Our Home Fairborn

Based on medical record review, review of facility self-reported incidents (SRI), staff interview, review of an audio recording, and policy review, the facility failed to ensure all residents were free from abuse. This affected one (Resident #08) of three residents reviewed for abuse. The facility census was 73. Findings include: Review of the medical record of Resident #08 revealed an admission date of 04/28/25. Diagnoses included Alzheimer's disease, anxiety, unspecified disorder of adult personality and behavior, insomnia, delusional disorders, and moderate dementia with agitation. Review of the Mini-Mental State Exam for Resident #08 dated 04/01/25, revealed the resident had moderately impaired cognition. Review of the Health Status and Activities of Daily Living (ADL) Evaluation for Resident #08 dated 04/28/25, revealed the resident was oriented to person and place, not capable of making decisions. The resident was independent with mobility, transferring, and toileting. Review of the facility SRI dated 03/02/26, revealed on 02/28/26 at 9:32 P.M., a Resident Care Associate (RCA) called Assistant Director of Nursing (ADON) #305 reporting there was another RCA (#300) who was agitating a memory care resident (#08) by calling her names. ADON #305 called the Director of Nursing (DON) to notify her and the DON called the Executive Director (ED) #400. The DON and ADON #305 came to the community and questioned the alleged perpetrator (RCA #300), had her write a statement, and then escorted her off the campus and advised her not to return until contacted, pending an investigation. The DON and ADON #305 evaluated the resident for injury and no injuries nor distress were noted. Statements were obtained from the staff in the community, in which it was reported the RCA also pushed the resident. The physician and responsible party were notified of the incident. Upon completion of the investigation, the allegation of physical and verbal abuse was substantiated, and RCA #300 was terminated on 03/02/26 for verbal/physical abuse of the resident. RCA #300 was reported to the abuse registry. All staff were re-educated on the abuse, neglect, and misappropriation policy. Review of witness statement undated and authored by ADON #305's, revealed on 02/28/26 at 9:32 P.M., she received a call from RCA #320, who explained there was an employee agitating a memory care resident. RCA #320 explained that the employee had called the resident names and the allegations were reported to her by the second staff member (RCA #315) who was working on the memory care unit that evening. ADON #305 states she first texted the second aide in memory care (RCA #315) and asked her to call when she was somewhere private and could talk. ADON #305 further stated she contacted the DON at 9:50 P.M. and called and spoke with LPN #310, to ensure the incident had been reported to her. ADON #305 stated she and the DON arrived at the building at 10:30 P.M. and pulled RCA #300 to the private dining room for questioning. RCA #300 stated Resident #08 called her an expletive and grabbed her. RCA #300 wrote a statement and was escorted to the memory care unit to collect her belongings and then escorted to the back door at 10:45 P.M. The DON and ADON #305 advised RCA #300 to not re-enter the building until she was contacted, pending an investigation. ADON #305 then spoke with RCA #315 regarding what she saw and heard and she explained she overheard RCA #300 call Resident #08 expletives and RCA #300 pulled up a picture of Resident #08's daughter-in-law on Facebook and was asking her who the person was and when Resident #08 did not answer, RCA #300 made comments about how Resident #08 was expletive stupid and must not care about her that much. RCA #315 reported RCA #300 was barking at Resident #08. Resident #08 then shoved RCA #300 and RCA #300 shoved her back and a shoving match followed. RCA #300 then stated she wished Resident #08 would croak and pointed at the resident and laughed. The DON and ADON #305 assisted the resident to the bathroom and checked for injuries; no injuries were noted. Resident #08 was pleasant and cooperative at that time. The DON and ADON #305 attempted to question Resident #08 regarding the incident; however, Resident #08 was unable to verbalize what transpired. Review of the witness statement dated 02/28/26 and authored by RCA #315, reported battles between RCA #300 and Resident #08 reached an unsafe level and RCA #305 was verbally calling Resident #08 expletives and stated she couldn't wait for the resident to croak. RCA #315 noted RCA #305 and Resident #08 also had physical contact and RCA #305 had her hands around her lower arm and noted they were pushing each other. RCA #315 noted she went to RCA #320 multiple times over the frustration and RCA #320 reached out to upper management while trying to wait for a response of what to do next. Management arrived shortly after being contacted and RCA #300 was removed from the facility. Review of the witness statement dated 02/28/26 and authored by RCA #320, revealed RCA #315 came to her about RCA #300 due to verbally abusing Resident #08. RCA #320 stated she went to the nurse on duty and called ADON #305. During an interview on 03/12/25 at 9:45 A.M., the DON reported on the night of 02/28/26, she received a call from ADON #315, who reported she was notified of an incident of staff-to-resident abuse. The DON stated she came to the facility and, after removing RCA #300 from the building, completed a head-to-toe assessment on Resident #08. The DON stated Resident #08 seemed unphased and was unable to provide any information regarding the incident. The DON stated staff working that night was questioned and abuse education was sent out to all staff within 24 hours of the incident. Review of the employee file of Caregiver #300 on 03/12/26 at 10:00 A.M., provided by the DON, revealed a hire date of 04/03/25 as an unlicensed caregiver. Caregiver #300 was terminated on 03/02/26 for a violation of policy/procedure when she was verbally and physically abusive to a memory care resident. During an interview on 03/12/26 at 11:24 A.M. with Resident #08; however, the resident was unable to answer any questions appropriately nor provide any information related to the incident. Review of two audio recordings with the DON on her phone on 03/12/26 at 11:46 A.M., revealed a female voice calling someone an expletive, followed by the same female voice saying you know who I wish would croak. Continued review revealed the same female voice saying who is this and she looked as scary as you do. The DON confirmed the female voice on the recording was RCA #300. During an interview on 03/12/25 at 11:46 A.M., the DON stated RCA #300 was never alone with any residents once ADON #305 was notified of the incident and enroute to the facility. The DON stated RCA #300 was in the common area of the memory care unit between the time RCA #320 called ADON #305 and when the DON and ADON #305 arrived at the facility. During an interview on 03/12/26 at 11:52 A.M., RCA #315 stated on the night of 02/28/26, RCA #300 seemed to be in a bad mood and was not herself. RCA #315 stated she observed RCA #300 call Resident #08 an expletive and couldn't wait for her to croak. RCA #315 stated, when RCA #300 said that to Resident #08, the resident looked at RCA #300 and asked if RCA #315 had just said that and RCA #315 verified she said it. RCA #315 stated she told the lead aid, RCA #320, who told LPN #310. RCA #315 stated she then went back to her duties and had Resident #10 in the air on a Hoyer lift, while obtaining her weight, when she observed RCA #300 and Resident #08 throwing things at each other and shoving each other. RCA #315 stated she told RCA #300 no, not. and redirected Resident #08 and told RCA #300 to go to the nurse station. RCA #315 stated she lowered Resident #10 into a safe position and left the unit to talk to RCA #320 and then LPN #310. RCA #315 stated RCA #320 then called ADON #305. RCA #315 stated she went back to the unit and she and RCA #300 started putting people in bed. RCA #315 estimated the DON and ADON #305 arrived approximately 45 minutes later and escorted RCA #300 off the premises. RCA #315 confirmed during the time between when she left the unit to talk to RCA #320 and LPN #310 and when the DON and ADON #305 arrived at the facility, RCA #300 continued to assist other residents with going to bed. RCA #315 confirmed she had audio recording of RCA #300 calling the resident expletives and saying she wanted her to croak, which she had shared with the DON. RCA #315 confirmed she did not intervene when RCA #300 was calling Resident #08 names. During an interview on 03/12/26 at 12:09 P.M., LPN #310 stated she was at the medication cart near the common area on the assisted living unit when RCA #320 came and told her RCA #300 was verbally aggressive with Resident #08 and was irritating her. LPN #310 stated RCA #320 reported that she had already called ADON #305. LPN #310 stated ADON #310 called her and let her know she and the DON were on their way to the unit. LPN #310 confirmed she did not go to the memory care unit at that time. LPN #310 stated she did not go back to the memory care unit because she was tied up on the assisted living side. LPN #310 stated RCA #320 let her know later that RCA #300 was in the common area of the memory care unit and away from other residents. LPN #310 stated she did not go back to the memory care unit because she knew RCA #315 was back there keeping an eye on things and she understood RCA #300 was in the common area away from other residents, including Resident #08. LPN #310 stated, following completion of her medication pass, RCA #315 came to the nurse station and reiterated what was happening and played the video, where she could hear RCA #300 saying Resident #08 was expletive and she meant it and that she hoped resident #08 would die because she was so annoying. LPN #310 reported she was told RCA #300 and Resident #08 were shoving and grabbing each other. LPN #310 stated, while she was talking to RCA #315, RCA #320 was back on the memory care unit with RCA #300. During an interview on 03/12/26 at 1:00 P.M., ADON #305 stated, on 02/28/26, she received a call from RCA #320 who said things were going on that were making her feel uncomfortable and said an aid was not being nice to a resident. ADON #305 stated she was on her way and verified she did not give RCA #320 any instructions on anything to do. ADON #305 stated she then sent RCA #315 a text message, asking her to go somewhere private and call her. ADON #320 stated RCA #315 called her, and she gave her instructions to keep an eye on RCA #300 and keep her away from Resident #08. ADON #305 stated she met the DON at the facility and went to the memory care unit and took RCA #300 to a non-clinical area, got her statement, escorted her back to the memory care unit to obtain her belongings, and then out of the facility. ADON #305 stated she conducted a skin assessment on Resident #08 but had no findings and then obtained staff statements. ADON #305 confirmed she should have told LPN #310 to go back to the memory care unit and ensure Resident #08 was safe and should have removed RCA #300 from the resident care areas. During a follow-up interview on 03/12/26 at 1:30 P.M., the DON denied knowledge of RCA #300 continuing to work on the unit once becoming aware of the abuse concerns. Review of the witness statement undated and authored by RCA #300's, revealed she washed her hands and was doing resident weights when Resident #08 grabbed her arm and was calling her expletives, and it was not the first time it had happened. RCA #300 stated she gave Resident #08 space to cool off. RCA #300 noted Resident #08 was being mean to RCA #315. Review of the witness statement undated and authored by Licensed Practical Nurse (LPN) #310's, revealed she was completing a medication pass when RCA #320 came to let her know RCA #300 was verbally agitating/irritating Resident #08 and RCA #315 had a recording of it. RCA #320 stated she had already called ADON #305 and, as LPN #310 was going to call ADON #305, ADON #305 called her. LPN #310 stated she told ADON #305 what she knew about the situation, and LPN #310 told her she was aware RCA #300 was verbally agitating/irritating Resident #08 and RCA #315 had a recording of it. After completing her medication pass, LPN #310 stated she was in the nurse's station and RCA #315 came to the nurse's station and played a recording of RCA #300 described Resident #08 with expletives, and she meant it. RCA #315 stated RCA #300 stated she hoped Resident #08 would die because she was so sick of her. RCA #315 informed LPN #310 that RCA #300 and Resident #08 had been shoving and grabbing each other. LPN #310 noted RCA #315 was visibly upset talking about the situation she had reported and was visibly shaking while talking about it. Review of the facility policy titled, Freedom from Abuse, Neglect, and ExploitationBased on medical record review, review of facility self-reported incidents (SRI), staff interview, review of an audio recording, and policy review, the facility failed to ensure all residents were free from abuse. This affected one (Resident #08) of three residents reviewed for abuse. The facility census was 73.

Findings include:

Review of the medical record of Resident #08 revealed an admission date of 04/28/25. Diagnoses included Alzheimer's disease, anxiety, unspecified disorder of adult personality and behavior, insomnia, delusional disorders, and moderate dementia with agitation.

Review of the Mini-Mental State Exam for Resident #08 dated 04/01/25, revealed the resident had moderately impaired cognition.

Review of the Health Status and Activities of Daily Living (ADL) Evaluation for Resident #08 dated 04/28/25, revealed the resident was oriented to person and place, not capable of making decisions. The resident was independent with mobility, transferring, and toileting.

Review of the facility SRI dated 03/02/26, revealed on 02/28/26 at 9:32 P.M., a Resident Care Associate (RCA) called Assistant Director of Nursing (ADON) #305 reporting there was another RCA (#300) who was agitating a memory care resident (#08) by calling her names. ADON #305 called the Director of Nursing (DON) to notify her and the DON called the Executive Director (ED) #400. The DON and ADON #305 came to the community and questioned the alleged perpetrator (RCA #300), had her write a statement, and then escorted her off the campus and advised her not to return until contacted, pending an investigation. The DON and ADON #305 evaluated the resident for injury and no injuries nor distress were noted. Statements were obtained from the staff in the community, in which it was reported the RCA also pushed the resident. The physician and responsible party were notified of the incident. Upon completion of the investigation, the allegation of physical and verbal abuse was substantiated, and RCA #300 was terminated on 03/02/26 for verbal/physical abuse of the resident. RCA #300 was reported to the abuse registry. All staff were re-educated on the abuse, neglect, and misappropriation policy.

Review of witness statement undated and authored by ADON #305's, revealed on 02/28/26 at 9:32 P.M., she received a call from RCA #320, who explained there was an employee agitating a memory care resident. RCA #320 explained that the employee had called the resident names and the allegations were reported to her by the second staff member (RCA #315) who was working on the memory care unit that evening. ADON #305 states she first texted the second aide in memory care (RCA #315) and asked her to call when she was somewhere private and could talk. ADON #305 further stated she contacted the DON at 9:50 P.M. and called and spoke with LPN #310, to ensure the incident had been reported to her. ADON #305 stated she and the DON arrived at the building at 10:30 P.M. and pulled RCA #300 to the private dining room for questioning. RCA #300 stated Resident #08 called her an expletive and grabbed her. RCA #300 wrote a statement and was escorted to the memory care unit to collect her belongings and then escorted to the back door at 10:45 P.M. The DON and ADON #305 advised RCA #300 to not re-enter the building until she was contacted, pending an investigation. ADON #305 then spoke with RCA #315 regarding what she saw and heard and she explained she overheard RCA #300 call Resident #08 expletives and RCA #300 pulled up a picture of Resident #08's daughter-in-law on Facebook and was asking her who the person was and when Resident #08 did not answer, RCA #300 made comments about how Resident #08 was expletive stupid and must not care about her that much. RCA #315 reported RCA #300 was barking at Resident #08. Resident #08 then shoved RCA #300 and RCA #300 shoved her back and a shoving match followed. RCA #300 then stated she wished Resident #08 would croak and pointed at the resident and laughed. The DON and ADON #305 assisted the resident to the bathroom and checked for injuries; no injuries were noted. Resident #08 was pleasant and cooperative at that time. The DON and ADON #305 attempted to question Resident #08 regarding the incident; however, Resident #08 was unable to verbalize what transpired.

Review of the witness statement dated 02/28/26 and authored by RCA #315, reported battles between RCA #300 and Resident #08 reached an unsafe level and RCA #305 was verbally calling Resident #08 expletives and stated she couldn't wait for the resident to croak. RCA #315 noted RCA #305 and Resident #08 also had physical contact and RCA #305 had her hands around her lower arm and noted they were pushing each other. RCA #315 noted she went to RCA #320 multiple times over the frustration and RCA #320 reached out to upper management while trying to wait for a response of what to do next. Management arrived shortly after being contacted and RCA #300 was removed from the facility.

Review of the witness statement dated 02/28/26 and authored by RCA #320, revealed RCA #315 came to her about RCA #300 due to verbally abusing Resident #08. RCA #320 stated she went to the nurse on duty and called ADON #305.

During an interview on 03/12/25 at 9:45 A.M., the DON reported on the night of 02/28/26, she received a call from ADON #315, who reported she was notified of an incident of staff-to-resident abuse. The DON stated she came to the facility and, after removing RCA #300 from the building, completed a head-to-toe assessment on Resident #08. The DON stated Resident #08 seemed unphased and was unable to provide any information regarding the incident. The DON stated staff working that night was questioned and abuse education was sent out to all staff within 24 hours of the incident.

Review of the employee file of Caregiver #300 on 03/12/26 at 10:00 A.M., provided by the DON, revealed a hire date of 04/03/25 as an unlicensed caregiver. Caregiver #300 was terminated on 03/02/26 for a violation of policy/procedure when she was verbally and physically abusive to a memory care resident.

During an interview on 03/12/26 at 11:24 A.M. with Resident #08; however, the resident was unable to answer any questions appropriately nor provide any information related to the incident.

Review of two audio recordings with the DON on her phone on 03/12/26 at 11:46 A.M., revealed a female voice calling someone an expletive, followed by the same female voice saying you know who I wish would croak. Continued review revealed the same female voice saying who is this and she looked as scary as you do. The DON confirmed the female voice on the recording was RCA #300.

During an interview on 03/12/25 at 11:46 A.M., the DON stated RCA #300 was never alone with any residents once ADON #305 was notified of the incident and enroute to the facility. The DON stated RCA #300 was in the common area of the memory care unit between the time RCA #320 called ADON #305 and when the DON and ADON #305 arrived at the facility.

During an interview on 03/12/26 at 11:52 A.M., RCA #315 stated on the night of 02/28/26, RCA #300 seemed to be in a bad mood and was not herself. RCA #315 stated she observed RCA #300 call Resident #08 an expletive and couldn't wait for her to croak. RCA #315 stated, when RCA #300 said that to Resident #08, the resident looked at RCA #300 and asked if RCA #315 had just said that and RCA #315 verified she said it. RCA #315 stated she told the lead aid, RCA #320, who told LPN #310. RCA #315 stated she then went back to her duties and had Resident #10 in the air on a Hoyer lift, while obtaining her weight, when she observed RCA #300 and Resident #08 throwing things at each other and shoving each other. RCA #315 stated she told RCA #300 no, not. and redirected Resident #08 and told RCA #300 to go to the nurse station. RCA #315 stated she lowered Resident #10 into a safe position and left the unit to talk to RCA #320 and then LPN #310. RCA #315 stated RCA #320 then called ADON #305. RCA #315 stated she went back to the unit and she and RCA #300 started putting people in bed. RCA #315 estimated the DON and ADON #305 arrived approximately 45 minutes later and escorted RCA #300 off the premises. RCA #315 confirmed during the time between when she left the unit to talk to RCA #320 and LPN #310 and when the DON and ADON #305 arrived at the facility, RCA #300 continued to assist other residents with going to bed. RCA #315 confirmed she had audio recording of RCA #300 calling the resident expletives and saying she wanted her to croak, which she had shared with the DON. RCA #315 confirmed she did not intervene when RCA #300 was calling Resident #08 names.

During an interview on 03/12/26 at 12:09 P.M., LPN #310 stated she was at the medication cart near the common area on the assisted living unit when RCA #320 came and told her RCA #300 was verbally aggressive with Resident #08 and was irritating her. LPN #310 stated RCA #320 reported that she had already called ADON #305. LPN #310 stated ADON #310 called her and let her know she and the DON were on their way to the unit. LPN #310 confirmed she did not go to the memory care unit at that time. LPN #310 stated she did not go back to the memory care unit because she was tied up on the assisted living side. LPN #310 stated RCA #320 let her know later that RCA #300 was in the common area of the memory care unit and away from other residents. LPN #310 stated she did not go back to the memory care unit because she knew RCA #315 was back there keeping an eye on things and she understood RCA #300 was in the common area away from other residents, including Resident #08. LPN #310 stated, following completion of her medication pass, RCA #315 came to the nurse station and reiterated what was happening and played the video, where she could hear RCA #300 saying Resident #08 was expletive and she meant it and that she hoped resident #08 would die because she was so annoying. LPN #310 reported she was told RCA #300 and Resident #08 were shoving and grabbing each other. LPN #310 stated, while she was talking to RCA #315, RCA #320 was back on the memory care unit with RCA #300.

During an interview on 03/12/26 at 1:00 P.M., ADON #305 stated, on 02/28/26, she received a call from RCA #320 who said things were going on that were making her feel uncomfortable and said an aid was not being nice to a resident. ADON #305 stated she was on her way and verified she did not give RCA #320 any instructions on anything to do. ADON #305 stated she then sent RCA #315 a text message, asking her to go somewhere private and call her. ADON #320 stated RCA #315 called her, and she gave her instructions to keep an eye on RCA #300 and keep her away from Resident #08. ADON #305 stated she met the DON at the facility and went to the memory care unit and took RCA #300 to a non-clinical area, got her statement, escorted her back to the memory care unit to obtain her belongings, and then out of the facility. ADON #305 stated she conducted a skin assessment on Resident #08 but had no findings and then obtained staff statements. ADON #305 confirmed she should have told LPN #310 to go back to the memory care unit and ensure Resident #08 was safe and should have removed RCA #300 from the resident care areas.

During a follow-up interview on 03/12/26 at 1:30 P.M., the DON denied knowledge of RCA #300 continuing to work on the unit once becoming aware of the abuse concerns.

Review of the witness statement undated and authored by RCA #300's, revealed she washed her hands and was doing resident weights when Resident #08 grabbed her arm and was calling her expletives, and it was not the first time it had happened. RCA #300 stated she gave Resident #08 space to cool off. RCA #300 noted Resident #08 was being mean to RCA #315.

Review of the witness statement undated and authored by Licensed Practical Nurse (LPN) #310's, revealed she was completing a medication pass when RCA #320 came to let her know RCA #300 was verbally agitating/irritating Resident #08 and RCA #315 had a recording of it. RCA #320 stated she had already called ADON #305 and, as LPN #310 was going to call ADON #305, ADON #305 called her. LPN #310 stated she told ADON #305 what she knew about the situation, and LPN #310 told her she was aware RCA #300 was verbally agitating/irritating Resident #08 and RCA #315 had a recording of it. After completing her medication pass, LPN #310 stated she was in the nurse's station and RCA #315 came to the nurse's station and played a recording of RCA #300 described Resident #08 with expletives, and she meant it. RCA #315 stated RCA #300 stated she hoped Resident #08 would die because she was so sick of her. RCA #315 informed LPN #310 that RCA #300 and Resident #08 had been shoving and grabbing each other. LPN #310 noted RCA #315 was visibly upset talking about the situation she had reported and was visibly shaking while talking about it.

Review of the facility policy titled, Freedom from Abuse, Neglect, and Exploitation

Based on observation, staff interview, and review of the facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 53 residents.

Findings include:

Observation on 02/27/25 at 9:59 A.M. revealed the walk-in refrigerator located in the hallway contained the following items: open containers of chicken, watermelon, and carrots, a large tub of potatoes with a discard date of 02/24/25, a large container of pasta with a discard date of 02/25/25, a large container of peas with a discard date of 02/25/25, a container of tomato sauce with a discard date of 02/22/25, a large tub of beef with a discard date of 02/21/25, a large container of pancake mix with a discard date of 02/26/25, an undated container of pork, an undated container of corn and peas, an undated package of sliced cheese.

Observation on 02/27/25 at 10:15 A.M. revealed the dry food storage area contained the following items: undated and opened bags of peas, black beans, great northern beans, breadcrumbs, fry mix, and cereal, two undated loaves of raisin bread, three undated loaves of white bread, two undated packages of English muffins, two undated packs of hot dog buns.

Interview on 02/27/25 at 10:05 A.M. with Cook #10 confirmed the walk-in refrigerator contained multiple containers of foods stored beyond their discard date.

Interview on 02/27/25 at 10:06 A.M. with Dietary Staff (DS) #55 confirmed leftover foods should be labeled with the date they were prepared and discarded within three to seven days depending on the food item.

Interview on 02/27/25 at 10:20 A.M. with Cook #10 confirmed the dry food storage contained multiple items that were undated and unlabeled.

Review of the facility policy titled Food Storage, Labeling, and Dating revealed the food service department will wrap, cover, label, date, and store food in a safe, appropriate manner.

Based on medical record review, staff interview and review of the facility policy, the facility failed to document medication administration in the residents' medical record. This affected three (#7, #2 and #58) of three residents reviewed for medication administration. Facility census was 66.

Findings include

1. Review of the medical record for Resident #58 revealed an admission on 09/16/23 with diagnoses including but not limited to vascular dementia, psychotic disturbances, mood disturbances with anxiety, diabetes mellitus, and peripheral vascular disease.

Review of the Medication Administration Record (MAR) for Resident #58 for the month of August 2024 revealed the following medications were not documented as administered or refused: acetaminophen 500 milligrams (mg) two tablets every eight hours on 08/07/24 and 08/19/24; Divalproex delayed release two capsules at bedtime on 08/07/24 and 08/19/24; docusate sodium tablet on 08/19/24, doxepin 10 mg capsule at bedtime on 08/07/24 and 08/19/24; ferrous sulfate on 08/19/24; zinc oxide cream on 08/04/24, 08/07/24, 08/09/24 and 08/19/24; and oxycodone 08/15/24. 08/16/24, 08/17/24, 08/19/24, 08/25/24 and 08/26/24.

Review of the MAR for Resident #58 for the month of September 2024 revealed the following medications were no documented as administered or refused: acetaminophen 500 mg two tablets every eight hours on 09/05/24, 09/19/24 and 09/21/24; Divalproex delayed release two capsules at bedtime on 09/21/24; mirtazapine 30 mg at bedtime on 09/21/24; and zinc oxide cream on 09/09/24, 09/15/24 and 09/21/24.

Review of the MAR for Resident #58 for the month of October 2024 revealed the following medication were not documented as administered or refused: acetaminophen 500 mg two tablets every eight hours 09/12/24.

2. Review of the medication record for Resident #2 revealed an admission on 07/03/2023 with diagnoses including but no limited to cognitive impairment, hypertension, osteoarthritis, non compliance with medical treatment, and kidney disease.

Review of the MAR for Resident #2 for the month of September 2024 revealed the following medications were not documented as administered or refused: aspirin 81 mg daily 09/28/24, 09/29/24; B-complex vitamin B12 daily on 09/28/24 and 09/29/24; losartan potassium 25 mg one tablet daily on 09/28/24 and 09/29/24; Magnesium oxide 400 mg once daily on 09/28/24 and 09/29/24; multivitamin with minerals tablet daily on 09/28/24 and 09/29/24; Trazodone 50 mg tablet 1/2 tablet at bedtime 09/18/24;, and vitamin D3 2000 units one tablet daily on 09/28/24 and 09/29/24.

Review of the MAR for Resident #2 for the month of October 2024 revealed the following medications were not documented as administered or refused: aspirin 81 mg daily 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; B-complex vitamin B12 daily on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; losartan potassium 25 mg one tablet daily on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; Magnesium oxide 400 mg once daily on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; multivitamins with minerals tablet daily on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; Trazodone 50 mg tablet 1/2 tablet at bedtime on 10/05/24; and vitamin D3 2000 units one tablet daily on 10/11/24, 10/12/24 and 10/13/24.

3. Review of the medical record for Resident #7 revealed an admission on 08/13/24 with diagnoses including but not limited to chronic kidney disease, dementia, depression, hypertension, and peripheral vascular disease.

Review of the MAR for Resident #7 for the month of September 2024 revealed the following medication were not documented as administered or refused donepezil oral tablet 10 mg on 09/28/24 and 09/29/24; sertraline 50 mg daily on 09/18/24 and 09/21/24; and acetaminophen 650 mg two times a day on 09/18/24, 09/21/24, 09/28/24 and 09/29/24.

Review of the MAR for Resident #7 for the month of October 2024 revealed the following medications were not documented as administered or refused donepezil oral tablet 10 mg on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24; sertraline 50 mg daily on 10/05/24; and acetaminophen 650 mg two times a day on 10/05/24, 10/06/24, 10/11/24, 10/12/24 and 10/13/24.

Interview on 10/17/24 at 2:13 P.M. with Executive Director (ED) verified the medications were not documented as administered or refused and should have been for Resident #2, #7 and #58.

Review of the facility policy titled Medication Administration, undated revealed the facility nurses would maintain and accurate and up to date MAR.

This violation represents non-compliance investigated under Complaint Number OH00158231. This violation represents ongoing noncompliance from the survey dated 07/25/24.

Based on medical record review and staff interview, the facility failed to ensure that wound care and dressings were provided as physician ordered. This affected one (#58) of three residents reviewed for implementation of physician ordered treatments. The facility census was 66.

Findings include

Review of the medical record for Resident #58 revealed an admission on 09/16/23 with diagnoses including but not limited to vascular dementia, psychotic disturbances, mood disturbances with anxiety, diabetes mellitus, and peripheral vascular disease.

Review of the physician orders for Resident #58 revealed an order dated 08/31/24 for open blister to left heel, clean with normal saline and pat dry. Apply medihoney to wound bed and cover with non stick pad. Wrap with kerilex and change three times a week and as needed to be completed by the facility nurse. Call hospice for any extra supplies and if questions as needed for wound blister due as needed on the shift that it is needed and an order for foam dressing to right bunion area one time a day until healed for reddened area dated 08/06/24.

Review of the medication administration record (MAR) for Resident #58 for August 2024 revealed the dressing on the right bunion was not marked as completed or refused on 08/06/24, 08/08/24, 08/10/24, 08/11/24, 08/12/24, 08/13/24, 08/14/24, 08/15/24, 08/16/24, 08/17/24, 08/18/24, 08/19/24, 08/21/24, 08/22/24, 08/24/24, 08/25/24, 08/26/24, 08/29/24, 08/30/24, and 08/31/24.

Review of the physicians orders for Resident #58 revealed an order dated 09/03/24 and discontinued on 09/13/24 for wound orders as follows for all four wounds noted right heel, left heel, right lateral foot times two wounds. All orders are the same for each wound cleanse wound with wound cleaner paint periwound with bedadine swab. Cover wound with calcium alginate and cover calcium alginate with abdominal dressing (ABD) pad. Wrap loosely with kerlix to be completed by the facility nurse three times a week and as need for saturation or dislodgement, and order dated 09/13/24 for right heel, right lateral foot times two, left heel. Cleanse wounds with wound cleanser. Pat dry. Paint periwound with betadine swab, cover with calcium alginate and cover with ABD pad, wrap loosely with kerlix every night she for wound care and an order dated 09/18/24 for Flagyl 250 milligram (mg) one tablet, make a slurry and paint left heel wound, do this to wound bed three times a week on Monday, Wednesday and Friday to be completed by the hospice nurse (document that the hospice did).

Review of the MAR for Resident #58 for September 2024 revealed the dressing on the right bunion was not marked as completed or refused on 09/01/24, 09/02/24, 09/05/24, 09/07/24, 09/08/24, 09/09/24, 09/12/24, 09/14/24, 09/15/24, 09/16/24, 09/19/24, 09/21/24, 09/22/24, 09/23/24, 09/26/24, 09/27/24, 09/28/24, and 09/29/24. Further review revealed no treatment was completed for the open blister to left heel on the MAR until 09/06/24. Additionally, the MAR was silent for documentation that Resident #58 received or refused treatment to the left heel on 09/09/24 and 09/12/24 as ordered.

Review of the MAR for Resident #58 for October 2024 revealed the dressing to the right bunion was not marked as completed or refused on 10/03/24, 10/04/24, 10/06/24, 10/10/24 and 10/12/24.

Interview on 10/17/24 at 2:13 P.M. with Executive Director (ED) verified the Resident #58's left heel treatment was omitted from the initial order when it was put in to the electronic health record on 09/03/24. The ED also verified the electronic health record was silent for refusals or completed treatment to the left heel on 09/09/24 and 09/12/24. Additionally, the ED verified the October 2024 MAR did not have documentation that the treatment to the right bunion was completed or refused on 10/03/24, 10/04/24, 10/06/24, 10/10/24 and 10/12/24 and should have.

This deficiency represents non-compliance investigated under Complaint Number OH00158231.

Based on observations, staff interviews and policy review, the facility failed to ensure water temperatures used to wash the facility dishes were within the recommended parameters of the dishwasher. Additionally, the facility failed to store and date food in a manner to protect against contamination and spoilage. The had the potential to affect all 66 residents residing in the facility. The facility census was 66.

Findings include:

1. Observations on 10/17/24 at 9:02 A.M. of the kitchen's with Dietary Manager revealed the following concerns: in the facility walk in cooler a bag of feta cheese opened and undated; a bag of Mozzarella shredded cheese open and undated; and a package of thawed opened and updated ground beef with one end twisted closed but dripping red colored liquid place on the bottom shelf of a four wheeled cart in the refrigerator.

Interview on 10/17/24 at 9:06 A.M. with the Dietary Manager confirmed the items were not dated and should be.

2. Observation on 10/17/24 at 9:10 A.M. of the facility's dishwasher revealed a plaque adhered to the dishwasher stating the recommended the minimum temperature for dishwashing was one hundred and twenty degrees to one hundred forty degrees.

Observation at 10/17/24 at 9:15 A.M. of the dishwasher cycle revealed the dishwater temperature was one hundred degrees Fahrenheit (F) for washing and one hundred and ten degrees F for the rinse cycle.

Interview on 10/17/24 at 9:20 A.M. with Dietary Manager revealed the dishwasher was a low temperature dishwasher and the chemicals used during the operation of the dishwasher were effective in the disinfecting process.

Interview on 10/17/24 at 11:45 A.M. with the Repair Man #150 for the dishwasher stated the unit does not have the capability to heat water to the correct temperature. Repair Man #150 verified the water should be between one hundred and twenty degrees F and one hundred and forty degrees F to be in a safe temperature range. Repair Man #150 advised the facility that there is a temperature booster that could be added to ensure the water temperatures were in the safe range.

Interview on 10/17/24 at 2:00 P.M. with the Executive Direct verified the dishwasher was not operating in the safe temperature range recommended for appropriate disinfecting cycles. The facility confirmed all 66 residents receive their meals from the kitchen.

Request for the policy related to the operation of the facility dishwater temptress was made during the survey and not provided for review.

Review of the facility policy titled Proper Food Storage, undated revealed the facility would prevent food borne illnesses, minimize food waste and uphold high standards of resident care and safety. All food was to be clearly labeled with the date of receipt and use by date. Staff should store items in airtight, moisture resistant packaging based on state of Ohio regulations and manufacturer recommendations.

This violation represents non-compliance investigated under Complaint Number OH00158231. This violation represents ongoing noncompliance from the survey dated 07/25/24.

Based on medical record review, staff interview and review of the facility policy, the facility failed to document medication administration in the residents' medical record. This affected two (Residents #10 and #12) of three residents reviewed for medication administration. The facility census was 63 residents.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date to the of 11/26/21 with diagnoses including obstructive sleep apnea, anxiety disorder, major depression and squamous cell carcinoma of skin.

Review of Medication Administration Record (MAR) for Resident #10 dated July 2024 revealed the following medication doses were not documented as administered or refused: carvedilol 6.25 milligram (mg) at bedtime on 07/06/24, 07/12/24,07/17/24, insulin glargine 8 units subcutaneously at bedtime on 07/06/24, 07/12/24, 07/17/24, levothyroxine 150 micrograms (mcg) in the morning on 07/04/24, 07/05/24. 07/06/24, 07/07/24,07/08/24, 07/11/24, 07/12/24, 0713/24, 07/14/24, 07/15/24, 07/16/24, Metformin 500 mg in the evening on 07/05/24, 07/06/24, 07/06/24, 07/12/24, 07/17/24 07/19/24, 07/20/24, losartan potassium 25 mg at bedtime on 07/06/24, 07/12/24, 07/17/24 07/19/24 and 07/20/24, trazodone 100 mg at bedtime for 07/06/24, 07/12/24, 07/17/24, 07/19/24, 07/20/24, artificial tears ophthalmic solution instill 1 drop in both eyes at bedtime for 07/06/24, 07/12/24, 07/17/24 07/19/24, 07/20/24, pramipexole tab 0.25 mg at bedtime for 07/06/24, 07/12/24, 07/17/24 07/19/24, 07/20/24, Xanax Oral tablet 0.5 mg at bedtime for07/06/24, 07/12/24, 07/17/24 07/19/24 and 07/20/24.

2. Review of the medical record for the Resident #12 revealed an admission date of 01/27/20 with diagnoses including major depression disorder, dysphasia, schizophrenia and cognitive communication deficit.

Review of the MAR for Resident #12 dated July 2024 revealed the following medication doses were not documented as administered or refused: Ingrezza 80 mg at bedtime on 07/06/24 , 07/12/24, 07/17/24, Pantoprazole tab 40 mg in the morning on 07/07/24, 07/13, 07/14/24, 7/16/24, 07/18/24, 07/19/24, 07/20/24,07/21/24, 07/22/24, aripiprazole tab 30 mg in the morning on 07/07/24, 07/08/24, 07/11/24, 07/13/24, 07/16/24, 07/18/24, 07/21/24, 07/22/24, carbamazepine tab 200 mg at bedtime on 07/06/24, 07/12/24, 07/17/24 , 07/20/24, 07/21/24, finasteride tab 5 mg at bedtime on 07/06/24, 07/12/24, 07/17/24, 07/20/24, furosemide tab 10 mg in the morning on 07/07/24, 07/08/24, 07/11/24, 07/13/24, 07/16/24, 07/18/24, 07/21/24, 07/22/24, loratadine tab 10 mg in the morning on 07/07/24, 07/08/24, 07/11/24, 07/13/24, 07/16/24, 07/18/24, 07/21/24, 07/22/24, paroxetine tab 20 mg one tablet by mouth once daily at HS 07/05/24, 07/12/24, 07/17/24. 07/20/24, 07/21/24, Simvastatin 20 mg in the morning on 07/05/24, 07/06/24, 07/07/24 07/11/24, 07/13/24, 07/14/24, 07/16/24, 07/17/24, 0718/24, 07/19/24, 07/20/24, 07/21/24, 07/22/24, 07/22/24, trazadone 50 mg at bedtime on 07/06/24, 07/12/24, 07/17/24, 07/20/24, 07/24/24.

Interview on 07/25/24 at 12:30 P. M. with the Director of Nursing (DON) confirmed Resident #10 and Resident #12 MARs were blank for multiple doses of the medication doses and it did not indicate if the residents received or refused medications. The DON further confirmed all doses of medication must be documented in the residents' MARs.

Interview on 07/25/24 at 2:24 P.M. by telephone with Licensed Practical Nurse (LPN) #131 confirmed she worked day shift and there were days she had not documented medication administration for Residents #10 and #12.

Interview on 07/25/24 at 3:30 P.M. by telephone with LPN #140 confirmed on 07/06/24, 07/12/24, 07/13/24, 07/14/24, 07/17/24 and 07/20/24 she did not have her employee badge which is needed to document medication administration. LPN #140 confirmed she had not documented medication administration for Residents #10 and #12.

Review of the facility policy titled Medication Administration undated revealed the facility nurses would maintain an accurate and up to date MAR.

Based on observation, staff interview and review of the facility policy, the facility failed to store and date food in a manner to protect against contamination and spoilage. This had the potential to affect all residents residing in the facility. The census was 63 residents.

Findings include:

1.Observation on 07/24/24 at 8:17 A. M. of the kitchen's dry storage area with Cook #105 revealed the following concerns: a five-pound bin of powdered sugar undated with the lid open, a plastic bin of dried cranberries with the lid open, a ten-pound bag of chocolate chips undated and unsealed, a large box of panko breadcrumbs open to the air, unsealed, and not dated, a large barrel of maple syrup undated with syrup covering the lid of the barrel and dripping down the sides.

Interview on 07/24/24 at 8:27 A.M. with Cook #105 confirmed the items in the dry storage area should be properly sealed or covered to prevent spoilage and the items should be dated when opened.

2. Observation on 07/24/24, at 8:53 A. M. of the walk-in cooler with Dietary Manager (DM) #100 revealed the following concerns: two open undated packs of block cheese, a bag of sliced cheese undated, unsealed and open to air, a cart with two 10-gallon pots of soup uncovered and undated.

Interview on 07/24/24 at 9:04 A.M. with DM #100 confirmed the soup was made the day before and should have been covered and dated. DM #100 further confirmed the cheeses should have been properly sealed and dated.

Review of the facility policy titled Proper Food Storage undated revealed the facility would prevent food borne illnesses, minimize food waste and uphold high standards of resident care and safety. All food was to be clearly labeled with date of receipt and use by date. Staff should store items in airtight, moisture resistant packaging based on state of Ohio regulations and manufacturer recommendations.

This violation represents noncompliance investigated under Complaint Number OH00155944.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to prevent resident elopements. This affected one (Resident #12) of 14 residents who resided in the facility's secured unit. The facility census was 63 residents.

Findings include:

Review of the medical record for Resident #12 revealed an admission date of 11/14/19 with diagnoses including dementia, atherosclerosis, unspecified atrial fibrillation, mood disorder and anxiety disorder.

Review of the care plan for Resident #12 undated revealed the resident was at elopement risk, was a wanderer, was actively exit-seeking, disoriented to place, had impaired safety awareness and a history of wandering in the last 90 days. Interventions included the following: staff to attempt to engage in pleasant, meaningful, purposeful enjoyable activities when episodes of wandering occur, distract resident by offering pleasant diversions, structured activities, food, conversation, television, books.

Review of the elopement risk assessment for Resident #12 dated 11/26/23 revealed the resident was at high risk for elopement.

Review of the progress note for Resident #12 dated 06/27/24 revealed the resident exited the front entrance doors following another resident's family member, unattended by staff. Staff caught up to the resident near the facility driveway by the road. Resident stated he wanted to go to the dollar store two businesses down the road. Staff was able to guide Resident #12 back to the facility.

Review of the incident report for Resident #12 dated 07/03/24 revealed the resident exited the B hall exit door to the outside sounding the alarm. Resident #12 was confused and told the caregiver he was going to Columbus, Ohio. Staff were ordered to maintain observation on Resident #12 to reduce the risk of further elopement.

Review of the progress note for Resident #12 dated 07/12/24 revealed a resident from the assisted living told the nurse there was a resident outside. Staff searched for Resident #12 and found him at the dollar store two doors down from the facility with his walker. Licensed Practical Nurse (LPN) #120 got into her vehicle and drove to the store to escort the resident back to the facility. The physician was notified but no orders were given to prevent further elopements.

Review of the physician's orders for Resident #12 revealed an order dated 07/24/24 for the resident to move to the secured unit of the facility.

Interview on 07/24/24 at 11:56 A. M. with LPN #120 confirmed Resident #12 had eloped a couple times. LPN #120 confirmed on 07/12/24 she was notified Resident #12 was outside, unattended and off the premises. LPN #120 confirmed she got into her vehicle and picked him up at the dollar store and brought him back to the facility.

Interview on 07/24/24 at 12:15 P. M. with the Director of Nursing (DON) confirmed Resident #12 had elopements on 06/27/24, 07/03/24, and 07/12/24. The DON further confirmed the facility did not implement interventions to prevent future elopements following his elopement on 07/12/24. The DON confirmed the facility and physician felt the resident would be appropriate for placement on the secured memory care unit, but the resident's representative had refused this intervention. The DON confirmed the physician's order to move Resident #12 to the secured unit was given by the doctor on 07/24/24 after the survey had been entered.

Review of the facility policy titled Abuse, Neglect of Residents/Misappropriation of Resident Property dated 08/24/20 revealed the facility was committed to a safe environment for each resident, visitor and employee.

This violation represents noncompliance investigated under Complaint Number OH00155944.