Wellington at North Bend Crossing-Hilltop, The

Based on observation, staff interview and policy review, the facility failed to procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility census was 75.

Findings included:

Observation of the kitchen on 05/01/25 at 9:29 A.M. with the Director of Nursing (DON) and Dining Chef #08, revealed the following:

A) The dry storage contained a half bag of chocolate sprinkles opened in a Ziploc bag unlabeled, two packs of opened taco shells wrapped in plastic wrap unlabeled, one pack of flour tortillas opened and wrapped in plastic wrap unlabeled, five half bags of dry pasta opened and unlabeled.

B) The walk-in refrigerator contained a half bag of unlabeled and opened spinach.

C) The reach in refrigerator contained a container of vitamin-d milk that expired on 04/29/25.

D) The soup station contained a half bin of Rice Krispies cereal labeled with a use by date of 04/17/25, a whole bin of Raisin Bran cereal labeled with a use by date of 04/30/25.

E) The grab and go refrigerator unit in the dining area revealed six two-ounce cups of milk with expiration dates of 04/28/25, 04/29/25 and 04/30/25, two two-ounce cups of cottage cheese containers with an expiration date of 04/30/25, two two-ounce cups of tuna salad with an expiration date of 04/30/25.

Interviews with Dining Chef #08 and the DON, during the aforementioned observations, verified the findings in the dry storage, the walk-in refrigerator, reach in refrigerator, soup station, and the grab and go refrigerator.

Continued observation of the kitchen on 05/01/25 at 9:42 A.M. with Dining Chef #08, revealed the dishwasher temperature gauge showed no temperature after two complete cycles. Interview with Dining Chef #08 at the same time, verified the dishwasher was a high-temperature dishwasher and should be reaching at a minimum of 160 degrees for washing and 180 degrees and the gauge wasn't showing a temperature.

Interview with the Maintenance Director #05 on 05/01/25 at 11:00 A.M., verified the dishwasher was a high temperature dishwasher and should be reaching at a minimum 160 degrees for wash and 180 degrees for rinsing. Maintenance Director #05 verified the dishwasher temperature was reading zero and stated they were using the three-sink method to clean and sanitize dishes until it is fixed later today. Maintenance Director #05 stated the repair had been called and were on their way to look at the dishwasher.

Subsequent interview with the Dining Services Director #03 on 05/01/25 at 1:30 P.M. while reviewing the dishwasher temperature logs from 03/06/25 to 05/01/25, revealed several days (03/06/25, 03/15/25, 03/23/25, 03/26/25, 03/28-04/02/25, 04/10/25, 04/11/25, 04/17/25, 04/25/25 and 05/01/25) where the dishwasher temperature was below the required minimum required temperatures for washing and rinsing. Dining Services Director #03 stated he was not aware the temperatures were falling below the required minimum temperatures and the staff did not inform him. Observation at the same time, revealed the repair company was on-site repairing the dishwasher.

Review of the Food Storage, Handling and Labeling Policy dated 07/01/22, revealed the facility will ensure food and non-food items are safe and of good quality. Food must be marked with a date and rotated. All food in the refrigerator walk in and storage areas should be properly labeled and include produced on and used by dates. All nonperishable items that are removed from their original container or packaging must be labeled with the common name of the item and date opened.

Based on staff interview and record review, the facility failed to provide annual training in fire prevention for regularly scheduled staff members on all shifts to be conducted by the State Fire Marshal or township, municipal or local legally constituted fire department. This potentially could affect all residents. The facility census was 75.

Findings include:

Record review of the annual fire training for staff members revealed no documented evidence of the training with the State Fire Marshal or township, municipal or local legally constituted fire department.

Interview on 05/01/25 at 11:40 A.M. with the Executive Director (ED) #06 verified no training with the State Fire Marshal or township, municipal or local legally constituted fire department and stated they were not aware of the requirement.

Based on medical record review, staff interviews, review of a facility Self-Reported Incident (SRI) investigation, review of video footage, review of a personnel file and policy review, the facility failed to ensure a staff member (Nurse Aide [NA] #900) did not use extensive force when redirecting a resident. This resulted in Actual harm when Resident #76 was being redirected by NA #900 and suffered a laceration to her face and significant bruising to her face, right thigh and both elbows. This affected one (Resident #76) of three residents reviewed who lived on the secured memory care unit. The facility census was 83.

Findings include:

Review of the medical record revealed Resident #76 was admitted to the facility on 04/11/24 with diagnoses of dementia, anxiety, arthritis and hyperlipidemia. The resident resided in the facility's secured memory care unit.

Review of the assessment dated 10/11/24 revealed Resident #76 required minimal assistance with bathing, dressing, toileting, and personal hygiene and was independent for eating, transfers and mobility. The resident had moderate cognitive impairment and was oriented only to person.

Review of Self-Reported Incident dated 12/03/24 revealed on 11/26/24 at approximately 3:45 A.M., Resident #76 is observed on facility video footage to be coming out of her apartment and is greeted by NA #900 who is doing her rounds. Resident #76 is noted to swing at the NA and the NA is observed to grab Resident #76's arms and forces her back into her apartment and closes her door. NA #900 proceeds to the next resident's room. Resident #76 is then observed coming out of her apartment at 3:46 A.M. and walking to the kitchen. When Resident #76 is seen coming out of the kitchen she was observed with a towel and blood on her face. The resident walked back to her apartment. NA #900 then appeared and continued to walk to the staff sitting area. Resident #76 was observed on video to walk the unit for approximately 20 minutes never crossing paths with NA #900. After walking the unit Resident #76 is observed to go to the common area and stay there until 6:04 A.M. when she was observed to walk to her apartment and remain in the apartment until 7:40 A.M. The video footage revealed Housekeeper #705 arrived on the unit at approximately 6:15 A.M. when she finds dried blood on the floor and sink. The dayshift NAs and the housekeeper are greeted in the hallway by Resident #76 where they then discover the resident having blood on her face and clothes. The dayshift nurse was notified and assessed resident. The Nurse Practitioner examined Resident #76 later that morning and found bruising to the right upper thigh, bilateral elbows and right side of the face. The bruising has been slowly fading each day and the wound to her face is healing with no signs or symptoms of infection. Resident #76 has had no reported signs of distress since the incident and it was reported by staff the resident had been smiling and pleasant to staff and other residents which is different from her baseline, but Resident #76 was ordered new medication on 11/12/24 for behaviors. The facility substantiated abuse verified by evidence.

Review of Housekeeper #705's written statement provided by the facility, as part of the Self-Reported Incident (SRI) investigation, revealed on 11/26/24 she went to the secured memory care unit around 6:15 A.M. to 6:20 A.M. to clean the dining room and noticed dried blood on the floor and sink. When NA #500 arrived at the secured memory care unit Housekeeper #705 showed NA #500 the dried blood and shared she overheard NA #900 say everything was good last night except Resident #76 was walking around all night. Housekeeper #705 then saw Resident #76 who had blood near her right eyebrow and a bruise on her right cheek. She also had blood under her chin and on her clothes. There was also blood in the resident's apartment on the bathroom door frame.

Review of NA #500's written statement provided by the facility, as part of the SRI investigation, revealed when NA #900 provided end of shift report, she stated everything was good except Resident #76 was up walking all night. Housekeeper #705 then showed her the blood on the dining room floor. NA #500 and Housekeeper #705 then saw Resident #76 coming out of her apartment and observed the resident had been bleeding from her face. This was reported to the nurse.

Review of a nursing note dated 11/26/24 authored by Licensed Practical Nurse (LPN) #400 revealed Resident #76 appeared in the hallway from her apartment at approximately 7:45 A.M. The resident had a clotted laceration and raised area to the corner of her right eye. The resident could not articulate what happened. Dried blood was found inside the resident's apartment and on the floor in a common dining area.

Review of the Assisted Living and Memory Care Incident Report dated 11/26/24 completed by LPN #400 revealed Resident #76, on 11/26/24 at approximately 7:45 A.M., appeared in the hallway and had a clotted cut and raised area to the corner of her right eye. The resident could not articulate what happened. Dried blood was found inside the resident's apartment and on the floor in the common dining area. A skin assessment on 11/26/24 revealed a laceration to the right temple and bruising to the right side of face. The incident report documented on 11/29/24 bruising was noted to the resident's right thigh and both elbows.

Review of the Family Nurse Practitioner (FNP) #3030's progress note dated 12/03/24 revealed Resident #76 had bruising on the right eye with an abrasion on the right eyebrow and bruising on the right temple, cheek and forehead. Viewing the video footage revealed the resident was wandering the hallways and became aggressive with NA #900. The resident was forcibly redirected into her room and the door was closed by NA #900. The resident came back out of her room very shortly after with bleeding from the laceration on the right eyebrow wound as noted. It is unclear from the video how this injury happened as it is not seen in the video. There is a chance that she hit her right eyebrow when she was blocked from hitting NA #900 and unsure as well it could have happened once door to the apartment was closed. The resident tells me that it doesn't concern you when asked how her injury happened. The laceration of the right eyebrow wound is closed with no signs of infection noted. Neurologically, it is difficult to assess due to resident's behavior and resistance. She is at baseline. This occurred over a week ago. No further action is needed.

Interview on 12/11/24 at 11:35 A.M. with Resident #76 did not reveal any additional information. When the resident was asked about the bruising under her right eye, she responded it happened a long time ago and then told the surveyor to leave pointing to the door.

Interview with the Executive Director and Wellness Director on 12/11/24 at 12:55 P.M. revealed the injury to Resident #76 was initially reported by LPN #400 to the Wellness Director on 11/26/24 at 8:30 A.M. as an unwitnessed fall. It was not until Memory Care Director #150 viewed the video footage on 11/29/24 that the circumstances of what really happened to Resident #76 were known. The Director of Nursing revealed Memory Care Director #150 initially viewed the video footage on 11/26/24 but apparently missed the incident because the video footage skipped, and it wasn't until the video footage was slowed down that the entire incident came to full light and this did not occur until Memory Care Director #150 went back and viewed the video footage again on 11/29/24. The Executive Director and Director of Nursing verified the SRI was not initiated until 12/03/24 because both were on vacation, and they verified the police were notified on 12/03/24 of the incident. The Director of Nursing could not provide an answer why the SRI was reported under an Injury of Unknown Origin and not Abuse.

Attempts were made to contact the police detective assigned to the case on 12/12/24 at 4:48 P.M. and 12/13/24 at 9:19 A.M. but were unsuccessful. On 12/12/24 a detailed message with a call-back number was provided.

Review of the video footage, of which a copy was provided, revealed at 3:45 A.M., Resident #76 was observed coming out of her apartment door and NA #900 who was in the corridor, met her at the door. The resident attempted to strike NA #900 with her right hand and NA #900 was then observed placing her left hand on the resident's right wrist and then moved her left hand to the resident's left wrist turning the resident to face the open door and then NA #900 placed her right hand on the resident's back and shoved the resident forcefully through the doorway of the apartment and into her room. When this happened, the resident dipped down, and it appeared the resident struck the right side of her face on either a shadow box located at the right door frame, with the top of the shadow box approximately five feet off the floor, or the right door frame itself. NA #900 then forcefully closed the resident's apartment door and went into the apartment located directly to the left of Resident#76's room. The resident soon exited her apartment and was seen with blood visibly dripping from the right eyebrow laceration. The blood was dripping down the right side of her face to her chin area.

Interview on 12/11/24 at 1:15 P.M. with Memory Care Director #150 revealed she was assisting Resident #76 with a shower on the morning of 11/29/24 and noted the bruising on the right hip and right elbow had become more pronounced in color. This, along with the previously reported blood drops in the dining room and resident's apartment, and the statement made by NA #900 of Resident #76 being up all-night walking, she decided to view the camera footage of the 11:00 P.M. to 7:00 A.M. shift from 11/25/24 to 11/26/24. Memory Care Director #150 confirmed on 11/29/24 at approximately 10:30 A.M. she viewed the camera footage to see if there might have been something captured on camera. The video footage revealed, at 3:45 A.M., Resident #76 was observed coming out of her apartment door and NA #900, who was in the corridor, met her at the door. The resident attempted to strike NA #900 with her right hand and NA #900 was then observed placing her left hand on the resident's right wrist and then moved her left hand to the resident's left wrist turning the resident to face the open door and then NA #900 placed her right hand on the resident's back and shoved the resident forcefully through the doorway of the apartment and into the room. When this happened, the resident dipped down, and it appeared the resident struck the right side of her face on either a shadow box located at the right door frame or the right door frame itself. After viewing this, Memory Care Director #150 immediately texted the Wellness Director of the incident and then called the Wellness Director to fully describe the incident. The Wellness Director then notified the Executive Director who directed the Assistant Wellness Director to call NA #900 and suspend her immediately pending investigation. NA #900 was suspended on 11/29/24 at 11:58 A.M.

Review of payroll records revealed NA #900 was allowed to work on 11/26/24 from 11:00 P.M. through 7:00 A.M.

Review of NA #900's personnel record revealed the NA was terminated on 12/05/24. The termination read the employee was aggressive toward a resident and caused an injury. After conclusion of an investigation and submission of a SRI to ODH, it was determined that the staff member was abusive to the resident.

Telephone interview on 12/11/24 at 4:34 P.M. with NA #900 revealed Resident #76 attempted to strike her and she just put her hands up to block the resident. NA #900 denied touching the resident, laying hands on the resident or shoving the resident back into her room and closing the door. NA #900 said she just turned and walked away but did admit to seeing the resident sitting in a common area with a television and said she did not see any bleeding from the resident's face.

Interview on 12/11/24 at 4:23 P.M. with the Wellness Director revealed on 12/11/24, Resident #76's bruises measured as follows: right hip/posterior thigh is 4.5 inches long by 2.5 inches wide and red in color; bilateral elbows reveal no bruising; right eyebrow laceration is healed; and bruise under right eye measured 1.25 inches long by 0.25 inches wide.

Review of the facility policy titled, Prevention of Abuse, Neglect and Misappropriation, dated 06/25/19, revealed the company will not tolerate any abuse, neglect or exploitation that would include the misappropriation of resident property. Also, the company supports each resident's right to support individual decision making and freedom from coercion and restraints. Any employee who engages in any of these actions towards a resident will be subject to discipline, up to and including dismissal from employment. The company also is required to report allegations of abuse, neglect or misappropriation to the Ohio Department of Health (ODH) and the local law enforcement, as required by law or rules. The ODH gateway is used to report the alleged abuse, neglect or misappropriation with the best practice of reporting within five business days of the allegation.

This deficiency represents non-compliance from a Self-Reported Incident Investigation, Control Number OH00160551.