Traditions of Deerfield

Based on record review, observation, staff interview and policy review, the facility failed to provide incontinence care to one (#43) out of three residents reviewed. The facility census was 107.

Findings Included:

Review of the medical record revealed Resident #43 admitted to the facility on 07/05/2021. On 01/10/25 Resident #43 moved on the memory care unit. Diagnoses included dementia, diabetes mellitus, depression, osteoporosis, Alzheimer's, and a history of seizures.

Review of the service plan dated 09/11/25 revealed Resident #43 needed active assistance from staff with using the bathroom and ensuring incontinence checks every two hours. The resident used incontinence briefs due to urgency and urinary tract infection risk.

Observation on 10/14/25 from 1:00 P.M. through 4:20 P.M., revealed at 4:20 P.M., Resident Advisor (RA) #251 took Resident #43 to her room to check and change. At 4:26 P.M., RA #251 completed incontinence care for Resident #43 who had soaked through her brief, pants, and the pad on the seat of the wheelchair, there were no skin issues at this time.

Interview on 10/14/25 at 4:26 P.M., RA #251 verified Resident #43 had last been taken to bathroom and toileted by staff after breakfast around 8:30 A.M. RA #251 verified Resident #43's brief was saturated with urine along with her pants, and the pad of the wheelchair. RA #251 said Resident #43 should be checked and changed.

Review of the facility policy titled Specialized Care: Toileting dated 12/2014 revealed the staff will provide assistance with toileting as needed to promote hygiene and to preserve the resident's dignity.

This violation represents non-compliance investigated under Master Complaint Number OH00168485 and Complaint Number OH00167973.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure a clean and safe environment. This affected two residents (#41, and #43) out of three reviewed. The facility census was 107.

Findings Included:

1. Review of the medical record revealed Resident #43 admitted to the facility on 07/05/2021. On 01/10/25 Resident #43 moved on the memory care unit. Diagnoses included dementia, diabetes mellitus, depression, osteoporosis, Alzheimer's, and a history of seizures.

Review of the service plan dated 09/11/25 revealed Resident #43 had housekeeping and personal laundry services every Wednesday and Saturday.

Observation on 10/14/25 at 12:55 P.M., of Resident #43's room with the Memory Care Director (MCD) #244 verified the dark brown floor had white flaky specks covering approximately 75 percent of the floor in the room, the bathroom, and the closet. There was a thicker layer of dust on the closet floor. Inside the bathroom near the shelf was a glossy, greasy, slippery substance on the floor, that was slippery when walked on. The MCD #244 verified the substance on the floor in the bathroom was slippery.

Interview on 10/14/25 at 12:59 P.M., the MCD #244 verified Resident #43's floor needed cleaned and the housekeeper had been off for awhile just came back to work.

Observation on 10/20/25 at 9:58 A.M., with Resident Assistant (RA) #240 in Resident #43's room revealed a tall laundry basket was spilling over the top with dirty clothes. In addition, there was a large pile of dirty clothes on the floor next to the laundry basket in the bathroom.

Interview on 10/20/25 at 9:58 A.M., RA #240 verified the laundry should have been taken out if it was full or during her shower day which was not today. RA #240 said all the dirty clothes were from last weekend.

2. Review of the medical record revealed Resident #41 admitted to the facility on 07/03/24. Diagnosis included dementia.

Review of the service plan dated 07/28/25 revealed Resident #41 had severe orientation deficits with past history of poor judgement creating potential for unsafe behaviors to self or others, was independently mobile, and required safety checks twelve times per day.

Observation on 10/20/25 at 9:52 A.M., of Resident #41 in his room revealed dirty dishes were left, the floor was dirty and covered with white crumbs, smashed chocolate brownies, candy wrappers and the trash can in the room was full of trash.

Interview on 10/20/25 at 9:53 A.M., the Resident Assistant (RA) #204 verified the floor in Resident #41's room was dirty with crumbs from the last weekend. RA #204 stated the housekeeper had not cleaned last weekend. RA #204 verified the trash can was full of trash yesterday however, the fast food restaurant cups were from her this morning on top of his trash. RA #204 stated that the dirty plates and trash should have been taken out of his room daily. RA #204 verified the dishes were from last weekend.

Interview on 10/20/25 at 12:48 P.M., the Executive Director said deep cleaning was completed weekly, but staff was expected to pick up trash or sweep large amounts of crumbs or dirt in any residents' rooms. The Executive Director said cleaning up the residents' rooms were expected timely and every day.

Review of the facility policy titled Resident Apartment Cleaning dated 06/2014 revealed the comfort and good health of residents was a primary goal of the community. Keeping the resident's personal space clean and hygienic was a part of that commitment. All apartments should be cleaned at least weekly, to include dusting, vacuuming, mopping, and cleaning kitchenette and bathroom.

This violation represents non-compliance investigated under Complaint Number OH00167973.

Based on medical record review, review of the hospital records, staff interview, and policy review, the facility failed to ensure the physician and the power of attorney were notified of medication refusals. This affected one (#43) out of three residents reviewed for medication. The facility census was 107.

Findings Included:

Review of the medical record revealed Resident #43 admitted to the facility on 07/05/2021. On 01/10/25 Resident #43 moved on the memory care unit. Diagnoses included dementia, diabetes mellitus, depression, osteoporosis, Alzheimer's, and a history of seizures.

Review of the physician order dated 01/01/25 revealed Resident #43 was ordered Divalproex (an anticonvulsant medication) 250 milligram (mg) delayed release twice a day.

Review of the hospital visit dated 02/28/25 revealed Resident #43 was brought in by the local emergency services after having a seizure at the assisted living facility. Review of the laboratory work-up dated 02/28/25 revealed Resident #43 had a low valproic acid level of 41.0 micrograms per liter (mcg/L) where 50 to 100 mcg/L was normal.

Review of the physician order dated 03/01/25 revealed Resident #43 was ordered Divalproex SOD 500 mg delayed release take one tablet twice a day.

Review of the physician order dated 04/10/25 revealed Resident #43 was ordered Divalproex 125 mg take four capsules by mouth two times a day.

Review of the service plan dated 09/11/25 revealed Resident #43 required assistance and had two hour safety checks.

Review of the medication administration record dated from 01/19/25 through 10/14/25 revealed Resident #43 had refused medication on the following dates: 01/19/25, 02/23/25, 03/11/25, 03/17/25, 03/23/25, 04/12/25, 04/16/25, 06/05/25, 08/12/25, 08/26/25, and 09/10/25. There was no documented notification to the physician or the power of attorney of the refusal of anticonvulsant medication.

Interview on 10/20/25 at 3:30 P.M., the Memory Care Director (MCD) #244 verified there was no indication or progress note of notification to the physician or power of attorney of Resident #43 medication refusals.

Interview on 10/21/25 at 11:59 A.M., the Executive Director stated the notification for the power of attorney was in the change in condition policy. The Executive Director stated there was no policy to notify the physician or the power of attorney of refusals.

Review of the facility policy titled Medication Administration dated 04/2023 revealed that no medication shall be given to any resident unless ordered by a physician or individual authorized under state law to prescribe medications. Ordered medications shall be administered unless the resident refuses or the resident exhibits symptoms that contraindicate medication administration. If a medication was not administered, the staff member responsible for administering the medication shall document in the resident's record why the medication was not administered. Such persona shall notify the resident's attending physician or other licensed healthcare professional working within their scope of practice of any undesirable effects and document these effects and the date and time of such notification in the resident's medication record.

Review of the facility policy titled Resident Change of Condition undated revealed using data and communication from resident, resident assistant, other staff, family member or responsible party, nurse and other health care professional regarding changes in the resident condition from baseline. For short term and or minor change the nursing staff was to notify the attending physician timely and document the notification and further orders if received. Nursing should notify the family or responsible party of the change in condition and what steps are being taken. If unable to reach the attending physician or family or responsible party, nursing documents the notification attempt and request for a call back. If the attending physician and family or responsible party has not returned the notification call by the end of the shift, nursing staff on the next shift were to notify for the follow up.

This violation represents non-compliance investigated under Complaint Number OH00168485.

Based on medical record review, staff interview, medical provider interview, interview of local health department staff, and review of the facility policy, the facility failed to implement effective infection control practices to mitigate a potential outbreak of a communicable disease. This affected 11 (Residents #2, #21, #34, #47, #49, #50, #54, #61, #62, #64, and #107) who resided on the secured memory care unit and had the potential to affect all residents residing in the facility. The facility census was 105 residents.

Findings include:

Review of the resident census dated 08/06/25 revealed Residents #2, #21, #34, #47, #49, #50, #54, #61, #62, #64, and #107 resided on the secured memory care unit.

Review of the infection control log dated 06/01/25 to 07/31/25 revealed 11 residents, Residents #2, #21, #34, #47, #49, #50, #54, #61, #62, #64, and #107, were noted to have a skin infection. Residents #2 and #61 were noted as having possible scabies (a highly contagious parasitic skin infection caused by tiny mites that burrow into the skin and lay eggs causing intense itching and a skin rash).

Interview on 08/06/25 at 12:35 P.M. with the Executive Director (ED), the Wellness Director (WD), and Memory Care Director (MCD) #200 confirmed Resident #61 had an emergency room visit on 06/29/25 at which the resident was diagnosed with scabies. The ED confirmed the facility sent a fax to the local health department to notify them of the case of scabies for Resident #61 and the other residents on the memory care unit who were treated for scabies. The ED confirmed the facility had no evidence of the fax such a fax confirmation report.

Interview on 08/06/25 at 3:48 P.M. with Nurse Practitioner (NP) #400 via telephone confirmed two of the residents in the memory care unit started experiencing itching and then more residents exhibited similar skin issues. NP #400 confirmed she had treating for contact dermatitis, but the residents' symptoms persisted. NP #400 stated she began treating all residents on the memory care unit (#2, #21, #34, #47, #49, #50, #54, #61, #62, #64, and #107) with ivermectin a medication used to treat scabies and lice, and this medication helped the residents' symptoms.

Interview on 08/06/25 at 3:58 P.M. with the ED, the WD, and MCD #200 confirmed the facility had changed laundry detergents but were unable to determine the source of the rash. Interview confirmed the facility had not considered the source of the rash could have been a communicable disease until Resident #61 was seen in the emergency room on 06/29/25 and diagnosed with scabies.

Interview on 08/08/25 at 8:43 A.M. via telephone with Epidemiologist #600 from the local health department confirmed the health department had no record of reporting of a potential outbreak of scabies in the facility in June 2025.

Review of the facility policy titled Infection Control reviewed 03/10/25 revealed employees should use proper precautions and practices to prevent the spread of infections.

This violation represents noncompliance investigated under Master Complaint Number OH00167391 and Complaint Number OH00167245.

Based on record review and staff interview, the facility failed to ensure staff had physical examinations per a physician or other health care professional within thirty days before starting work or on the first day of work. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Review of the employee file for Licensed Practical Nurse (LPN) #6 revealed a hire date of 03/26/23. LPN #6's file did not include documentation of physical examination at the time of hire.

Interview on 01/08/25 at 11:19 AM. with Business Office Manager (BOM) #103 confirmed the facility had not ensured LPN #6 had a physical examination upon hire.

Based on record review and staff interview, the facility failed to ensure Resident Care Assistants (RCAs) completed first aid training within 60 days of hire. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Review of the employee file for RCA #23 revealed a hire date of 10/24/24. RCA #23's file did not include documentation of completion of first aid training.

Interview on 01/08/25 at 11:13 AM. with Business Office Manager (BOM) #103 confirmed the facility had not ensured RCA#23 completed a first aid training course.

Based on record review and staff interview, the facility failed to ensure a licensed nurse provided education to Resident Care Assistants (RCAs) regarding personal care techniques and skills. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Review of the employee file for RCA #42 revealed a hire date of 11/07/24. RCA #42's file did not include documentation of education per a licensed nurse regarding personal care techniques.

Interview on 01/08/25 at 11:07 AM. with Business Office Manager (BOM) #103 confirmed the facility had not ensured RCA #42 received education per a licensed nurse regarding personal care techniques.

Based on record review and staff interview, the facility failed to ensure staff were checked against the Nurse Aid Registry (NAR) for possible abuse, neglect, misappropriation, and exploitation upon hire. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Review of the employee file for Licensed Practical Nurse (LPN) #23 revealed a hire date of 10/24/24. LPN #23's file did not include documentation of a check of the NAR for LPN #23 for possible abuse, neglect, misappropriation, and exploitation.

Interview on 01/08/25 at 11:15AM. with Business Office Manager (BOM) #103 confirmed the facility had not completed a check of the NAR for LPN #23 upon hire.

This violation is a recite to the survey dated 03/02/23.

Based on medical record review and staff interview, the facility failed to check the sex offender registry for residents being admitted into the facility. This affected four (Residents #80, #73, #74, #6 ) of five residents sampled. The facility census was 104 residents.

Findings include:

Review of the medical record for Resident #80 revealed an admission date of 06/27/23 with no documentation of completion of a sex offender registry check upon admission.

Review of the medical record for Resident #73 revealed an admission date of 09/06/24 with no documentation of completion of a sex offender registry check upon admission.

Review of the medical record for Resident #74 revealed an admission date of 09/06/24 with no documentation of completion of a sex offender registry check upon admission.

Review of the medical record for Resident #6 revealed an admission date of 10/16/24 with no documentation of completion of a sex offender registry check upon admission.

Interview on 01/08/25 at 4:03 P.M. with the Executive Director (ED) confirmed the facility had no documentation of completion of a sex offender registry check upon admission for Residents #80, #73, #74 and #6.

Based on medical record review, observation and staff interview, the facility failed to ensure staff provided mobility assistance to residents in a safe manner. This affected one (Resident #28) of five residents sampled. The facility census was 104 residents.

Findings include:

Review of the medical record for Resident #28 revealed an admission date of 02/09/19 with diagnoses including history of pelvic fracture and peripheral vascular disease.

Review of the fall risk assessment for Resident #28 dated 09/09/24 revealed the resident was at high risk for falls.

Observation on 01/08/25 at 12:10 P.M. revealed Resident Care Assistant (RCA) #86 was pushing Resident #28 down the hallway to the dining room using a rollator. Resident #28 was facing RCA #86 who was pushing the resident quickly down the hallway.

Interview on 01/08/25 at 12:15 P.M. with RCA #86 confirmed she pushed Resident #28 from the resident's room and down the hallway to the dining room using a wheeled rollator.

Interview on 01/08/25 at 1:40 P.M. with the Health and Wellness Director (HWD) confirmed Resident #28 had a wheelchair which staff should use if transporting the resident for long distances. HWD further confirmed the rollator was not a safe means of resident transport.

Based on employee personnel record review, staff interview, and review of the facility policy, the facility failed to ensure employees received a two-step tuberculosis (TB) test upon hire. This had the potential to affect all of the residents in the facility. The facility census was 104 residents.

Findings include:

Review of the personnel file for Licensed Practical Nurse (LPN) #6 revealed a hire date of 03/26/23 with no documentation of a two-step TB test completed upon hire.

Review of the personnel file for LPN #23 revealed a hire date of 10/24/24 with no documentation of a second step TB test.

Review of the personnel file for Server #91 revealed a hire date of 10/26/24 with no documentation of a second step TB test.

Review of the personnel file for the Resident Care Assistant (RCA)#42 revealed a hire date of 11/07/24 with no documentation of second step TB test.

Review of the personnel file for Server #41 revealed a hire date of 12/26/24 with no documentation of completion of a TB test upon hire.

Review of the personnel file for the Executive Director (ED) revealed a hire date of 01/02/24 with no documentation of completion of a TB test upon hire.

Interview on 01/08/25 at 11:15 A.M. with Business Office Manager (BOM) #103 confirmed the facility had not completed appropriate TB testing upon hire for LPN #6, LPN #23, Server #91, RCA #42, Server #41, and the ED.

Review of the facility policy titled Tuberculosis Screening of Employee/Residents revealed new employees were required to have a two-step TB skin test performed upon hire.

Based on observation, staff interview, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Observation on 01/08/2025 at 9:45 A.M. of the main kitchen with the Culinary Services Director (CSD) revealed the following items were stored in the main freezer: a package of undated hamburger patties, a package of undated hamburger buns, three undated loaves of bread, a bag of undated cod fillets. The following items were stored in the refrigerator: a container of cheddar cheese which was open to air, a container of prepared sloppy joe filling which was open to air. The following items were stored in the dry storage area: seven loaves of undated white bread, one loaf of undated rye bread.

Interview on 01/08/25 at 9:50 A.M. with the CSD confirmed the undated items and the open-to-air items. The CSD further confirmed all foods should be dated upon opening and food containers need to be closed and not open to air.

Observation on 01/08/2025 at 11:30 A.M of the serving kitchen with the CSD revealed the cabinets used for dry storage had a sticky residue inside them and on the outside of the drawers. The drawers in the serving kitchen all had debris and dust in them.

Interview on 01/08/2025 at 11:35 A.M with the CSD confirmed that drawers and cabinets should be cleaned when dirty.

Review of the facility policy titled Storage Procedures: Policies and Procedures Culinary dated 05/31/16 revealed food should be dated and labeled.

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to ensure adequate hot water for showers. This affected six (Residents #2, #5, #12, #69, #71, and #85) of six residents observed for inadequate water temperatures. The facility also failed to ensure adequate hot water in the kitchen for staff handwashing. This had the potential to affect all of the residents residing in the facility. The facility census was 104 residents.

Findings include:

Observation on 01/08/2025 at 10:03 A.M with the Maintenance Director (MD) revealed the water temperature in the main kitchen's hand washing station on the right side of the kitchen was 70.2 degrees Fahrenheit (F). The water temperature in the main kitchen's hand washing station on the left side of the kitchen was 79.6 degrees F.

Interview on 01/08/2025 at 10:05 A.M with the MD confirmed the hot water temperatures in main kitchen were not acceptable and the water was not hot enough to allow for adequate handwashing.

Observation on 01/08/2025 at 10:06 A.M with the MD revealed the water temperature in Resident #71's room was 95.6 degrees F, and the water temperature in Resident #50's room was 103.7 degrees F.

Interview on 01/08/2025 at 10:19 A.M with MD confirmed the hot water temperatures in Resident #71 and #50's rooms were not acceptable.

Review of the water temperature log for 01/08/25 revealed the water temperature in Resident #2's room was 94.8 degrees F. The water temperature in Resident #5's room was 96.9 degrees F. The water temperature for Resident #69's room was 104.1 degrees F. The water temperature for Resident #85's room was 95.8 degrees F.

Interview on 01/08/25 at 4:30 P.M. with the MD confirmed the water temperatures in Resident #2, #5, #69, and #85's rooms were not acceptable.

Review of the facility policy titled Water Temperatures revealed water temperatures should be between 105 and 120 degrees F.

This violation is a recite to the survey dated 03/02/23.