Enclave of Newell Creek The

Based on record review, interview and review of the facility policy, the facility failed to reasonably prevent resident falls. This affected one resident (#7) of three residents reviewed for falls. Facility census was 108. Findings include: Review of Resident #7's medical record revealed an admission date of 02/24/25 and diagnoses including lupus, hypertension, neuropathy, overactive bladder, chronic kidney disease and chronic pain. Review of Resident #7's Ohio Health and Service Assessment dated 05/01/25 revealed Resident #7 had a Saint Louis Mental Status Examination (SLUMS) score of 22, indicative of mild cognitive disorder. Resident #7 required moderate one-person assistance for transfers and utilized grab bars. Resident #7 also required extensive hands-on assistance with bathing and utilized a shower chair, grab bar and hand-held shower. Review of Resident #7's resident care flow sheet for August 2025 revealed she required the complete assistance of one staff for bathing every Monday and Thursday on second shift. Review of an incident report dated 08/16/25 at 9:40 A.M. and a progress note dated 08/16/25 at 11:29 A.M. revealed the following information: Caregiver (not specified) alerted this nurse to Resident #7's apartment. Upon entering apartment, Resident #7 was noted to be face down on her bathroom floor laying on her right arm, nude. Shower was running. Resident was incontinent of stool on the wheelchair, shower chair, toilet seat and herself. Resident #7 has chronic pain in her right shoulder and denies any new pain. Resident #7 was cleaned up and assisted off the floor via three staff members (not identified). Head to toe assessment completed. Resident #7 stated that the caregiver placed her in the shower and then left to go get someone else some food. Caregiver came into apartment while this nurse and Director of Wellness (DOW) #207 were in Resident #7's apartment and was educated that they cannot leave Resident #7 unsupervised in the shower alone. Notifications to nurse practitioner and power of attorney made. Resident #7 refused to go to the emergency room. The incident report contained vitals and reported no injuries as a result of the fall but did not identify the caregiver involved with Resident #7's fall. Interview on 02/13/26 at 9:01 A.M. with Resident #7 revealed she had many falls during the close to a year she had been at the facility. Resident #7 recalled she fell (no date shared) because she was in the shower and the caregiver (could not recall a name or description) did not stay with her as she had to go to someone else and then she lost her balance and fell. Resident #7 stated the entire time she had been at the facility she had had one person assist her with showering and washing her body. Interview on 02/13/26 at 1:21 P.M. with DOW #207 recalled helping with the fall on 08/16/25 and stated a caregiver who she could not recall and whose name was not on the incident report had assisted with Resident #7 then left to give another resident (not identified) breakfast. When the caregiver came back, Resident #7 had fallen in her shower onto the floor. During a follow-up interview on 02/13/26 at 2:45 P.M. DOW #207 was asked to elaborate on what complete assistance for bathing entailed per Resident #7's resident care flow sheet (service plan) and stated staff would assist the resident into the shower, help wash their body and their hair and help them get out of the shower once completed. DOW #207 verified staff should not leave during the resident's shower as had occurred on 08/16/25 and resulted in Resident #7's fall as this did not follow the facility's expectations. Review of the facility policy, Activities of Daily LivingBased on record review, interview and review of the facility policy, the facility failed to reasonably prevent resident falls. This affected one resident (#7) of three residents reviewed for falls. Facility census was 108.

Findings include:

Review of Resident #7's medical record revealed an admission date of 02/24/25 and diagnoses including lupus, hypertension, neuropathy, overactive bladder, chronic kidney disease and chronic pain.

Review of Resident #7's Ohio Health and Service Assessment dated 05/01/25 revealed Resident #7 had a Saint Louis Mental Status Examination (SLUMS) score of 22, indicative of mild cognitive disorder. Resident #7 required moderate one-person assistance for transfers and utilized grab bars. Resident #7 also required extensive hands-on assistance with bathing and utilized a shower chair, grab bar and hand-held shower.

Review of Resident #7's resident care flow sheet for August 2025 revealed she required the complete assistance of one staff for bathing every Monday and Thursday on second shift.

Review of an incident report dated 08/16/25 at 9:40 A.M. and a progress note dated 08/16/25 at 11:29 A.M. revealed the following information: Caregiver (not specified) alerted this nurse to Resident #7's apartment. Upon entering apartment, Resident #7 was noted to be face down on her bathroom floor laying on her right arm, nude. Shower was running. Resident was incontinent of stool on the wheelchair, shower chair, toilet seat and herself. Resident #7 has chronic pain in her right shoulder and denies any new pain. Resident #7 was cleaned up and assisted off the floor via three staff members (not identified). Head to toe assessment completed. Resident #7 stated that the caregiver placed her in the shower and then left to go get someone else some food. Caregiver came into apartment while this nurse and Director of Wellness (DOW) #207 were in Resident #7's apartment and was educated that they cannot leave Resident #7 unsupervised in the shower alone. Notifications to nurse practitioner and power of attorney made. Resident #7 refused to go to the emergency room. The incident report contained vitals and reported no injuries as a result of the fall but did not identify the caregiver involved with Resident #7's fall.

Interview on 02/13/26 at 9:01 A.M. with Resident #7 revealed she had many falls during the close to a year she had been at the facility. Resident #7 recalled she fell (no date shared) because she was in the shower and the caregiver (could not recall a name or description) did not stay with her as she had to go to someone else and then she lost her balance and fell. Resident #7 stated the entire time she had been at the facility she had had one person assist her with showering and washing her body.

Interview on 02/13/26 at 1:21 P.M. with DOW #207 recalled helping with the fall on 08/16/25 and stated a caregiver who she could not recall and whose name was not on the incident report had assisted with Resident #7 then left to give another resident (not identified) breakfast. When the caregiver came back, Resident #7 had fallen in her shower onto the floor.

During a follow-up interview on 02/13/26 at 2:45 P.M. DOW #207 was asked to elaborate on what complete assistance for bathing entailed per Resident #7's resident care flow sheet (service plan) and stated staff would assist the resident into the shower, help wash their body and their hair and help them get out of the shower once completed. DOW #207 verified staff should not leave during the resident's shower as had occurred on 08/16/25 and resulted in Resident #7's fall as this did not follow the facility's expectations.

Review of the facility policy, Activities of Daily Living

Based on record review, observation, and staff interviews, the facility failed to ensure specific isolation precautions were identified for one, (#17) of one identified as being in isolation. The total facility census was 105.

Findings include:

Review of Resident #17's medical record admission 04/24/24 with diagnosis of anemia, muscle weakness, and dehydration.

Review of the progress note dated 02/21/25 at 4:44 A.M. revealed Resident #17 was sent to the hospital for shortness of breath and increased heart rate. The resident was diagnosed with Influenza A and was returned to the facility with new orders and for staff to follow airborne precautions while caring for the resident.

Interview and observation with Licensed Practical Nurse (LPN) # 88 on 02/25/25 at approximately 8:45 A.M. in front of Resident #17's room where there was an isolation be with Personal Protective Equipment (PPE) stored for use with a resident in isolation. There was no observed signage on the door or on the bin to indicate what PPE was required to enter the room of Resident #17. LPN # 88 confirmed there was no signage to indicate the resident was in isolation for airborne transmission precautions and no signage indicating what PPE was required to enter the room.

Tour of the facility on 02/25/25 at approximately 9:30 A.M. with Director of Maintenance # 30 revealed there was a clear stackable isolation bin in front of Resident #17's room. Director of Maintenance #30 stated he was not sure what the protocol for isolation or infection control was except for SARs-CoV-2 (COVID-19).

Interview with Assistant Executive Director #25 on 02/25/25 at approximately 1:21 P.M. revealed the facility had no protocol to track residents who were in isolation or to indicate they type of isolation the resident required or the length of the isolation.

Policy review on 02/25/25 at 2:20 P.M. titled Infection Control, Communicable Diseases revised date 01/25 stated that all Department Managers will be notified when there is a resident that has a communicable disease.

Based on observation, interview, and facility policy review, the facility failed to store food in a manner that protects it against spoilage and contamination. This had the potential to affect all 105 residents. The census was 105.

Findings include:

Tour of the kitchen on 02/25/25 at 11:26 A.M. with Dietary Manager # 41 revealed a large undated clear container of mixed fruit in the refrigerator. The freezer contained a large opened undated, plastic bag with 10 frozen pieces of seasoned bread, and an opened undated plastic bag with approximately 26 frozen meat patties. Interview with Dietary Manager #41 on 02/25/25 at the time of the observation confirmed the food items were undated and not stored correctly.

Review of policy titled Food Supply and Storage Procedure revised on 07/21 stated unused products will be labeled, covered, and dated.

Based on observations, interviews, and policy review the facility failed to provide and maintain a clean and sanitary kitchen. This affected 105 residents in the facility.

Findings include:

The tour of the kitchen on 02/25/25 at 11:45 A.M. with Dietary Manager #41 revealed that sanitation strips were not available and no indication when the strips were used last. The Dietary Manager # 41 was unable to determine how long the sanitation solution had been on the counter.

The interview with the Dietary manager #41 on 02/25/25 at approximately 1:30 P.M. determined that there was some test strips wet in a plastic bag found that were unusable.

Review of the policy on 02/25/25 at 2:00 P.M. revised 07/21 Sanitation food Contact Policy states that the sanitation bucket must be replaced and tested every two hours and retest for the proper parts per million indicated on the test strip per manufactures guideline.

Based on observation, record review and staff interviews, the facility failed to store hazardous materials in a secured manner to ensure resident safety. This had the potential to affect 29 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #34) who lived on the memory care unit who the facility identified as independently mobile and cognitively impaired. The memory care unit census was 41. The total facility census was 105.

Findings include:

Observation with Licensed Practical Nurse (LPN) # 34 on 02/25/25 at approximately 8:45 A.M. in Resident # 34 room revealed an aerosol can of Lysol Disinfectant Spray on the bathroom counter with the cap off. LPN # 34 took the aerosol out of the resident's room and placed it in nurse's station. Interview with LPN #34 during the observation it was verified that hazardous chemicals should be stored in a locked room.

Observation during medication pass observation on 02/25/25 at approximately 9:00 A.M. revealed Licensed Practical Nurse (LPN) #34 left her scissors unattended on top of the medication cart when she was passing medications in two separate resident rooms. During an interview with the LPN at the time of the observation LPN #34 verified that the scissors are to be locked up when not in use and are not to be left unattended on top of the medication cart.

Tour of Resident 68's rooms with Care Giver # 95 on 02/25/25 at 9:20 A.M. revealed glass cleaner, Glade Air Spray and Aerosol body spray in Resident #68's opened closet. The items were removed by Care Giver #95 and locked in the nurse's station after the observation.

Review of Safety Data Sheets provided by the facility revealed that the window cleaner and Lysol disinfectant spray are considered hazardous and to maintain appropriate storage.

Interview with Maintenance Director #12 on 02/25/25 at 12:25 P.M. indicated the facility had no additional Safety Data Sheets for the Glade Air spray or the Aerosol body spray.

Based on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure medications were given according to physician orders. This affected one resident (#38) of one reviewed for medication administration. The facility census was 107.

Findings include:

Review of the medical record for Resident #38 revealed he was admitted to the facility on 02/28/23 with diagnoses that included lung cancer, hypertension, and heart disease.

Review of Resident #38 service plan dated 09/17/24 revealed he was alert and oriented to person, place, and time. Review of the service plan revealed Resident #38 required medication administration by a certified medication technician or licensed nurse. Further review of the service plan revealed Resident #89 had a history of wandering and required assistance from staff for activities of daily living (ADL).

Review of the physician orders dated 06/28/24 at 4:14 P.M. revealed Resident #38 had severe itching all over despite Benadryl being given twice. Resident #38 received a new order for prednisone and to increase Benadryl.

Review of the progress note dated 09/18/24 at 11:40 A.M. revealed Resident #38 was on antibiotics for skin issues and remained on a steroid.

Review of the progress note dated 09/20/24 at 1:20 P.M. revealed Resident #38 continued steroids for itching and had less complaints of itching.

Review of the physician orders dated 10/23/24 revealed an order for Banophen (Benadryl) 25 milligram (mg) (antihistamine) capsule to be given two capsules by mouth every four hours as needed for itching.

Observation on 12/31/24 at 12:04 P.M., located on the memory care unit, revealed Resident #38 sitting in a chair in the hallway. Resident #38 was observed scratching his arms, legs, neck, and torso. Resident #38 was observed holding a small white pill bottle while he was putting a small tablet into his mouth before closing the bottle and placing it into his right coat pocket.

Interview on 12/31/24 at 12:04 P.M. with Resident #38 revealed he was itching all over. Resident #38 revealed, after inquiry by the state surveyor, that he had a small bottle of acetaminophen that his son provided to help with his itching. Resident #38 refused to provide state surveyor observation of the bottle of pills.

Observation and interview on 12/31/24 at 12:06 P.M. with Licensed Practical Nurse (LPN) #821 and Medication Technician (MT) #836 revealed Resident #38 was alert and oriented and after being assessed for medication administration, he was unable to self-medicate. Observation with LPN #821 and MT #836 revealed Resident #38 still remained sitting in a chair in the hallway with complaints of itching all over. LPN #821 requested to see the mediations located in Resident #38 pocket, and Resident #38 withdrew the bottle of pills and handed them to LPN #821. Resident #38 informed LPN #821 that he had the pills in his pocket due to his itching, and they were provided by his son.

Observation of the bottle of pills located on Resident #38 revealed a small white bottle with pink labeling with the words Meijer Multi-Symptom Allergy Tablets with diphenhydramine and antihistamine. Observation revealed the bottle had already been opened.

Review of the physician orders revealed Resident #38 had no orders for Meijer Multi-Symptom Allergy Tablets or any over the counter (OTC) allergy medications and/or medications related to his itching.

Interview on 12/31/24 at 12:15 P.M. with LPN #821 confirmed and verified Resident #38 was not to self-administer medications and he did not have a physician order to take OTC Meijer Multi-Symptom Allergy Tablets. LPN #821 revealed she was not aware that Resident #38 son provided him with the bottle of pills.

Review of the facility document titled Medication Assistance Procedures

Based on resident record reviews, staff interviews, review of the incident log, review of the Self-Reported Incident (SRI), review of the facility investigation, and facility policy review, the facility failed prevent an incident of resident-to-resident sexual abuse and failed to ensure a complete investigation was completed after an incident of resident-to-resident sexual abuse was substantiated. This affected two residents (#20 and #89) of four reviewed for abuse, but had the potential to affect all forty-three residents (#2, #9, #10, #12, #16, #17, #22, #24, #30, #32, #34, #35, #36, #37, #38, #42, #43, #45, #50, #51, #52, #54, #55, #56, #57, #60, #61, #64, #69, #70, #72, #76, #77, #79, #84, #86, #88, #94, #95, #97, #98, #107, and #109) located on the memory care unit. The facility census was 107.

Findings include:

1. Review of the medical record for Resident #89 revealed she was admitted to the facility on 09/21/19 with diagnoses that included Alzheimer's disease, hypertension, and depression.

Review of Resident #89's service plan dated 10/30/24 revealed she required memory care, was alert and oriented with cognitive impairment and required frequent supervision. Review of the service plan revealed Resident #89 had a history of wandering and required assistance from staff for activities of daily living (ADL).

Review of the progress note, dated 12/05/24 at 2:32 P.M., located in Resident #89's medical record revealed a memory care caregiver (MCC) entered Resident #89's apartment around 8:15 A.M. and observed Resident #20 in bed with Resident #89. Resident #89 was dressed in a night shirt and brief. Resident #20 was fully clothed, had her legs wrapped around Resident #89, had her hand inside Resident #89 brief and was moving her hand around inside the brief. The MCC called for help to remove Resident #20 from Resident #89's apartment due to Resident #20's increased aggression and agitation since admission to the community. A staff nurse (SN) came with two MCCs to assist. Resident #89 was assessed and found to be without any complaints of pain, signs and symptoms of vaginal or any type of injury. Resident #89 was unable to give a description of the incident due to cognitive impairment. The Ohio Department of Health (ODH), Resident #89's family, and physician were notified of the incident.

Review of the progress note, dated 12/06/24 at 4:23 P.M., located in Resident #89 medical record revealed she displayed no behaviors, was watching television in the common area, and had meals in the dining room.

Review of the progress note dated 12/07/24 at 11:55 A.M., 12/08/24 at 8:38 P.M., and 12/09/24 at 8:19 P.M., located in Resident #89 medial record revealed she showed no change in behaviors or emotional distress.

2. Review of the medical record for Resident #20 revealed she was admitted to the facility on 11/30/24 with diagnoses that included dementia, dysuria, and arthritis.

Review of Resident #20 service plan dated 11/14/24 revealed she required memory care, was alert and oriented with cognitive impairment and required frequent supervision. Review of the service plan revealed Resident #20 had a history of wandering and required assistance from staff for ADL.

Review of the progress note, dated 12/04/24 at 2:08 P.M., located in Resident #20 medical record revealed she was alert and ambulating throughout the community in other resident rooms, difficult to redirect at times, and unable to sit still for any length of time.

Review of the progress note, dated 12/05/24 at 9:50 A.M., located in Resident #20 medical record revealed she had extreme aggression and combative behaviors with staff and other residents, difficult to redirect, and in other resident rooms.

Review of the progress note, dated 12/05/24 at 10:04 A.M., located in Resident #20's medical record revealed she was sent out to the emergency room for evaluation and treatment due to increased behaviors and aggression. Resident #20 was provided transportation via Resident #20's daughter's personal vehicle.

Review of the progress note, dated 12/05/24 at 1:08 P.M., located in Resident #20's medical record revealed a MCC entered Resident #89 apartment around 8:15 A.M. and observed Resident #20 in bed with Resident #89. Resident #89 was dressed in a night shirt and brief. Resident #20 was fully clothed, had her legs wrapped around Resident #89, had her hand inside Resident #89 brief and was moving her hand around inside the brief. The MCC called for help to remove Resident #20 from Resident #89's apartment due to Resident #20's increased aggression and agitation since admission to the community. A SN came with two MCCs to assist. Resident #20 became combative when attempting to remove her from Resident #89's apartment but was successfully removed without harm. Resident #20's physician and family were notified, and Resident #20 was transported to a local hospital for evaluation due to increased behavioral disturbances.

Review of the progress note, dated 12/10/24 at 2:55 P.M., located in Resident #20's medical record revealed she displayed typical behaviors such as wandering in other resident rooms but was easily redirected.

Review of the progress note, dated 12/11/24 at 1:43 A.M., located in Resident #20's medical record revealed she was observed in another resident's room trying to urinate on clothes.

Review of the progress note, dated 12/11/24 at 11:29 A.M., located in Resident #20's medical record revealed she was attempting to go in other resident rooms.

Review of the progress note, dated 12/12/24 at 1:36 P.M., located in Resident #20's medical record revealed she was in another resident room in her bra and brief and was able to be redirected. Resident #20 continued to try to open other resident's doors to enter their rooms.

Review of the progress notes dated 12/12/24 at 3:30 P.M., 12/13/24 at 4:15 A.M., 12/13/24 at 5:34 A.M., 12/27/24 at 1:32 P.M., 12/28/24 at 3:07 P.M., and 12/28/24 at 11:00 P.M., located in Resident #20's medical record revealed she continued to wander inside other resident rooms.

Review of the incident log dated 10/01/24 to 12/30/24 revealed Resident #20 and Resident #89 had an incident on 12/05/24, that resulted in both residents being assessed for injuries and Resident #20 being transferred to the hospital for assessment. Review of the log revealed neither resident sustained injuries.

Review of the investigation completed by the facility reported on 12/05/24 at 8:15 A.M. revealed MCC #841 prepared to get Resident #89 up for morning care when she observed Resident #20 in bed with Resident #89. Resident #89 was observed in bed dressed in a night shirt and brief. Resident #20 was observed to be fully clothed with her legs wrapped around Resident #89 with her hand inside Resident #89 brief while moving her hand around inside the brief. MCC #841 called for help to remove Resident #20 from Resident #89's apartment due to Resident #20's increased aggression and agitation since admitting to the facility. Resident #20 became combative during removal from Resident's #89 apartment by Wellness Nurse (WN) #827 and MCC's #840 and #860. Resident #20 was removed without harm. Resident #89 was assessed by WN #827 with no complaint of pain or signs or symptoms of vaginal or any other type of injury. Resident #89 was unable to give a description of the incident due to cognitive impairment.

Review of the facility investigation revealed on 12/05/24 MCC #841 was completing rounds at approximately 8:15 A.M. when she entered Resident #89's room and saw an extra person in bed. MCC #841 revealed she stepped forward and saw Resident #20 with her legs wrapped around Resident #89 with her hands in Resident #89's brief. MCC #841 revealed she saw Resident #20 hand moving around inside Resident #89's brief. MCC #841 revealed she called for help and MCC's #840, #860 and WN #827 came to assist. MCC #841 revealed Resident #20 fought and yelled the entire time during the attempt to remove her from Resident #89's room. MCC #841 revealed she spent the rest of the morning trying to deescalate Resident #20 until Resident #20's daughter arrived to deescalate her.

Review of the facility investigation revealed on 12/05/24 at approximately 8:00 A.M. MCC #860 and MCC #840 heard Resident #89 yelling for help and at that time checked on her with Resident #89 stating she was okay and observed no other person in the room with her at that time. MCC #860 revealed, at approximately 8:15 A.M., MCC #841 called for help. MCC #860 revealed when she entered the apartment, both Resident #20 and #89 were in bed and Resident #20 legs were over Resident #89 legs. MCC #860 revealed WN #827 assisted with getting Resident #20 out of bed and Resident #89's apartment. MCC #860 revealed Resident #20 was upset that she had to leave and as a result, the doors had to be locked, and she had to stay with Resident #20 until her daughter arrived.

Review of the facility investigation revealed on 12/05/24 at approximately 8:15 A.M., WN #827 was called to Resident #89's apartment. Upon entering, WN #827 observed Resident #89 with her shirt and no pants on, with Resident #20 in Resident #89 bed with her clothes on. WN #827 attempted with the help of MCC's #840, #841, and #860 to remove Resident #20 from Resident #89's apartment, but Resident #20 became aggressive while yelling and resisting. WN #827 revealed once Resident #20 was outside of Resident #89's apartment door, Resident #89 door was locked because Resident #20 continued efforts to reenter Resident #89's apartment. WN #827 and MCC's #840, #841, and #860 redirected Resident #20 to her own apartment. WN #827 assessed Resident #89 and found no signs and/or symptoms of injury with no complaints of pain. WN #827 and MCC's #840, #841, and #860 continued to redirect Resident #20 until Resident #20's daughter arrived. Resident #20 was subsequently sent to the hospital for evaluation.

Review of the facility investigation revealed no other information or documentation. Review of the facility investigation revealed no other staff were interviewed and no other residents were interviewed and/or assessed or received skin checks. Review of the facility investigation revealed Resident #20 continued to display aggression, combativeness, and enter other resident rooms.

Both Resident #20 and Resident #89 remained in the facility.

Interview on 12/31/24 at 9:04 A.M. with the Director of Wellness (DOW) #905 revealed Resident #20 was a new admission located on the memory care unit. DOW #905 revealed Resident #20 climbed in bed with Resident #89 and had her hands down in her pants. DOW #905 revealed Resident #20 was transported out of the facility to a geropsychiatric hospital. DOW #905 revealed Resident #89 was assessed with no injuries, adverse reactions or behaviors. DOW #905 revealed the facility initiated a full and complete investigation that included interviewing only staff and residents named in the incident.

Interview on 12/31/24 at 12:06 P.M. Licensed Practical Nurse (LPN) #821 revealed Resident #20 was newly admitted and had to be kept in the open due to her behaviors. LPN #821 revealed Resident #20 wandered in and out of other resident rooms, combative when being redirected, and required more assistance than what the facility could manage. LPN #821 revealed she was not aware of any other staff interviewed outside of those present at the time of the incident and no other residents were assessed regarding the incident.

Interview on 12/31/24 at 1:28 P.M. with LPN #827, identified as the nurse present during the incident, was attempted via phone. However, LPN #827 was unable to be reached, and her voicemail inbox was full, and no message was able to be left.

Interview on 12/31/24 at 1:29 P.M. with MCC #841, identified as the MCC present during the incident, revealed he no longer worked at the facility, but he recalled the incident in question. MCC #841 declined to continue interview with state surveyor and stated have a good day before hanging up the call abruptly.

Interview on 12/31/24 at 2:02 P.M. with MCC #840, identified as being present during the incident, revealed approximately 15 minutes prior to the incident, Resident #89 was lying in bed yelling for help but did not recall her immediate need. MCC #840 revealed, at that time, no other resident was present in her room. MCC #840 revealed she left Resident #89's room and continued to make rounds when MCC #841 yelled out for help because he observed Resident #20 in bed with Resident #89. MCC #841 revealed she did not witness the incident. MCC #840 revealed Resident #20 wandered in and out of other resident rooms before and after the incident.

Follow-up interview on 12/31/24 at 2:30 P.M. with DOW #905 confirmed and verified no other residents located on the memory care unit were interviewed or assessed despite Resident #20 having behaviors that included repeatedly entering other resident rooms. DOW #905 also revealed no other staff were interviewed as it related to the allegation of abuse.

Review of the facility document titled Abuse, Neglect and Exploitation revised September 2023, revealed the facility had a policy in place that defined sexual abuse as sexual harassment, sexual coercion, and sexual assault including fondling, unwanted sexual touching, forcing a victim to perform sexual acts, such as oral sex or penetration. Review of the policy revealed the facility would ensure safety by initiating an investigation promptly and confidentially via private interviews with residents, staff and witnesses. Review of the document revealed the facility did not implement the policy regarding the allegation.

This violation represents non-compliance investigated under Self-Reported Incident, Control Number OH00160477.

Based on observation, resident interviews, staff interviews, and review of the weekly menus and resident council meeting minutes, the facility failed to ensure concerns were timely investigated with reasonable resolution. This had the potential to affect all residents that resided in the facility. The facility census was 107.

Findings include:

Interview on 12/31/24 at 9:15 A.M. with Resident #91 was seated in the main dining room for the breakfast meal. Resident #91 revealed the food provided by the facility was not good, was sometimes old leftovers, not well prepared, and lacked variety of choices. Resident #91 revealed all the meals were recycled from leftovers. Resident #91 revealed residents had voiced their concerns to management during resident council meetings.

Interview on 12/31/24 at 9:20 A.M. with Resident #90 revealed the meal menus were terrible, awful, not edible, and had no variety. Resident #90 revealed the facility served pork, chicken and pasta in the same three-day rotation. Resident #90 revealed the facility lacked combinations of meals. Resident #90 revealed the facility was aware of the concerns with the kitchen.

Interview on 12/31/24 at 2:21 P.M. with Resident #13 revealed the biggest complaint he had with the facility was the food. Resident #13 revealed he felt sorry for the residents that had to eat all three meals from the facility daily. Resident #13 revealed the facility had gone through multiple cooks, the same food was served every third day, daily soup was from the previous day's leftovers, and nothing served was fresh. Resident #13 revealed the Executive Director was aware of all concerns regarding the kitchen and it was documented in resident council meetings.

Review of the weekly menu dated 12/29/24 through 01/04/25 revealed the breakfast meal was made to order daily with a variety of choices that included egg of choice, hot or cold cereal, hash browns, sausage links, bacon, fresh fruit, banana, 100 percent (%) juice, toast of choice and options that ranged from breakfast casseroles, mini Danishes, variable flavors of muffins, pancakes, French toast and gravy and biscuits.

Further review of the menu revealed for the lunch and dinner meals there were different variations of potatoes daily that ranged from roasted sweet potatoes, mashed potatoes with option of gravy, baked potatoes, tater tots, French fries, roasted red potatoes, sweet potatoes fries, potato salad, potato chips, and herb roasted potatoes. Review of the menu revealed also revealed there were only variations of chicken, pork, and ham served daily with two out of seven days, a choice of cod or beef was offered. Review of the weekly menu revealed little to no variations regarding meals.

Review of the resident council meeting minutes dated 09/11/24 revealed concerns regarding cold food.

Review of the resident council meeting minutes dated 10/04/24 revealed concerns regarding too many noodles and starches as food choices.

Review of the resident council meeting minutes dated 12/09/24 revealed concerns regarding too many sandwiches, chicken and pasta and too much salt in food.

Review of the resident council meeting minutes and the weekly menus revealed concerns regarding the kitchen meals were voiced during resident council meetings dated from September 2024 through December 2024, but no changes had been made to honor the request and preferences of the residents.

Interview on 12/31/24 at 11:50 A.M. with Kitchen Manager (KM) #803 revealed he had worked in the facility for the last three weeks. KM #803 appeared visibly frustrated. KM #803 revealed the residents complained all day long about the meals produced in the kitchen. KM #803 revealed he followed the recipes from the menus produced by Grove Menus. KM #803 revealed he was not aware of any overcooked or undercooked food, but he had also not attended any resident council meetings or food committee meetings. KM #803 revealed all meals were made to order unless cooked in bulk to ensure all meals were served hot. KM #803 revealed he taste-tested the food frequently to ensure palatability. KM #803 revealed the menus produced by the facility were a mess, jacked up