Artis Senior Living of Mason

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly label insulin vials with an open date and an expiration date. This affected one (Resident #2) of two facility-identified residents with orders for insulin. The facility census was 33 residents.

Findings include:

Review of the medical record for Resident #2 revealed an admission date of 12/07/22 with diagnoses including dementia and diabetes mellitus.

Review of the functional assessment for Resident #2 dated 12/23/24 revealed the resident had impaired cognition and required medication administration by a licensed nurse.

Review of the physician's orders for Resident #2 dated February 2025 revealed an order for insulin three times a day with meals per sliding scale and 24 unit of insulin at bedtime.

Observation on 02/12/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #19 revealed Resident #2's insulin vial was opened but was not labeled with the open date and the expiration date.

Interview on 02/12/25 at 11:30 A.M. with LPN #19 confirmed Resident #2's insulin vial should have been labeled with an open date and an expiration date.

Review of the facility policy titled Medication Storage and Administration dated April 2024 revealed unopened insulin pens and vials should be stored in the refrigerator until opened. Upon opening, insulin pens and vials should be labeled with date opened and the expiration date.

Based on medical record review, review of spreadsheets, observation, staff interview, and review of the facility policy, the facility failed to serve mechanical soft food portions as planned by the Registered Dietitian (RD). This affected six residents, (Residents #3, #4, #30, #31, #32, and #29) of six facility-identified residents with orders for mechanical soft diets. The facility census was 33 residents.

Findings include:

Review of physician's orders dated February 2025 for Residents #3, #4, #30, #31, #32, and #29 revealed orders for mechanical soft diets.

Review of the lunch menu spreadsheet dated 02/11/25 revealed residents on mechanical soft diets should receive three ounces of mechanical soft meat, two slices of bread, four ounces of rice, and four ounces of vegetable.

Observation on 02/11/25 at 11:52 A.M. revealed Caregiver (CG) #18 served Residents #3, and #4 a lunch meal that consisted of no bread, an unknown amount of mechanical soft meat from an unlabeled tablespoon, and two- and one-half ounces of rice.

Observation on 02/11/25 at 12:15 P.M. revealed CG #4 served Residents #30, #31, #32, and #29 a lunch meal that consisted of one roll, an unknown amount of mechanical soft meat from an unlabeled tablespoon, and two- and one-half ounces of rice.

Interview on 02/11/25 at 11:52 A.M. with CG #18 confirmed she had no menu to know what the food portions were for the lunch meal. She stated she took the scoops from the unit drawer and used what she thought was the correct portion for the food at each meal.

Interview on 02/11/25 at 12:15 P.M. CG #4 revealed she didn't know what food portions were supposed to be served for the lunch meal and she decided what scoop sizes to use based on what looked right to her.

Interview on 02/11/25 at 12:20 P.M. with Dietary Manger (DM) #56 confirmed there was no menu provided to CG #4 and #18 to know what portion size utensils to use when serving the lunch meal. DM #56 verified there was no bread sent to the units for the CG #4 and #18 to serve. DM #56 stated the foods should be prepared and served as listed on the menu and the foods served were less than listed on the planned menu.

Review of facility policy titled Portion Control undated revealed foods should be served according to the menu guide. The serving utensils used for portion control would be maintained in the kitchen and delivered to each house kitchen at mealtime. The Caregivers would portion out the food items to the residents.

Review of the facility policy titled Meal Delivery revealed serving utensils were selected by the chef based on the planned menu and a daily menu was delivered to the unit on each meal cart. The Caregivers should serve residents the correct portion of food according to the menu.

Based on record review, staff interview, and review of the facility policy, the facility failed to conduct fire drills on all shifts at varied times, failed to conduct fire drills so each shift had a drill every third month, and failed to verify fire alarm signals were transmitted and received within the allotted time following the fire drill. This had the potential to affect all the residents residing in the facility. The facility census was 33 residents.

Findings include:

Review of the facility fire drill records revealed the following drills were conducted on the first shift: 04/30/24 at 9:47 A.M., 09/26/24 at 11:10 A.M., 11/21/24 at 12:25 P.M. The following fire drills were conducted on the second shift: 02/28/24 at 3:40 P.M., 5/23/24 at 5:30 P.M., 07/31/24 at 3:38 P.M., 10/29/24 at 6:35 P.M., 01/30/25 at 10:00 P.M. The following drills were conducted on the third shift: 03/28/24 at 6:05 A.M., 06/26/24 at 6:15 A.M., 08/27/24 at 5:50 A.M., 12/11/24 at 6:00 A.M. Further review of the fire drill records revealed there was no record of signal transmission received for the drills conducted on 02/28/24, 08/27/24, and 10/29/24.

Interview on 02/11/24 at 9:00 A.M. with Director of Environmental Services (DES) #33 confirmed the facility had not conducted fire drills at varying times on third shift, had not conducted fire drills every third month for each shift and there was no record of fire alarm signal transmission for the drills conducted on 02/28/24, 08/27/24, and 10/29/24.

Review of the facility policy titled Fire and Emergency Drills revealed fire drills should be conducted monthly with each shift participating in a fire drill four times per year.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the water temperature residents' rooms was maintained in an appropriate range. This affected five (Residents #17, #57, #26, #25, and #28) of five residents observed for water temperatures. The facility census was 33 residents.

Findings include:

Observation on 02/12/25 at 9:45 A.M. with the Director of Environmental Services (DES) #33 revealed the following water temperatures in resident rooms: Resident #17's room at 124.0 degrees Fahrenheit (F), Resident #57's room at 132.0 degrees F, Resident #26's room at 124.8 degrees F, Resident #25's room at 132.4 degrees F., Resident #28's room at 130.2 degrees F.

Interview on 12/09/24 at 9:50 A.M with DES #33 confirmed the water temperatures in Resident #17, #57, #26, #25, and #28's rooms were too high and should be adjusted down.

Review of the facility policy titled Hot Water Temperatures revealed the water temperature in outlets accessible by residents should be maintained between 95-120 degrees F.

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure potentially hazardous chemicals were properly secured. This had the potential to affect all of the residents in the facility. The facility census was 33 residents.

Findings include:

Observation on 02/11/25 at 8:30 A.M. revealed there was a shampoo bottle labeled to keep out of reach of children in the common shower area of the Pine Hill wing. Further observation revealed there was a bottle of isopropyl alcohol and bottles of nail polish in an unlocked cabinet of the pantry to the Pine Hill wing.

Interview on 02/11/25 at 8:30 A.M. with Director of Environmental Services (DES) #33 confirmed there was a bottle shampoo bottle in the common shower area of the Pine Hill wing and there was a bottle of alcohol and bottles of nail polish in the unlocked pantry cabinet of the Pine Hill wing. DES #33 further confirmed the items found in the Pine Hill wing shower and pantry cabinet should be locked/secured for resident safety.

Observation on 02/11/25 at 8:35 A.M. revealed there was a shampoo bottle and a conditioner bottle both labeled to keep out of reach of children in the common shower area of the Main Street wing.

Interview on 02/11/25 at 8:35 A.M. with DES #33 confirmed there was a bottle of shampoo and a bottled of conditioner in the common shower area of the Main Street wing and these items should be locked/secured for resident safety.

Review of the facility policy titled Hazardous Material Storage and Handling revealed that personnel should follow all safety guidelines per the manufacturer's instructions.

Based on fire drill record review, emergency plan review and staff interviews, the facility failed to conduct fire drills on each shift at least every three months; failed to complete evacuation of residents capable of self-evacuation on at least two drills each shift as required: failed to conduct the fire drills under varied times; and failed to verify receipt of the alarm signal to the appropriate fire department or monitoring station. This has the potential to affect all 54 residents residing in the facility. The facility census is 54. Findings include: Review of the fire drill reports for the months of January 2023 to December 2023, revealed no fire drill was conducted for the month of April 2023. Further record review reveals there were only two fire drills conducted on the night shift, 11:01 P.M. to 7:00 A.M. These were conducted in the months of February 2023 at 6:00 A.M. and October 2023 at 5:55 A.M. Neither of these two fire drills included the evacuation of residents capable of self-evacuation or were conducted at varied times. Fire drills conducted on the day shift, 7:01 A.M. to 3:00 P.M., were conducted in the months of March 2023 at 10:32 A.M., May 2023 at 10:00 A.M., August 2023 at 11:25 A.M. and November 2023 at 10:30 A.M. The March 2023 drill included the evacuation of residents capable of self-evacuation. The other three fire drills did not. Fire drills conducted on the evening shift, 3:01 P.M. to 11:00 P.M., were conducted in the months of January 2023 at 3:20 P.M., June 2023 at 3:30 P.M., September 2023 at 7:45 P.M., and December 2023 at 3:22 P.M. Only the January 2023 fire drill included the evacuation of residents capable of self-evacuation and the times of the drills were not varied. None of the fire drills submitted for review provided verify receipt of the alarm signal to the fire department or monitoring station. Review of the plan titled Artis Senior Living of Mason Fire / Tornado Preparedness PlanBased on fire drill record review, emergency plan review and staff interviews, the facility failed to conduct fire drills on each shift at least every three months; failed to complete evacuation of residents capable of self-evacuation on at least two drills each shift as required: failed to conduct the fire drills under varied times; and failed to verify receipt of the alarm signal to the appropriate fire department or monitoring station. This has the potential to affect all 54 residents residing in the facility. The facility census is 54.

Findings include:

Review of the fire drill reports for the months of January 2023 to December 2023, revealed no fire drill was conducted for the month of April 2023. Further record review reveals there were only two fire drills conducted on the night shift, 11:01 P.M. to 7:00 A.M. These were conducted in the months of February 2023 at 6:00 A.M. and October 2023 at 5:55 A.M. Neither of these two fire drills included the evacuation of residents capable of self-evacuation or were conducted at varied times.

Fire drills conducted on the day shift, 7:01 A.M. to 3:00 P.M., were conducted in the months of March 2023 at 10:32 A.M., May 2023 at 10:00 A.M., August 2023 at 11:25 A.M. and November 2023 at 10:30 A.M. The March 2023 drill included the evacuation of residents capable of self-evacuation. The other three fire drills did not.

Fire drills conducted on the evening shift, 3:01 P.M. to 11:00 P.M., were conducted in the months of January 2023 at 3:20 P.M., June 2023 at 3:30 P.M., September 2023 at 7:45 P.M., and December 2023 at 3:22 P.M. Only the January 2023 fire drill included the evacuation of residents capable of self-evacuation and the times of the drills were not varied. None of the fire drills submitted for review provided verify receipt of the alarm signal to the fire department or monitoring station.

Review of the plan titled Artis Senior Living of Mason Fire / Tornado Preparedness Plan

Based on observation, staff interview, and Material Safety Data Sheet (MSDS) review, the facility failed to secure hazardous chemicals in the Mill Creek Neighborhood (100 hall). This has the potential to affect five (# 2, # 12, # 14, # 15, # 16) cognitively impaired independently mobile residents who resided on the 100 hall. The facility census is 54.

Findings include:

Observation on 01/02/24 at 9:30 A.M., in the Mill Creek Neighborhood (100 hall) revealed a cabinet under the hand sink that was unsecured due to a non-functioning child proof safety latch. The cabinet contained the following chemicals: RTU Sanitizer (one quart spray bottle); Reliable Disinfectant (one quart spray bottle); WD-40 (aerosol spray can); and an unlabeled spray bottle containing an unknown liquid (half quart).

Observation and interview on 01/02/24 at 2:01 P.M., with the Director of Health & Wellness (DHW) #1 confirmed the latch was not functioning as it should and the chemicals were unsecured. DHW #1 instructed a staff member on the Mill Creek Neighborhood to remove these chemicals immediately from this cabinet and place them in a secured cabinet.

Interview on 01/02/24 at 3:15 P.M., with the Director of Environmental Services (#6) confirmed the child proof safety latch was not functioning properly and will be replaced.

Review of the MSDS sheets revealed: WD-40: May be fatal if swallowed and enters airways; Reliable Brand RTU Disinfectant Cleaner: Causes severe skin burns and eye damage; Considered poisonous to ingest. and RTU Surface Sanitizer: Causes serious eye irritation; contact with skin causes redness, pain and irritation.

This violation represents the continued noncompliance from the survey dated 10/21/21.