Avenue at Wooster Assisted Living

Based on personnel record reviews and interviews, the facility failed to ensure that, prior to providing personal care unsupervised, the Resident Aides (RA) completed skills techniques for personal care with a competency of skills completed by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). This had the potential to affect all 20 residents in the facility.

Findings Include:

Record review revealed during orientation Resident Aide (RA) #310 (with a 06/24/24 date of hire) and RA #312 (with a 02/29/24 date of hire) had no documented evidence that their skills techniques were checked for competency by an RN or LPN prior to being able to complete the skills unsupervised on the nursing unit.

Interview on 07/22/25 at 11:00 A.M. with Human Resources (HR) #304 revealed that RA #310 and RA #312 had no documented evidence that their skills competency checks were completed by an RN or LPN prior to being able to perform the skill on the nursing unit unsupervised.

Based on record reviews and interview, the facility failed to ensure the admission assessment included the type of care or services and the skilled care/impact on personal care. This affected two residents (Resident #56 and Resident #63) out of five reviewed in the survey sample.

Findings Include:

1. Review of the medical record for Resident #56 revealed an admission date of 11/11/24 and the diagnoses of enlarged prostate and heart disease.

Further record review revealed that Resident #56's admission assessment did not include the type of care or services and/or the skilled care/impact on personal care.

2. Review of the medical record for Resident #63 revealed an admission date of 05/20/25 and the diagnoses of high blood pressure, gout, insomnia, macular degeneration, diabetes type two, cerebral infarction, chronic kidney disease and congestive heart failure.

Further record review revealed that Resident #63's admission assessment did not include the type of care or services and/or the skilled care/impact on personal care.

Interview on 07/22/25 at 11:45 A.M. with Licensed Practical Nurse (LPN) #309 confirmed that Resident #56 and Resident #63 did not have the type of care or services and skilled care/impact on personal care assessments completed on admission.

Based on observations, interviews, review of facility cleaning check lists, and policy reviews, the facility failed to ensure proper food storage, preparation, and distribution to prevent contamination and spoilage. This had the potential to affect all 20 residents at the facility.

Findings Include:

1. Observation on 07/21/25 at 10:56 A.M. revealed there was a rack near the walk-in refrigerator that contained numerous packets of hot dog buns, hamburger buns, and bread that had an expiration sticker of 07/04/25 on them. Nine packets of buns and bread had green mold on them.

Interview on 07/21/25 at 10:57 A.M. with Dietary Aide (DA) 308 confirmed there were outdated and moldy buns and bread on the rack near the walk-in refrigerator that kitchen staff were pulling from to use for the lunch service.

Observation on 07/22/25 at 8:07 A.M. revealed that the packages of outdated buns continued to be on the rack to be used for meals.

Interview on 07/22/25 at 8:08 A.M. with Dietician #307 confirmed there were packages of buns that were outdated on the bread rack being used for meals.

Review of the undated facility policy Food Safety and Sanitation

Based on observation, interview and review of the kitchen cleaning checklist, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents at the facility. The census at the facility was 20.

Findings Include:

1. Observation on 07/21/25 at 10:33 A.M. revealed several bowls that had been placed on the shelf and were being used to serve resident's food in, had several spots of dried food on them.

Interview on 07/21/25 at 10:52 A.M. with Dietary Aide (DA) #308 confirmed there were several bowls that had dried food on them, and the bowls were on the shelf as clean and ready to use.

Observation on 07/22/25 at 8:08 A.M. revealed a tray of bowls being used to serve breakfast to the residents had dried food on several bowls.

Interview on 07/22/25 at 8:09 A.M. with Dietician #307 revealed some of the bowls on the tray that were being used to serve food in, did have old, dried food on them.

2. Observation on 07/21/25 at 10:53 A.M. revealed there was food laying on the walk-in refrigerator floor under the shelving units. Many of the shelves and counters had dust and old food crumbs on them. The floor was visibly dirty with pieces of food.

Interview on 07/21/25 at 10:55 A.M. with Dietary Aide (DA) 308 confirmed there was food on the floor in the walk-in refrigerator under the shelving unit. DA #308 confirmed that the shelves, counters, and floor needed to be cleaned.

Review of the undated kitchen cleaning checklist titled Daily Cleaning Checklist

Based on review of facility fire drills, interviews, and policy reviews, the facility failed to ensure that residents were evacuated during fire drills on third shift at a minimum of two times during the last 12 months. Additionally, the facility failed to ensure alarm transmission and receipt confirmed within 12 hours of coded announcement from the alarm company. This had the potential to affect all 20 residents at the facility.

Findings Include:

1. Review of facility fire drills revealed that no residents were evacuated during the third shift fire drills during the months of September 2024, December 2024, March 2025, and June 2025.

Interview on 07/21/25 at 9:35 A.M. with Director of Maintenance (DOM) #303 verified that residents were not evacuated during third shift fire drills in the months of September 2024, December 2024, March 2025, and June 2025.

Review of the undated facility policy titled Perform a Fire Drill During 1st Shift

Based on record review and staff interview the facility failed to ensure annual fall assessments, functional assessments, and self-administration evaluations were completed. This affected four (Residents #1, #3, #8 and #10) of five residents reviewed for annual assessments. The facility census was 18.

Findings include:

1. Review of the medical record for Resident #1 revealed an admission date of 07/01/21. Diagnoses included chronic kidney disease, atrial fibrillation, and osteoarthritis. Review of the medical record revealed the last functional assessment, self-administration evaluation and last fall assessment were completed on 07/01/21.

2. Review of the medical record for Resident #1 revealed an admission date of 07/01/21. Diagnosis included hypertension. The medical record revealed no functional assessment or self-administration evaluation was completed and the last fall assessment was completed 07/31/21.

3. Review of the medical record for Resident #8 revealed an admission date of 12/21/20. Diagnoses included heart failure, depression, and osteoarthritis. Review of the medical record revealed the last functional assessment and self-administration evaluation were completed on 04/08/21 and the last fall assessment was completed on 05/28/21.

4. Review of the medical record for Resident #10 revealed an admission date of 08/10/18. Diagnoses included dementia, hearing loss, and osteoarthritis. Review of the medical record revealed the last functional assessment, self-administration evaluation, and last fall assessment were completed on 02/12/21.

Interview on 12/21/22 at 2:09 P.M. with the Director of Nursing (DON) revealed comprehensive assessments were to be completed annually. The DON verified Residents #1, #3, #8 and #10 had not had an annual functional assessment, fall assessment, or self-administration evaluation annually.

Based on observation and interview, the facility failed to ensure meals were palatable and served at an appropriate temperature to prevent contamination. This finding had the potential to affect all eighteen residents residing on the assisted living. The facility census was eighteen.

Findings include:

A test tray was conducted on 12/19/22 at 11:56 A.M. with Kitchen Manager #883 and Registered Dietitian (RD) #999 which consisted of baked paprika chicken, green beans, noodles with red sauce, banana pudding, bread, and butter. The chicken's temperature was 126.2 degrees Fahrenheit, the green beans temperature was 113.6 degrees Fahrenheit, the noodles with red sauce's temperature was 108.9 degrees Fahrenheit. The chicken was slightly warm and not hot, the noodles and the green beans were cold.

Interview on 12/19/22 at 11:58 A.M. with RD #999 confirmed the chicken was required to have a holding temperature of 135 degrees Fahrenheit and the chicken did not meet the required temperature to prevent bacteria growth. She also confirmed the green beans and the noodles with red sauce were cold to the taste.

Interview on 12/19/22 at 1:25 P.M. with Diet Tech #899 indicated she handled some of the food council meetings which had a lot of cold food complaints. She confirmed the food council met monthly.

Interview on 12/20/22 at 8:57 A.M. with the Administrator indicated the plate warmer had been broken for approximately six months and needed repaired.

Interview on 12/21/22 at 10:24 A.M. with Resident #2 indicated the food was cold at times.

Interview on 12/21/22 at 10:31 A.M. with Resident #4 indicated the food was warm but not hot. He stated once it a while it was cold, and he was disappointed in the food.