Wellington at Dayton The

Based on record review and staff interview, the facility failed to ensure a licensed nurse provided appropriate training in provision of personal care services to unlicensed resident assistants prior to allowing the caregivers to provide personal care to residents. This had the potential to affect all of the residents residing in the facility. The facility census was 45 residents.

Findings include:

Review of personnel files for Nurse Aides (NAs) #10, #250, and #370 revealed they did include documentation of a skills evaluation completed by a licensed nurse.

Interview on 07/15/25 at 3:41 P.M. with the Business Director (BD) confirmed NAs #10, #250, and #370 did not have documentation of a skills evaluation completed by a licensed nurse.

Based on record review and staff interview, the facility failed to ensure staff members who provided personal care services had eight hours of continuing education annually This had the potential to affect all of the residents residing in the facility. The facility census was 45 residents.

Findings include:

Review of personnel files for Nurse Aides (NAs) #10, #250, and #370 did not include documentation of eight hours of continuing education annually.

Interview on 07/15/25 at 3:50 P.M with the Business Director (BD) confirmed the personnel files for NAs #10, #250, and #370 did not include documentation of eight hours of continuing education annually.

Based on employee personnel record review and staff interview, the facility failed to ensure newly hired employees received a two-step tuberculosis (TB) skin test and failed to ensure employees had either an annual TB skin test or completed a TB signs and symptoms questionnaire. This had the potential to affect all of the residents residing in the facility. The facility census was 45 residents.

Findings include:

1. Review of the personnel file for Housekeeping Supervisor (HS) #750 revealed a hire date of 06/13/25 with a first step TB skin test completed on 06/13/25 and no second step TB skin test completed.

Interview on 07/15/25 at 3:46 P.M the Business Director (BD) confirmed HS #750 did not have second step TB skin test upon hire.

Review of the personnel file for Nurse Aide (NA) #10 revealed a hire date of 05/16/25 with a first step TB skin test completed 05/18/25 and no second step TB skin test completed.

Review of the personnel file for NA #250 revealed a hire date of 06/21/25 with a first step TB skin test completed 06/18/25 and no second step TB skin test completed.

Review of the personnel file for NA #370 revealed a hire date of 06/19/25 with a first step TB skin test completed 06/19/25 and no second step TB skin test completed.

Interview on 07/15/25 at 3:46 P.M. with the BD confirmed HS #750 and NAs #10, #250, and #370 did not have second step TB skin tests completed upon hire.

2. Review of the personnel file for Dietary Staff (DS) #630 revealed a hire date of 09/30/10. DS #630's file did not include an annual TB skin test or a completed TB questionnaire.

Review of the personnel file for Licensed Practical Nurse (LPN) #50 revealed a hire date of 05/31/24. LPN #50's file did include an annual TB skin test or a completed TB questionnaire.

Interview on 07/15/25 at 3:50 P.M. with the BD confirmed the personnel files for DS #630 and LPN #50 did not include an annual TB skin test or completed TB questionnaire.

Based on observation, staff interview, and review of the facility policy, the facility failed to properly store food and failed to ensure kitchen fixtures were clean. This had the potential to affect all of the residents residing in the facility. The census was 45 residents.

Findings include:

1. Observation on 07/15/25 at 9:39 A.M. with Dining Services Director (DSD) #510 revealed there was an unlabeled open bag of frozen sausage patties in the freezer.

Interview on 07/15/25 at 9:40 A.M. with DSS #510 confirmed the sausage patties in the freezer were not labeled and they did not know when they had been opened.

2. Observation on 07/15/25 at 9:42 A.M. with DSD #510 revealed there was an unlabeled open package of salami in the refrigerator.

Interview on 07/15/25 at 9:43 A.M. with DSD #510 confirmed the open salami package in the refrigerator was unlabeled and they did not know when it had been opened.

3.Observation on 07/15/25 A.M. at 9:50 A.M. with DSD #510 revealed there was dirt and a crusted substance on the hinges and front inside of the ice machine.

Interview on 07/15/25 at 9:50 A.M. with DSD #510 confirmed there was dirt and a crusted substance on the ice machine. DSD #510 stated that the ice machine should be cleaned once monthly but did not know the date of the last cleaning.

Interview on 07/15/25 at 03:55 P.M with the Executive Director (ED) confirmed the kitchen staff did not complete the monthly cleaning/sanitation log form, but they used it as a guide for when to clean kitchen equipment.

Review of the facility policy titled Monthly Cleaning/Sanitation Log revised on 07/01/22 revealed the ice machine should be cleaned monthly or as needed. Interview with Executive Director (ED) #870 on 07/15/25 at 03:55 P.M. confirmed that at this time the kitchen staff does not fill out the Monthly Cleaning/ Sanitation Log, but they use it as a guide for when to clean kitchen equipment.

4.Observation on 07/15/25 at 9:53 A.M. with DSD #510 revealed there were crumbs and crusted food particles on the shelves and thermometer inside of the refrigerator.

Interview on 07/15/25 at 9:54 A.M. with DSD #510 confirmed there were crumbs and crusted food particles in the refrigerator.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure hazardous cleaning chemicals were stored securely and labeled appropriately. This had the potential to affect 10 facility-identified cognitively impaired and independently mobile (Residents #150, #160, # 170, #180, #185, #190, #195, #200, #210, #215) residents residing in the memory care unit. The facility census was 45 residents.

Findings include:

1.Observation on 07/15/25 at 9:02 A.M. revealed the linen closet door on the memory care unit was unlocked and contained a spray bottle labeled wound cleanser with a warning to avoid contact with eyes, a tube of triple antibiotic ointment and a container of spray deodorant with a warning to keep away from mouth, avoid breathing in and do not spray into eyes.

Interview on 07/15/26 at 9:08 with Licensed Practical Nurse (LPN) #20 verified the linen closet door should always be locked. LPN #20 confirmed the wound cleanser, spray deodorant, and triple antibiotic ointment should be stored in a secured location inaccessible to residents.

2. Observation on 07/15/26 at 9:18 A.M. revealed the laundry closet door on the memory care unit was unlocked and contained a bottle of all-purpose cleaner, a bottle of bathroom cleaner, and a bottle of peroxide multiple surface cleaner and disinfectant.

Interview on 07/15/26 at 9:21 with LPN #20 confirmed the bottles of cleaners were unsecured and should be stored in a location inaccessible to residents.

Review of the facility policy titled Storage and Disposal of Hazardous Material undated revealed all chemical and cleaning solvents must be stored in a secure manner and should never be left in areas which were accessible to residents or visitors.

Based on medical record review, staff interview, policy review, review of facility Self-Reported Incidents (SRI), and review of the Ohio Pharmacy Laws and Administrative Rules, the facility failed to maintain an effective and accurate system of accounting for controlled substances. This affected four (Residents #01, #07, #19, and #26) of four residents reviewed for narcotic administration. The facility identified 17 residents who received controlled substances. The facility also failed to ensure a thorough investigation was completed following identification of missing controlled substances. This had the potential to affect all of the residents residing in the facility. The facility census was 44 residents.

Findings include:

1. Review of the medical record for Resident #26 revealed an admission date of 12/04/23 with diagnoses including dementia, osteoporosis, low back pain, cervical stenosis, repeated falls, squamous cell carcinoma, wedge compression fracture.

Review of the service plan for Resident #26 dated 06/10/24 revealed the resident had moderately impaired cognition.

Review of physician's orders for Resident #25 revealed an order dated 05/05/24 for tramadol (a controlled substance pain medication) 50 milligrams (mg) by mouth three times per day.

Review of a pharmacy packing slip for Resident #26 dated 06/27/24 revealed the pharmacy delivered three packs of 30 tablets each (a total of 90 tablets) of tramadol 50 mg.

Review of the controlled substance shift count sheet dated 06/28/24 timed at 6:00 A.M. revealed Licensed Practical Nurse (LPN) #320 and LPN #315 added three packs of tramadol 50 mg to the count.

Review of the controlled substance shift count sheet dated 07/06/24 timed at 6:00 P.M. revealed Agency LPN #325 removed one pack of tramadol 50 mg for Resident #26. The column containing the initials for a second nurse verifying the removal did not match the initials of the oncoming nurse, LPN #315.

Review of the controlled substance shift count sheet dated 07/10/24 timed at 6:00 P.M. revealed LPN removed one pack of tramadol 50 mg for Resident #26. The column containing the initials for a second nurse verifying the removal did not match the initials of the oncoming nurse, LPN #315.

Review of the medical record of Resident #26 revealed there was one controlled drug receipt/record/disposition form (a form sent by the pharmacy for narcotics accountability) for Resident #26. The form was dated 06/28/24 and accounted for 30 of the 90 tablets of tramadol (3 of 3). The first form and the second form, which accounted for the remaining 60 tablets, were not present in Resident #26's medical record.

Interview on 09/04/24 at 3:15 P.M. with Wellness Director (WD) #335 confirmed the initials for second nurse verification did not match the initials of the oncoming nurse for the 07/06/24 and 07/10/24 removals of Resident #26's tramadol. WD #335 further confirmed the facility was unable to locate the first and second controlled drug receipt/record/disposition dorms for Resident #26's tramadol.

2. Review of the medical record for Resident #07 revealed an admission date of 11/30/23 with diagnoses including end-stage renal disease, diabetic neuropathy, and degenerative disc disease.

Review of physician's orders for Resident #07 revealed an order dated 05/24/24 for oxycodone (a controlled substance pain medication) five mg tablet every evening for pain and oxycodone immediate release) IR five mg every four hours as needed for pain or shortness of breath.

Review of the medical record of Resident #07 revealed there were two controlled drug receipt/record/disposition forms for Resident #07. The forms were dated 06/28/24 and accounted for 60 of the 90 tablets of oxycodone IR (1 of 3 and 2 of 3). The third form, which pertained to the remaining 30 tablets, was not present in Resident #07's medical record. Further review of the controlled drug receipt/record/disposition form for the 2 of 3 oxycodone IR revealed a handwritten 1 of 3 was crossed out and 1 of 2 was written above the crossed-out notation.

Interview on 09/04/24 at 3:15 P.M. with WD #335 confirmed the facility was unable to located the third controlled drug receipt/record/disposition form for Resident #07's oxycodone IR.

3. Review of the medical record for Resident #19 revealed an admission date of 07/29/22 with diagnoses including Alzheimer's disease, arthritis, and anxiety disorder.

Review of physician's orders for Resident #19 revealed an order dated 08/14/23 for Norco (a controlled substance pain medication) one tablet every eight hours.

Review of the medical record of Resident #19 revealed there were two controlled drug receipt/record/disposition forms for Resident #26. The forms were dated 06/20/24 and accounted for 60 of the 90 tablets of Norco (2 of 3 and 3 of 3). The first form, which pertained to the remaining 30 tablets was not present in Resident #19's medical record.

Interview on 09/04/24 at 3:15 P.M. with WD #335 confirmed the facility was unable to locate the first controlled drug receipt/record/disposition form (1 of 3) for Resident #19's Norco.

4. Review of the medical record of Resident #01 revealed an admission date of 09/08/23 with diagnoses including dementia, chronic pain, hydrocephalus, and seizure disorder.

Review of physician's orders for Resident #01 revealed an order dated 02/15/24 for Norco twice daily for pain.

Review of the medical record for Resident #01 revealed there were two controlled drug receipt/record/disposition forms for Resident #26. The forms were dated 06/19/24 and accounted for 60 of the 90 tablets of Norco (1 of 3 and 2 of 3). The third form, which accounted for the remaining 30 tablets, was not present in Resident #26's medical record.

Interview on 09/04/24 at 3:15 P.M. with WD #335 confirmed the facility was unable to locate the third controlled drug receipt/record/disposition form (3 of 3) for Resident #01's Norco.

Review of the facility policy titled Administration of Scheduled/Controlled Medications dated 06/21/17 revealed the facility should maintain a record and a signed scheduled medication count at each change of shift by the oncoming nurse with the off going nurse, using a controlled drug count verification form or a facility approved form, to include the date, time, confirmation of drug count, signature of staff member coming on duty, and the signature of staff member going off duty. When the supply of scheduled medication was exhausted and the resident's controlled drug receipt/record/disposition form reflected a remaining quantity of zero, the individual resident's controlled drug receipt/record/disposition form would be placed into the resident's permanent medical record.

5. Review of an SRI and the corresponding investigation dated 08/01/24 revealed on 07/26/24 at 6:00 P.M. the floor nurse, LPN #320, notified WD #335 that Resident #26's medications were running low. Upon investigation, WD #335 found that the medication card and sign-off sheet were not in the cart. All nurses who worked since the pharmacy delivered the medication were interviewed and they had no information regarding the missing medication. The pharmacy completed an audit and determined there were a total of five medication cards and their corresponding controlled drug receipts which could not be located. The medications were delivered 06/18/24, 06/19/24, and 06/27/24. The exact number of missing narcotics was unable to be determined as the drug receipts were missing. Each medication card held a thirty-day supply. The local police department was notified.

Interview on 09/04/24 at 10:20 A.M. with the Executive Director (ED) #310 and WD #335 confirmed following the identification of missing narcotics, the facility administration interviewed all the nurses, but they did not drug test any of the nurses. ED #310 stated the facility's policy was to drug test staff upon suspicion of misappropriation of narcotics.

Review of the facility policy titled Substance Abuse dated 03/01/22 revealed employees would be tested for the presence of dugs if there was reasonable suspicion of the employee using/have used drugs.

Review of the facility policy titled Prevention of Abuse, Neglect, and Misappropriation dated 06/25/19 revealed when an incident had been identified as potential abuse, neglect, or misappropriation, the facility should complete a thorough investigation.

This violation represents noncompliance investigated under Complaint Number OH00156752.

Based on record review and staff interview, the facility failed to ensure Resident Caregivers completed their first aide training within the first sixty days of employment. This had the potential to affect all 46 residents at the facility. The facility census was 46.

Findings included:

Review of Resident Caregiver #20 revealed a hire date of 08/18/23. Further review of Resident Caregiver 20's employee file revealed no documented evidence of any first aide training.

Review of Resident Caregiver #44 revealed a hire date of 10/11/21. Further review of Resident Caregiver#44's employee file revealed no documented evidence of any first aide training.

Review of Resident Caregiver #50 revealed a hire date of 10/13/22. Further review of Resident Caregiver#50's employee file revealed no documented evidence of any first aide training.

Interview on 02/01/24 at 3:14 P.M. with Business Director #1 verified the facility failed to provide the first aide training to Resident Caregivers #20, #44 and #50.

Based on review of personnel files and staff interview, the facility failed to ensure all staff providing personal care was evaluated by a licensed nurse prior to providing personal care to residents. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Review of the personnel file for Resident Caregivers #20, #25, #44 and #50 revealed no documented evidence of a skills evaluation completed by a licensed nurse.

Interview on 02/01/24 at 3:07 P.M. with Business Director #1 confirmed no evidence of a skills evaluation signed off by a licensed nurse for Resident Caregivers #20, #25, #44 and #50.

Based on record reviews and staff interviews, the facility failed to check the nurse aide registry for new employees prior to hire. This affected four employees (Resident Caregivers #20, #25, #44 and #50) of the six employee files reviewed. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Review of the employee records for Resident Caregivers #20, #25, #44 and #50 revealed no documented evidence of screening of potential abuse history through the nurse aide registry.

Interview on 02/01/24 at 2:50 P.M. with the Business Director #1 confirms no evidence Resident Caregivers #20, #25, #44 and #50 were screened for potential abuse through the nurse aide registry.