Hilliard Assisted Living & Memory Care

Based on observation, record review, and staff interview, the facility failed to ensure basic toiletry items and paper products were provided to the residents. This had the potential to affect all 93 residents residing in the facility.

Findings include:

Review of the facility's Admission/Residency Agreement revealed language indicating residents were responsible for providing personal supplies and household items, including toilet paper, soap, and paper products.

During an interview on 05/28/26 at 10:55 A.M., the Administrator verified the company policy requires residents to provide their own toilet paper, soap, and other toiletry items. When asked what would occur if a resident did not have those supplies, the Administrator stated she had not been the Administrator for very long and had not encountered that situation.

During an observation on 05/28/26 at 11:00 A.M., the housekeeping closet revealed housekeeping supplies were utilized for facility operations. No stock of toilet paper, soap, or other basic toiletry items designated for resident use was observed.

This violation represents non-compliance investigated under Complaint Number OH00169957.

Based on documentation review and staff interviews, the facility failed to maintain a complete incident/accident log. This had the potential to affect all 93 residents in the facility.

Findings include:

Upon entry, a request was made for the Incident/Accident log for the past six months. The log provided for the surveyors started 04/01/26 and continued through 05/25/26.

Interview on 05/26/25 at 10:11 A.M. with the Administrator and Director of Nursing (DON) revealed there was no documentation prior to the current management company taking over management on 04/01/26 for falls investigations and incidents.

Interview on 05/27/26 at 8:30 A.M. with the Administrator and the DON confirmed there was no documentation of the incident/accident log available prior to 04/01/26. The previous documentation was in electronic systems belonging to the prior management company and was no longer available.

This was an incidental finding discovered during the complaint investigation.

Based on record review, policy review, and staff interviews, the facility failed to maintain medical records pertaining to the administration of medications for the residents. This affected two residents (#54 and #55) and had the potential to affect all 93 residents in the facility.

Findings include:

1. Review of the medical record for Resident #55 revealed a move in date of 03/17/25. The facility administered Resident #55's medications.

Review of Resident #55's medication administration records (MAR) for 01/01/26 to 03/31/26 revealed there were no MARs to review for Resident #55.

2. Review of the medical record for Resident #54 revealed a move in date of 03/17/25. The facility administered Resident #54's medications.

Review of Resident #54's medication administration records (MAR) for 01/01/26 to 03/31/26 revealed there were no MARs to review for Resident #54.

Interview on 05/26/25 at 10:11 A.M. with the Administrator and Director of Nursing (DON) revealed there was no documentation prior to the current management company taking over management on 04/01/26. They stated all documentation was electronic and they only have access to the current management company's systems. They did not print off previous documentation from other systems prior to the current management company. They confirmed there were no MARs for Residents #55 and #54 prior to 04/01/26.

Review of the facility policy titled Medication and Treatment Management dated April 2026 revealed specific steps to safely administer medication including specifically the nurse should observe the resident swallowing the medication and document medication administration in the resident's medical record.

This was an incidental finding discovered during the complaint investigation.

Based on record review and staff interviews, the facility failed to maintain complete medical records for all residents in the facility. This affected Residents #33, #35, #54, and #55 and had the potential to affect all residents who reside in the facility.

Findings include:

Records were reviewed for Residents #33, #35, #54, and #55 revealing all four residents had no documentation in their medical record prior to 04/01/26. Resident #33 had a physical move-in date and financial move-in date of 11/13/24; Resident #35 had a physical move-in date and financial move-in date of 07/13/24; Resident #55 had a move in date of 03/17/25; and Resident #54 revealed an admission date of 03/17/25.

Interview on 05/27/26 at 11:24 A.M. with the Administrator confirmed there were no paper records or electronic records prior to the current management company taking over 04/01/26 for any resident, including Residents #33, #35, #54, and #55.

This was an incidental finding discovered during the complaint investigation.

Based on record review and staff interviews, the facility failed to maintain records for current or discharged residents for the required seven years. This has the potential to affect all current and all residents discharged in the past seven years.

Findings include:

Records were reviewed for Residents #33, #35, #54, and #55 revealing all four residents had no documentation in their medical record prior to 04/01/26. Resident #33 had a physical move-in date and financial move-in date of 11/13/24; Resident #35 had a physical move-in date and financial move-in date of 07/13/24; Resident #55 had a move in date of 03/17/25; and Resident #54 revealed an admission date of 03/17/25.

Interview on 05/27/26 at 11:24 A.M. with the Administrator confirmed there were no paper records or electronic records prior to the current management company taking over 04/01/26 for any resident, including Residents #33, #35, #54, and #55.

This was an incidental finding discovered during the complaint investigation.

Based on medical records review and interview, the facility failed to ensure medications were available and administered per physician order. This affected three residents (#5, #6, and #8) out of five residents reviewed for medication administration. The census was 96.

Findings Include:

1. Review of the medical record for Resident #8 revealed an admission date of 06/19/25 with diagnoses of diabetes, hypertention, and insomnia.

- Review of Resident #8's physician orders revealed she was ordered Buspirone 15 milligrams (mg) three times a day. Review of Resident #8's medication administration review (MAR) revealed on 12/14/24, 01/01/26 & 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Hydrocodone 5/325 tab three times a day for pain. Review of Resident #8's MAR revealed on 12/14/25, 01/01/26, 01/20/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Amlodipine Besyl 10 mg once a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Carvedilol 25 mg two times a day.

Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Duloxetine 60 mg once a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Levothyroxine 137 micrograms (mcg) one time a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Loratadine 10 mg one time a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Losartan 100 mg one time a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Meclizine HCL 25 mg three times a day. Review of Resident #8's MAR revealed on 01/01/26, 01/20/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Metformin 500 mg one time a day. Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

- Review of Resident #8's physician orders revealed she was ordered Oxybutynin Chlor 5 mg two times a day.

Review of Resident #8's MAR revealed on 01/01/26 and 01/30/26 the medication was not signed off by a nurse on duty.

Further review of the medical record revealed no documentation the facility followed up with the pharmacy or physician.

2. Review of the medical record for Resident #5 revealed an admission date of 06/19/25 with diagnoses of Lewy Body Dementia, back pain, and sciatica .

Review of Resident #5's physician orders revealed she was ordered lidocaine pain patch 4% daily for pain. Review of Resident #5's MAR revealed on 12/26/25 and 12/29/25 the medication was not administered due to the medication was not available.

Further review of the medical record revealed no documentation the facility followed up with the pharmacy or physician.

3. Review of the medical record for Resident #6 revealed an admission date of 06/19/25 with diagnoses of bladder cancer, Stint, blood cancer, and scoliosis.

Review of Resident #6's physician orders revealed he was ordered lidocaine pain patch 4% daily for pain. Review of Resident #6's MAR revealed on 12/26/25 and 12/29/25, the medication was not administered due to the medication was not available.

Further review of the medical record revealed no documentation the facility followed up with the pharmacy or physician.

Interview on 02/03/26 at 11:45 A.M. with the Wellness Director (WD) confirmed there were holes in MARs for Residents #8, #5, and #6, indicating medications were not administered. The WD further confirmed medications were not available for Residents #5 and #6. The WD verified there was no follow-up with the pharmacy or physician noted.

This violation represents non-compliance investigated under Complaint Number OH00169308.

Based upon observation, interview, and record review the facility failed to record food substitutions from the published menu. This had the potential to affected all facility residents who received food from the kitchen. The facility census was 89.

Findings Include:

Observation of lunch meal service between 11:06 A.M. and 12:28 P.M. on 12/02/25 revealed residents being served turkey sandwiches on white bread and potato salad. Record review of the menu for lunch on 12/02/25 stated residents were to be served turkey club croissant and macaroni salad.

Cook # 57 provided the facility's menu substitution form after lunch at approximately 2:08 P.M. on 12/02/25. Record review revealed no substitutions on the menu substitution form for 12/02/25. Interview with Cook #57 on 12/02/25 about 2:08 P.M. confirmed the service of turkey sandwiches on white bread and potato salad that day.

Interview with Resident #81 on 12/02/25 about 12:15 P.M. during lunch service revealed substitutions are a frequent occurrence at the facility.

This violation represents non-compliance investigated under Complaint Number OH168927.

Based on observations, staff interviews, and policy review, the facility failed to ensure the kitchen, dining room and food storage areas were maintained in safe and sanitary environment. This affected all facility residents as all the residents received food/beverages from the facility kitchen. The facility census was 87.

Findings include

Observations on 08/19/25 at 9:35 A.M. to 9:42 A.M. revealed the facility kitchen and dining felt humid and warm. The air vents in the kitchen and dining areas had a black substance in them and around them. One vent in the dining room had noticeable blackish-brown spotting on the drywall nearby from moisture and it appeared to be about one foot by two feet in size. In the kitchen dry storage area, a vent had splattered spotting of a blackish-brown mold-like substance, about two feet by 10 feet in size. The dry storage area wall and floor also had a splattered pattern with a fuzzy substance on the floor. The dry storage area also had a dehumidifier running. The walk-in fridge and an additional fridge both had a blackish brown spotted, wet mold-like substance on the gasket (rubber seal) of the doors. The walk-in refrigerator also had a two-feet in diameter standing puddle outside the freezer door related to a problem with the seal.

Interview on 08/19/25 at 9:42 A.M. with Kitchen Manager #104 revealed the kitchen had a moisture issue and the dry storage room had been cleaned recently. He confirmed the mold like substance had been reported to Maintenance, but the facility was currently without a regular maintenance staff full-time and they had someone from corporate filling in. He confirmed it had been an ongoing issue since he started several months ago and the spots just kept reappearing. He reported the freezer door problem was known to maintenance corporate staff as well, and he thought facility was working on getting quotes.

Interview and observations on 08/19/25 at 9:42 A.M. with Corporate Maintenance #106 revealed he was not aware of any concerns related to mold-like substances in the kitchen and dining room or standing water in the walk in fridge outside the walk in freezer. He confirmed the vents had a black substance in and around them and a blackish brown splattered mold-like substance on the ceiling, wall, and floor of the dry storage room. He also confirmed a mold-like substance on the walk-in refrigerator door and another refrigerator door, and confirmed a large puddle of standing water in the walk-in fridge. He was unsure if the facility had any evidence of work orders in process and was unsure of any issue with the walk-in refrigerator or quotes received to fix the leaking from the walk-in freezer.

Interview on 08/19/25 at 9:42 A.M. with the Executive Director revealed she started at the facility a few weeks ago and was not aware of issues of a mold-like substance in the kitchen and dining room. She confirmed it appeared to be mold and confirmed the facility had no evidence or knowledge of any mold testing.

Review of facility policy titled Quick Resource Tool: QRT Food Storage