The Gardens at Liberty Park

Based on interviews with staff and residents, record reviews and observations the facility did not ensure all residents were free from physical, verbal, mental and emotional abuse and were treated at all times with courtesty, respect and dignity. This affected three residents (#78, #47 and #93) out of seven residents reviewed for abuse/dignity/respect. The facility census was 93.

Finding include:

1. Review of Resident #78's medical record revealed an admission date of 08/29/22. Diagnosis included anxiety disorder, dysphasia, irritable bowel syndrome, and hypothyroidism.

Review of Resident #78's service plan revealed they had intact cognition, was periodically incontinent of bowel and bladder, required assist for toileting, routine skin care, and dressing.

Interview on 07/31/25 at 2:48 P.M. with the Ombudsman revealed on 07/10/25 Resident #78 reported to them they would like Resident Assistant (RA) #803 to be removed from his care. Resident #78 did not give further consent to provide details and just asked to notify the Administrative staff of this request so the Ombudsman did this via email. The Ombudsman stated she received a follow up email on 07/11/25 from the DON stating they completed an investigation and appropriate discipline was given to RA #803. The Ombudsman stated on 07/15/25 she was informed RA #803 was terminated from the facility on 07/14/25 due unsatisfactory job performance and the situation that occurred with Resident #78.

Interview on 07/31/25 at 3:25 P.M. with the Administrator revealed the DON was currently under suspension due to lack of communication and was available by phone for interview. The Administrator stated Resident #78 reported to the DON RA #803 was verbally abusive. The Administrator stated she was not part of the investigation and was unwarned there were allegations on physical abuse as well until after RA #803 was terminated. The Administrator confirmed both the physical and verbal abuse reported to the DON was not reported to the State agency and revealed she only reports PA to the state agency and was not required to report anything else.

Interview on 08/05/25 at 2:12 P.M. with the DON revealed she spoke with Resident #78 on 07/11/25 regarding request for RA #803 be removed from his care and the resident stated RA #803 grabbed him by his shirt collar and shoved him into his wheelchair, and threw his shoe at him and yelled at him to put his (expletive) shoes on. The DON stated the resident does not make things up and believed this situation happened. The DON spoke with RA #803 via a phone call on 07/11/25 and notified them they were suspended until the investigation was complete. The DON stated RA #803 stated there was no physical or verbal abuse. RA #803 was then terminated on 07/14/25 due to the allegations of abuse and other complaints rough care, RA #803 had been disciplined prior for becoming defensive with staff. The DON stated when questioned if they interviewed any other residents they stated no, the DON stated they did not interview other staff on duty at time of incident, they did not complete an incident report nor did they report the allegations of physical and verbal abuse to the state agency.

Interview on 08/05/25 at 2:36 P.M. with Resident #78 revealed he believed he was both physically and verbally abused by RA #803. Resident #78 stated he was aware RA #803 was fired and felt safe at the facility now. Resident #78 stated RA #803 grabbed him by his shirt collar and shoved him sideways into his wheelchair and did not help to reposition him and then threw his shoes at him and stated Put your (expletive) shoes on.

2. Review of Resident #47's medical record revealed an admission date of 06/01/20, diagnosis included anemia, anxiety, aortic aneurysm, cerebral infarction and hypertension.

Review of Resident #47's Service plan dated 07/08/25 revealed the resident had intact cognition was independent with mobility, incontinent at times and required use of assistive device including a cane and wheelchair.

3. Review of Resident #93's medical record revealed and admission date of 12/02/20. Diagnosis included osteoporosis, hypertension, and mild cognitive impairment.

Review of Resident #93's Service plan dated 06/30/25 revealed the resident was oriented to self and had moderate to severe impairment of her short term and long term memory. Resident #93 required use of walker with assist by one staff member, toileting every two hours, and cues or supervision with activities of daily living.

Interview on 07/31/25 at 2:58 P.M. with Resident #93's daughter revealed she had brought multiple concerns to the administrative team including providing video footage of staff RA #804 smoking their vape pen in the residents room and felt it was not being taken care of appropriately as this staff was still working at the facility and stated they felt their mother was not treated with dignity or respect due to RA #804 smoking in the resident's room. There was also footage of RA #804 on their phone when they were supposed to be providing care for Resident #93.

Observation on 08/07/25 3:20 P.M. RA #804 was observed to be sleeping in resident common area with Resident #47 attempting to get their attention for assistance.

Interview on 08/07/25 at 3:26 P.M. with Resident #47 revealed RA #804 does not treat them with respect or dignity, they are always on their cell phone and not providing care for the resident when needed, they have observed RA #804 using their vape pen in resident care areas. Resident #47 stated for example today RA #804 was sleeping in the common area and they were trying to get his attention due to needing assistance in her room.

Observation on 08/07/25 at 4:08 P.M. of RA #804 in resident common area on his phone with Resident #47 attempting to speak with him related to their care and they did not acknowledge the resident.

Interview on 08/07/25 at 4:08 P.M. with RA #804 revealed they confirmed they were sleeping and not aware a resident was attempting to get their attention, and confirmed they were on their phone ignoring Resident #47.

Interview on 08/07/25 at 4:15 P.M. with the Administrator revealed they were aware RA #804 was caught on Resident #93's camera and watched the video footage of RA #804 smoking their vape pen and on their phone and were disciplined for these issues.

This violation represents non-compliance investigated under Complaint Number OH00167543, OH00165862

Based on interview, record review, facility investigation review, and schedule review, the facility failed to ensure sufficient staffing levels to provide appropriate supervision and treatment when Resident #93 fell. This affected one resident (Resident #93) with the potential to affect all 92 residents residing in the facility.

Findings include:

Closed record review revealed Resident #93 was admitted to the facility on 01/26/24 with diagnoses including anxiety, insomnia, ataxia post cerebrovascular disease, constipation, hypertension, and Alzheimer's. Resident #93 was discharged on 09/08/24.

Review of the plan of care for Resident #93 revealed the resident was a high risk for falls and had deficits in self-care. Interventions included assist with personal hygiene with two staff and assist of two (staff) for toileting. The resident's plan of care also reflected the resident had fall precautions in place including the use of an alarm to the wheelchair and to the bed.

Review of the facility schedule from the night of 08/10/24 through the morning of 08/11/24 revealed one nurse and three resident assistants (RA) were scheduled for third shift, two being dedicated to the memory care unit where Resident #93 resided. Review of the schedule revealed one RA on the memory care unit called off, leaving only RA #406 who came in late at 12:53 A.M. on the memory care unit. The second RA, RA #417, in the facility worked off the memory care unit.

Review of Resident #93's late entry nursing progress note dated 08/11/24 at 12:20 P.M. by Licensed Practical Nurse (LPN) #400 revealed RA #419 informed her something was wrong with Resident #93 because she found resident sitting in a chair, still in her night clothes and her leg looked out of place. Between 9:00 A.M. and 9:30 A.M. RA #419 asked LPN #400 to help get the resident up because the resident was not moving. When staff tried to move the resident out of the chair she yelled out in pain. LPN #400 called the resident's daughter and advised her of the incident around 9:30 A.M. Resident #93's daughter and son arrived at bedside between 9:45 A.M. and 10:15 A.M. At 10:50 A.M. LPN #400 sent a text message to the nurse practitioner and received orders for an x-ray and 1000 milligrams (mg) of Tylenol for pain. Due to the resident's level of pain, the daughter did not want to wait for the x-ray company to get the films, she wanted the resident to be sent to the hospital. At 12:06 P.M. LPN #400 called the ambulance and at approximately 12:20 P.M. the resident was transported to the hospital.

Review of the facility Resident Incident Report revealed on 08/11/24 RA #406 and RA #417 on duty during night shift around 5:00 A.M., picked Resident #93 up off the floor and placed her in the chair. The night shift LPN on duty was never notified of the fall at the time of the occurrence.

Review of RA #406's Witness Statement provided by the facility regarding Resident #93's fall revealed she went into Resident #93's room and the resident was on the floor in front of her chair by the door alarm. The alarm was not going off because the batteries came out. The statement included the RA called for help, but they were so short staffed. RA #406 asked the resident if she hit her head and helped get her in her chair around 6:25 A.M. RA #406 indicated they were done assisting the resident by 6:30 A.M. and she did not notify the nurse. RA #406 indicated the resident was not voicing sounds of pain.

Review of RA #417's Witness Statement provided by the facility revealed the RA was called to come help pick Resident #93 off the floor and she helped put the resident in the chair. RA #417 did not hear sounds of pain.

Interview on 09/12/24 at 9:00 A.M. with Resident #93's daughter revealed she was upset the RA's were not terminated after the resident fell, treatment was delayed, and the resident had a left leg fracture requiring surgery.

Interview on 09/12/24 at 10:30 A.M. with LPN #400 confirmed she was not notified of Resident #93's fall that had occurred during the night shift on 08/11/24 from night shift staff because the night shift nurse was not notified of the fall. LPN #400 stated she saw the resident sleeping in her chair around 6:30 A.M. when she arrived on the unit and then an RA asked her to help assist with the resident between 9:00 A.M. and 9:30 A.M.. LPN #400 revealed she called for an ambulance to transfer the resident to the hospital at 12:06 P.M.

Interview on 09/12/24 at 11:26 A.M. with RA #419 revealed on 08/11/24 (when she arrived for work on day shift) no staff were there to give her report from night shift, and all the residents were still in bed except Resident #93 who was in her chair still in her night gown. The RA again stated she punched in at 7:00 A.M. on 08/11/24 and no staff were there to give her report from night shift and residents were still in bed. She stated she started her rounds and when she came to Resident #93's room and tried to move resident because she was a one person assist, she was unable to and the resident hollered out in pain and her leg looked deformed. She immediately thought there was something wrong and informed LPN #400.

Interview on 09/12/24 at 12:27 P.M. with RA #406 verified on 08/11/24 she found Resident #93 on the floor in her bedroom around 5:00 A.M. after she returned to Resident #93's memory care unit. RA #406 was located on another memory care unit when Resident #93 fell. She stated she called RA #417 for assistance, and they placed the resident in the chair. RA #406 revealed she made sure Resident #93 wasn't bleeding and had no bruises. She then proceeded to assist other residents needing help. RA #406 acknowledged she did not notify the night shift nurse of the event. RA #406 stated she was aware of the rules and procedures, she tried to find the nurse, but stated she (the nurse) was somewhere on the floor passing medication. RA #406 revealed her shift ended, she had to go pick up her children, so she left.

Interview on 09/12/24 at 12:40 P.M. with LPN #408 revealed if an RA finds a resident on the floor they were to get the nurse and not get the resident up. The nurse would do assessment, vitals, and neurological checks and after that depending on injuries the resident may have to go out (to the hospital).

Interview on 09/12/24 at 4:35 P.M. with Resident Wellness Director (RWD) #439 revealed she was notified by LPN #400 that something happened to Resident #93 on 08/11/24, in which she called daughter and then the nurse practitioner (NP) to receive orders. During RWD #439's investigation of the event she discovered RA #406 found Resident #93 on the floor in her room with bed alarm broken on floor and batteries fallen out. RA #406 called RA #417 to help assist resident off the floor and into a chair. Neither RA notified the nurse on night shift of the fall; therefore, the resident was not assessed or treated timely.

Interview on 09/12/24 at 4:55 P.M. with RWD #439 revealed the ADON writes schedules for RA's based on census. The facility typically staffed one nurse and four RA's on night shift, with two RA's dedicated to memory care units. When Resident #93 fell on 08/11/23 during night shift, there was only one RA on the memory care unit instead of the normally scheduled two. RWD #439 revealed the facility did not have a policy on staffing or for the memory care units.

Interview on 09/12/24 at 6:00 P.M. with RWD #430 revealed when she contacted Resident #93's daughter two to three days after the incident, the daughter indicated Resident #93 had a fracture to her left leg which required surgery.

Review of the facility policy titled, Post Fall Assessment and Action Plan Policy revealed residents must receive appropriate care if they were injured. Staff must take every precaution to reduce the risk of falls. The policy also stated to assess the situation to determine if emergency services are needed and must check evidence of body parts obviously out of proper position/alignment, the inability to move. Documentation of the fall in the resident's record on how the resident was found, the position and any obvious environmental cues, an assessment to be completed, and to complete an Incident Report.

This violation represents non-compliance investigated under Complaint Number OH00157366.

Based on interview, closed record review, facility investigation review, and fall policy review, the facility failed to ensure Resident #93 was properly assessed and treated after a fall resulting in a delay in medical treatment.

Actual harm occurred to Resident #93 on 08/11/24 when the resident fell and facility staff failed to conduct a thorough assessment for injury or need for medical attention before resident assistant (RA) staff transferred the resident (from the floor) to a chair. The resident went without proper assessment and treatment from approximately 5:00 A.M. to 9:00 A.M. at which time the resident was transferred to the hospital and diagnosed with a left leg fracture requiring surgery. This affected one resident (#93) of three residents reviewed for falls.

Findings include:

Closed record review revealed Resident #93 was admitted to the facility on 01/26/24 with diagnoses including anxiety, insomnia, ataxia post cerebrovascular disease, constipation, hypertension, and Alzheimer's. Resident #93 was discharged on 09/08/24.

Review of the plan of care for Resident #93 revealed the resident was a high risk for falls and had deficits in self-care. Interventions included assist with personal hygiene with two staff and assist of two (staff) for toileting. The resident's plan of care also reflected the resident had fall precautions in place including the use of an alarm to the wheelchair and to the bed.

Review of Resident #93's late entry nursing progress note dated 08/11/24 at 12:20 P.M. by Licensed Practical Nurse (LPN) #400 revealed Resident Assistant (RA) #419 informed her something was wrong with Resident #93 because she found resident sitting in a chair, still in her night clothes and her leg looked out of place. Between 9:00 A.M. and 9:30 A.M. RA #419 asked LPN #400 to help get the resident up because the resident was not moving. When staff tried to move the resident out of the chair she yelled out in pain. LPN #400 called the resident's daughter and advised her of the incident around 9:30 A.M. Resident #93's daughter and son arrived at bedside between 9:45 A.M. and 10:15 A.M. At 10:50 A.M. LPN #400 sent a text message to the nurse practitioner and received orders for an x-ray and 1000 milligrams (mg) of Tylenol for pain. Due to the resident's level of pain, the daughter did not want to wait for the x-ray company to get the films, she wanted the resident to be sent to the hospital. At 12:06 P.M. LPN #400 called the ambulance and at approximately 12:20 P.M. the resident was transported to the hospital.

Review of the facility Resident Incident Report revealed on 08/11/24 RA #406 and RA #417 on duty during night shift around 5:00 A.M., picked Resident #93 up off the floor and placed her in the chair. The night shift LPN on duty was never notified of the fall at the time of the occurrence.

Resident #93's medical record and incident report for 08/11/24 did not contain an assessment of the resident.

Review of RA #406's Witness Statement provided by the facility regarding Resident #93's fall revealed she went into Resident #93's room and the resident was on the floor in front of her chair by the door alarm. The alarm was not going off because the batteries came out. The statement included the RA called for help, but they were so short staffed. RA #406 asked the resident if she hit her head and helped get her in her chair around 6:25 A.M. RA #406 indicated they were done assisting the resident by 6:30 A.M. and she did not notify the nurse. RA #406 indicated the resident was not voicing sounds of pain.

Review of RA #417's Witness Statement provided by the facility revealed the RA was called to come help pick Resident #93 off the floor and she helped put the resident in the chair. RA #417 did not hear sounds of pain.

Interview on 09/12/24 at 9:00 A.M. with Resident #93's daughter revealed she was upset the RA's were not terminated after the resident fell, treatment was delayed, and the resident had a left leg fracture requiring surgery.

Interview on 09/12/24 at 10:30 A.M. with LPN #400 confirmed she was not notified of Resident #93's fall that had occurred during the night shift on 08/11/24 from night shift staff because the night shift nurse was not notified of the fall. LPN #400 stated she saw the resident sleeping in her chair around 6:30 A.M. when she arrived on the unit and then an RA asked her to help assist with the resident between 9:00 A.M. and 9:30 A.M.. LPN #400 revealed she called for an ambulance to transfer the resident to the hospital at 12:06 P.M.

Interview on 09/12/24 at 11:26 A.M. with RA #419 revealed on 08/11/24 (when she arrived for work on day shift) no staff were there to give her report from night shift, and all the residents were still in bed except Resident #93 who was in her chair still in her night gown. The RA again stated she punched in at 7:00 A.M. on 08/11/24 and no staff were there to give her report from night shift and residents were still in bed. She stated she started her rounds and when she came to Resident #93's room and tried to move resident because she was a one person assist, she was unable to and the resident hollered out in pain and her leg looked deformed. She immediately thought there was something wrong and informed LPN #400.

Interview on 09/12/24 at 12:27 P.M. with RA #406 verified on 08/11/24 she found Resident #93 on the floor in her bedroom around 5:00 A.M. She stated she called RA #417 for assistance, and they placed the resident in the chair. RA #406 revealed she made sure Resident #93 wasn't bleeding and had no bruises. She then proceeded to assist other residents needing help. RA #406 acknowledged she did not notify the night shift nurse of the event. RA #406 stated she was aware of the rules and procedures, she tried to find the nurse, but stated she (the nurse) was somewhere on the floor passing medication. RA #406 revealed her shift ended, she had to go pick up her children, so she left.

Interview on 09/12/24 at 12:40 P.M. with LPN #408 revealed if an RA finds a resident on the floor they were to get the nurse and not get the resident up. The nurse would do assessment, vitals, and neurological checks and after that depending on injuries the resident may have to go out (to the hospital).

Interview on 09/12/24 at 4:35 P.M. with Resident Wellness Director (RWD) #439 revealed she was notified by LPN #400 that something happened to Resident #93 on 08/11/24, in which she called daughter and then the nurse practitioner (NP) to receive orders. During RWD #439's investigation of the event she discovered RA #406 found Resident #93 on the floor in her room with bed alarm broken on floor and batteries fallen out. RA #406 called RA #417 to help assist resident off the floor and into a chair. Neither RA notified the nurse on night shift of the fall; therefore, the resident was not assessed or treated timely.

Interview on 09/12/24 at 6:00 P.M. with RWD #430 revealed when she contacted Resident #93's daughter two to three days after the incident, the daughter indicated Resident #93 had a fracture to her left leg which required surgery.

Review of the facility policy titled, Post Fall Assessment and Action Plan Policy revealed residents must receive appropriate care if they were injured. Staff must take every precaution to reduce the risk of falls. The policy also stated to assess the situation to determine if emergency services are needed and must check evidence of body parts obviously out of proper position/alignment, the inability to move. Documentation of the fall in the resident's record on how the resident was found, the position and any obvious environmental cues, an assessment to be completed, and to complete an Incident Report.

This violation represents non-compliance investigated under Complaint Number OH00157366.

Based on observation, interview and policy review, the facility failed to store Tuberculin Purified Protein (serum used for intradermal injection to test for tuberculosis) in a manner to ensure efficacy of the medication. This had the potential to affect all residents residing in the facility. The facility census was 90. Findings include: On 05/28/24 at 12:55 P.M. an observation of the medication storage room revealed an open container of Tuberculin Purified Protein one milliliter in the refrigerator. There was approximately one-half milliliter of serum in the vial. The container was unlabeled as to when it was opened. An interview with Licensed Practical Nurse (LPN) #265 at the time of the observation verified the container of Tuberculin Purified Protein serum was unlabeled. Review of the package insert for the Tuberculin Purified Protein revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the policy titled, Medication ManagementBased on observation, interview and policy review, the facility failed to store Tuberculin Purified Protein (serum used for intradermal injection to test for tuberculosis) in a manner to ensure efficacy of the medication. This had the potential to affect all residents residing in the facility. The facility census was 90.

Findings include:

On 05/28/24 at 12:55 P.M. an observation of the medication storage room revealed an open container of Tuberculin Purified Protein one milliliter in the refrigerator. There was approximately one-half milliliter of serum in the vial. The container was unlabeled as to when it was opened. An interview with Licensed Practical Nurse (LPN) #265 at the time of the observation verified the container of Tuberculin Purified Protein serum was unlabeled.

Review of the package insert for the Tuberculin Purified Protein revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Review of the policy titled, Medication Management

Based on interview and record review the facility failed to have a signed witnessed authorization statement to manage resident funds for Resident #41. The facility also failed to have authorizations witnessed by a person not affiliated with the facility for Residents #46, #60 and #64. This affected four residents (#41, #46, #60, and #64) of five residents reviewed for resident funds. The facility census was 90.

Findings include:

Review of resident funds for Resident #41 revealed a balance of $510.00. There was no signed and witnessed authorization for the facility to manage funds for Resident #41.

Review of resident funds for Resident #46 revealed a balance of $200.00. There was a signed authorization to manage the funds that was undated. The signature on the witness signature line was Admissions and Marketing Director (AMD) #267. A printed line under the witness signature line stated the witness cannot be an employee of Gardens at Liberty Park.

Review of resident funds for Resident #60 revealed a balance of $80.00. There was a signed authorization to manage the funds dated 02/24/24. The signature on the witness signature line was AMD #267. A printed line under the witness signature line stated the witness cannot be an employee of Gardens at Liberty Park.

Review of resident funds for Resident #64 revealed a balance of $900.00. There was a signed authorization to manage the funds dated 12/07/23. The signature on the witness signature line was AMD #267. A printed line under the witness signature line stated the witness cannot be an employee of Gardens at Liberty Park.

On 05/29/24 at 8:30 A.M. an interview with the Director verified there was no authorization to manage resident funds for Resident #41. The Director also verified the witness signature on the authorization forms for Residents #46, #60 and #64 was the signature of AMD #267 who is an employee of the facility.

Based on observation and interview, the facility failed to serve carrots at a palatable temperature. This had the potential to affect all 90 residents in the facility who receive meals from the kitchen.

Findings include:

On 05/28/24 at 11:00 A.M. an observation of the tray line revealed the following food temperatures: mashed potatoes at 160 degrees Fahrenheit, gravy at 154 degrees Fahrenheit, hamburgers at 189 degrees Fahrenheit, hotdogs at 190 degrees Fahrenheit, carrots at 165 degrees Fahrenheit and a chef salad at 44 degrees Fahrenheit. Staff began plating the food for the carts to the memory care unit at 11:10 A.M. The food carts left the kitchen at 11:15 A.M. and arrived on the memory care unit at 11:17 A.M.

At 11:20 A.M. the test tray was received. The following temperatures were obtained: mashed potatoes at 144.8 degrees Fahrenheit, hamburger at 135.5 degrees Fahrenheit, and carrots were at 107 degrees Fahrenheit. The carrots tasted cold.

On 05/28/24 at 11:20 A.M. Dietary Manager #240 tasted the carrots and verified they were not at a palatable temperature.

Based on observation and interview, the facility failed to store food and maintain a clean and sanitary kitchen in a manner to prevent foodborne illness and food contamination. This had the potential to affect all 90 residents residing in the facility who were receiving food from the kitchen.

Findings include:

On 05/28/24 at 10:00 A.M. a tour of the kitchen revealed built up dirt and debris on top of dishwasher. The floor had built up dirt and debris at the edges of shelving/prep counters around entire kitchen. There was a four-cup scoop located inside of a 25-pound bag of flour that was half full.

On 05/28/24 during the kitchen tour, an interview with Dietary Manager (DM) #240 revealed floors were to be cleaned daily in the kitchen. DM #240 also verified the built-up dirt and debris on top of the dishwasher and the four-cup scoop in the bag of flour.

This violation is a recite to the surveys completed 08/15/23 and 10/26/23.

Based on review of facility fire drill documentation and staff interview, the facility failed to conduct quarterly fire drills on each shift, failed to evacuate of able residents, and failed to ensure transmission signal testing. This had the potential to affect all 90 residents residing in the facility.

Findings include:

Review of the fire drills from June 2023 through May 2024 revealed no quarterly fire drill on third shift for June of 2023.

Review of the fire drills dated 09/27/23, 12/27/23, and 03/29/24 revealed no resident evacuation to safety areas on at least two fire drills conducted on third shift.

Review of the fire drills revealed no monthly transmission signal verification was completed for 09/29/23, 12/27/23, and 03/29/24.

On 05/28/24 at 10:00 A.M. an interview with Maintenance Director #269 verified the concerns of the above fire drills.

This violation is a recite to the survey completed 08/15/23.

Based on observation, interview and policy review, the facility failed to provide a clean environment for Resident #85 and failed to fix two broken doors in the facility. This had the potential to affect all 90 residents residing in the facility.

Findings include:

Observation on 05/28/24 at 7:54 A.M. upon entrance to the facility revealed the second door had an automatic closure that was not functioning causing the door to close quickly.

Observation on 05/28/24 at 8:15 A.M. during initial tour of the building with Maintenance Director (MD) #269 verified the front door was not closing slowly due to the automatic closure not functioning. During the tour it was also noted the door to the to the courtyard located outside of the kitchen in the hallway would not close. An interview with MD #269 during the tour verified the door would not close unless one pulled up on it and pulled it very hard.

On 05/28/24 at 10:20 A.M. an interview with the Director revealed the front door and the courtyard door had been broken for some time. The Director also provided emails containing quotes for the repair of the two doors. There was not a date scheduled for repair.

On 05/29/24 at 9:05 A.M. observation of the room for Resident #85 revealed dried bowel movement (BM) on the floor in front of dresser. Dried BM was also observed on the toilet seat in Resident #85's bathroom. Dried BM was observed on the inside sides of the garbage can. One pair of purple pants with a urine odor were observed on the floor in corner of the bathroom. The findings were verified by Resident Attendant (RA) #244 at the time of the observation. RA #244 stated direct care staff were to tidy rooms between cleaning and were to wash any soiled clothing.

A review of the undated policy titled Housekeeping revealed residents deserve a safe, clean, clutter-free place to live. On page three, the policy also stated resident assistants were responsible for keeping resident rooms clean and tidy between their scheduled cleaning date performed by the housekeeper.

This violation represents noncompliance investigated under Master Complaint Number OH00153948 and Complaint Number OH00153520 and is a recite to the survey completed on 08/15/23.

Based on observation, interview, and review of Material Safety Data Sheets (MSDS), the facility failed to ensure chemical cleaners were stored in a safe manner on the secured memory care unit (SMCU). This had the potential to affect 22 residents (#70, #71, #72, #73, #74, #75, #76, #78, #81, #82, #83, #84, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) identified by the facility as independently mobile, residing on the SMCU. The facility census was 90.

Findings include:

On 05/28/24 at 8:15 A.M. a tour of the Memory Care Unit revealed the laundry room door propped open. There was an 84 fluid ounce bottle of liquid Tide laundry detergent sitting on top of washer.

An unlocked cabinet under the sink of the sub kitchen in the 600-hall of the Memory Care Unit contained two bottles of Neutrostat (all-purpose cleaner). One was a quart sized bottle that was half full and one was a full 19-ounce bottle. The unlocked cabinet also contained a quart-sized bottle of Kleer glass cleaner that was half full.

On 05/28/24 at 8:25 A.M. the Maintenance Director (MD) #269 verified the unsecured Tide detergent, the unsecured Neutrostat and the unsecured glass cleaner, MD #269 stated that all cleaning supplies were to be kept locked.

Review of the MSDS for Neutrostat revealed to use gloves and eye protection if eye contact was possible. The potential health effects included eye irritation and damage and irritation to mucous membranes if swallowed.

Review of the MSDS sheet for Tide liquid laundry detergent revealed harmful if swallowed.

Review of the MSDS sheet for Kleer glass cleaner revealed the product causes serious eye irritation. The MSDS also stated if ingestion occurs, induce vomiting immediately by sticking finger down throat to trigger gag reflex and seek medical attention immediately.

This violation is a recite to the surveys completed on 08/15/23 and 10/26/23.

Based on observation, record review and interview, the facility failed to ensure exit doors opened automatically for safe and clear egress from the building. This affected Resident #102 and had the potential to affect all facility residents. The census was 93.

Findings include:

Review of Resident #102's medical record revealed an admission date of 01/11/20. Diagnoses included chronic obstructive pulmonary disease (COPD), history of stroke, heart disease, gout, and end stage renal disease (ESRD). Record review revealed the resident used a wheelchair for mobility. Resident #102 was alert and oriented to person, place and time.

Observations on 04/24/24 between 9:15 A.M. and 2:15 P.M. of the facility front doors revealed there were two sets of doors between the outside and interior reception area of the facility. The outside door would open automatically, but you needed to pull/tug on the handle first. There was no button to push for automatic opening of the door. The inside door, to the reception area, did not open automatically in any way. The receptionist was tasked with assisting residents and visitors to open the inside door if needed.

Interview on 04/24/24 at 8:55 A.M. with the Executive Director revealed she was aware of issues with the doors and had obtained a quote from an approved company to replace the doors and security system for the front entrance. She reported the corporate office had approved the funds and construction was currently scheduled for June 2024.

Interview on 04/24/24 at 9:15 A.M. with Resident #102 revealed he could not exit the building unless a person assisted with opening the inside door.

Interview on 04/24/24 at 9:53 A.M. with Ombudsman #25 revealed the front doors had been a concern for many months. Ombudsman #25 reported the facility Administrator (Executive Director) had told her the doors were to be fixed several times with no evidence of repair. The Ombudsman revealed the current status of the doors prevented residents from independently entering and exiting the facility.

Interview of 04/24/24 at 11:54 A.M. with Resident #102's daughter revealed she routinely visited the facility and had ongoing concerns with the doors in the facility and concerns that resident's could not enter and/or exit the building without assistance. The daughter voiced concerns the main exterior and interior door were completely not handicap accessible and had not operated correctly in a number of years. The daughter indicated she had been voicing concerns to the facility Administrator, corporate staff and Ombudsman about the doors for an extended period of time (dating back to 2022). The daughter indicated the doors do not stay open for handicap accessibility 100% of the time. The exterior door works at times but the interior door just slams shut. There was no button on the interior wall or the exterior of the building, whatsoever. The daughter also shared an observation during a visit on 04/11/24 that had occurred at about 5:30 P.M. She stated when she was leaving the facility there was a resident (name not provided) who wanted to go out to the porch. The resident had a mobility cart with leg and arm issues and was completely unable to exit without her assistance with both doors. She stated the resident thanked her but did complain to her about the doors being not fully functional.

This violation represents non-compliance investigated under Complaint Number OH00152925.

Based on record review and interview the facility failed to ensure timely reconciliation and delivery of medications. This affected one of four sampled residents, Resident #17.

Findings include:

Review of the medical record revealed Resident #17 was admitted on 11/08/23 with diagnoses including type two diabetes with kidney complications, hypertension, chronic obstructive pulmonary disease, and atrial fibrillation.

Further review of the medical record revealed a signed consent form for the pharmacy dated 11/08/23; however, there was no record of the consent being faxed to the pharmacy. Review of the progress note dated 11/10/23 timed 4:33 P.M. revealed medications were clarified with the physician and the medication list was electronically submitted to the pharmacy for the following medications: albuterol inhaler, Plavix, carvedilol, digoxin, empagliflozin, escitalopram, Flonase, furosemide, potassium, adult multivitamin, omeprazole, tiotropium bromide inhaler, and Trazadone. There was no documentation in the medical record indicating there was any follow up regarding receipt of the medications until 11/18/23. Review of the nurse progress note dated 11/18/23 timed 3:23 A.M. revealed Resident #17 informed the nurse he had not had any of his routine medications since admission and the pharmacy had yet to deliver any of the medication.

Interview on 01/30/24 at 2:17 P.M. with Assistant Director of Nursing (ADON) #104 revealed the pharmacy needed a signed consent form from Resident #17 before they would send the medications to the facility; however, the pharmacy did not communicate this to the facility until 11/18/23. ADON #104 was unable to confirm the signed release dated 11/08/23 had been forwarded to the pharmacy prior to 11/18/23. The pharmacy delivered the medications on 11/18/23 and the nurse administered the medications until Resident #17 left the facility on a leave of absence with family from 11/22/23 to 12/20/23.

Review of an untimed statement authored by ADON #106 dated 02/01/24 revealed when Resident #17 arrived to the facility he had a plastic bag full of medications. Several bottles were dirty or missing labels and several others had expired. The only medication list provided at the time of admission was from an inpatient hospital stay in September of 2023 which included incorrect medications, incorrect doses, intravenous medications, etc. ADON #106 attempted to reconcile medications with list from hospital and noted several discrepancies. Medications were put back in plastic bag and returned to resident on 11/08/24. Resident #17 was instructed to continue medications as he was taking at home until he could be seen by the physician or nurse practitioner. He verbalized understanding of instructions at that time. The nurse practitioner was notified of discrepancies on 11/09/24.

This violation represents non-compliance investigated under Complaint Number OH00150013.

Based on observation, interview, and review of the facility policy the facility failed to store food in a manner to prevent food borne illness and contamination. This had the potential to affect all 87 residents residing in the facility who were receiving food from the kitchen.

Findings include:

Observation on 10/26/23 at 8:50 A.M. a tour of the secured memory care unit 600 hall revealed two bowls of mixed fruit that were uncovered and unlabeled.

Observation on 10/26/23 at 8:50 A.M. during the tour of the secured memory care unit 600 hall, the Executive Director and Maintenance Director #130 verified the two bowls of uncovered and unlabeled fruit.

On 10/26/23 at 8:55 A.M. an interview with Personal Caregiver #168 revealed the two bowls of uncovered and unlabeled fruit were from dinner the previous night.

Observation on 10/26/23 at 9:15 A.M. a tour of the main kitchen revealed five quart sized Ziploc bags of sliced ham. One bag was one quarter full, and four bags were three quarters full. The discard date on each bag was 10/22/23.

On 10/26/23 at 9:15 A.M. the Director of Dietary Services #115 verified the discard dates on the five Ziploc bags of ham.

A review of the policy titled Dining Services; Reheating revealed to avoid keeping foods past four to seven days after preparation.

This violation represents non-compliance investigated under Complaint Number OH00146831.

This violation is a recite to the survey completed on 08/15/23.

Based on observation and interview the facility failed to maintain clean and sanitary main kitchen and sub-kitchens for the preparation and storage of food. This had the potential to affect all 87 residents residing in the facility who receive food from the kitchen.

Findings include:

Observation on 10/26/23 at 8:55 A.M. a tour of the secured memory care unit 500 hall revealed a dirty refrigerator in the sub-kitchen. There was dried red fluid on the bottom shelf. There were multiple rings of dried fluids noted on the shelves of the door. The refrigerator in the sub-kitchen of the 700 hall of the secured memory care unit also contained a dried red fluid on the bottom shelf.

During the tour of the secured memory care unit on 10/26/23 at 8:55 A.M. the Executive Director and Maintenance Director #130 verified the above findings in the refrigerators.

Observation on 10/26/23 at 9:15 A.M. a tour of the main kitchen revealed noodles and broccoli in the strainer of the automatic dishwasher.

On 10/26/23 at 9:15 A.M. during the main kitchen tour, the Director of Dietary Services (DDS) #115 verified the noodles and broccoli in the strainer. DDS #115 stated the noodles and broccoli were from dinner the previous night. DDS #115 stated the strainer was to be cleaned after every meal.

This violation represents non-compliance investigated under Complaint Number OH00146831.

This violation is a recite to the survey completed on 08/15/23

Based on observation, interview, and review of Material Safety Data Sheets (MSDS), the facility failed to ensure chemical cleaners were stored in a safe manner on the secured memory care unit (SMCU). This had the potential to affect all 24 residents (#65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, and #88) residing in the SMCU.

Findings include:

Observation during the initial tour of the SMCU on 10/26/23 at 8:50 A.M. 600 Hall, revealed a 28-ounce bottle of Avistat-D, (all-purpose disinfectant cleaner) underneath the sink of the sub-kitchen in an unlocked cabinet. Also noted in the 700 Hall sub-kitchen of the SMCU, in an unlocked cabinet under the sink were chemical cleaners including a 28-ounce bottle of Avistat-D (all-purpose disinfectant cleaner), a 19-ounce bottle of Neutrostat (all-purpose disinfectant cleaner), a 32- ounce bottle of Purell (all-purpose disinfectant) with two ounces of cleaner in it, two large, 160 count, Microkill wipes (disinfectant wipes) and a full can, 21 ounces of Comet cleanser (a scouring powder for cleaning). The 500 Hall of the SMCU sub-kitchen also had unsecured cleaning chemicals in an unlocked cabinet under the sink. The cleaning chemicals included a 15-ounce aerosol can of Gleme Glass Cleaner that appeared full, a 128-ounce bottle of Libman disinfectant cleaner (all-purpose disinfectant cleaner) that was half full, and a 21-ounce can of Comet cleanser that was full. Each label on the cleaning products read keep out of reach of children.

An interview with the Executive Director and Maintenance Director #130 on 10/26/23 during the tour of the SMCU verified the chemicals in each unlocked cabinet in the sub-kitchens.

A review of the MSDS for Avistat-D revealed to avoid contact with eyes, avoid prolonged exposure, and provide adequate ventilation. It also revealed that the product will cause serious eye damage and eye irritation.

A review of the MSDS for Neutrostat revealed to use gloves and eye protection if eye contact was possible. The potential health effects included eye irritation and damage and irritation to mucous membranes if swallowed.

A review of the MSDS for Microkill wipes revealed that inhalation of vapors has a narcotic effect. Symptoms included headache, fatigue, and dizziness. It also revealed product was harmful if inhaled. Treatment for inhalation included to call Poison Control. The product may also cause eye irritation such as redness, swelling, tearing, and blurred vision.

A review of the MSDS for Purell cleaner revealed to seek medical attention if there was eye exposure or if product was swallowed.

A review of the MSDS for Comet cleanser revealed harmful if inhaled and to move person to fresh air and seek medical attention. If there was contact to eyes, the affected eye should be rinsed for 15 minutes and consult an eye specialist. It also revealed the product was harmful if swallowed and to seek medical attention.

A review of the MSDS for Gleme glass cleaner revealed to call Poison Control if ingested. It also revealed to seek medical attention with eye or skin contact.

A review of the MSDS for Libman cleaner revealed to call Poison Control if ingested. It also revealed the product may cause skin irritation, serious eye irritation, respiratory irritation, drowsiness, or dizziness.

This violation represents non-compliance investigated under Complaint Number OH00146831.

This violation is a recite to the survey completed on 08/15/23.

Based on observations, interviews with staff and review of the facility policy, the facility failed to store food items in a safe and sanitary manner. This affected all 89 residents in the facility who ate food prepared in the kitchen.

Findings included:

Observation of the kitchen on 08/10/23 at 9:50 A.M. with Dietary Manger #204 revealed in the preparation refrigerator a plastic container of cooked hot dogs, 12 bowls of pre-made salads, two plastic bags of lunch meat, one plastic bag of shredded cheddar cheese, four bowls of fruit cocktail, one large plastic container of fruit cocktail, one large plastic container of pineapple, one large plastic container of applesauce, one large plastic container of potato salad with no dates as to when they were prepared. There was one plastic bag of bacon bits and plastic bag of shredded mozzarella cheese with no date and both bags open to air. In the walk-in cooler there was a half of a ham wrapped in plastic wrap, one bag of pepperoni slices, two pitchers of orange juice, two pitcher of apple juice, two pitchers of cranberry juice with no date as to when they were prepared. There were also eight trays of cooked egg rolls for the days lunch open to air with no date as to when they were prepared. In the dry storage there was one stainless steel container with croutons in it, covered with plastic wrap and no date as to when they were opened.

An interview at this time with Dietary Manger #204 revealed he verified all the above concerns.

Review of the facility policy titled, Hazard Analysis and Critical Control Point: Storing

Based on observations, interviews with staff and review of the facility policy, the facility did not ensure food was prepared under sanitary conditions. This affected all 89 residents in the facility who ate food prepared in the kitchen.

Findings included:

Observation of the kitchen on 08/10/23 at 9:50 A.M. with Dietary Manger #204 revealed the stove had a white substance spilled down the side of it, the wall on the left side of the stove had a buildup of grease splatter down it, the floor between the stove and the wall had a large amount of debris, grease buildup and a large piece of black food debris. The inside of both the ovens were dirty and had a large amount of food debris laying on the bottom shelves. The shelf underneath the steam table was dirty and had a buildup of food debris, top the dish washer was dirty with a buildup of food debris and dirt, the top of the plate warmer was dirty with dirt and food debris and the whole floor in the kitchen was dirty and needed cleaned.

An interview at this time with Dietary Manger #204 revealed everything was to be cleaned once a week in the kitchen and he verified the areas of concerns identified above.

Review of the facility policy titled, Equipment Sanitation, dated 2018 revealed routine and thorough cleaning of equipment surfaces using heat and chemical was vital to the food service cleaning and maintenance program. To keep equipment free of harmful levels of bacteria or other contaminates. Sanitize tables, stoves, sinks, peelers, choppers, mixers, and cooking utensils after each use.

Based on record review, interview with the staff and review of the facility policy the facility failed to ensure monthly fire drills were completed. This affected all 89 residents in the facility.

Findings included:

Review of the facility's monthly fire drills since the last annual revealed they only had one dated 07/19/23.

On 08/10/23 at 12:55 P.M. an interview with Maintenance #205 revealed he just started at the facility in May 2023, He stated he could not find the fire drills from the previous maintenance director. He verified at this time he only had fire drills, disaster drills and self-inspection for July 2023.

Review of the facility policy titled, Fire Safety

Based on record review and interview with the staff the facility failed to ensure required disaster drills were completed. This affected all 89 residents in the facility.

Findings included:

Review of the facility's annual disaster drills since the last annual revealed they only had one tornado drill dated 07/19/23.

On 08/10/23 at 12:55 P.M. an interview with Maintenance # 205 revealed he just started at the facility in May 2023, He stated he could not find the fire drills from the previous maintenance director. He verified at this time he only had fire drills, disaster drills and self-inspection for July 2023.

Based on record review and interview with the staff the facility failed to ensure monthly fire self-inspection were completed. This affected all 89 residents in the facility.

Findings included:

Review of the facility's monthly self-inspections since the last annual revealed they did not have monthly fire self-inspection completed and recorded.

On 08/10/23 at 12:55 P.M. an interview with Maintenance # 205 revealed he just started at the facility in May 2023, He stated he could not find the fire drills from the previous maintenance director. He verified at this time he only had fire drills, disaster drills and self-inspection for July 2023.

Based on observation and interview with the staff the facility failed to maintain the trash dumpster in a sanitary manner. This affected all 89 residents in the facility.

Finding included:

Observation on 08/10/23 at 10:05 A.M. revealed the lid on the dumpster was open and full of trash. There was large amount trash and resident briefs laying on the ground outside the dumpster.

An interview with Dietary Manager #204 at this time revealed the facility had been having issues with raccoons getting into the dumpster and tearing the trash out. He verified the above concerns.

Based on observation, interview with family, interview with the staff, and review of the manufacture instructions, the facility failed to properly contain or store chemical cleaners in the Memory Care Unit. This had the potential to affect 18 Residents ( Resident #4, #7, #10, #20, #25, #28, #43, #45, #47, #51, #52, #57, #66, #74, #78, #80, #84, #87) who were cognitively impaired but independently mobile. The facility census was 89.

Findings included:

Observation on 08/10/23 at 11:05 A.M. revealed there was a bottle of Comet cleaner sitting on the bathroom sink in the room of Resident #66 on the Memory Care Unit.

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On 08/10/23 at 11:07 A.M. an interview with Family Member # 300 revealed the bottle had been in the bathroom since 07/11/23. She stated she was tired of telling the staff to not leave cleaning products in her mother's room. She stated she was pretty sure her mother would not eat it but there were other residents who wandered in and out of her room throughout the day.

On 08/10/23 at 11:10 A.M. an interview with State Tested Nursing Assistant #211 verified the Comet should not be left in a resident's room and should be locked up in the cleaning closet.

Review of the Comet manufacture instructions revealed may be harmful if swallowed or inhaled. Do not get in eyes, on skin or on clothing. Wear rubber gloves when handling. Use only in well-ventilated areas. Do not mix with other household chemicals such as products containing ammonia, toilet bowl cleaners, rust removers, vinegar, or acids.

Based on observation and interview with the staff the facility failed to maintain privacy with Resident #40's medical information.

Findings included:

Observation of medication administration on 08/14/23 at 11:10 A.M. reveal Licensed Practical Nurse #200 prepared medication for Resident #40. When she went into the resident's room to administer the medication, she left private resident information open on the computer screen in the hallway. She verified at this time she should have locked the screen.

Based on record review, interview, and policy review the facility failed to ensure residents were assessed for fall risk upon admission. This affected one resident (Resident #68) of three residents reviewed for falls. The facility census was 83 residents.

Findings include:

Review of Resident #68's medical record revealed an admission date of 03/15/23 with diagnoses including Alzheimer's disease without behavioral disturbance and hypertension.

Review of Resident #68's electronic medical record revealed no assessments had been completed.

Review of Resident #68's paper medical record revealed an admission assessment dated 03/15/23 that had a section on falls that was incomplete with a notation that Resident #68 had a history of falls/ a few recent falls. No fall risk assessment form was present in Resident #68's paper medical record.

Interviews on 04/21/23 at 9:58 A.M. and 10:52 A.M. with the Executive Director verified a fall assessment had not been completed for Resident #68 upon admission and should have been completed within 24 hours.

Review of the facility policy, Fall Risk Management

Based on interview, record review, and policy review the facility failed to assess residents for fall risk on a routine basis. This affected one resident (Resident #51) of three residents reviewed for falls. The facility census was 83 residents.

Findings include:

Review of Resident #51's medical record revealed an admission date of 09/24/17 with diagnoses including unspecified dementia, history of mental and behavioral disorders, peptic ulcer, asthma, age-related osteoporosis without pathological fracture, and chronic obstructive pulmonary disease.

Review of Resident #51's electronic medical record revealed the most recent fall risk assessment was dated 09/09/19. Resident #51 scored seven on the assessment and was not considered a risk for falls.

Review of Resident #51's paper chart revealed no fall risk assessments.

Interview on 04/21/23 at 9:58 A.M. with the Executive Director verified no additional fall assessments were completed for Resident #51 and indicated resident fall risk was to be assessed annually.

Review of the facility policy, Fall Risk Management

Based on record review, interview, and policy review the facility failed to ensure complete and accurate documentation regarding resident status. This affected one resident (Resident #63) of three residents reviewed for falls. The facility census was 83.

Findings include:

Review of Resident #63's medical record revealed an admission date of 09/06/22 with diagnoses including anxiety disorder, abnormal weight loss, chronic obstructive pulmonary disease, vascular dementia, depression, and altered mental status.

Review of the facility's incident log indicated Resident #63 had falls on 03/01/23, 03/19/23, 03/29/23, and 04/05/23.

Review of Resident #63's nurses' notes indicated she had fallen on 03/02/23 at 1:00 A.M. and on 03/29/23 at 1:07 P.M. There was a late entry note on 04/06/23 at 3:37 A.M. for a fall on 04/05/23 at 11:20 P.M. No nurses' note documented Resident #63's fall on 03/19/23.

Interview on 04/21/23 at 9:58 A.M. with the Executive Director verified falls were to be documented in a nurses' note.

Interview on 04/21/23 at 10:06 A.M. with Health and Wellness Director (HWD) #407 verified falls were to be documented in a nurses' note.

Review of the facility policy, Notification of Changes

Based on record review, observation of medication administration, staff interview, and review of the facility policy on medication management, the facility failed to provide all medications as ordered to Resident #49. This affected one resident (#49) of three residents observed for medication administration. The census was 77.

Findings include:

Review of the medical record for Resident #49 revealed an admission date of 03/31/17. Diagnoses included hypertension, chronic atrial fibrillation, bradycardia, and presence of cardiac pacemaker.

Review of the physician's orders for March 2023 identified orders for Propranolol, a medication for heart disease and high blood pressure, 20 milligrams (mg) twice daily.

Observation on 03/01/23 at 7:49 A.M. of the medication administration revealed Resident #49 did not receive her Propranolol. Interview at the time of observation with Licensed Practical Nurse (LPN) #130 verified Propranolol was not provided to Resident #49 because it was not available in the medication cart.

Review of the facility policy titled Medication Management

Based on resident interview, staff interview, review of the facility activity calendar, and review of the facility policy on activities, the facility failed to ensure activities were provided to ensure optimal social, physical, and emotional resident well-being. This had the potential to affect all 77 residents residing in the facility.

Findings include:

Review of the facility activities calendar for February 2023 revealed group activities were replaced with activities packets for 02/20/23 through 02/28/23.

Interview on 02/27/23 at 11:03 A.M. with Resident #76 stated she was tired of being cooped up in her room with no activities to keep her busy.

Interview on 02/27/23 at 10:51 A.M. with Licensed Practical Nurse (LPN) #106 confirmed group activities had been canceled. She stated even church was canceled and residents were upset about that.

Interview on 03/06/23 at 11:53 A.M. with LPN #127 confirmed activities were canceled for several days due to the COVID-19 outbreak at the facility.

Interview on 03/06/23 at 5:20 P.M. with the Administrator stated there were no attendance records or documentation for activities. She verified that activities were canceled for seven days to try to reduce the spread of COVID-19 in the facility.

Review of the facility policy titled Activities

Based on medical record review, review of police reports, review of weather information at www.timeanddate.com, local map review, review of elopement drills, staff interview, resident interview, and facility policy review, the facility failed to ensure two residents (#57 and #70) were provided a safe environment and adequate supervision to prevent elopements. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death, when Resident #70 who had a history of exit seeking behaviors eloped from the facility after dark in the evening hours on 02/11/23. Resident #70 was located by Local Law Enforcement Officers and escorted back to the facility on 02/11/23 at approximately 7:30 P.M. The facility did not know Resident #70 was missing until she was brought back to the facility and did not know how long she had been outside. Following Resident #70's elopement, facility staff did not interview or assess like-residents residing in the assisted living unit or implement any security measures to ensure safety of all residents. On 02/16/23 at approximately 7:49 P.M., Resident #57 eloped from the facility and was returned to the facility by a Good Samaritan. Review of the police report indicated Local Law Enforcement had received multiple calls regarding an elderly woman walking in the roadway near the facility, whom they later identified was Resident #57. The facility did not know Resident #57 was missing until she was brought back to the facility and did not know how long she had been outside. Resident #57 had a diagnosis of dementia and was oriented to person only. Following Resident #57's elopement, the facility did not interview or assess like-residents residing in the assisted living unit for safety needs/elopement risk. The facility did not investigate Resident #57 or Resident #70's elopement to ensure proper safety interventions were in place to address the root cause of elopement.

In addition, a concern that did not rise to a Real and Present Danger occurred when the facility failed to ensure Resident #55, who exhibited exit-seeking behaviors, had a functioning door alarm per physician's order, to assist in ensuring a safe environment for the resident and to decrease the risk for elopement. This affected three residents (Resident #55, Resident #57, and Resident #70) of three residents reviewed for elopement.

On 03/01/23 at 11:02 A.M., the Executive Director and Director of Training and Development #200 were notified Real and Present Danger began on 02/11/23 when the facility failed to ensure all residents were provided a safe environment and adequate supervision to prevent elopements. On 02/11/23 at approximately 7:30 P.M., Resident #70 was escorted back to the facility by police after being gone from the facility for an unknown amount of time without staff knowledge. The facility failed to implement effective systems to ensure the safety of all residents following the incident. On 02/16/23, five days later, Resident #57 eloped from the facility. The facility failed to implement proper interventions to prevent resident elopements, assess residents for risk of elopement, and thoroughly investigate incidents of elopement.

The Real and Present Danger was abated on 03/07/23 when the facility implemented the following corrective actions:

On 02/11/23, Resident #70 was moved to the secured memory care unit, an Elopement Risk Assessment was completed, and the Nurse Aide Information Sheet was updated by the floor nurse at the time of the incident.

On 02/16/23, Resident #57 was moved to the secured memory care unit, an Elopement Risk Assessment was completed, and the Nurse Aide Information Sheet was updated by the floor nurse at the time of the incident.

On 02/17/23, the Executive Director provided an in-service on elopement to facility staff including five nurses and five resident assistants.

On 02/17/23, an alarm was placed on the back employee entrance.

On 03/01/23, the new employee orientation onboarding was updated to include the elopement policy.

On 03/01/23, an alarm was placed on the front main entrance of the facility until Elopement Risk Assessments were completed for all residents on the assisted living unit.

On 03/01/23, all staff were notified via text message to complete an elopement in-service when they arrived for their next shift.

On 03/02/23 and 03/03/23, the Director of Nursing (DON) provided an in-service to Resident Assistants on the function of the Resident Assistant Book.

On 03/02/23 and 03/03/23, the Executive Director and DON completed in-services on elopement with all staff as they arrived for their shift.

On 03/02/23 and 03/03/23, the DON completed in-services on change of condition and notification of changes with Licensed Practical Nurses (LPN).

On 03/02/23 and 03/03/23, the DON completed in-services on standard of care for resident supervision and two-hour safety checks with all nursing staff.

On 03/03/23, the DON completed Elopement Risk Assessments for all residents on the assisted living unit.

On 03/03/23, the facility implemented a plan for all residents identified as at-risk for elopement and with the ability to elope to be immediately placed on the secured memory care unit or discharged. The facility identified Resident #55 was at risk for elopement and did not reside on the secured memory care unit. The resident was not moved to the secured unit but was to have an alarm on her door to alert staff when leaving the room. However, observations on 03/01/23 and 03/06/23 revealed the resident's door alarm was not functional.

On 03/03/23, the Executive Director completed an investigation into the elopements that occurred involving Resident #70 on 02/11/23 and Resident #57 on 02/16/23.

On 03/03/23, the Director of Training and Development #200 completed an in-service on incident investigations with the Executive Director and DON. The facility implemented a plan for investigations to be completed for all incidents and would include but not be limited to witness statements, notifications to physicians, families, and supporting agencies.

On 03/03/23 the facility implemented a plan for all assisted living residents to be re-assessed for elopement risk if they have a change in condition and annually.

On 03/03/23 the facility implemented a plan for the Executive Director to conduct a monthly audit of Resident Assessments and Elopement Risk Assessments.

On 03/06/23, the facility had a meeting scheduled with Resident #55's family to discuss moving the resident to secured memory care unit due to elopement risk. If Resident #55's family was unwilling to move to memory care, the facility would issue a discharge notice.

Interviews on 03/06/23 with Licensed Practical Nurse (LPN) #103, Resident Assistant #104, Housekeeper #116, and LPN #127 verified they had been educated on elopement protocols, resident assistant books and care plans, and resident change of condition protocols.

On 03/07/23 the facility conducted an elopement drill to ensure staff training was completed related to incidents of elopement.

The facility implemented a plan for Resident #55 to move to the secured memory care unit with family consent on 03/08/23.

Although the Real and Present Danger was abated on 03/07/23, the violation remains as the facility was in the process of monitoring and implementing their corrective actions.

Findings include:

1. Review of the medical record for Resident #70 revealed an admission date of 09/19/22. Diagnoses included Parkinson's disease, major depressive disorder, psychophysiologic insomnia, hypercholesterolemia, hypothyroidism, anorexia, dizziness and giddiness.

Review of the Resident Assessment dated 09/21/22 revealed Resident #70 was independent for transfers, independent for mobility, and there was no scoring to indicate the level of risk for elopement.

Review of the undated nurse aide information sheet that drives the plan of care revealed Resident #70 had wandering behaviors. There was no indication of Resident #70's supervision level to identify how often the resident was checked on and no interventions to address elopement risk.

Review of the progress note dated 10/24/22 at 3:33 P.M. revealed Resident #70 was redirected to return to the facility twice due to wanting to go to her sister's house to retrieve her dog.

Review of the progress note dated 11/27/22 at 6:39 P.M. revealed Resident #70 had called the police to arrange a ride to her sister's house. Resident #70 was educated about not calling for a ride.

Review of the progress note dated 12/21/22 at 3:45 A.M. revealed Resident #70 tried to go outside, and the pharmacy delivery driver redirected her away from the door. Resident #70 was educated on safety.

Review of a police report, dated 02/11/23 revealed the police received a call at 7:18 P.M. from a concerned citizen who observed an elderly female (identified to be Resident #70) walking near the corner of Frost Road and Aurora-Hudson Road. Local Law Enforcement Officers arrived on scene at 7:34 P.M. and located Resident #70 near the intersection of Frost Road and Greentree Parkway. Officers quickly discovered she was a resident of the facility. They escorted her back to the facility and advised nursing of the situation.

Review of the progress note dated 02/12/23 at 3:33 A.M. revealed Resident #70 was brought back to the facility at 7:30 P.M. by the police. Police had located Resident #70 on Frost Road near the streetlight. Resident #70 was immediately placed on the secured memory care unit.

Review of the progress note dated 02/12/23 at 11:43 P.M. revealed Resident #70 pulled the fire alarms and stated she would keep pulling the alarms until she could go back to her other room.

Review of the elopement risk assessment, dated 02/12/23, indicated Resident #70 was at-risk for elopement. Resident #70 was occasionally disoriented, ambulatory, had full mobility, and had attempted or left facility in the past. Further review of the medical record revealed no other elopement risk assessments were completed for Resident #70.

Review of the weather information at https://www.timeanddate.com/weather/@5173210/historic?month=2&year=2023 revealed the temperature outside on 02/11/23 at 5:54 P.M. when Resident #70 eloped was 39 degrees Fahrenheit (F) and sunny, and on 02/11/23 at 7:54 P.M. the temperature was 33 degrees F and clear skies.

Review of the location information at https://onthegomap.com/?m=r&u=mi&d=461&f=643865a089&n=1&dm=1&context=share&r2=mYxx7roqmFn4~X1 revealed Resident #70 was observed 0.29 miles away from the facility, near interstate 480, at the time the concerned citizen called the police on 02/11/23.

On 02/27/23 at 2:09 P.M., interview with the Executive Director verified Resident #70 eloped on 02/11/23. She stated the incident was not reported to State officials (as a possible incident of neglect) because she was not aware it had to be reported until the deadline for reporting the incident had passed. She confirmed she still did not report the incident to State officials as a facility reported incident (FRI) even after learning incidents of that nature needed to be reported.

On 02/27/23 at 3:02 P.M., interview with the Executive Director revealed nobody in the facility knew Resident #70 was missing until she was brought back to the facility.

On 02/28/23 at 9:29 A.M., interview with the Executive Director verified Resident #70 did not have an elopement risk assessment completed prior to her elopement on 02/11/23.

On 02/28/23 at 11:11 A.M., interview with the Director of Nursing (DON) stated she was not aware of Resident #70 having wandering or exit seeking behaviors prior to her elopement on 02/11/23. Upon review, the DON verified the progress notes dated 10/24/22, 11/27/22, and 12/21/22 indicated Resident #70 had exit seeking behaviors on those days. She stated Resident #70 did not have any interventions in place at the time of the elopement because the DON did not feel Resident #70 was at-risk for elopement. The DON confirmed an elopement risk assessment was completed after the elopement and there were no other elopement risk assessments completed for Resident #70. The DON stated she was unsure how long Resident #70 was out of the building, did not know what she was wearing at the time of the elopement, verified she eloped after dark, and that no formal investigation was completed because the nurse's note documented the incident. The DON revealed there were no staff statements from staff working on the day of the incident to determine when the resident had last been seen by staff prior to her being returned by police. She also stated they did not do any elopement risk assessments or interviews with like-residents and indicated they had additional residents residing on the unsecured assisted living unit who had cognitive impairments. She stated she reviewed the census and did not identify any residents that she felt were a safety risk.

On 02/28/23 at 1:12 P.M., interview with Law Enforcement Dispatcher #201 revealed the police received a call on 02/11/23 regarding an elderly woman walking along Frost Road in the dark while wearing dark clothing.

On 02/28/23 at 3:13 P.M., interview with the DON revealed the facility did not have a camera system and she did not know which door Resident #70 exited through on 02/11/23.

On 02/28/23 at 3:18 P.M., interview with Licensed Practical Nurse (LPN) #138 revealed she arrived for her shift on 02/11/23 at 7:00 P.M. and did not see Resident #70 until police brought her back to the facility around 7:30 P.M. She indicated she did not know when Resident #70 had left the building or how long she had been gone. LPN #138 stated Resident #70's room was the first room by the front door on assisted living, there were no alarms on the front door, and indicated Resident #70 did have wandering and exit seeking behaviors prior to the elopement incident on 02/11/23.

On 03/01/23 at 3:25 P.M., interview with regional Director of Training and Development #200 revealed the facility had no standard of care regarding how often staff checked on residents, as this was individualized based on resident needs.

Interview on 03/06/23 at 4:46 P.M. with Resident Assistant #140, who was assigned to Resident #70's hall on 02/11/23, stated she could not recall when Resident #70 was last seen in the facility prior to the elopement. She said Resident #70 had a tendency to walk the halls of the facility.

Review of the facility policy titled Resident Emergency - Lost or Missing Resident

Based on record review, family interview, staff interview, and review of the facility policy on elopement, the facility failed to ensure Resident #55's medical record was accurate an noted an incident of exiting the facility on 01/26/23. This affected one resident (#55) of three residents reviewed for elopement. The census was 77.

Findings include:

Review of the medical record for Resident #55 revealed an admission date of 02/19/22. Diagnoses included dementia, type two diabetes mellitus, and hypertension.

Review of the Elopement Risk Assessment, dated 01/27/23, revealed Resident #55 was at-risk of elopement due to disoriented occasionally, ambulatory, slightly limited mobility, and has attempted or has left the community in the past. Interventions included door alarm, discussed memory care placement with family and family declined, and one hour checks.

Review of the Elopement Risk Assessment, dated 03/02/23, revealed Resident #55 was at-risk of elopement due to disoriented occasionally, ambulatory, slightly limited mobility, and has attempted or has left the community in the past. Interventions included a door alarm, one hour safety checks, and a risk agreement.

Review of the physician's orders for March 2023 identified an order for a door alarm to be turned on every night at 8:00 P.M. and turned off every morning at 7:00 A.M. for safety.

Review of the progress notes dated February 2022 through February 2023 revealed no documentation of an elopement in January 2023.

Interview on 03/06/23 at 2:25 P.M. with Resident #55's daughter stated Resident #55 went out the front door of the facility on 01/26/23 around 6:00 A.M. and was brought back inside by a staff member.

Interview on 03/06/23 at 3:21 P.M. with the Administrator verified Resident #55 did exit the facility on 01/26/23. She stated Resident #55 was found on the front patio by Activities Assistant #105 when she arrived for her shift. The Administrator verified there were no notes in Resident #55's chart regarding the incident.

Review of the witness statement dated 01/26/23 by Activities Assistant #105 revealed she saw Resident #55 outside the facility at approximately 5:50 A.M., redirected her back to her room, and notified the nurse of the incident.

Review of the facility policy titled Resident Emergency - Lost or Missing Resident

Based on record review, family interview, staff interview, and review of the facility incident log, the facility failed to ensure the incident log was accurate and included all resident elopements. This affected one resident (#55) of three residents reviewed for elopement. The census was 77.

Findings include:

Review of the medical record for Resident #55 revealed an admission date of 02/19/22. Diagnoses included dementia, type two diabetes mellitus, and hypertension.

Review of the Elopement Risk Assessment, dated 01/27/23, revealed Resident #55 was at-risk of elopement due to disoriented occasionally, ambulatory, slightly limited mobility, and has attempted or has left the community in the past. Interventions included door alarm, discussed memory care placement with family and family declined, and one hour checks.

Review of the Elopement Risk Assessment, dated 03/02/23, revealed Resident #55 was at-risk of elopement due to disoriented occasionally, ambulatory, slightly limited mobility, and has attempted or has left the community in the past. Interventions included a door alarm, one hour safety checks, and a risk agreement.

Review of the physician's orders for March 2023 identified an order for a door alarm to be turned on every night at 8:00 P.M. and turned off every morning at 7:00 A.M. for safety.

Review of the progress notes dated February 2022 through February 2023 revealed no documentation of an elopement in January 2023.

Interview on 03/06/23 at 2:25 P.M. with Resident #55's daughter stated Resident #55 went out the front door of the facility on 01/26/23 around 6:00 A.M. and was brought back inside by a staff member.

Review of the incident log dated 12/01/22 to 02/23/23 identified no elopement incident on 01/26/23.

Interview on 03/06/23 at 3:21 P.M. with the Administrator verified Resident #55 did exit the facility on 01/26/23. She stated Resident #55 was found on the front patio by Activities Assistant #105 when she arrived for her shift. The Administrator verified the incident was not included on the provided incident log.

Review of the witness statement dated 01/26/23 by Activities Assistant #105 revealed she saw Resident #55 outside the facility at approximately 5:50 A.M., redirected her back to her room, and notified the nurse of the incident.

This violation represents non-compliance investigated under Complaint Number OH00140420.

Based on record review, facility policy and procedure review and interview the facility failed to ensure all medications were administered to Resident #71 as ordered by the physician. This affected one resident (#71) of three residents reviewed for medication administration. The facility census was 81.

Findings Included:

Review of the medical record for Resident #71 revealed an admission date of 12 /02/20 with diagnoses including mild cognitive impairment, hypertension, atrial fibrillation, osteoporosis, and iron deficiency anemia.

Review of the Resident Assessment dated 06/06/22 revealed Resident #71 required physical assistance for bathing and dressing. The resident was independent for transferring and ambulation with a walker. Resident #71 was independent for eating but needed meal reminders. The resident was oriented to person only.

Review of physician orders for January 2023 revealed Resident #71 was ordered acetaminophen 500 milligrams (mg) two tablets by mouth three times daily at 6:00 A.M., 12:00 P.M. and 9:00 P.M. starting on 06/16/22. Folic acid 400 micrograms (mcg) one tablet once daily at 12:00 P.M. was ordered on 06/16/22. Losartan 25 mg once daily at 12:00 P.M. was ordered on 07/25/22. Lopressor 25 mg twice daily at 12:00 P.M. and 9:00 P.M. was ordered on 07/25/22.

Review of the Medication Administration Record and Electronic Medication Administration Review (MAR/EMAR) for Resident #71 for January 2023 revealed Folic acid was not administered on 01/05/23, 01/17/23, or 01/21/23. Losartan was not administered on 01/05/23, 01/17/23, or 01/21/23. Lopressor was not administered on 01/05/23, 01/08/23, 01/11/23, or 02/12/23. One of three doses of Tylenol were not administered on 01/05/25, 01/09/23, 01/12/23, 01/16/23, or 01/21/23.

On 01/25/23 at 12:29 P.M. interview with the Director of Nursing (DON) verified the medications for Resident #71 had not been administered to the resident in January 2023 as ordered.

Review of the Medication Management policy, dated 04/2020 revealed if a medication was not administered in a timely manner, the community certified staff authorized to administer medications, may report this to Resident Wellness Director, designee and/or physician or healthcare practitioner for further instructions on how to proceed as necessary. Licensed nursing staff would review MAR's/EMAR's monthly for accuracy, correctness, and proper documentation - there shall be no omission/holes left on the MAR'S/EMAR's.

This violation represents non-compliance investigated under Complaint Number OH00139584. This violation is also an example of continued non-compliance from the survey dated 09/29/22 and 12/29/22.

Based on observation, medical record review, review of facility Self-Reported Incidents (SRIs), review of staffing schedules, review of the facility Abuse, Social Media and Cell Phone policy and procedures and interview, the facility failed to ensure two residents, Resident #63 and Resident #64, who were assessed to be cognitively impaired were free from staff to resident verbal/emotional abuse when Caregiver #309 was recorded verbally mocking both residents on two different occasions and the videos were posted to social media sites. This resulted in Real and Present Danger on 01/17/23 when Caregiver #308 made a cell phone recording of Caregiver #309 verbally mocking and spitting on Resident #63 while the resident was in the bathroom seated on the toilet with her pants down. A second video, involving the same staff, also posted to social media showed Caregiver #309 verbally mocking Resident #64, while the resident was overheard crying and asking the staff to leave. The actual or potential for psychosocial harm occurred as a result of the acts of verbal and emotional abuse which dehumanized and potentially humiliated the involved residents. This affected two residents (#63 and #64) of three residents reviewed for abuse. The facility census was 81.

On 01/24/23 at 1:48 P.M. the Executive Director was notified Real and Present Danger began on 01/17/23, between approximately 3:00 P.M. and 11:00 P.M. (exact time unknown), when Caregiver #308 made a cell phone recording of Caregiver #309 verbally mocking and spitting on Resident #63 and then verbally mocking Resident #64. Both videos were posted to social media sites without evidence of either resident's consent or knowledge.

The Real and Present Danger was abated on 01/25/23, when the facility implemented the following corrective actions:

On 01/18/23 at approximately 4:00 P.M. the Executive Director received an anonymous phone call stating a video involving a resident (Resident #63) at The Gardens at Liberty Park was viral on social media.

On 01/18/23 at approximately 4:10 P.M. the alleged perpetrators, Caregiver #308, and Caregiver #309, who were identified to be involved with the incident were removed from their assignments.

On 01/18/23 at approximately 4:20 P.M. the Executive Director notified the local police department the facility had been made aware of the video that was posted to several media outlets, violating resident rights. Two police officers arrived at the facility at approximately 4:30 P.M. When interviewed the two employees admitted to the recordings and told police no other residents were involved in any videos.

On 01/18/23 at approximately 6:00 P.M. the Executive Director terminated Caregiver #308 and Caregiver #309 involved in the video of the resident.

On 01/18/23 at approximately 6:10 P.M. the Executive Director notified Resident #63's daughter of the situation.

On 01/19/23 at 9:00 A.M. It was brought to the Executive Director's attention a second video involving a resident (Resident #64) was viral on social media.

On 01/19/23 at approximately 9:30 A.M. the Executive Director notified the local police department of the second video posted to media outlets, violating resident rights. One police officer arrived at the facility at 9:40 A.M.

On 01/19/23 at approximately 10:00 A.M. the Executive Director notified Resident #64's family of the situation.

On 01/19/23 the Executive Director notified the facility ombudsman of the two videos of the residents' posted to social media.

On 01/19/23 the Executive Director and Inspirit Corporation worked with the social media outlets to have the videos removed from Instagram.

On 01/19/23 the Executive Director investigated to make sure no additional residents were involved in any of the recordings. And implemented a plan for the management team (Executive Director, Assistant Director of Nursing, Business Office Manager, Maintenance, and Activities) to monitor employees for phone use in common areas.

On 01/19/23 the Executive Director and Director of Nursing spoke with the residents on the Assisted Living unit, and none were affected or aware of the videos that went viral on social media. The Executive Director and Director of Nursing were unable to interview residents in the Memory Care unit due to cognitive impairment. All the residents were assessed, and no concerns were noted.

On 01/19/23 the Director of Nursing trained staff on the facility Abuse, Injury of Unknown origin and Resident Rights policy and procedures. As of 01/19/23 30 of 80 employees had been trained. The facility implemented a plan to ensure all employees were trained, with training completion no later than 02/19/23. A plan for the Director of Nursing to monitor future training needs for long-term staff, agency staff and new hires was implemented.

On 01/25/23 At 5:00 P.M. the Executive Director began training on the Employee On-boarding Manual. Staff would be trained on Resident Rights, Resident Abuse and Reporting, Resident Care, Notification of change, Communications, Facility Rules, Social Media policy, and (new) Cell Phone policy. This training began on 1/25/2023. A plan for agency, new hires and long-term staff was implemented on this date to occur during orientation and quarterly.

On 01/25/23 the facility indicated an all-staff meeting would be held on 01/30/23 to address additional training and education needs of the staff. The facility indicated 75% of all facility staff would be trained on this date with all training to be completed no later than 2/17/23. Training will be completed by Executive Director, Director of Nursing, or Concierge.

Although the Real and Present Danger was abated on 01/25/23 the violation remains as the facility was in the process of implementing and monitoring corrective actions.

Findings Included:

1. Review of the medical record for Resident #63 revealed the resident was admitted to the facility on 11/01/21 with diagnoses including Alzheimer's disease, dementia without behavioral disturbance, anxiety disorder, and paranoid personality disorder. The resident resided in the Memory Care Unit.

Review of the Resident Assessment dated 04/06/22 revealed the resident was oriented to self only. The resident had identified behaviors of aggression and wandering.

Review of a nursing progress note dated 01/18/23 at 7:19 P.M. revealed the facility received a phone call, from an unknown number, stating that an alleged incident occurred involving Resident #63 and a staff member. The note documented the resident's power of attorney (POA), and physician were notified. An investigation was started.

Review of a facility self-reported incident (SRI) dated 01/18/23 revealed an allegation of emotional/verbal abuse involving Resident #63. On 01/18/23, the Executive Director received a phone call stating a video was on social media involving Resident #63. The video showed Resident #63 using the bathroom. In the video an employee was observed verbally mocking the resident and appeared to be spitting on her. The Executive Director immediately had a staff member go and check on the resident. Resident #63 did not show any signs of distress. A head-to-toe assessment was completed on the resident with no injuries identified. The police were called. Two staff members were identified (Caregiver #308 and Caregiver #309) and were immediately removed from their units. The police and the Executive Director questioned the two employees. Both employees admitted the incident occurred (however, the staff member denied spitting on the resident). The employees provided statements and were subsequently terminated and removed from the facility. Family of the resident, the physician, ombudsman, and the Ohio Department of Health were notified. As a result of the SRI and facility investigation, the allegation of verbal/emotional abuse was substantiated.

On 01/19/23 the facility indicated the staff who worked the day of the incident (01/17/23) were interviewed and denied knowledge of the incidents. Additional staff working over the following two days were interviewed and denied knowledge of the incidents at the time it occurred. However, there were no staff statements documented as part of the investigation. The Executive Director revealed to the facility knowledge, no staff were aware of the situation until the video went viral.

On 01/23/23 at 9:08 A.M. interview with the Executive Director revealed on 01/18/23 the facility received an anonymous phone call telling them an employee had posted a video of a resident (Resident #63) on Instagram. On 01/19/23 the facility discovered a second video had been posted of another resident (Resident #64). The Executive Director indicated the videos had been taken at the facility of the residents and posted on social media.

On 01/24/23 at 4:02 P.M. review of the video of Resident #63 with the Executive Director, revealed it appeared to be an altered version of the original video. The resident could be seen from an angle on the toilet with her pants down and shirt on. The video was altered with parts of the video covered by comments and areas were blacked out.

On 01/23/23 at 3:46 P.M. Resident #63 was observed dressed, lying on her bed. The resident stated she did not want to talk to anyone.

On 01/24/23 at 2:12 P.M. interview with the Police Department revealed the police report related to the incident had not been completed as of this date and the investigation was still open.

2. Review of the medical record for Resident #64 revealed the resident was admitted on 01/26/21 with diagnoses including dementia with behavioral disturbance, hypertension, and major depressive disorder.

Review of the Resident Assessment dated 06/06/22 revealed the resident required physical assistance from staff for bathing, dressing, and toileting. The resident's hearing, vision, and speech were good. Resident #64 was oriented to person only.

Review of a nursing progress note dated 01/19/23 at 2:16 P.M. revealed it was reported an alleged incident occurred involving Resident #64 and a staff member. The note indicated the resident's POA, and physician were notified. An investigation had been started.

Review of the nursing progress note dated 01/19/23 at 3:28 P.M. revealed a head-to-toe skin assessment was completed for Resident #64. All skin was intact.

Review of a facility SRI dated 01/19/23 revealed an allegation of emotional/verbal abuse involving Resident #64 was reported to the State agency. The SRI noted, on 01/19/23 at 9:00 A.M. an employee notified the Executive Director of a second resident, Resident #64, being recorded, crying on a video. The video had been posted to social media. A head-to-toe assessment was completed on the resident with no injuries identified. The police were called again. The family of the resident, the physician, ombudsman, and the Ohio Department of Health were notified. As a result of the SRI and facility investigation the allegation of emotional/verbal abuse was substantiated.

On 01/19/23 the facility indicated the staff who worked the day of the incident (01/17/23) were interviewed and denied knowledge of the incidents. Additional staff working over the following two days were interviewed and denied knowledge of the incidents at the time it occurred. However, there were no staff statements documented as part of the investigation. The Executive Director revealed to the facility knowledge, no staff were aware of the situation until the video went viral.

On 01/23/23 at 9:08 A.M. interview with the Executive Director revealed on 01/18/23 the facility received an anonymous phone call telling them an employee had posted a video of a resident (Resident #63) on Instagram. On 01/19/23 the facility discovered a second video had been posted of another resident (Resident #64). The Executive Director indicated the videos had been taken at the facility of the residents and posted on social media.

On 01/24/23 at 4:02 P.M. the Executive Director revealed there was no copy of the video available to view related to the incident involving Resident #64.

On 01/23/23 at 1:40 P.M. Resident #64 was observed sitting in a recliner in her room, covered with a throw, and holding two stuffed animals. Resident #64 was not interviewable. The resident was calm, cheerful, and relaxed.

On 01/24/23 at 2:12 P.M. interview with the Police Department revealed the police report related to the incident had not been completed as of this date and the investigation was still open.

Review of the staff schedule for 01/17/23 revealed Caregiver #308 and Caregiver #309 were scheduled to work 3:00 P.M. to 11:00 P.M. Review of the personnel files for both employees, on 01/25/23 revealed both were terminated on 01/18/23. Caregiver #308 did not have a reason documented. Caregiver #309 had work performance as the reason.

Review of the facility Abuse Prohibition policy, dated 2018 revealed the written policy included the following key components: Screening of potential new hires; training of employees; prevention; identification of possible incidents or allegations which need investigation; investigation of incidents and allegations; protection of residents during investigations; reporting of incidents, investigations, and the facility response to the results of their investigations.

Review of the facility undated Cell Phone policy revealed the use of a personal cell phone was discouraged. Cell phone use was confined to breaks and meal periods. When cell phone use interfered with satisfactory performance the privilege could be taken away and disciplinary action taken.

Review of the facility Social Media policy revealed Behavior and content that may be deemed disrespectful, dishonest, offensive, harassing, or damaging to the company's interest or reputation are not permitted. The use of social media channels on company time for personal purpose is not allowed.

This violation represents non-compliance investigated under SRI Control Number OH00139536. This violation is also an example of continued non-compliance from the survey dated 09/29/22.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure showers were provided as scheduled. This affected two residents (#35 and #72) of three residents reviewed for receiving showers as scheduled. The facility census was 81.

Findings Include:

1. Review of Resident's #35 plan of care revealed Resident #35 required assistance of one to two staff for her showers. The resident was unable to walk by herself and staff were required for providing showers.

Review of the shower sheets for the month of December 2022 revealed Resident #35 did not receive any showers during the month of December 2022.

On 01/13/23 at 11:00 A.M. Resident #35 was observed sitting up in her recliner. Interview with the resident at the time of the interview revealed the resident had concerns about the facility including a concern she did not get showers as scheduled.

Interview with the Director of Nursing (DON) on 01/14/23 revealed shower sheets were located in a big box, and she provided all that were available for Resident #35. The DON revealed showers had been identified as a problem from a survey conducted in December 2022, but corrections had not been made as of this time. The DON revealed the facility was currently working on a plan of correction.

2. Review of Resident #72's shower sheets from December 2022 revealed Resident #72 had not been provided showers during the month.

Interview with the Director of Nursing (DON) on 01/14/23 revealed shower sheets were located in a big box, and she provided all that were available for Resident #72. The DON revealed showers had been identified as a problem from a survey conducted in December 2022, but corrections had not been made as of this time. The DON revealed the facility was currently working on a plan of correction.

Review of the facility undated policy titled Patient Care Policy revealed the facility did not implement their policy to provide care that addresses the needs and preferences of their residents.

This violation represents non-compliance investigated under Complaint Number OH00139225 and Complaint Number OH00139415 and is an example of continued noncompliance from the survey dated 12/29/22 and 09/29/22.

Based on closed record review and interview the facility failed to ensure individualized and effective interventions were initiated to prevent falls for Resident #83. This affected one resident (#83) of four residents reviewed for falls. The facility census was 81.

Findings Included:

Review of Resident #83's closed medical record revealed an admission date of 09/09/22 with admitting diagnoses including congestive heart failure, chronic obstructive pulmonary disease, type II diabetes, repeated falls, and pulmonary fibrosis.

Review of the resident's admission assessment, dated 09/09/22 revealed the resident was alert and oriented to self with some intermittent confusion. The assessment revealed the resident was up ad lib and ambulated with the assistance of a walker. This resident was also continent of bowel and bladder and was at risk for falls.

Review of this resident's Kardex information (information for direct care staff detailing the resident's care needs) noted the resident had a history of falls and needed reminders to use his walker when ambulating.

Review of the Incident/accident Log from the past three months revealed the resident had multiple falls including falls on 01/01/23, 01/02/23, and 01/05/23.

Review of the fall investigation for the fall dated 01/05/23 revealed an unwitnessed fall occurred at 02:15 A.M. on this date. The Care Assistant walked into room and found the resident laying on his left side with his left arm tucked under his head. The nurse came and obtained vital signs, the Care Assistant attempted to sit the resident up and he screamed that his hip hurt and to leave him on the floor. The nurse checked the resident's range of motion. A blanket was placed under the resident's head until the ambulance arrived, and the resident was sent to the emergency room for further evaluation. The physician was notified at 3:00 A.M. The resident was returned to the facility later that day with no additional orders.

Interview with the Director of Nursing (DON) during the survey revealed no new interventions were implemented following the fall on 01/05/23. She stated she did send the resident out to the hospital on the fall that occurred on 01/05/23 and was able to get physical therapy to come and evaluate him after the fall on 01/05/23 but the resident passed away three days later so therapy was not started. The DON verified there was no additional assessment completed after the fall.

This violation represents non-compliance investigated under Complaint Number OH00139225 and is an example of continued noncompliance from the survey dated 12/29/22.

Based on observation, record review and interview the facility failed to ensure all residents were provided a functional and appropriate call signal system. This affected two residents (#11 and #35) of three residents reviewed for call lights. The facility census was 81.

Findings Included:

Observation of the 100 hallway 01/12/23 between 10:00 A.M. and 11:00 A.M.. revealed a total of ten residents, Resident #10, #11, #19, #35, #68 #69 and #78 residing on the unit.

Observation and interview on 01/12/23 at 1:15 P.M. with Resident #35 revealed she had concerns regarding getting assistance. She stated the pull cord in her room does not work so the facility gave her a pendant to call for help. The resident stated that often the pendant was not working. Resident #35 pulled and initiated the signal, but no one was observed to check on the resident for 24 minutes. Resident #35 wanted up to attend an activity.

Licensed Practical Nurse (LPN) #209 verified on 01/12/13 at 1:55 P.M. she had the receiver for the 100 hall in her pocket. She verified at that time there was no alert indicating Resident #35's call pendant had been activated. Resident #35 was observed to re-press the pendant. The pendant flashed red signaling it was charged, and it was pressed appropriately. LPN #209 verified the receiver did not signal this resident had called.

Interview with Maintenance Director (MD) #204 on 01/12/23 at 2:50 P.M. regarding the pendants revealed a test of them. MD #204 proceeded to go to Resident #35's room and activated her pendent. He then assured this surveyor the resident's pendant was charged and working. The Maintenance Director then proceeded to the locked unit to check out the receiver the nurse had. Upon further inspection, the Maintenance Director stated the problem was that LPN #209 never checked the receiver prior to taking it to ensure it was charged. The receiver the nurse was carrying had a dead battery.

Further interview at this time with the Maintenance Director revealed the pendant was as reliable as its users. He stated when that hallway was first opened, they did have a call bell system in place the was functional and worked like the systems throughout the other halls. He stated that company went out of business, so they were unable to get fixed and went to the pendant system. He stated that when a new resident was admitted, the call pendant was set with the receiver and program, so the receiver can receive signals. He stated if the receiver and the pendant were fully charged, there should be no issues with communication between the two. He did indicate if one or the other was not charged then the communications between the receiver and the pendant does not work. He revealed with a new resident, he programs the receiver and provides the pendant to the resident after verified it was working. He verified the pendent signals the receiver unless the receiver was silenced and then forgot that was done. He verified the pendent would not signal again after being silenced unless it was pressed an additional time.

In addition, during the survey Resident #11 was observed to pull her call cord at the head of her bed on 01/12/23 at 10:10 A.M. Interview with the resident at the time of the observation, revealed she was told by staff to just use the pull cord at the head of her bed. She stated that was the only call bell she had in her room. There was no audible sound and no light on outside of the room.

This violation represents non-compliance investigated under Complaint Number OH00139225 and is an example of continued noncompliance from the survey dated 12/29/22.

Based on observation, record review and interview the facility failed to ensure adequate interventions and staff supervision were in place to prevent Resident #83 from exiting the facility without staff knowledge and assistance. This affected one resident (#83) of three residents reviewed for elopement.

Findings included:

Review of the closed medical record for Resident #83 revealed an admission date of 09/08/22 with admitting diagnoses including congestive heart failure, chronic obstructive pulmonary disease, type II diabetes, repeated falls, and pulmonary fibrosis.

Review of this resident's admission assessment dated 09/09/22 revealed this resident was alert and oriented to self with some intermittent confusion. He was up ad lib and ambulated with the assistance of a walker. This resident was also continent of bowel and bladder. He was at risk for falls. He was not at risk for elopements.

Review of the nursing progress notes dated 09/09/22 at 7:18 A.M. revealed the alarm panel was going off at the Memory Care nursing station. The nursing staff on duty went to check the door. When the staff went outside, they saw Resident #83 outside past the back driveway holding on to a light pole. The resident was unable to give details or recall why or how he got outside due to impaired memory, the resident did state he was scared. The resident was assisted times two back into the facility and was placed in a wheelchair. An assessment was completed, and no apparent injuries were noted. The resident denied pain or discomfort. Vital signs were within normal limits. One hour safety checks were performed.

On 10/27/22 at 11:00 P.M. a nursing progress note revealed a nurse and resident assistant were summoned by the Wellness director to the exit door on the 100 hall television room due to a resident being outside. The resident was sitting on the step and was calling for help. The staff assisted to lift the resident (Resident #83) and assist him to ambulate inside where he was placed on the couch in the television room. Vital signs were obtained, and a resident assessment was completed. The resident's temperature was 96.9. The report revealed it was not cold but chilly outside. The resident stated he was warm and did not complain of pain. When asked what he was doing outside, the resident stated he was not sure. He then asked if his car was in the parking lot and the staff informed the resident his son had his car. The resident denied falling and stated he just sat down on the step. The staff re-iterated to the resident to not go outside. The resident was then ambulated back to his room.

On 01/12/23 at 11:15 A.M. interview with the Wellness Director revealed the director was not aware of this elopement incident. When asked how long the resident was outside, she stated he was found almost immediately. She also stated she did not think this was an actual elopement since the resident did not leave the property. She further stated the resident was new to the facility at that time so he was not aware of his surroundings. When she was asked what safety interventions were implemented for the resident, she indicated nothing really except for one hour checks for the day. When asked if a new elopement assessment was completed for this resident, she stated no it was not done.

Observations during a walking tour and interview with Corporate Development Coordinator (CDC) #205 on 01/12/23 at 1:15 P.M. revealed the resident had walked down the 100 hall into the main entrance area, through the dining area and down the hall right next to the dining area. The resident had walked down that hall to the exit door and walked out. He then walked past a gate on his right-hand side onto the paved area where one side of the area had a roof covered area for staff smoking located on the left side and the dumpster on the right side. At the end of this paved area was a parking area and then some grass with a light pole on it. This was where the resident was found according to CDC #205. The alarm the staff were referring to was on a wall panel that flashed the door was opened but was not audible. Opening of the door at this time, also revealed no audible alarm sounding. The CDC further stated at this time, the alarms for the doors were set so they were not audible during the day but were audible at night. He further stated the corporate office was working to change that so the door alarms were audible all the times.

Interview with the Wellness Director on 01/13/23 and 01/19/23 at 9:15 A.M. and 12:09 P.M. revealed she was walking down towards the 100-television area and heard the resident yelling. She walked to the door and saw the resident outside. When she went outside to the resident, he was sitting on the step trying to put his shoes on. She stated there were two pairs of the resident's shoes outside with him. The resident was unable to state why he was outside. She called the nurse to come to help and when staff came to the area the resident was then assisted up from the step and assisted inside. According to the National Weather Service the temperature was around 56 degrees at the time of the incident.

Observation during a walking tour with the Wellness Director on 01/13/23 at 9:30 A.M. revealed the resident walked to the 100 halls to the television room. This was about 41 normal steps from his room door. The door was then pushed open by this surveyor which did not alarm. The Wellness Director revealed the facility alarms were not set to ring during the day, but the alarm panel should be flashing. The alarm panel was checked in the entryway area, and it was not alarming or showing the door had been opened. She stated she would have to follow up with the corporate development person.

On 01/13/23 at 9:15 A.M. and 01/19/23 at 12:09 P.M. interview with the Wellness Director revealed no new assessment for elopement had been completed for the resident following this incident and no new interventions had been initiated to maintain the resident's safety after this second elopement.

On 01/19/23 at 11:10 A.M. interview with Corporate Developer #205 revealed the television exit door by the 100 hall does not lock and does not have an alarm on it. He stated the assisted living residents were allowed to go outside etc. He further stated the other door alarms had since been updated and would now ring anytime of the day when opened.

This violation represents non-compliance investigated under Complaint Number OH00139225.

Based on observation, interview, and record review, the facility failed to ensure showers were provided as scheduled. This affected two (Residents #18 and #58) of three residents reviewed for showers.

Findings include:

1. Review of the medical record for Resident #58 revealed an admission date of 06/05/21 and diagnoses included dementia without behavioral disturbance, hypothyroidism, and atrial fibrillation (abnormal heart rhythm).

Review of the resident assessment dated 06/05/21 revealed Resident #58 required staff supervision for bathing and was alert to person but disoriented to some spheres and time.

Observation of facility documents titled, Caregiver Daily Task Sheet

Based on record review, interviews and facility policy, the facility failed to all medications were administered to Resident #56 as ordered by the physician. This affected one of three residents reviewed for medication administration. The facility census was 79.

Findings include:

Review of the medical record for Resident #56 revealed an admission date of 11/14/20 and diagnoses included hereditary and idiopathic neuropathy (nerve damage), major depressive disorder, incontinence, gastroesophageal reflux disease (stomach content flowed up into the esophagus) without esophagitis (inflammation of the esophagus), and fibromyalgia (pain disorder).

Review of the resident assessment dated 11/16/20 revealed Resident #56 was independent for bathing, dressing, combing hair, eating, toileting, ambulation, and oral care and was alert to person, place, and time.

Review of physician orders for Resident #56 revealed an order dated 04/05/22 for Pregabalin (an anticonvulsant medication which can be used to treat pain caused by nerve damage), one 75 milligram (mg) capsule daily in the morning and one 100 mg capsule at bedtime.

Review of October 2022 Medication Administration Records (MARs) for Resident #56 revealed the administration documentation areas were blank and not signed off as given by nursing staff for the 75 mg dose at 5:00 A.M. on 10/13/22 and 10/28/22 and for the 100 mg dose at bedtime on 10/16/22 and 10/29/22.

Review of November 2022 MARs for Resident #56 revealed the administration documentation areas were blank and not signed off as given by nursing staff for the 75 mg dose at 5:00 A.M. on 11/23/22 and 11/28/22 and for the 100 mg dose at bedtime on 11/11/22 and 11/13/22.

Review of December 2022 MARs for Resident #56 revealed the administration documentation areas were blank and not signed off as given by nursing staff for the 75 mg dose at 5:00 A.M. on 12/02/22, 12/03/22, 12/08/22, 12/09/22, 12/10/22, 12/17/22, 12/25/22, and 12/29/22 and for the 100 mg dose at bedtime on 12/09/22 and 12/22/22.

Interview on 12/29/22 at 9:44 A.M. with Resident #56 confirmed she had not received all of her medications a couple times. She indicated she had a lot of pain in her feet when she did not receive her Pregabalin.

Interview on 12/29/22 at 2:52 P.M. with Wellness Director #300 confirmed there were blanks on Resident #56's MARs. Wellness Director #300 stated she had no reason for the blank spots and could not verify that those medications were given as ordered as they were not signed off as given by nursing staff.

Review of facility policy, Medication Management

Based on observation, interview, and record review, the facility failed to initiate appropriate interventions to promptly resolve issues with the emergency call system after Resident #18 fell and lay on the floor. This affected one of three residents reviewed for call lights.

Findings include:

Review of the medical record for Resident #18 revealed an admission date of 01/11/20 and diagnoses included chronic obstructive pulmonary disease (COPD), transient ischemic attack (temporary period of symptoms similar to those of a stroke), hyperlipidemia (elevated lipid levels in the blood), and atherosclerotic heart disease.

Review of the resident assessment dated 01/11/20 revealed Resident #18 required staff supervision for transfers and ambulation, was a fall risk, and was alert to person, place, and time.

Review of facility incident report for Resident #18 revealed on 12/26/22 at 8:15 A.M. he was observed laying in his bedroom by the bathroom door on his left side. Resident #18 said he felt weak and went down to the floor. He stated he did not hit his and was not hurt. The facility assessed Resident #18 for injuries and assisted him up and to the bathroom. The facility indicated their system follow-up would be to continue to educate Resident #18 on the use of call bell. There was no information included related to the facility addressing the issue with his call pendant not working properly and him laying on the floor until staff happened upon him.

Interview on 12/29/22 at 8:54 A.M. with Resident #18 revealed call lights were a sore subject for him. He said he had a fall on 12/26/22. He stated he got up and was weak and fell and then pushed his call pendant for help and lay on the floor at least 30 minutes waiting for assistance when a nurse came in the room and found him on the floor when she was bringing his medication to him.

Observation on 12/29/22 at 9:04 A.M. revealed Resident #18 activated his call pendant and waited for assistance. Resident Assistant (RA) #352 acknowledged the call light on 12/29/22 at 11:14 A.M., over two hours after it had been activated.

Interview and observation on 12/29/22 at 11:22 A.M. with RA #352 revealed she just got Resident #18's call pendant notification at 11:14 A.M. She confirmed his pendant was not paired to her receiver so it did not not functioning properly. RA #352 stated she paired Resident #18's pendant at 11:14 A.M. so it would now function correctly. RA #352 did not know how the pendant became unpaired. At that time Resident #18's pendant was again pushed and RA #352's handheld receiver immediately beeped and lit up with Resident #18's room number.

Interview on 12/29/22 at 1:17 P.M. with Wellness Director #300 revealed the residents who used the pendant call system in the facility were those residents who resided in rooms on the 100 hall, which is the area where Resident #18 resided. She confirmed the call light system is silent except for those residents on the 100 hall who use the pendant system. She is unaware of how the pendant systems get unpaired.

Interview on 12/29/22 at 1:51 P.M. with Licensed Practical Nurse #303 confirmed she had walked into Resident#18's room on 12/26/22 to give him his medications and found him on the floor. She acknowledged the handheld receiver she had in her pocket that day never indicated Resident #18 had activated his call pendant. LPN #303 stated Resident #18 had told her he had pressed his call pendant for help but lay on the floor for a period of time when she found him. LPN #303 had no idea how the call system pendants were becoming unpaired, but verified this made them nonfunctional.

Interview on 12/29/22 at 2:29 P.M. with RA #357 revealed there were times when the call system pendants were unpaired, which made them nonfunctional. She was not sure why the call pendent systems were becoming unpaired.

Interview on 12/29/22 at 3:01 P.M. with Maintenance #327 confirmed the pendant call systems did not always work. He stated residents and family members would let him know when they were not working correctly. He confirmed the pendants did get unpaired at times. Maintenance #327 stated once the handheld receiver went off from a pendant call activation, staff were to hit the reset button once on the handheld receiver. If a staff member hit the reset button on the handheld receiver multiple times or would hold the reset button too long, it would unpair the pendants, which made them nonfunctional.

Based on interview, observation, and facility policy, the facility failed to ensure individuals performed proper hand hygiene during medication administration. This affected two (Residents #72 and #81) out of three residents reviewed for medication administration.

Findings include:

Observation of a medication administration on 12/29/22 between 8:17 A.M. and 8:42 A.M. with Licensed Practical Nurse (LPN) #303 revealed at 8:17 A.M. she approached the medication cart. LPN #303 opened the cart with her keys, opened the medication cart drawer, and proceeded to prepare medications for Resident #81 without first washing or sanitizing her hands. She prepared one tablet of Vitamin B12, one 500 milligram (mg) tablet of Oyster Shell Calcium plus Vitamin D, one tablet of 50 mg sertraline (used to treat depression), one capsule of Culturelle (probiotic), one capsule of 100 mg docusate sodium (used to treat constipation), one tablet of losartan potassium (used to treat high blood pressure), and two tablets of 325 mg acetaminophen (used to treat mild to moderate pain) into a plastic medicine cup for Resident #81. LPN #303 placed Resident #81's Spiriva inhaler (used to treat lung diseases) and Symbicort inhaler (used to control and prevent symptoms caused by asthma) along with the plastic medicine cup of dispensed pills in a blue plastic square basket. LPN #303 took the inhalers and medications to Resident #81's room. After the medications were administered, LPN #303 did not wash or sanitize her hands. LPN #303 returned to the medication cart, unlocked the medication cart, opened the medication drawer, and proceeded to prepare medications for Resident #72 without first washing or sanitizing her hands. LPN #303 prepared one 50 mg tablet of hydralazine (used to treat high blood pressure), one capsule of gabapentin (used to treat neurotic pain), one 5000 international units (IU) of Vitamin D3, one 500 mg tablet of Vitamin B12, one 100 mg tablet of levothyroxine (used to treat an underactive thyroid), ½ tab of a 40 mg tablet of furosemide (used to treat extra fluid in the body), one 5 mg tablet of amlodipine (used to treat high blood pressure), one 6.25 mg tablet of carvedilol (used to treat high blood pressure), one 0.1 mg tablet of clonidine(used to treat high blood pressure), one 40 mg tablet of pantoprazole (used to treat certain stomach and esophagus problems), one 50 mg tablet of losartan potassium (used to treat high blood pressure), and one 1 mg tablet of Detrol (used to treat an overactive bladder) into a plastic medicine cup. LPN #303 placed the medicine cup with the dispensed medication plus Resident #72's Spiriva inhaler into a blue rectangular plastic basket to take to Resident #72's room. After the medications were administered to Resident #72, LPN #303 came back to the medication cart to start another medication preparation and pass for the next resident. LPN #303 did not wash or sanitize her hands after administering medication in Resident #72's room.

Interview on 12/29/22 at 8:42 A.M. with LPN #303 confirmed hand hygiene was not done prior to and after medication administration for Residents #72 and #81 as required.

Review of facility policy, Handwashing

Based on observation, interview, and facility policy, the facility failed to respond to ensure the resident call system functioned properly in all rooms. This affected ten residents residing on the 100 hall (Residents #2, #10, #11, #18, #35, #37, #38, #72, #73, and #81) where the call pendant system was used and all other residents on the other five resident halls (200, 300, 500, 600 and 700) where a wall pull cord call system was used. The facility census was 79.

Findings include:

1. Review of the medical record for Resident #18 revealed an admission date of 01/11/20 and diagnoses included chronic obstructive pulmonary disease (COPD), transient ischemic attack (temporary period of symptoms similar to those of a stroke), hyperlipidemia (elevated lipid levels in the blood), and atherosclerotic heart disease. Resident #18 resided on the 100 hall.

Review of the resident assessment dated 01/11/20 revealed Resident #18 required staff supervision for transfers and ambulation, was a fall risk, and was alert to person, place, and time.

Interview on 12/29/22 at 8:54 A.M. with Resident #18 revealed the call lights were a sore subject with him. Resident #18 explained he had a fall on 12/26/22. He stated he pushed his call light for help as he lay on the floor and waited at least 30 minutes before the nurse came into his room as she was bringing him his medication. Resident #18 said his call light was not working properly.

Observation on 12/29/22 at 9:04 A.M. revealed Resident #18 activated his call pendent and waited for assistance. Resident Assistant (RA) #352 acknowledged the call light on 12/29/22 at 11:14 A.M., over two hours after it had been activated.

Interview and observation on 12/29/22 at 11:22 A.M. with RA #352 revealed she just got Resident #18's call pendant notification at 11:14 A.M. She confirmed his pendant was not paired to her receiver so it did not not functioning properly. RA #352 stated she paired Resident #18's pendant at 11:14 A.M. so it would now function correctly. RA #352 did not know how the pendant became unpaired and why it did not send the call signal to the receivers she had. At that time Resident #18's pendant was again pushed and RA #352's handheld receiver immediately beeped and lit up with Resident #18's room number.

Interview on 12/29/22 at 1:17 P.M. with Wellness Director #300 revealed the only residents who used the pendant call system in the facility were the ten residents (Residents #2, #10, #11, #18, #35, #37, #38, #72, #73, and #81) who resided on the 100 hall where this pendent call system was being used.

Interview on 12/29/22 at 1:51 P.M. with Licensed Practical Nurse #303 confirmed she had walked into Resident#18's room on 12/26/22 to give him his medications and found him on the floor. She acknowledged the handheld receiver she had in her pocket that day never indicated Resident #18 had activated his call pendant. LPN #303 stated Resident #18 had told her he had pressed his call pendant for help when she found him. LPN #303 had no idea how the call system pendants were becoming unpaired, which made them nonfunctional.

Interview on 12/29/22 at 2:29 P.M. with RA #357 revealed there were times when the call system pendants were unpaired, which made them nonfunctional. She was not sure why the call pendent systems were becoming unpaired.

Interview on 12/29/22 at 3:01 P.M. with Maintenance #327 confirmed the pendant call systems did not always work. He stated residents and family members would let him know when they were not working correctly. He confirmed the pendants did get unpaired at times. Maintenance #327 stated once the handheld receiver went off from a pendant call activation, staff were to hit the reset button once on the handheld receiver. If a staff member hit the reset button on the handheld receiver multiple times or would hold the reset button too long, it would unpair the pendants, which made them nonfunctional.

Review of the facility policy titled, Emergency Response Systems

Based on observation, interview, and facility policy, the facility failed to respond to residents' reasonable requests and inquires to ensure the resident call system functioned properly in all rooms. This affected ten residents residing on the 100 hall (Residents #2, #10, #11, #18, #35, #37, #38, #72, #73, and #81) where the call pendant system was used and all other residents on the other five resident halls (200, 300, 500, 600 and 700) where a wall pull cord call system was used. The facility census was 79.

Findings include:

1. Review of Resident Council Minutes from the 10/20/22 meeting revealed there were concerns voiced by residents indicating it took long for staff to respond to call lights. No resident names were provided. There was documentation of any follow-up action by the facility management staff to address this concern.

2. Review of the medical record for Resident #18 revealed an admission date of 01/11/20 and diagnoses included chronic obstructive pulmonary disease (COPD), transient ischemic attack (temporary period of symptoms similar to those of a stroke), hyperlipidemia (elevated lipid levels in the blood), and atherosclerotic heart disease. Resident #18 resided on the 100 hall.

Review of the resident assessment dated 01/11/20 revealed Resident #18 required staff supervision for transfers and ambulation, was a fall risk, and was alert to person, place, and time.

Interview on 12/29/22 at 8:54 A.M. with Resident #18 revealed the call lights were a sore subject with him. Resident #18 explained he had a fall on 12/26/22. He stated he pushed his call pendant for help as he lay on the floor and waited at least 30 minutes before the nurse came into his room as she was bringing him his medication. Resident #18 said his call light was not working properly.

Observation on 12/29/22 at 9:04 A.M. revealed Resident #18 activated his call pendant and waited for assistance. Resident Assistant (RA) #352 acknowledged the call light on 12/29/22 at 11:14 A.M., over two hours after it had been activated.

Interview and observation on 12/29/22 at 11:22 A.M. with RA #352 revealed she just got Resident #18's call pendant notification at 11:14 A.M. She confirmed his pendant was not paired to her receiver so it did not not functioning properly. RA #352 stated she paired Resident #18's pendant at 11:14 A.M. so it would now function correctly. RA #352 did not know how the pendant became unpaired and why it did not send the call signal to the receivers she had. At that time Resident #18's pendant was again pushed and RA #352's handheld receiver immediately beeped and lit up with Resident #18's room number.

Interview on 12/29/22 at 1:17 P.M. with Wellness Director #300 revealed the only residents who used the pendant call system in the facility were the ten residents (Residents #2, #10, #11, #18, #35, #37, #38, #72, #73, and #81) who resided on the 100 hall where this pendant call system was being used.

Interview on 12/29/22 at 1:51 P.M. with Licensed Practical Nurse #303 confirmed she had walked into Resident#18's room on 12/26/22 to give him his medications and found him on the floor. She acknowledged the handheld receiver she had in her pocket that day never indicated Resident #18 had activated his call pendant. LPN #303 stated Resident #18 had told her he had pressed his call pendant for help when she found him. LPN #303 had no idea how the call system pendants were becoming unpaired, which made them nonfunctional.

Interview on 12/29/22 at 2:29 P.M. with RA #357 revealed there were times when the call system pendants were unpaired, which made them nonfunctional. She was not sure why the call pendant systems were becoming unpaired.

Interview on 12/29/22 at 3:01 P.M. with Maintenance #327 confirmed the pendant call systems did not always work. He stated residents and family members would let him know when they were not working correctly. He confirmed the pendants did get unpaired at times. Maintenance #327 stated once the handheld receiver went off from a pendant call activation, staff were to hit the reset button once on the handheld receiver. If a staff member hit the reset button on the handheld receiver multiple times or would hold the reset button too long, it would unpair the pendants, which made them nonfunctional.

Review of the facility policy titled, Emergency Response Systems

Based on record review and interview the facility failed to ensure criminal records checks were requested in accordance with paragraph (F) of rule 3701-13-03 of the Administrative Code, by submitting the request to BCII, no later than five business days after an employee begins conditional employment. This had the potential to affect all 75 residents residing in the facility

Findings Include:

Review of a new hire list revealed the facility had 15 new hires since 07/28/22. A review of a sample of these employees revealed the following:

Caregiver (CG) #101 had a hire date of 08/19/22.

CG #104 had a hire date of 08/08/22.

CG #105 had a hire date of 08/29/22.

CG #106 had a hire date of 09/14/22.

CG #107 had a hire date of 09/14/22

Registered nurse (RN) #108 had a hire date of 09/21/22.

Record review revealed no evidence these employees, hired after 07/28/22 including CG #101, CG #104, CG #105, CG #106, CG #107 and RN #108 were included on the facility criminal background log for evidence of background checks being completed.

On 09/27/22 at 12:34 P.M. interview with Human Resource (HR) #300 verified the 15 new employees hired since 07/28/22 were not included on the facility BCII log. HR #300 revealed the facility used a company in Akron to conduct background checks and the company would send invoices for the staff they provided background checks for. HR #300 was unable to provide evidence of background checks for the sampled employees above. HR indicated it usually took a month to get the results back from the background checks. He stated the employees reviewed probably went to another background check facility, but stated he could not verify that and had no evidence of background checks being completed.

Review of the facility policy titled Abuse Prohibition, dated 2018 revealed the facility would not tolerate any form of abuse, neglect, or exploitation. The policy indicated staff must be skilled in working with confused residents so that challenging behaviors were avoided whenever possible and handled with dignity and compassion when they occurred. Screening of staff would include to reference the Nurse Aide Registry for each Certified Nursing Assistant prior to hiring and do a criminal background check of all potential employees.

This violation is an incidental finding to Master Complaint Number OH00136141.

Based on record review and interview the facility failed to provide evidence all staff completed the form(s) or provided fingerprint impressions as required by division (B)(2) of section 3721.121 of the Revised Code as required prior to employment. This had the potential to affect all 75 residents residing in the facility

Findings Include:

Review of a new hire list revealed the facility had 15 new hires since 07/28/22. A review of a sample of these employees revealed the following:

Caregiver (CG) #101 had a hire date of 08/19/22.

CG #104 had a hire date of 08/08/22.

CG #105 had a hire date of 08/29/22.

CG #106 had a hire date of 09/14/22.

CG #107 had a hire date of 09/14/22

Registered nurse (RN) #108 had a hire date of 09/21/22.

Record review revealed no evidence these employees, hired after 07/28/22 including CG #101, CG #104, CG #105, CG #106, CG #107 and RN #108 were included on the facility criminal background log for evidence of background checks being completed.

On 09/27/22 at 12:34 P.M. interview with Human Resource (HR) #300 verified the 15 new employees hired since 07/28/22 were not included on the facility BCII log. HR #300 revealed the facility used a company in Akron to conduct background checks and the company would send invoices for the staff they provided background checks for. HR #300 was unable to provide evidence of background checks for the sampled employees above. HR indicated it usually took a month to get the results back from the background checks. He stated the employees reviewed probably went to another background check facility, but stated he could not verify that and had no evidence of background checks being completed.

Review of the facility policy titled Abuse Prohibition, dated 2018 revealed the facility would not tolerate any form of abuse, neglect, or exploitation. The policy indicated staff must be skilled in working with confused residents so that challenging behaviors were avoided whenever possible and handled with dignity and compassion when they occurred. Screening of staff would include to reference the Nurse Aide Registry for each Certified Nursing Assistant prior to hiring and do a criminal background check of all potential employees.

This violation is an incidental finding to Master Complaint Number OH00136141.

Based on record review, review of the resident handbook and interview the facility failed to ensure Resident #21 and Resident #22, who required staff assistance with activities of daily living care were provided showers as scheduled. This affected two residents (#21 and #22) of four residents reviewed for showers.

Findings Include:

1. Review of the medical record revealed Resident #22 was admitted to the facility on 06/01/20 with diagnoses including cerebral infarction, hemiplegia, urinary tract infection, major depression, aortic aneurysm, anemia, anxiety, adjustment disorder, hypertension, difficulty walking and diabetes.

Review of the facility shower schedule revealed Resident #22 was to receive a shower on day shift every Tuesday and Friday.

Review of the Resident Assessment, dated 06/04/22 revealed Resident #22 was oriented to person, place and time and required physical assistance (from staff) for bathing.

Review of the shower sheets for August 2022 revealed no evidence Resident #22 had received a shower on her scheduled shower days on 08/05/22, 08/09/22 or 08/23/22.

Review of the shower sheets for September 2022 revealed no evidence Resident #22 had received a shower on her scheduled shower days on 09/16/22 or 09/20/22.

On 09/26/22 at 10:40 A.M. interview with Licensed Practical Nurse (LPN) #109 revealed resident showers were not getting done. The LPN revealed Resident #22 had complained about her and her husband (Resident #21) not getting their showers.

On 09/26/22 at 11:00 A.M. interview with Resident #22 revealed concerns that neither she or her husband, Resident #21 had been getting their showers. She stated the caregivers did not give her a reason why, they just tell her they do not have time. She stated she reported this concern to the Resident Wellness Director, who stated she spoke to the caregivers. However, Resident #22 revealed the caregivers now just document they had it (a shower) or they refused. Resident #22 revealed neither she nor her husband had ever refused a shower. The resident denied receiving showers last week and indicated the last shower they had received was on 09/13/22.

On 09/28/22 at 3:00 P.M. interview with Resident Wellness Director #102 revealed residents were scheduled showers per their preferences. She indicated showers were to be documented on shower sheets. She verified there was no evidence Resident #22 had received a shower as scheduled on 08/05/22, 08/09/22, 08/23/22, 09/16/22 or 09/20/22.

Review of the resident handbook revealed to maintain optimum health, the resident was encouraged to bathe at least once weekly, and more often when necessary or if desired. Documentation in the handbook revealed staff would assist the resident with two scheduled showers per week as part of their basic care rate.

2. Review of the medical record revealed Resident #21 was admitted to the facility on 06/01/22 with diagnoses including hemiplegia following cerebral infarction, hypertension, muscle weakness, repeated falls, enlarged prostate, dysphagia, vascular dementia, and adjustment disorder.

Review of the facility shower schedule revealed Resident #21 was scheduled to receive a shower on day shift every Tuesday and Friday.

Review of the Resident Assessment, dated 06/04/22 revealed Resident #21 was oriented to person, place and time and required physical assistance with bathing.

Review of the shower sheets for August 2022 revealed no evidence Resident #21 had received a shower on his scheduled shower days on 08/05/22, 08/09/22 or 08/23/22.

Review of the shower sheets for September 2022 revealed no evidence Resident #21 had received a shower on his scheduled shower days on 09/16/22 or 09/20/22.

On 09/26/22 at 10:40 A.M. interview with Licensed Practical Nurse (LPN) #109 revealed resident showers were not getting done. The LPN revealed Resident #22 had complained about her and her husband (Resident #21) not getting their showers.

On 09/26/22 at 11:00 A.M. interview with Resident #22 revealed concerns that neither she or her husband, Resident #21 had been getting their showers. She stated the caregivers did not give her a reason why, they just tell her they do not have time. She stated she reported this concern to the Resident Wellness Director, who stated she spoke to the caregivers. However, Resident #22 revealed the caregivers now just document they had it (a shower) or they refused. Resident #22 revealed neither she nor her husband had ever refused a shower. The resident denied receiving showers last week and indicated the last shower they had received was on 09/13/22.

On 09/28/22 at 3:00 P.M. interview with Resident Wellness Director #102 revealed residents were scheduled showers per their preferences. She indicated showers were to be documented on shower sheets. She verified there was no evidence Resident #21 had received a shower as scheduled on 08/05/22, 08/09/22, 08/23/22, 09/16/22 or 09/20/22.

Review of the resident handbook revealed to maintain optimum health, the resident was encouraged to bathe at least once weekly, and more often when necessary or if desired. Documentation in the handbook revealed staff would assist the resident with two scheduled showers per week as part of their basic care rate.

This violation substantiates Complaint Number OH00136018.

Based on observation, record review and interview the facility failed to ensure ordered medications were administered to Resident #51 and Resident #74. This affected two residents (#51 and #74 ) of four residents reviewed for medication administration.

Findings Include:

1. Review of the medical record revealed Resident #51 was admitted to the facility on 02/19/22 with diagnoses including osteoarthritis, wedge compression fracture of the fourth lumbar vertebra, hematuria, hyperlipidemia, osteoporosis, diabetes, and Vitamin D deficiency.

Review of the Resident Medication Self-Administration Assessment, dated 05/15/22 revealed Resident #51 was not able to administer her own medications.

Review of a Resident Assessment, dated 06/06/22 revealed Resident #51 was alert to person, place, and time.

Review of the September 2022 medication administration record revealed Resident #51 was to be administered at 8:00 A.M. one tablet of Fosamax 70 milligrams (mg), one tablet of Losartan potassium 50 mg, one and half tablets of Zoloft 25 mg, one capsule of Vitamin D 50,000 units, one tablet of Vitamin B12 1000 micrograms. This medication administration would result in the administration of five and a half pills for the resident.

On 09/27/22 at 9:45 A.M. Resident #51 was observed standing in the doorway of her room with a plastic cup of medication in her hand. The resident was asking what she was to do with the cup of medications. There were five and a half pills in the cup, the cup of medications were given to Resident Wellness Director #102.

On 09/27/22 at 10:15 A.M. interview with Licensed Practice Nurse (LPN) #109 verified the medication in Resident #51's room were her morning medications. The LPN verified the medications had not been administered to the resident on this date as of this time.

Review of the facility policy titled Medication Administration, dated 2018 revealed the policy was to ensure each resident received the right medication, in the right dosage, at the right time, and with all the right precautions. Residents could self-administer their own medication if approved by their physician. For those residents who do self-administer their medication, licensed nursing staff of the facility, may perform a quarterly self-administration assessment form. If the resident was assessed to be unable to self-administer medications, the licensed nursing staff would communicate with the resident's primary care physician and the facility would implement for staff to administer all medication to the resident.

2. Review of the medical record revealed Resident #74 was admitted to the facility on 06/29/21 with diagnoses including dementia, hypertension, hyperlipidemia, Vitamin B12 deficiency, hypothyroidism,and Alzheimer's disease.

A Resident Assessment, dated 06/04/22 revealed Resident #74 was oriented to person only.

Review of the Resident Medication Self- Administration Assessment, dated 06/07/22 revealed the resident was unable to self-administer her medications.

On 09/29/22 at 12:30 P.M. interview with Family Member #400 revealed on 09/25/22 at 1:30 P.M. she and her husband had gone to the facility to see Resident #74 (her mother). She stated the resident was sitting out in the bistro area, so they wheeled her back to her room. Family Member #400 revealed on her mother's bedside table was a small plastic cup with medications in it, the medications were in a pink substance (yogurt or pudding), and it was three fourths full of pills and pudding with two glasses of water nearby. Family Member #400 revealed she took the medication up to the nurse's station and asked the nurse why the pills were not given to her mother and just sat on her table. She stated she told the nurse her mother does not understand she needs to take them because of her Parkinson's. She stated the nurse seemed disgusted and said the medications were left from the midnight shift nurse. She stated the nurse told her they had been having trouble with midnight shift staff leaving medication and not giving them to the residents. She stated the nurse told her she would let the Executive Director know the next day which was Monday. She stated she was very concerned about her mother not getting her medications for her Parkinson's disease and her blood pressure. She stated she was not sure what the medications were in the cup.

Review of the facility policy titled Medication Administration, dated 2018 revealed the policy was to ensure each resident received the right medication, in the right dosage, at the right time, and with all the right precautions. Residents could self-administer their own medication if approved by their physician. For those residents who do self-administer their medication, licensed nursing staff of the facility may perform a quarterly self-administration assessment form. If the resident was assessed to be unable to self-administer medications, the licensed nursing staff would communicate with the resident's primary care physician and the facility would implement for staff to administer all medication to the resident.

This violation is an incidental finding to Master Complaint Number OH00136141.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure medications were administered to Resident #72 as prescribed. This affected one resident (#72) of four residents reviewed for medication administration.

Findings Include:

Review of the medical record revealed Resident #72 was admitted to the facility on 09/24/17 with diagnoses including dementia, malignant neoplasm of the skin, behaviors, peptic ulcer disease, asthma, osteoporosis, chronic pulmonary disease, chronic obstructive pulmonary disease, polyneuropathy, and cataracts.

A Resident Assessment, dated 06/04/22 revealed Resident #72 was alert to person, place, and time.

Review of a Resident Medication Self-Administration Assessment, dated 05/26/22 revealed Resident #72 was not able to administer her own medications.

On 09/28/22 at 11:05 A.M. interview with Resident #72 revealed she had received the wrong medications at 10:00 A.M. She stated she told the Executive Director (ED), however the ED just walked away for her without even looking into her concern. The resident revealed she had received too many pills this A.M. when the nurse gave her the medication cup. The resident stated she had never seen the nurse who gave her her pills before today. Observation at the time of the interview revealed the resident was holding a cup of medications.

Reconciliation of the September 2022 medication administration record, the pills and the packets the medications were dispensed in on 09/28/22 at 11:20 A.M. with Resident Wellness Director #102 revealed Resident #74 was given her 9:00 A.M. medications which included one capsule of Cymbalta 30 milligrams, Folic acid one mg, two capsules of Gabapentin 100 mg, one tablet of Magnesium 400 mg, one tablet of Oxybutynin five mg, one tablet of Calcium with Vitamin D 500/200 mg, one tablet of Thera gram-M and one tablet of Venlafaxine 37.5 mg. In addition, the resident was also given her 1:00 P.M. medications which included two capsules of Gabapentin 100 mg and one tablet of Oxybutynin 5 mg.

On 09/28/22 at 11:30 A.M. interview with Agency Licensed Practical Nurse (LPN) #110 revealed it was her first day working in the facility. The LPN verified she had given Resident #72 her 9:00 A.M. and her 1:00 P.M. medications at the same time which was an accident.

Review of the facility policy titled Medication Administration, dated 2018 revealed the policy was to ensure each resident received the right medication, in the right dosage, at the right time, and with all the right precautions. Residents could self-administer their own medication if approved by their physician. For those residents who do self-administer their medication, licensed nursing staff of the facility may perform a quarterly self-administration assessment form. If the resident was assessed to be unable to self-administer medications, the licensed nursing staff would communicate with the resident's primary care physician and the facility would implement for staff to administer all medication to the resident.

This violation is an incidental finding to Master Complaint Number OH00136141.

Based on observation, record review and interview the facility failed to ensure resident trash was emptied timely and resident rooms were cleaned as scheduled to maintain a clean and healthy resident environment. This affected three residents (#22, #38 and #49) reviewed for physical environment and had the potential to affect all 75 residents residing in the facility.

Findings Include:

1. Review of the medical record revealed Resident #22 was admitted to the facility on 06/01/22 with diagnoses including cerebral infarction, major depression, aortic aneurysm, anemia, anxiety, adjustment disorder, hypertension, difficulty walking, and diabetes.

A Resident Assessment, dated 06/04/22 revealed Resident #22 was oriented to person, place and time and required physical assistance from staff for bathing.

On 09/26/22 at 10:40 A.M. interview with Licensed Practical Nurse (LPN) #109 revealed resident rooms were not being cleaned on a regular basis and resident trash was not being picked up.

On 09/26/22 at 11:00 A.M. interview with Resident #22 revealed concerns no one cleaned her room. She stated the housekeepers had been working midnights and want to come in and clean your room in the middle of the night when residents were trying to sleep. The resident revealed there had been feces on the wall and on the floor in the bathroom for over a month because her husband (Resident #21) had diarrhea, and nobody cleaned it up.

On 09/26/22 at 11:00 A.M. observation of Resident #22's room revealed the floor had food debris all over it and the resident's bedside table was dirty with dried food and a red liquid. Further observation revealed feces present on the bathroom floor around the toilet and splattered up the wall behind the toilet.

On 09/26/22 at 11:20 A.M. interview with Housekeeper # 111 revealed she only worked Monday through Friday, no weekends. She stated she and Housekeeper #130 sometimes had to work midnights because they did not have a ride during the day. She stated they were not able to clean resident rooms when they worked midnights, so they only cleaned they common areas. She stated it was usually one or two days a week they worked midnights. She stated they had a cleaning schedule for when resident rooms were to be cleaned, however they could not clean those rooms if they worked midnights.

On 09/26/22 at 11:44 A.M. interview with Caregiver #112 revealed the care giver staff were to pick up trash in the resident rooms every shift and the housekeepers were to do it when they were cleaning the room. She indicated trash was never picked up and was normally overflowing in the resident rooms when she came to work.

On 09/26/22 at 2:00 P.M. observation and interview with Resident Wellness Director #102 verified Resident #22's room needed cleaned and the trash needed emptied.

In addition, review of the resident council minutes from the meeting dated 07/21/22 revealed Resident #49 complained her trash was not being picked up.

Review of the resident handbook revealed housekeeping services were provided weekly by the housekeeping staff, bathrooms were cleaned daily.

2. Review of the medical record revealed Resident #38 was admitted to the facility on 12/08/09 with diagnoses including traumatic brain injury, sick sinus syndrome, anxiety, pacemaker, pulmonary emboli, major depressive disorder, and osteoarthritis

On 09/26/22 at 10:40 A.M. interview with LPN #109 revealed resident rooms were not being cleaned on a regular basis and resident trash was not being picked up.

On 09/26/22 at 10:50 A.M. interview with Resident #38 revealed staff does not empty her trash, she had to place it in the hallway. The resident revealed her room had not been cleaned in a couple weeks.

On 09/26/22 at 10:50 A.M. Resident #38's trash was observed to be full of trash overflowing on to the floor. The resident had food debris all over the floor and her carpet was dirty.

On 09/26/22 at 11:20 A.M. interview with Housekeeper # 111 revealed she only worked Monday through Friday, no weekends. She stated she and Housekeeper #130 sometimes had to work midnights because they did not have a ride during the day. She stated they were not able to clean resident rooms when they worked midnights, so they only cleaned they common areas. She stated it was usually one or two days a week they worked midnights. She stated they had a cleaning schedule for when resident rooms were to be cleaned, however they could not clean those rooms if they worked midnights.

On 09/26/22 at 11:44 A.M. interview with Caregiver #112 revealed the care giver staff were to pick up trash in the resident rooms every shift and the housekeepers were to do it when they were cleaning the room. She indicated trash was never picked up and was normally overflowing in the resident rooms when she came to work.

On 09/26/22 at 2:00 P.M. observation and interview with Resident Wellness Director #102 verified Resident #38's room needed cleaned and the trash needed emptied.

In addition, review of the resident council minutes from the meeting dated 07/21/22 revealed Resident #49 complained her trash was not being picked up.

Review of the resident handbook revealed housekeeping services were provided weekly by the housekeeping staff, bathrooms were cleaned daily.

This violation substantiates Complaint Number OH00136018.

Based on record review and interview the facility failed to ensure a hospital bed was obtained for Resident #55 in a timely manner. This affected one resident (#55) of three residents reviewed for durable medical equipment.

Findings Include:

Review of the medical record revealed Resident #55 was admitted to the facility on 11/03/20 with diagnoses including Alzheimer's disease, hypertension, hypothyroidism, asthma, malignant neoplasm of the colon, anxiety, macular degeneration and weakness.

Review of the nurse's note, dated 06/18/22 at 2:03 P.M. revealed the power of attorney was notified Resident #55 fell out of bed. The note revealed the resident possibly needed a hospital bed with two one half side rails for safety and was placed on the physician's list to see resident so they could get an order for a hospital bed.

Review of a nurse's note, dated 08/12/22 at 9:09 P.M. revealed the resident's daughter stated the resident should have had a hospital bed over a month ago. The daughter was told staff would follow up on it Monday.

Review of a nurse's note, dated 08/23/22 at 12:44 P.M. revealed the facility was still waiting on the resident's primary care physician (PCP) to give an order so the facility could obtain a hospital bed for the resident. The note indicated the PCP was faxed several times with no response.

Review of a nurse's note, dated 08/25/22 at 4:50 P.M. revealed the resident's daughter called and inquired about the hospital bed the facility was supposed to get for the resident. The note indicated the wellness director called the doctor's office and spoke with a staff member. The staff member sated the person who handled medical equipment was off for the rest of the day. She stated she was able to look back in the notes and confirm a prescription was just recently signed by the doctor.

Review of the standard written order, dated 08/29/22 revealed the physician signed an order for a semi-electric hospital bed for Resident #55.

On 09/26/22 at 10:20 A.M. interview with Family Member #120 revealed her mother had fallen on 06/08/22 and on 06/14/22. She stated she was talking to the nurse, and she suggested a hospital bed and she had agreed it would be a good idea. She stated the nurse told her she would put her mother on the list to be seen by the physician so he could write an order (for the bed). However, no one followed through with it. She stated she had asked numerous times why her mother had not gotten the hospital bed and staff just kept telling her the physician had to write the order. She stated it took the facility two and half months to get the bed, which she felt was unacceptable.

On 09/27/22 at 1:30 P.M. interview with Resident Wellness Director #102 revealed the date on the order for the hospital bed for Resident #55 was the date when the physician's office wrote the order. However, it had been sent to the office a while before that date, she was not exactly sure when it was sent to the physician's office to be signed. The wellness director revealed the nurse's note in June was when it was recommended not when it was actually ordered.

This violation substantiates Complaint Number OH00136020.

Based of record review, review of a facility self-reported incident, review of facility investigative notes including witness statements, personnel file review, review of staffing schedules, facility policy and procedure review and interview the facility failed to ensure Resident #35 was free from verbal and physical abuse by a staff member. This affected one resident (#35) of three residents reviewed for abuse.

Findings Include:

Review of the medical record revealed Resident #35 was admitted to the facility on 05/28/21 with diagnoses including dementia, hypertension, hypothyroidism, hyperlipidemia, depression, and vitamin B12 deficiency. Record review revealed Resident #35 was discharged to the hospital on 09/16/22 due to escalating behaviors and was not in the facility at the time of the survey.

A Resident Assessment, dated 08/25/22 revealed Resident #35 was only oriented to person, was independent with ambulation, had aggressive and wandering behaviors and resided on the facility memory care unit.

Review of a facility investigation, dated 09/08/22 revealed Caregiver (CG) #100 was witnessed yelling at the resident after she had scratched him on the forehead. The CG was removed from the facility, placed on administrative leave pending an investigation and terminated on 09/12/22.

Review of a signed witness statement, dated 09/08/22 at 5:54 P.M. revealed Resident Wellness Director (RWD) #102 was walking to the 700 halls in the memory care unit (MCU) to check on the residents and staff at dinner time. As she approached the end of the hall, she could hear Resident #35 yelling loudly and CG #100 yelling back at her to stop yelling and asking her if she wanted to go back to her room. CG #100 was yelling at the resident and as she turned the corner to walk up the 700 hall, she heard Resident #35 begin yelling and CG #100 in an aggressive tone ask the resident if she just scratched him on the face. CG #101 was walking into the resident's room. RWD #102 ran down the hallway to the resident's room and when she approached the resident's room, CG #100 was turning away from the resident facing the doorway. RWD #102 removed CG #100 from the room and asked him to gather his things. CG #101 stayed with the resident as she walked CG #100 off the MCU to the Executive Director's (ED) office.

Review of a signed witness statement, dated 09/08/22 from CG #101 revealed dinner was over and she and CG #100 were taking all the residents into the TV room when Resident #35 had started screaming. As CG #100 started to walk the resident to her room, the resident grabbed at his face and scratched him. CG #100 became angry and pulled the resident's hands up over her head and put her on her bed.

Review of the daily staff schedule dated 09/08/22 revealed CG #100 worked from 3:00 P.M. to 5:15 P.M. on the MCU (Cottages).

Review of an incident report, dated 09/09/22 revealed a head to toes assessment was completed on this date as the resident would not cooperate for an assessment on 09/08/22. Resident #35 had scattered yellow bruises on her back, left hip, right hip and right eye and she had a scratch to her left hand. The son and physician were notified.

An employee termination form, dated 09/12/22 revealed CG #100 was terminated for unsatisfactory job performance.

On 09/26/22 at 1:30 P.M. interview with RWD #102 revealed on 09/08/22 she was walking over to the 700 hallway on the MCU before she went home for the day around 5:15 P.M. and she heard CG #100 talking very loudly to Resident #35. She stated then the CG started yelling aggressively at the resident stating she had scratched him. She stated then it sounded like he put his hands on her and there was a scuffling, but she had not made it into the room yet, so she had not seen anything. She stated when she got to the room. CG #100 was stating behind Resident #35 and CG #101 was in the room also. She stated she told CG #100 he could not speak to a resident that way and took him immediately to the ED's office. She stated she, CG #100 and CG #101 had filled out witness statements regarding the incident. RWD #102 revealed she interviewed CG #101, and she stated CG #100 had Resident #35 restrained in a hold where he was standing behind her, had her arms up in the air, and his arms were hooked around hers with both his hands on the back of her head (a police hold), pushing her forward and the resident could not move. RWD #102 revealed she had assessed the resident and had not seen any bruising or marks on her, but it was very dim in the room and she could not see very well. She stated the ED said she was going to report the incident to the appropriate authorities. RWD #102 revealed on 09/09/22 around 9:00 P.M. she was still in the facility and there was discussion regarding reporting the incident or providing CG #100 additional training. RWD #102 revealed as of 09/12/22 the ED still had not reported the incident to the appropriate authorities. RWD #102 revealed the facility reported an injury of unknown origin related to the bruising she found on the resident on 09/09/22 when she did her second assessment in better lighting on Resident #35 but not the incident with CG #100.

On 09/26/22 at 3:10 P.M. interview with CG #101 revealed on the afternoon shift on 09/08/22 she had been working with CG #100 and they were on the 700 hallway after supper. She stated Resident #35 had been very anxious and was trying to push Resident #14 in the wheelchair. She stated CG #100 had hooked his arm through Resident #35's arm and told her to come with him to her room. Resident #35 had lashed out at him and scratched the CG on his forehead which brought blood. She stated CG #100 had flipped out and started screaming at Resident #35 saying she had just scratched him in the face and was bleeding. She stated CG #100 put Resident #35 in a hold with his arms up under the resident's armpits and his hands on the back of her head, like a police hold and carried her like that for about 25-30 feet from the hall into her room. CG #101 revealed she followed to the resident's room, and observed CG #101 toss the resident down on the bed. She stated she was standing in the doorway and could see RWD #102 running down the hallway towards the room. She stated RWD #102 told CG #100 to immediately leave the unit and go to the ED's office. CG #101 revealed she had to fill out an incident report that night related to what had happened.

On 09/26/22 at 9:20 P.M. interview with Former Memory Care Director (FMCD) #201 revealed on 09/08/22 she had just left the building at 5:00 P.M. and RWD #102 had called her and told her about the incident with CG #100 and Resident #35. She stated the next day she had worked the floor and when she was done at 3:30 P.M. she, RWD #102 and the ED started an investigation. She stated they did skin sweeps on all the residents on the MCU and interviewed staff and residents. She stated they had worked until 9:00 P.M. that evening. She stated they did notice bruising on the hip of Resident #35, but she could not remember which one it was. She stated it was a large bruise with a purple middle with a yellow outer circle and it was fading. She stated it looked like she had fallen so she went back to look for an incident report and could not find one for a fall or injury of unknown origin. She stated on 09/12/22 she was in the ED's office with the ED and RWD #102 and they were on a call with corporate staff. She stated the ED had on earphones so she could not hear what was said from corporate staff, but the ED stated corporate staff directed the facility staff not to report the incident and to put on the incident report the bruises were found on Resident #35 when staff were putting her pajamas on her. She stated she told corporate staff and the ED she was not lying on an incident report and if this was how they were going to handle the situation they could have her keys and she never went back to the facility.

Review of CG #100's personnel file revealed a hire date of 08/17/22 and a termination date of 09/12/22. Review of the facility criminal background log revealed no evidence a background check (BCII) had been completed for CG #100 at the time of hire.

On 09/27/22 at 3:40 P.M. interview with Human Resources (HR) #300 verified CG #100 was not listed on the facility BCII log. HR #300 was able to find a completed background check which he indicated contained no actions against the employee at the time of hire. HR #300 was unable to explain why the employee was not listed on the background log.

Review of facility self-reported incident (SRI), tracking number 226638 revealed an incident was created and submitted to the State agency on 09/12/22 at 1:21 P.M. involving Resident #35. The SRI revealed on 09/10/22 Resident #35 was found with an injury of unknown origin, left and right hip bruising, yellowing. As of 09/29/22 the SRI was incomplete and a final investigation/summary had not been submitted to the State agency. The SRI did not include any type of summary of conclusion.

Review of the facility policy titled Abuse Prohibition, dated 2018 revealed the facility would not tolerate any form of abuse, neglect, or exploitation. The policy included staff must be skilled in working with confused residents so that challenging behaviors were avoided whenever possible and handled with dignity and compassion when they occurred. Screening of staff would include to reference the Nurse Aide Registry for each Certified Nursing Assistant prior to hiring and completion of a a criminal background check of all potential employees. The policy revealed incidents of abuse would be reported to the State Regulatory Agency within three days of the occurrence when there was specific verbal or written allegation of resident abuse, reasonable suspicion of abuse or actual knowledge of resident abuse.

This violation substantiates Complaint Number OH00136141 and Complaint Number OH00136139.