Kentridge Senior Living The

Based on record reviews, interviews, and review of facility policy, the facility failed to administer medications as ordered for Resident #85. This affected one (Resident #85) of three residents reviewed for medication administration. The facility census was 85.

Findings include:

Review of the medical record for Resident #85 revealed an admission date of 02/25/26. Diagnoses included bipolar disease, dementia and other longer term drug therapy (added 03/17/26).

Review of the comprehensive assessment, dated 02/25/26, revealed Resident #85 was cognitively intact. Resident #85 was independent with all activities of daily living except medication administration.

Review of the service plan dated 02/25/26 revealed Resident #85 was dependent on staff for medication management and transportation needs. Resident #85 was independent with all other activities of daily living (ADLs).

Review of the February 2026 orders revealed an order on 02/26/26 for Lithium Carbonate Extended Release (ER) 300 milligrams (mg) (a medication that treats bipolar disorder), take two tablets twice a day. On 03/26/26 the order changed to Lithium Carbonate ER 300 mg take one tablet twice a day.

Review of a late entry progress note dated 03/12/26 at 10:32 A.M. revealed the nurse spoke to the outside community physician to verify Resident #85's lithium dosage. Per the physician's office Resident #85 was to receive 600 mg twice a day.

Further review of the medical record for Resident #85 revealed progress notes dated 03/13/26 to 03/16/26 that revealed Resident #85's family was concerned about the current dose of lithium and took her to the hospital where she was admitted for evaluation and readmitted to the facility on 03/16/26 with a medication list and order for a change in lithium dose to 300 mg one tablet twice a day. The physician was notified of the medication change and stated the facility should follow orders from the hospital.

Review of the March 2026 Medication Administration Record (MAR) for Resident #85 revealed Medication Technician (MT) #235 administered 300 mg Lithium two tablets on the evening shift on 03/18/26 and Lithium two tablets on the evening shift on 03/20/26.

Review of the Medication Error report dated 04/08/26 completed by Regional Wellness Director revealed Resident #85 returned from the hospital on 03/16/26. Upon return her lithium order changed from 300 mg twice a day. While waiting for the order to be updated in the eMAR, a paper MAR was being utilized. During this time, a medication partner stated they did not have the paper MAR and followed the order in the eMAR (electronic MAR), which was incorrect, on two occasions.

Interview on 04/22/26 at 1:18 P.M. with MT #235 verified she had administered two tablets of Lithium on 03/18/26 and 03/20/26 but should have only administered one tablet of Lithium on the evening shift per physician order. MT #235 stated she was to follow the paper MAR and what was written on the paper MAR.

Interview on 04/22/26 at 2:02 P.M. with Resident #85 revealed she did not recall she had a hospitalization since her admission to the facility, but stated she knew the facility had given her too much lithium.

Interview on 04/21/26 at 1:27 P.M. with the Executive Director (ED) and Director of Wellness (DOW) verified when Resident #85 readmitted from the hospital on 03/16/26 her lithium order was for 300 mg take one tablet by mouth twice a day. The DOW stated upon return, a paper MAR was filled out with the new order which staff were to follow. The DOW stated she did an investigation and discovered the prior lithium order was still in the e-MAR so if the MTs or nurses were not following the paper MAR, then they would have been following the prior order for two tablets twice a day, but the e-MAR should have been updated to reflect the new order on 03/16/26. The ED and DOW stated the investigation showed what they believed was only the two doses being administered not according to the new physician order. Staff were provided education on several topics including pharmacy orders.

Review of facility policy titled Medication Administration dated 03/17/26, revealed the facility should ensure medications were properly given and medication was to be administered as directed per physician orders.

This violation represents non-compliance investigated under Complaint Number OH00170416.

Based on record reviews and interviews the facility failed to ensure the physician was notified of Resident #85's hospitalization. This affected one resident (#85) of three residents reviewed for change of condition. The census was 85.

Findings include:

Review of the medical record for Resident #85 revealed an admission date of 02/25/26. Diagnoses included bipolar disease, dementia and other longer term drug therapy (added 03/17/26).

A note on 03/13/26 at 5:28 P.M. revealed the daughter decided to take Resident #85 to the emergency room for an evaluation however staff was not notified. A note on 03/13/26 at 6:36 P.M. revealed the son called the facility executive director (ED) stating Resident #85 was at the local hospital. A note on 03/13/26 at 7:14 P.M. revealed the hospital called the facility stating Resident #85 was admitted. There was no evidence the physician (MD #600) was notified.

Interview on 04/22/26 at 3:17 P.M. with MD #600's office revealed they were not aware Resident #85 had a hospitalization on 03/13/26 through 03/16/26 stating there was no documentation of it in their records.

Interview on 04/23/26 at 1:28 P.M. with MD #600 revealed MD #600 stated he did not remember being notified by the facility of Resident #85 being hospitalized on 03/13/26.

Interview on 04/23/26 at 4:06 P.M. with the Director of Wellness (DOW) and ED verified there was no documented evidence in the medical record for Resident #85 to indicate Physician #600 had been notified of Resident #85 being sent to the hospital. DOW stated she did notify the physician of the residents return.

This violation represents an incidental finding discovered during the complaint investigation.

Based on staff interviews and record review, the facility failed to ensure a resident on continuous oxygen use had physician orders for oxygen administration and was checked on every two hours per the resident's service plan. This affected one (Resident #85) of three residents reviewed for care services. The facility census was 83.

Findings include:

Record review for Resident #85 revealed an admission date of 11/06/25 and a discharge date of 12/05/25. Diagnoses included chronic respiratory failure with hypoxia, diastolic congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and dependence on supplemental oxygen.

Review of the Comprehensive Resident Evaluation For Resident #85 dated 11/26/25 completed by Director of Wellness revealed Resident #85 required severely cognitively impaired and Resident #85 required required oxygen and a bipap. Resident #85's respiratory needs for oxygen included Resident #85 required staff monitoring and assistance routine/continuous. Resident #85 used an oxygen concentrator and a nasal cannula. Resident #85 required status checks every two hours every shift due to recent hospitalization, illness, history of falls, medication change, etc. and regularly scheduled care.

The medical record revealed Resident #85 did not have any physician orders for oxygen use.

Review of the facility's camera footage of the hallways revealed Resident #85's door was never closed fully shut. It was only shut partially during the evening of 12/04/25 from 9:00 P.M. to 09/05/25 at 12:40 A.M. The footage revealed at 9:00 P.M., a Certified Nursing Assistant (CNA) went into the room. At 9:30 P.M., a nurse went into the resident's room. There were no staff observed entering or looking through the door to check on Resident #85 until 12/05/25 at 12:40 P.M. when the resident was found absent of vital signs. Resident #85 went over three hours to be checked on during the night on 12/04/25 to 12/05/25.

Interview on 12/16/25 at 4:55 P.M. with Memory Care Support Partner (MCSP) #161 revealed the staff was supposed to check on Resident #85 multiple times an hour because she frequently pulled her oxygen tubing off.

Interview on 12/16/25 at 6:00 P.M. with MCSP #109 revealed Resident #85 was supposed to be on four liters of oxygen continuous but she constantly removed the oxygen tubing herself. The intervention was for frequent checks to make sure her oxygen tubing was kept on.

Interview on 12/17/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #113 revealed Resident #85 was admitted with four liters of oxygen on her initial admission and had worn oxygen at four liters continuously since admission

Interview on 12/17/25 at 2:30 P.M. with Regional Coordinator #163 confirmed Resident #85 was admitted to the facility on 11/06/25 with oxygen at four liters per minute continuously. Regional Coordinator #163 confirmed there was no physician order obtained or written for Resident #163 to receive oxygen and confirmed nurses were not documenting the administration of oxygen for Resident #85.

Interview on 12/17/25 at 2:35 P.M. with Executive Director confirmed Resident #85 was not checked on by staff from 12/04/25 at 9:40 P.M. to 12/05/25 at 12:40 P.M.

This violation represents non-compliance investigated under Complaint Number OH000169158.

Based on interview, review of the facilities Self-Reported Incidents (SRI), review of investigation, record review, and review of the facility policy, the facility failed to implement their policy when they failed to report and thoroughly investigate an allegation of neglect and failed to suspend the alleged perpetrator during the investigation. This affected one (Resident #85) of three residents reviewed for abuse. The facility identified there were 22 current residents residing on the memory care unit. The facility census was 83.

Findings include:

Record review for Resident #85 revealed an admission date of 11/06/25. Diagnoses included chronic respiratory failure with hypoxia, diastolic congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, dependence on supplemental oxygen, vascular dementia, and anxiety disorder. Resident #85 died in the facility on 12/05/25.

Review of the Comprehensive Resident Evaluation for Resident #85 dated 11/26/25 completed by Director of Wellness (DOW) revealed Resident #85 had severe cognitive impairment, required oxygen. Resident #85 required status checks every two hours every shift due to recent hospitalization, illness, history of falls, medication change, etc. in addition to regularly scheduled care.

Review of the wellness note dated 12/05/25 at 12:50 A.M. for Resident #85 revealed this nurse was called to Memory Care Unit (MCU) and the resident was found unresponsive, absent of vital sounds 12:40 A.M.

Review of the facilities SRI from 12/05/25 to 12/15/25 revealed there was no SRI filed involving Resident #85. The facility was unable to provide an investigation into the allegation of neglect involving Resident #85 on 12/16/25.

Through staff interviews, the staff alleged Resident #85 was neglected when they alleged staff shutting Resident #85's door, not checking on her every two hours, and oxygen was off the resident and was found dead.

Interview on 12/16/25 at 4:55 P.M. with Memory Care Support Partner (MCSP) #161 revealed MCSP #109 was responsible for Resident #85 on the night shift from 12/04/25 to 12/05/25. MCSP #161 heard from MCSP #104 that Resident #85 was yelling out and MCSP #109 closed the door around 9:00 P.M. After midnight, MCSP #109 was standing in the hall and said she thought Resident #85 was dead. MCSP #104 went into Resident #85's room and verified she was gone. MCSP #161 revealed the staff was supposed to check on Resident #85 multiple times because she frequently pulled her oxygen tubing off. MCSP #161 revealed she was concerned because MCSP #109 closed Resident #85's bedroom door around 9:00 P.M. because she was yelling and never checked on her again until after 12:00 A.M. when she was found with her oxygen off and expired. MCSP #161 reported it immediately to Licensed Practical Nurse (LPN) #113 and #162 who were sitting together on 12/07/25 at approximately 6:15 P.M. and MCSP #109 continued to work that night and was never suspended for an investigation.

Interview on 12/16/25 at 6:00 P.M. with MCSP #109 revealed Resident #85 was supposed to be on four liters of oxygen continuous but she constantly removed the oxygen tubing herself. The intervention was for frequent checks to make sure her oxygen tubing was kept on. MCSP #109 confirmed she was assigned to care for Resident #85 on 12/04/25 on the night shift. MCSP #109 stated Resident #85 was yelling out for her mom, and she closed the door some. MCSP #109 stated left it slightly open so she could peek in on her, denied it was never fully shut. MCSP #109 stated the last time she checked on her was from 11:30 P.M. to 11:45 P.M.; she was lying sideways, grabbing at the air, she pulled her gown off, and did not enter the room. (Per facility camera footage, MCSP #109 never checked on her at this time and only checked on at 9:00 P.M. and 12:40 P.M.) MCSP #109 stated came back around 12:30 A.M. (video footage showed 12:40 P.M.), and at that time Resident #85 was not moving so she came all the way in. When I went in and found her not moving, Resident #85's nasal cannula was not attached to her nose. MCSP #109 stated, I checked on her every hour to hour and 15 minutes that night. MCSP #109 revealed no one from management or any staff ever talked to her about Resident #85 after she died. MCSP #109 confirmed she worked the rest of that night until 6:00 A.M. and confirmed she was never suspended.

Interview on 12/17/25 at 9:40 A.M. with LPN #113 revealed she worked until 10:00 P.M. the night Resident #85 passed. Resident #85 had been screaming help. She had some calm moments but then she would start screaming for help again. Resident #85 would not leave her C-pap on so her oxygen was put back on at four liters. LPN #113 revealed Resident #85 was admitted by Hospice that evening who ordered morphine and Ativan for Resident #85. She administered the morphine and Ativan to help calm her down. Resident #85 was admitted with four liters of oxygen on her initial admission and had worn oxygen at four liters continuously since admission and revealed staff would never shut Resident #85's door because she needed to check on frequently. LPN #113 revealed on 12/07/25 between 6:00 P.M. and 6:15 P.M. on 12/07/25, MCSP #161 approached and was red faced and teary eyed, she said she heard one of our care partners closed the door and didn't check on Resident #85 until after midnight, from 9:30 P.M. to 10:00 P.M. until she was found deceased. LPN #113 asked her for more information, and LPN #113 immediately called and reported the allegation to the Director of Wellness (DOW) on the telephone, and DOW told her it would be investigated.

Telephone interview on 12/17/25 at 10:00 A.M. with DOW, and the Executive Director (ED) was present confirmed on 12/07/25, LPN #113 called her on the telephone and reported day shift heard from a different staff member that MCSP #109 was closing Resident #85's apartment door. The DOW stated the care partners were supposed to check on residents every two hours, they sign a binder, they would check on Resident #85 more often, but it had not necessarily cared planned, but the night shift staff said they checked on her more often. The concern was that she was not being checked on often enough. The DOW looked at the sign off records in the electronic medical records and the binder. The DOW stated she asked one of the other care partners, and questioned if MCSP #109 was checking on Resident #85 every two hours but did not ask about closing the door. The DOW confirmed MCSP #109 was never suspended for investigation.

Interview on 12/17/25 at 10:11 A.M. with the ED revealed the ED was not told Resident #85's door was shut, or no one checked on her. The ED stated staff did call her when Resident #85 passed but no concerns were discussed. The ED confirmed the allegation should have been investigated, and MCSP #109 should have been suspended during the investigation. The DOW never called the ED that night she was made aware of the allegation (12/07/25). The ED stated she would have expected the DOW to report to the ED about it. The ED confirmed the facility had cameras throughout and confirmed they were not checked during any investigation for Resident #85.

Interview on 12/17/25 at 2:30 P.M. with ED confirmed after speaking again with DOW, DOW verified she never interviewed MCSP #109 and confirmed MCSP #109 was never suspended for any investigation and confirmed an SRI was never completed. Review of the staff schedule with ED confirmed MCSP #109 worked 6:00 P.M. to 6:00 A.M. on 12/04/25, 12/05/25, 12/06/25, 12/14/25, and 12/16/25.

Review of the facility policy titled Abuse and Neglect, Observed or Suspected revised 07/31/24 revealed Neglect - failure or omission by one's self, caretaker or another person with the duty to provide goods or services which are reasonably necessary to ensure safety and well-being and to avoid physical or mental harm or illness. It is the policy that residents will not be abused or neglected by anyone at any time while residing at the property. All instances of observed or suspected abuse and or neglect will be handled as follows which included: All alleged perpetrators will be removed from premises immediately after obtaining written statement: if they do not willingly vacate property police will be called. If staff is involved or suspected as perpetrators, they will be suspended immediately, pending investigation. State agency will be notified within two hours, or time frame as dictated per state guidelines, of awareness of event or allegation by the community's Administrator or Executive Director.

This violation represents non-compliance investigated under Complaint Number OH00169158.

Based on observation, review of the food safety code, and interview, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all 83 residents.

Findings include:

1. Observations on 11/12/25 at 10:45 A.M. revealed food splatters on all sides and on the door of the inside of the microwave. The waffle maker had a thick brown buildup on the hinge.

On 11/12/25 at 10:56 A.M., Sous Chef #130 verified the waffle maker had a thick brown build-up on the hinge.

On 11/13/25 at 9:15 A.M., Dietary Director #140 stated the company that owned the waffle maker was supposed to do the cleaning/maintenance but did not arrive when it was due to be cleaned. The facility should have cleaned it.

2. On 11/12/25 at 3:45 P.M., Server #135 was observed standing on the opposite side of the steam table preparing lemon slices. Server #135's hair was not covered/restrained and her hair pulled back into a ponytail was moving around when she moved.

On 11/12/25 at 3:48 P.M., Server #135 verified she had been preparing lemon slices. Server #135 stated she was never told she needed to wear a hair covering.

On 11/13/25 at 9:15 A.M., Dietary Director #140 stated only the cook or somebody preparing food needed to wear a hair covering. Dietary Director #140 had an uncovered beard and long hair which was pulled back and secured. Only the hair on the top of his head was covered as he walked past food preparation areas.

On 11/13/25 at 10:02 A.M., Dietary Director #140 began stirring food on the stove. Facial hair was uncovered. The hair covering on top of his head did not constrain his long hair.

On 11/13/25 at 10:27 A.M., a phone interview with Registered Dietitian (RD) #145 revealed beards should be covered. RD #145 stated hair should be pulled back. Upon discussing the Ohio Food Safety Code, RD #145 revealed all hair should be covered if there was a potential for hair to come into contact with exposed food.

On 11/13/25 at 10:35 A.M., the Executive Director verified Dietary Director #140 was not wearing a beard cover or hair covering that fully covered his hair. The Executive Director stated she educated all dietary staff to wear hair coverings.

Review of the Ohio Uniform Food Safety Code (dated 09/05/24) revealed food employees were to effectively restrain hair by wearing hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covered body hair, that were designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils or linens or unwrapped single-service or single-use articles.

Based on review of personnel files and interview, the facility failed to ensure each member of the staff was provided a copy of the addresses and telephone numbers of the Board of Health of Portage County, the Portage County Department of Human Services, the State Department of Health and Human Services, the state and local offices of the Department of Aging and Ohio nursing home Ombudsman program. This had the potential to affect all 83 residents.

Findings include:

Review of personnel files for the Executive Director, Care Partner #100, Care Partner #105, Server #110, Care Partner #115, and Medication Aide #120 revealed no evidence any of them received a copy of the advocacy groups (Board of Health of Portage County, the Portage County Department of Human Services, the State Department of Health and Human Services, the state and local offices of the Department of Aging and Ohio nursing home Ombudsman program) and their contact information.

On 11/12/25 1:00 P.M., Business Office Director #105 stated the information regarding advocacy groups was reviewed during orientation but staff were not provided a copy of the information.

On 11/12/25 at 1:35 P.M., the Executive Director verified she was unaware of staff being provided a copy of the advocacy groups but the information was posted in the employee break room.

Based on record review and interview, the facility failed to ensure residents and their responsible parties were notified of changes in the service fees provided in the facility during the admission process and in writing when service charges were changed. This affected one resident (#56) and had the potential to affect all 74 residents residing in the facility.

Findings include:

A review of Resident #56's clinical record revealed an admission date of 07/14/23 with diagnoses including cellulitis, edema, hypothyroidism, polyarthritis, gastroesophageal reflux disease, atherosclerosis of aorta, depression, high blood pressure, and bunion/hammer toe of the right and left foot.

A review of Resident #56's Residency Agreement dated 07/07/23 indicated under the Rights and Responsibilities of Resident Section number 5(e): Rate Changes revealed the monthly fee may be adjusted by the facility at any time upon 30 days advance written notice. The fee would not be increased more than annually from the anniversary date of the agreement. If the level of care for the resident increased and additional services were needed, the facility would provide a written notice to the resident/resident representative within two days of the increase of the charge for the increased services provided by the facility. The fee for optional services may be adjusted at any time upon two days of advance written notice to the resident.

A review of Resident #56's comprehensive Resident Evaluation Assessment (REA) dated 01/29/25 indicated a full assessment was performed with a score of 53. The REA revealed as assessment of Resident #56's activity of daily living needs/preferences, bowel and bladder continence, risk of falls, psychosocial capabilities, cognitive capabilities, medication management, special medical needs and miscellaneous other needs for shopping, housekeeping and telephone use. The REA did not indicate what a score of 53 was used to determine or how the score was calculated.

An interview with Resident #56's daughter on 10/01/25 at 8:56 A.M. revealed the previous Director of Wellness (DOW) notified her by phone during the month of April 2025 that Resident #56's service charges would increase by 238 dollars because her mother had diagnoses of anxiety and depression. The previous DOW stated the facility used this criteria to determine the staffing level in the facility. Resident #56's daughter stated she disagreed with the previous DOW that her mother needed additional care. Resident #56's daughter stated Resident #56 did not have behaviors and did not reside in the memory care unit in the facility and did not need additional level of care services. Resident #56's daughter stated she was Resident #56's Power of Attorney (POA) for healthcare and financial decisions. Resident #56's daughter stated she spoke to the current Administrator and administrative staff who informed her of the increase in the cost for level of care services. Resident #56's daughter stated she did not understand how the facility determined the care costs and stated the facility failed to provide justification for the increased cost for the services provided by the facility.

An interview with Resident #56 on 10/01/25 at 10:17 A.M. revealed she didn't understand why the facility had increased her cost for level of care services. Resident #56 stated she was treated for depression with medication which controlled her symptoms. Resident #56 denied she had anxiety or that anxiety caused her to be more dependent on the staff for her care in the facility.

Interview with Resident Care Partner (RCP) #80 on 10/01/25 at 10:45 A.M. revealed she had worked at the facility for over a year and had provided care for Resident #56 many times. RCP #80 stated Resident #56 had no increase in the level of care provided in past several months and stated there was one episode approximately one year ago where Resident #56 was very depressed and needed extra emotional support. RCP #80 indicated the facility had not increased the number of staff during Resident #56's depression episode a year ago and did not feel she needed additional direct care after the incident.

An interview with Administrator on 10/01/25 at 1:00 P.M. revealed the facility performed a REA for each resident every six months to determine if there were changes to the resident's level of care and need to adjust their level of care cost in the facility. The Administrator stated in January of 2025 Resident #56's REA had a score of 53 which was an increase from the previous REA with a score of 51. Administrator indicated the previous DOW would have notified Resident #56 and Resident #56's daughter (POA) of the increase in the level of care cost for services provided in the facility. The Administrator stated each point on the REA corresponded to a 15-dollar charge for services. Administrator agreed that the resident admission agreement did not specify how the level of care services were calculated for a resident or of an explanation that the care costs could change every six months according to the score on the REA assessment. The Administrator agreed the policy and procedure titled Care-Based Assessment and Individualized Service Plan dated 09/20/2024 indicated a comprehensive assessment (REA) would be performed to evaluate a resident's physical, emotional and cognitive needs and preferences performed by the wellness director or qualified designee semi-annually. The REA would be used to determine the cost of the services provided in the facility. The REA must be signed by the resident and/or resident's responsible party through written or electronic signature or through telephone or written correspondence with proper documentation of how consent was obtained. The signature and date of the authorized REA assessor must be on the REA and individualized service plan. The Administrator agreed there was no documentation in Resident #56's clinical record that Resident #56 and/or Resident #56's daughter had agreed to the increase in charges in April of 2025 or that written notice was provided to Resident #56 and/or Resident #56's daughter regarding the increased level of care as indicated on the REA dated 01/25/25.

This violation represents non-compliance investigated under Complaint Number OH00168008.