18/24 at 12:10 P.M., revealed if a resident was depended on staff for medication administration, then the nurse should watch the medications be consumed by the residents. CD #601 stated the nursing staff should not place residents' medications in a cup then leave the resident without an observation of the resident consuming the medication. CD #601 stated a nurse should remain with a resident until the medications were consumed.

Review of the facility policy titled, Administering Medications, undated, revealed only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Further review of the policy confirmed the residents may self-administer their own medication only if the attending physician has determined the residents have the decision-making capacity to do so safely.

Based on observation, record review, staff interview, review of online resources from the Centers for Disease Control (CDC), and review of facility policy, the facility failed to provide effective infection control practices to aide in the prevention of the spread of the Coronavirus (COVID-19). This affected three (#99, #85 and #13) residents three residents reviewed for infection control practices but had the potential to affect all residents who resided in the facility. The facility census was 108.

Findings include:

1) Review of the medical record for Resident #99 revealed the resident was admitted to the facility on 05/19/19. Diagnoses included heart failure, atrial fibrillation, atherosclerotic heart disease, essential primary hypertension, dementia, anxiety, cerebral infarction, hypothyroidism, major depressive disorder, and COVID-19.

Review of the Functional Assessment, dated 04/17/24 for Resident #99, revealed the resident was cognitively intact.

Review of the active physician orders for Resident #99 dated 09/15/24, revealed Resident #99 tested positive for COVID-19 on 09/15/24 and required isolation precautions.

2) Review of the medical record for Resident #85 revealed the resident was admitted to the facility on 02/01/23. Diagnoses included acute kidney failure, ketoacidosis, osteoarthritis, major depressive disorder, diabetes mellitus (DM) 1, dementia, dysphagia, anxiety disorder, peptic ulcer disease, and COVID-19.

Review of the Functional Assessment, dated 08/23/23 for Resident #85, revealed the resident was cognitively intact.

Review of a nurse's progress note dated 09/11/24, revealed Resident #85 had tested positive for COVID-19 and notification was given to family and physician.

3) Review of the medical record for Resident #13 revealed the resident was admitted to the facility on 06/06/21. Diagnoses included COVID-19, diabetes mellitus, psychosis and hypothyroidism.

Review of the Functional Assessment, dated 05/01/24, revealed Resident #13 was cognitively intact.

Observation on 09/18/24 at 8:43 A.M., revealed Dietary Aide (DA) #300 was delivering room trays for breakfast with a surgical in place. Located outside of Resident #99's room was a sign indicating staff to apply the appropriate Personal Protective Equipment (PPE) which included gloves, gown, an N-95 respirator, and eye protection. DA #300 failed to apply an N-95 respirator. DA #300 carried the lunch tray into Resident #99's room. DA #300 exited Resident #99's room a short time later and removed her PPE including her surgical mask. DA #300 applied a new surgical mask without doing any hand hygiene. Interview with DA #300 at the same time, verified she failed to apply a N-95 respirator when she entered Resident #99's room because the cart next to Resident #99's room did not have any N-95 respirators in it. DA #300 verified she did not complete any hand hygiene between the soiled surgical mask and the new surgical mask because she could not locate any hand sanitizer.

Continued observation on 09/18/24 at 8:48 A.M., revealed DA #300 delivered a meal tray to Resident #85's room without completing any hand hygiene. Located outside Resident #85's room was a sign indicated for staff to apply the appropriate PPE. DA #300 applied the PPE and entered Resident #85's room to deliver the meal tray. DA #300 exited Resident #85's room and removed her PPE. DA #300 then retrieved a food tray and delivered it to Resident #13 without completing any hand hygiene after she removed the PPE when she exited Resident #85's room. Interview with DA #300 at the same time, verified she removed her PPE after exiting Resident #85's room and then delivered a meal tray to Resident #13's room without completing any hand hygiene.

Review of the facility policy titled, Covid-19 Prevention & Management, dated 01/02/24, confirmed the facility will identify residents who are confirmed or suspected to have signs or symptoms of Covid -19. The policy stated it is mandated for staff to wear N-95 respirators to be worn, wear eye protection, gown, and gloves prior to entering a resident's room with a diagnosis of COVID-19.

Review of the facility policy titled, Personal Protective Equipment, dated 01/02/24, confirmed the facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. The policy stated to wear an approved N-95 respirator. Further review of the policy confirmed the staff were expected to perform hand hygiene before donning gloves and after their removal. Gloves were not a substitute for hand hygiene.

Review of online resources from CDC (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) dated 02/27/24 titled Clinical Safety: Hand Hygiene for Healthcare Workers, revealed healthcare personnel should complete hand hygiene immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patients surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal.

Based on observation, staff interview, record review and facility policy review, the facility failed to store, prepare, and serve food in a manner a safe and sanitary manner and palatable. This affected two (#92 and #107) residents of three residents reviewed; however, this had the potential to affect all 108 residents who received food from the kitchen. The facility census was 108.

Findings include:

1) Review of medical record for Resident #92 revealed the resident was admitted to the facility on 06/01/11. Diagnoses included dementia, anxiety, post cholecystectomy syndrome, anemia, anemia, major depressive disorder, gastro-esophageal reflux disease (GERD), and cellulitis.

Review of the Functional Assessment, for Resident #92 dated 11/30/23, revealed the resident had some mild cognitive deficits and was dependent on staff to administer medications.

2) Review of a medical record for Resident #107 revealed the resident was admitted to the facility on 02/18/24. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), essential primary hypertension, diabetes mellitus, and chronic kidney disease.

Review of the Functional Assessment for Resident #107 dated 02/18/24, revealed the resident had some mild cognitive impairment.

Interview with Resident #92 on 09/18/24 at 7:48 A.M., revealed the food was often cold and the facility did not follow the menu.

Interview with Resident #107 on 09/18/24 at 8:04 A.M. revealed the food was always cold and does not look or taste appealing.

Review of a recent local health Department inspection report titled, Food Inspection Report, dated 08/13/24, indicated the facility was out of compliance for not having clean contact surfaces, not having a clean physical facility, food debris was noted throughout the kitchen preparation area and under the stove/fryer equipment, and the ventilation system had dust and debris located above the steam table.

Observation of the kitchen during the initial tour on 09/17/24 at 9:49 A.M. with Dietary Aide (DA) #300 revealed the kitchen had heavily black soiled flooring throughout the kitchen with food debris scattered throughout the kitchen. The kitchen preparation area and appliances including the stove, ice machine, and toaster oven, had various food items and food debris scattered underneath. The appliances had food splatters and debris running down the sides. The sink area next to the dishwasher had active black flies and gnats flying throughout the area. The kitchen trash cans had food debris and splatter running down each one. The kitchen vents and ceiling lights located above the food preparation and serving area had black fuzzy substance hanging from them. The inside lid of the ice machine had black spots throughout the lid directly above the ice storage bin. There was an unknown black substance along the top of the sink and walls surrounding the three-compartment sink. The reach-in refrigerator contained a large, unlabeled and undated white plastic gallon container of beets with no lid, a large container of opened whipped cream icing unlabeled and undated, a large bag of cabbage unlabeled and undated, and a large bag of carrots unlabeled and undated. The walk-in freezer contained a large blue trash bag filled with various vegetables with no label or date, a large opened plastic bag of frozen okra and a large, opened bag of frozen hushpuppies unlabeled and undated . Interview with DA #300 at the same time verified the findings.

Interview with Dietary Manager (DM) #605 on 09/18/24 at 8:14 A.M., revealed he was seated at a desk near the ice machine. Observation at the same time revealed flies and gnats flying around the kitchen and a trash can overflowing with trash with no trash can liner. DM #605 verified the flies and gnats. DM #605 verified the findings of the kitchen during the initial tour. DM #605 stated the kitchen had a low number of staff and they did not have time to follow a cleaning schedule.

An observation on 09/18/24 at 8:43 A.M. revealed a food cart containing five resident food trays in the kitchen to be delivered to the resident Rooms and a surveyor test tray. At 8:53 A.M. all resident trays were delivered, and the test tray food temperature was obtained. The scrambled eggs holding temperature was 118.5 Fahrenheit (F) and the sausage patty was 97.4 degrees F. The eggs tasted cold and did not have a good flavor as well as the sausage patty. DA #300 verified the holding temperatures and indicated the scrambled eggs appeared dry and unappetizing and the sausage patty tasted cold and chewy.

Interview with the Food Service District Manager (FSDM) #700 on 09/18/24 at 3:04 P.M. indicated the cleanliness of the facility kitchen could use some work. DM #700 stated if a bag or food item was opened, it should contain a label and date.

Review of the facility policy titled, Labeling and Dating, undated, confirmed all opened and leftover items will be labeled with the date of opening/date stored and a discard/use-by date.

Review of the facility policy titled, Food: Preparation, dated 02/2023, revealed the facility follows the Food and Drug Administration (FDA) regulations for food preparation. Further review of the policy stated the Dining Services Cooks will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and 135 degrees F.

This violation represents non-compliance investigated under Complaint Number OH00156460.

Based on observation, staff interview, record review and review of facility policy, the facility failed to maintain an effective pest control program. This had the potential to affect all 108 residents that received food from the kitchen. The facility census was 108.

Findings include:

Observation of the kitchen during the initial tour on 09/17/24 at 9:49 A.M. with Dietary Aide (DA) #300 revealed a large number of gnats and black flies throughout the kitchen. DA #300 verified the gnats and flies.

Interview with Dietary Manager (DM) #605 on 09/18/24 at 8:14 A.M., revealed he was seated at a desk near the ice machine. Observation at the same time revealed flies and gnats flying around the kitchen. DM #605 verified the gnats and flying around the kitchen.

Review of the recent local Health Department inspection report titled, Food Inspection Report, dated 08/13/24, revealed the facility was marked out of compliance related to pest control in the kitchen. There was a presence of live flies by the dishwasher machine equipment and throughout the kitchen preparation area.

Review of the facility policy titled, Pest Control Program, dated 12/12/23, revealed the facility will maintain an effective pest control program that eradicates and contains an effective pest control program.

This violation represents non-compliance investigated under Complaint Number OH00156460.

Based on observation, staff interviews, record review, and review of facility policy, the facility failed to store chemicals and hazardous materials in a safe manner. This had the potential to affect all 108 residents who received food from the kitchen. The facility census was 108.

Findings include:

Observation of the kitchen on 09/18/24 at 7:34 A.M. with Dietary Cook (DC) #307 revealed next to the three-compartment sink and the food preparation area was a container of a Adios (soap and scum film removed), a container of Scrub Free oven cleaner, two spray bottles of Clorox Clean Up cleaner, a large plastic gallon of commercial Murphys Oil Cleaner, and two cans of Oatey drain cleaner.

Interview with Dietary Manager (DM) #605 on 09/18/24 at 7:36 A.M. verified the multiple containers of cleaners next to the three-compartment sink and near the food preparation area.

Review of the facility policy titled, Storage, Chemicals, dated 02/2023, revealed all chemicals will be stored in a separate and secure area.

Based on medical record review and staff interviews, the facility failed to ensure oxygen was administered as ordered. This affected one (#239) out of the four residents reviewed for change of condition. The facility census was 97.

Findings included:

Review of the medical record for Resident #239 revealed an admission date of 07/15/21 with medical diagnoses of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), hypothyroidism, anxiety, and depression. Review of the medical record revealed Resident #239 expired on 12/05/23.

Review of the medical record for Resident #239 revealed a Resident Assessment, dated 11/29/23, which indicated Resident #239 was alert and oriented to person, place, time, and situation. The assessment stated Resident #239 was independent with ambulation, toileting, transfers, dressing, and showering and the facility staff administer medications. Review of the medical record for Resident #239 revealed she tested positive for Coronavirus Disease 2019 (COVID-19) on 12/02/23.

Review of the medical record for Resident #239 revealed a Nurse Practitioner (NP) note, dated 12/04/23, which stated Resident #239 was seen due to concerns about her breathing and recently tested positive for COVID-19. The note stated Resident #239 had complained of dyspnea (shortness of breath), chest tightness, cough, and wheezing. The note revealed Resident #239's oxygen saturation level of 91% on room air and Resident #239 refused to be sent to the hospital. The note continued to state Resident #239 requested oxygen and orders were written for oxygen per nasal cannula (NC) at two liters per minute and prednisone taper 40 milligrams (mg) to 10 mg over 12 days. NP #250 noted she explained to Resident #239 that oxygen isn't kept at the facility, but the staff wound find her a concentrator as soon as possible.

Review of the medical record for Resident #239 revealed a physician order, dated 12/04/23, for oxygen per NC at one to two liters per minute to maintain oxygen saturation levels at 92% or greater for three weeks. Further review of the medical record for Resident #239 revealed no documentation to support oxygen was administered as ordered.

Interview on 12/12/23 at 1:00 P.M. with Clinical Director #230 stated the facility ordered oxygen concentrators through home health companies, which could take several days and required multiple days of documentation of a residents' oxygen saturation levels. Clinical Director #230 stated in emergent situations, the facility would get an oxygen concentrator from the nursing home on campus for a resident on the assisted living portion of the campus. Clinical Director #230 confirmed the medical record for Resident #239 did not contain documentation to support the facility administered oxygen as ordered or that it was addressed with NP #250 that the oxygen was not administered as ordered. Clinical Director #230 confirmed Resident #239 did refuse to go to the hospital for evaluation.

Interview on 12/12/23 at 1:58 P.M. with NP #250 stated she visited Resident #239 on 12/04/23 for complaints of respiratory distress and not feeling well. NP #250 confirmed she ordered Resident #239 oxygen for her respiratory distress and informed Resident #239 that the facility would get an oxygen concentrator as soon as possible. NP #250 stated she believed the oxygen would be administered by the evening on 12/04/23 because the facility staff would borrow oxygen concentrators from the nursing home on the campus. NP #250 stated she was not aware the oxygen was not administered as ordered. NP #250 confirmed Resident #239 refused to be transported to the hospital.

This violation represents non-compliance investigated under Master Complaint Number OH00149018 and Complaint number OH00149016.

Based on medical record reviews, review of time sheets, observations, staff and resident interviews, and policy review, the facility failed to implement infection control policies and procedures to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected three (#20, #40 and #176) out of the three residents reviewed for infection control precautions. This had the potential to affect all 108 residents residing in the facility. The facility census was 108.

Findings included:

1. Review of the medical record for Resident #20 revealed an admission date of 06/29/21 with medical diagnoses of hyperlipidemia, depression, hypertension (HTN), anxiety, and epilepsy.

Review of the medical record for Resident #20 revealed a Resident Assessment, dated 05/10/22, which indicated Resident #20 was alert and oriented to person, place, and time and was independent with activities of daily living (ADL's).

Review of the medical record for Resident #20 revealed his medication administration record (MAR) for November 2023 which indicated Licensed Practical Nurse (LPN) #313 administered his medications throughout the day on 11/24/23.

Interview on 11/28/23 at 11:00 A.M. with Resident #20 stated LPN #313 administered his medications throughout the day on 11/24/23. Resident #20 stated he learned LPN #313 had tested COVID-19 positive on 11/24/23 sometime during the shift and continued to administer medications to residents.

2. Review of the medical record for Resident #40 revealed an admission date of 03/21/22 with medical diagnoses of anxiety, HTN, and atherosclerotic heart disease.

Review of the medical record for Resident #40 revealed a Resident Assessment, dated 03/21/22, which indicated Resident #40 was alert and oriented to person, place, and time and was independent with ADL's.

Review of the medical record revealed the November MAR which indicated LPN #313 administered medications to Resident #40 throughout the day on 11/24/23. Further review of the medical record for Resident #40 revealed a progress note, dated 11/26/23 at 6:45 P.M., which stated Resident #40 tested positive for COVID-19.

Observation with interview on 11/28/23 at 11:10 A.M. with Resident #40 revealed an isolation cart located outside of Resident #40's door. The isolation cart contained personal protective equipment (PPE) which included gloves, gowns, face shields, and N95 masks. Observation of Resident #40's room revealed there was not a trash bin to discard PPE upon leaving Resident #40's room. Interview with Resident #40 stated staff had not been donning PPE prior to entering her room. During the interview, LPN #302 walked into Resident #40's room and was wearing a surgical mask and no other PPE. LPN #302 handed Resident #40 a bottle of pop.

Interview on 11/28/23 at 11:11 A.M. with LPN #302 confirmed she was aware Resident #40 was on droplet isolation precautions for COVID-19 and that she had not donned PPE prior to entering Resident #40's room. LPN #302 also confirmed Resident #40's room did not contain a trash bin in her room or outside of her room to discard PPE.

3. Review of the medical record for Resident #176 revealed an admission date of 05/11/22 with medical diagnoses of hypothyroidism, Depression, anxiety, HTN, and post-traumatic stress disorder (PTSD).

Review of the medical record for Resident #176 revealed a Resident Assessment, dated 05/11/22, which indicated Resident #40 was alert and oriented to person, place, and time. The assessment indicated Resident #176 was independent with ADL's.

Review of the medical record revealed the November MAR indicated LPN #312 administered her medications throughout the day on 11/24/23. Review of the medical record for Resident #176 revealed a nurse progress note, dated 11/27/23 at 5:24 P.M. which stated Resident #176 stated she had not been feeling well and requested a COVID-19 test. The note stated Resident #176 tested positive for COVID-19.

Observation on 11/28/23 at 9:50 A.M. revealed an isolation cart outside the door to Resident #176's room with PPE, which included gloves, gowns, and N95 masks, inside the cart. The isolation cart did not contain any face shields. A face shield was observed resting on the handrail outside Resident #176's room. No disinfectant supplies were observed on or in the isolation cart.

Interview on 11/28/23 at 9:53 A.M. with LPN #303 confirmed the isolation cart sitting outside of Resident #176's room did not contain any face shields. LPN #303 stated the all the staff used the face shield that rested on the handrail outside of Resident #176's room. LPN #303 confirmed the staff did not disinfect the face shield between staff members using the face shield.

Interviews on 11/28/23 from 9:24 A.M. to 9:53 A.M. with Resident Aide (RA) #310, RA #326 and LPN #303 confirmed they all work on 11/24/23 with LPN #312 and #313 and that LPN #312 and #313 tested positive at some point while at work. RA #310, RA #326 and LPN #303 confirmed LPN #312 and #313 worked for around four hours after testing positive for COVID-19 and there were not any staff brought in to replace them.

Interview with Director of Nursing (DON) #319 confirmed both LPN #312 and #313 tested positive for COVID-19 at some point on 11/24/23 while at work. DON #319 stated she was not sure how much time was left in their shift when they tested positive. DON #319 confirmed both LPN's finished their shift for the day and continued to pass medications to residents.

Review of the time sheets for 11/24/23 confirmed LPN #312 worked from 7:00 A.M. to 7:07 P.M. and LPN #313 worked from 6:56 A.M. to 7:06 P.M.

Review of the facility policy titled, COVID-19 Resident policy

Based on medical record review and staff interview, the facility failed to perform annual resident assessments in a timely manner. This affected three residents (#12, #16, and #34) of four resident assessments reviewed. The census was 107.

Findings Include:

1. Resident #12 was admitted to the facility on 01/12/22. His diagnoses were encephalopathy, major depressive disorder, altered mental status, hallucinations, type II diabetes, congestive heart failure, hypothyroidism, hypertension, hyperlipidemia, alcohol abuse, and dysphagia. Review of the resident's most recent health assessment dated 04/09/23, revealed the resident was cognitively intact.

Review of the resident health assessment dated 04/09/23 for Resident #12, revealed this was the most recent health assessment and was not within 30 days of the anniversary date of the prior health assessment dated 01/12/22.

2. Resident #16 was admitted to the facility on 08/06/21. Her diagnoses were other intervertebral disc degeneration, type II diabetes, major depressive disorder, vitamin deficiency, psychosis, cognitive communication deficit, age related physical debility, nicotine dependence, pain in right ankle, spinal stenosis, low back pain, adult failure to thrive, hypertension, hypothyroidism, hyperlipidemia, anxiety disorder, and need for assistance with personal care. Review of the resident's most recent health assessment dated 05/10/23, revealed the resident was cognitively intact.

Review of the resident health assessment dated 05/10/23 for Resident #16, revealed this was the most recent health assessment. The last one completed was 08/06/21 and there was no documented evidence a current one had been completed.

3. Resident #34 was admitted to the facility on 11/18/21. Her diagnoses were chronic obstructive pulmonary disease, acrodermatitis continua, hyperlipidemia, psychosis, heart failure, major depressive disorder, heart failure, obesity, chronic pain syndrome, insomnia, metabolic encephalopathy, anemia, chronic respiratory failure with hypoxia, chronic kidney disease (stage III), muscle wasting and atrophy, cerebral infarction, and anxiety disorder. Review of the resident's most recent health assessment dated 11/18/21, revealed the resident was cognitively intact.

Review of the resident health assessment dated 11/18/21 for Resident #16, revealed this was the most recent health assessment completed and there was no documented evidence a current one had been completed.

Interview with General Manager #200 on 09/08/23 at 2:20 P.M. confirmed each resident's assessment was outside the requirements for annual resident assessments. She confirmed Resident #34 did not have a current resident assessment completed as well.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide adequate investigation/documentation of resident falls. This affected one resident (#34) of three residents falls reviewed. The census was 107. Findings Include: Resident #34 was admitted to the facility on 11/18/21. Her diagnoses were chronic obstructive pulmonary disease (COPD), acrodermatitis continua, hyperlipidemia, psychosis, heart failure, major depressive disorder, heart failure, obesity, chronic pain syndrome, insomnia, metabolic encephalopathy, chronic respiratory failure with hypoxia, chronic kidney disease (stage III), muscle wasting and atrophy, cerebral infarction, and anxiety disorder. Review of the resident health assessment, dated 11/18/21, revealed the resident was cognitively intact. Review of Resident #34's progress notes, dated 08/20/23 to 09/08/23, revealed no documentation to support Resident #34 had a fall. There was no documentation throughout her medical records to support any investigation, review, or interventions put in place regarding a fall on 08/24/23. Review of facility Incident/Accident Log, dated August 2023, revealed a self-reported fall by Resident #34 on 08/24/23. She reported she got herself up and there were no injuries. There was no documented investigation done to support how the fall occurred, what was done when the fall occurred, and interventions put in place to reduce the likelihood of the resident falling again. Interview with Resident #34 on 09/08/23 at 10:16 A.M. confirmed she fell on 08/24/23. The resident confirmed she pushed her call pendant, and no one came to help her until about three hours later. The resident confirmed a nurse went to her room and helped her off the ground. At times, her hip will go outBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide adequate investigation/documentation of resident falls. This affected one resident (#34) of three residents falls reviewed. The census was 107.

Findings Include:

Resident #34 was admitted to the facility on 11/18/21. Her diagnoses were chronic obstructive pulmonary disease (COPD), acrodermatitis continua, hyperlipidemia, psychosis, heart failure, major depressive disorder, heart failure, obesity, chronic pain syndrome, insomnia, metabolic encephalopathy, chronic respiratory failure with hypoxia, chronic kidney disease (stage III), muscle wasting and atrophy, cerebral infarction, and anxiety disorder. Review of the resident health assessment, dated 11/18/21, revealed the resident was cognitively intact.

Review of Resident #34's progress notes, dated 08/20/23 to 09/08/23, revealed no documentation to support Resident #34 had a fall. There was no documentation throughout her medical records to support any investigation, review, or interventions put in place regarding a fall on 08/24/23.

Review of facility Incident/Accident Log, dated August 2023, revealed a self-reported fall by Resident #34 on 08/24/23. She reported she got herself up and there were no injuries. There was no documented investigation done to support how the fall occurred, what was done when the fall occurred, and interventions put in place to reduce the likelihood of the resident falling again.

Interview with Resident #34 on 09/08/23 at 10:16 A.M. confirmed she fell on 08/24/23. The resident confirmed she pushed her call pendant, and no one came to help her until about three hours later. The resident confirmed a nurse went to her room and helped her off the ground. At times, her hip will go out

Based on observation, interview and record review, the facility failed to ensure a resident's dog received an annual physical examination and vaccinations. This affected one (#05) out of three residents reviewed for having pets. The facility census was 91.

Findings include:

Review of the Resident #05's chart revealed Resident #05 admitted to the facility on 07/19/21 with diagnoses including other cerebral infarction due to occlusion or stenosis of smell artery, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, unspecified asthma, cognitive communication deficit and major depressive disorder.

Review of Resident #05's resident assessment dated 11/10/22 revealed Resident #05 was oriented to person, place, and time. Resident #05 required supervision with ambulation, and reminders for toileting, dressing, and grooming. Resident #05 was totally dependent for showering and was independent with eating.

Review of Resident #05's resident agreement dated 04/18/23 revealed Resident #05 acknowledged that she had been informed of the community's pet policy as provided in the resident information guide and a one time pet deposit was required.

Observation of Resident #05's room on 05/25/23 at 12:35 A.M. revealed Resident #05 to be in her room with her dog. Resident #05's dog was noted to be friendly with no aggression noted.

Interview with General Manager #501 on 05/25/23 at 2:30 P.M. verified the facility did not have any veterinarian records for Resident #05's dog.

Telephone interview on 05/25/23 at 2:37 P.M. with Veterinarian Receptionist #800 verified Resident #05's dog had not been seen at the veterinarian office and had not had any vaccinations since 2018 and was past due on all vaccinations.

Review of Resident #05's dog's veterinarian records revealed the facility did not have any records on file for Resident #05's dog.

Review of the facility's pet policy dated November 2000 revealed documentation must be provided that the pet has all required vaccinations per the state requirement.

This deficiency represents non-compliance investigated under Complaint Number OH00142089.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted on each shift quarterly at varied times. This had the potential to affect all 105 residents who resided in the facility.

Findings include:

During record review of the facilities fire drills on 03/23/23 at 1:30 P.M., revealed no documented evidence of fire drills being conducted for 03/01/22 through 07/01/22.

Interview with the Executive Director on 03/23/23 at 1:35 P.M. verified the facility had no documented evidence of fire drills being conducted from 03/01/22 through 07/01/22.

This violation is a recite to annual survey completed 01/24/22.

Based on observation and staff interviews, the facility failed to properly label, store and/or discard food items. This had the potential to affect all 106 residents residing in the facility. The census was 106.

Findings include:

Observation with Cook #9 and District Manager #10 on 02/14/23 at 3:13 P.M. revealed there was an unmarked, unopened large clear bag containing discolored food on the top shelf of the same refrigerator. Cook #5 and District Manager #10 could not verify the contents, and further stated it was either lettuce or Cole slaw. There was a metal container which contained two whole tomatoes and one which was sliced in half. These were uncovered and undated. This was verified at the time of the observation with District Manager #10. The items were discarded.

Observation with District Manager #10 of the freezer revealed a metal pan partially covered with aluminum foil marked chicken broccoli casserole 01/28/23 there were ice crystals on top of the foil and a corner of the foil was pulled back, leaving the food exposed. Inspection of the food revealed it to be freezer burnt. A ziplocked bag containing breaded fish fillets covered in ice crystals dated 08/29/22 were found on a shelf. These were verified and discarded by District Manager #10. The facility confirmed all 106 residents receive their meals from the kitchen.

This violation represents non-compliance investigated under Complaint Number OH00140233.