Hoover Haus

Based on medical record review, observation, and interview, the facility failed to ensure medications were clearly labeled with the residents name, the medication name, the medication strength, and pharmacy information. This affected one resident (#19) out of three residents reviewed for medication administration. The census was 19.

Findings Include:

Review of the medical record for Resident #19 revealed an admission date of 05/03/22 with diagnoses of anxiety and depression.

Review of Resident #19's physician orders revealed she was ordered Alprazolam (Xanax) 0.5 milligrams (mg) three times daily for anxiety.

Observation of the medication room on 10/27/25 at 10:30 A.M. with Caregiver #61 revealed a container with multiple drawers for each resident. Resident #19's drawer contained a pill inside of a blister pack that seemed to be cut from a cardboard sheet. The information on the blister pack was blank and did not contain the residents name, the medication name, the medication strength, and pharmacy information.

Interview on 10/27/25 at 10:30 A.M. with Caregiver #61 confirmed the medication in the blister pack was Resident #19's Xanax 0.5 mg. Caregiver #61 stated the nurse would come in at night and prepare the medications and for Resident #19 that involved her Xanax, and that she was the only resident who received controlled medications in that way. Caregiver #61 confirmed the blister pack was not labeled with the residents name, the medication name, the medication strength, and pharmacy information. When asked how she knew it was Xanax, she stated she just knew.

Based on medical record review, observation, interview, and review of facility policy and procedure, the facility failed to ensure resident falls were appropriately investigated and interventions were consistently implemented to prevent additional falls with potential for injury. This affected one resident (#4) of two residents reviewed for falls. Five total resident records were reviewed. The census at the community was 19.

Findings include:

Medical record review revealed Resident #4 was admitted to the facility on 12/21/14 with diagnoses of fracture of left femur dated 12/25/24.

Further review of the medical record revealed an incident report dated 01/31/25 at 6:10 A.M. that indicated the resident fell while transferring self from recliner-chair to bed. No injuries were noted. The incident report included the residents family was notified of Resident #4 needing an anti-slip mat.

Review of Resident #4's functional assessment and service plan dated 11/06/24 did not include an update with the anti-slip mat intervention. Further review of incident reports from the medical record revealed Resident #4 had falls on the following dates 03/09/25, 03/27/25, 04/06/25, 05/18/25, 09/15/25 and 09/30/25.

Observation on 10/27/25 at 4:40 P.M. revealed the anti-slip mat was not at the base of Resident #4's recliner. Additional observation of the resident's room failed to produce evidence of the anti-slip mat.

Interview with the Administrator on 10/28/25 at 4:45 P.M. confirmed the anti-slip mat was not located in front of the resident's recliner-chair and the Administrator also acknowledged the slip mat was not located in the room and there was no documentation to support when and why the anti-slip mat was removed.

Review of facility policy and procedure titled Accident Protocol, dated 03/2025 revealed administration will review and complete follow up as needed and the center will track and trend accident reports to identify concerns.

Based on personnel record review, staff interview, review of facility policy, and review of the facility pre-employment agreement, the facility failed to ensure staff received a physical exam prior to or upon their date of hire. This had the potential to affect all facility residents. The facility census was 24.

Findings include:

Review of the personnel record for Caregiver #72 revealed the employees date of hire was estimated to be 04/01/24. There was no specific date of hire on the file, though the orientation forms revealed an initial date of 04/01/24. There was no evidence of a physical exam being conducted on or prior to the first day of work. There was no physical included in the employee file for review.

Interview on 01/22/25 at 4:20 P.M. with Administrative Assistant #55 confirmed Caregiver #72 had no evidence of a physical being completed.

Review of facility policy/checklist, undated, revealed staff were required to complete an employee physical prior to day one of starting.

Review of the pre-employment agreement revealed the facility required a physical examination prior to employment.

This violation is a recite to the annual survey completed 12/27/23.

Based on personnel record review and staff interview, the facility failed to ensure staff received orientation for tasks and responsibilities before working without close supervision. This had the potential to affect all 24 residents.

Findings include:

1. Review of the personnel record for Caregiver #70 revealed the employees date of hire was 04/15/24. There was no evidence of a signoff or skills check off that showed an orientation of caregiver skills related to techniques of personal care services or observational skills. The orientation sheets and check offs in the record were left blank besides one training list which had no items checked off, but it did include a nurses name typed on the signature line.

2. Review of the personnel record for Caregiver #72 revealed the employees date of hire was estimated to be 04/01/24. There was no specific date of hire on the file, though the orientation forms revealed an initial date of 04/01/24. There was no evidence of a signoff or skills check off that showed an orientation of caregiver skills related to techniques of personal care services or observational skills.

Interview on 01/22/25 at 4:20 P.M. with Administrative Assistant #55 confirmed the check off and orientation materials were left blank and facility had no additional evidence that skills trainings had been completed for Caregivers #70 and #72.

Based on observations, staff interviews, record review, review of facility inservices, and review of facility policy, the facility failed to ensure medications administered through a gastrostomy (G) tube (a tube that is surgically inserted through the abdomen into the stomach) were administered in accordance with acceptable standards of practice. This affected one resident (#2) of five residents reviewed for medication administration. The facility identified one resident (#2) that utilized a G tube for medication administration. The facility census was 24.

Findings include:

Review of the medical record for Resident #2 revealed an admission date of 02/03/19. Diagnoses included anxiety, multiple sclerosis, depression, dementia, hypothyroidism and body mass index less than 20 percent. The record revealed on 03/07/24 the resident had been assessed and could self administer medications with assistance from staff/family/hospice, once obtained from the locked medication room.

Review of January 2025 physician orders for Resident #2 revealed orders for as needed Isosource 1.5 calories continuous feed at 45 milliliters (ml) per hour every 22 hours with instructions to flush with 30 ml of water every hour if food intake was less than 25 percent daily over a 48 hour period, may choose as needed feed per patients request, give ordered medications through feeding tube as needed, Ferrous sulfate enteric coated (EC) 325 milligram (mg) tablet twice daily, Ibuprofen 800 mg tablet three times daily, Levothyroxine 100 micrograms (mcg) tablet once in the morning, Levothyroxine 25 mcg tablet with instructions to provide a half tablet (12.5 mcg) once in the morning, Multivitamin tablet (no measurement amount) every morning, Potassium Chloride extended release (ER) capsule 10 milliequivalents (mEq) twice daily, Senna-time 8.6 mg tablet every morning, Aspirin 81 mg EC tablet every morning, Atorvastatin 40 mg tablet at bedtime, Baclofen 10 mg tablet three times daily, Bupropion 100 mg sustained release (SR) tablet twice daily, Cephalexin 250 mg capsule once daily, Valproic acid 250 mg/5 ml solution with instructions to give 500 mg/10 ml's three times daily, Lorazepam 0.5 mg tablet with instructions to provide a half tablet (0.25 mg) by mouth every three hours as needed, and Oxybutynin 5 mg tablet twice daily.

Observation and interview on 01/23/25 at 8:24 A.M. with Caregiver #95 revealed all tablet medications were crushed using a pill crusher device and mixed in a cup of warm water, two capsules were pulled apart and added to the crushed pills and water mixture, and 10 ml's of valproic acid was poured into the mixture and stirred. At 8:30 A.M., Caregiver #95 sat the medication mixture on the counter in the upstairs kitchen. Caregiver #95 confirmed that it was going to take some time for the medications to dissolve and she walked away leaving the medications unattended. A few minutes later, Caregiver #95 left the facility to run an errand and returned at 8:55 A.M. While Caregiver #95 was away, residents were present around the kitchenette area as breakfast time was near. No staff were present while the medication was on the counter. The medications mixed in the cup of water were left unattended until 9:18 A.M. when they were administered to Resident #2 by AA #55.

Observation and interview on 01/23/25 at 9:18 A.M. with Administrative Assistant (AA) #55 revealed AA #55 administered medications to Resident #2 via the residents G tube. AA #55 did not check for placement of the tube with the use of a stethoscope. AA #55 also used a plunger to force medications into the G tube instead of allowing free flow gravity administration, as the facility training guide instructed. AA #55 revealed Resident #2's G tube had debris or residue on the inside of the tube that would not allow medications to freely pass, therefore staff needed to push the medications slowly using the plunger, forcing it down the tube. Resident #2 did not assist in any part of the medication administration (crushing, pouring, mixing, or during any steps of administering). AA #55 stated facility staff did not need to check placement of the G tube, but they would check its placement if the resident was complaining of pain or discomfort.

Review of the in-service titled, Feeding through a Gastrostomy Tube Skill, revealed the proper use of the tube feed and steps to initiate a feed. It stated feeds should be provided by use of syringe and flow by gravity through the feeding tube. The in-service was undated and no staff sign-in for the in-service was provided.

Review of facility policy titled, Gastrostomy Feeding Tube Policy

Based on observations, staff interviews, record review, review of personnel files, review of facility inservices, review of facility policies and procedures, review of the Ohio Administrative Code (OAC), the facility failed to ensure appropriate staff administered medication through a gastrostomy (G) tube (a tube that is surgically inserted through the abdomen into the stomach). This affected one resident (#2) of five residents reviewed for medication administration. The facility identified one resident (#2) that utilized a G tube for medication administration. The facility census was 24.

Findings include:

Review of the medical record for Resident #2 revealed an admission date of 02/03/19. Diagnoses included anxiety, multiple sclerosis, depression, dementia, hypothyroidism and body mass index less than 20 percent. The record revealed on 03/07/24 the resident had been assessed and could self administer medications with assistance from staff/family/hospice, once obtained from the locked medication room.

Review of January 2025 physician orders for Resident #2 revealed orders for as needed Isosource 1.5 calories continuous feed at 45 milliliter (ml) per hour every 22 hours with instructions to flush with 30 ml of water every hour if food intake less than 25 percent daily over a 48 hour period, may choose as needed feed per patients request, give ordered medications through feeding tube as needed, Ferrous sulfate enteric coated (EC) 325 milligram (mg) tablet twice daily, Ibuprofen 800 mg tablet three times daily, Levothyroxine 100 micrograms (mcg) tablet once in the morning, Levothyroxine 25 mcg tablet with instructions to provide a half tablet (12.5 mcg) once in the morning, Multivitamin tablet (no measurement amount) every morning, Potassium Chloride extended release (ER) capsule 10 milliequivalents (mEq) twice daily, Senna-time 8.6 mg tablet every morning, Aspirin 81 mg EC tablet every morning, Atorvastatin 40 mg tablet at bedtime, Baclofen 10 mg tablet three times daily, Bupropion 100 mg sustained release (SR) tablet twice daily, Cephalexin 250 mg capsule once daily, Valproic acid 250 mg/5 ml solution with instructions to give 500 mg/10 ml's three times daily, Lorazepam 0.5 mg tablet with instructions to provide a half tab (0.25 mg) by mouth every three hours as needed, and Oxybutynin 5 mg tablet twice daily.

Observation and interview on 01/23/25 at 8:24 A.M. with Caregiver #95 revealed all tablet medications were crushed using a pill crusher device and mixed in a cup of warm water, two capsules were pulled apart and added to the crushed pills and water mixture, and 10 ml's of Valproic acid was poured into the mixture and stirred. At 8:30 A.M., Caregiver #95 sat the medication mixture on the counter in the upstairs kitchen. Caregiver #95 confirmed that it was going to take some time for the medications to dissolve and she walked away leaving the medications unattended. A few minutes later, Caregiver #95 left the facility to run an errand and returned at 8:55 A.M. While Caregiver #95 was away, residents were present around the kitchenette area as breakfast time was near. No staff were present while the medication was on the counter. The medications mixed in the cup of water were left unattended until 9:18 A.M. when they were administered to Resident #2 by AA #55.

Observation and interview on 01/23/25 at 9:18 A.M. with Administrative Assistant (AA) #55 revealed AA #55 administered medications to Resident #2 via the residents G tube. AA #55 did not check for placement of the tube with use of a stethoscope. AA #55 also used a plunger to force medications into the G tube instead of allowing free flow gravity administration, as the facility training guide instructed. AA #55 revealed Resident #2's feeding tube had debris or residue on the inside of the tube that would not allow medications to freely pass, therefore staff needed to push the medications slowly using the plunger, forcing it down the tube. Resident #2 did not assist in any part of the medication administration (crushing, pouring, mixing, or during any steps of administering). AA #55 stated facility staff did not need to check placement of the G tube, but would check its placement if the resident was complaining of pain or discomfort. AA #55 confirmed the facility had no medication technicians (medication trained/certified aides) employed at the facility. She also confirmed the nurse did not come into the facility daily. AA #55 confirmed the facility had no schedule of when the nurse came to the facility or how often the nurse was there. AA #55 revealed the Caregivers assisted Resident #2 in administering the medications through her G tube.

Review of the personnel record for AA #55 revealed she was originally hired as a Caregiver. The personnel record included no information of her being a medication technician and there was no evidence of medication administration training or training related to feeding tubes or G tube medication administrations.

Review of four additional personnel records for Caregiver's #70, #72, #74 and #76 revealed no evidence of any staff with a medication technician certification or specific training/certification to provide tube feeds or medications via G tube.

Review of the in-service titled, Feeding through a Gastrostomy Tube Skill, revealed the proper use of the tube feed and steps to initiate a feed. It stated feeds should be provided by use of syringe and flow by gravity through the feeding tube. The in-service was undated and no staff sign-in for the in-service was provided.

Review of facility policy titled, Gastrostomy Feeding Tube Policy

Based on observation, staff interview, record review, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected one resident (#2) of five residents reviewed for medication administration. The facility census was 24.

Findings include:

Review of the medical record for Resident #2 revealed an admission date of 02/03/19. Diagnoses included anxiety, multiple sclerosis, depression, dementia, hypothyroidism and body mass index less than 20 percent. The record revealed on 03/07/24 the resident had been assessed and could self administer medications with assistance from staff/family/hospice, once obtained from the locked medication room.

Review of January 2025 physician orders for Resident #2 revealed orders to give ordered medications through feeding tube as needed, Atorvastatin 40 milligram (mg) tablet daily at bedtime and Lorazepam 0.5 mg tablet with instructions to provide a half tablet (0.25 mg) by mouth every three hours as needed.

Observation and interview on 01/23/25 at 8:24 A.M. with Caregiver #95 revealed Resident #2's morning medications were crushed and mixed with water, to be administered through the residents' gastrostomy (G) tube (a tube that is surgically inserted through the abdomen into the stomach).

Observation on 01/23/25 at 9:18 A.M. with Administration Assistant (AA) #55 revealed medications were administered through Resident #2's G tube. Resident #2 was showing no signs of anxiety at the time of the observation.

Interview and observation on 01/23/25 at 10:49 A.M. with AA #55 revealed Resident #2's daily morning medications included Atorvastatin (a medication ordered to be administered in the evening) and Lorazepam (an as needed medication). AA #55 confirmed the two medications were administered during the morning medication administration and were not given according to the physician orders.

Review of the facility policy titled, Medication Assistance

Based on observations, staff interviews, record review, and review of facility policy and procedure, the facility failed to ensure safe and sanitary storage of resident medications. This had the potential to affect 17 residents (Residents #1, #3, #4, #5, #6, #7, #8, #9, #11, #12, #16, #17, #19, #20, #21, #23, and #24) who facility identified to be alert and mobile. The facility census was 24.

Findings include:

1. Review of the medical record for Resident #25 revealed an admission date of 07/30/15 and a discharge date of 12/24/24. Diagnoses included dementia, diabetes and gastric reflux disease.

Review of Resident #25's physician orders revealed orders for Basaglar pen 100 units/milliliter (u/ml) with instructions to provide 20 units in the morning and 40 units in the evening subcutaneously twice daily.

Review of the medical record for Resident #26 revealed an admission date of 05/05/21 and discharge date of 11/30/24. Diagnoses included diabetes, dementia and pneumonia.

Review of Resident #26's physician orders revealed orders for Humalog Kwikpen injector with instructions to inject six units subcutaneously before meals and at bedtime for diabetes.

Observation on 01/22/25 at 8:40 A.M. of the refrigerator in the upstairs kitchenette revealed a labeled bag with two insulin pens for Resident #25, a labeled bag with two insulin pens for Resident #26, and a fifth medicated pen outside of any labeled bag and laying free in the crisper drawer of the refrigerator. The unlabeled pen had no label to determine what medication was inside or which resident it belonged to. The crisper drawer of the refrigerator containing all five pens was found unlocked and had food and a sticky brown residue inside of it.

Interview on 01/22/25 at 1:40 P.M. with Administrative Assistant (AA) #55 confirmed the facility had five insulin pens in total, two for Resident #25, two for Resident #26, and an unknown medicated pen in an unlocked drawer in the upstairs kitchenette refrigerator. AA #55 confirmed both Residents #25 and #26 had discharged over one month prior and revealed they should have disposed of the medications. AA #55 also confirmed the facility had two lock boxes of medications in the refrigerator and confirmed none of the insulin pens found, were locked and secured from resident access.

2. Review of the medical record for Resident #13 revealed an admission date of 06/10/22. Diagnoses included dementia, altered mental status, high blood pressure, and pyuria.

Review of physician orders for Resident #13 revealed orders for Lorazepam with instructions to administer 0.25 milliliters (ml)(0.5 milligrams) by mouth or under the tongue every four hours as needed for anxiety and restlessness.

Review of the medical record for Resident #22 revealed an admission date of 07/11/24. Diagnoses included neurocognitive disorder with Lewy bodies, depression, and hallucinations.

Review of physician orders for Resident #22 revealed orders for Lorazepam with instructions to administer 0.25 ml (0.5 milligrams) by mouth or the under tongue every four hours as needed for anxiety and restlessness.

Interview and observation on 01/22/25 at 8:50 A.M. of the main kitchen revealed Lorazepam medications for Resident #13 and #22 stored in a bag and located in the refrigerator. Caregiver #60 confirmed the findings and stated hospice provided those medications to the residents.

Observation and interview on 01/22/25 at 12:20 P.M. with Caregiver #80 revealed the Lorazepam medications for Resident #13 and #22 remained in the main kitchen refrigerator. Caregiver #80 revealed the refrigerator locked and the kitchen locked, but acknowledged that all staff had access to that area and could gain access to those medications.

Interview on 01/22/25 at 4:50 P.M. with Administrative Assistant (AA) #55 confirmed Lorazepam was a controlled substance, and all staff had access to the main kitchen refrigerator. AA #55 also confirmed the medications were not in a locked container or secured from the potential of misappropriation of medication.

3. Review of the medical record for Resident #2 revealed an admission date of 02/03/19. Diagnoses included anxiety, multiple sclerosis, depression, dementia, hypothyroidism and body mass index less than 20 percent. The record revealed on 03/07/24 the resident had been assessed and could self administer medications with assistance from staff/family/hospice, once obtained from the locked medication room.

Review of January 2025 physician orders for Resident #2 revealed orders for ordered medications through feeding tube as needed, Ferrous sulfate enteric coated (EC) 325 milligram (mg) tablet twice daily, Ibuprofen 800 mg tablet three times daily, Levothyroxine 100 micrograms (mcg) tablet once in the morning, Levothyroxine 25 mcg tablet with instructions to provide a half tablet (12.5 mcg) once in the morning, Multivitamin tablet (no measurement amount) every morning, Potassium Chloride extended release (ER) capsule 10 milliequivalents (mEq) twice daily, Senna-time 8.6 mg tablet every morning, Aspirin 81 mg EC tablet every morning, Atorvastatin 40 mg tablet at bedtime, Baclofen 10 mg tablet three times daily, Bupropion 100 mg sustained release (SR) tablet twice daily, Cephalexin 250 mg capsule once daily, Valproic acid 250 mg/5 ml solution with instructions to give 500 mg/10 ml's three times daily, Lorazepam 0.5 mg tablet with instructions to provide a half tablet (0.25 mg) by mouth every three hours as needed, and Oxybutynin 5 mg tablet twice daily.

Observation and interview on 01/23/25 at 8:24 A.M. with Caregiver #95 revealed all tablet medications were crushed using a pill crusher device and mixed in a cup of warm water, two capsules were pulled apart and added to the crushed pills and water mixture, and 10 ml's of valproic acid was poured into the mixture and stirred. At 8:30 A.M., Caregiver #95 sat the medication mixture on the counter in the upstairs kitchen. Caregiver #95 confirmed that it was going to take some time for the medications to dissolve and she walked away leaving the medications unattended. A few minutes later, Caregiver #95 left the facility to run an errand and returned at 8:55 A.M. While Caregiver #95 was away, residents were present around the kitchenette area as breakfast time was near. No staff were present while the medication was on the counter. The medications mixed in the cup of water were left unattended until 9:18 A.M. when they were administered to Resident #2 by AA #55.

Observation on 01/23/25 at 9:18 A.M. with Administrative Assistant (AA) #55 revealed AA #55 administered medications to Resident #2 via the residents G tube.

Review of the facility policy titled, Medication Assistance

Based on observation, staff interview, record review, and review of facility policy and procedure, the facility failed to ensure veterinary records were maintained and failed to ensure resident pets were up to date on annual examinations and vaccinations. This had the potential to affect all facility residents. The facility census was 24.

Findings include:

Observation on 01/22/25 at 8:48 A.M. revealed Resident #16 was in the dining room with his dog.

Review of Resident #16's dog veterinary (vet) records revealed the facility had a vet statement dated 06/23/23 that noted the dog had an examination and also received the Distemper, Hepatitis, Parvovirus, Parainfluenza, and Corona vaccine (Parvo/DHP vaccine with Corona) and the Bordetella vaccine. The statement also revealed Resident #16's dog had vet reminders for vaccinations for Parvo/DHP with Corona and Bordetella due on 06/22/24. The facility was unable to supply evidence of an annual vet visit from 2024 or evidence that the vaccinations were current.

Interview on 01/22/25 at 1:10 P.M. with Administration Assistant (AA) #55 revealed the facility did not have additional health records for Resident #16's dog. AA #55 confirmed the last vet records were dated 06/23/23 with no evidence of a visit in 2024 and the dogs vaccinations were not current.

Review of facility policy titled, pet rules and responsibilities undated, revealed the facility shall maintain animal health records.

Based on personnel record review, staff interview, review of the facility pre-employment agreement, review of facility policy, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure staff received adequate tuberculosis (TB) testing upon hire. This had the potential to affect all facility residents. The facility census was 24.

Findings include:

1. Review of the personnel record for Caregiver #70 revealed the employees date of hire was 04/15/24. The record revealed step one of the employees TB test was completed on 04/11/24 with no evidence of the two step being completed.

Review of the new employee file checklist revealed a handwritten notation related to TB testing stating; test given 04/11/24 but no indication she returned.

2. Review of the personnel record for Caregiver #72 revealed the employees date of hire was estimated to be 04/01/24. There was no specific date of hire on the file, though the orientation forms revealed an initial date of 04/01/24. The record revealed no evidence of a TB test being completed.

3. Review of the personnel record for Caregiver #74 revealed the employees date of hire was 12/01/24. The record revealed step one of the employees TB test was completed on 11/26/24 with no evidence of the two step being completed. The section for the two step had a line through it.

4. Review of the personnel record for Caregiver #76 revealed the employees date of hire was 08/05/24. The record revealed step one of the employees TB test was completed on 07/31/24 with no evidence of the two step being completed. The section for the two step had a line through it.

Interview on 01/22/25 at 4:20 P.M. with Administrative Assistant (AA) #55 confirmed Caregiver #70, #74 and #76 had no evidence of a TB two step testing completed or a TB test completed for Caregiver #72. AA #55 revealed it was her and the owner's understanding that a one step should be completed, and if it was positive a second test would be completed, but if it was negative they did not have to complete a second step. She revealed they were following CDC guidance, but was unable to provide the guidance to support the one step TB test.

Review of guidance from the CDC titled, Baseline Tuberculosis screening and testing for healthcare personnel

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure food was prepared and served in a way to prevent contamination. This affected all facility residents. The facility census was 24.

Findings include:

1. Observation and interview on 01/22/25 at 8:50 A.M. revealed Caregiver #60 was working in the kitchen and did not have a hairnet on. She confirmed she was not wearing a hairnet and stated the facility had hairnets in a box by the door.

2. Observation and interview on 01/22/25 at 12:20 P.M. revealed Caregiver #60 was working in the kitchen, taking food temperatures. Caregiver #60 placed the thermometer in the hot chicken noodle soup, then rinsed it under the sink water and wiped with a paper towel. Caregiver #60 then placed the thermometer in the cold ground turkey salad mixture. Caregiver #60 confirmed she did not appropriately sanitize the thermometer between food items.

3. Observation and interview on 01/22/25 at 12:22 P.M. revealed Caregiver #60 was working in the kitchen, taking food temperatures. Caregiver #60 took the temperature of a cold food item (ground turkey salad) and the thermometer read 51 degrees Fahrenheit (F). The thermometer was adjusted and read 47 degrees F and was readjusted again and read 53 degrees F. Caregiver #60 confirmed the goal temperature was for the cold food to be around 42 degrees F and was she not sure why the ground turkey salad was not meeting that temperature. She then began making up sandwiches with the ground turkey mixture, even with it being outside of the safe temperature range. The sandwiches were served to all residents.

Review of facility policy Review of Food Service Rules

Based on record review, staff interview, and review of facility policy, the facility failed to ensure fire drills were completed at least once each quarter on each shift. This had the potential to affect all facility residents. The facility census was 24.

Findings include:

Review of facility fire drills revealed a third shift fire drill was conducted 05/28/24 (quarter two) and not again until 11/29/24 (quarter four). The facility noted a third shift fire drill was completed on 08/21/24, but the time was noted to be at 8:30 A.M. (first shift).

Interview on 01/22/25 at 10:15 A.M. with Administration Assistant (AA) #55 revealed facility staff began the first shift at 8:00 A.M. She also revealed the facility had scheduled fire drills with staff with staff that came in for the drills. AA #55 stated facility fire drills were not random and were not unannounced, and she confirmed no third shift fire drill was completed for quarter three in 2024 (from July 2024 to September 2024).

Review of the facility policy titled, Fire and Disaster Plan revised March 2024, revealed the facility would conduct fire drills quarterly on each shift.

Based on personnel record review and staff interview, the facility failed to ensure acknowledgements were provided and signed by staff for information related to resident rights, transfer and discharge, and contacts for the local agencies such as the health department and the Ombudsman's office. This had potential to affect all residents.

Findings include:

Review of the personnel record for Caregiver #70 revealed no evidence of any signed acknowledgments completed indicating they were informed of information related to resident rights, transfer and discharge, and contacts for the local agencies such as the health department and the Ombudsman's office. The forms in the personnel record were left blank and not signed as acknowledged/received.

Interview on 01/22/25 at 4:20 P.M. with Administrative Assistant #55 confirmed the acknowledgements were not signed as received for Caregiver #70 and further confirmed the facility did not have any evidence of the forms being completed.

This violation is a recite to the annual survey completed 12/27/23.

Based on review of facility personnel files and staff interview, the facility failed to complete the required check of new employees for a criminal record. This had the potential to affect all 23 residents residing in the facility.

Findings include:

Review of six personnel files revealed an absence of a criminal background check for two of the personnel files. The personnel files reviewed were: Administrator #9 hired 3/15/09, Caregiver #11 hired 9/22/19, Caregiver #16 hired 8/16/21, Caregiver #15 hired 11/23/23, Caregiver #17 hired 7/26/23, and Caregiver #1 hired 10/1/23. Caregiver #15 and Caregiver #17 did not have background checks completed.

Interview with Administrator #9 on 12/27/23 at 3:00 P.M., verified the two employee's background checks were not completed when they were hired in 2023.

Based on review of facility personnel files and staff interview, the facility failed to have employees examined by a physician or other health care professional within thirty days before commencing work or on the first day of work. This had the potential to affect all 23 residents residing in the facility.

Findings include:

Review of six personnel files revealed an absence of a physical examination for two of the personnel files. The personnel files reviewed were: Administrator #9 hired 3/15/09, Caregiver #11 hired 9/22/19, Caregiver #16 hired 8/16/21, Caregiver #15 hired 11/23/23, Caregiver #17 hired 7/26/23, and Caregiver #1 hired 10/1/23.

Caregiver #15 and Caregiver #17 did not have physical examinations completed.

Interview with Administrator #9 on 12/26/23 at 5:50 P.M., verified the two employee's physical examinations were not completed when they were hired in 2023.

Based on resident record review, communal log review, and staff interview, the facility failed to make a notation of the change in health status, the intervention taken, and the notification of the sponsor to the resident's status change in the resident's record. This affected five residents (#17, #21, #15, #22, and #11) of the five reviewed for documentation. The census was 23.

Findings include:

Review of the resident records, revealed there were no progress notes identifying resident conditions or any changes in condition.

Review of a facility communal log revealed the facility has a log that if anything out of the ordinary happens with any resident they write in the log instead of writing a progress note in the resident's medical record.

Interview with Administrator #9 on 12/27/23 at 3:05 P.M., verified progress notes and changes in condition are recorded in a communal record that does not get placed in the residents' records.

Based on review of facility personnel files and staff interview, the facility failed to have employees tested for tuberculosis. This had the potential to affect all 23 residents residing in the facility.

Findings include:

Review of six personnel files revealed an absence of any tuberculosis testing for two of the personnel files. The personnel files reviewed were: Administrator #9 hired 3/15/09, Caregiver #11 hired 9/22/19, Caregiver #16 hired 8/16/21, Caregiver #15 hired 11/23/23, Caregiver #17 hired 7/26/23, and Caregiver #1 hired 10/1/23.

Caregiver #15 and Caregiver #17 did not have tuberculosis testing completed.

Interview with Administrator #9 on 12/26/23 at 5:50 P.M., verified the two employee's tuberculosis tests were not completed when they were hired in 2023.

Based on observation, staff interview, and policy review the facility failed to store food in a manner that protects it against contamination and spoilage. This had the potential to affect all 23 residents.

Findings include:

Observations in the facility's kitchen on 12/26/23 at 11:38 A.M., revealed one opened bag of fiesta blend cheese, opened margarine, and opened Hershey's chocolate syrup without a label or date in the refrigerator. One opened jar of creamy peanut butter and one open bag of tortilla chips were observed without a label or date on a kitchen shelf.

Interview with Caregiver #13 on 12/26/23 at 11:40 A.M., verified all previously stated items were open and undated, and the facility policy is to date all food.

Review of the facility's Labeling Food and Date Marking policy dated 4/7/06, stated, Foods are labeled following delivery, preparation or opening to identify the item and to provide date, time and, or temperature information. A handwritten note on the policy dated 1/2023, stated, Please use date food was prepared.

Based on record review and staff interview, the facility failed to keep a written acknowledgment by staff members of the receipt of copies of the address and phone numbers of any Ohio nursing home ombudsman program. This had the potential to affect all 23 residents residing in the facility.

Findings include:

Review of six personnel files revealed an absence of the written acknowledgment receipt. The personnel files reviewed were: Administrator #9 hired 3/15/09, Caregiver #11 hired 9/22/19, Caregiver #16 hired 8/16/21, Caregiver #15 hired 11/23/23, Caregiver #17 hired 7/26/23, and Caregiver #1 hired 10/1/23.

Interview with Administrator #9 on 12/26/23 at 4:50 P.M., verified the administration had not been giving the staff a copy of the address and phone numbers of the Department of Aging Ombudsman.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident falls were documented in the medical record as well as ensure the care provided or action taken as a result of a fall was included on the incident log. This affected three Residents (#13, #21, and #25) of three reviewed for falls. The census was 22.

Findings include:

1. Review of the medical record for Resident #25 revealed an admission date of 10/23/19 and discharge date of 06/20/23. Resident #25's diagnoses included non-verbal status, seizure disorder, dementia with behaviors, and diabetes.

Review of Resident #25's medical record revealed no documentation in the medical record regarding Resident #25 falling on 05/15/23.

Review of incident and accident log revealed Resident #25 had a fall on 05/15/23. The log had no information related to the care provided or action taken for Resident #25's fall on 05/15/23.

Interview on 07/05/23 at 3:30 P.M. with Director #50 confirmed there was no documentation in the medical record related to Resident #25's fall, injury, and hospitalization. Director #50 revealed the facility only completes the incident/accident log after a fall. Director #50 revealed Resident #25's wife had been contacted related to the injury and requested to take Resident #25 to the hospital after she was off work around 11:30 A.M.

Interview on 07/06/23 at 8:30 A.M. with Care Aide #44 revealed she worked the morning of 05/15/23 when Resident #25's injury to the eye was identified. She revealed she found blood marks on Resident #25's floor. Staff checked on Resident #25 more frequently until his wife came to the facility around 11:30 A.M. to take him to the hospital.

Interview on 07/06/23 at 8:40 A.M. with Care Aide #53 revealed she worked the morning of 05/15/23 when Resident #25's injury to te eye was found. She revealed she saw and assessed Resident #25 and he had swelling on his eye with minimal bruising initially, however the bruising intensified as time progressed. Staff checked on Resident #25 more frequently until his wife came around 11:30 A.M. to take him to the hospital.

Interview on 07/06/23 at 1:35 P.M. with Aide #56 revealed he had checked on Resident #25 on 05/15/23 around 3:30 A.M. to 4:00 A.M. and Resident #25 was asleep with no visible injuries. The next time Resident #25 was observed was around 5:30 A.M. and he had spotting on his face. Aide #56 revealed Resident #25 was sleeping and the room lights were dimmed and it looked like Resident #25 had residue from markers or crayons. He revealed he looked at Resident #25's face for possible injury and did not see any other injuries outside of the facial injury. Aide #56 revealed after an incident/accident staff should complete an investigation statement and submit it to management.

2. Review of the medical record for Resident #13 revealed an admission date of 07/15/19. Resident #13's diagnoses included depression and dementia.

Review of Resident #13's medical record revealed no documentation regarding a fall on 06/10/23, 06/13/23, and 06/26/23.

Review of incident log revealed Resident #13 had falls on 06/10/23, 06/13/23, and 06/26/23.

Interview on 07/06/23 at 3:28 P.M. with Director #50 confirmed there was no documentation in Resident #13's medical record to the falls on 06/10/23, 06/13/23, and 06/26/23.

3. Review of the medical record for Resident #21 revealed an admission date of 07/27/20. Diagnoses included osteoarthritis, pain, dementia, hypertension, and peripheral vascular disease.

Review of the medical record for Resident #21 revealed no documentation related to Resident #21's fall on 05/30/23.

Review of the incident log revealed Resident #21 had a fall on 05/30/23.

Interview on 07/06/23 at 3:28 P.M. with Director #50 confirmed there was no documentation in Resident #21's medical record related to Resident #21's fall on 05/30/23.

Review of facility policy titled Accident and Incident Protocol