Hamlet at Chagrin Falls

Based on closed record review and interview, the facility failed timely identify and treat a urinary tract infection for Resident #80 and failed to to ensure personal care services for Resident #80 showers and wound care were implemented properly. This affected one resident (#80) of four residents reviewed for personal care services. The facility census was 77.

Findings include:

Review of Resident #80's closed medical record revealed the resident was admitted on 11/19/20 and transferred to the hospital on 04/03/25. The resident did not return to the facility following the hospitalization. Resident #80 had diagnoses including vascular dementia, essential primary hypertension, age-related osteoporosis without current pathological fracture and unspecified nondisplaced fracture of the seventh cervical vertebra initial encounter for closed fracture (dated 12/03/20).

Review of Resident #80's Brief Interview for Mental Status (BIMS) form dated 01/31/25 revealed the resident had moderate cognitive impairment.

a. Review of Resident #80's medical record revealed the resident was scheduled for showers Wednesday, Friday and Sunday.

Review of Resident #80's Service Plan Report dated 02/13/25 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to an impaired gait.

Review of Resident #80's shower documentation from 02/01/25 to 04/30/25 revealed no evidence the resident received scheduled showers on 02/02/25, 02/05/25, 03/17/25, 03/19/25, 03/21/25, 03/23/25, 03/26/25, 03/28/25 or 03/30/25.

Interview on 11/06/25 at 7:12 A.M. with Care Companion Supervisor #807 revealed on 03/05/25 she had went to check on the resident and a facility caregiver had the resident sitting on the toilet with the lid closed. Care Companion Supervisor #807 revealed the caregiver was providing a sponge bath to the resident and the resident kept repeating stop, the water was cold. Care Companion Supervisor #807 confirmed the caregiver did not stop bathing the resident and revealed the facility was not showering the resident appropriately. Care Companion Supervisor #807 revealed she reported the concern to the Director of Nursing (DON).

Interview on 11/06/25 at 10:32 A.M. with the Director of Nursing (DON) confirmed the resident did not get showers as scheduled. At the time of the interview, the DON denied knowledge of Resident #80 being bathed in cold water on 03/05/25.

On 11/13/25 at 8:38 A.M. interview with Resident #80's daughter revealed concerns related to personal care. the daughter revealed the resident did not receive showers as ordered and believed the resident was showered in cold water as retaliation for her (family) complaining about the resident's care.

b. Review of Resident #80's physician orders revealed an order dated 03/13/25 for Cephalexin capsule 500 mg(antibiotic) one capsule by mouth twice daily (14 doses) for seven days for a urinary tract infection (UTI).

Review of Resident #80's MAR and TAR from 03/13/25 to 03/20/25 revealed 12 doses of the antibiotic were administered instead of 14 as ordered.

Review of Resident #80's urology After Visit Summary form dated 03/18/25 revealed the instructions following the visit included bladder hygiene and peri care daily. The form indicated the prevention of recurrent UTIs can take several months. The following plan would be instituted including to encourage plenty of water, bowel regimen (MiraLax) to promote one soft bowel movement per day, timed voiding every two to three hours, a probiotic, daily d-mannose and daily cranberry tablets.

Review of Resident #80's Documentation Survey Report form from 03/18/25 to 04/03/25 did not reveal evidence of timed voiding or peri care daily to reduce the likelihood of a UTI.

Review of an Emergency Department (ED) Provider Note dated 04/03/25 revealed the resident presented to the ED with a history of hypercholesterolemia and hypertension with dementia for evaluation of a fall. The resident was a poor historian who apparently had a walker to ambulate at baseline and she had an unwitnessed fall just before coming to the emergency department (ER). The resident's record revealed the resident had a UTI and antibiotics were ordered though no fever or other red flags were noted to suggest the resident was septic (from the UTI).

Interview on 11/06/25 at 9:11 A.M. with the DON confirmed Resident #80's antibiotic was not administered as ordered.

Interview on 11/06/25 at 11:16 A.M. with the DON confirmed Resident #80's medical record did not reveal evidence of timed voiding or daily peri care as instructed in the urology discharge documentation to reduce the likelihood of recurrent UTIs. The DON confirmed the resident had two documented UTI's while residing in the facility which were treated with antibiotics.

On 11/13/25 at 8:23 A.M. interview with Resident #80's daughter revealed concerns related to the her mother developing UTIs. The daughter indicated a third UTI was identified when the resident was sent to the emergency room on 04/03/25 (the UTI was first diagnosed in the ER). The daughter stated the UTI was really bad. Resident #80's daughter revealed she had concerns with the facility not appropriately monitoring the symptoms related to UTI's. The daughter stated in the care conference on 03/05/25 at 10:15 A.M. the DON tried to get the resident to get a low dose antibiotic but the nurse practitioner did not feel the resident needed these antibiotics.

c. Review of Resident #80's progress note dated 03/13/25 at 3:02 P.M. revealed the power-of-attorney (POA) notified the nurse the resident may have a new wound that no one knew about due to a bandage being on it (the family had not been notified). The nurse went to the resident's apartment and noted a small pink dressing to the resident's lower left leg. The nurse removed the dressing and noted small scabs. The nurse asked the resident what happened and the resident was unable to say. The scabs were left open to air and the nurse reported back to the POA about the dressing that was present on the wound.

Review of Resident #80's medical record did not reveal evidence the physician was notified of the wound to the left lower leg as well as continued monitoring and/or treatments to the left lower leg wound.

Interview on 11/10/25 at 8:49 A.M. with the DON confirmed Resident #80's medical record did not have evidence the physician was notified or monitoring and treatments for Resident #80's lower left leg wound.

On 11/13/25 at 8:38 A.M. interview with Resident #80's daughter revealed on 03/23/25 the resident was hospitalized and a dressing was observed on the lower left leg without knowledge of what the wound was or what caused it.

Review of the Resident Care Services policy revised 05/03/21 revealed personal care would be provided to all residents based on an individual basis according to findings from admission appraisals and subsequent re-appraisals. All resident care was planned and delivered in a resident-centered manner, and personal service plans should address any individual resident needs.

This violation represents non-compliance identified under Complaint Number OH00167825.

Based on closed record review, interview and facility policy review, the facility failed to ensure Resident #80's medications were administered as ordered. This affected one resident (#80) of three resident reviewed for medications. The facility census was 77.

Findings include:

Review of Resident #80's closed medical record revealed the resident was admitted on 11/19/20 and discharged to the hospital on 04/03/25. Resident #80 had diagnoses including vascular dementia, essential hypertension and age-related osteoporosis.

Review of Resident #80's Brief Interview for Mental Status (BIMS) form dated 01/31/25 revealed the resident exhibited moderate cognitive impairment.

a. Review of Resident #80's progress note dated 01/31/25 at 2:32 P.M. revealed the resident returned to the facility around 10:45 A.M. The resident had been hospitalized and in a skilled nursing facility prior to this date.

Review of Resident #80's medication administration record (MAR) and treatment administration record (TAR) dated 01/31/25 revealed two entries including Tylenol 325 milligrams (mg) every two hours as needed and artificial tears daily. The resident did not receive the Tylenol as needed but received the artificial tears. No other orders were documented on the form.

Review of Resident #80's MAR and TAR dated 02/01/25 revealed the resident was ordered Atorvastatin 10 mg at bedtime (administered), Calcium Plus D 600/400 every day (not administered), Lisinopril 5 mg every day (not administered), Mirabegron 25 mg daily (not administered), Sertraline 25 mg every day (not administered), eye drops both eyes twice daily (not administered in the morning but administered at night).

Review of Resident #80's general note form dated 02/01/25 at 9:26 A.M. revealed the medication delivery was pending.

On 11/11/25 at 12:01 P.M. information provided by Resident #80's daughter revealed the family had concerns the resident was not administered ordered medications upon her return to the facility on 01/31/25.

On 11/12/25 at 4:25 P.M. information from the Director of Nursing (DON) revealed Resident #80's new medication list arrived to the facility and was profiled by the pharmacy upon her return to the facility on 01/31/25. Although the MAR and TAR indicated the resident did not receive medications as ordered the DON claimed the resident did not go without medications. The DON provided no further information as to the MAR/TAR indicating the medications were not administered.

On 11/13/25 at 8:31 A.M. interview with Resident #80's daughter revealed she had visualized the resident's medications in the medication cart several days prior to the resident returning to the facility on 01/31/25 and she was upset because the resident did not receive her medications as ordered on 01/31/25 and 02/01/25. Resident #80's daughter revealed the sister personally handed the resident's discharge paperwork to the facility upon her return to the facility.

On 11/13/25 at 9:06 A.M. interview with Pharmacist #818 revealed Resident #80's medications including Mirabegron, Artificial tears, Calcium, Tylenol, Atorvastatin, Lisinopril and Sertraline were delivered on 02/01/25 at 2:21 A.M.

b. Review of Resident #80's physician orders revealed an order dated 03/13/25 for Cephalexin capsule 500 mg(antibiotic) one capsule by mouth twice daily (14 doses) for seven days for a urinary tract infection (UTI).

Review of Resident #80's MAR and TAR from 03/13/25 to 03/20/25 revealed 12 doses of the antibiotic were administered instead of 14 as ordered.

Interview on 11/06/25 at 9:11 A.M. with the DON confirmed Resident #80's antibiotic was not administered as ordered.

c. Review of Resident #80's medical record revealed the resident was admitted on 11/19/20, discharged out to the hospital on 12/03/24, readmitted on 01/31/25, discharged to the hospital on 02/23/25 and readmitted on 02/24/25 and discharged out to the hospital on 04/03/25. The resident did not return to the facility after being transferred to the hospital on 04/03/25.

Review of Resident #80's urology After Visit Summary form dated 03/18/25 revealed the instructions following the visit included bladder hygiene, peri care daily, encourage plenty of water, bowel regimen (MiraLAX) to promote one soft bowel movement per day, timed voiding every two to three hours, start a daily probiotic, d-mannose and cranberry tablets.

Review of Resident #80's MAR and TAR from 03/18/25 to 04/03/25 did not reveal evidence the MiraLAX was administered as ordered.

Interview on 11/06/25 at 11:16 A.M. with the DON confirmed Resident #80's medical record did not reveal evidence the MiraLAX was administered as ordered.

Review of the facility undated Medication Administration policy revealed nurse must use at least two unique identifiers, other than room number, prior to all procedures including the administration of medications.

This violation represents non-compliance identified under Complaint Number OH00167825.

Based on closed record review, interview, and facility policy review, the facility failed to take immediate and proper steps, and implement comprehensive, individualized and necessary intervention(s) to decrease Resident #80's risk of falls and/or injuries associated with falls. In addition, the facility failed to ensure Resident #80 was comprehensively assessed following falls, failed to ensure appropriate interventions were in place post-fall, and failed to ensure notification of falls to the physician were completed. This affected one resident (#80) of three residents reviewed for falls. The facility census was 77.

Actual harm occurred on 04/03/25 when Resident #80, who had a diagnosis of vascular dementia with moderate cognitive impairment and a history of falls sustained a fractured neck (C-1 and C-2) as a result of a fall. Prior to the fall incident, there was no evidence the facility had comprehensive, individualized and effective intervention(s) in place to decrease Resident #80's risk of falls and/or injuries associated with falls.

Findings include:

Review of Resident #80's medical record revealed the resident was admitted to the facility on 11/19/20 and discharged on 04/03/25 to the hospital. The resident did not return to the facility. Resident #80 had diagnoses including vascular dementia, essential primary hypertension, age-related osteoporosis without current pathological fracture and unspecified nondisplaced fracture of the seventh cervical vertebra initial encounter for closed fracture.

Review of Resident #80's fall/safety plan interventions that were in place prior to the fall on 11/17/24 revealed to ensure non-skid footwear, medication reconciliation, frequent safety checks and physical therapy (PT) and occupational therapy (OT). The plan did not specify the actual frequency that safety checks would be completed.

Review of Resident #80's progress note dated 11/17/24 at 7:07 P.M. authored by Licensed Practical Nurse (LPN) #801 revealed the resident reported a fall during the night and sustained a skin tear to the upper right arm. The area was left open to air with no pain. The resident stated she fell while trying to get into bed and did not hit her head. The progress note revealed the resident's power of attorney (POA) was notified. However, there was no written evidence the physician was notified. Record review revealed no evidence new fall safety interventions were implemented following this fall/incident.

Review of Resident #80's Fall Incident report form dated 12/02/24 at 10:31 P.M. revealed the resident was on the floor and lying on her left shoulder/arm. The resident stated she was in a lot of pain. The resident's daughter was called and advised to have her mother sent to the hospital. The form did not have evidence the physician was notified of the resident's fall. A progress note dated 12/03/24 at 3:47 A.M. authored by LPN #802 revealed the nurse contacted the emergency department to get a report and was told of a possible fracture of her the resident's shoulder.

Record review revealed no nursing progress note was completed following the fall on 12/02/24. There was no comprehensive assessment of the resident including an assessment of the resident's vital signs (blood pressure, pulse, respiration and temperature) or range of motion at the time of the incident.

Review of Resident #80's Status Post Fall interventions dated 12/03/24 at 8:13 P.M. revealed the facility implemented call don't fall signs, a nightlight and PT/OT upon return from the hospital. A new intervention noted was the use of a nightlight.

Review of Resident #80's progress note dated 12/13/24 at 12:49 P.M. revealed the resident was discharged from the hospital to a rehab facility.

Review of Resident #80's progress note dated 01/31/25 at 2:32 P.M. revealed the resident returned (re-admitted) to the facility around 10:45 A.M.

Review of Resident #80's Brief Interview for Mental Status form dated 01/31/25 revealed the resident had moderate cognitive impairment.

Review of Resident #80's evaluation form dated 01/31/25 revealed the resident was capable of independent decision making, required facility staff for medication management, was independent with eating on a regular diet, required (staff) assistance with bathing and dressing, required a manual wheelchair for mobility and had more than one fall in the last three months. The evaluation was not specific to the resident's fall safety and/or supervisory needs to prevent falls/accidents.

Record review revealed an activities of daily living (ADL) self-care service plan dated 01/31/25 that revealed Resident #80 wound maintain current level of function. Interventions included (staff) assisting with dressing every morning and at bedtime created 02/05/25; an intervention dated 01/31/25 to assist with showering for safety and assist with escorting to the dining room for each meal. The plan revealed the resident required safety checks every shift and to check the resident's apartment for tripping hazards.

Review of Resident #80's progress note dated 02/04/25 at 3:52 P.M. authored by LPN #801 revealed the nurse was notified the resident had a fall. The nurse observed the resident lying on her back next to the bed. The resident stated she tried to get into bed and lost her balance but did not hit her head. No injuries were noted. Family and physician were notified. Vitals were completed including blood pressure, heart rate and temperature. Review of the fall interventions revealed following the incident the facility indicated they would remind the resident not to get up without assistance; remind the resident to call for assistance; and complete every two-hour safety checks. Record review revealed the resident had been on frequent safety checks prior to her hospitalization for a fall with injury in December 2024.

Review of Resident #80's Documentation Survey Report form (caregiver tracking) dated 02/04/25 revealed documentation of two-hour safety checks for day shift (7:00 A.M. to 3:00 P.M.) at 9:21 A.M. and third shift (11:00 P.M. to 7:00 A.M.) at 6:59 A.M. The medical record did not have evidence of second shift (3:00 P.M. to 11:00 P.M.) safety checks being completed on this date.

Review of Resident #80's progress note dated 02/06/25 at 1:35 P.M. (for date of occurrence on 02/05/25 at 11:25 A.M.) authored by the Director of Nursing (DON) revealed the resident was observed sitting on the floor while holding herself up on her right arm. A skin tear was noted on the left side of the resident's forehead. The resident was assisted to her wheelchair. The POA and physician were notified. Record review noted fall safety interventions included call pendant in place, safety checks every two hours (however there was no written evidence this was being completed), non-skid footwear and therapy orders obtained. Record review revealed no new fall safety interventions were initiated following this fall or evidence the existing interventions were individualized and effective to address the resident's fall risk and repeated falls.

Review of Resident #80's Documentation Survey Report dated 02/05/25 revealed two-hour safety checks during the day shift were documented at 8:15 A.M. The documentation did not reveal evidence two-hour checks were completed from 3:00 P.M. to 7:00 A.M. (second shift and third shift) on this date.

Review of Resident #80's progress note dated 02/12/25 at 10:40 A.M. authored by LPN #804 revealed the nurse observed the resident at 10:00 A.M. lying on the floor in front of her bed. The physician and POA were notified. Interventions included call pendent in place, safety checks every two hours, non-skid footwear, therapy and more assistance with ADLs. Record review revealed no new fall safety interventions were initiated following the incident or evidence the existing interventions were individualized and effective to address the resident's fall risk and repeated falls.

Review of Resident #80's Documentation Survey Report form dated 02/12/25 revealed no evidence two-hour safety checks were completed from 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. on this date (first, second and third shifts) on this date.

Record review revealed the resident did receive therapy services from 02/20/25 until 04/02/25. The resident was discharged from therapy due to the resident's discharge to the hospital (on 04/03/25). At discharge the resident was at risk of falls, required (staff) set up or clean up assistance with sit to stand, was fearful of falling, and worried about falling. Record review revealed no evidence a comprehensive, individualized and effective fall safety plan was in place during this time period to address the resident's continued risk of falls, fear of falling and/or worry about falling.

Review of Resident #80's urology After Visit Summary form dated 03/18/25 revealed the instructions following the visit included bladder hygiene and peri care daily. The form indicated the prevention of recurrent UTIs can take several months. The following plan would be instituted including to encourage plenty of water, bowel regimen (MiraLax) to promote one soft bowel movement per day, timed voiding every two to three hours, a probiotic, daily d-mannose and daily cranberry tablets.

Review of Resident #80's Documentation Survey Report form from 03/18/25 to 04/03/25 did not reveal evidence of timed voiding or peri care daily to reduce the likelihood of a UTI.

Review of an Incident Note dated 04/03/25 at 3:39 P.M. revealed the resident came to the nursing station and showed the nurse a skin tear on the right forearm. The resident did not know how the wound occurred. The note indicated the nurse cleansed the wound and covered it with an adhesive bandage. The nurse notified the resident's power of attorney. There was no evidence of new safety interventions being initiated following the identification of this injury.

Review of Resident #80's progress note dated 04/03/25 at 5:53 P.M. authored by LPN #805 revealed the resident stated she fell and hit her head. The POA was notified, and the resident was sent to the hospital. A progress note dated 04/03/25 at 6:00 P.M. revealed the provider/physician was notified. The note failed to contain where the resident fell, the circumstances of the fall and/or an investigation of the fall.

Review of Resident #80's Documentation Survey Report form dated 04/03/25 revealed fall interventions included two-hour safety checks which were documented as resident unavailable (RU) at 6:54 A.M. and 2:59 P.M. and out of the facility (OO) at 5:11 P.M. and a fall intervention for caregivers to make sure call pendant was in place which was documented on 04/03/25 at 12:00 A.M. as in place, 2:00 A.M. as in place, 4:00 A.M. as in place, 6:00 A.M. as in place, 8:00 A.M. as resident unavailable (RU), 10:00 A.M. as RU, 12:00 P.M. as RU, 2:00 P.M. as RU, 4:00 P.M. as in place and 6:00 P.M. as in place.

Review of a squad report form dated 04/03/25 revealed the squad arrived to Resident #80 at 4:52 P.M. and left the facility at 5:10 P.M. arriving at the hospital at 5:24 P.M. The report documented a female resident who had fallen and was complaining of neck pain. On scene, the resident was lying in bed and stated that she fell forwards on the carpet in her room and hit her head and now she had neck pain. The resident stated she did not lose consciousness when she fell and that she was not on blood thinners. The resident stated that she did not have pain or tenderness to her neck or back on palpitation but when she's not holding her neck, it hurt. The resident was put into a C-collar and then helped from the bed to a cot with no signs of visible injuries upon assessment. The resident was brought to the ambulance for further assessment. In the ambulance, vital signs and intravenous access and a three-lead electrocardiogram (EKG) were completed. The resident was transported to the hospital per the daughter's request over the phone. The squad report revealed the resident's blood pressure remained very high and the hospital was notified.

Review of the Emergency Department (ED) Provider Note dated 04/03/25 revealed the resident with a history of hypercholesterolemia and hypertension with dementia presented for evaluation of a fall. The resident was a poor historian who apparently had a walker to ambulate at baseline, and she had an unwitnessed fall just before coming to the emergency room (ER). The resident fell forward striking her face and there was a small abrasion of her forehead. She also complained of neck pain and held her right hand up to her posterior neck stating it felt better to hold her hand in this position. The resident had no numbness or tingling and denied any antecedent symptoms such as lightheadedness, palpitations, or chest pain to suggest syncope. She denied a headache and denied visual disturbance or nausea and repeatedly refused a cervical collar from the paramedics. The resident's record did not have specific reference to a previous cervical fracture, but she did have multilevel cervical spondylosis with degenerative anterolisthesis of the C5 and C6.

Review of Resident #80's cat scan (CT Scan) dated 04/03/25 at 7:26 P.M. revealed no acute intracranial abnormality was identified. C1 and C2 fractures with traumatic subluxation of the lateral masses of C1 relative to the body of C2.

Review of Resident #80's CT of the Head with intravenous contrast dated 04/03/25 at 10:15 P.M. revealed the resident had an acute fracture of the anterior C1 and bilateral posterior C1 arches (right greater than left). Mild chronic compression fracture deformity of T3. Severe chronic compression fracture deformity of T7.

Review of Resident #80's progress note dated 04/05/25 at 6:34 P.M. authored by LPN #801 documented the resident had a fractured neck with a large bruise to the left shoulder and eye. Per the nurse, the resident had a fractured neck, a large bruise to the left shoulder and eye, an unhealed fracture to the left clavicle, high blood pressure and confusion which required a sitter due to the resident constantly trying to take the neck brace off. No discharge date was provided.

Review of Resident #80's progress note dated 04/14/25 at 1:25 P.M. revealed the family called the facility and reported the resident had passed away because she broke her neck.

On 10/15/25 at 1:00 P.M. interview with the DON confirmed Resident #80's physician was not notified of the resident's falls on 11/17/24 or 12/02/24 and new safety/fall risk interventions were not implemented that were comprehensive or individualized to decrease the resident's risk of falls including falls with injury. Additionally, the DON confirmed Resident #80's medical record did not have evidence of comprehensive assessments being completed following falls including vital signs (blood pressure, respirations, pulse and temperature).

Interview on 11/06/25 at 11:16 A.M. with the DON confirmed Resident #80's medical record did not reveal evidence of timed voiding or daily peri care as instructed in the urology discharge documentation to reduce the likelihood of recurrent UTIs.

On 11/07/25 at 7:57 A.M. information provided from the DON revealed the nursing staff did not document Resident #80's fall on 02/05/25 specifically under the incident report tab in the electronic health record so the DON corrected the error and that was why the incident note in the electronic medical record and the progress note did not match the date and time.

On 11/10/25 at 10:34 A.M. interview with LPN #805 revealed Resident #80 came to her and reported a skin tear on 04/03/25. The LPN was unable to state how the skin tear occurred and LPN #805 revealed the resident did not report a fall and she didn't know how the skin tear occurred. During the interview LPN #805 revealed she was called to the resident's room by Caregiver #815 later on this same day and upon arriving to the resident's room, the resident was in bed. LPN #805 stated she interviewed the resident and the resident reported she had fallen, picked herself up off the floor and crawled into bed.

A telephone interview on 11/10/25 at 10:42 A.M. with Caregiver #815, who found Resident #80 on the floor on 04/03/25, revealed she did not remember the resident or remember specific information related to the resident's falls on this date.

On 11/12/25 at 2:01 P.M. a follow-up interview with the DON revealed Resident #80 had sustained C1 to C2 fracture of the neck following the fall on 04/03/25. The DON verified there was no information obtained or available from Caregiver #815, the staff member who found the resident on the floor. During the interview the DON revealed she was unaware why staff documented RU for the safety checks on 04/03/25 when the resident was in the facility. The DON also confirmed she was unaware of why staff had documented RU for the call pendant checks on 04/03/25 from 8:00 A.M. to 2:00 P.M. The DON confirmed the resident's fall interventions in place included only safety checks (which were not routinely documented as being completed) and the use of a call pendant.

On 11/12/25 at 2:27 P.M. interview with Resident #80's daughter revealed she had concerns related to her mother's care at the facility and concerns with the falls she sustained. The daughter revealed family was not notified of the resident's falls on 11/17/24, 02/04/25, or 02/12/25. Further interview with the daughter revealed she was informed on 02/13/25 that the resident had fallen twice on this date (contrary to the resident's medical record). Resident #80's daughter indicated due to the facility not providing notification of falls, the family hired care companions to sit with the resident (which began on 02/15/25). The care companions were designed to visit with the resident and not provide hands on care. The daughter also indicated LPN #805 called her and reported a fall earlier in the day on 04/03/25 but then the incident report she received (concerning the skin tear) did not reflect a fall. The daughter indicated family was notified later in the day of a fall with the resident complaining of neck pain. Resident #80's daughter voiced concerns that as a result of the fall, the resident had the large bruise on the left shoulder but she did not feel the injuries were consistent with a fall. The family member felt the facility caregiver or nurse must have picked the resident up off the floor and put the resident back in bed instead of the facility report of the resident putting herself back in bed. She felt the resident would not have been able to put herself back in bed due to the extent of her injuries. Resident #80's daughter revealed the care companion hired to work on 04/03/25 was just walking into the resident's room on this date when the resident was being transported to the hospital and did not witness the fall.

On 11/12/25 at 2:55 P.M. an attempted to reach LPN #816 (the day shift nurse on 02/13/25) was unsuccessful.

On 11/12/25 at 3:01 P.M. interview with LPN #817 (the nightshift nurse on 02/13/25) revealed the nurse could not remember a fall for Resident #80 on 02/13/25.

Telephone interview on 11/13/25 at 8:23 A.M. with Resident #80's daughter revealed the resident's third UTI was identified when she was sent to the emergency room on 04/03/25 (when they found it). She stated it was bad at this time. Resident #80's daughter revealed she had concerns with the facility not appropriately monitoring the symptoms related to UTI's.

Review of the Falls Management Program policy dated 10/02/23 indicated if a resident falls, the following steps were to be taken including the resident's vital signs (pulse, temperature, respirations and blood pressure), inspection for bruises, swelling and lacerations, level of consciousness, presence of pain, presence of other injuries, notification to the physician and family representative and a post fall risk assessment should be completed.

This violation represents non-compliance identified under Complaint Number OH00167825.

Based on closed record review and interview the facility failed to ensure fall incidents were thoroughly investigated to determine a root cause/circumstances of the fall and failed to ensure all falls/incidents were documented on the facility incident and accident log as required. This affected one resident (#80) of three residents reviewed for falls. The facility census was 77.

Findings include:

Review of Resident #80's closed medical record revealed the resident was admitted to the facility on 11/19/20 and discharged on 04/30/25. Resident #80 had diagnoses including vascular dementia, essential primary hypertension, age-related osteoporosis without current pathological fracture and unspecified nondisplaced fracture of the seventh cervical vertebra initial encounter for closed fracture.

Review of Resident #80's progress note dated 11/17/24 at 7:07 P.M. authored by Licensed Practical Nurse (LPN) #801 revealed the resident reported a fall during the night and sustained a skin tear to the upper right arm. The resident stated she fell while trying to get into bed and did not hit her head. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident. In addition, staff did not complete a Fall Investigation Report form to indicate the description of the incident, immediate action taken, injuries observed at the time of the incident, level of pain, mental status, injuries reported post incident, predisposing environmental factors, predisposing physiological factors, predisposing situation factors and any other information.

Review of Resident #80's Fall Incident report form dated 12/02/24 at 10:31 P.M. revealed the resident was on the floor and lying on her left shoulder/arm. The resident stated she was in a lot of pain. The resident's daughter was called and advised to have her mother sent to the hospital. A progress note dated 12/03/24 at 3:47 A.M. authored by LPN #802 revealed the nurse contacted the emergency department to get a report and was told of a possible fracture of her left shoulder. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident.

Review of Resident #80's progress note dated 12/13/24 at 12:49 P.M. revealed the resident was discharged from the hospital to a rehab facility.

Review of Resident #80's progress note dated 01/31/25 at 2:32 P.M. revealed the resident returned to the facility around 10:45 A.M.

Review of Resident #80's progress note dated 02/04/25 at 2:52 P.M. authored by LPN #801 revealed the nurse was notified the resident had a fall. The nurse observed the resident lying on her back next to the bed. She stated she tried to get into bed and lost her balance but did not hit her head. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident.

Review of Resident #80's progress note dated 02/06/25 at 1:35 P.M. authored by the Director of Nursing (DON) revealed the resident was observed sitting on the floor while holding herself up on the right arm. A skin tear was noted on the left side of the forehead. The resident was assisted to her wheelchair. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident.

Review of Resident #80's progress note dated 02/12/25 at 10:40 A.M. authored by LPN #804 revealed the nurse observed the resident at 10:00 A.M. lying on the floor in front of her bed. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident.

Review of Resident #80's progress note dated 04/03/25 at 5:53 P.M. authored by LPN #805 revealed the resident stated she fell and hit her head. The POA was notified, and the resident was transferred to the hospital. Record review revealed no comprehensive investigation of the fall to determine the circumstances of the fall, root cause of the fall or staff statements to reflect staff knowledge or involvement in the incident. In addition, staff did not complete a Fall Investigation Report form to indicate the description of the incident, immediate action taken, injuries observed at the time of the incident, level of pain, mental status, injuries reported post incident, predisposing environmental factors, predisposing physiological factors, predisposing situation factors and any other information.

Review of Resident #80's progress note dated 04/05/25 at 6:34 P.M. authored by LPN #801 revealed the resident had a fractured neck with a large bruise to the left shoulder and eye. An unhealed fracture of the left clavicle with high blood pressure and confusion. The resident did not return to the facility.

Interview on 10/15/25 at 1:00 P.M. with the DON confirmed the resident's falls were not thoroughly investigated to determine the circumstances of the fall or root cause of the resident's falls.

On 11/07/25 at 7:57 A.M. information obtained from the DON revealed nursing staff did not document Resident #80's fall that had occurred on 02/05/25 specifically under the incident report tab in the electronic health record (EHR) so the DON corrected the error and that was why the incident note in the EHR and the progress note did not match the date and time.

On 11/10/25 at 10:34 A.M. telephone interview with LPN #805 revealed on 04/03/25 the resident came to her and told her she had a skin tear. LPN #805 denied the resident had reported she fell, and she did not know how the skin tear occurred. LPN #805 revealed later in the day, Caregiver #815 called her on the walkie and told her that Resident #80 had fallen. She stated when she went into the apartment, Resident #80 was in bed and stated she had put herself in bed. LPN #805 indicated the resident complained of neck pain and that was the reason she was sent to the hospital.

On 11/10/25 at 10:42 A.M. an attempt to interview Caregiver #815 revealed she did not remember Resident #80 and could not provide any details related to the fall.

This violation represents non-compliance identified under Complaint Number OH00167825.

Based on observation and interview the facility failed to ensure dryers were free of excessive lint. This finding had the potential to affect 28 residents on the first floor (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #28) and 20 residents on the second floor (Residents #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48). The facility census was 77.

Findings include:

Observation on 12/02/24 starting at 12:47 P.M. with Housekeeping Supervisor (HS) #222 revealed the laundry room on the first floor had two washers and two dryers. At 12:48 P.M. Housekeeper #219 pulled out the lint trap on one of the dryers which had a thick buildup of paper bits and lint and remarked, this hasn't been checked in a while.

Continued tour on 12/02/24 at 12:54 P.M. of the second floor (assisted living side) revealed one washer and one dryer present in the laundry room. HS #222 pulled out the lint trap and lint had collected onto the trap and had not been removed. At 1:05 P.M. observation of the second floor (memory care side) revealed one washer and one dryer present in the laundry room. HS #222 pulled out the lint trap and a large amount of lint had collected onto the trap and had not been removed.

Interviews with HS #222 during the observations confirmed the above findings. HS #222 indicated lint was to be removed from dryer lint traps after each use by housekeeping and/or caregiver staff.

Based on observation, interview, record review and review of the facility policy, the facility failed to prevent breaches in infection control during medication administration. This affected one resident (#45) of three residents observed during medication administration. The facility census was 77.

Findings include:

Review of Resident #45's medical record revealed an admission date of 03/24/23 and diagnoses included dementia, hypertension and anxiety.

Review of Resident #45's physicians' orders as of 12/02/24 revealed an order dated 08/23/23 for rivastigmine 4.6 milligram (mg)/24 hour patch, apply one transdermal patch topically once daily for dementia and remove per schedule and an order dated 08/23/23 for docusate sodium 100 mg softgel, give one capsule by mouth every morning and evening for constipation.

Observation of medication administration on 12/02/24 starting at 8:19 A.M. with Licensed Practical Nurse (LPN) #244 revealed eight oral medications were pre-packaged together for Resident #45 from the pharmacy as follows: acetaminophen 325 mg, Centrum silver vitamin, docusate sodium 100 mg, levothyroxine 75 micrograms (mcg), omeprazole 20 mg, quetiapine 25 mg, sucralfate one gram and turmeric 450 mg. LPN #244 popped the medications out of the blister pack into a medication cup. All medications but the turmeric, omeprazole and docusate sodium were placed into a pill pouch. LPN #244 donned gloves then crushed the medications in the pill pouch. The docusate sodium softgel fell into the open medication cart as medications were being moved around between the medication cup and pill pouch; LPN #244 retrieved the softgel from the base of the cart drawer and placed it back into the medication cup. The turmeric capsule and omeprazole were opened and added to the crushed medication and the docusate sodium was placed on top then also mixed around in the medication cup. At 8:26 A.M. LPN #244 dated a new rivastigmine patch for '12/2 8:26 A.M.' and placed the patch on the top of the medication cart. LPN #244 prepared memantine 5 milliliters (ml) of 2 mg/ml oral solution and administered that and Resident #45's oral medications to her. LPN #244 then removed the old rivastigmine patch off Resident #45's neck and back area, reaching around in the back of her sweater to do so. Without donning new gloves, LPN #244 applied the new rivastigmine patch to Resident #45's neck and back area.

Interview on 12/02/24 at 8:33 A.M. with LPN #244 revealed a medication dropped into the open medication cart should not be wasted as it did not hit the floor. LPN #244 confirmed she should have changed gloves between taking Resident #45's old rivastigmine patch off and placing the new patch on her body.

Interview on 12/02/24 at 8:52 A.M. with Health and Wellness Director (HWD)/LPN #282 verified LPN #244 should have wasted the docusate sodium and got a new capsule from the house stock in the correct dosage Resident #45 required after it fell into the medication cart. HWD/LPN #282 also confirmed gloves should be changed between taking off a topical patch and applying a new one.

Review of the facility policy, Standard Precautions: Infection Control

Based on observation, interview, and facility document review, the facility failed to discard foods upon expiration. This had the potential to affect all 77 residents in the facility.

Findings include:

Observation of the main kitchen on 12/02/24 starting at 9:23 A.M. with Director of Dining Services (DDS) #205 revealed in the dry stock room, there were seven boxes of honey cornbread with an expiration date of 01/19/22 and a box of hard taco shells with an expiration date of 10/29/24. Interview with DDS #205 confirmed the expired foods at the time of observation.

Observation of the memory care kitchenette on 12/02/24 starting at 9:47 A.M. with Memory Care Coordinator (MCC) #243 revealed in the pantry there were two bottles of Kid Essential supplement with an expiration date of 06/06/24, seven bottles of Boost supplement with an expiration date of 05/18/24 and three bottles of Premier Protein supplement with an expiration date of 05/27/24. Interview with MCC #243 confirmed the expired supplements at the time of observation.

Review of Relias Dietary Training dated 07/15/22 revealed all foods have a preferred temperature for storage and shelf life and you should always follow these guidelines, remembering that manufacturer's instructions and expiration dates must be followed.

Based on observation, interview and record review the facility failed to ensure the high temperature dishwashing machine hit the minimum temperature for effective sanitation. This had the potential to affect all 77 residents receiving food from the kitchen. Findings include: Observation of the kitchen on 12/02/24 starting at 9:37 A.M. with Director of Dining Services (DDS) #205 revealed a high-temperature dish machine with a placard located on it stating it required a minimum hot rinse temperature of 180 degrees Fahrenheit (F). The dish machine was run and both the wash and rinse gauges read 145 degrees F. A plate thermometer was placed into a rack during a dishwashing cycle at 9:40 A.M. and registered a maximum high temperature of 158.7 degrees F. A new plate thermometer was run through the dish machine at 9:44 A.M. and registered a maximum high temperature of 149.5 degrees F. Interviews with DDS #205 verified the observed temperatures at the time of discovery and indicated the dish machine normally ran 180 degrees F through its rinse cycle which was not achieved during the observation as required. Review of a Dining Site Visit Report dated 10/30/24 revealed the dish machine was not reaching 180 [degrees F] on rinse cycle. Order disc thermometer to check. Machine will need to be repaired if not reaching the required temperature. Review of an undated document, Defining DiningBased on observation, interview and record review the facility failed to ensure the high temperature dishwashing machine hit the minimum temperature for effective sanitation. This had the potential to affect all 77 residents receiving food from the kitchen.

Findings include:

Observation of the kitchen on 12/02/24 starting at 9:37 A.M. with Director of Dining Services (DDS) #205 revealed a high-temperature dish machine with a placard located on it stating it required a minimum hot rinse temperature of 180 degrees Fahrenheit (F). The dish machine was run and both the wash and rinse gauges read 145 degrees F. A plate thermometer was placed into a rack during a dishwashing cycle at 9:40 A.M. and registered a maximum high temperature of 158.7 degrees F. A new plate thermometer was run through the dish machine at 9:44 A.M. and registered a maximum high temperature of 149.5 degrees F.

Interviews with DDS #205 verified the observed temperatures at the time of discovery and indicated the dish machine normally ran 180 degrees F through its rinse cycle which was not achieved during the observation as required.

Review of a Dining Site Visit Report dated 10/30/24 revealed the dish machine was not reaching 180 [degrees F] on rinse cycle. Order disc thermometer to check. Machine will need to be repaired if not reaching the required temperature.

Review of an undated document, Defining Dining

Based on observation and interview, the facility failed to ensure first aid supplies were accessible as required. This affected 29 residents residing on the third floor (Residents #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76 and #77). Additionally, the facility failed to ensure first aid kits were free of expired eye wash affecting all 28 residents on the first floor (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #28) and 20 residents on the second floor (Residents #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, and #48). The facility census was 77.

Findings include:

Observation on 12/02/24 starting at 1:05 P.M. with Housekeeping Supervisor (HS) #222 revealed in the third floor laundry room, there was a first aid kit on the wall but it was secured with a zip tie and unable to be opened. A white sticker was noted on the front of the first aid kit with FOR STAFF ONLY DO NOT OPEN in black text on the label. HS #222 verified the kit was sealed and not accessible at the time of observation.

Observations on 12/02/24 starting at 1:30 P.M. with Health and Wellness Director (HWD)/Licensed Practical Nurse (LPN) #282 revealed the first aid kit on the second floor was in the nurses' station and contained an expired bottle of eye wash dated November 2024. Continued observation at 1:33 P.M. revealed the first aid kit in the third floor laundry room was sealed and not accessible as required. Observation at 1:42 P.M. revealed the first aid kit on the first floor was located in a copy room and contained an expired bottle of eye wash dated December 2007 and an expired bottle of eye wash dated August 2018. HWD/LPN #282 verified the expired eye washes on the first and second floors and the sealed and inaccessible first aid kit on the third floor at the time of discovery.

Interview on 12/02/24 at 1:39 P.M. with Director of Engineering (DE) #290 revealed he could not explain the label on the first aid kit on the third floor but shared the first aid kits came to the facility sealed with a zip tie when new and were placed on the floors about a year ago.

Interview on 12/02/24 at 1:44 P.M. with the Administrator revealed she was unaware the first aid kit on the third floor was sealed with a zip tie and labeled to not be opened and could not state how long the kit had been that way.

Based on observation, interview, record review and review of the facility policy, the facility failed to maintain privacy during medication administration. This affected one resident (#45) of three residents observed for medication administration. The facility census was 77. Findings include: Review of Resident #45's medical record revealed an admission date of 03/24/23 and diagnoses including dementia, hypertension and anxiety. Review of Resident #45's physicians' orders as of 12/02/24 revealed an order dated 08/23/23 for rivastigmine 4.6 milligram (mg)/24 hour patch, apply one transdermal patch topically once daily for dementia and remove per schedule. Observation of medication administration on 12/02/24 starting at 8:19 A.M. with Licensed Practical Nurse (LPN) #244 revealed eight oral medications and one liquid medication were prepared for administration for Resident #45. At 8:26 A.M. LPN #244 dated a new rivastigmine patch for '12/2 8:26 A.M.' and placed the patch on the top of the medication cart. LPN #244 then took her gloved hands to administer the oral medications to Resident #45 as she sat in the dining room. LPN #244 then took her gloved hands to remove the old rivastigmine patch off Resident #45's neck and back area, reaching around in the back of her sweater to do so. Without donning new gloves, LPN #244 applied the new rivastigmine patch to Resident #45's neck and back area. Interview on 12/02/24 at 8:33 A.M. with LPN #244 revealed she normally would apply a topical medication such as Resident #45's rivastigmine patch in a more private area, such as the resident's room. LPN #244 identified the nine residents that were present as she reached down Resident #45's back inside her sweater as Residents #9, #37, #38, #39, #40, #41, #42, #44 and #46. When asked about if this practice was dignified, LPN #244 stated she felt it was dignified for memory care and did not elaborate further. Interview on 12/02/24 at 8:52 A.M. with Health and Wellness Director (HWD)/LPN #282 verified LPN #244 should have taken Resident #45 back to her room for patch removal and application of a new patch. HWD/LPN #282 stated LPN #244 knew better. Review of the facility policy DignityBased on observation, interview, record review and review of the facility policy, the facility failed to maintain privacy during medication administration. This affected one resident (#45) of three residents observed for medication administration. The facility census was 77.

Findings include:

Review of Resident #45's medical record revealed an admission date of 03/24/23 and diagnoses including dementia, hypertension and anxiety.

Review of Resident #45's physicians' orders as of 12/02/24 revealed an order dated 08/23/23 for rivastigmine 4.6 milligram (mg)/24 hour patch, apply one transdermal patch topically once daily for dementia and remove per schedule.

Observation of medication administration on 12/02/24 starting at 8:19 A.M. with Licensed Practical Nurse (LPN) #244 revealed eight oral medications and one liquid medication were prepared for administration for Resident #45. At 8:26 A.M. LPN #244 dated a new rivastigmine patch for '12/2 8:26 A.M.' and placed the patch on the top of the medication cart. LPN #244 then took her gloved hands to administer the oral medications to Resident #45 as she sat in the dining room. LPN #244 then took her gloved hands to remove the old rivastigmine patch off Resident #45's neck and back area, reaching around in the back of her sweater to do so. Without donning new gloves, LPN #244 applied the new rivastigmine patch to Resident #45's neck and back area.

Interview on 12/02/24 at 8:33 A.M. with LPN #244 revealed she normally would apply a topical medication such as Resident #45's rivastigmine patch in a more private area, such as the resident's room. LPN #244 identified the nine residents that were present as she reached down Resident #45's back inside her sweater as Residents #9, #37, #38, #39, #40, #41, #42, #44 and #46. When asked about if this practice was dignified, LPN #244 stated she felt it was dignified for memory care and did not elaborate further.

Interview on 12/02/24 at 8:52 A.M. with Health and Wellness Director (HWD)/LPN #282 verified LPN #244 should have taken Resident #45 back to her room for patch removal and application of a new patch. HWD/LPN #282 stated LPN #244 knew better.

Review of the facility policy Dignity

Based on interview and record review the facility failed to maintain an accurate background check log to include the Executive Director and Licensed Practical Nurse (LPN) #600. The had the potential to affect all 81 residents living in the facility.

Findings included:

1. Review of personnel file for LPN #600 revealed a hire date of 12/27/21.

Review of undated BCI Log revealed LPN #600 was not on the log.

Interview 09/26/23 at 3:03 P.M. with Executive Director verified LPN #600 was not on the log.

2. Review of personnel file for Executive Director revealed a hire date of 05/05/21.

Review of undated BCI Log revealed Executive Director was not on the background check log.

Interview on 09/26/23 at 3:26 P.M. with Business Office Manager #604 verified the Executive Director was not on the background check log.

3. Review of undated BCI Log revealed the column under the titles of application date and start date were blank.

Interview on 09/26/23 at 4:35 P.M. with Executive Director verified the column under the titles of application date and start date were blank.

Review of facility handbook undated titled Criminal Background Check revealed all applicants hired would be subject to a criminal background check.

Based on observation, interview and policy review the facility failed to provide and maintain a sanitary kitchen. This had the potential to affect 81 residents.

Findings include:

1. Observation of the kitchen revealed the two shelved prep area across from the oven had dirt, crumbs, and dust on both levels.

Interview with Dietary Director #601 on 09/26/23 at 11:21 A.M. verified the dirt, crumbs and dust.

2. Observation of the kitchen revealed dried food dripped on the side of the sandwich cart, crumbs, dried food on the robo coupe (a food processor), and dried food on the spice rack.

Interview with the Dietary Director #601 on 09/26/23 at 11:40 A.M. verified the dirt, dried food and crumbs.

3. Observation of the kitchen revealed three large containers on wheels of flour, sugar and bread crumbs. All containers had dirt, and dried food on the top of the clear lids. The flour container had a styrofoam bowl in the bottom of it.

Interview on 09/26/23 at 11:47 A.M. with the Dietary Director #601 verified the dirt, dried food and the styrofoam bowl in the bottom of the flour. Dietary Director #601 revealed the staff should not be using the styrofaom bowl as a scoop.

Review of the undated Cook's Checklist revealed the cleaning procedures in the kitchen.

Based on interview and record review the facility failed to ensure two disaster preparedness drills were conducted in the last 12 months. This affected all 81 residents residing at the facility.

Findings included:

Review of disaster drills from September 2022 to September 2023 revealed the facility completed one tornado drill on 03/28/23 at 2:45 P.M.. There was no other evidence of any other disaster drills completed in the last 12 months.

Interview on 09/27 /23 at 7:55 A.M. with Director of Operations #603 verified the facility only completed one disaster drill (tornado) in the last 12 months.

Review of facility policy labeled, Emergency Preparedness Plan updated April 2023 revealed education and training would be utilized to achive proficiency during emergency response. The plan did not specify the frequency of disaster drills.

Based on observation and interview the facility failed to ensure all first aid supplies were maintained. This had the potential to affect all 81 residents.

Findings include:

Observation during environmental rounds on 09/26/23 from 1:49 P.M. to 2:38 P.M. with Director of Plant Operations (DPO) # 603 revealed in each laundry room on all three floors the eye wash expiration date was April of 2023.

Interview on 09/26/23 at 2:38 P.M. with DPO 3603 verified the eyewash in all three laundry rooms was expired.

Review of Emergency Preparedness Plan revised April of 2023 did not discuss first aid supplies.