Walnut Creek Care Community

Based on observation, staff interview, and review of facility policy, the facility failed to keep medication carts locked on the memory care unit. This affected one resident (#81) and had the potential to affect 17 (#41, #42, #43, #44, #46, #47, #48, #49, #51, #72, #74, #77, #78, #79, #80, #82, #83) additional residents who were identified on the memory care unit as independently mobile and confused. The facility census was 83. Findings include: Observation on 10/23/25 from 8:51 A.M. to 8:53 A.M. in the memory care unit revealed the medication cart was unattended in the hallway, parked against the wall with drawers facing the hallway, the top drawer was open with medications inside the drawer, and the cart was unlocked. At 8:53 A.M. Resident #81 ambulated down the hallway, stopped at the medication cart, looked inside the medication drawer, and continued to ambulate down the hallway past the medication cart. Observation on 10/23/25 at 8:55 A.M. revealed Licensed Practical Nurse (LPN) #114 walked from a resident's room into the hallway next to the medication cart. Interview on 10/23/25 at 8:56 A.M. with LPN #114 confirmed the top drawer of the medication cart contained medications and was open. The medication cart was unlocked. Interview on 10/27/25 at 3:13 P.M. with the Director of Nursing (DON) verified the medication carts should be locked when the nurses are away from the carts. Review of the policy titled Administering MedicationsBased on observation, staff interview, and review of facility policy, the facility failed to keep medication carts locked on the memory care unit. This affected one resident (#81) and had the potential to affect 17 (#41, #42, #43, #44, #46, #47, #48, #49, #51, #72, #74, #77, #78, #79, #80, #82, #83) additional residents who were identified on the memory care unit as independently mobile and confused. The facility census was 83.

Findings include:

Observation on 10/23/25 from 8:51 A.M. to 8:53 A.M. in the memory care unit revealed the medication cart was unattended in the hallway, parked against the wall with drawers facing the hallway, the top drawer was open with medications inside the drawer, and the cart was unlocked. At 8:53 A.M. Resident #81 ambulated down the hallway, stopped at the medication cart, looked inside the medication drawer, and continued to ambulate down the hallway past the medication cart.

Observation on 10/23/25 at 8:55 A.M. revealed Licensed Practical Nurse (LPN) #114 walked from a resident's room into the hallway next to the medication cart.

Interview on 10/23/25 at 8:56 A.M. with LPN #114 confirmed the top drawer of the medication cart contained medications and was open. The medication cart was unlocked.

Interview on 10/27/25 at 3:13 P.M. with the Director of Nursing (DON) verified the medication carts should be locked when the nurses are away from the carts.

Review of the policy titled Administering Medications

Based on record review, staff interview, and review of facility policy, the facility failed to record the administration of medications to three (#76, #80, #81) of three residents reviewed for medication administration. The facility census was 83.

Findings include:

1. Review of the medical record revealed Resident #76 was admitted to the facility on 07/08/2025. Diagnoses included psychotic disorder with delusions, type 2 diabetes mellitus, anxiety disorder, and Alzheimer's disease.

Review of October 2025 medication administration record (MAR) revealed on 10/20/25 during the day shift the following medications were not documented as administered: atorvastatin calcium 40 milligrams (mg), cyanocobalamin 1000 micrograms (mcg), galantamine hydrobromide 8 mg, magnesium 400 mg, thiamine hydrochloride (HCL) 100 mg, trazodone HCL 100 mg, Zoloft 50 mg, Ativan 0.5 mg, clotrimazole-betamethasone external cream 1-0.05 %, Eliquis 5 mg, hydrocodone-acetaminophen 5-325 mg, metoprolol succinate extended release (ER) 24 hour sprinkle 25 mg, Cymbalta, Tylenol Extra Strength 500 mg, and Zyprexa 5 mg.

2. Review of the medical record revealed Resident #80 was admitted to the facility on 03/27/25. Diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol dependence.

Review of the October MAR revealed on 10/20/25 during the day shift the following medications were not documented as administered: aspirin 81 mg, cimetidine 200 mg, cyanocobalamin 100 mcg, isosorbide mononitrate ER daily, omeprazole 20 mg, Namenda 5 mg, fluticasone propionate nasal suspension 50 mcg, Provera 40 mg, Vitamin D 10 mcg times three, Zoloft 100 mg, Zyprexa 5 mg, depakote 125 mg, and gabapentin 100 mg.

3. Review of the medical record revealed Resident #81 was admitted to the facility on 02/01/24. Diagnoses included dementia, peripheral autonomic neuropathy, and polyneuropathy.

Review of the October MAR revealed on 10/20/25 during the day shift the following medications were not documented as administered: Biotin 10 mg. Exelon transdermal patch 24 hour, ferrous sulfate 325 mg, Lasix 20 mg, magnesium 250 mg, melatonin 3 mg, metronidazole external gel 0.75 %, sertraline 25 mg, Synthroid 88 mcg, Eliquis 2.5 mg, memantine 10 mg, and Preservision one tablet.

Interview on 10/23/2025 at 11:24 A.M. with the Director of Nursing (DON) revealed he saw the nurse giving the morning medications on 10/20/25, but he didn't notice she wasn't documenting the administered medications. The DON stated he believed the nurse gave the medications and just didn't document it in the medical record.

Interview on 10/23/2025 at 11:39 A.M. with the DON confirmed medications are separated and packed by date and time. The medications remaining in the medication cart where Resident #76, #80 and #81 reside were for 10/23/25 for the afternoon and evening.

Interview on 10/23/2025 at 11:39 A.M. the DON verified the nurse must not have documented the medications to the residents on 10/20/25.

Review of the policy titled Administering Medications

Based on observation, staff interview and review of the resident handbook, the facility failed to maintain confidentiality of the residents' medical records. This had the potential to affect 23 of 23 residents in the memory care unit. The facility census was 83.

Findings include:

Observation on 10/23/25 from 8:51 A.M. to 8:53 A.M. revealed the medication cart in the memory care unit was unattended in the hallway. The laptop with the electronic health record (EHR) system was opened. The laptop screen displayed multiple residents and pictures.

Observation on 10/23/25 at 8:55 A.M. revealed Licensed Practical Nurse (LPN) #114 walked out into hallway next to the medication cart out of a resident room.

Interview on 10/23/25 at 8:56 A.M. with LPN #114 confirmed the laptop was open with the EHR up on the screen with multiple residents and pictures showing. The LPN #114 confirmed the laptop should have been closed and locked when she was not next to the cart.

Interview on 10/23/25 at 3:12 P.M. with the Director of Nursing (DON) revealed nursing staff should close the EHR screen when walking away from the laptop.

Review of the resident handbook revealed the facility is required to maintain the privacy and security of the health information.

This violation represents non-compliance investigated under Complaint Number OH00168637.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to administer medications as ordered. This affected one (#51) out of three residents reviewed for medication administration. The facility census was 81.

Findings include:

Review of the medical record for Resident #51 revealed an admission date of 03/03/25 with medical diagnoses of post-traumatic stress disorder, hyperlipidemia, and chronic pain.

Review of the medical record for Resident #51 revealed a functional assessment, dated 03/03/25, which indicated Resident #51 was independent with activities of daily living. Review of Assisted Living resident evaluation, dated 06/11/25, indicated Resident #51 was cognitively intact and independent with activities of daily living and medication administration.

Review of the medical record for Resident #51 revealed a physician order dated 03/03/25 for buspirone 30 milligram (mg) one tablet by mouth two times per day, physician orders dated 03/04/25 for atorvastatin 40 mg one tablet by mouth daily and omeprazole 20 mg one tablet by mouth daily, an order dated 03/05/25 for gabapentin 100 mg one tablet by mouth three times per day, orders dated 08/21/25 for trazadone 100 mg one tablet by mouth at bedtime, gabapentin 300 mg one tablet by mouth two times per day, and hydrocodone-acetaminophen 7.5-325 mg one tablet three times per day. Further review revealed a physician orders dated 08/25/25 for trazodone 50 mg give 1.5 tablet by mouth at bedtime, an order dated 08/27/25 for amoxicillin-potassium clavulanate 875-125 mg one tablet by mouth every 12 hours, and an order dated 08/28/25 for gabapentin 100 mg one tablet by mouth three times per day.

Review of the medical record for Resident #51 revealed an August 2025 Medication Administration Record (MAR) which had no documentation to support Resident #51 received medications as ordered on 08/04/25, 08/13/25, 08/20/25, 08/21/25, 08/24/25, 08/25/25, 08/29/25, and 08/30/25. Review of the September 2025 MAR revealed no documentation to support Resident #51 received medications as ordered on 09/01/25, 09/03/25, 09/06/25, 09/07/25, 09/11/25, 09/12/25, 09/15/25-09/17/25, 09/21/25, and 09/23/25.

Interview on 10/08/25 at 10:45 A.M. with Resident #51 stated he does not always get his medications as ordered. Resident #51 stated the nurses have his medications in the medication cart and the nurses are supposed to bring his medications to him at the scheduled times but sometimes he doesn't even get his medications.

Interview on 10/08/25 at 12:20 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #51 did not have documentation to support Resident #51 received medications as ordered in August or September 2025.

Review of the facility policy titled, Administering Medications

Based on medical record review, staff interview, and policy review, the facility failed to investigate an incident (i.e. allegation of abuse) involving a resident. This affected one (#39) out of three residents reviewed for abuse. The facility census was 81.

Findings include:

Review of the medical record for Resident #39 revealed an admission ate of 08/08/25 with medical diagnoses of Alzheimer's dementia, late stage with mild agitation, anxiety, schizophrenia, and psychosis.

Review of the medical record for Resident #39 revealed an Assisted Living evaluation, dated 08/08/25, which indicated resident had impaired cognition and required some assistance with activities of daily living.

Review of the medical record for Resident #39 revealed a nurse's note, dated 09/13/25 at 7:13 P.M. which stated another resident came to this nurse and complained that Resident #39 had groped her unwilling and she was uncomfortable. The note stated the nurse educated Resident #39 on touching other people without permission and Resident #51 stated ok. The note indicated the Director of Nursing (DON) was aware and all parties were aware.

Interview on 10/09/25 at 10:28 A.M. with DON confirmed the medical record for Resident #39 had documentation which stated Resident #39 groped another resident. DON confirmed the facility had not completed an investigation into the incident or allegation of abuse or reported the incident to the State Agency. The DON confirmed the facility policy is to investigate incidents of potential abuse and to report them to the State Agency.

Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and MA of Resident Property

Based on observations, staff interviews, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 81 residents residing in the facility. The census was 81.

Findings include:

Observation on 10/08/25 at 8:55 A.M. in the walk-in cooler revealed an opened package of boiled eggs and an opened package of sliced ham both stored together in a larger plastic bag with no date marking. Further observation at this time revealed another opened bag of sliced ham dated 09/19/25 and another bag of boiled eggs opened and dated 09/25/25 stored on a different shelf inside the walk-in cooler. These findings were verified with Dietary Supervisor #257 at the time of observation.

Observation on 10/08/25 at 8:58 A.M. revealed multiple boxes of food items stored on the floor of the walk-in freezer. Items on the floor included two boxes of sweet potato fries, one box of sausage links, two boxes of beef patties, one box of mixed vegetables, one box of pancakes, and one box of pre-sliced pies amongst other food items stacked on top of these food items.

Observation on 10/08/25 at 9:05 A.M. revealed no internal temperature gauge was readily visible inside the walk-in freezer. This finding was verified with Dietary Supervisor #257 at the time of observation. Dietary Supervisor #257 also could not locate an internal temperature gauge in the walk-in freezer to check the temperature inside the walk-in freezer.

Interview on 10/08/25 at 9:05 A.M. with Dietary Supervisor #257 verified the date markings on the food items in the cooler were labeled to indicate the date the food item was opened. Dietary Supervisor #257 stated time and temperature controlled for safety foods should be discarded within seven days of opening the product. Further interview with Dietary Supervisor #257 at this time revealed the foods seen on the floor in the walk-in freezer were delivered the previous evening on 10/07/25, and the foods were being kept on the floor while some of the storage racks in the freezer were out of repair.

Observation on 10/08/25 at 12:00 P.M. revealed Cook #271 was not wearing a hairnet to cover their beard while preparing and serving foods for lunch service from the smaller/auxiliary kitchen. This finding was verified with Cook #271 at the time of observation.

Observation on 10/09/25 at 11:45 A.M. revealed Dietary Aide #209 did not wash their hands prior to donning gloves and preparing plates for lunch service in the memory care unit. This finding was verified with Dietary Aide #209 at the time of observation.

Review of the facility policy titled Food Storage dated 2021 revealed foods will be stored by methods designed to prevent contamination or cross contamination. Further review of this policy revealed all food should be stored off the floor and specified that food should be stored a minimum of six inches above the floor. Additional review of this policy revealed leftover food should be clearly labeled and dated before being refrigerated, and leftover foods must be used within seven days or discarded as per the 2017 Federal Food Code.

Review of the facility policy titled Employee Sanitary Practices dated 2021 revealed all employees will wear hair restraints such as a hairnet, hat, and/or beard restraint to prevent hair from contacting exposed food. Additional review of this policy revealed hands must be washed prior to using gloves and after removing gloves for food service.

Based on review of facility disaster drill records and staff interview, the facility failed to conduct two disaster preparedness drills within the past year as required. This had the potential to affect all 81 residents residing in the facility. The facility census was 81.

Findings include:

Review of the facility disaster drills logbook revealed one disaster drill has been conducted in the past year, which was a tornado drill conducted on 04/20/25. Further review of the disaster drills logbook revealed no other disaster drills were conducted within the past year as of the date of the survey.

Interview on 10/09/25 at 2:29 P.M. via phone call with Maintenance Director #223 confirmed the facility had not conducted any other disaster drills within the past year besides the tornado drill that was conducted on 04/20/25

Based on observation and staff interview, the facility failed to ensure past survey results were readily accessible to residents as required. This had the potential to affect all 81 residents residing in the facility. The facility census was 81.

Findings include:

Observation on 10/08/25 at 1:40 P.M. revealed there were no readily accessible records of past survey results in the common areas around the entrance of the facility, as well as the library adjacent to the lobby towards the entrance of the facility. Additional observation at this time revealed there was no signage posted regarding availability of past survey results by request.

Interview on 10/08/25 at 1:44 P.M. with the Director of Regional Operations #200 revealed facility staff were unable to locate past survey results upon request.

Based on medical record review and staff and resident interviews, the facility failed to schedule an Ophthalmologist appointment timely. This affected one (#51) resident out of three reviewed for ancillary services. The facility census was 81.

Findings include:

Review of the medical record for Resident #51 revealed an admission date of 03/03/25 with medical diagnoses of post-traumatic stress disorder, hyperlipidemia, and chronic pain.

Review of the medical record for Resident #51 revealed a functional assessment, dated 03/03/25, which indicated Resident #51 was independent with activities of daily living. Review of Assisted Living resident evaluation, dated 06/11/25, indicated Resident #51 was cognitively intact, independent with activities of daily living and medication administration and had not issues with his vision.

Review of the medical record for Resident #51 revealed an Optometrist note, dated 08/27/25, which stated Resident #51 had cataracts and indicated a referral to Ophthalmologist was needed for cataract surgery. Review of the medical record for Resident #51 revealed no documentation to support an appointment for an Ophthalmologist had been scheduled.

Interview on 10/08/25 at 10:45 A.M. with Resident #51 stated he had impaired vision and was supposed to see an eye surgeon, but an appointment hadn't been made yet.

Interview on 10/08/25 at 12:30 P.M. with Regional Director of Clinical Operations (RDCO) #205 confirmed the facility staff had not scheduled an appointment for Resident #51 to see an Ophthalmologist.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to store resident's medications in a proper and safe manner. This directly affected 12 residents (#02, #06, #10, #12, #17, #19, #20, #21, #22, #23, #77, and #81) and had the potential to affect one additional (#32) resident who the facility identified as being cognitively

Findings include:

1) Review of the medical record for Resident #02 revealed the resident was admitted to the facility on 08/25/25. Diagnoses included Congestive Heart Failure (CHF), bipolar disorder, anxiety disorder, paroxysmal atrial fibrillation, essential primary hypertension, and hyperlipidemia.

Review of the Resident Assessment for Resident #02 dated 08/25/25, revealed the resident was cognitively intact. Resident #02 was dependent on staff for medication administration.

Review of the active physician order summary for Resident #02 revealed he was ordered to receive carvedilol (antihypertensive/beta blocker medication) 25 milligrams (mg), Eliquis (anticoagulant) five mg, hydralazine (antihypertensive) 100 mg, Lasix (antidiuretic) 80 mg, metformin (for diabetes mellitus) 500 mg two times per day, and potassium chloride (supplement for low potassium) 20 milliequivalents (mEq) one tablet by mouth two times per day.

2) Review of the medical record for Resident #06 revealed the resident was admitted to the facility on 06/20/25. Diagnoses included insomnia, spondylosis, dorsalgia, dizziness, and giddiness.

Review of the Resident Assessment for Resident #06 dated 06/21/25 revealed she was cognitively intact. Resident #06 was dependent on staff for medication administration.

Review of the active physician order summary for Resident #06 revealed she was ordered to receive Lorazepam (for anxiety) 0.5 mg give one tablet three times daily.

3) Review of the medical record for Resident #10 revealed the resident was admitted to the facility on 12/14/24. Diagnoses included nonrheumatic mitral valve insufficiency, essential primary hypertension, morbid obesity, dementia, diabetes mellitus, major depressive disorder, edema, and chronic kidney disease.

Review of the Resident Assessment dated 06/06/25 revealed Resident #10 had impaired cognition and was dependent on staff for medication administration. Further review of the resident evaluation revealed Resident #10 required queuing and reminders for safety.

Review of the active physician orders for Resident #10, revealed she was ordered to receive atorvastatin calcium (for cholesterol) 40 mg one tablet in the evening and donepezil (for memory) 10 mg one tablet in the evening.

4) Review of the medical record for Resident #12, revealed the resident was admitted to the facility on 08/20/25. Diagnoses included essential primary hypertension, chronic kidney disease, pure hypercholesterolemia, iron deficiency, and anemia.

Review of the Resident Assessment for Resident #12 dated 08/20/25, revealed she was cognitively intact. Resident #12 was dependent on staff for medication administration.

Review of the active physician summary for Resident #12, revealed she was ordered to receive simvastatin (for cholesterol) 10 mg one tablet at night.

5) Review of the medical record for Resident #17, revealed the resident was admitted to the facility on 02/20/25. Diagnoses included hypothyroidism, diabetes, essential primary hypertension, hyperlipidemia, and traumatic subarachnoid hemorrhage.

Review of the Resident Assessment for Resident #17 dated 06/11/25, revealed she was cognitively intact. Resident #17 was dependent on staff for medication administration.

Review of the active physician order summary for Resident#17, revealed she was ordered to receive Tylenol (for pain) 325 mg give two tablets every evening, Lantus solution (long acting insulin) 100 unit inject five units subcutaneously in the evening and atorvastatin calcium 40 mg.

6) Review of the medical record for Resident #19 revealed the resident was admitted to the facility on 03/10/25. Diagnoses included heart failure, polyneuropathy, anemia, major depressive disorder, and hemiplegia, and hemiparesis.

Review of the Resident Assessment for Resident #19 dated 06/05/25, revealed he was cognitively intact. Resident #19 was dependent on staff for medication administration.

Review of the active physician order summary for Resident #19, revealed he was ordered to receive Metformin 500 mg one tablet daily, melatonin five (for insomnia) one tablet in the evening, atorvastatin 40 mg one tablet in the evening, carbamazepine (for seizures) 200 mg give two tablets two times per day, Tylenol extra strength 500 mg give one tablet 3 times, Zoloft (for depression) give 50 mg at bedtime, and carvedilol 3.125 mg one tablet by mouth every morning and bedtime.

7) Review of the medical record for Resident #20 revealed the resident was admitted to the facility on 12/12/24. His diagnoses included chronic obstructive pulmonary disease (COPD), hypothyroidism, schizophrenia, acute respiratory failure with hypoxia, anxiety disorder, anemia, post-traumatic stress disorder (PTSD), and major depressive disorder.

Review of the Resident Assessment for Resident #20 dated 06/11/25, revealed he was cognitively intact and dependent on staff for medication administration.

Review of the physician order summary for Resident #20, revealed he was ordered to receive olanzapine (for Schizophrenia) 20 mg in the evening, tramadol (for pain) 50 mg one tablet in the afternoon, and Tylenol 325 mg every six hours,

8) Review of the medical record for Resident #21 revealed the resident was admitted to the facility on 01/22/25. His diagnoses included CHF, hyperlipidemia, schizophrenia, insomnia, cardiomyopathy, PVD, GERD, OA, and anxiety disorder.

Review of the Resident Assessment for Resident #21 dated 01/22/25, revealed he was cognitively intact. He was dependent on staff for medication administration.

Review of the physician order summary for Resident #21 revealed he was ordered to receive Tylenol 500 mg by mouth every 8 hours, carvedilol 6.25 mg one table by mouth two times per day, divalproex sodium (for bipolar) give two tablets by mouth, glipizide (for DM) 5 mg give 2 tablets by mouth 2 times daily, Humalog KwikPen subcutaneous pen injector 100 mg sliding scale, atorvastatin 20 mg, melatonin (for insomnia) 10 mg, Ernesto (congestive heart failure) 24-26 mg give 1 tablet 2 times per day, tamsulosin (for prostatic hyperplasia) 0.4 mg give one capsule by mouth in the evening, and Zyprexa (for Schizophrenia) one tablet five mg give one tablet by mouth.

9) Review of the medical record for Resident #22 revealed the resident was admitted to the facility on 08/11/25. His diagnoses included GERD, homicidal ideations, encephalopathy, bipolar disorder, hypokalemia, PTSD, encephalopathy, human immunodeficiency virus (HIV), hypomagnesemia, essential primary hypertension, and encephalopathy.

Review of the Resident Assessment for Resident #22 dated 08/11/25 revealed he was cognitively intact. Resident #22 was dependent on staff for medication administration.

Review of the physician order summary for Resident #22 revealed he was ordered to receive cranberry fruit oral (for supplement) 465 mg one capsule by mouth in the morning, famotidine (for heartburn) oral tablet 20 mg one tablet in the morning, carvedilol 6.25 give one tablet each morning and bedtime, lamotrigine (mood stabilizer/seizures) oral tablet 100 mg by mouth one time a day, and alprazolam (for anxiety) one mg every morning and at bedtime.

10) Review of the medical record for Resident #23 revealed the resident was admitted to the facility on 05/05/25. His diagnoses included COPD, hyperlipidemia, schizophrenia, delusional disorder, anxiety disorder, dysphagia, and gastro-esophageal reflux disease.

Review of the Resident Assessment for Resident #23 dated 06/06/25 revealed he was cognitively intact. He was dependent on staff for medication administration.

Review of the active physician order summary for Resident #23, revealed he was ordered to receive amitriptyline (for depression) 50 mg one tablet at bedtime, Caplyta (for depression) 42 mg one tablet at bedtime for depression, and Eliquis five mg one tablet at bedtime.

11) Review of the medical record for Resident #77 revealed the resident was admitted to the facility on 06/11/25. Her diagnoses included ischemic cardiomyopathy, diabetes mellitus (DM), apraxia, myocardial infarction, congestive heart failure, and cerebral infarction.

Review of the most recent Resident Assessment for Resident #77 revealed she was cognitively intact. Resident #77 was dependent on staff for medication administration.

Review of the physician orders for Resident #77 revealed he was ordered to receive ibuprofen (for pain) 800 mg one tablet every eight hours, Lantus subcutaneous solution 100 units inject 10 unit subcutaneously, Humalog 100 unit inject five unit subcutaneously before meals. Gabapentin (for neuropathy) 300 mg one tablet by mouth three times a day, Apixaban (for apraxia) five mg one tablet by mouth two times per day, and losartan potassium (antihypertension) 25 mg one tablet per day,

12) Review of the medical record for Resident #81 revealed the resident was admitted to the facility on 04/01/25. His diagnoses included anxiety disorder, gastro-esophageal reflux disease (GERD), major depressive disorder, paranoid schizophrenia, COPD, and anemia.

Review of the Resident Assessment for Resident #81 dated 04/01/25 revealed he was cognitively intact. Resident #81 was dependent on staff for medication administration.

Review of the physician orders for Resident #81 revealed an order to receive trazadone (for insomnia) 100 mg one tablet by mouth at bedtime, and famotidine 20 mg one tablet by mouth 2 times per day.

Observation of the facility on 08/27/25 at 5:00 P.M. revealed a medication cart situated on corner of the T1 and T2 hallway and no nurse was observed near the medication cart. There were eleven clear medication cups that contained medications with resident names written in marker sitting on top of the medication cart with some medication cups stacked on top of each other. In addition to the clear medication cups, there was a prepackaged medication package from the pharmacy with Resident #22's name on it along with two insulin syringes filled with medications and an insulin quick pen lying on top of the unattended medication cart.

Interview on 08/27/25 at 5:05 P.M. with the Director of Nursing (DON), verified the 11 medication cups of pre-pulled medications, the prepackaged medications for Resident #22, the two insulin syringes with medications in them and the insulin quick pen sitting on top the medication cart unattended. The DON stated medications should not be pre-pulled for the residents.

Interview on 08/27/25 at 5:07 P.M. with Licensed Practical Nurse (LPN) #100 stated she had pre-pulled various resident ' s medications in and placed them in the medication cups with the resident ' s names and stacked them on top of each other so she could administer them to the residents who were not eating in the dining room LPN #100 stated the prepackaged pill pack was for Resident #22 who was not there for his morning medications. LPN #100 stated the pre-pulled medications were for the evening medication round for 6:00 P.M. to 9:00 P.M. LPN #100 reviewed each medication cup and stated the medication cups were for Residents #02, #06, #10, #12, #17, #19, #20, #21, #22, #23, #77, and #81.

Subsequent interview with the DON on 08/27/25 at 5:45 P.M. stated it was the expectation that nurses should not pre-pull medications and nurses should secure all medications inside a locked medication carts.

Review of the facility policy titled Administering Medications dated 08/2021 revealed medications would be administered in a safe and timely manner and as prescribed. Medications must be administered within one hour of their prescribed time. During administration of medications, the medication cart would be kept closed and locked when out of sight of the medication nurse or aide. No medications are to be kept on top of the cart and the cart must be visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Review of the facility policy titled Medication Storage, undated confirmed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Ohio Department of Health guidelines. All medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel

Based on medical review and staff interview, the facility field to complete laboratory values (labs) as ordered by physician. This affected one (#59) of three residents reviewed for change in condition. The facility census was 75.

Findings include:

Review of Resident #59's medical record revealed an admission date of 10/16/24. Diagnose listed include enterocolitis due to clostridium difficile (C.diff), uterine cancer, heart failure, and major depressive disorder.

Review of physician orders revealed an order dated 05/06/25 to check stool for C.diff times three days, on separate days.

Review of labs recorded for Resident #59 revealed a stool sample for C.diff was collected on 05/07/25 and resulted as negative on 05/10/25. No other stool samples were documented as being collected and there was no results for any other C.diff results.

Interview with Assisted Living Director (ALD) #100 on 05/22/25 at 1:12 P.M. confirmed three stool samples to be checked for C.diff had not been collected as ordered for Resident #59.

This violation represents non-compliance investigated under Complaint Number OH00165580.

Based on medical record review, review of the facility's incident log, and staff interview, the facility failed to investigate the origin of a resident's injury. This affected one (#28) of three residents reviewed for abuse. The facility census was 75.

Findings include:

Review of Resident #28's medical record revealed an admission date of 06/24/14. Diagnoses listed include dementia, major depression, hypertension, and osteoarthritis.

Review of progress notes dated 03/25/25 at 6:18 P.M. revealed a nurse standing behind Resident #28 notice her right hand was purple and swollen. When the nurse asked Resident #28 what happened she stated some man grabbed her last night. Resident #28 was unsure what the man looked like or who it was. All Resident #28 could say is that it was a man.

Review of the facility's incident log revealed no documentation of any incident for Resident #28 on 03/25/25.

Further review of Resident #28's medical record revealed no evidence of any investigation into Resident #28' swollen right hand.

Interview with Assisted Living Director (ALD) #100 on 05/27/25 at 9:39 A.M. confirmed the cause of Resident #28's purple and swollen hand had not been investigated.

This violation represents non-compliance investigated under Complaint Number OH00165364.

Based on medical record review, staff and resident representative interviews, and review of the facility policy, the facility failed to ensure residents were free from sexual abuse. Additionally, the facility failed to implement their abuse policy to thoroughly investigate incident of resident to resident sexual abuse. This affected two (#32 and #60) of five residents reviewed for abuse. The facility census was 75.

Findings include:

1. Review of Resident #60's medical record revealed an admission date of 03/27/25. Diagnoses listed dementia and alcohol dependence.

Review of physician notes dated 03/28/25 revealed Resident #60 resides in the facility's memory care unit of the assisted living and had impaired cognition. Resident #60 was unable to be interviewed about family history of medical conditions due to cognitive status.

Review of progress notes dated 05/07/25 at 3:44 P.M. revealed Resident #60 was found in the closet of a female resident's room. Resident #60 had taken a shower and was in the closet getting out clothes to put on. Resident #60 was re-directed to his room. Resident #60's wife was present.

Review of progress notes dated 05/10/25 at 2:47 P.M. revealed Resident #60 was with a naked female in his bed. Resident #60 stated he was grown and that's what he does. Nurse dressed female resident and left the area.

Review of progress notes dated 05/11/25 at 11:32 A.M. revealed Resident #60 was found on female resident's room. Resident #60 was in between her legs performing a sex act on her. A care aide had walked in the room and came across Resident #60 and the female resident performing sex acts on each other. Nurse separated the female resident and Resident #60. Resident #60 grabbed another female resident while staff was taking him to his room. Resident #60's psychiatric service provider was called for guidance.

Review of progress notes dated 05/11/25 at 6:08 P.M. revealed Resident #60 was pink slipped (emergency discharged) to a local hospital for behaviors.

Review of progress notes dated 05/12/25 at 3:00 P.M. revealed the nurse was called over the intercom to report to a female resident's room as soon as possible (ASAP). As the nurse approached the room a woman outside in the hallway was visibly upset. The woman introduced herself as the female resident's sister. The lady then told this writer, When walked into my sister's room there was a naked man in bed with her. The woman asked the man, Who are you? and he said, Resident #60's name. The woman then said to him, please get up and leave my sister's room. The man did not move. The sister asked him again

Based on medical record review, staff interview and policy review, the facility failed to complete the annual health assessments for two (#01 and #70) out of six residents reviewed for annual health assessments. The facility census was 69.

Findings include.

1. Review of the medical record review for Resident #01 revealed she was admitted to the facility on 12/15/23. Her diagnoses included dementia, rhabdomyolysis, iron deficiency anemia, cerebral infarction, hyperlipidemia, anxiety disorder, and essential primary hypertension.

Review of the most recent Health Assessment dated 12/15/23, for Resident #01 revealed she was cognitively impaired. Resident #01 was dependent on staff for medication administration and incontinence care. Resident #01 required assistance with eating and bathing.

Interview with the Assistant Director of Nursing (ADON) #263 on 04/16/25 at 11:50 A.M., verified Resident #01's last annual Health Assessment was 12/15/23.

2. Review of closed medical record review for Resident #70 revealed she was admitted to the facility on 02/19/24. Resident #70 had a fall that resulted in a fractured left hip. Resident #70 passed away at the facility with Hospice services on 02/08/25. Her diagnoses included encephalopathy, chronic kidney disease, hypertension, and transient ischemic attack (TIA).

Review of the Health Assessments for Resident #70 revealed no documented evidence of an annual Health Assessment completed for Resident #70.

Interview with the DON on 04/16/25 at 5:46 P.M. verified there was no documented annual Health Assessment for Resident #70.

Review of the facility policy titled, Nursing Admission/Readmission/Annual Assessment Policy, dated September 2018, revealed a Nursing Admission Assessment is done on each new admission to provide information for quality care and communication of the residents' conditions to increase continuum of care throughout the transfer and admission process. Complete annual assessment within thirty days at an anniversary of last assessment.

This violation is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, interview with facility staff, review of fall investigations, and review of facility policy on falls, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, and failed to implement appropriate fall interventions to reduce and/or eliminate further falls. This resulted in Real and Present Danger and Actual Harm related to serious-life threatening injuries, negative health outcomes and death for one resident when Resident #70 had multiple falls, including a fall on 02/04/25 where she sustained an acute comminuted intertrochanteric fracture of the left hip. This affected one (#70) of seven residents reviewed for falls. Additionally, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, and failed to implement appropriate fall interventions to reduce and/or eliminate further falls placing five additional residents (#01, #20, #32, #42, and #44) at risk for potential physical harm, out of seven residents reviewed for falls. The facility census was 69.

On 04/15/25 at 2:42 P.M., the Administrator and Director of Nursing (DON) were notified the Real and Present Danger began on 02/04/25 at approximately 6:00 A.M., when Resident #70, who was cognitively impaired due to a diagnosis of dementia, resided in the Memory Care Unit (MCU), was at risk for falls, and who had several prior unwitnessed falls, sustained another unwitnessed fall from her bed and was found in the floor. Resident #70 continued to express extreme pain in her left hip when the facility obtained a stat (immediate) x-ray. The resident was diagnosed with a fractured hip and continued to decline until the resident passed away from her injuries on 02/08/25 at approximately 12:45 P.M.

The Real and Present Danger was abated on 04/16/25 when the facility took the following corrective actions:

As of 02/08/25, Resident #70 no longer resides in the facility.

On 04/15/25, Regional Director of Clinical Operations (RDCO) #515 and the Administrator educated the DON and Assistant Director of Nursing (ADON) #263 on fall service planning and tracking/trending for root cause analysis (RCA). Along with education, RDCO #515 and the Administrator provided a copy of the fall policy and provided a fall checklist. Lastly, a list of possible interventions was placed into the service plan binders.

On 04/15/25, the DON and ADON #263 educated 25 Licensed Practical Nurses (LPNs) and four Registered Nurses (RNs) on fall service planning, fall assessments and incident reporting. All staff will be educated on fall reporting. As needed (PRN) staff members and agency staff will be educated prior to their shifts by the DON and/or ADON #263. The Administrator will ensure education is completed by using an employee check-off sheet and the daily schedules. A digital education was sent out on 4/15/25 at 3:48 P.M. to all staff. Four Certified Nursing Assistants (CNAs) consistently work the Assisted Living (AL); however, we mostly use care givers at the AL who do similar work as CNAs. We are educating all staff from the Skilled Nursing Facility (SNF) and AL just in case they cross over and work at the AL. We are also educating all departments in case they witness a fall. The Administrator/designee will ensure all staff were educated by auditing all Inservice Sign-in-Sheets to the staff rosters to ensure everyone was educated.

On 04/15/25, new Fall Risk Assessments were completed on all residents by RDCO #515, DON and ADON #263 and service plans were initiated or completed to reflect new fall assessments. Fall interventions were audited on 4/15/25 and services plans were put in place for all residents regarding falls. All provider orders were audited for any fall interventions on 4/15/25 and everything was compared to service plans and updated as needed.

On 04/15/25, the DON and ADON #263 created binders for service plans and fall interventions to be placed at two nurse's stations (main nurse's station and memory care nurse's station) for the caregivers to have access to review each resident who resides in the facility. Upon completion of assessing all residents and creating the binders, the DON and ADON #263 completed walking rounds on 04/15/25 to ensure all fall interventions were in place.

Starting on 04/15/25, audits of falls, fall interventions, and service plan updates will be conducted by the DON, ADON #263 and AL Director #520 daily for two weeks, then three times a week for two weeks to ensure compliance. Any discrepancies will be reported to the Quality Assurance (QA) committee and immediate education will be conducted by the DON.

Starting on 04/15/25, ongoing monitoring will be conducted weekly during at-risk meetings with any discrepancies reported to the QA Committee. At-risk meeting is a weekly meeting that reviews high risk residents like skin, falls, weight changes, dialysis residents and hospice needs. Those who attend risk meetings are the DON, ADON #263, Licensed Social Worker (LSW) #249, Director of Therapy #511, Administrator, AL Director #520, and the Dietary Solutions company.

On 04/15/25, an Ad hoc QA committee meeting was held to address the abatement plan. Those who attended the Ad hoc meeting were the DON, ADON #263, LSW #249, Director of Therapy #511, Administrator, AL Director #520, Medical Records #119, Human Resources Director (HRD) #225, Housekeeping Director #216, Business Office Manager (BOM) #88, Maintenance Director #239, Central Supply/Transportation #245, Activity Director #121, and Dietary Director #179.

Starting on 04/15/25, the results of the audits will be reviewed monthly by the Administrator and AL Director #520 for tracking and trending. The Administrator and Administrator in Training (AIT) #240, will manage this process.

On 04/15/25, Vice President of Clinical #525, along with RDCO #515, and the Administrator reviewed the fall policies. No changes were made.

Starting on 04/16/25, all falls will continue to be discussed and reviewed for a plan of action during the daily morning clinical meetings with the Interdisciplinary Team (IDT). This meeting will be ongoing in the clinical meetings with the IDT consisting of the DON, ADON #263, LSW #249, Director of Therapy #511, Administrator, and AL Director #520.

Although the Real and Present Danger was abated on 04/16/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring for ongoing compliance.

Findings include:

1) Review of the medical record review for Resident #70 revealed she was admitted to the facility on 02/19/24. Diagnoses included encephalopathy, chronic kidney disease, hypertension, and transient ischemic attack (TIA).

Review of the most recent Mini Mental Status Exam (MMSE) dated 02/19/24, revealed Resident #70 had impaired cognition.

Review of a health status note for Resident #70 dated 07/29/24 at 3:26 A.M., revealed the resident was found on the dining room floor lying on her right side at approximately 7:45 P.M. (07/28/24). The resident was in distress and appeared uncomfortable. Vital signs were assessed, range of motion was assessed, and the resident moved all extremities and no injuries to report. The resident was assisted to her room and helped to bed. The DON and family were contacted. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #70 dated 07/29/24 at 11:13 A.M., revealed the resident had no complaints of pain or discomfort post fall. The resident was alert with confusion, range of motion was within normal limits, had decreased safety awareness at times by ambulation without the use of a walker and was cooperative with redirection.

Review of a health status note for Resident #70 dated 09/21/24 at 6:27 P.M., revealed the resident complained of right-hand pain during ambulation with her walker. Resident #70 had bruising to bilateral forearms and her right-hand grasp was significantly weaker than her left. Resident #70 was unable to tolerate passive or active range of motion assessment of her right hand or arm. Resident #70 stated she fell during the night. The resident's vital signs were within normal limits and no other injuries were noted to skin. The resident took routine Tylenol (over the counter pain medication), and ice was applied to the affected area intermittently for slight swelling. The physician was notified and ordered a stat (immediate) x-ray of the right hand, wrist, elbow and shoulder. The resident has been behaving more confused and having more emotional outbursts. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a physician's progress note for Resident #70 with a 09/23/24 date of service and signed on 10/21/24 at 11:26 P.M., authored by Physician #500, revealed the resident was seen for swelling for right upper extremity. There was no documentation regarding the fall on 09/21/24.

Review of a Fall Risk Assessment for Resident #70 dated 09/24/24, revealed the resident was assessed due to recent Falls. Resident #70 was assessed to have impaired vision, confined to a chair, disoriented, required hands on assistance to move from place to place, used discontinuous or short shuffled steps, no immediate interventions, and summary indicated a fall. Resident #70 was assessed to be at a high risk for falls.

Review of a health status note for Resident #70 dated 09/28/24 at 4:30 A.M., revealed an RN with LPN from the SNF went to the AL around 4:30 A.M. for a fall. The resident was found on the floor and had a bleeding bruise on her left temple. The resident was alert and oriented to person, and the nurse obtained vital signs. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a physician's progress note for Resident #70 dated 01/13/25 and authored by Physician #500, revealed the resident was seen for increased muscle weakness and the resident had a history of pain and falls. There were no new orders or new fall interventions documented.

Review of a health status note for Resident #70 dated 01/30/25 at 5:50 P.M., revealed the resident had a large bruise on her left buttock and was unsure how it happened. Staff would continue with the care plan. There was no documented evidence of any investigation, or any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #70 dated 02/04/25 at 8:11 A.M., authored by LPN #265, revealed the resident was found lying down on the floor in her bedroom. The resident was on her right side to the foot of the bed lying against the dresser. There were no injuries observed. The resident's vital signs were collected. The resident was assisted off the floor and neurological (neuro) checks were initiated. The family, physician and the DON were notified.

Review of a health status note for Resident #70, recorded as a late entry for 02/04/25 at 10:55 A.M., revealed the IDT met to discuss the resident being found on floor bedside. The call light was in reach prior to getting out of bed but not used. Interventions were to encourage and assist the resident with toileting needs upon rising in the morning.

Review of a health status note for Resident #70 dated 02/04/25 at 11:57 A.M., authored by LPN #174, revealed the resident was screaming in pain and could not get up out of the bed. The resident's leg is turned inward and when lifted up, it caused excruciating pain. The physician and family contacted.

Review of a health status note for Resident #70 dated 02/04/25 at 11:59 A.M., authored by LPN #174, revealed the resident had new orders for a stat x-ray of her hips, pelvis and lumbar spine. Morphine (narcotic pain medication) five milligrams (mgs) every eight hours routine and every two hours as needed and Ativan (anti-anxiety) 0.5 mg every eight hours routine and every two hours as needed was ordered.

Review of a Nurse Practitioner (NP) note for Resident #70 dated 02/04/25 at 3:22 P.M., authored by NP #501, revealed the resident was seen for Coronavirus (COVID-19). The resident had a history of pain and falls. The staff reported the resident had generalized weakness, denied any new falls but stated the resident had mild COVID-19 symptoms. The resident admits to fatigue and intermittent coughing; however, the staff reported no new issues or concerns with the resident. The resident's pain was assessed to be three (pain scale where zero is no pain and 10 is severe pain) and recorded from notes on 02/04/25 at 8:50 A.M. The physical examination revealed the resident had full range of motion, with no inflammation, and all laboratory (labs) and images reviewed. The resident will be continually monitored closely by the nursing staff for any acute changes.

Review of a health status note for Resident #70 dated 02/04/25 at 3:49 P.M., and authored by the DON, revealed the resident was found lying down on the floor in her bedroom. The resident was on the right side to the foot of the bed lying against the dresser. There were no injuries observed upon assessment. The resident's vital signs were collected, the resident was assisted off the floor and on to the bed and neuro checks were initiated. The family, physician and the DON were notified.

Review of a health status note for Resident #70 dated 02/04/25 at 6:11 P.M., authored by LPN #174, revealed the x-ray results were received, and the resident had an acute comminuted intertrochanteric fracture of the left hip. The family and the physician were contacted.

Review of a physician order dated 02/04/25 at 7:00 P.M., revealed the resident was ordered a left hip x-ray.

Review of an x-ray report for Resident #70 dated 02/04/25 at 7:48 P.M., revealed the resident had an acute comminuted intertrochanteric fracture of the left hip.

Review of a health status note crossed over from the Medication Administration Record (MAR) dated 02/04/25 at 8:22 P.M., revealed the resident took pain medication due to excruciating pain in left hip and refused all other medications.

Review of a physician order for Resident #70 dated 02/04/25 at 8:38 P.M., revealed the resident had new orders for Morphine five mgs (give 0.25 milliliters [mL]) every eight hours routine and every two hours as needed (PRN) and Ativan 0.5 mg every eight hours routine and every two hours PRN.

Review of a health status note dated 02/04/25 at 8:58 P.M., and authored by LPN # 174, revealed the resident had a new order for a Hospice evaluation due to fractured left hip. The paperwork was faxed to the Hospice agency.

Review of a NP note for Resident #70 dated 02/05/25 at 8:52 A.M. and authored by NP #501, revealed the resident was being seen for a follow-up. The resident was noted to have pain which was last assessed on 02/04/25 at 8:24 P.M. Resident #70 was seen for a fractured hip and referred to Hospice. The family declined hospitalization. The resident was assessed in bed without signs of uncontrolled pain and the staff voiced no new concerns. The resident was assessed with full range of motion. The resident was diagnosed with COVID-19, closed hip fracture, restlessness and agitation. The resident had no acute issues and remained stable. The NP spoke with the son via phone to update him on the resident's current status.

Review of an IDT note for Resident #70 dated 02/05/25 at 11:16 A.M. and authored by the DON, revealed the IDT reviewed a fall that occurred on 02/04/25 when the resident was found on the floor in her room. The resident was assessed and reported no injuries at that time. The oncoming shift (at 7:00 A.M.) reported resident was complaining of increased pain in right hip. An x-ray was ordered which indicated a positive fracture along with pain medication to manage pain concerns. The physician was notified along with the party responsible. The responsible party decided to not complete surgery to fix and agreed to a Hospice consultation.

Review of a Physical Therapy Evaluation for Resident #70 dated 02/05/25 at 12:14 P.M. and authored by Physical Therapist (PT) #510, revealed the resident demonstrated an obvious deformity to the left hip area and the resident had obvious pain.

Review of a health status note dated 02/05/25 at 6:46 P.M., and authored by LPN #253, revealed the resident was turned and cleaned during medication administration due to extreme pain of having a broken hip. The resident did not eat today, and Hospice arrived before the nurse left for the day. The family was notified of the pending Hospice consult. The NP called and updated the family.

Review of the Hospice Care Contract for Resident #70 dated 02/06/25 at 9:30 P.M., revealed the resident began Hospice Services for diagnosis of senile degeneration of the brain.

Review of a health status note for Resident #70 dated 02/07/25 at 12:42 P.M., and authored by LPN #198, revealed Hospice came in and assessed the resident. All medications were discontinued except comfort medications. The resident was resting comfortably in bed and the family was notified.

Review of a health status note for Resident #70 dated 02/08/25 at 7:00 A.M., authored by LPN #265, revealed the resident was unresponsive while lying in bed around 12:45 A.M. during routine care. The nurse completed an assessment and observed the resident to be unresponsive and vitals were absent. The on-shift night supervisor was called to confirm the resident was dead. Hospice was notified about the resident condition. Hospice arrived at 2:30 A.M. The family, physician and DON were notified.

Review of a handwritten, undated and unsigned Health Assessment for Resident #70 revealed the resident was dependent on staff for medication administration and required the use of a walker for ambulation. Resident #70's fall risk was not assessed.

Interview with ADON #263 on 04/14/25 at 4:29 P.M., verified Resident #70 had unwitnessed falls on 07/29/24, 09/21/24, 01/30/25 and 09/28/24 and no fall interventions were implemented. ADON #263 also verified Resident #70 had an additional fall on 02/04/25 and sustained a fractured hip.

Interview with Physician #500 on 04/15/25 at 5:48 P.M. revealed she has not reviewed any falls with the facility since January 2025 or possibly longer. Physician #500 stated she was not able to verify the facility called her about any residents' falls. Physician #500 stated she was not aware that the facility was not implementing immediate interventions for residents who fell or that they failed to complete thorough investigations of the resident's falls. Physician #500 stated she ordered a stat x-ray for Resident #70 when she fell on 02/04/25 and once the results showed a hip fracture, the family was given the option to have Resident #70 remain at the facility for Hospice services including comfort care or to have Resident #70 go the hospital for surgery on her hip. Physician #500 stated the facility reported to her that the family chose for the resident to remain in the facility with Hospice services. Physician #500 felt the fall on 02/04/25 where the resident fractured her hip, contributed to Resident #70's death.

Interview with PT #510 on 04/16/25 at 11:25 A.M. revealed she completed a PT assessment on Resident #70 on 02/05/25. PT #510 stated it was very evident; the resident was in significant pain when her left leg was touched. PT #510 stated the resident's leg had a deformity by the way it was laying. PT #510 stated she questioned a nurse after she completed her assessment and learned Resident #70's left hip was fractured. PT #510 stated the nurse informed her that Resident #70 would be assessed for Hospice services. PT #510 stated there were no additional services provided to Resident #70.

2) Review of the medical record for Resident #01 revealed she was admitted to the facility on 12/15/23. Diagnoses included dementia, rhabdomyolysis, iron deficiency anemia, cerebral infarction, hyperlipidemia, anxiety disorder, and essential primary hypertension.

Review of the Health Assessment for Resident #01 dated 12/15/23, revealed the resident was severely cognitively impaired. The Health Assessment did not include a fall risk assessment.

Review of a health status note for Resident #01 dated 12/23/24 at 4:06 A.M., revealed the resident was found on the floor in her bedroom. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #01 dated 01/30/25 at 10:04 P.M., revealed the resident was found on the dining room floor. Resident #01 was assessed with no reported injuries. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Interview with ADON #263 on 04/14/25 at 4:29 A.M., verified Resident #01 had unwitnessed falls on 12/23/24 and 01/30/25 and the facility failed to implement any fall interventions to reduce and/or eliminate additional falls.

3) Review of the medical record for Resident #20 revealed she was admitted to the facility on 10/16/24. Diagnoses included morbid obesity, hyperlipidemia, obstructive sleep apnea, gastro esophageal reflux disease (GERD), essential primary hypertension, insomnia, major depressive disorder, and heart failure.

Review of the Fall Risk Assessment for Resident #20 dated 10/10/24, revealed the resident scored a 23, which indicated the resident was at a high risk for falls.

Review of the Health Assessment for Resident #20 dated 10/16/24, revealed the resident was cognitively impaired and required assistance with transfers.

Review of a health status note for Resident #20 dated 11/05/24 at 7:32 A.M., revealed the resident had an unwitnessed fall. Resident #20 was found lying on the left side on the floor on the right side of Resident #20's bed. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of the incident log revealed Resident #20 had an unwitnessed fall on 11/05/24.

Review of a health status note for Resident #20 dated 12/15/24 at 12:18 A.M., revealed the resident had a fall when attempting to transfer from the wheelchair to her bed. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Interview with the DON on 04/16/25 at 10:10 A.M., verified Resident #20 had unwitnessed falls on 11/05/24 and 12/15/24. The DON verified the facility did not implement any fall interventions for the resident's falls on 11/05/24, and 12/15/24.

4) Review of the medical record for Resident #32 revealed she was admitted to the facility on 12/23/24. Her diagnoses included cerebral edema, traumatic subdural hemorrhage with loss of consciousness, diabetes mellitus, fibromyalgia, mixed hyperlipidemia, and anxiety disorder.

Review of the Health Assessment for Resident #32 dated 12/23/24, revealed she was cognitively intact and independent with transfers.

Review of a health status note for Resident #32 dated 03/06/25 at 2:54 P.M., revealed the resident had an unwitnessed fall when she was found on the floor on the left side of the bed. Resident #32 stated she dozed off after sitting on the side of the bed. Resident #32 had a skin tear on Resident #32's left upper arm. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Interview with the DON on 04/16/25 at 10:10 A.M., verified Resident #32 had an unwitnessed fall on 03/06/25. The DON verified there were no fall interventions implemented after the fall.

5) Review of the medical record for Resident #42 revealed she was admitted to the facility on 08/13/20. Her diagnoses included atrial fibrillation (A-fib), hyponatremia, chronic obstructive pulmonary disease (COPD), and anxiety.

Review of the Health Assessment for Resident #42, dated 08/20/24, revealed she had impaired cognition, required a wheelchair for ambulation and assistance from staff with transfers. The health assessment did not include a fall risk assessment.

Review of a health status note for Resident #42 dated 12/26/24 at 9:03 P.M., revealed the resident had an unwitnessed fall. Resident #42 stated she tried to bend over and fell on the floor. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #42 dated 02/28/25 at 6:03 P.M., revealed the resident was found seated on the floor next to a recliner chair. Resident #42 could not state what happened. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of the Incident Log revealed Resident #42 had an unwitnessed fall on 12/26/24.

Interview with the DON on 04/16/25 at 10:10 A.M., verified Resident #42 had falls on 12/26/24 and 02/28/25 and no fall interventions were implemented.

6) Review of the medical record for Resident #44 revealed he was admitted to facility on 05/30/19. His diagnoses included gout, Parkinson's Disease, celiac disease, and dementia.

Review of the Health Assessment for Resident #44 dated 05/11/24, revealed he was cognitively impaired. Resident #44 had an unsteady gait and required the assistance of a wheelchair. The health assessment did not include a fall risk assessment.

Review of a health status note for Resident #44 dated 10/06/24 at 5:33 P.M., revealed the resident was found on the floor in the bathroom. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 10/20/24 at 3:45 P.M., revealed the resident had a fall in the bathroom and was bleeding. The resident had a skin tear on his left pinky finger. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 11/16/24, revealed the resident had an unwitnessed fall with no injuries. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 11/25/24 at 8:13 P.M., revealed the resident an unwitnessed fall. Resident #44 stated he attempted to transfer to his wheelchair and fell on his bottom. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 02/04/25 at 4:02 P.M., revealed a housekeeper called for the nurse because Resident #44 was found on the bathroom floor. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 03/06/25 at 7:09 A.M., revealed the resident was found lying on the floor on his stomach in front of the lounge chair. Resident #44 stated he attempted to go the dining room. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of a health status note for Resident #44 dated 03/09/25 at 7:11 P.M., revealed the resident fell after he climbed out of bed. Resident #44 stated he tried to go the bathroom. There was no documented evidence of any interventions to reduce and/or eliminate falls being implemented.

Review of the incident log revealed Resident #44 had unwitnessed falls on 11/16/24, 11/25/24, 02/04/25, and 03/06/25.

Interview with the DON on 04/16/25 at 10:10 A.M. verified Resident #44 had unwitnessed falls on 10/06/24, 10/20/24, 11/16/24, 11/25/24, 02/04/25, 03/06/25, and 03/09/25. The DON verified the facility failed to implement any fall interventions for Resident #44's falls on 10/06/24, 10/20/24, 11/16/24, 11/25/24, 02/04/25, 03/06/25, and 03/09/25 to reduce and/or eliminate future falls.

Review of the facility fall policy titled, Falls, and Fall Risk Management, dated 08/2024, revealed the facility staff will identify interventions related to the resident's risk and causes to try to prevent the resident from falling and try to minimize complications from falling. The facility will have a Resident-Centered approach to managing falls and fall risks. This approach included input from the attending physician or Nurse Practitioner, a systematic evaluation of the resident's fall risk identified several possible interventions, if the underlying cause cannot be identified or corrected the staff may try various interventions. The facility will monitor falls and fall risks and this included, staff will monitor a resident's response to interventions intended to reduce falls or risks of falls. If a resident continues to fall, staff will revaluate the situation and whether it is appropriate to continue or change current intervention. As needed, the physician will help the staff reconsider possible causes that may not have been previously identified.

This violation represents non-compliance investigated under Complaint Number OH00163459.

Based on medical record review, observation, staff interview and policy review, the facility failed to provide wound care as ordered by a physician. This affected two (#36 and #32) of three residents reviewed for wound care. The facility census was 69.

Findings include:

1. Review of the medical record for Resident #36 revealed she was originally admitted to the facility on 09/24/24. Her diagnoses included, fracture of vertebra, fracture of the fifth lumbar, peripheral vascular disease, atrial fibrillation, and congestive heart failure (CHF). Resident #36 was discharged to the hospital on 03/05/25 and readmitted to the facility on 04/07/25.

Review of the Health Assessment for Resident #36, dated 09/24/24, revealed Resident #36 was cognitively intact. Resident #36 was dependent on staff for medication administration and incontinence care. Resident #36 required the use of a wheelchair or walker for ambulation. Resident #36 required minor assistance from staff with bathing.

Review of Resident #36 assessment titled, Mini Mental Status Exam, dated 09/24/24, revealed she was cognitively intact.

Review of a April 2025 active physician's order summary, revealed Resident #36 was ordered to have bilateral lower extremities (BLE) cleansed with Vashe (wound solution designed to clean, irrigate and promote wound healing), patted dry, Hydrin lotion (used to treat dry, scaly skin conditions) applied to intact skin, adaptic alginate dressing (non-adherent dressing for dry to high exuding wounds) applied to open areas, covered with abdominal (ABD) pad, foot and leg wrapped with Kerlix and ace wraps, leave the toes open and extend the wrap to the leave of tibial tuberosity twice daily. Encourage the resident to elevate legs every day and night shift.

Review of the April TAR for Resident #36 revealed no documented evidence the resident's order for having her bilateral lower extremities (BLE) cleansed with Vashe (wound solution designed to clean, irrigate and promote wound healing), patted dry, and Hydrin lotion (used to treat dry, scaly skin conditions) applied to intact skin, adaptic alginate dressing (non-adherent dressing for dry to high exuding wounds) applied to open areas, covered with abdominal (ABD) pad, foot and leg wrapped with Kerlix and ace wraps and leave the toes open and extend the wrap to the leave of tibial tuberosity was completed on 04/08/25, 04/09/25, and 04/10/25.

Observation of a wound care for Resident #36 on 04/14/25 at 1:10 P.M. provided by Licensed Practical Nurse (LPN) #174 and LPN #237, revealed Resident #36 was seated in a recliner chair with her legs resting on the footrest. LPN #174 and LPN #237 placed a protective barrier cloth over the footrest of the recliner. LPN #174 had already donned gloves. LPN #237 donned gloves without completing any hand hygiene. The Kerlix bandages and ace bandages were in plastic covering and were lying across the resident's living room floor along with a pair of scissors. Observed LPN #237 ask LPN #174 where the scissors where and LPN #237 located the scissors on the floor, picked the scissors up and began cutting off Resident #36's bandages. LPN #174 removed all the dressing from the resident's wounds and dropped the dressings into the trash. LPN #174 removed her gloves and put on new ones without any hand hygiene and picked up the clean bandages and wrapped the left leg. LPN #174 got up and sanitized her hands with hand sanitizer and stated she is waiting on LPN #237 to return with more bandages. LPN #174 took her phone out of her hand a to text the other nurse. She placed her hand in her pocket and then put on fresh gloves. LPN #237 came into the room and put on gloves without completing any hand hygiene and began putting wound cleaner on the open wound of Resident #36's right leg as LPN #237 held the right leg. Once the treatment was completed neither LPN #174 nor LPN #237 completed any hand hygiene as they exited the room.

Interview with LPN #237 and LPN #174 on 04/14/25 at 1:30 P.M. verified they missed opportunities to complete hand hygiene and verified they used a pair of scissors that had been lying on the floor of the resident's room

2. Review of the medical record for Resident #32 revealed she was admitted to the facility on 12/23/24. Her diagnoses included cerebral edema, traumatic subdural hemorrhage with loss of consciousness, diabetes mellitus (DM), fibromyalgia, mixed hyperlipidemia, iron deficiency, and anxiety disorder.

Review of the Health Assessment for Resident # 32, dated 12/23/24, revealed she was cognitively intact. Resident #32 was dependent on staff for medication administration and incontinence care. Resident #32 required assistance from staff with bathing, grooming, and dressing. She was independent with eating and transfers.

Review of the active April 2025 physician orders for Resident #32 dated 03/24/25, revealed an order for ace wraps on in the morning and off in the evening.

Review of the March 20025 TAR for Resident #32 revealed there was documented evidence the treatment of Ace wraps was completed for 03/27/25, 03/29/25, 03/30/25, and 03/31/25.

Interview on 04/14/25 at 12:00 P.M. with the Assistant Director of Nursing (ADON) #263 verified the missed wound treatments for Residents #36 and #32.

Review of the facility policy titled, Wound Care, dated 08/2024, confirmed staff are expected to document in the Residents medical chart once a wound treatment is completed.

This violation represents non-compliance investigated under Complaint Number OH00163459.

Based on medical record review and staff interview, the facility failed to complete wound treatments as ordered. This affected one (#68) of three residents reviewed. The census was 64.

Findings include:

Review of Resident #68's closed medical record revealed an admission date of 11/20/23 and was discharged 12/30/24. Diagnoses listed included irritable bowel syndrome, hyperlipidemia. end stage renal disease, and type two diabetes mellitus.

Review of progress notes dated 07/30/24 revealed Resident #68 was seen by nurse practitioner (NP). A new treatment for left fourth digit toenail was obtained to cleanse the area with soap and water. May cover with dry sterile dressing daily and as needed (PRN) until healed.

Review of physician order revealed an order dated 07/30/24 for cleanse affected left fourth toenail with soap and water. May cover with dry sterile dressing every day and PRN until healed.

Review of treatment administration records (TAR) revealed no documentation of the left fourth toenail treatment ever being completed. No treatment order for the left fourth toe was noted on the TAR.

Further review of physician orders revealed an order dated 08/17/24 cleanse wound in gluteal fold with Vashe (wound cleanser) wash apply collagen to wound bed and cover lightly with moistened Vashe soaked gauze cover with foam dressing every day and PRN.

Review of TAR revealed the treatment to Resident #68's gluteal fold wound was not documented as being completed on 10/01/24, 10/04/24,10/07/24, 10/09/24, 10/14/24, 10/18/24, 10/19/24, 10/21/24, 10/23/24, 10/24/24, 10/26/24, 10/27/24, 10/28/24, 11/01/24, 11/04/24, 11/05/24, 11/06/24, and 11/08/24.

Interview with the Assisted Living Director (ALD) #9 on 01/23/25 at 12:10 P.M. confirmed that Resident #68's left fourth toe treatment was not documented as being completed as ordered. ALD #9 confirmed the left fourth toe treatment was not on TAR. ALD #9 also confirmed Resident #68's gluteal fold treatment was not documented as being completed as ordered.

This violation represents non-compliance investigated under Complaint Number OH00161205.

Based on medical record review, staff interview, and policy review, the facility failed to complete a thorough investigation following a fall. This affected one (#12) resident of three residents reviewed. The facility census was 55. Findings include: Review of the medical record of Resident #12 revealed an admission date of 06/24/14. Diagnoses included dementia without behavioral disturbance, hypertension, hypothyroidism, gastro-esophageal reflux disease, gout, osteoarthritis, and major depressive disorder. Review of the Health Assessment for Resident #12 dated 06/20/24, revealed the resident had moderate cognitive impairment, was independent with ambulation while utilizing a walker. Review of a progress note for Resident #12 dated 07/01/24 at 8:23 A.M., revealed the Director of Nursing (DON) received a report from the night shift supervisor of a fall with discomfort to the resident's right arm. Resident #12 was noted in the morning with a contusion to the right elbow region and the resident had active range of motion. The physician assessed the resident that morning and gave a new order for an x-ray of the right elbow, right shoulder, and right wrist. Resident #12's guardian was notified of the incident. Interview with the Director of Nursing (DON) on 07/30/24 at 2:25 P.M., revealed there was no investigation completed on Resident #12's fall. The DON confirmed a fall investigation should be completed on all resident falls in the facility. Review of the facility policy titled, Falls in Assisted LivingBased on medical record review, staff interview, and policy review, the facility failed to complete a thorough investigation following a fall. This affected one (#12) resident of three residents reviewed. The facility census was 55.

Findings include:

Review of the medical record of Resident #12 revealed an admission date of 06/24/14. Diagnoses included dementia without behavioral disturbance, hypertension, hypothyroidism, gastro-esophageal reflux disease, gout, osteoarthritis, and major depressive disorder.

Review of the Health Assessment for Resident #12 dated 06/20/24, revealed the resident had moderate cognitive impairment, was independent with ambulation while utilizing a walker.

Review of a progress note for Resident #12 dated 07/01/24 at 8:23 A.M., revealed the Director of Nursing (DON) received a report from the night shift supervisor of a fall with discomfort to the resident's right arm. Resident #12 was noted in the morning with a contusion to the right elbow region and the resident had active range of motion. The physician assessed the resident that morning and gave a new order for an x-ray of the right elbow, right shoulder, and right wrist. Resident #12's guardian was notified of the incident.

Interview with the Director of Nursing (DON) on 07/30/24 at 2:25 P.M., revealed there was no investigation completed on Resident #12's fall. The DON confirmed a fall investigation should be completed on all resident falls in the facility.

Review of the facility policy titled, Falls in Assisted Living

Based on observations staff interview, and policy review, the facility failed to ensure food items in the kitchen were within their expiration date. Additionally, the facility failed to label or date foods in the freezer at the facility. This had the potential to affect all 49 residents residing in the facility. Facility census was 49.

Findings included:

Observation on 11/03/22 at 8:40 A.M. with walk in freezer that had a large cookie sheet that had items with expired dates. The following items were observed: sponge cake with expiration date 05/20/2021; clear shells in wrapped already opened bag with expiration date 05/10/2021; another clear shells in bag that had date 05/31/22; and chocolate muffins five quantity in large zip lock bag that were already made that had no label with date or label.

Interview on 11/03/22 at 8:42 A.M. with Dietary Technician #244 who confirmed these food items were expired and unlabeled. Dietary Technician #244 confirmed all 49 residents residing in the facility receive their food from the kitchen.

Review of Labeling and Dating Food Policy dated on 03/16/2021 revealed in accordance with the Ohio Uniform Food Safety Code food will be marked as follows: the day of preparation is counted as day one. Foods prepared in house may be kept six days. Any opened package food, prepared food or leftover food that will be stored for future use must be clearly labeled with the name of the food and a use-by date.