Heritage Senior Living of Plain City

Based on medical record review, staff interview, review of the incident reports, and policy review, the facility failed to prevent resident to resident physical abuse. This resulted in Actual Harm for one resident (#41) when Resident #44 with known physical aggression pushed Resident #41 to the ground fracturing her left wrist. Resident #44 continued to show physical aggression towards other residents until he was emergently discharged from the facility. This affected four (#35, #37, #38, and #41) of six residents reviewed for abuse. The facility census was 43.

Findings Included:

1. Review of the medical record for Resident #44 revealed an admission date 03/31/25. Diagnoses included anxiety disorder, insomnia, drug induced acute dystonia, frontotemporal neurocognitive disorder, dementia, obsessive compulsive disorder behavior, altered mental status, and mental disorders due to known physiological condition.

Review of the facility assessment dated 01/21/26 revealed Resident #44 was a 47-year-old man who walked/wandered independently, he displayed aggressive and combative behaviors and needed supervision and monitoring of one staff to help manage and redirect. The resident level of care score was 107 indicating he required medication administration cuing or reminders and had dementia care and services. Resident #44 resided on the memory care unit.

2. Review of the medical record for Resident #41 revealed an admission date of 03/27/25. Diagnoses included anemia, dementia, and muscle weakness.

Review of the assessment dated 05/16/25 revealed Resident #41 required full assistance with daily care with one person. Resident #41 had dementia requiring supervision.

Review of an incident report dated 12/08/25 revealed Resident #41 came out of her room and walked down the hallway, when she saw the commotion out in the hallway/dining room she turned around to go back to her room. While walking away Resident #44 struck Resident #41 in the back with force. Resident #41 went back to her apartment and denied any injuries.

Review of a progress note dated 12/17/25 written by the Executive Director (ED) revealed that an email was sent to the guardian of Resident #44 to schedule a care conference as soon as possible to discuss a recent incident involving another resident. The note revealed the Director of Nursing (DON) reached out a couple of times previously with no response from the guardian. Care conference needed to follow up on where the family was at with finding a better placement for Resident #44 due to his behavior putting other residents' safety at risk.

Review of a progress note dated 01/13/26 written by the ED revealed Resident #44 pushed Resident #41 into the wall causing her to fall onto her left side. Resident #41 complained of pain in her left wrist with immediate swelling. An X-ray was ordered with verified fractures in the left wrist.

Review of the incident report dated 01/13/26 revealed Resident #44 pushed Resident #41 into the wall in the hallway, causing Resident #41 to fall on her left side.

Review of the X-ray result dated 01/13/26 revealed that Resident #41's left wrist had an acute fracture of the distal radius.

3. Review of the medical record for Resident #37 revealed an admission date of 07/06/25. Diagnoses included dementia, nonrheumatic mitral valve disorder, and hyperlipemia.

Review of the assessment dated 07/17/25 revealed Resident #37 required dementia care, cueing and reminders, and medication delivered by staff.

Review of an incident report dated 01/16/26 revealed Resident #37 hit the back of Resident #44's legs with a folding chair after Resident #44 had pushed Resident #37 when Resident #44 was found in the bathroom in Resident #37 and #38's room. Resident #37 stated Resident #44 was in their bathroom and pushed him, so he hit Resident #44 in the back of the legs with a folding chair. Treatment/Intervention was to make sure to keep their door locked to protect them from wandering residents. No witnesses to the incident.

4. Review of the medical record revealed Resident #35 was admitted on 09/17/25. Diagnoses included type two diabetes and dementia.

Review of the assessment dated 12/19/25 revealed Resident #35 required assistance from one staff for bathing, meal preparation, and housekeeping. Resident #35 had dementia and required medication administration by staff, and cueing and reminders.

Review of an incident report dated 01/18/26 revealed a Resident Assistant (RA) heard a commotion in the hallway on the memory care unit. Resident #35 yelled Let me go or I will hit you. RA #248 came down the hallway and saw Resident #44 pushing Resident #35 up against the counter by the memory care entrance door. Both residents were redirected by RA #248.

5. Review of the medical record for Resident #38 revealed an admission date of 07/16/25. Diagnoses included hypothyroidism, anxiety disorder, insomnia, and macular degeneration.

Review of the assessment dated 07/17/25 revealed Resident #38 required one person assistance for bathing, dressing, medication, meal setup, and housekeeping. Resident #38's level of care was 102 indicating she needed dementia care, cueing and reminders, and medication delivered by staff.

Review of an incident dated 01/23/26 revealed Resident #44 pushed Resident #38 down in her room. Resident #44 was sent to the hospital for physical aggression.

Interview on 02/02/26 at 11:49 A.M., Life Enrichment Director (LED) #245 stated on 01/13/26 Resident #41 was yelling sounding scared. The LED #245 said she ran back to the memory care unit from the assisted living and saw Resident #44 push Resident #41 to the floor from the memory care unit window at the exit door. The LED #245 stated she saw Resident #44 who had been physically aggressive to residents and staff. The LED #245 further stated last year Resident #44 would push or body check other residents including Resident #35 and Resident #38.

Interview on 02/02/26 at 12:56 P.M., the DON stated the facility had explained to Resident #44's family he had behaviors that included hitting, or pushing residents, staff, and guests, and the family acknowledged the behaviors then dismissed the actions.

Interview on 02/02/26 at 5:23 P.M., the ED stated the family of Resident #44 was asked to provide supervision that included family and private duty help for one-on-one. The ED said the facility could not make the family provide the needed supervision. The ED said the facility had a third aid that floated from the assisted living to the memory care unit. The facility could not provide one-on-one supervision.

Interview on 02/02/26 at 5:44 P.M., RA #214 stated she went into Resident #38's room and saw Resident #38 was on her bed, and she kept saying Resident #44 had pushed her and then she saw Resident #44 was in Resident #38's bathroom.

Review of the facility policy titled Abuse, Neglect and Exploitation Policy undated revealed the facility was to provide protections for the health, welfare, and rights of each resident. The facility had procedures in place that worked towards preventing abuse, neglect and exploitation including screening potential employees for a history of abuse, training employees on prevention, detection and reporting procedures. Take immediate action to ensure the health and welfare of the individual. Call state licensure authority or State Ombudsman within 24 hours.

This violation represents non-compliance investigated under Complaint Number OH00169249.

Based on record review, observations, and staff interviews, the facility failed to ensure a cognitively impaired resident was treated with respect and dignity when staff inappropriately physically assisted the resident who was displaying behaviors. This affected one (#42) of three residents reviewed for resident rights. The facility census was 44.

Findings include:

Review of Resident #42's medical record revealed an admission date of 03/27/25 with diagnoses including end-stage vascular dementia with behaviors, agitation, generalized weakness, and confusion. Upon admission, she was assessed as exhibiting behaviors including wandering, demonstrating impaired judgement, and occasional noisy or inappropriate behavior.

Review of nursing note written by Licensed Practical Nurse (LPN) #96 dated 07/27/25 at 2:00 P.M. stated his help was requested to return Resident #42 to the memory care unit. Resident #42 became combative with LPN #96, attempting to hit his face and stomach. LPN #96 reported he was able to get Resident #42 halfway down the hallway before another aide took over and got her back in the memory care unit. LPN #96 notified the resident's Primary Care Physician (PCP) and the Director of Nursing (DON) of the resident's combative behaviors. The medical record did not contain any assessments or lab work following her behaviors.

Review of surveillance video of the hall leading to the memory care unit time-stamped on 07/27/25 at 12:57:35 P.M. to 12:59:41 P.M. revealed Resident Assistant (RA) #60 walking with Resident #42 in the hallway leading to the memory care unit. Resident #42 was resistant to return to memory care, RA #60 attempted to redirect and reapproach. Resident #42 remained resistant. RA #60 approached the nurse's station to ask for help. Resident #42 continued to walk down the hallway away from the memory care unit and is seen rummaging in the planter box of artificial flowers. Resident #42 left view of the camera away from the memory care unit. LPN #96 left the nurse's station and walked in the same direction as Resident #42. Approximately 20 seconds later, LPN #96, Resident #42, and Receptionist #94 were seen walking together down the hall towards the memory care unit, LPN #96 is seen with his right arm around Resident #42's shoulders guiding her down the hall. Resident #42 then attempted to turn to the right and enter the business office. LPN #96 put his hands on each of Resident #42's shoulders and pulled her out of the office. LPN #96 pivoted Resident #42 out of the doorway and oriented her down the hallway towards the door to the memory care unit. LPN #96 continued to stand behind Resident #42 and held her by the shoulders forcing her down the hallway. LPN #96 turned Resident #42 into the wall and held her in a reverse bear hug. Resident #42 made a slapping motion with her right hand but did not make contact with anyone. LPN #96 continued to hold Resident #42 from behind and force her down the hall. Two RAs (#99 and #103) are seen running down the hallway towards LPN #96 and Resident #42 and gather around them. LPN #64 arrived in the hallway and stood back to observe. LPN #96 lets go of Resident #42, who turns into RA #99. LPN #96 returned to the nurse's station while RA #99 and RA #103 continued to assist Resident #42 back to the memory care unit without further incident. There was no sound with the video.

Interview with RA #60 on 08/20/25 at 10:16 A.M. revealed she was walking around the assisted living facility with Resident #42 on 07/27/25. Resident #42 did not want to return to the memory care unit so RA #60 asked LPN #96 for assistance while RA #60 went to get the memory care director. RA #60 stated she heard Resident #42 screaming and saw LPN #96 grabbing Resident #42 from behind with his arms underneath her armpits. RA #60 stated she immediately reported the incident to the DON, who instructed all witnesses to write statements and place them under her office door. RA #60 stated she was unsure if LPN #96's actions were abuse but felt it was inappropriate, rough behavior. RA #60 stated she assessed Resident #42 and found a new bruise approximately the size of a quarter on her wrist that she didn't think was not present during their walk. RA #60 reported Resident #42 did not display any other behaviors or indicate distress throughout the remainder of the day. RA #60 stated all direct care staff were assigned training's in the facilities online training environment but had not received any new education regarding abuse policies and procedures.

Interview with RA #103 on 08/20/25 at 11:32 A.M. revealed RA #103 was not present for the beginning of the incident involving LPN #96 and Resident #42 on 07/27/25 but stated she heard screaming and went to see what was happening. RA #103 stated she saw LPN #96 standing behind Resident #42 and scooped her up under his arms. RA #103 told LPN #96 to let go of Resident #42 who then released her. RA #103 reported that RA #99 comforted Resident #42 and assisted RA #60 and #103 with returning Resident #42 to the memory care unit. RA #103 asked if she was okay. Resident #42 responded that her forearm hurt but was otherwise okay. RA #103 felt that LPN #96's actions were not professional but did not think it rose to the level of abuse. RA #103 stated all direct care staff were assigned training's in the facilities online training environment but had not received any new education regarding abuse policies and procedures.

Interview with Weekend Receptionist (WR) #94 on 08/20/25 at 11:44 A.M. revealed she witnessed the entire incident involving LPN #96 and Resident #42 on 07/27/25. WR #94 reported she heard yelling and went to see what was going on. WR #94 stated she saw Resident #42 trying to open the door into the dining room and LPN #96 attempting to redirect Resident #42 back to memory care. Resident #42 continued to yell at LPN #96, called him names, and attempted to punch LPN #96. WR #94 stated she could not confirm if Resident #42 made contact with LPN #96. WR #94 reported LPN #96 put his arms around Resident #42 under her armpits in what appeared to be an attempt to contain her and keep her calm. WR #94 stated Resident #42 remained agitated and combative as LPN #96 walked Resident #42 down the hallway towards memory care. WR #94 stated a few aides came running down the hallway to assist and took over the situation. WR #94 reported she did not see Resident #42 for the rest of the day but stated that is not unusual as she is the receptionist and remains in the lobby area. WR #94 stated she did not feel LPN #96 was acting in an abusive manner and was trying to de-escalate the situation in the best way he knew how. WR #94 stated she has not had any new training's assigned since the incident.

Interview with LPN #96 on 08/20/25 at 12:04 P.M. revealed on 07/27/25, RA #60 had requested his assistance getting Resident #42 back onto the memory care unit. LPN #96 stated he was concerned Resident #42 was going to hurt herself because she was walking in the direction of the kitchen. LPN #96 stated Resident #42 had hit him in the stomach and was worried she was going to fall over so we walked behind her for additional support. LPN #96 stated he called Resident #42's physician and her family to inform them of her behaviors. LPN #96 reported that he finished his shift as scheduled. When asked about his actions to return Resident #42 to the memory care unit, LPN #96 denied forcefully turning and moving the resident. LPN #96 stated he did not complete a full body exam of Resident #42 following the incident. LPN #96 reported that he was educated by the DON and Executive Director (ED) that he cannot physically reorient residents as it is a form of restraint. LPN #96 stated he had to complete online training's in facilities online training environment prior to returning to work.

Interview with DON on 08/20/25 at 12:48 P.M. revealed she was notified of the incident involving LPN #96 and Resident #42 by RA #60 via text message on 07/27/25 at 2:16 P.M. that LPN #96 was too forceful when assisting Resident #42 back to the memory care unit. The DON notified the ED immediately and LPN #96 was immediately removed from the schedule while the facility conducted an investigation into the incident. DON confirmed that a full body exam should have been conducted by the other LPN on duty and confirmed that the assessment was missing from the resident's medical record. DON stated she was not notified of any new bruising or injuries. DON confirmed LPN #96's report to Resident #42's physician and family were incomplete as the report did not include his use of physical restraint to redirect Resident #42 back to memory care. DON stated LPN #96 was removed from the schedule and returned to work on 08/08/25 and had to complete two online training's: Understanding Wandering and Elopement and How to Help When Someone is Lost in Time or Place. DON reported that LPN #96 was not required to have one-on-one supervision of techniques upon his return to work.

Interview with ED on 08/20/25 at 3:45 P.M. revealed she was not aware of the incident on 07/27/25 involving LPN #96 and Resident #42 until she came into work the following day on 07/28/25. The ED stated on 07/28/25, she notified LPN #96 that he would be taken off the schedule during the investigation. ED reported that the incident was initially reported to the DON and that the DON did not feel it was necessary for her to come in. ED stated she called the Ohio Department of Health (ODH) to report the incident and stated Resident #42's family has not been notified of the entirety of the incident as she wanted to wait for ODH to complete its investigation. ED reported she completed a head-to-toe assessment of Resident #42 on 07/28/25 and found no redness, bruising, or other marks, and that Resident #42 was her usual self. ED stated that because there were no findings, there was no documented assessment or notes in the resident's medical record. ED reported the investigation included written statements from all witnesses, review of camera footage of the day and time of the incident, and a report to ODH. ED reported that LPN #96 was not required to have one-on-one supervision of techniques upon his return to work.

Review of Plan of Action developed for LPN #96 revealed an incident report was completed and Resident #42's Power of Attorney (POA) was notified when the incident occurred on 07/27/25. LPN #96, as well as all direct care staff, was assigned new online training's: Understanding Wandering and Elopement due by 08/13/25, and How to Help When Someone is Lost in Time or Place due by 08/31/25. LPN #96 was able to return to work on 08/08/25 after completing all new education and meeting with the ED and DON.

Review of LPN #96's online training transcripts revealed LPN #96 completed the training Understanding Wandering and Elopement on 08/04/25; Alzheimer's Disease and Related Disorders: Approaches to Treatment on 08/08/25; and How to Help When Someone is Lost in Time or Space on 08/15/25.

Review of the Interdisciplinary Team Meeting log for the week of 07/23/25 to 07/30/25 revealed Resident #42 displayed behaviors on 07/27/25 at 4:00 P.M. in the hallway outside of the nursing station. The reported intervention states, Resident hit staff twice, redirected resident. No other outcomes noted in the meeting log or medical record.

Review of the policy titled Abuse, Neglect and Exploitation Policy, not dated, states if staff suspect abuse, neglect, or exploitation they must report it to a director. A director is to call the state licensure authority or the Ombudsman within 24 hours of receiving the report. A director is also to notify the resident's contact person of the incident.

This violation represents non-compliance investigated under Complaint Number OH00167785.

Based on observation and interview, the facility failed to maintain the washing machines in a clean and sanitary manner. This had the potential to affect all 34 residents residing in the facility.

Findings include:

Observation on 03/24/25 at 9:50 A.M. and 3:02 P.M. revealed four of the six washers in the facility had gray and white build up around the opening of the washer.

Interview on 03/24/25 at 3:02 P.M. with the Executive Director (ED) verified the four washers needed cleaned.

Based on observation, interview, and review of facility policy, the facility failed to store and serve food in a sanitary manner. This had the potential to affect all 34 residents who consumed food from the kitchen.

Findings include:

Observation and interview on 03/24/25 at 9:00 A.M. of the walk-in refrigerator wth Lead Cook #111 revealed a cart containing trays of food. This cart was observed to have food splatter and debris on most rows. Lead Cook #111 verified the cart needed cleaned.

Observation on 03/24/25 at 9:02 A.M. of the kitchen revealed a row of opened containers of cereal. One was labeled honey nut cheerios with no date, one was cheerios dated 08/16, one was raisin bran dated 12/16, one was cornflakes dated January 2025, and one was observed to be a rice cereal but was unlabeled and undated.

Interview on 03/24/25 from 11:20 A.M. to 11:54 A.M. with Lead Cook #111 verified the cereal items were not labeled or dated appropriately.

Observation on 03/24/25 from 11:20 A.M. to 11:54 A.M. with Cook #110 revealed her working the tray line. Cook #110 washed her hands at the beginning of meal service, but was not observed doing so again, although she changed her gloves multiple times. Cook #110 was observed cutting a piece of chicken in half on the food prep surface in front of the hot holding unit and putting half of it back in the hot holding unit with the remaining chicken. Throughout meal service, Cook #110 was observed touching almost every item that went out on every single plate. When scooping potatoes with a spoon, she used her hands to adjust their positioning, she did the same with vegetables, and biscuits. Three times during the observation, she was observed preparing plates with half orders of foods, she put potatoes on the plate (touching them), cut a piece of chicken (while touching it), and then cut a

piece of biscuit (while touching it). One half of these biscuits was returned to the hot holding unit, after being cut.

Interview on 03/24/25 from 11:20 A.M. to 11:54 A.M. with Cook #110 verified she touched the food items with her gloves and when she changed gloves, she did not wash or sanitize her hands between glove use.

Review of the policy titled 'Food storage, labeling, and dating' undated, revealed all pre-packaged open containers were to be dated. Dates were to be written on the container representing the date it was opened.

Review of the policy titled 'Handwashing' undated, revealed staff were to wash their between handling different types of foods.

Based on interview and record review the facility failed to complete fire drills as required, and failed to ensure evacuations occurred during fire drills. This had the potential to affect all 34 residents residing in the facility.

Findings include:

Review of facility fire drills from March 2024 to February 2025 revealed the following concerns:

a. Only one fire drill was performed during the evening shift all year long.

b. Only two fire drills were completed during the night shift all year long

c. Fire drills were not completed every three months on first shift when the facility went March 2024, April 2024, and May 2024 without having a first shift fire drill

. Fire drills did not include alarm activation on 03/20/24, 09/09/24, 10/31/24, 11/12/24, 12/03/24, and 02/28/25

e. Evacuations did not occur on at least two fire drills per shift per year

Interview on 03/24/25 at 1:05 P.M. with the Executive Director (ED) verified the missing fire drills. The ED reported she was unaware of the regulations for how many fire drills per shift per year. She reported they usually did evacuations, but verified the documentation did not prove this.

Based on interview and record review, the facility failed to evaluate fire drills as they were conducted. This had the potential to affect all 34 residents residing in the facility.

Findings include:

Review of fire drills from March 2024 to February 2025 revealed the fire drills were not evaluated for the months of August 2024, October 2024, November 2024, and December 2024.

Interview on 03/24/25 at 1:05 P.M. with the Executive Director (ED) verified the fire drills were not evaluated for the months of August 2024, October 2024, November 2024, and December 2024. The ED reported she had recently learned there was a second form that needed completed with fire drills.

Based on interview and record review, the facility failed to complete the monthly self-inspection form for fire safety. This had the potential to affect all 34 residents residing in the facility.

Findings include:

Review of the monthly self-inspection forms revealed they were not completed during the months of May 2024 and February 2025.

Interview on 03/24/25 at 1:05 P.M. with the Executive Director (ED) verified the self-inspection form was not completed in May 2024 and February 2025. The ED reported they had a maintenance worker leave in April and had been unaware it needed done in May.

Based on observation, interview, review of facility policy, and record review, the facility failed to ensure Resident #23 who utilized oxygen had a No smoking sign located on the door of room. This affected one (#23) of two residents reviewed for oxygen use. The facility census was 34.

Findings include:

Review of Resident #23's medical record revealed an admission date of 01/17/22 with diagnoses including osteoporosis, chronic obstructive pulmonary disease, and asthma.

Review of the physician note dated 01/08/25 revealed Resident #23 required oxygen continuously.

Observation on 03/24/25 at 9:55 A.M. of Resident #23 revealed she was in her room, with oxygen in use. There was no sign in the doorway to indicate oxygen was in use or no smoking.

Interview on 03/24/25 at 9:58 A.M. with Licensed Practical Nurse (LPN) #107 verified there was no sign indicating no smoking on Resident #23's door of room.

Review of the policy titled Oxygen Use' undated, revealed 'No Smoking-Oxygen in use' signs were to be posted in areas where oxygen was used or stored.