Inn at Belden Village The

Based on observation, interview, and policy review, the facility failed to ensure food was properly stored, expired or spoiled items were timely discarded, and food temperatures were routinely monitored. This had the potential to affect all residents in the facility. The facility census was 85.

Findings include:

Observation on 07/10/25 at 9:15 A.M. revealed the small kitchen fridge contained expired lactose free milk dated 06/19/25, sour cream dated 07/07/25, and cocktail sauce dated 05/25/25. The fridge contained multiple salad dressing bottles with no open dates.

Interview on 07/10/25 at 9:15 A.M. with Dietary Manager #200 verified the findings at the time of observation.

Observation on 07/10/25 at 9:25 A.M. revealed the kitchen storage room contained multiple cereals unlabeled and undated. There was a creamy substance in a storage bag without a label or date. There was a paper bag of bread crumbs with a moisture spot on the bag and a paper bag of corn meal stored on a shelf next to chemicals. There was a scoop stored in the flour bin.

Interview on 07/10/25 9:31 A.M. with Dietary Manager #200 verified cereal should be dated. Dietary Manager #200 was unaware of what the creamy substance was and discarded the item. Dietary Manager #200 verified food should not be stored by chemicals. Dietary Manager #200 confirmed the scoop was in the flour bin and verified the scoop is normally stored inside the flour bin. Dietary Manager #200 reported the kitchen storage was normally different, but the facility was currently storing the neighboring church's food inventory.

Observation on 07/10/25 at 9:33 A.M. revealed the large kitchen fridge contained expired seafood base dated 11/15/24. The large kitchen fridge additionally contained hot dogs, moldy pepperoni, and lunch meat with no date or label.

Interview on 07/10/25 at 9:50 A.M. with Dietary Manager #200 verified the expired food in the large kitchen fridge. Dietary Manager #200 stated all foods should be dated and labeled.

Observation on 07/10/25 at 11:33 A.M. of lunch service revealed Dietary Manager #200 could not find the thermometer to check the temperatures of food. Dietary Manager #200 went to the store to purchase a thermometer. Dietary staff continued to serve lunch without first checking the temperatures the food items.

Interview on 07/10/25 at 11:50 A.M. with Dietary Manager #200 confirmed no food temperatures were taken that day due to the facility not having a thermometer. Dietary Manager #200 could not locate temperature logs for 2025. The only food temperature logs available were from 2024.

Review of the facility's policies on storage and food temperature, undated, revealed food should be stored in a sanitary container, covered, labeled, dated, and stored appropriately. The policy additionally stated the temperatures of the food items will be taken and properly recorded on the food temperature check log.

Based on record review, interview, review of the facility investigation and facility policy, the facility failed to ensure Resident #7's call light was answered in a timely manner. This finding affected one resident (#7) of four residents reviewed for staffing and call light response. The facility census was 88.

Findings include:

Review of Resident #7's medical record revealed the resident was admitted on 09/27/24 with diagnoses including essential hypertension, personality disorder and fibromyalgia.

Review of Resident #7's Mental Status Questionnaire dated 12/30/24 revealed the resident exhibited intact cognition.

Review of Resident #7's Service Plan Functional Assessment dated 12/30/24 revealed the resident was independent for bathing, denture care, hand and nail care, toileting and/or continence care, independent with operating the call light system and independent for dressing and grooming including brushing the hair, washing the face and brushing the teeth.

Interview on 01/13/25 at 8:23 A.M. with the Executive Director (ED) indicated Resident #7 reported a long call light response time on 12/18/24 and it was investigated. She stated she put in new interventions in place including ordering walkie talkies for staff. She stated the reason the call light response was longer than usual was because the facility had a gastrointestinal virus going around for residents and staff, and staff were involved with the other residents when Resident #7's call light went off.

Review of the Call History form dated 12/18/24 revealed Resident #7's call time was reported on 12/17/24 at 7:21 A.M. and cancel time was reported on 12/17/24 at 7:50 A.M. for a total wait time of 28 minutes; on 12/17/24 at 10:10 A.M. and cancel time on 12/17/24 at 10:34 A.M. for a total wait time of 23 minutes; on 12/18/24 at 6:26 A.M. and cancel time on 12/18/24 at 6:32 A.M. for a total wait time of five minutes; and on 12/18/24 at 7:12 A.M. and cancel time on 12/18/24 at 7:51 P.M. for a total wait time of 38 minutes.

Interview on 01/13/25 at 8:38 A.M. with Resident #7 stated he felt he was discriminated against because he was not in a wheelchair. He stated that on 01/01/25, his call light response was over an hour, and he was not provided care timely. Resident #7 stated he called the police department.

A second interview on 01/13/25 at 9:50 A.M. with the ED confirmed Resident Care Associate (RCA) #819 usually worked on the secured memory care unit (SMCU) but was working a double shift on 01/01/25 and forgot to change her phone program from the SMCU to the general assisted living. The ED indicated RCA #819 was unaware Resident #7's call light was going off for approximately one hour. The ED confirmed RCA #819 and Licensed Practical Nurse (LPN) #820 was reprimanded for not answering Resident #7's call light timely. She confirmed RCA #819 and LPN #820 received a verbal reprimand as they had not had any previous care concerns identified.

Telephone interview on 01/13/25 at 10:15 A.M. with Sheriff Office #821 indicated the police responded to a report from Resident #7 that his call light was not answered timely. She stated the police office took the report and left. No other information was noted in the report.

Review of the call history report dated 01/01/25 revealed Resident #7's call time was on 01/01/25 at 7:25 A.M. and the cancel time was on 01/01/25 at 8:55 A.M. for a call light response time of 90 minutes (the facility call history report inaccurately states one hour).

Review of the undated Investigation Summary form revealed on 01/01/25, the ED was informed by the receptionist that Resident #7 had a one-hour call light wait time from 7:14 A.M. to 7:28 A.M. he had called the police department. (The investigation contradicts the call history report of 7:25 A.M. to 8:55 A.M.) and The ED had informed the receptionist to verify the concern, and it was verified. The ED instructed the receptionist to contact LPN #820 to call the ED immediately and to call RCA #819 to find out the reason for the long response time. RCA#819 had reported that she did not have the call light app open on her phone and was verbally counseled as this was her first offense. Both LPN #820 and RCA #819 agreed to watch all call lights closely throughout the day. and all other staff members were educated as well.

Review of the undated Call Light policy revealed the purpose was to respond promptly to a resident's call for assistance and to assure the call system was in proper working order.

This violation represents non-compliance investigated under Master Complaint Number OH00160994.

Based on record review and interview, the facility failed to report an outbreak of nausea, vomiting, and diarrhea to the local health department. This finding affected 31 Residents (#6, #10, #11, #13, #17, #24, #25, #26, #27, #29, #30, #32, #34, #37, #39 #43, #46, #47, #56, #58, #59, #65, #68, #70, #73, #74, #75, #76, #78, #84, #90) and had the potential to affect the 88 residents residing in the facility.

Findings include:

Interview on 01/13/25 at 11:58 A.M. with the Director of Nursing (DON) revealed 31 residents including Residents #6, #10, #11, #13, #17, #24, #25, #26, #27, #29, #30, #32, #34, #37, #39 #43, #46, #47, #56, #58, #59, #65, #68, #70, #73, #74, #75, #76, #78, #84, #90 and 20 staff members including Resident Care Assistants (RCAs) #807, #823, #824, #825; LPNs #826, #827, #829, #830; Assistant Director of Nursing (ADON) #828; the DON; Human Resources (HR) Assistant and Nurse Scheduler #831; Business Director #832; Marketing Director #833; Housekeeping Director #834; Receptionist #835; Dietary Servers #812, #836, #837, #838, #839 had gastrointestinal symptoms including nausea, vomiting, and diarrhea between 12/12/24 and 12/24/24. The DON confirmed she had prior infection control education for her previous employment. She also confirmed she did not call the local health department to report the gastrointestinal outbreak as required. The DON denied any residents were hospitalized or died because of the gastrointestinal outbreak.

Interview on 01/13/25 at 12:16 P.M. with the Executive Director and the DON of Local Health Department #822 revealed the facility should have reported an outbreak of gastrointestinal symptoms of 31 residents and 20 staff members.

Review of the undated Infection Prevention and Control Guidelines indicated the infection prevention control designee would be a registered nurse with experience in infection control, would be the infection control designee, overseeing the implementation and training of the facility's infection prevention control policy and procedure including collaboration with and at the direction of the local public health authority.

This violation represents non-compliance investigated under Complaint Number OH00160902.

Based on record review and interview, the facility failed to transmit or validate the receipt of an alarm signal during all fire drills as required. In addition, the facility failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift. This had the potential to affect all 88 residents residing in the facility.

Findings include:

Review of the facility fire drill records for the drills conducted between August 2023 and July 2024 revealed there was no evidence residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility during any of the drills conducted during the third shift.

Further review of the fire drill records revealed there was no evidence the facility verified receipt of the alarm with the alarm company for the fire drills conducted on 12/06/23, 02/29/24, 03/28/24, and 07/28/24.

On 08/08/24 at 5:08 P.M., an interview with the Executive Director verified the facility failed to ensure resident evacuations to safe areas or to the exterior of the facility were completed as required during the third shift fire drills and also verified the missing verifications for receipt of the alarm.