Courtyard at Troy, The

Based on medical record review, observations and staff and resident interviews, the facility failed to administer medication as ordered by physician. This affected one (#14) of three residents observed for medication administration. The facility was census of 35.

Findings include:

Review of medical records for Resident #14 revealed Resident #14 was admitted to the facility on 10/09/25 with the diagnosis including, Alzheimer's disease, anxiety, and glaucoma.

Review of current physician medication orders on 03/02/25 was to administer refresh liquigel ophthalmic solution 1% with one drop into each eye four times a day.

Observation on 11/06/2025 at 7:40 A.M. noted Licensed Practical Nurse (LPN) #108 administered one drop of refresh liquigel ophthalmic solution 1% to Resident #14's left eye and one drop of opium tears to right eye. LPN #108 confirmed there was no current order for opium tears to Resident #14's right eye.

Interview on 11/06/2025 at 7:41 A.M. with LPN #108 revealed Resident #14 is aware of Resident #14's medication and specifically wants refresh drop in left eye and opium tears in right eye due to being blind in left eye. LPN #108 stated the family supplies Resident #14's eye drops.

Interview on 11/06/2025 at 9:14 A.M. with Resident #14 revealed Resident #14 was told refresh drops go into left eye and opium tears go into right eye. If refresh is used in her good eye (right eye) it will make Resident #14's right eye go blind.

Based on medical record review, observation, staff interview, and policy review, the facility failed to appropriately store medications, specially eye drops that were kept at a resident's bedside. This affected one (#14) of three residents medication administration. The facility census was 35.

Findings include:

Review of medical record for Resident #14 revealed an admission date of 10/07/25. Diagnosis included Alzheimer's disease, anxiety, and glaucoma.

Review of the History and Physical Evaluation for Resident #14, dated 10/09/25, revealed the resident is not capable of self-administering medication due to Alzheimer's disease and Resident #14 is blind in the left eye and going blind in the right eye.

Review of Self-Administering Medication form for Resident #14 revealed self-administering medication form was not completed for Resident #14 upon admission.

Observation on 11/06/2025 at 7:40 A.M. with License Practical Nurse (LPN) #108 revealed Resident #14 had four eye drop bottles with no box on her dresser. This includes: Refresh tears 1%, opium tears, dorzolaminde hydrochloride and timolol maleate ophthalmic 2%-0.05% and latanoprol ophthalmic 0.005%.

Interview with LPN #108 at time of finding verified Resident #14 did not have an order to self-administer eye drops and no self-administration form for medication was completed.

Review of facility policy, Self Administration of Medications, undated, verified self-administration of medications would be assessed/evaluated within the first week of admission. If resident had the ability to self-administer their medications and order would be obtained by resident's practitioner.

Based on observation and interview, the facility failed to ensure open date and resident identification information were on medications. This affected two (#14 and #16) out of three residents observed for medication administration/storage. The facility census was 35.

Findings include:

Observation on 11/06/2025 at 7:32 A.M. through 8:10 A.M. with Licensed Practical Nurse (LPN) #108 revealed four eye drop bottles, not in a box, in Resident #14's room without an open date. The eye drops observed were Refresh tears 1%, opium tears, dorzolaminde hydrochloride and timolol maleate ophthalmic 2%-0.05% and latanoprol ophthalmic 0.005%. Refresh tears and opium tears did not have resident identification information on bottles. Further observations of medication storage revealed one bottle of polyvinyle lubricant eye drops for Resident #16 with no open date delivered to facility on 07/15/25 was found in medication cart.

Interview with Licensed Practical Nurse (LPN) #108 at time of finding verified no open date on all five bottles of eye drops for Resident #14 and #16. LPN #108 confirmed the refresh and opium tears observed in Resident #14's room did not have resident identification information on bottles.

Based on observations and staff interviews, the facility failed to ensure dietary staff completed hand hygiene and changed gloves during food preparation. Additionally, the facility failed to clean/disinfect a temperature probe between use on multiple food items to potentially prevent cross contamination. This had the potential to affect all 35 residents residing in the facility who receive meals from the kitchen. The facility census was 35.

Findings include:

Observation of facility kitchen on 11/05/25 at 12:05 P.M. revealed Dining Services Director (DSD) #101 placed temperature probe into fish stating it was 187 Fahrenheit (F). DSD #101 then placed the probe into the rice, stating it was 210 F. Lastly, DSD #101 placed the probe into the mixed vegetable, stating it was 176 F. During the observation, DSD #101 did not clean/disinfect the temperature probe with alcohol between food items.

Interview on 11/05/25 at 12:08 P.M. with DSD #101 verified he did not sanitize temperature probe before, in between and after probing food for temperature. DSD #101 revealed he did not know he needed to sanitize the probe. DSD #101 searched the kitchen area and found no sanitizing wipe available in the kitchen area.

Observation of facility kitchen on 11/05/25 at 12:10 P.M. revealed DSD #101 was wearing gloves and pulled down multiple containers from shelves with lids, open containers and rummage through containers with hands. DSD #101 moved multiple spices on shelves. DSD #101 pulled open drawers and used hands to rummage through items in drawers. DSD #101 grabbed a spatula out of a drawer. DSD #101 took two pieces of fish out of the oven from a pan with multiple fish on it. DSD #101 placed the two pieces of fish in the blender and chopped it in small pieces. DSD #101 placed the small pieces into a small metal container onto the steam container. DSD #101 processed to take the washcloth out of the sanitizer bucket in the sink and wash a small area by the blender with right hand then place the washcloth back into the bucket. DSD #101 opened the refrigerator door, removed the lid on the egg container, removed an egg, and placed it in a salad bowl to be delivered. During the observation, DSD #101 wore the same pair of gloves and no hand hygiene was observed.

Interview on 11/05/25 at 12:32 P.M. with DSD #101 verified he did not complete properly change gloves before preparing food. DSD #101 stated Why wear gloves then, if you have to change them. You know people don't realistically do that.

Based on observation, staff interview, review of kitchen logs and facility policy, the facility failed to ensure the dishwasher gauge was operating to get an accurate temperature reading. Additionally, the facility failed to implement their policy to maintain their kitchen logs regarding completing dishwasher temperature checks, sanitizer level checks of the 3-sink and/or food temperature checks. This had the potential to affect all 35 residents residing in the facility that receive meals from the kitchen. The facility census was 35.

Findings include:

Observation of the kitchen on 11/05/25 between 8:58 A.M. to 10:48 A.M. revealed dish washer temperature was a high temperature dishwasher. Observations of the dishwasher revealed the rinse temperature gauge was broke. The dial on the gauge did not move when the dishwasher was being used. Dining Services Director (DSD) #101 placed temperature disk into dishwasher for temperature reading. Observations revealed the highest temperature reading was 159.9 degrees Fahrenheit (F). DSD #101 re-checked the temperature with the same disk and the temperature was 159.9 degrees F. DSD #101 used a different temperature disk and received a reading of 156.9 degrees F. DSD #101 found a strip test that indicated if a blue line turned to orange the water was above 180 degrees F. The strip test was placed in dishwasher and turn orange. Observations of the test strip bottle revealed an expiration date was noted as 06/30/25. The Executive Director (ED) placed new batteries in disk one of the disk, temperature was found to be 160.0 degrees F. DSD #101 and the ED confirmed the gauge on the dishwasher was broke.

Interview on 11/05/25 throughout the tour of kitchen with DSD #101 verified four attempts with different temperature disks verifying the dishwasher did not rise an appropriate temperature to sanitize the dishes. DSD #101 verified the temperature testing strip used was expired on 06/30/25. DSD #101 verified the sanitizer quantum strips that was used to test the three-sink and washcloth bucket was expired on 10/26/25. During the interview DSD #101 stated, Who cares, I am sure they are fine. It showed 400. Should be all you care about.. DSD #101 verified the missing log sheets, dishwasher temperatures , pot and pan sanitizer checks, and food temperatures . DSD #101 stated I knew some pages of the logs were missing..

Interview on 11/05/25 at 1:45 P.M. with ED revealed DSD #101 threw away the temperature disks because DSD #101 did not like them. ED will be ordering new testing strips, delivery date unknown. The dishwasher is rented from Company #12 and ED will be calling then regarding the broken temperature gauge.

Observation of 3-sink sanitizer and washcloth bucket on 11/05/25 8:58 A.M. to 10:48 A.M. revealed the sanitizer quantum strips the facility had be using were expired on 10/26/25.

Observation of dishwasher on 11/06/26 at 8:45 A.M. revealed DSD #101 was washing the morning breakfast dishes. No temperature disk was observed in the kitchen area. No temperature strips were in the kitchen area.

Review of the kitchen log records from 10/01/25 to 11/05/25 revealed facility did not check the temperatures of the dishwasher on dates of 10/02/25, 10/04/25, 10/05/25, 10/07/25, 10/14/25, 10/21/25, and 11/05/25. No sanitizer check were completed on pot and pan sanitizer for the 3-sink on dates of 10/02/25, 10/14/25, and 10/21/25. No food temperatures were completed for lunch and/or supper on dates of 10/02/25, 10/04/25, 10/05/25, 10/07/25, 10/14/25, 10/21/25, and 11/05/25. The facility did not complete food temperature sheets for the dates of 10/01/25, 10/02/25, 10/03/25, 10/06/25, 10/08/25, 10/09/25, 10/10/25, 10/11/25, 10/12/25, 10/15/25,10/16/25, 10/17/25, 10/20/25, 10/22/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25,10/28/25, 10/29/25, 11/03/25, and 11/04/25.

Review of facility policy Dishwasher/Warewashing Policy, dated 2025, stating high-temp machines: maintain wash/rinse temperatures per manufactures specs. Record machine wash and final rinse temperatures at start of each service period. Spot-check final rinse temps per shift. For three-sink compartment, verify sanitizer ppm with test strips and record per shift. Check parts per million (ppm) every hours change if ppm is low or water is dirty.

Based on record review and staff interview, the facility failed to notify alarm system within twelve hours after silent alarm was completed. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Findings include:

Review of facilities fire drills on 11/05/25 revealed silent alarms were completed on day shift 02/07/25 at 10:00 A.M. and 04/15/25 at 11:00 A.M. with no contact with alarm system within twelve hours after silent alarms. Night shift had silent alarms completed on 02/28/25 at 8:06 P.M., 03/09/25 at 9:00 P.M., 05/19/25 at 1:00 A.M., 06/18/25 at 2:00 A.M., 07/20/25 at 1:00 A.M., 08/12/25 at 11:40 P.M., 09/08/25 at 11:00 P.M., and 10/22/25 at 4:45 A.M. with no contact with alarm system within twelve hours after silent alarm.

Interview on 11/05/25 at 3:10 P.M. with Executive Director verified silent alarms were completed but the facility did not notify alarm system within twelve hours to ensure transmission of the fire alarm signal.

Based on observation and staff interview, the facility failed to use proper fire safety self inspection sheets. Additionally, the facility failed to complete a fire safety self inspection every month as required. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Findings include:

Review of the facilities fire safety self inspection sheets on 11/05/25 revealed facility is using incorrect self inspection sheets dated with revised 10/28/98. Further review of the month of October 2025 was signed off with completion with the date of 09/20/25 at 9:00 A.M..

Interview with Executive Director on 11/05/25 at 3:20 P.M. verified the facility has not been using the updated fire self inspection sheet provided by Ohio Department of Health. The ED further verified for October 2025 it was signed in the month prior to October.

Based on observation and staff interview, the facility failed to post the most recent licensure inspection report as required. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Findings include:

Observation on 11/05/2025 at 4:10 P.M. of posted survey book revealed survey book was in Executive Director's office behind desk laying on a credenza. The survey book was missing recent licensure inspection report including: follow up/revisit on 04/23/25, complaint visit on 06/02/25, complaint visit on 08/20/25, and complaint survey on 10/01/25.

Interview with Executive Director 11/05/25 at 4:13 P.M. revealed she was aware that licensure inspection/survey results were not posted. Executive Director stated document will be printed out and placed in survey binder.

Based on interview, observation, and record review, the facility failed to have sanitizer available for santizing kitchen surfaces and cookware. This could potentially affect all 49 residents residing in the building.

Findings include:

Observation in the kitchen on 06/02/25 at 8:54 A.M. with the Executive Director (ED) revealed Cook #13 washing two large cookie sheet pans in the three compartment sink. The three sink compartments were empty and the water was running. Cook #13 placed the two pans in one of the sink compartments. There was a small plastic container with water and a rag inside observed. Cook #13 confirmed she was using the rag to clean the counters. She confirmed the sanitization level was zero with the sanitization strips.

Interview on 06/02/25 at 8:55 A.M with Cook #13 confirmed she was using the detergent and sanitizer to hand wash the pans and then placing the pans in one compartment to air dry. She stated she does not put the two pans in the dishwasher due to being too large.

Interview on 06/02/25 at 8:56 A.M. with the ED confirmed Cook #13 was not using appropriate sanitization for hand washing cookware. The ED stated the three compartment sink was only used by Cook #13 and she was not aware Cook #13 was hand washing the large pans. She stated they currently do not have sanitizer for the kitchen due to previously ordering the wrong kind. They disposed of the digreaser they were using as sanitizeron 05/29/25 when the local health department was at the facility and the ED was made aware. The order for the correct sanitizer was placed on 05/29/25 and was to be delivered on 06/02/25 anytime between 2:00 P.M. to 5:00 P.M.

Interview on 06/02/25 at 9:20 A.M. with Local Health Department Staff confirmed the facility was using degreaser as a sanitizer during the inspection on 05/29/25. He confirmed the facility removed it on the same day. He stated Cook #4 was in the kitchen and stated he did not know the product in use was not sanitizer as the containers look alike.

Interview on 06/02/25 at 9:53 A.M. via telephone with Cook #4 confirmed he removed the degreaser on 05/29/25. He stated it was accidentally put into use. He stated he does not hand wash any cook ware in the kitchen, he only uses the dishwasher.

Interview on 06/02/25 at 11:00 A.M. the ED confirmed the facility does not currently use a sanitization log for the three compartment sink.

This violation represents non-compliance investigated under Complaint Number OH00166121.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure food items that had been opened and placed in storage were properly sealed closed and dated. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.

Findings include:

Observation on 02/03/25 at 8:49 A.M. of the facility kitchen revealed two bags of lettuce and one bag of sausage links in the refrigerator were opened, not dated, and the bags were not sealed closed. Further observations in the kitchen revealed a bag of pasta noodles in dry storage were opened, not dated, and not sealed closed. Observation also revealed a plastic container filled with sugar had two plastic cups inside the container.

Interview on 02/03/25 at 8:55 A.M. with Cook #200 confirmed the two bags of lettuce, the one bag of sausage links, and the bag of pasta noodles were opened, not dated, and the bags were not sealed closed. Cook #200 also confirmed that the plastic container of sugar contained two plastic cups inside the container. The facility confirmed all 38 residents residing in the facility receive their meals/food from the kitchen.

Review of the facility policy titled, Dates and Labels for Food

Based on review of the facility fire drill documentation, staff interview and policy review, the facility failed to ensure residents were evacuated during fire drills as required. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.

Findings include:

Review of the facility fire drill documentation from February 2024 to January 2025 revealed no documentation to support residents were evacuated during any of the fire drills.

Interview on 02/03/25 at 11:08 A.M. with Maintenance Director #205 confirmed residents were not evacuated during any of the fire drills from February 2024 to January 2025.

Review of the facility policy titled, Fire Evacuation Drill

Based on review of the facility fire training documentation and staff interview, the facility failed to conduct annual staff fire prevention training. This had the potential to affect all 38 residents residing in the facility. The facility census was 38.

Findings include:

Review of the facility fire training records revealed no documentation to support the facility conducted annual staff fire prevention training in 2024. Review of the documentation revealed the most recent facility staff fire prevention training was in 2023.

Interview on 02/03/25 at 11:08 A.M. with Maintenance Director #205 confirmed the facility had not conducted annual staff fire prevention training in 2024.

This violation is a recite to the annual survey completed 07/28/22.