Mulberry Gardens Memory Care

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the Goodyear laundry room dryer was free of lint buildup. This had the potential to affect 27 residents using the Goodyear laundry room. The facility census was 46.

Findings include:

Observation on 10/08/25 at 8:45 A.M. in the Goodyear laundry room revealed a dense lint build up behind the dryer on the wall, dryer hoses, and pipes leading into the machine.

Interview on 10/08/25 at 8:50 A.M. with the Health Service Director confirmed the lint build up behind the dryer.

Review of the facility policy titled Dryer Vent: Complete In-House Cleaning System

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when dietary personal were observed not wearing hair coverings to cover beards. This had the potential to affected all 46 residents residents served food from the kitchen. The facility census was 46.

Findings include:

Observation of the kitchen on 10/08/25 at 10:30 A.M. revealed that Cook #231 and Dietary Aide #218 had beards and were not wearing hair coverings over the beards when preparing food.

Interview with the Dietary Manager on 10/08/25 at 10:30 A.M. verified Cook #231 and Dietary Aide #218 were not wearing hair coverings over their beards. The Dietary Manager further stated he was told by the local health department that hair coverings for the beards were not a requirement.

Policy review of the Ohio Administrative Code Rule 3717-1-02.3 Management and Personnel: Hygienic Practices

Based on observation, staff interviews and review of the manufactures specifications, the facility failed to ensure the dishwasher met the required rinse temperature to ensure sanitization. This had the potential to affect all 46 residents who receive food from the kitchen. The facility census was 46.

Findings include:

Observation with the Dietary Manager on 10/08/25 at 10:40 A.M., after watching six dishwashing attempts, the dishwasher wash water temperature reached 162 degrees Fahrenheit. The rinse water temperature reached 173 degrees Fahrenheit.

Interview on 10/08/25 at 10:40 A.M. with Dietary Manager at the time of the observation confirmed the rinse water temperature was 173 degrees Fahrenheit. The Dietary Manager stated the hot water rinse should reach 180 degrees Fahrenheit to ensure sanitization.

Interview with the technician from the dishwasher mechanical company on 10/09/25 at 9:15 A.M. revealed the dishwasher rinse water was not meeting 180 degrees Fahrenheit as required for sanitization, verifying the highest temperature the rinse water temperature reached was 173 degrees Fahrenheit.

Review of the manufacturer specification at the base of the dishwasher revealed, for sanitization, the hot water rinse temperature must reach 180 degrees Fahrenheit.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #37's breathing treatment medication was available to be administered per physician orders. This affected one resident (Resident #37) out of four residents reviewed for medication administration. The facility census was 49.

Findings include:

Review of Resident #37's medical record revealed an admission date of 09/22/23 and diagnoses included frontotemporal dementia, Alzheimer's dementia with behavioral disturbances and delirium.

Review of Resident #37's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation dated 01/20/25 revealed Resident #37 had severe cognitive impairment.

Review of Resident #37's Senior Living Assessment dated 09/28/24 included Resident #37 occasionally resisted assistance with Activities of Daily Living's. Resident #37 required assistance with ADL's and was easily distracted, had periods of restlessness, periods of lethargy and cognitive decline.

Review of Resident #37's care plan dated 12/06/24 included Resident #37 received medication assistance as needed.

Review of Resident #37's Medication Administration Record revealed on 01/18/25 a physician order was written for Albuterol Inhalation Solution 0.083 percent, one vial via nebulizer every four hours as needed for wheezing.

Observation on 01/21/25 at 10:56 A.M. of Licensed Practical Nurse (LPN) #200 revealed she walked to LPN #206's medication cart and together they checked the cart for Resident #37's Albuterol Solution vials. LPN #200 stated she could not find Resident #37's Albuterol in her med cart, Resident #37 needed it because she could hear her wheezing all the way down the hall. LPN #200 stated the Albuterol was ordered recently, there should still be vials available, and someone might have mistakenly discarded it. LPN #200 stated she was going to contact the pharmacy to have more vials sent.

Observation on 01/21/25 at 10:58 A.M. of Resident #37 with LPN #200 revealed Resident #37 was wheezing but it was not so loud it could be heard in the hall. Resident #37 began coughing very forcefully, and it was a hoarse cough with congestion heard in her chest. LPN #200 gave Resident #37 sips of water and the rest of her medications which were due. LPN #200 asked for something for her cough and LPN #200 stated the Albuterol was not available but she could give a pill for the cough. LPN #200 prepared benzonatate 100 mg capsule and administered it to Resident #37. Resident #37's husband was in the room sitting next to Resident #37 and stated he wished Resident #37 was better.

Review of a fax sent to the pharmacy on 01/21/25 at 2:19 P.M. revealed a telephone verbal physician order prescribed by Nurse Practitioner (NP) #205 for Resident #37's Albuterol INH (inhalation) Solution 0.083 percent, 3 ml as a nebulizer every four hours as needed, please bill the facility for this box if insurance will not pay.

Interview on 01/21/25 at 2:30 P.M. of LPN #200 confirmed she was unable to locate Resident #37's Albuterol vials which were ordered to be used via nebulizer for a respiratory treatment for wheezing as needed. LPN #200 stated Resident #200 could be heard wheezing all the way down the hall and when asked if she checked Resident #37's oxygen saturation level when she was wheezing, LPN #200 stated she checked it and it was 96 percent. LPN #200 stated she reordered the Albuterol and it would be drop shipped later today.

Review of Resident #37's progress notes dated 01/21/25 at 8:15 P.M. written by LPN #200 revealed Albuterol 0.083% 3ml solution reordered from pharmacy for wheezing, cough, SOB (shortness of breath), and right lower lobe pneumonia. Order written with the permission of Nurse Practitioner (NP) #205 and Health Services Director (HSD) #201. The pharmacy was notified of the new order that was faxed and asked them to drop ship it STAT (immediately). Resident #37 was on two ATB's (antibiotics) for RLL (right lower lobe) pneumonia. The Albuterol solution was dropped (drop shipped) at 7:45 P.M. and treatment was given. Resident #37's wheezing improved and she was afebrile. Resident #37's color continued to be pale, temperature was 97.5 F, oxygen saturation level was 95 percent, respirations were 20 per minute, blood pressure was 132/78 and pulse was 62.

Interview on 01/22/25 at 3:19 P.M. of LPN #200 revealed on 01/21/25 at 10:58 A.M. Resident #37 was wheezing, but it was not like previous days when she could hear her wheezing all the way down the hall. LPN #200 stated Resident #37's wheezing was not as bad, was much better, but she wanted to give a breathing treatment to open her airway to prevent atelectasis. LPN #200 confirmed again she could not find Resident #37's albuterol to give her a breathing treatment.

Review of the facility policy titled Medication Management revised 12/19/22 included residents who were receiving assistance with the administration of their medications by facility staff must have all their medications centrally stored in a designated locked facility storage area that was not accessible to persons other than employees responsible for the supervision of centrally stored medications. All medications for residents would be kept together but would be physically separated from other residents medications. Medications not administered would be accompanied by a reason for not administering. All medications were to be dispensed or administered according to prescribed physician orders.

This violation represents non-compliance investigated under Complaint Number OH00160318.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #43 had treatments completed for an open area to her right elbow. This affected one resident (Resident #43) out of three residents reviewed for wounds. The facility census was 49.

Findings include:

Review of Resident #43's medical record revealed an admission date of 08/01/23 and diagnoses included left MCA (middle cerebral artery) infarct, and left MCA M1 and M2 thrombus 01/23/22 (a blood clot located within the M1 and M2 segments of the middle cerebral artery), right hemiparesis, expressive and receptive language aphasia.

Review of Resident #43's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation dated 12/02/24 revealed Resident #43 had severe cognitive impairment.

Review of Resident #43's Senior Living Evaluation dated 12/03/24 included Resident #43 was not resistive to assistance. Resident #43 required assistance with toileting and Activity of Daily Living's

Review of Resident #43's progress notes dated 01/19/25 at 7:15 A.M. included on 01/19/25 at 5:05 A.M. Resident #43 was found on the floor and had a skin tear to the right elbow. Resident #43 denied hitting her head and stated she did not know how she ended up on the floor. Resident #43 was able to move all extremities without pain. Resident #43 had an open area, 4.0 cm by 4.0 cm oval, with a small amount of serosanguineous drainage. Vaseline gauze was applied, and a non-stick pad secured with Kerlix. Resident #43 had two navy-blue areas noted, a 4.0 cm by 4.0 cm area to the right wrist and a 7.0 cm by 4.0 cm area to the right forearm. Resident #43 was assisted to bed by staff members.

Review of Resident #43's progress notes dated 01/19/25 at 7:47 A.M. included Resident #43's hospice agency was notified of the incident and someone would be sent to the facility to evaluate Resident #43. Resident #43's physician and son were notified.

Review of Resident #43's progress notes dated 01/19/25 at 8:29 A.M. revealed the hospice nurse arrived for post fall visit, order to hold Eliquis (anticoagulant) today due to skin tear. The progress notes did not specify if a order was written for treatment of Resident #43's right elbow.

Review of Resident #43's progress notes dated 01/19/25 at 8:29 A.M. through 01/21/25 at 7:05 A.M. did not reveal documentation regarding her right elbow open area including treatments.

Review of Resident #43's physician orders dated 01/19/25 at 8:29 A.M. through 01/21/25 at 7:05 A.M. did not reveal a treatment order for Resident #43's right elbow.

Review of Resident #43's Medication and Treatment Administration Record dated 01/19/25 through 01/21/25 did not reveal a treatment was completed for Resident #43's right elbow.

Observation on 01/21/25 at 7:05 A.M. of Resident #43 with Licensed Practical Nurse (LPN) #200 revealed Resident #43 had a dark red scab on her right elbow about two inches long and one inch wide, and there was a dried, tattered piece of what appeared to be Vaseline gauze partially adhered to the right elbow scab. In addition there was a second, small nickel size scab near the elbow and it was dark red. Resident #43 had two large dark purple bruises on her forearm, and each bruise was about three to four inches in length and width. LPN #200 confirmed the presence of the open scabbed areas on Resident #43's right elbow, and bruises on her forearm, and stated Resident #43 got skin tears easily.

Interview on 01/21/25 at 8:10 A.M. of Health Services Director (HSD) #201 revealed physician orders could be on paper or in the electronic record and she would have Resident #43's electronic record and hard chart reviewed for treatment orders for Resident #43's right elbow.

Interview on 01/21/25 at 8:19 A.M. of LPN #202 revealed she checked Resident #43's verbal physician orders and hospice orders and could not find a treatment order for Resident #43's right elbow.

Interview on 01/21/25 at 8:30 A.M. revealed LPN #202 stated she called the hospice agency and there was no treatment order for Resident #43's right elbow written when the hospice nurse was in the facility on 01/19/25. LPN #202 stated the hospice agency gave her a verbal order when she called (01/21/25) and the order was to cleanse Resident #43's right elbow skin tear, apply triple antibiotic ointment and a gauze border dressing. LPN #202 indicated she would soak the dried Vaseline gauze off Resident #43's right elbow, assess it and call the hospice agency if she needed an additional dressing. LPN #202 stated Resident #43's hospice nurse was going to visit Resident #43 and follow up later today.

Interview on 01/21/25 at 3:40 P.M. of Hospice Registered Nurse Case Manager (HRNCM) #203 and Hospice Registered Nurse Quick Response Team (HRNQRT) #204 revealed she visited Resident #43 on 01/19/25 and evaluated her after her fall and stated when she arrived there was already a dressing on Resident #43's right elbow and the nurse told her she treated the open area and put a dressing on it. HRNQRT #204 stated she did not know if there was a physician order for Resident #43's dressing, but there was a dressing on the elbow and if there was a dressing she thought the nurse had received an order for it.

Review of Resident #43's hospice physician orders dated 01/21/25 at 4:00 P.M. revealed apply triple-antibiotic ointment to skin tear on right elbow and cover with island dressing every day until healed.

Interview on 01/22/25 at 9:38 A.M. of HSD #201 revealed there was a verbal telephone physician order dated 01/19/25 from Resident #43's primary care physician for her right elbow open area, it needed signed and was not entered into the system. HSD #201 stated the order was found in Resident #43's physician mailbox.

Review of Resident #43's physician orders provided by the facility on 01/22/25 revealed a telephone order dated 01/19/25 at 7:15 A.M. from Resident #43's physician stated cleanse right elbow wound with wound wash, blot dry with clean, dry gauze. Cut Vaseline gauze to fit, cover with non-stick pad and secure with Kerlix. Crossroads hospice to follow-up with wound care and notified per telephone call of such.

Interview on 01/22/25 at 3:19 P.M. of LPN #200 revealed she was working on 01/19/25 at 5:30 A.M. when Resident #43 fell and experienced a skin tear to her right elbow. LPN #200 stated she completed a treatment for Resident #43's right elbow skin tear. LPN #200 indicated she put Vaseline gauze on it because it was a non stick dressing and wrapped the area with Kerlix. LPN #200 stated she called hospice to report Resident #43's fall and skin tear, and hospice was responsible to write treatment orders. LPN #200 stated the treatment was probably not on the MAR because she thought hospice was going to write the orders. LPN #200 stated normally the facility nurses would put a treatment in place and write orders. LPN #200 stated she let Resident #43's physician know she was hospice and they would take it from here and she did not receive a treatment order. After stating she did not get a treatment order LPN #200 then stated she did get a verbal order and put it in Resident #43's mailbox for him to sign.

Review of the facility policy titled Skin Care Oversight Guidelines dated 11/24/22 included the purpose of the policy was to develop a system to monitor skin concerns and ensure proper skin care was provided to all residents. The nurse would notify the attending physician and family of any findings. Additionally home health may be requested to provide comprehensive wound care oversight. The nurse would document wound management orders obtained and or review order to ensure orders were in place to manage the wound, skin concerns. The nurse would place the resident in Alert Charting Status and update the 24 hour communication log.

This violation represents non-compliance investigated under Complaint Number OH00160318.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure infection control practices were followed during Resident #19's medication administration. This affected one resident (Resident #19) out of four resident reviewed for infection control during medication administration. The facility census was 49.

Findings include:

Review of Resident #19's medical record revealed an admission date of 02/28/24 and diagnoses included dementia, acute metabolic encephalopathy, and mild late onset Alzheimer's dementia with psychotic disturbance.

Review of Resident #19's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation dated 01/20/25 revealed Resident #19 had moderate cognitive impairment.

Observation on 01/21/25 at 10:22 A.M. of Licensed Practical Nurse (LPN) #206 revealed she was standing at the medication cart preparing medications for Resident #19. LPN #206 placed Preservision, Risperidone 0.5 mg tablet, Sertraline 50 mg tablet, Eliquis 2.5 mg tablet, and vitamin D 2000 IU (international units) into a small plastic container and while she was putting the medications in the container one of the medications fell onto the top of the medication cart. LPN #206 picked the tablet up from the medication cart with bare fingers and placed the tablet into the plastic cup with the other medications. LPN #206 picked the cup up and prepared to enter Resident #19's room to administer the medications. Before the medications were administered the surveyor stopped LPN #206 and asked her if she picked the tablet up with her bare fingers and placed it in the medication cup. LPN #206 confirmed she picked the tablet up from the top of the med cart and placed it in the cup with the other medications. LPN #206 stated she thought the dropped medication was Eliquis and said even though she dropped the pill on the medication cart, picked it up with her bare fingers, placed it in the cup, and knew it was an infection control issue she would normally still administer the medications because there was no back up pills she could give. LPN #206 discarded the medications, and used the next day supply (for 01/22/25) of Resident #19's medications and administered the prescribed medications to Resident #19.

Interview on 01/21/25 at 12:38 P.M. of Health Services Director (HSD) #201 revealed LPN #206 picking up Resident #19's medication from the top of the medication cart with bare fingers and placing the tablet in the cup with the other medications and planning to administer the pills to Resident #19 was an infection control issue, should not be done, and she would educate the nurses.

Review of the facility policy titled Standard Precautions dated 01/25/18 included Standard Precautions were used for all resident care. The were based on a risk assessment and make use of common-sense practices and personal protective equipment (PPE) use that protects the community staff from infection and prevent the spread of infection from resident to resident and staff to resident. Standard Precautions include a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status in any setting which healthcare was delivered.

Based on record review and interview the facility failed to ensure fire drills were conducted as required. This has a potential to affect all 54 residents residing in the facility.

Findings include:

Review of the facility fire drill records for the drills conducted in the previous 12 months revealed there was no third shift fire drill conducted during the first quarter (January to March) 2024.

In addition, there was no evidence residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year during the second shift or during the third shift as required.

Further review of fire drill records revealed during the third shift when silent drills were conducted there was no documentation of the alarm transmission to the monitoring system as required.

Interview on 08/01/24 at 1:32 P.M. and 2:14 P.M. with Director of Maintenance (DOM) #432 verified the above findings.