Windhaven House, Inc

Based on observation and staff interview, the facility failed to ensure food was stored, prepared and served in a sanitary manner to prevent contamination and foodborne illness. This had the potential to affect 24 residents who received meals from the kitchen. The facility census was 24.

Findings include:

Observation during the initial tour of the kitchen on 09/16/25 between 10:00 A.M. and 10:25 A.M. revealed the stand-up freezer had numerous packages of frozen hamburger that were not dated. The refrigerator had a bag of sliced oranges, a package of American cheese, and a bag of shredded cheese that were undated. Peanut butter and oregano were found to be undated on a shelf in the food prep area.

Interview of Cook #52 on 09/16/25 at 10:10 A.M. verified numerous packages of frozen hamburger, a bag of sliced oranges, package of American cheese, and a bag of shredded cheese, a container of peanut butter and oregano were found to be undated.

Based on observation, record review and interview, the facility failed to have sufficient staff to ensure residents' total care, supervisory and emotional needs were met, to ensure only qualified staff administered medications and to to provide dietary, housekeeping, laundry, maintenance and recreational activities. This had the potential to affect 26 residents residing in the facility.

Findings include:

Review of the facility staffing revealed the facility employed seven total staff which included an Administrator/Executive Director (ED), Assistant Manager #300 and five (unlicensed) care givers to cover the facility 24 hours a day seven days per week. None of the staff were required to punch in/out to reflect the dates/times they actually worked.

Review of the staffing schedules which were noted to be created in 2023 revealed no licensed nurses were employed by the facility. There was noted to be at least two caregivers (CGs) written on the schedule to work at all times, with a usual schedule consisting of three CGs from 8:00 A.M. to 6:00 P.M. and two CGs from 5:00 P.M. to 9:00 A.M.

Weekend staffing coverage consisted of a rotating schedule of two CGs to cover the weekend shift which was from Friday at 10:00 A.M. through Sunday at 6:30 P.M. for a total of 56.5 hours worked by each employee.

The facility did not utilize a time clock to capture time punches and staff scheduled for the residential care facility (RCF) were also noted to provide services for the individuals who lived in a group home that was in another building next door.

Review of facility schedule on 05/12/25 dated 2023 (Schedule 2024), Monday revealed CG #301 was scheduled to work 8:00 A.M. to 6:00 P.M., CG #302 was scheduled to work 8:00 A.M. to 6:00 P.M. and CG #303 was scheduled to work 8:00 A.M. to 6:00 P.M. On Monday evening CG #313 was scheduled from 5:00 P.M. to 9:00 A.M. and CG #314 was scheduled to work from 5:00 P.M. to 9:00 A.M. (However, this was not worked as per the schedule because both CG #313 and #314 reported off).

On 05/12/25 at 8:30 A.M. observation revealed one CG (CG #303) and no licensed nurses present at the facility to care for 26 residents. CG #303 was observed washing a car outside upon arrival.

Interview on 05/12/25 at 8:30 A.M. with CG #303 revealed she worked alone all weekend (beginning on Friday) and needed to stay later on this date (Monday) to cook lunch for the residents. CG #303 revealed she was currently working by herself, because CG #301 and CG #302 who were scheduled to work on this date had not yet arrived. In addition, Assistant Manager #300, who was scheduled to work on this date had also not arrived as of this time.

Review of the facility activity calendar revealed the only group activity was a 2:00 P.M. coffee hour daily. No other activities were planned for the residents.

A telephone interview on 05/12/25 at 9:50 A.M. with the Executive Director (ED) revealed he would not be in to the facility on this date as he was on vacation out of state. The ED revealed all staff scheduled including himself and Assistant Manager #300 would care for residents, cook, clean, do laundry and provide activities.

A telephone interview on 05/12/25 at 1:15 P.M. with the ED verified the facility utilized himself, an assistant manager and five caregivers (seven total unlicensed staff) for all of the staffing in the facility. The ED revealed the CGs schedule was always the same but they had rotating weekends. The ED counted himself and the assistant manager as staff who cared for the residents along with ideally a kitchen aide, and two CGs during the day and two CGs during the night. The ED verified no staff punched in or punched out for shifts.

Observation on 05/13/25 at 7:30 A.M. revealed CG #302 was in the basement cooking breakfast. CG #302 stated he was responsible for cooking, cleaning, medication administration, laundry, activities, and supervision of 26 residents residing in the facility.

On 05/13/25 at 9:31 A.M. interview with CG #301 revealed the staff schedule of seven employees included staff who go back and forth working simultaneously between the residential care facility (RCF) and the group home that was located next door. CG #301 stated it was not good to leave the residents alone in the RCF building because it was not safe. CG #301 stated the weekend shift required staff to work from Friday at 10:00 A.M. through Sunday 6:30 P.M. for a total of 56.5 hours worked. There were to be two CGs scheduled, but if one CG called off there was only one staff member on site to care for all residents.

Interview on 05/13/25 at 9:35 A.M. with Assistant Manager #300 revealed CG #303 left early on Monday because she worked Friday night, Saturday and into Sunday night. Assistant Manager #300 also stated on Monday night (05/12/25) CGs #313 and #314 called off, therefore CG #302 worked from Monday 05/12/25 at 10:00 A.M. to Tuesday 05/13/25 at 6:00 P.M. (a total of 31 hours straight). She also stated the facility did not utilize agency staff to cover if a CG called off for a shift. (However, an interview with CG #302 stated he was scheduled to work through Wednesday, 05/14/25 at 9:00 A.M.)

Interview on 05/13/25 at 9:40 A.M. with CG #302 revealed he worked Monday 05/12/25 beginning at 10:00 A.M. and was still in the facility on 05/13/25 at 9:40 A.M. He stated he was the only CG who stayed overnight. He stated he tried to get some sleep on the couch in the basement, but it was difficult because one (unnamed) resident liked to leave the building at night and other residents yelled downstairs that they needed something. CG #302 stated he was responsible for all duties in the facility including preparing meals, medication administration, housekeeping, laundry, maintenance, and activities, etc. He stated he would like to do more activities with the residents but stated had to pay for supplies out of his own pocket. CG #302 stated he was scheduled to work through Wednesday, 05/14/25 at 9:00 A.M.

Interview on 05/13/25 at 11:43 A.M. with CG #301 revealed the weekend shift for a caregiver was from Friday at 10:00 A.M. through Sunday at 6:30 P.M. for a total of 56.5 hours. There were usually two caregivers scheduled, but if one reports off, there was only one staff on-site to care for the residents. He had to go back and forth between the RCF and the group home next door. He stated he was responsible for all duties in the facility including preparing meals, medication administration, housekeeping, laundry, maintenance, and activities, etc.

Record review and interviews with CG staff revealed the facility did not have a system in place to ensure call off shifts were covered or that staff were not required to work 56.5 hours straight.

Observations on 05/12/25 and 05/13/25 revealed no group activities were provided to residents, and staff were observed to cooking meals, assisting with medication administration, housekeeping, laundering resident clothing and linens in the basement while also being responsible to provide care to meet the resident needs.

The facility did not have a staffing policy for review.

Review of Job description titled Caregiver revealed the role provided direct supervision and personal care to residents at the community and did not indicate any licenses were required for the role. Caregivers assisted with activities of daily living, including with medication as assigned, report status change immediately to the supervisor, act immediately on any resident crisis, following protocol and basic first aid training. The caregivers did not document any changes in condition, reaction to medication or psychosocial status change. The job description did not indicate it was the caregivers responsibility to assess resident changes in condition or that the caregiver was qualified to do so.

Review of the undated resident agreement revealed Windhaven House Incorporated would provide residents with the following care services including walking, eating, hair care, assistance with self-administration of medication, grooming, dressing, toileting, oral hygiene, nail care, bathing, special diets and other care as needed. The facility would provide transportation to health care appointments, social activities, shopping and other needs. The facility would provide laundering for all residents' clothing and bed and bath linen. Recreation and leisure included opportunities for residents to engage in the activities of the facility.

Review of the risk agreement revealed Windhaven House Incorporated accepted individuals who could no longer be maintained in their own homes without guidance, but did not require nursing home care, and/or were ambulatory and required some insight throughout the day, and/or whose level of care had been determined non-institutional care. The facility offered 24-hour availability of staff, automatic fire alarm and sprinkler system, semi-private and private rooms, three home cooked meals per day and a snack, color televisions and cable, group trips and picnics, transportation to and from medical appointments, and housekeeping and laundry service.

This violation is an example of a noncompliance investigation under Complaint Number OH00164951.

Based on observation, record review, and interview, the facility failed to ensure an annual determination by a physician or other licensed healthcare professional working within their scope of practice was completed and accurate related to each residents capability of self-administering medications. This affected 13 residents (#1, #2, #3, #5, #7, #10, #11, #12, #22, #23, #24, #26 and #30) reviewed and/or identified by Agency Registered Nurse (RN) #307 as unable to identify the medications they take and had the potential to affect all 26 residents residing in the facility.

Findings include:

A telephone interview on 05/12/25 at 9:50 A.M. with the Executive Director (ED) revealed there was no nurse on staff for the facility, and every resident was deemed appropriate to self-administer medication.

An interview on 05/12/25 at 12:00 P.M. with Assistant Manager #300 revealed Home Health RN hours were based on the needs of the residents and the RN was not responsible for medication administration because all residents were deemed able to self-medicate, so an RN was not present when medications were administered to residents by CG staff.

Interview with Home Health Agency RN #307 on 05/13/25 at 9:40 A.M. revealed she did not see all of the residents in the facility, only the residents on her case load, which included Resident #1, # 2, #5, #7, #10, #11, #12, #22, #23, #24, #26 and, #30. RN # 307 stated these residents she visited were not able to state the medications they were taking.

a. Review of the medical record for Resident #5 revealed an admission date of 08/31/17 with diagnoses including hypothyroid, bipolar disorder, diabetes type two, hypertension, respiratory failure and schizophrenia.

Resident #5's Health Assessment Capability for Medication Administration document dated 02/28/24 and completed by Physician #312 indicated the resident needed reminders when to take medication and needed staff member to take medication from locked storage and hand it to the resident. The assessment contained no details to denote how the resident had ability to self-administer, and the medical record contained no nursing documentation/progress notes to reference. No service plan was available in the medical record to review regarding self-administration of medication.

Review of Resident #5's Medication Administration Record (MAR) for May 2025 revealed a list of medication including Lamictal 200 milligrams (mg) (anticonvulsant and mood stabilizer) by mouth at 8:00 A.M., Synthroid 0.15 mg (hormone replacement agent) by mouth at 8:00 A.M., Prinivil 10 mg angiotensin converting enzyme (ACE) inhibitor used to treat high blood pressure) at 8:00 A.M., Glucophage 500 mg (antidiabetic) by mouth at 8:00 A.M. and 5:00 P.M., Paliperidone extended release 6 mg (antipsychotic) by mouth at 8:00 A.M., Senokot 8.6 mg (laxative) at 8:00 P.M., Zocor 5 mg (lipid lowering agent) at 8:00 A.M., Vitamin D 50,000 international units (supplement) at 8:00 A.M., Tylenol extra strength 500 mg (analgesic) by mouth twice a day at 8:00 A.M. and 8:00 P.M., Lipitor 20 mg (cholesterol lowering medication) at 8:00 P.M., Colace (stool softener) by mouth at 8:00 A.M,, Vasotec 5 mg (ACE inhibitor) at 8:00 A.M., Gabapentin 600 mg (anticonvulsant) by mouth four times a day at 8:00 A.M, , 12:00 P.M. , 4:00 P.M. and 8:00 P.M., Synthroid 0.75 mg at 8:00 A.M., Claritin 10 mg (antihistamine) at 8:00 A.M.

All medications were documented as being administered by unlicensed Assistant Manager #300 twenty-four hours a day seven days a week from 05/01/25 through 05/12/25.

On 05/12/25 at 12:00 P.M. CG #302 was observed with Resident #5 in front of the kitchenette area. CG #302 reached up into a padlocked cupboard door above a counter area and removed multiple bins of medication filled with unknown medications onto a countertop. CG #302 popped the afternoon slot of the medication planner into Resident #5's cupped hands. Resident #5 drank water from an Igloo cooler in the kitchenette and took the medication and left the room to eat lunch. No binder was available to track medication administration by the CG. At no time did CG #302 involve Resident #5 in the process of medication administration. There was no evidence based on the observation Resident #5 was self-administering the medication but rather was dependent on the CG staff to obtain and administer the medication. CG #302 did not refer to the medication administration record (MAR) to determine if the medications administered matched the MAR and did not document whether medication was taken or refused

Interview with CG #302 verified the above findings and indicated they assisted Resident #5 with medication as they do with all 26 facility residents in the same way. CG #302 stated staff obtained all medication from bubble packs in a locked cupboard. In addition, if a resident had an order for an as needed (PRN) medication, it was the responsibility of the resident to ask for the medication and then the CG would decide if the medication was needed and obtain the medication from the locked cupboard. CG #302 verified he did not have a nursing license or certificate to administer medication.

An interview on 05/12/25 at 4:00 P.M. with Resident #5 revealed she could not recall the medication administered at noon and stated she needed help with staff to pop the medication out of the package.

An interview on 05/13/25 at 10:12 A.M. with Assistant Manager #300 revealed the MAR was not part of the resident's medical record, but was placed on site in a filing cabinet sorted by month. In addition, the service plan was part of the annual assessment. Assistant Manager #300 stated she filled out the MARs for all residents stating if a resident was administered medication or refused medication despite the CGs actually being responsible for giving the medications to the residents.

b. Review of the medical record for Resident #3 revealed an admission date of 09/16/17 with diagnoses including schizophrenia, major depression, hypertension, congestive heart failure, chronic obstructive pulmonary disease, gastroesophageal reflux disorder, sleep apnea, hyperlipidemia.

An annual assessment completed on 05/01/24 indicated Resident #3 needed bath aid and verbal prompting. Resident #3 was independent with walking and using the telephone. Assistance was needed with bathing, grooming, oral hygiene, nail care, hair care, shopping, meal prep, housework, managing financial affairs, and smoking.

Resident #3's document titled, Capability for Medication Administration, dated 05/01/24 and completed by Physician #312 indicated the resident needed a reminder when to take medication and needed watched to ensure resident followed directions on the container. The assessment contained no details to denote how the resident had ability to self-administer, and the medical record had no nursing documentation to reference or a service plan regarding self-administration of medication.

Review of Resident #3's MAR for May 2025 revealed medication including Lipitor 20 mg by mouth at 8:00 P.M., Cogentin 0.5 mg (antiparkinson) at 8:00 A.M. and 8:00 P.M., Breo Ellipta (steroid) one puff by mouth once a day at 8:00 A.M., chewable aspirin 81 mg (blood thinner) by mouth at 8:00 A.M., Plavix 75 mg (antiplatelet) by mouth at 8:00 A.M., Clozaril 100 mg (antipsychotic) tablet at 8:00 A.M. and 8:00 P.M., Robinul Forte 2 mg (anticholinergic) at 8:00 A.M. and 8:00 P.M., Haldol Decan inject on milliliter intramuscular (IM) every 28 days, Imdur 30 mg (vasodilator) at 8:00 A.M., Claritin 10 mg at 8:00 A.M., Ativan 0.5 mg (antianxiety, controlled medication) at 8:00 A.M., 12:00 P.M. and 8:00 P.M, Melatonin 5 mg (hormone) at 8:00 P.M., Nicodem patch (nicotine patch) topically every day, Protonix 20 mg 9reduces stomach acid) at 8:00 A.M. and Exelon 4.5 mg (medication to treat dementia) at 8:00 A.M. and 8:00 P.M. All medications were signed off as administered by unlicensed Assistant Manager #300 twenty-four hours a day seven days a week from 05/01/25 through 05/12/25, and CG #302 did not refer to the MAR to determine if the medications administered matched the MAR and did not document whether medication was taken or refused.

On 05/12/25 at 12:05 P.M. CG #302 was observed in the kitchenette while residents were standing in line. CG #302 reached up into a padlocked cupboard above the counter area and retrieved a pharmacy box of prepackaged medication bubble pack in a white plastic box. Each bubble pack had resident name, date and time of medications were due, and a list of medication and strength were due with frequency directions. CG #302 was observed to pop out medication through the pouches and popped the medication in resident cupped unwashed hands. Residents did not request assistance and were not offered to open medications. At no time did Resident #3 actively participate in the medication management process other than the administration of respiratory inhaler that Resident #3 stated he was unsure if any medication came out. Interview at the time of observation with CG #302 verified the above findings.

Interview on 05/12/25 at 4:05 P.M. Resident #3 revealed she was unable to name a medication routinely taken or a reason why a medication was routinely taken. Resident #3 reported the facility CGs would get the medication from the locked cupboard and provided them with medicine when needed.

This violation is an example of a noncompliance investigation under Complaint Number OH00164951.

Based on observation, record review, and interview, the facility failed to ensure medications were administered to residents only by staff qualified to administer medications. This affected two residents (#3 and #5) and had the potential to affect all 26 residents residing in the facility.

Findings include:

A telephone interview on 05/12/25 at 9:50 A.M. with the Executive Director (ED) revealed no nurse was on staff because every resident was deemed appropriate to self-administer medication.

Observation on 05/12/25 at 10:00 A.M. revealed two Caregivers (CGs) #302 and #304 and Assistant Manager #300 with no licensed nurses present in the facility to care for 26 residents. An interview at the time of observation with Caregiver #302, who was assigned to pass out the noon medications revealed he did not need to tell the residents the name of the medications because he felt all residents knew the names of their medications. CG #302 revealed during medication administration he removed each resident's medications from a centrally located pad-locked cabinet, manually removed each medication from a bubble pack and handed the medications to the resident for the resident to then place them in their mouth.

An interview on 05/12/25 at 12:00 P.M. with Assistant Manager #300 revealed Home Health RN hours were based on the needs of the residents and the RN was not responsible for medication administration because all residents were deemed able to self-medicate, so an RN was not present when medications were administered to residents by CG staff.

On 05/12/25 at 12:05 P.M. CG #302 was observed in the kitchenette while residents were standing in line. CG #302 reached up into a padlocked cupboard above the counter area and retrieved a pharmacy box of prepackaged medication bubble pack in a white plastic box. Each bubble pack had resident name, date and time of medications were due, as well as a list of medication and strength with frequency directions. CG #302 was observed to pop out medication through the pouches and popped the medication in resident cupped unwashed hands. There was no evidence the process reflected the self-administration of medications; but rather staff administration of medications.

Interview with Home Health Agency RN #307 on 05/13/25 at 9:40 A.M. revealed she did not see all of the residents in the facility, only the residents on her case load, which included Resident #1, # 2, #5, #7, #10, #11, #12, #22, #23, #24, #26 and, #30. RN # 307 stated these residents she visited were not able to state the medications they were taking.

On 05/13/25 at 11:43 A.M. interview with Caregiver (CG) #301 revealed during his shift he was responsible for all duties in the facility including medication administration. There was no evidence the CG was qualified to administer medications.

There was no evidence that residents residing in the facility maintained possession of their medications, self-administered medications and/or self-administered with staff assistance as defined in 3701-16-09(F).

a. Review of the medical record for Resident #5 revealed an admission date of 08/31/17 with diagnoses including hypothyroid, bipolar disorder, diabetes type two, hypertension, respiratory failure and schizophrenia.

Resident #5's Health Assessment Capability for Medication Administration document dated 02/28/24 and completed by Physician #312 indicated the resident needed reminders when to take medication and needed staff member to take medication from locked storage and hand it to the resident. The assessment contained no details to denote how the resident had ability to self-administer, and the medical record contained no nursing documentation/progress notes to reference. No service plan was available in the medical record to review regarding self-administration of medication.

Review of Resident #5's Medication Administration Record (MAR) for May 2025 revealed a list of medication including Lamictal 200 milligrams (mg) (anticonvulsant and mood stabilizer) by mouth at 8:00 A.M., Synthroid 0.15 mg (hormone replacement agent) by mouth at 8:00 A.M., Prinivil 10 mg angiotensin converting enzyme (ACE) inhibitor used to treat high blood pressure) at 8:00 A.M., Glucophage 500 mg (antidiabetic) by mouth at 8:00 A.M. and 5:00 P.M., Paliperidone extended release 6 mg (antipsychotic) by mouth at 8:00 A.M., Senokot 8.6 mg (laxative) at 8:00 P.M., Zocor 5 mg (lipid lowering agent) at 8:00 A.M., Vitamin D 50,000 international units (supplement) at 8:00 A.M., Tylenol extra strength 500 mg (analgesic) by mouth twice a day at 8:00 A.M. and 8:00 P.M., Lipitor 20 mg (cholesterol lowering medication) at 8:00 P.M., Colace (stool softener) by mouth at 8:00 A.M,, Vasotec 5 mg (ACE inhibitor) at 8:00 A.M., Gabapentin 600 mg (anticonvulsant) by mouth four times a day at 8:00 A.M, , 12:00 P.M. , 4:00 P.M. and 8:00 P.M., Synthroid 0.75 mg at 8:00 A.M., Claritin 10 mg (antihistamine) at 8:00 A.M.

All medications were documented as being administered by unlicensed Assistant Manager #300 twenty-four hours a day seven days a week from 05/01/25 through 05/12/25.

On 05/12/25 at 12:00 P.M. CG #302 was observed with Resident #5 in front of the kitchenette area. CG #302 reached up into a padlocked cupboard door above a counter area and removed multiple bins of medication filled with unknown medications onto a countertop. CG #302 popped the afternoon slot of the medication planner into Resident #5's cupped hands. Resident #5 drank water from an Igloo cooler in the kitchenette and took the medication and left the room to eat lunch. No binder was available to track medication administration by the CG. At no time did CG #302 involve Resident #5 in the process of medication administration. There was no evidence based on the observation Resident #5 was self-administering the medication but rather was dependent on the CG staff to obtain and administer the medication. CG #302 did not refer to a medication administration record (MAR) to determine if the medications administered matched the MAR and did not document whether medication was taken or refused.

Interview with CG #302 verified the above findings and indicated they assisted Resident #5 with medication as they do with all 26 facility residents in the same way. CG #302 stated staff obtained all medication from bubble packs in a locked cupboard. In addition, if a resident had an order for an as needed (PRN) medication, it was the responsibility of the resident to ask for the medication and then the CG would decide if the medication was needed and obtain the medication from the locked cupboard. CG #302 verified he did not have a nursing license or certificate to administer medication.

An interview on 05/12/25 at 4:00 P.M. with Resident #5 revealed she could not recall the medication administered at noon and stated she needed help with staff to pop the medication out of the package.

An interview on 05/13/25 at 10:12 A.M. with Assistant Manager #300 revealed the MAR was not part of the resident's medical record, but was placed on site in a filing cabinet sorted by month. In addition, the service plan was part of the annual assessment. Assistant Manager #300 stated she filled out the MARs for all residents stating if a resident was administered medication or refused medication despite the CGs actually being responsible for giving the medications to the residents.

b. Review of the medical record for Resident #3 revealed an admission date of 09/16/17 with diagnoses including schizophrenia, major depression, hypertension, congestive heart failure, chronic obstructive pulmonary disease, gastroesophageal reflux disorder, sleep apnea, hyperlipidemia.

An annual assessment completed on 05/01/24 indicated Resident #3 needed bath aid and verbal prompting. Resident #3 was independent with walking and using the telephone. Assistance was needed with bathing, grooming, oral hygiene, nail care, hair care, shopping, meal prep, housework, managing financial affairs, and smoking.

Resident #3's document titled, Capability for Medication Administration, dated 05/01/24 and completed by Physician #312 indicated the resident needed a reminder when to take medication and needed watched to ensure resident followed directions on the container. The assessment contained no details to denote how the resident had ability to self-administer, and the medical record had no nursing documentation to reference or a service plan regarding self-administration of medication.

Review of Resident #3's MAR for May 2025 revealed medication including Lipitor 20 mg by mouth at 8:00 P.M., Cogentin 0.5 mg (antiparkinson) at 8:00 A.M. and 8:00 P.M., Breo Ellipta (steroid) one puff by mouth once a day at 8:00 A.M., chewable aspirin 81 mg (blood thinner) by mouth at 8:00 A.M., Plavix 75 mg (antiplatelet) by mouth at 8:00 A.M., Clozaril 100 mg (antipsychotic) tablet at 8:00 A.M. and 8:00 P.M., Robinul Forte 2 mg (anticholinergic) at 8:00 A.M. and 8:00 P.M., Haldol Decan inject on milliliter intramuscular (IM) every 28 days, Imdur 30 mg (vasodilator) at 8:00 A.M., Claritin 10 mg at 8:00 A.M., Ativan 0.5 mg (antianxiety, controlled medication) at 8:00 A.M., 12:00 P.M. and 8:00 P.M, Melatonin 5 mg (hormone) at 8:00 P.M., Nicodem patch (nicotine patch) topically every day, Protonix 20 mg 9reduces stomach acid) at 8:00 A.M. and Exelon 4.5 mg (medication to treat dementia) at 8:00 A.M. and 8:00 P.M. All medications were signed off as administered by unlicensed Assistant Manager #300 twenty-four hours a day seven days a week from 05/01/25 through 05/12/25, and CG #302 did not refer to the MAR to determine if the medications administered matched the MAR and did not document whether medication was taken or refused.

On 05/12/25 at 12:05 P.M. CG #302 was observed in the kitchenette while residents were standing in line. CG #302 reached up into a padlocked cupboard above the counter area and retrieved a pharmacy box of prepackaged medication bubble pack in a white plastic box. Each bubble pack had resident name, date and time of medications were due, and a list of medication and strength were due with frequency directions. CG #302 was observed to pop out medication through the pouches and popped the medication in resident cupped unwashed hands. Residents did not request assistance and were not offered to open medications. At no time did Resident #3 actively participate in the medication management process other than the administration of respiratory inhaler that Resident #3 stated he was unsure if any medication came out. Interview at the time of observation with CG #302 verified the above findings.

An interview on 05/12/25 at 12:15 P.M. with Assistant Manager #300 revealed all residents were deemed able to self-medicate, so a nurse or medication tech was not present when medications were administered to residents by CG staff.

Interview on 05/12/25 at 4:05 P.M. Resident #3 revealed she was unable to name a medication routinely taken or a reason why a medication was routinely taken. Resident #3 reported the facility CGs would get the medication from the locked cupboard and provided them with medicine when needed.

This violation is an example of a noncompliance investigation under Complaint Number OH00164951.

Based on record review, interview and review of the facility policy, the facility failed to ensure licensed staff were available to timely reassess residents after falls and/or injuries to ensure immediate and proper steps were in place to prevent additional injuries. In addition, the facility failed to document the incidents in the resident's on-site medical records. This affected two residents (#13 and #7) reviewed for accidents and had the potential to affect all 26 facility residents residing in the facility.

Findings include:

1. Review of Resident #13's closed medical record revealed an admission date of 04/30/18 with diagnoses including schizophrenia, asthma and hypertension. Resident #13's closed record did not delineate a definitive discharge date from the facility.

An annual assessment completed on 03/20/24 indicated Resident #13 needed bath aid and verbal prompting. Resident #13 needed assistance with bathing, grooming, oral hygiene, nail care, hair care, and dressing.

Review of the document titled Fall Risk Assessment, dated 03/20/24, revealed Resident #13 was a negative fall risk.

Continued review of Resident #13 medical record revealed no progress notes were available for review.

A facility incident report located in the incident log binder dated 03/22/25 at 7:37 A.M. for Resident #13 revealed Resident #13 was found in the hallway. The narrative included the ambulance was called, and the resident was taken to the hospital. Corrective measures included changes in medication. The physician was notified, and the case manager was notified. There was no signature on the form to indicate who completed the form.

Review of the emergency medical services (EMS) Run Report Number 25-26802 dated 03/22/25 at 7:32 A.M. revealed EMS was dispatched to the facility for breathing problems, emergency response. Scene information included the resident (Resident #13) slid down the wall laying on the floor by the front door of the facility. Negative head injury, positive incontinence and alert and oriented times one (name only). The resident was not able to stand and stated he may have had a seizure. The chief complaint was change in responsiveness.

Interview with the Assistant Manager #300 on 05/12/25 at 4:30 P.M. verified the incident report was the investigation and was not part of the medical record and stated Resident #13 fell due to his mental health and was taken to the hospital. Resident #13 was found by the front door by staff, and staff called EMS because Resident #13 had a change in condition. Assistant Manager #300 stated the physician and Power of Attorney (POA) were notified, but it was not documented in the medical record. She verified there were no progress notes related to the incident in Resident #13's on-site medical record.

2. Review of Resident #7's medical record revealed a readmission date of 03/08/24 with diagnoses including bipolar disorder, mental delay, diabetes type two, hyperthyroid, obesity and cellulitis.

Review of the document titled, Annual Assessment, dated 03/13/24 revealed Resident #7 needed bath aid and needed verbal prompting. Assistance was needed for bathing, grooming, oral hygiene, nail care, hair care. Resident #7 did not smoke.

Review of the facility document titled, Fall Risk Assessment, dated 03/13/24 revealed Resident #7 was a negative fall risk.

Continued review of Resident #7's medical record revealed no progress notes were available for review.

Review of the facility incident log located in the incident log binder reported a fall dated 02/12/25 at 12:15 P.M. revealed Resident #7 fell while walking out of the building. Resident #7 tripped over a rug. The narrative included: the rug was nailed to the floor to prevent further incidents. Corrective measures included: the rug was nailed down to the floor. The physician and the resident's legal guardian were not notified. There was no signature on the form to indicate who completed the form. There was no EMT run report available to review because the resident was not sent to the hospital.

Interview with Assistant Manager #300 at 05/12/25 at 4:35 P.M. verified an incident report was the investigation and was not part of the medical record. She verified the incident was not documented in Resident #7's medical record and there were no further follow-up assessments by a licensed nurse after the incident in the on-site medical record.

A telephone interview on 05/12/25 at 1:15 P.M. with the Executive Director revealed if a resident had a change in condition, the facility would send the resident to the hospital or place the resident on a list for the medical doctor to see the resident during the next visit to the facility. If a resident fell, EMs would be called if the resident was in pain. The ED stated he and Assistant Manager #300 documented the incident logs that were kept separate from the medical record. The ED stated he notified the physician if a resident fell and stated there was not a nurse on duty, but the facility hired a home health nurse to visit with residents and provide care according to physician orders.

A telephone interview on 05/12/25 at 1:54 P.M. with Director of the Home Health Agency #310 stated the agency provided nurses to evaluate client's needs, assist with documentation of client assessments, supervisory visits, and coordinate services when needed. The home health nurse informed the ED or Assistant Manager #300 of changes in the condition and the needs of the resident, observed signs and symptoms and reported to the physician, family, ED or Assistant Manager #300. The licensed nurse administered drug injections, maintained accurate assessments, and non-medical treatments of residents and stated the licensed nurse cared for residents with dementia in the facility. The home health nurse was to document on the agency's computer and did not see all the residents in the facility. Home Health Agency Director #310 stated, if a resident did fall, the licensed nurse would assess the resident on the next planned visit which could vary.

Interview on 05/12/25 at 4:29 P.M. with Assistant Manager #300 revealed the facility called a home health agency for nursing care, and no nurses were employed by the facility. The home health license nurse had no set schedule, and the hours she was in the building depended on physician orders. The licensed nurse would visit the facility after she visited the Group Home next door to the facility. Assistant Manager #300 stated caregivers (CG) were advised to call 911 or EMS for emergencies.

Interview on 05/12/25 at 4:32 P.M. with CG #302 and CG #301 indicated when there was an emergency, the ED or Assistant Manager #300 were called (neither were licensed nurses), unless a resident was not breathing or bleeding heavily then they would call emergency services. If a resident fell, the process was for the CG to assess residents for injury or pain then notify the ED or Assistant Manager #300. If there was no injury, the CG got the resident up, but if there was a concern, the resident was not moved, and the CG would wait for directions from the ED or Assistant Manager #300. Assistant Manager #300 filled out the incident reports.

Interview on 05/13/25 at 9:40 A.M. with RN #307 verified she was not employed by the facility but employed by a home health agency. RN #307 stated she was in the facility five of the seven days during a week but did not see all residents in the facility. RN #307 denied documenting anything regarding incidents since the facility did not use the home health progress notes, and she did not review any incident reports or take part in planning interventions. RN #307 stated, at times, the facility would request her to check on a resident the next visit, but the visits were documented within the home health progress notes. The facility did not have access to her notes due to Health Insurance Portability and Accountability Act (HIPAA) reasons, but residents could review their personal home health progress notes.

Review of the Job description labeled Caregiver revealed the role provided direct supervision and personal care to resident at the community and did not indicate any licenses were required for the role. Caregivers assisted with activities of daily living, including with medication as assigned, report status change immediately to the supervision, act immediately on any resident crisis, following protocol and basic first aid training. The care givers did not document any change in condition, reaction to medication or psychosocial status change. The job description did not indicate it was the caregiver's responsibility to assess resident changes in condition or that the caregiver was qualified to do so.

Review of the facility Incident Log from 11/22/24 to 05/13/25 revealed two residents had fallen since the last annual review completed on 11/21/24. A separate incident log was maintained including the time, name, date, and place of each incident, but the incident documentation was not part of the resident's medical record.

The facility was not able to provide a policy related to falls/accidents.

This violation is an example of a noncompliance investigation under Complaint Number OH00164951.

Based on record review and interview the facility failed to establish and implement appropriate policies and procedures to ensure control of the development and transmission of infections and disease. This had the potential to affect 26 residents residing in the facility.

Findings include:

A telephone interview on 05/12/25 at 1:15 P.M. with the Executive director revealed he was the facility Infection Preventionist. The ED stated he was not a licensed nurse, and did not complete training in medicine, medical technology, laboratory technology, public health, epidemiology or biology. The ED also stated he was unsure when he last had training in infection control. The ED stated he educated his staff on Universal Precautions to control the development of infectious diseases.

A telephone interview on 05/13/25 at 9:37 A.M. with the ED revealed he did not have a surveillance analysis, analysis of antibiotic use, or an infection control log of infections and stated he was not sure when he attended a certification education regarding infection control. The ED stated he was not a licensed nurse and had a degree in psychology and business.

Review of personnel file, for the Administrator/Executive Director (ED), revealed the ED was hired 05/05/18 to supervise residents and assist residents. A Certificate of Attendance, Bloodborne Pathogens/infectious Control Procedures, dated 02/08/01 provided by Rural Metro Ambulance Regional Training Center was noted in the ED's personnel file.

Review of facility undated policy titled Infection Control revealed staff were to wash hands with soap and water before and after resident care.

This violation is an example of a noncompliance investigation under Complaint Number OH00164951.

Based on observation and review of the Ohio Fire Marshal report, the facility failed to maintain a safe, clean-living environment. This had the potential to affect 17 residents (#2, #3, #10, #11, #12, #14, #16, #21, #22, #23, #24, #25, #27, and #30) identified by the facility as residents who smoke. The facility census was 26.

Findings include:

The facility identified 17 residents, Resident #2, #3, #10, #11, #12, #14, #16, #21, #22, #23, #24, #25, #27, and #30 who smoked.

On 05/13/25 at 10:55 A.M. Fire Marshall (FM) #304 approached the surveyor requesting she join him for an observation of two residents smoking in Room #5.

On 05/13/25 at 11:00 A.M. FM #304 and the surveyor completed an environmental observation of Room #5 which was an indoor smoking room. Observation of the room revealed there were coffee cans used to put out cigarette butts. The walls were covered in dark soot like material, the floor and furniture were also covered in had dark soot like material, and there were three large holes punched in the drywall of the smoking room that needed repaired.

Review of a copy of the Ohio Fire Marshall report dated 05/13/25 revealed a violation of Fire Resistance Rated Construction related to Smoking Room #5. The report indicated the room structure was not properly maintained or properly repaired or restored when damaged.

This violation is an incidental finding identified during the complaint investigation.

Based on record review and interview, the facility failed to complete Resident #29's fall-risk evaluation during the initial comprehensive health assessment. This affected one resident (#29) of five residents reviewed for comprehensive health assessments.

Findings include:

Review of Resident #29's medical record revealed the resident was admitted to the facility on 04/10/23.

Review of Resident #29's Initial Health Assessment form dated 04/06/23 revealed a fall-risk evaluation was not completed as part of the initial health assessment as required for the resident.

Interview on 11/28/23 at 12:45 P.M. with the Executive Director confirmed Resident #29's Initial Health Assessment record did not have evidence a fall-risk evaluation was completed to determine if the resident was at risk for falls.

Based on record review and interview, the facility failed to complete annual fall-risk evaluations as part of the annual assessment process. This affected four residents (#13, #14, #16 and #17) of five residents reviewed for annual comprehensive health assessments.

Findings include:

1. Review of Resident #13's medical record revealed the resident was admitted on 09/24/07 and the last annual comprehensive assessment was dated 03/15/23. The comprehensive assessment did not include a fall-risk evaluation.

2. Review of Resident #14's medical record revealed the resident was admitted on 08/23/21 and the last annual comprehensive assessment was dated 03/15/23. The comprehensive assessment did not include a fall-risk evaluation.

3. Review of Resident #16's medical record revealed the resident was admitted on 03/01/17 and the last annual comprehensive assessment was dated 03/08/23. The comprehensive assessment did not include a fall-risk evaluation.

4. Review of Resident #17's medical record revealed the resident was admitted on 06/23/16 and the last comprehensive assessment was dated 03/19/23. The comprehensive assessment did not include a fall-risk evaluation.

Interview on 11/28/23 at 11:30 A.M. with the Executive Director confirmed Resident #13, #14, #16 and #17's annual comprehensive health assessments (history and physicals) did not include an evaluation to determine the fall-risk of the residents.

Based on observation and interview, the facility failed to ensure the broken interior window in the first floor smoke room was repaired timely. This had the potential to affect 18 residents (#3, #4, #5, #6, #10, #11, #16, #17, #18, #19, #20, #21, #22, #23, #24, #27, #28, and #30) identified to be smokers in the facility.

Findings include:

Observation on 11/28/23 at 9:30 A.M. with the Executive Director revealed the lower interior window of the first floor smoke room was broken on the inside window pane with sharp edges visible on the inside middle of the glass.

Interview on 11/28/23 at 9:35 A.M. with the Executive Director confirmed the window was broken and indicated it had been broken for quite a while. The Executive Director confirmed the window needed to be repaired.

The Executive Director revealed 18 residents, Resident #3, #4, #5, #6, #10, #11, #16, #17, #18, #19, #20, #21, #22, #23, #24, #27, #28, and #30 were smokers and utilized the smoke room.