Fairborn Assisted Living

Based on observations and interviews, the facility failed to ensure the dishwasher was functioning at the appropriate temperature. This had the potential to affect all 71 residents residing in the facility who receive food from the kitchen.

Findings include:

Observation on 04/08/25 at 9:04 A.M. of the dishwasher revealed it was a high temperature machine. The label indicated the wash temperature should be 160 degrees Fahrenheit (F) and 180 degrees F for the rinse cycle. The gauge indicated the wash temperature only reached 130 degrees F. Dining Service Director (DSD) #29 verified the wash temperature was 130 degrees F at the time of the observation. DSD #29 stated she would contact the dishwasher company and staff would utilize the three-compartment sink.

Observation on 04/08/25 at 5:00 P.M. of the dishwasher revealed the wash temperature continued to only reach 130 degrees F, which was confirmed by DSD #29.

Based on policy review, staff interview, and observation, the facility failed to make accommodations for residents who smoke outdoors and failed to ensure smoking materials were disposed of properly. This had the potential to affect the 71 residents residing in the facility.

Findings include:

Observation on 04/08/25 at 11:45 A.M. revealed the facility designated smoking area was open with no covering and has one bench.

Observation on 04/08/25 at 11:50 A.M. revealed two plant holders next to the facility's main entrance with multiple cups and trash with smoking materials inside.

Interview on 04/08/25 with the Director of Nursing (DON) #9 confirmed they do not have a covered designated smoking area.

Interview on 04/08/25 with the Business Office Manager (BOM) #7 confirmed the waste and smoking materials combined in both plant holders.

Review of the facility's policy titled Smoke Free Environment and Electronic Cigarettes revealed it stated all leftover smoking materials must be placed in a fire-resistant receptacle.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure resident choices were provided during a meal service. This affected two (#75 and #73) of seven residents observed during meals. The census was 77.

Findings include:

1. Review of the medical record for Resident #75 revealed an admission date of 12/29/22. Medical diagnosis included dementia.

Review of the care plan dated 07/18/24 for Resident #75 revealed she was able to make safe judgements and function appropriately in social situations. She could make her needs understood.

During an observation on 11/12/24 at 11:20 A.M. revealed Resident #75 asked for a cup of coffee with her lunch meal and Resident Care Associate (RCA) #85 stated there was not any available. Observation of the kitchen counter at the same time revealed there was an oversized dispenser used for coffee.

Interview with RCA #85 on 11/12/24 at 11:54 A.M. confirmed Resident #75 asked for coffee, but the coffee dispenser on the counter top was from the night before and she did not ask anyone to get coffee for the resident.

2. Medical record review for Resident #73 revealed and admission date of 05/10/24. Medical diagnosis included dementia.

Review of Resident #73's care plan dated 08/02/24 revealed she was able to make safe judgements and function appropriately in social situations. She could make needs understood.

During an observation of Resident #73 on 11/12/24 at 11:25 A.M. revealed the resident complained to RCA #85 that she did not like the rice or pork on her plate for lunch. RCA #85 did not offer a substitute for the meal.

Interview with Resident #73 on 11/12/24 at 11:42 A.M. revealed she did not like the rice or pork that were served for lunch, and was not able to get a substitute. The resident stated if a resident complained about the meal the staff act like the residents should eat the meal and not complain about it.

Interview with RCA #85 on 11/12/24 at 11:55 A.M. confirmed she did not ask Resident #73 if she wanted a substitution. RCA #85 confirmed a substitution could not be provided because the kitchen does not answer the phone, and confirmed Resident #73 was not offered a substitution.

This violation represents non-compliance investigated under Complaint Number OH00158931.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide effective pain management during resident transfers. This affected one (#3) of one residents reviewed for pain. The census was 77. Findings include: Medical record review for Resident #3 revealed an admission date of 02/26/24. Medical diagnoses included unspecified dementia and cervical disc disorder. Review of the care plan dated 08/01/24 revealed Resident #3 makes safe judgments and functions appropriately in social situations. He can make himself understood. The care plan also revealed the resident has pain and to notify the nurse if pain persists or the resident verbalizes a new complaint of pain. Review of Resident #3's physician order dated 08/15/24 revealed an order for the narcotic pain medication Tramadol with instructions to give 50 milligrams (mg) every six hours as needed for moderate pain associated with connective tissue and disc stenosis of the intervertebral foramina of lumbar region. Review of Resident #3's November 2024 medication administration record (MAR) revealed Tramadol was administered for pain on 11/01/24 and 11/06/24. During an observation of a mechanical (Hoyer) lift transfer on 11/12/24 at 2:57 P.M. revealed Resident Care Associate (RCA) #111 and Medication Technician (MT) #107 placed the Hoyer lift fasteners to the sling that was underneath Resident #3, and lifted him up to place him in the bed. During the transfer the resident was grimacing and stated, Oh God. Oh God. RCA #111 and MT #107 acknowledged the resident and continued to place him in the bed. Continued observation on 11/12/24 at 2:57 P.M. revealed RCA #111 and MT #107 exchanged the Hoyer lift sling and secured a different sling to the Hoyer lift equipment. When the staff lifted the resident to transfer to him to the wheelchair, Resident #3 grimaced and stated, Oh God. Oh God. Resident #3's eyes were watering at that time. The two staff members continued to acknowledge the resident, told him the transfer was almost over, and placed him in his wheelchair. At no time did RCA #111 or MT #107 ask Resident #3 if they should stop the transfer, get pain medications, or offer another intervention to comfort the resident. Interview with the RCA #111 and MT #107 on 11/12/24 at 3:10 P.M. stated Resident #3 had chronic pain in his back. Both staff members stated the resident had pain every time they lift him into the Hoyer sling and moved him to the bed and back to the chair. RCA #111 and MT #107 stated they did not report the resident's pain to anyone, and confirmed they did not ask him if he needed something for pain. During an interview with the Director of Nursing (DON) on 11/12/24 at 3:17 P.M. revealed no staff member reported Resident #3's pain to her. Interview with Resident #3 on 11/12/24 at 3:17 P.M. revealed he has been at the facility for two months and has a lot of pain when the staff transfer him with the Hoyer lift. Resident #3 stated he would like pain medication before Hoyer lift transfers but the staff do not offer him pain medication. Review of the undated policy titled, Resident Bill of RightsBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide effective pain management during resident transfers. This affected one (#3) of one residents reviewed for pain. The census was 77.

Findings include:

Medical record review for Resident #3 revealed an admission date of 02/26/24. Medical diagnoses included unspecified dementia and cervical disc disorder.

Review of the care plan dated 08/01/24 revealed Resident #3 makes safe judgments and functions appropriately in social situations. He can make himself understood. The care plan also revealed the resident has pain and to notify the nurse if pain persists or the resident verbalizes a new complaint of pain.

Review of Resident #3's physician order dated 08/15/24 revealed an order for the narcotic pain medication Tramadol with instructions to give 50 milligrams (mg) every six hours as needed for moderate pain associated with connective tissue and disc stenosis of the intervertebral foramina of lumbar region.

Review of Resident #3's November 2024 medication administration record (MAR) revealed Tramadol was administered for pain on 11/01/24 and 11/06/24.

During an observation of a mechanical (Hoyer) lift transfer on 11/12/24 at 2:57 P.M. revealed Resident Care Associate (RCA) #111 and Medication Technician (MT) #107 placed the Hoyer lift fasteners to the sling that was underneath Resident #3, and lifted him up to place him in the bed. During the transfer the resident was grimacing and stated, Oh God. Oh God. RCA #111 and MT #107 acknowledged the resident and continued to place him in the bed.

Continued observation on 11/12/24 at 2:57 P.M. revealed RCA #111 and MT #107 exchanged the Hoyer lift sling and secured a different sling to the Hoyer lift equipment. When the staff lifted the resident to transfer to him to the wheelchair, Resident #3 grimaced and stated, Oh God. Oh God. Resident #3's eyes were watering at that time. The two staff members continued to acknowledge the resident, told him the transfer was almost over, and placed him in his wheelchair. At no time did RCA #111 or MT #107 ask Resident #3 if they should stop the transfer, get pain medications, or offer another intervention to comfort the resident.

Interview with the RCA #111 and MT #107 on 11/12/24 at 3:10 P.M. stated Resident #3 had chronic pain in his back. Both staff members stated the resident had pain every time they lift him into the Hoyer sling and moved him to the bed and back to the chair. RCA #111 and MT #107 stated they did not report the resident's pain to anyone, and confirmed they did not ask him if he needed something for pain.

During an interview with the Director of Nursing (DON) on 11/12/24 at 3:17 P.M. revealed no staff member reported Resident #3's pain to her.

Interview with Resident #3 on 11/12/24 at 3:17 P.M. revealed he has been at the facility for two months and has a lot of pain when the staff transfer him with the Hoyer lift. Resident #3 stated he would like pain medication before Hoyer lift transfers but the staff do not offer him pain medication.

Review of the undated policy titled, Resident Bill of Rights

Based on observations, staff interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect all 73 residents residing in the facility. residents. The facility census was 73. Findings include Observation of the kitchen on 08/22/24 at 10:30 A.M. to 10:55 A.M. with Cook #83, revealed the walk-in refrigerator had a container of peas and carrots mixture that was undated, two 1/2 gallons of milk expired on 08/21/24, a large box of potatoes (over 20 potatoes) was undated, eight pitchers of orange juice, lemonade, and fruit punch were undated and a dish of individually wrapped muffins approximately 25 were undated. The walk-in refrigerator had documented as being over temperature several days in the last month. Observation and review of the walk-in refrigerator log dated 07/30/24 to 08/22/24 revealed temperatures were taken twice daily and found numerous entries over 41 degrees Fahrenheit (F). The walk-in freezer contained four bags of meatballs that were undated and unlabeled, a packet of unidentified meat was undated, and the bread was undated. Observation and review of the walk-in freezer log dated 07/30/24 to 08/22/24, revealed temperatures were taken twice daily and found numerous entries over zero degrees F. Interview with Cook #83 at the same time confirmed the findings related to food storage. Cook #83 stated the expired milk was served at breakfast and was scheduled to be served during the lunch tray service. Cook #83 confirmed the temperatures listed on the logs and stated the walk-in refrigerator temperature should be kept at 41 degrees F or below and the freezer should be maintained below zero degrees F or below. Review of the walk-in refrigerator log hanging outside the walk-on refrigerator revealed the following: a) On 08/01/24 the morning temperature was recorded as 42 degrees F. b) On 08/02/24 the evening temperature was recorded as 42 degrees F. c) On 08/03/24 the morning temperature was recorded as 45 degrees F. ) On 08/04/24 the morning temperature was recorded as 45 degrees F. e) On 08/05/24 the morning temperature was recorded as 44 degrees F. f) On 08/06/24 the evening temperature was recorded as 42 degrees F. g) On 08/08/24 the morning temperature was recorded at 45 degrees and the evening temperature was recorded as 42 degrees F. h) On 08/09/24 the morning temperature was recorded as 45 degrees F. i) On 08/13/24 the morning temperature was recorded as 45 degrees F. j) On 08/15/24 the morning temperature was recorded as 42 degrees, and the evening temperature was recorded at 42 degrees F. k) On 08/17/24 the morning temperature was recorded as 45 degrees F. l) On 08/18/24 the morning temperature was recorded at 42 degrees F, and the evening temperature was recorded as 45 degrees F. m) On 08/19/24 the morning temperature was recorded at 43 degrees F, and the evening temperature was recorded as 42 degrees F. n) On 08/20/24 the morning temperature was recorded as 42 degrees F. Review of the walk-in freezer log hanging outside the freezer revealed the following: a) On 08/12/24 the morning temperature was recorded as three degrees F. b) On 08/13/24 the morning temperature was recorded as four degrees F. c) On 08/14/24 the morning temperature was recorded as two degrees F. ) On 08/16/24 the morning temperature was recorded as one degree F. e) On 08/17/24 the morning temperature was recorded as two degrees F, and the evening temperature was recorded as 10 degrees F. Observation of tray line on 08/22/24 at 11:15 A.M., revealed Cook #83 took holding temperatures of the hot food items. The sloppy joe mixture had a temperature of 122 degrees F. Cook #122 continued to serve and stated she was unsure if she should put the food back in the oven or hot box to reheat it. The food was left on the steam table and plates continued to be served without rewarming the food over 135 degrees F. Interview on 08/22/24 at 11:40 A.M. with Executive Director (ED) revealed the kitchen staff were recently trained by Registered Dietician #81 which included food storage, and the food temperatures. The ED revealed staff had not brought up any issues related to the temperatures in the walk-in refrigerator and freezer not maintaining safe temperatures. Interview on 08/22/24 at 1:35 P.M. with RD #81 revealed she completed training with the staff on food storage and the temperatures and they should know how to respond when food did not get to the correct temperatures. Review of facility policy titled, Cooking ProceduresBased on observations, staff interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect all 73 residents residing in the facility. residents. The facility census was 73.

Findings include

Observation of the kitchen on 08/22/24 at 10:30 A.M. to 10:55 A.M. with Cook #83, revealed the walk-in refrigerator had a container of peas and carrots mixture that was undated, two 1/2 gallons of milk expired on 08/21/24, a large box of potatoes (over 20 potatoes) was undated, eight pitchers of orange juice, lemonade, and fruit punch were undated and a dish of individually wrapped muffins approximately 25 were undated. The walk-in refrigerator had documented as being over temperature several days in the last month. Observation and review of the walk-in refrigerator log dated 07/30/24 to 08/22/24 revealed temperatures were taken twice daily and found numerous entries over 41 degrees Fahrenheit (F). The walk-in freezer contained four bags of meatballs that were undated and unlabeled, a packet of unidentified meat was undated, and the bread was undated. Observation and review of the walk-in freezer log dated 07/30/24 to 08/22/24, revealed temperatures were taken twice daily and found numerous entries over zero degrees F. Interview with Cook #83 at the same time confirmed the findings related to food storage. Cook #83 stated the expired milk was served at breakfast and was scheduled to be served during the lunch tray service. Cook #83 confirmed the temperatures listed on the logs and stated the walk-in refrigerator temperature should be kept at 41 degrees F or below and the freezer should be maintained below zero degrees F or below.

Review of the walk-in refrigerator log hanging outside the walk-on refrigerator revealed the following:

a) On 08/01/24 the morning temperature was recorded as 42 degrees F.

b) On 08/02/24 the evening temperature was recorded as 42 degrees F.

c) On 08/03/24 the morning temperature was recorded as 45 degrees F. ) On 08/04/24 the morning temperature was recorded as 45 degrees F.

e) On 08/05/24 the morning temperature was recorded as 44 degrees F.

f) On 08/06/24 the evening temperature was recorded as 42 degrees F.

g) On 08/08/24 the morning temperature was recorded at 45 degrees and the evening temperature was recorded as 42 degrees F.

h) On 08/09/24 the morning temperature was recorded as 45 degrees F.

i) On 08/13/24 the morning temperature was recorded as 45 degrees F.

j) On 08/15/24 the morning temperature was recorded as 42 degrees, and the evening temperature was recorded at 42 degrees F.

k) On 08/17/24 the morning temperature was recorded as 45 degrees F.

l) On 08/18/24 the morning temperature was recorded at 42 degrees F, and the evening temperature was recorded as 45 degrees F.

m) On 08/19/24 the morning temperature was recorded at 43 degrees F, and the evening temperature was recorded as 42 degrees F.

n) On 08/20/24 the morning temperature was recorded as 42 degrees F.

Review of the walk-in freezer log hanging outside the freezer revealed the following:

a) On 08/12/24 the morning temperature was recorded as three degrees F.

b) On 08/13/24 the morning temperature was recorded as four degrees F.

c) On 08/14/24 the morning temperature was recorded as two degrees F. ) On 08/16/24 the morning temperature was recorded as one degree F.

e) On 08/17/24 the morning temperature was recorded as two degrees F, and the evening temperature was recorded as 10 degrees F.

Observation of tray line on 08/22/24 at 11:15 A.M., revealed Cook #83 took holding temperatures of the hot food items. The sloppy joe mixture had a temperature of 122 degrees F. Cook #122 continued to serve and stated she was unsure if she should put the food back in the oven or hot box to reheat it. The food was left on the steam table and plates continued to be served without rewarming the food over 135 degrees F.

Interview on 08/22/24 at 11:40 A.M. with Executive Director (ED) revealed the kitchen staff were recently trained by Registered Dietician #81 which included food storage, and the food temperatures. The ED revealed staff had not brought up any issues related to the temperatures in the walk-in refrigerator and freezer not maintaining safe temperatures.

Interview on 08/22/24 at 1:35 P.M. with RD #81 revealed she completed training with the staff on food storage and the temperatures and they should know how to respond when food did not get to the correct temperatures.

Review of facility policy titled, Cooking Procedures

Based on observation, staff interview and record review, the facility failed to ensure puree foods were made to the correct consistency and were made following a recipe. This affected two (#65 and #72) residents of the two residents who were ordered puree textures foods. The Facility census was 73.

Findings include

1) Review of the medical record for Resident #65 revealed an admission date of 05/12/21. Diagnoses included urinary tract infection, vascular disease, and gastro esophageal reflux disease (GERD).

Review of a physician order dated 06/28/24 for Resident #65 revealed the resident was ordered a pureed diet texture

Review of the plan of care dated 07/26/24 for Resident #65 revealed the resident received a pureed diet.

Review of the Mini Mental Exam dated 08/20/24 revealed Resident #65 scored a zero (indicative of severe cognitive impairment) and the resident resided on the locked memory care unit.

2) Review of the medical record for Resident #72 revealed an admission date of 01/02/23. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, and anxiety.

Review of a physician order dated 07/08/24 revealed Resident #72 was ordered a pureed diet.

Review of the Mini Mental Exam dated 08/02/24 revealed Resident #72 scored a one (indicative of severe cognitive impairment) and the resident resided on the locked memory care unit.

Observation of the pureed diet process on 08/22/24 at 10:35 A.M. revealed Cook #83 was making puree corn. Cook #83 added three servings of canned corn including the liquid into a mixer with an additional unmeasured amount of chicken broth and blended it together. Cook #83 then poured the soupy mixture into the divided plates for Residents #65 and #72 and the mixture did not hold form and filled the space on the plate. The mixture had visible chunks from the corn kernel skin and the mixture was tasted by Cook #83 and surveyor and chunks were confirmed with taste test. The blending cup was run through the dishwasher and did not get dried. The sloppy joe meat was added to the blending cup which contained a layer of dish washer water. Three servings of sloppy joe mix were placed in the blending cup along with unmeasured broth and was blended. It was poured into Resident #65 and #72's plates and filled the section and did not hold to form.

Interview on 08/22/24 at 11:40 A.M. with the Executive Director (ED), revealed the staff had been trained by Registered Dietician (RD) #81 recently on making puree foods. The ED stated the facility did not have foods for which they had molds (bought in puree form from manufacturer and kept cold until use).

Interview on 08/22/24 at 1:35 P.M. with RD #81 confirmed the facility did not have molds and stated the facility staff should not be pureeing corn as it is not safe to puree due to the skin. RD #81 confirmed she had conducted training with the staff over puree consistency. RD#81 confirmed puree food should hold its shape such as mashed potatoes and not be too liquidly and fill the space.

Review of the puree instructions for corn revealed the facility shall use a mold of 3.2 ounces (oz) of puree corn.

Review of facility policy titled Technique for puree production, undated, revealed the food shall be placed in blending device and mixed to a fine consistency. Then add liquid to get a smooth consistency. Scrape the sides of the blender and continue to blend.

Based on record review and staff interview, the facility failed to ensure the fire drill alarms were transmitted to the alarm monitoring company in a timely manner. This had the potential to affect all facility residents. The facility census was 73.

Findings include:

Review of the fire drill dated 07/15/24 at 7:15 P.M. revealed N/A or not applicable was recorded on the form when asked the time of when the alarm company received the transmission.

Review of fire drill dated 08/07/24 at 3:05 P.M. revealed N/A or not applicable was recorded on the form when asked the time of when the alarm company received the transmission.

Interview on 08/22/24 at 4:00 P.M. with the Executive Director (ED) confirmed the previous Maintenance Director was terminated about two weeks ago and a new one started on 08/16/24. ED confirmed the fire drills were marked as not applicable and did not provide all the details related to when the alarm was transmitted to the alarm company.

Based on observation, staff interviews and record review, the facility failed to ensure the functionality of bathroom resident-activated call system. This affected 14 Residents (#60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) residing in the Memory Care Unit (MCU). The facility census was 73.

Findings include

Observations of the MCU on 08/22/24 at 12:00 P.M., revealed the four community bathrooms had pull cords affixed to the wall for the resident-activated call system.

Observation on 08/22/24 at 12:08 P.M. revealed the surveyor activated a pull cord on the first-floor MCU bathroom. Assistant Director of Nursing (ADON) #55 was observed outside the bathroom door in the kitchen area and walked by the area several times without noticing the resident-activated call system via the pull cord had been activated. Observation revealed there were no audible alarms or sounds, visible alerts, no pagers were alerting, and no walkie talkie messages were heard.

Interview on 08/22/24 at 12:20 P.M. with ADON #55 revealed she was covering the MCU as the nurse and aide with providing care the residents. ADON #55 indicated the staff were required to carry pagers so they could be alerted to a resident worn pendent and/or a pull cord alarms in the bathrooms. ADON #55 confirmed she was not carrying a pager. ADON #55 was observed calling staff from another part of the facility to bring her a pager upon surveyor intervention. ADON #55 revealed she was not in close proximity of any walkie talkies. ADON #55 verified she was not aware of the pull cord activation at 12:08 P.M. by the surveyor. ADON #55 also called the other staff to see if any resident activated alerts went to their pagers and was informed no messages had been received regarding any call light alerts.

Interview on 08/22/24 at 12:35 P.M. with Care Partner #57 revealed the facility had issues with the pagers and they only had one pager where the MCU bathroom call lights/alarms went to. Care Partner #57 confirmed staff were to carry the only working pager and announce over the walkie talkie if any call lights/alarms were going off. Care Partner #57 confirmed the staff were not alerted by walkie talkie about the active resident-activated call system going off from the MCU bathroom.

Interview on 08/22/24 at 4:00 P.M. with Executive Director (ED) revealed her expectations were for the MCU staff to carry pagers and walkie talkies when working and the call lights/alarms in the MCU should accurately disperse the message to all pagers for timely follow up.

Review of facility policy titled, Nurse Call Bell System undated revealed an emergency button shall be located in the bathrooms and timely assistance would be provided to emergency pull cords to ensure prompt assistance immediately.

This violation represents non-compliance investigated under Complaint Number OH00156957.

Based on review of personnel files, staff interview and policy review, the facility failed to ensure staff completed physical exams within 30 days prior to starting employment or on the first day of employment. This affected one staff (Care Aide #27) of six reviewed for personnel files. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of the personnel file for Care Aide #27 revealed a start date of 01/22/24. Care Aide had a physical dated 01/23/24.

Interview on 06/25/24 at 12:31 and again 3:30 P.M. with Human Resource #44 confirmed no other physicals were found and physical was completed after Care Aide #27 had started employment.

Review of facility policy titled, New Hire Policy

Based on record review, resident and staff interviews and policy review, facility failed to ensure residents were assisted with bathing and showering as needed. This affected three (#11, #16, and #27) of three residents reviewed for showers. Facility census was 56.

Findings include:

1. Review of the medical record for Resident #11 revealed an admission date of 05/22/24. Diagnoses included hypertension, heart disease, cerebral infarct, seizures, stemi, cardiogenic shock, hemiplegia, and heart failure.

Review of the assessment dated 05/16/24 (prior to admission) revealed Resident #16 was cognitively impaired with a Brief Interview for Mental Status (BIMS) of five out of 15. The assessment revealed resident required assistance with bathing/showering.

Review residents medical record found no evidence of shower or bed baths being offered or provided.

2. Review of the medical record for Resident #16 revealed an admission date of 04/26/24. Diagnoses included hypertension, anxiety and kidney disease.

Review of the assessment dated 04/18/24 revealed Resident #16 was cognitively intact with a BIMS of 13 out of 15. The assessment revealed resident required assistance with showering /bathing.

Review residents medical record found no evidence of shower or bed baths being offered or provided.

3. Review of the medical record for Resident # 27 revealed an admission date of 01/13/23. Diagnoses included hypertension, hypothyroidism and hyperlipidemia.

Review of the service plan dated 01/17/23 revealed resident required assistance with bathing with interventions to assist as required for transfers, cueing, steadying and use a shower chair.

Review of the assessment dated 05/17/24 revealed Resident #27 was cognitively impaired with a BIMS of nine out of 15. Assessment revealed resident required assistance with showering/bathing.

Review residents medical record found no evidence of shower or bed baths being offered or provided.

Interview on 06/26/24 at 10:08 A.M. with Resident #27 revealed she had not received assistance with a shower in a few weeks. Resident #27 revealed she was unsure when her scheduled showers were and revealed staff do not always have time to help with showers.

Interviews on 06/26/24 from 10:30 A.M. to 4:23 P.M. with Care Aide #34, #31, and #30 confirmed showers should be documented in the task section of the medical record. They revealed at times tasks were difficult due to low staffing.

Interview on 06/26/24 at 4:20 P.M. with Licensed Practical Nurse (LPN) #40 revealed showers should be documented in the electronic medical record under tasks.

Interview on 6/26/24 at 4:25 P.M. with Human Resources #44 and the Executive Director confirmed facility had no documentation or evidence of showers being offered or provided for Resident's #11, #16, and #27.

Interview on 06/26/24 at 12:15 P.M. with Resident #16 revealed staff do not assist her with showers.

Review of facility policy titled, How to Shower or Bath

Based on record review, observations and resident, staff and physician interviews, the facility failed to ensure medications were given according to physician's order. This affected four (#11, #18, #24, and #53) of five residents reviewed for medication administration. Facility identified all facility residents had orders for evening and bedtime medication as well as PRN (as needed) medications. Facility census was 56.

Findings include:

1. Review of the medical record for Resident # 11 revealed an admission date of 05/22/24. Diagnoses included hypertension, heart disease, cerebral infarct, seizures, stemi, cardiogenic shock, hemiplegia, and heart failure.

Review of the assessment dated 05/16/24 (prior to admission) revealed Resident #11 was cognitively impaired with a Brief Interview for Mental Status (BIMS) of five out of 15. The assessment revealed resident was unable to manage medications and required assistance from staff for medication management.

Physician order dated 05/20/24 for Atorvastatin Calcium tablet 80 milligrams (MG) with instructions to give one tablet in the evening. Physician order dated 05/20/24 revealed an order for Seroquel 50 MG with instructions to given one tablet in the evening. Physician order dated 05/20/24 revealed an order for Eliquis 5 MG tablet with instructions to given one tablet twice daily. Physician order dated 05/20/24 revealed an order for Levetiracetam tablet 500 MG with instructions to give one tab by mouth twice daily. Physician order dated 05/20/24 revealed an order for Midodrine HCl tablet 10 MG with instructions to give one tab by mouth three times daily.

Interview on 06/25/24 at 10:40 A.M. with Human Resources (HR) #44 revealed all residents have orders for some PRN (as needed) orders and evening/bedtime orders. HR #44 revealed residents were given these medications (evening and bedtime) during the last med pass of the day 3:00 P.M. to 7:00 P.M. including Resident #11.

2. Review of the medical record for Resident #18 revealed an admission date of 09/30/23. Diagnoses included depression fractured pelvis and hyperlipidemia.

Physician order dated 12/23/23 for Rosuvastatin Calcium Oral 20 MG Tab with instructions to give one tablet once daily. Physician order dated 01/11/24 revealed an order for Mirtazapine 30 MG with instructions to given one tablet by mouth at bedtime. Physician order dated 01/30/24 revealed an order for Eliquis 5 MG tablet with instructions to given one tablet twice daily. Physician order dated 01/31/24 revealed an order for Calcitriol capsule 0.25 micrograms (mcg) with instructions to give one capsule by mouth twice daily.

Review of the assessment dated 04/09/24 revealed Resident #18 was cognitively impaired with a mini mental score of 15 for moderate cognitive impairment. The assessment also revealed resident was unable to manage medications and required assistance from staff for medication management.

Observation and interview on 06/25/24 at 4:05 P.M. Licensed Practical Nurse (LPN) #40 provided medications Rosuvastatin calcium, Mirtazapine, Eliquis, and Calcitriol were provided. LPN #40 revealed medications ordered for evening and bedtime, were provided at 4:05 P.M. and prior to dinner.

3. Review of the medical record for Resident #24 revealed an admission date of 09/06/23. Diagnoses included unspecified non-displaced fracture of second vertebra, infection of hip prosthesis, kidney failure, and dementia.

Review of the assessment dated 06/14/24 revealed Resident #24 was cognitively impaired with a mini mental score of 17 indicating moderate cognitive impairment. The assessment revealed resident was unable to manage medications and required assistance from staff for medication management.

Physician order dated 09/07/23 revealed an order for Doxycycline 100 MG with instructions to given one tablet twice daily for infection in hip. Physician order dated 09/26/23 for Donepezil HCl tablet 10 MG with instructions to give one tablet at bedtime.

Observation and interview on 06/25/24 at 4:16 P.M. with LPN #40 revealed resident was given doxycycline and Donepezil HCl medications. LPN #40 confirmed Resident #24 was given evening medications and a bedtime medication at 4:16 P.M. prior to dinner.

4. Review of the medical record for Resident #53 revealed an admission date of 08/31/23. Diagnoses included hypertension, vascular disease, muscle weakness, diabetes and schizophrenia.

Review of the assessment dated 06/13/24 revealed Resident #53 was cognitively intact. The assessment revealed resident was unable to manage medications and required assistance from staff for medication management.

Physician order dated 08/29/23 for metformin HCl ER tablet 500 MG with instructions to give one tablet in the evening. Physician order dated 09/22/23 revealed an order for trazadone 100 MG tablet with instructions to given one tablet the evening. Physician order dated 10/26/23 revealed an order for tramadol HCl tablet 50 MG with instructions to give one tab by mouth twice daily. Physician order dated 03/04/24 revealed an order for Tamsulosin HCl 0.4 MG with instructions to given one capsule in the evening. Physician order dated 04/09/24 revealed an order for Sucralfate oral tablet 1 GM with instructions to give one tab by mouth four times daily.

Interview and observation on 06/25/24 at 4:05 P.M. with LPN #40 and Health and Wellness Director (HWD) #09 revealed licensed nursing staff worked 6:00 A.M. to 6:00 P.M. with no evening or overnight coverage. If a PRN medication was needed after hours staff could contact the HWD to come and provide the requested medication. All evening and bedtime medications were provided along with dinner-time medications.

Observation and interview on 06/25/24 at 4:20 P.M. with LPN #40 revealed Resident #53 was providing his evening medicine prior to lunch being served and his medication ordered for several timely daily had all doses given within a twelve-hour period. LPN #40 revealed evening and bedtime medications are given around dinner before the nurse leaves. LPN #40 confirmed she had given bedtime and evening medications at 4:00 P.M. LPN #40 also confirmed medications ordered twice daily would be given in the morning and at dinner and medications ordered three or four times daily would also get their medications within a time period under 12 hours.

Interview on 06/26/24 at 5:59 P.M. with Physician #200 revealed ideally residents should get their evening meds at dinner 5:00 to 6:00 P.M. and bedtime meds should be given at bedtime, but due to facility staffing and only having a nurse from 6:00 A.M. to 6:00 P.M. or 7:00 A.M. to 7:00 P.M., facility was unable to accommodate these times. Physician #200 revealed staff will leave cups of bedtime pills in the resident room for them to take before going to bed and she puts an order in place for this to occur. Physician #200 revealed if facility had a nurse even till 11 or so, it would solve a lot of these issues.

This violation represents non-compliance investigated under Complaint Number OH00154636.

Based on record review, observations, resident, staff and physician interviews and policy review, the facility failed to ensure medications were safely and securely stored and not left unattended. This affected two (#18 and #27) of five residents reviewed for medication administration. Facility census was 56.

Findings include:

1. Review of the medical record for Resident #18 revealed an admission date of 09/30/23. Diagnoses included depression fractured pelvis and hyperlipidemia.

Physician order dated 12/23/23 for Rosuvastatin Calcium Oral 20 milligrams (MG) Tab with instructions to give one tablet once daily. Physician order dated 01/11/24 revealed an order for Mirtazapine 30 MG with instructions to given one tablet by mouth at bedtime. Physician order dated 01/30/24 revealed an order for Eliquis 5 MG tablet with instructions to given one tablet twice daily. Physician order dated 01/31/24 revealed an order for Calcitriol capsule 0.25 micrograms (mcg) with instructions to give one capsule by mouth twice daily. Review of physician orders dated 04/17/24 revealed an order for may leave medication at bedside. The medication was ordered by the house facility physician and not residents Physician.

Medication self-administration assessment dated 03/31/24 revealed resident was not approved to self-administer medication.

Review of the assessment dated 04/09/24 revealed Resident #18 was cognitively impaired with a mini mental score of 15 for moderate cognitive impairment. The assessment also revealed resident was unable to manage medications and required assistance from staff for medication management.

Interview on 06/25/24 at 10:40 A.M. with Human Resources (HR) #44 revealed all residents have orders for some PRN (as needed) orders and evening /bedtime orders. HR #44 revealed residents were given a cup of pills to take themselves when they wanted. HR #44 revealed she was she was unsure about the process to assess residents for ability to self-administer medication.

Observation and interview on 06/25/24 at 4:05 P.M. Licensed Practical Nurse (LPN) #40 left a cup of four pills on table in Resident #18's room during medication pass. LPN #40 revealed the medication self-administration assessment for Resident #18 stated resident was not approved to self-administer medications and revealed the assessment was more of an assessment whether residents could store medications in their rooms full time, but revealed staff can put pills in a cup and leave them at bedside for when they were ready to take them. LPN #18 confirmed she did not stay with Resident #18 and watch them take all their medication.

2. Review of the medical record for Resident #27 revealed an admission date of 01/13/23. Diagnoses included hypertension, hypothyroidism and hyperlipidemia.

Review of physician orders revealed no order for meds to be left at bedside. Physician order dated 12/29/23 revealed an order for potassium chloride ER tablet 10 milliequivalent (MEQ) to give one tablet daily. Physician order dated 01/14/23 for omeprazole to give 40 MG by mouth once daily.

Review of the service plan dated 01/17/23 revealed nurse to administer medications unless given order by primary care physician (PCP).

Medication self-administration assessment dated 01/25/24 revealed Resident #27 was not approved to self-administer medication.

Review of the assessment dated 05/17/24 revealed Resident #27 was cognitively impaired with a BIMS of nine out of 15.

Observation and interview on 06/26/24 at 10:08 A.M. with Resident #27 revealed two pills were left in residents room. Resident stated staff left them while she was in the bathroom.

Interview on 06/26/24 at 10:20 A.M. with LPN #40 confirmed she left pills in Resident #27's room. LPN #40 stated Resident #27 doesn't like to take all her pills at once and prefers to wait on the omeprazole and potassium chloride medications. LPN #40 confirmed Resident #27 did not have any orders in place for meds to be left at the bedside and also had an assessment stating she was not approved to self-administer medication.

Interview on 06/26/24 at 5:59 P.M. with Physician #200 revealed ideally residents should get their evening meds at dinner and bedtime meds should be given at bedtime, but due to facility staffing and only having a nurse from 6:00 A.M. to 6:00 P.M. or 7:00 A.M. to 7:00 P.M., facility was unable to accommodate these times. Physician #200 revealed staff will leave cups of bedtime pills in the resident room for them to take before going to bed and she puts an order in place for this to occur. Physician #200 acknowledged residents should be assessed for safety with leaving medications at bedside and only if approved to manage medication and cognitively intact should medications be left in residents room. Physician #200 revealed she was not aware some residents had orders for leaving medications at bedside that went against their assessment for medication self-administration and also residents that were cognitively impaired with orders to leave medications at bedside. Physician #200 acknowledged this was a storage and safety issue. Physician #200 revealed if facility had a nurse even till 11 or so, it would solve a lot of these issues.

Review of facility policy titled, Store General Medication and Treatments, undated, revealed medications and treatments shall be stored in a clean neat, locked container or medication cart, unsecured medications should not be left unattended.

Review of facility policy titled, Self Administration of Medication Review, undated, revealed Resident assessment for self medication included a residents ability to identify the medication, the expiration of medications, use of medication, administration time and dosage and proper handling techniques. The assessment also included a finding of whether resident was assessed and approved to self administer medications.

This violation represents non-compliance investigated under Complaint Number OH00154636.

Based on observations, staff interview and record review, facility failed to maintain dryers in a safe manner by cleaning them from excessive lint routinely. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Observation and interview on 06/24/24 at 10:14 A.M. revealed the laundry room on second floor of memory care had a sign off sheet for lint being cleaned out. Observation of the lint trap revealed it was full of lint. Care Aide #30 confirmed the laundry lint trap was full and the sign off stated it was last cleaned out on 04/19/24.

Observation and interview on 06/24/24 at 10:20 A.M. revealed the laundry room on first floor of memory care had a sign off sheet for lint being cleaned out that was blank. Observation of the lint trap revealed it was full of lint. Care Aide #34 confirmed the laundry lint trap was full and the sign off was blank. Care Aide #34 also revealed it was the responsibility of Maintenance as the lint traps were bolted into the machine.

Review of lint trap sign offs on the first, second, and third floor assisted living and revealed the first floor was last cleaned 05/19/24, the second floor was cleaned 05/09/24 and the third floor was last cleaned 03/31/24.

Interview on 06/25/24 at 10:14 A.M. with Maintenance Director (MD) #22 revealed it was the responsibility of housekeeping to clean the lint traps. MD #22 confirmed he had no additional records related to lint being cleaned out of the machines.

Interview on 06/25/24 at 10:40 A.M. with Human Resources #44 revealed it was the responsibility of the aides to maintain the lint traps in good order.

Review of resident council meeting dated 04/25/24 revealed a complaint laundry lint traps were too full of lint and needed emptied. Review of resident council meeting minutes dated 04/25/24 revealed complaints of the dryer lint being backed up and not maintained. Facility did not provide any evidence of follow up or addressing resident concerns.

Based on observations, resident and staff interviews, review of resident council meeting minutes and policy review, facility failed to ensure food was stored in a safe and sanitizing manner. The facility also failed to ensure food temperatures were within safe ranges and food tasted palatable. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Interview on 06/24/24 at 9:30 A.M. with Executive Director (ED) revealed the facility did not have a kitchen Manager in place and also had several opening for cooks. The ED revealed she had been cooking along with Human Resources and Activity Director for the last few weeks.

Observation and interview on 06/24/24 at 9:41 A.M. with Activity Director (AD) #21 revealed six juice pitchers were unlabeled and undated, a pack of shredded parmesan cheese was undated, a package of pepperoni was undated, a package of rice was undated and croutons was undated, and a container of oranges was undated. A case of biscuits was opened and uncovered. AD #21 confirmed findings and revealed she knew items needed dates but revealed no training on safe food storage practices.

Observation and interview on 06/24/24 at 11:10 A.M. with AD #21 revealed food was cooked and on the steam table. AD #21 revealed the food temperatures were 67 degrees Fahrenheit (F) for mashed potatoes, 50 degrees F for broccoli and 70 degrees F for meat loaf. AD #21 revealed she was unsure what the temperatures should be and confirmed no temperatures were taken after cooking and no temperatures had been taken for last week. AD #21 revealed she was unfamiliar with how to use the steam table and did not have the plate warmers turned on. The surveyor tasted the mashed potatoes and they were lukewarm.

Observations on 06/24/24 at 11:36 A.M. with Resident #43, #46, and #51 were eating in the dinning room and discussed their cold food. When a resident came over and asked what they were eating, Resident #51 stated ice-cold meat loaf.

Interview on 06/24/24 at 12:15 P.M. with Care Aide #32 revealed resident's had complained of cold food previously and confirmed that was not a new concern.

Observation and interview related to the test tray dated 06/24/24 at 12:28 P.M. revealed the facility thermometer was not working. The mashed potatoes had warm gravy on them, the meat loaf was cold and the broccoli was cold.

Interview on 06/26/24 at 9:00 A.M. with Diet Tech #225 confirmed pureed food should have smooth consistency and be free of any chunks or distinct pieces. Diet Tech #225 revealed facility had recipe instructions for making pureed items.

Interview on 06/26/24 from 10:25 A.M. to 12:15 P.M. with Resident #12 and #16 revealed the food was not very good and frequently cold.

Review of the resident council meeting minutes revealed concerns related to food was brought up 06/29/23, 09/28/23, 11/30/23, 02/29/24, and 04/25/24 related to temperature, texture, taste, quality, and palatability.

Review of facility policy titled, Cooking Procedures

Based on observations, resident and staff interviews, review of resident council meeting minutes and policy review, facility failed to ensure kitchen staff used planned serving sizes and provided all items on the menu unless marked on the substitution log. The facility also failed to ensure resident were provided menu items of choice when Resident #12 was given a food item she was allergic to. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

1. Review of the medical record for Resident #12 revealed an admission date of 07/01/23. Diagnoses included atrial fibrillation, Parkinson's unspecified dementia, anemia and osteoporosis.

Review of allergies revealed Resident #12 was allergic to the following food items: corn, nuts, peanut, sesame seed, and chocolate.

Review of the assessment dated 04/04/24 revealed Resident #12 had moderate cognitive impairment with a mini mental score of 12.

Interview on 06/24/24 at 12:15 P.M. with Kitchen Aide #42 revealed she used the slips on the bulletin board to guide likes dislikes and allergies.

Observation and interview on 06/24/24 at 12:22 P.M. revealed Kitchen Aide #42 provided chocolate cake to Resident #12, who was allergic to chocolate. Resident #12 declined the item and stated, I cannot have that

Based on review of facility fire drill documentation, staff interviews and policy review, the facility failed to ensure fire drills were conducted every month and at least once per shift per quarter. The facility also failed to provide evidence of alarm transmission within 12 hours of each fire drill. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of fire drill documentation dated 03/15/24 revealed drills were conducted on third shift at 6:00 A.M. and 6:30 A.M. and first shift at 8:30 A.M. and 9:00 A.M. When asked if the alarm was received by the fire department it was marked as NA not applicable.

Review of fire drill documentation dated 04/13/24 revealed drills were conducted on third shift at 4:30 A.M. and 5:00 A.M. and first shift at 7:30 A.M. and at 8:00 A.M. When asked if the alarm was received by the fire department it was marked as NA not applicable.

Review of the facility fire drill documentation revealed the facility was unable to provide evidence of any fire drills from 06/2023, 07/2023, 08/2023, 09/2023, 10/2023, 11/2023, 12/2023, 01/2024, 02/2024, 05/2024 and 06/2024.

Interview on 06/24/24 at 1:00 P.M. with Maintenance Director #22 revealed he started about one months prior with employment. MD #22 revealed he was unable to find any additional evidence of fire drills being completed for the previous year. MD #22 provided TELS (maintenance check task system) that had check offs for fire drills but did not include any of the required information such as time of drill, staff present, residents involved, weather at the time of the drill, and a self examination of the drill. MD #22 also confirmed the completed drills marked NA (not applicable) for the transmission of the alarm with 12 hours.

Review of facility policy titled, fire drills undated, revealed fire drills must be executed monthly as per state regulation and every shift must participate at least once per state regulations. The Executive Director (ED) or designee was responsible for planning and conducting the fire drills. After the fire drills was completed, a fire drill report must be completed including the date and time of the drill, names of associates and residents present during the drill and location of the fire. The report shall be kept on file.

Based on staff interview, and record review, facility failed to ensure monthly fire inspections were completed as required. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of the monthly fire self-inspection log revealed the only documented inspection was 02/19/24. Facility had no evidence of monthly self-inspections being completed in the other 11 months under review.

Interview on 06/24/24 at 1:00 P.M. with Maintenance Director (MD) #22 revealed he started about one months prior with employment. MD #22 revealed he was unable to find any additional evidence of monthly fire self-inspections being completed.

Based on staff interview, and record review, facility failed to ensure a transfer agreement was in place in case of emergency transfers. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of the documentation for entrance documents, revealed facility did not have a transfer agreement in place prior to entrance.

Interview on 06/24/24 at 12:50 P.M. with Executive Director revealed facility did not have a transfer agreement in place prior to entrance.

Based on observations, staff interviews and policy review, facility failed to ensure resident accessible bathrooms were equipped with an emergency call system in the memory care unit. This had the potential to affect all 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) residents on the memory care unit. Facility census was 56.

Findings include:

Observation and interview on 06/24/24 at 10:30 A.M. revealed a bathroom on the second floor of the memory care unit across from the dining room had an open door and was accessible for resident use. The bathroom did not have any safety pull cord in place. Care Aide #31 confirmed no pull alert cord was in this bathroom. Care Aide #31 revealed residents on memory care are not provided with alert button necklaces.

Observation and interview on 06/25/24 at 1:20 P.M. with Care Aide #34 confirmed the bathroom on second floor of memory care unit across from the dining area had no pull cord for safety.

Observation and interview on 06/25/24 at 1:25 P.M. with the Health and Wellness Director (HWD) #9 confirmed the memory care units had three bathrooms without pull cords observed. On the second floor across from the dining room and off the TV lounge are and on the first floor off the TV lounge area. All three were left open and unlocked and accessible to residents. The facility confirmed there are 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) residents residing on the memory care unit who could potentially be affected.

Review of facility policy titled, Nurse/call bell system

Based on observation, staff interview, and policy review, facility failed to ensure a chemicals were stored in a safe and secure manner on the memory care unit. This had the potential to affect all 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents residing on the memory care unit. Facility census was 56.

Findings include:

Observation and interview on 06/24/24 at 10:14 A.M. revealed the laundry room on the first floor was left open. The laundry room contained chemicals including one gallon of extra laundry detergent with a warning label for eye and skin irritation. Care Aide #30 confirmed the laundry room was unlocked with chemicals within reach.

Observation and interview on 06/24/24 at 10:20 A.M. revealed the laundry room on the first floor was left open. The laundry room contained several cleaning chemicals including orange cleaner spray with a warning label for eye irritation and one gallon of extra laundry detergent with a warning label for eye and skin irritation. Care Aide #34 confirmed the laundry room was unlocked with chemicals within reach.

Interview on 06/24/24 at 12:50 P.M. with Executive Director and Human Resources #44 confirmed chemicals should be kept with laundry rooms locked on memory care unit. The facility confirmed there are 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents residing on the memory care unit that could potentially be affected by unsecured chemicals and laundry items.

Review of facility policy titled, Hazard Communications Program

Based on staff interview, and record review, the facility failed to ensure a grievance committee was in place as required. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of the documentation for entrance documents, revealed facility did not have a grievance committee, procedure or grievance log.

Interview on 06/24/24 at 12:50 P.M. with Human Resources #44 revealed per the Executive Director, they are an assisted living and not a nursing home and do not have a grievance procedure and do not keep a grievance log.

Based on record review and staff interview, facility failed to ensure staff training and acknowledgements upon hire related to transfer and discharge regulations. This affected two staff (Licensed Practical Nurse #53 Care Aide #27) of six reviewed for personnel files. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

1. Review of the personnel file for Care Aide #27 revealed an original start date around 01/22/24. Facility had no evidence a signed acknowledgement for transfer and discharge.

2. Review of the personnel file for Licensed Practical Nurse #53 revealed a start date of 10/23/23. Facility had no evidence a signed acknowledgement for transfer and discharge.

Interview on 06/25/24 at 12:31 and again 3:30 P.M. with Human Resource (HR) #44 confirmed facility was not aware of the requirements for signed acknowledgements for transfer and discharge upon hire. HR confirmed Licensed Practical Nurse #53 and Care Aide #27 did not receive this information upon hire.

Based on observations, staff interviews, and policy review, the facility failed to ensure a safe and secure environment in the memory care unit. This had the potential to affect three #1, #2 and #3) residents on the first floor of memory care. Facility census was 56.

Findings include:

Observation and interview on 06/24/24 at 10:20 A.M. revealed Care Aide #63 did not have a key card to get out of the secured memory care unit and requested to borrow Care Aide #34's key card. Care Aide #34 provided the key card and after opening the door, Care Aide #63 left the key care on the hand rail inside the locked unit. Residents were observed in the common areas and in the hallway at this time and the door and key card were not monitored by any staff. Care Aide #34 confirmed key card was left in reach of residents.

Interview on 06/24/24 at 12:50 P.M. with Executive Director and Human Resources #44, and Health and Wellness Director #9 confirmed a lot of staff do not have key cards for the memory care and confirmed a key card should not be left within resident access to get off the secured memory unit. The facility confirmed the unsecured key card had the potential to affect three #1, #2 and #3) residents on the first floor of memory care.

Review of facility policy titled, The Dementia Program, undated, revealed facility shall encourage independence while eliminating unreasonable risk. For caregivers it meant paying special attention to controllable safety factors while providing the least restrictive mode of care. Facility shall ensure a safe structured and supportive environment for residents, staff and family. Facility shall provide a secure environment and ensure those that wander were in locked unit and door alarms were armed at all times and in good working order.

Based on review of resident council meeting minutes, resident and staff interviews and policy review, the facility failed to ensure resident inquiries and concerns were responded to and/or addressed in a timely manner. This had the potential to affect all 56 residents residing in the facility. Facility census was 56.

Findings include:

Review of resident council meetings revealed concerns related to food was brought up 06/29/23, 09/28/23, 11/30/23, 02/29/24, and 04/25/24. Concerns related to showers was brought up 09/28/23, 11/30/23, 03/28/24, and 04/25/24. Concerns related to laundry (missing, delayed and not done timely) was brought up 08/31/23, 09/28/23, 10/26/23, 11/30/23, 12/28/23, 01/25/24, 03/28/24, and 04/25/24. Concerns related to housekeeping was brought up 10/26/23, 11/30/23, 01/25/24, 02/29/24, and 04/25/24. Concerns related to poor phone connection was brought up 07/27/23, 08/31/23, 09/28/23, and 10/26/23. Concerns related to low staffing and long call light responses was brought up 10/26/23, 01/25/24, 02/29/24, 03/28/24, and 04/25/24. The facility had no evidence of follow up of any concerns or complaints.

Interview on 06/24/24 at 2:30 P.M. with Human Resources (HR) #44 and Health and Wellness Director (HWD) #9 revealed the facility did not complete concern forms and was unsure if they have any documentation showing they respond to resident concerns.

Interview on 06/25/24 at 10:40 A.M. with HR #44 confirmed facility had no documentation of addressing resident concerns from resident council meetings.

Interviews on 06/26/24 from 10:08 A.M. to 12:15 P.M. with Resident #12, #16, and #27 who revealed resident concerns are not addressed timely and revealed the same topics come up at resident council meetings month after month.

Review of facility policy titled, Resident Council, undated, revealed resident council meetings would be held monthly to discuss issues or concerns residents may have. A resident council representative shall communicate information to the Executive Director or designee. The policy revealed any issues or concerns identified by council should be brought to the attention of the Executive Director or designee for appropriate follow up.

Based on medical record review, staff interview, and record review, the facility failed to ensure a resident's falls were documented on the facility's incident log. This affected one resident (#101) of three residents reviewed for falls. The facility census was 91.

Findings include:

Review of Resident #101's medical record revealed Resident #101 was admitted to the facility on 01/04/24 with diagnoses including syncope and collapse, pulmonary embolism, muscle weakness, and major depressive disorder. Resident #101 discharged from the facility 04/05/24.

Review of Resident #101's progress note dated 01/25/24 at 9:17 A.M. revealed the nurse was told by the care partner on 01/25/24 that when she went to get the resident, the resident slipped out of her chair. The nurse went to assess the resident and the resident was alert and did not complain of any pain. Resident #101 was monitored for the remainder of the shift.

Review of Resident #101's progress note dated 02/25/24 at 6:27 P.M. revealed Resident #101 was found on the floor that evening by the care partner. The care partner came and told the nurse that the resident fell again and was laying on the floor with part of her back against the wall. The fall was unwitnessed, and the resident had a reddened area on the back of her head and her left hand that was in her sling was swollen and very bruised from what skin could be seen. Resident #101 was sent to the hospital. There was no other fall was documented in the progress notes on 02/25/24.

Review of Resident #101's fall investigation dated 02/25/24 at 6:58 A.M. revealed care partners informed the nurse that Resident #101 was on the floor. Resident #101 was assessed and had a bump on the back of her head. Neurological check and vitals were within normal limits. Resident #101 stated she slid out of her chair.

Review of Resident #101's fall investigation dated 02/25/24 at 5:55 P.M. revealed the care partner told the nurse that Resident #101 was on the floor again. The nurse went to the room to assess the resident. Resident #101 was on the floor with her feet bent up and her left arm down by her side. Resident #101 was taken to the hospital.

Review of the facility's incident and accident log from 01/01/24 to 05/08/24 revealed Resident #101 fell at the facility on 02/21/24. Further review of the log revealed Resident #101's fall on 01/25/24 and two falls on 02/25/24 were not listed on the facility's incident and accident log.

Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #800 on 05/08/24 at 3:00 P.M. verified Resident #101's fall on 01/25/24 and two falls on 02/25/24 were not on the facility's incident log. The DON stated the facility did not consider Resident #101's progress note from 01/25/24 a fall because she slid out of a chair onto the floor. LPN #800 stated she was present at the facility on 01/25/24 when Resident #101 slid out of the chair. LPN #800 reported a care partner was in Resident #101's room and Resident #101 slid out of her chair onto the floor. LPN #800 stated she did not consider sliding out of a chair a fall.

This was an incidental finding discovered during the course of the complaint investigation.

Based on record review, resident and staff interviews, the facility failed to provide showers for residents. This affected two (#09 and #10) residents of three residents reviewed for showers. The facility census was 41.

Findings include,

1) Record review for Resident #09 revealed she was admitted to the facility on 08/09/22. Her diagnoses included dementia, diabetes mellitus, hypertension, chronic respiratory failure, and sleep apnea.

Review of Resident #09's most recent assessment titled, Resident Evaluation, dated 02/08/24, revealed the resident was alert to person, place, and time. Resident #09 required the assistance of two staff for bathing and transfers.

Review of Resident #09's Mini Mental Status Exam (MMSE) dated 03/01/24, revealed the resident was cognitively intact.

Review of Resident #09's shower documentation revealed the staff provided the resident with a shower 01/12/24, 01/18/24, 01/29/24, 02/01/24, 02/12/24, 02/16/24, 03/01/24, and 04/05/24. Resident refused showers on 01/15/24, 01/17/24.

Interview on 04/16/24 at 8:25 A.M. with Resident #09 revealed she had not had a shower in three weeks, prior to her shower on 04/05/24. Resident #09 stated she is not sure why she has trouble getting staff to help her with her showers. Resident #09 stated she is supposed to receive two scheduled showers per week.

2) Record review revealed Resident #10 revealed the resident was admitted to the facility on 07/01/23. Her diagnoses included, hyperlipidemia, gastro esophageal reflux disease, hyperlipidemia, atrial fibrillation, dementia, Parkinson's disease, anemia, and osteoporosis.

Review of Resident #10's most recent assessment titled, Resident Evaluation, dated 04/05/24 revealed the resident was alert to person, place, and time. Resident #10 had an unsteady gait and required assistance from staff with bathing or showering.

Review of Resident #10's most recent history and physical dated 07/05/23 revealed the resident scored a 16/30 on her MMSE which indicated the resident was cognitively impaired.

Review of Resident #10's shower documentation revealed she received showers on 01/12/24, 01/20/24, 01/26/24, 02/02/24, and 03/15/24. The resident refused a shower on 01/19/24, 03/01/24, 03/06/24, and 03/27/24.

Interview on 04/16/24 at 2:05 P.M. with Resident #10 revealed she would refuse her showers at times because she feels she cannot depend on the staff to give her showers. Resident #10 stated she was supposed to receive a shower two times per week; however, she never knew if the facility would follow through with her scheduled showers, so she tried to clean herself up with a bed bath. Resident #10 stated she was upset today because she had put her shirt on backwards because staff was not there to assist her getting dressed.

Interview on 04/16/24 at 3:15 P.M. with the Executive Director (ED) confirmed the facility scheduled the resident's showers for Residents two times per week. The ED confirmed if there were missing shower sheets for Residents # 09 and #10 from January 2024 to April 2024, it was because the shower did not happen. The ED stated the facility did not have a policy related to showers or activities of daily living.

This violation represents non-compliance investigated under Complaint Number OH00151772.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored properly. This affected two (#06, and #10) residents of the three residents reviewed. The facility census was 41.

Findings include:

1) Record review for Resident #06 revealed he was admitted to the facility on 01/05/24. Diagnoses included dementia, hypertension, obesity, and anxiety disorder. Resident #06 was housed in the secured memory care unit related to dementia and the potential for elopement.

Review of Resident #06's most recent assessment titled, Resident Evaluation, dated 02/04/24 revealed Resident #06 was alert to person but confused. The medication assistance questions were left unmarked.

Review of Resident #06's assessment titled, Self-Administration of Medications Review, dated 02/08/24, revealed the resident was not able to self-administer medications.

Review of Resident #06's Physician Order Summary revealed orders for 02/29/24 included Aspirin 81 milligrams (mgs) one time per day for his heart, Vitamin b-12 oral tablet 500 mgs one time per day for oral supplement, zinc oral table 50 mgs one tablet by mouth for diet supplement, and fish oil oral capsule 300 mgs one time per day for diet supplement. Orders for 11/09/23 included, Metoprolol Succinate extended release (ER) oral tablet 50 mg one time a day for high blood pressure.

Review of Resident #06's most recent History and Physical, dated 11/08/23, revealed the resident had mild to moderate dementia. Resident #06 scored a 20 out of 30 on his Mini Mental Status Exam (MMSE) which indicated impaired cognition.

Observation of Resident #06's on 04/16/24 at 9:08 A.M. with Licensed Practical Nurse (LPN) #56 revealed the resident was housed on the MCU. There was a stacked pile of clear medication cups with Resident #06's name written on the side of each cup and a large pill container on top of the mini refrigerator. LPN #56 was able to identify the top medicine cup contained seven blood pressure pills, eleven aspirin tablets, two vitamin c tablets and one calcium tablet. LPN #56 verified the large pill container contained a total of 84 pills that she was unable to identify. LPN#56 stated Resident#06's daughter must have brought in the pill organizer that contained 84 unknown pills.

Interview with Resident #06 on 04/16/24 at 9:15 A.M. revealed the medications on the counter in the plastic medication cups was given to him by the nurses. Resident #06 stated the large pill container with 84 unknown medications was given to him by his daughter.

Interview with Care Partner (CP) #72 on 04/16/24 at 9:27 A.M. revealed the staff were aware of the medication container located on Resident #86's mini fridge which contained the 84 unknown pills. CP #72 stated she was told by a nurse that Resident #06 could keep the mediation container in his room because Resident #06's daughter brought it in.

Interview with Resident #06's Primary Care Physician (PCP) #500 on 04/16/24 at 3:18 P.M. revealed Resident #06 was unable to administer his medications due to his diagnosis of dementia and being on MCU. PCP) #500 was unaware of the medication storage and reported Resident #06 should never be permitted to self-medicate or have unsecured medications in his room.

Interview with the Health and Wellness Director (HWD) #57 on 04/16/24 at 3:45 P.M. confirmed Resident #06's was not able to self-medicate and should not have medications stored in his room. HWD #57 stated her expectations were for the nurses to administer the medications then watch the resident to make sure the medications were taken.

2) Record review revealed Resident #10 was admitted to the facility on 07/01/23. Diagnoses included, hyperlipidemia, gastro esophageal reflux disease, hyperlipidemia, atrial fibrillation, dementia, Parkinson's disease, anemia, and osteoporosis.

Review of Resident #10's most recent assessment titled, Resident Evaluation, dated 04/05/24 revealed the resident was alert to person, place, and time and required medication administration from staff. Resident #10 was unable to manage her medications independently, including storage, set up, taking, and ordering.

Review of Resident #10's most recent History and Physical, dated 07/05/23 revealed she scored a 16/30 on her MMSE which indicated the resident was cognitively impaired.

Review of Resident #10's current physician's order summary revealed Resident #10 had no active order to self- administer medications. The physician's orders revealed her morning medications consisted of Aricept 5 mg for Dementia, Calcium 600-5mg for supplement, Furosemide 20 mg for edema, Lisinopril 10 mg for blood pressure, Magnesium Oxide 400 mg for supplement, Colestipol HCI one gram (gm) two tablets for hyperlipidemia, potassium chloride extended release (ER) eight milliequivalents (mEqs) for supplement, topiramate 50 mg for epilepsy, and presser vision for eye health.

Review of Resident #10's Medication Administration Report (MAR) revealed the resident was provided with the following medications on 04/16/24: Aricept 5 mg, Calcium 600-5 mg, Furosemide 20 mg, Lisinopril 10 mg, Magnesium Oxide 400 mg, Colestipol HCI one gm two tablets, potassium chloride ER eight mEqs, topiramate 50 mg, and presser vision.

Observation of resident's room on 04/16/24 at 3:52 P.M. with LPN #120 revealed a container of medications on the resident's table by her chair. LPN #120 verified she left the medications because Resident #10 had not finished getting ready for the day when she administered the medications. LPN #120 stated she thought Resident #120 was able to self-administer her medications.

Review of the facility policy titled, How to store general medications and treatment, undated, revealed medication must be stored in a clean and neat, locked container or medication cart and unsecured medications should not be left unattended.

Based on observations, staff and resident interviews, record review, and review of facility policy, the facility failed to ensure a clean and safe environment. This affected two (#06, and #39) residents of the three residents reviewed. The facility census was 41.

Findings include:

1. Record review for Resident #06 revealed he was admitted to the facility on 01/05/24. His diagnoses included dementia, dementia, obesity, and anxiety disorder. Record review for Resident #06 revealed he was required to be placed on a secure memory care unit related to his dementia and potential for elopement.

Review of Resident #06's most recent assessment titled, Resident Evaluation, dated 02/04/24 revealed Resident #06 was alert to person, however, not place or time, and his level of consciousness was marked confused. The medication assistance questions were left unmarked.

Review of Resident #06's most recent History and Physical, dated 11/08/23, revealed the resident had mild to moderate dementia. Resident #06 scored a 20 out of 30 on his Mini Mental Status Exam (MMSE) which indicated he had impaired cognition.

During the initial facility tour on 04/16/24 at 9:08 A.M. with Licensed Practical Nurse (LPN) #56 revealed the second floor appeared to be empty and the lights were off. LPN #56 indicated the second floor was an established Memory Care Unit (MCU) and accessible only by using a key from a staff member. LPN #56 indicated Resident #06's was being housed on the second floor by himself and without any staff present. Observation of Resident #06's room revealed numerous medications in a large pill container and no device such as a call light, pull cord or pendant for the resident to get help from staff if needed. Resident #06's room had debris and trash piled in the trash cans without trash liners and appeared as though the room has not been cleaned in a while. The toilet had yellow stains around the seat and stains inside the toilet bowl. Interview with LPN #56 at the same time verified the condition of the resident's room.

Interview with Resident #06 on 04/16/24 at 9:15 A.M. revealed he did not have any type of device in his room to call for help if needed. Resident #06 stated he would yell, help, if he had an emergency.

Observation of Resident #06 room on 04/16/24 at 3:10 P.M. with Health and Wellness Director (HWD) #57 confirmed Resident #06 was being housed in the MCU by himself and without any staff present. HWD #57 verified Resident #06's room did not have any type of device for the resident to use in the event of an emergency. HWD #57 indicated Resident #06 should not be housed on the MCU by himself and without any staff.

Interview with Resident #06's Primary Care Physician (PCP) #500 on 04/16/24 at 3:18 P.M. revealed Resident #06 was required to be placed on a secured MCU related to his dementia and potential for elopement. PCP #500 revealed she was not aware the facility staff would permit Resident #06 to stay in his room alone on the second floor without staff on the floor and without any device to call for help. PCP #500 indicated Resident #500 should have staff available on the same floor as Resident #06 and should have access to something to call for help.

2) Record review for Resident #39 revealed she was admitted to the facility on 05/12/21. Her diagnoses included major depressive disorder, insomnia, pneumonia, and hypothyroidism.

Review of Resident #39's most recent assessment titled, Resident Evaluation, dated 03/14/24, revealed she required assistance from staff with all activities of daily living (ADLs).

Observation of Resident #39's room on 04/17/24 with Care Partner (CP) #66 revealed Resident#39's toilet had a taped sign on the lid which stated, it needed repaired. CP #66 stated the toilet had been this way since January 2024. Observation also revealed the resident's room had dirt, trash, and debris across the floor and the toilet was soiled with a brown ring, and stains on the toilet seat. CP #66 verified the condition of the resident's room.

Interview on 04/17/24 at 3:20 P.M. with the Executive Director (ED) revealed the facility had several toilets in the facility that needed replaced; however, she was not aware that Resident #39's toilet was still in need of repair.

This violation represents non-compliance investigated under Complaint Number OH00151722.

Based on observation and staff interview, the facility failed to ensure trash cans in the kitchen had tight fitting lids. This had the potential to affect 41 of 41 residents in the facility. The facility census was 41.

Findings include:

Observation on 06/13/23 at 11:16 A.M., revealed an uncovered trash can directly next to the steel prep table.

Interview on 06/13/23 11:30 A.M., with Cook #30 verified the trash can was not covered. Cook #30 verified the trash can was not covered and there was no lid for the trash can available.

Observation on 06/13/23 at 3:30 P.M., revealed Cook #30 preparing chicken salad for the dinner meal on the prep table. The trash can remained directly next to the prep table and uncovered.

Based on record review and staff interview, the facility failed to ensure fire alarm transmission or receipt were verified within twelve hours of conducting a silent fire drill. This had the potential to affect 41 of 41 residents in the facility. The census was 41.

Findings include:

Review of the assisted living (AL) and Memory Care (MC) fire drills conducted conducted between 9:00 P.M. and 6:00 A.M., revealed no alarm system was used to announce the drill. The Fire Department was not notified. There was no evidence of verification of the alarm transmission being completed within twelve hours of the fire drill.

The drills were as follows: on 08/07/22 at 9:15 P.M. and at 9:25 P.M.; on 09/17/22 at 11:10 P.M. and 09/18/22 at 3:10 A.M.; on 11/28/22 at 10:12 P.M. and at 10:31 P.M.; on 12/13/22 at 6:30 A.M. and at 6:15 A.M.; and on 03/09/23 at 2:20 A.M. and at 6:15 A.M.

Interview on 06/13/23 at 2:05 P.M., with Environmental Service Manager (ESM) #19 verified there was no evidence of verification of alarm transmission being completed within twelve hours of each documented fire drill. ESM #19 stated he was told he didn't have to do that anymore.

Based on observation and staff interview, the facility failed to ensure all toileting facilities had a call system available to residents. This had the potential to affect 15 of 15 residents residing on the memory care unit. The facility census was 41.

Findings include:

Observation on 06/13/23 at 12:25 PM, revealed the unlocked bathroom on memory care unit, across from dining room #1, was not equipped with a call system in bathroom.

Interview on 06/13/23 at 12:25 PM, with Care Provider (CP) #28, verified the bathroom door is not locked and there is no call system in the bathroom. CP #28 stated independently mobile residents utilize the bathroom across from the dining room.