Senior Suites at St Clair Commons

Based on record review, personnel file review, review of time sheets, job description review, observation, and interviews the facility failed to ensure the administrator provided adequate staffing oversight to ensure the residents' needs were met. This had the potential to affect all 66 residents residing in the facility.

Findings included:

1. Interview on 01/06/26 at 8:14 A.M., with Administrator #141 revealed she started on 12/01/25, however she had spent the first two days in the corporate office, and she was still in orientation. The Administrator #141 confirmed Executive Director (ED) #145 was the administrator on record with the state department and comes two to three days a week. The Administrator #141 confirmed the facility did not have a Wellness Director (WD) or an Infection Preventionist (IP) for a few months now.

Review of personnel files revealed the previous WD was also the infection preventionist (IP), and her last day of employment was 10/19/25.

Review of ED #145's time sheet dated 11/05/25 to 12/01/25 revealed ED #145 worked 11/06/25 from 8:07 A.M. to 6:06 P.M., 11/11/25 from 8:20 A.M. to 7:00 P.M., 11/12/25 from 8:15 A.M. to 6:37 P.M., 11/13/25 from 8:15 A.M. to 6:22 P.M., 11/17/25 from 8:30 A.M. to 6:00 P.M., 11/18/25 from 8:07 A.M. to 6:10 P.M., 11/19/25 8:00 A.M. to 5:39 P.M., 11/20/25 7:30 A.M. to 6:32 P.M., 11/24/25 from 8:20 A.M. to 7:00 P.M., and 11/26/25 from 8:00 A.M. to 5:43 P.M.

Review of the Wellness Director job description (undated) revealed the purpose of the job position was to plan, organize, develop and direct the overall operations of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest degree of quality care was maintained at all times. Duties include developing, maintaining, and periodically update written policies and procedures that govern the day to day functions of the nursing service department, perform administrative duties such as competing medial forms, reports, evaluation, charting and etc., determine the staffing need of the nursing service department necessary to meet the total nursing needs of the residents, make daily rounds to ensure all nursing services personnel are performing their work assignments in accordance with acceptable nursing standards, develop written care plans, report and investigate all allegation of abuse, and assist with infection control.

Review of the infection control logs revealed no evidence a log was maintained for December 2025 or January 2026.

Review of the incident log revealed there was no comprehensive incident log for December 2025 or January 2026. The log provided was dated 10/01/25 to 01/05/26 contained the resident's name, date, and time. There was one elopement and 32 falls. There was no evidence of location of incident, general description, or action/care provided.

Interview on 01/05/26 at 6:32 A.M., with Personal Care Assistant (PCA) #136 confirmed the facility currently did not have a Wellness Director of oversee nursing staffing.

Interview on 01/05/26 at 6:39 A.M., with PCA #124 confirmed the facility currently does not have a Wellness Director. The PCA reported on night shift there was not adequate staffing to evacuate residents in an emergency. The building was four stories, and some residents need assistive devices for ambulation. The staff have voiced concerns numerous times but no changes in staffing have been made.

Interview on 01/05/26 at 7:21 A.M. and 11:47 A.M., with LPN #109 confirmed the facility did not have a Wellness Director since October (2025) and there has not been oversite for nursing to ensure incident logs, infection control logs, and investigation reports are completed accurately. The facility had asked nursing staff to fill in until a Wellness Director was hired, however all the nursing staff declined to fill in.

Interview on 01/05/26 at 11:00 A.M., with Resident #235 confirmed there were not enough staff to answer call lights timely.

Observation on 01/06/26 at 7:10 A.M., revealed there were three Personnel Care Assistants (PCA) working from 7:00 A.M. to 7:00 P.M. and two nurses. At the time of the observation, interview with LPN #102 revealed she only works until 9:30 A.M. to help with morning medication pass due to there being a call off today, then it will leave one nurse to provide care to 60 residents.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 revealed nursing staff were doing their own schedule with oversite from LPN #109. Currently the facility has two nurses on dayshift and one nurse from 6:00 P.M. to 10:00 P.M., and one from 6:00 P.M. to 6:00 A.M. on night shift. There are three PCAs on dayshift and two on night shift.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 confirmed the facility did not have a Wellness Director to oversee nursing staff and services provided to residents. LPN #104 confirmed staff start the incident reports, however, there is no one to follow up on them after they are started to ensure interventions are implemented and incidents are logged. Today she is the only nurse after the LPN leaves around 9:00 A.M., however she felt she could provide adequate care to the 60 some residents as long as there was no incidents.

Interview on 01/06/26 at 11:00 A.M.,. with Administrative Assistant (AA) #140 confirmed the facility has a lot of calls offs. Today there had been two call offs. LPN #109 tries to help with the schedule.

Interview on 01/06/26 at 12:41 P.M., with ED #145 confirmed in October and November she was the active Administrator for the facility. The new Administrator (#141) started on 12/01/25. The ED confirmed the new Administrator was still in orientation and she comes twice a week to help. The ED confirmed the facility doesn't have a Wellness Director or an Infection Preventionist since 10/20/25. ED #145 reported she had offered the position to each of the nursing staff, and they all declined the position. Staff do self-scheduling and LPN #109 looks over it. She would like to have two nurses on night shift, but currently there is only for four hours and one for 12 hours. She had added a third staff member to dayshift and if the census increases she will add more staff to night shift. ED #145 confirmed the incident and infection control logs were not completed due to the facility not having a Wellness Director or Infection Preventionist.

Interview on 01/06/26 at 1:48 P.M., with Resident #263 confirmed there were not enough staff on night shift to answer call lights timely.

Interview on 01/06/26 at an undisclosed time with Anonymous Staff Member #302 revealed there was not adequate staffing to ensure medication was administered timely and proper supervision of residents to prevent falls and elopements. The staff confirmed there was no Wellness Director to oversee the nursing department. Staff are basically doing their own schedule and working with each other to cover shifts. Some days there is only one nurse for the entire four-story building. Staff have been quitting since ED #145 had cut staffing levels. The nurses need training on the incident reports, incident logs, and infection control. The facility is not monitoring/addressing resident behaviors appropriately. Anonymous Staff Member #302 confirmed there had been three residents leaving the facility in the last month unsupervised and without the facility acknowledgement.

Interview on 01/07/26 at 11:51 A.M., with Administrator #141 revealed there was no way to determine who worked the last 30 days due to no one was tracking call offs. The Wellness Director was responsible for tracking the actual working schedule, but since the facility didn't have a Wellness Director no one had been tracking the call-offs and schedule. The facility doesn't have a Medical Director. The facility has a contract with Abode (a group of medical providers), and the NP comes to see some of the residents and she is overseen by the Medical Coordinator (from the Adobe Group). Administrator #141 confirmed the staff nor herself knows which residents are on two-hour checks. She had spoken to staff, and they reported the Wellness Director used to give them a list with dots on it (that indicated the resident required two hour checks from staff), however since there was no Wellness Director the staff don't know for sure who requires two-hour checks.

Interview on 01/08/26 at an undisclosed time with Anonymous Staff Member #128 revealed there aren't enough staff to supervise residents especially on night shifts due to the residents' behavior. Residents have voiced concerns they are not getting medications timely. Sometimes there is only one nurse for day and night shift for 60 residents. On day shift there are supposed to be three aides and usually one calls off leaving only two aides. The facility doesn't have an activity director, and they are using one of the PCAs to fill the position.

Interview on 01/08/26 at an undisclosed time with anonymous residents revealed the facility has gone downhill. Nursing doesn't always respond timely or at all. One resident reported that once, her blood pressure was elevated, and she asked to see the nurse and the aide came back and said the nurse said to take your nerve pill and go to sleep. The trash doesn't get emptied daily like it supposed to and the food is awful. The resident reported her toilet had not been cleaned for two weeks. Observation of the toilet confirmed there was a dark ring on the inside of the toilet.

Review of an anonymous letter that was left to the surveyor undated revealed there were several issues with how things are done around the facility. The facility doesn't have a Wellness Director. The residents complain about not getting their call lights answered timely by dayshift. The author of the letter had a resident cry to them about how the staff are mean to them on dayshift. We have residents that are not appropriate for assisted living and only have one nurse and two aides on night shift. It had been brought to several people's attention that if there was ever an emergency on night turn that would not be good. There are people on the top floors that are not able to get down the steps. The residents also complain about the cleanliness of the facility. Day shift always had a problem with people not coming to work. The residents pay our paychecks, and they can't get the proper care they are paying for because of management cutting corners and staffing.

This violation represents non-compliance from survey completed on 11/04/25.

This violation represents non-compliance investigated under Complaint Number OH00169265.

Based on observation, interview, and policy review the facility failed to provide sufficient staff members to meet the comprehensive needs of the residents. This affected all 66 residents residing in the facility.

Findings included:

Observation on 01/06/26 at 7:10 A.M., revealed there were three personal care assistants (PCA)s working from 7:00 A.M. to 7:00 P.M. and two nurses for 64 residents. At the time of the observation, interview with Licensed Practical Nurse (LPN) #102 revealed she was only working until 9:30 A.M. to help with morning medication pass due to there being a call off today. LPN #102 confirmed after she left the facility that she would leave one nurse for 60 some residents.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 revealed Executive Director (ED) #145 was the administrator for the building in October and November 2025. ED #145 was also the Administrator for a sister facility at that time. ED #145 would split her time up between the buildings. Administrator #141 reported she was still in orientation and ED #145 was still coming to the building. (ED #145 was listed as the administrator of record with the state department). Administrator #141 confirmed without a Wellness Director (WD) (since 10/20/25) that the incident reports, incident logs, and infection control logs were either not completed or not comprehensively completed. Administrator #141 confirmed the facility did not have an infection preventionist (IP) as well. Per Administrator #141, ED #145 had the Wellness Director from the sister facility go back through the incidents for the last three months and attempt to complete an incident log, however the log was not complete, nor did it contain all the components required by the regulation. Administrator #141 reported she could not find an infection control log for December 2025 or January 2026 and there was no evidence that residents met criteria for treatment. There was no evidence that resident infections were being monitored for trends for August, September, October or November of 2025. Administrator #141 confirmed staff were doing their own schedule with oversite from LPN #109. Currently the facility has two nurses on dayshift and one nurse from 6:00 P.M. to 10:00 P.M., and one from 6:00 P.M. to 6:00 A.M. on nights shift. There are three PCA on dayshift and two on night shift.

Interview on 01/06/26 at an undisclosed time with Anonymous Staff Member #302 revealed there was not adequate staffing to ensure medication was administered timely and proper supervision to prevent falls and elopements. The staff confirmed there was no Wellness Director to oversee the nursing department. Staff are basically doing their own schedule and working with each other to cover shifts. Some days there is only one nurse for the entire four-story building. Staff have been quitting since ED #145 had cut staff. The nurses need training on the incident reports, incident logs, and infection control. The facility is not monitoring/addressing resident behaviors appropriately, as an example, Resident #246 who drinks daily and takes Ambien with alcohol. He is still driving while under the influence and is going to kill someone or himself. The facility needs two nurses on night shift to deal with all the residents with behaviors. Another example is Resident #235 who has behavioral issues and would not be safe to be on the road in the cold in a wheelchair on the mall road due to it's a busy road and cars speed on the road even though the speed limit was 25. She would have stopped him from leaving without transportation.

Interview on 01/06/26 at an undisclosed time with Anonymous Staff Member #303 confirmed there were not enough staff to meet the residents ' needs. Residents voice complaints of not receiving morning medication until lunch or after lunch. There were not enough staff to supervise residents to prevent elopements and monitor behaviors.

Interview on 01/06/26 at 12:41 P.M., with ED #145 confirmed in October and November 2025 she was the active Administrator for the facility. The new Administrator (#141) started on 12/01/25. The ED confirmed the new Administrator was still in orientation and she comes twice a week to help. The ED confirmed the facility hasn't had a Wellness Director or an Infection Preventionist since 10/20/25. ED #145 reported she had offered the position to each of the nursing staff, and they all declined the position. Staff do self-scheduling and LPN #109 looks over it. She would like to have two nurses on night shift, but currently there is only one for four hours and one for 12 hours. She had added a third staff member to dayshift and if the census increases she will add more staff to night shift. ED #145 confirmed the incident and infection control logs were not completed due to the facility not having a Wellness Director or Infection Preventionist. ED #145 confirmed that Residents #235 and #246 were referred to ViaQuest yesterday for behaviors. The residents are encouraged to sign in and out in the book and include reasons for leaving, but it's not required and it's not her business where they go.

Interview on 01/06/26 at 1:48 P.M., with Resident #263 confirmed there were not enough staff on night shift to answer call lights timely.

Interview on 01/07/26 at 11:51 A.M., with Administrator #141 revealed there was no way to determine staff who worked the last 30 days due to no one was tracking staff call offs. The Wellness Director was responsible for tracking the actual working schedule, but since the facility hasn't had a Wellness Director no one had been tracking the call-offs and schedule. The facility doesn't have a Medical Director. The facility has a contract with Abode (a group of medical providers), and the nurse practitioner (NP) comes to see some of the residents and the NP is overseen by the Medical Coordinator (from the Adobe Group). Administrator #141 confirmed neither the staff nor herself knows which residents require two-hour checks to ensure resident safety. Administrator #141 had spoken to staff, and they reported the Wellness Director used to give them a list with dots on it (indicating residents who require two hour checks), however since there was no Wellness Director the staff doesn't know for sure what residents required the two-hour checks to ensure their safety.

Interview on 01/08/26 with two anonymous staff members at an undisclosed time revealed the facility was short-staffed and staff were not able to answer call lights timely and properly supervise residents. Most days there were only two aides on dayshift, and they have to do housekeeping duties as well. Resident #246 left the facility about a month and half ago with a visitor around 9:00 P.M., drunk and didn't sign out or tell staff. The resident was gone over 15 hours. Resident #246 is going to hurt someone or himself,. He wanders in other residents' rooms. One night he was found in another resident's bed. The ED #145 is aware and said there was nothing the facility can do and do not call the police. Resident #231 had eloped one night, and the staff were not sure how she did it because she just had surgery and staff had to assist her with almost everything. The facility was not monitoring or addressing resident behaviors. Residents #235 and #246 are examples of staff not monitoring and treating behaviors. Staff were told not to go into Resident #235 room alone. The staff members reported Resident #235 would not be safe to leave the facility unsupervised.

Interview on 01/08/26 at an undisclosed time with anonymous residents revealed the facility has gone downhill. Nursing doesn't always respond timely or at all. One resident reported that once her blood pressure was elevated, she asked to see the nurse and the aide came back and said the nurse said to take your nerve pill and go to sleep.

Review of an undated, anonymous letter that was left to the surveyor revealed there were several issues with how things are done around the facility. The facility doesn't have a Wellness Director. The residents complain about not getting their call lights answered timely by dayshift. The author identified that they had residents cry to them about how the staff are mean to them on dayshift. We have residents that are not appropriate for assisting living and only have one nurse and two aides on night shift. It had been brought to several people ' s attention that if there was ever an emergency on night turn that would not be good. There are people on the top floors that are not able to get down the steps. The residents also complain about the cleanliness of the facility. Day shift always had a problem with people not coming to work. The residents pay our paychecks, and they can ' t get the proper care they are paying for because of management cutting corners and staffing.

This violation represents non-compliance investigated under Complaint Number OH00169265.

Based on medical record review and interview the facility failed to ensure the comprehensive needs of all residents were met. This affected three (#231, #235, and #246) of three residents reviewed. The facility census was 66.

Findings included:

1. Review of Resident #235's medical record revealed the resident was admitted to the facility on 11/05/25 from a skilled nursing facility with diagnoses including hemiplegia, dehydration, alcohol abuse, cannabis abuse, chronic pain syndrome, low back pain, blindness in left eye (artificial eye), acute kidney failure, and acute embolism and thrombosis of unspecified veins.

Review of Resident #235's Pain Management note dated 10/28/25 (prior to admission) revealed the resident was seen as a new patient with complaints of chronic bilateral knee pain and chronic neck pain. The note included the patient admittedly uses marijuana products as well as alcohol so he would have a non-narcotic care plan with this facility. The patient will return to the office in four weeks around 11/25/25 for review of x-rays and continued plan of care.

Review of Resident #235's pre-screening questionnaire dated 11/05/25 completed by the skilled nursing facility revealed the resident needed assistance with medication administration. The questionnaire revealed the resident drinks one alcoholic beverage daily. The resident had a history of smoking and marijuana use. This was completed prior to Resident #235's admission to the assisted living facility.

Review of Resident #235's Transfer Discharge report from the skilled nursing facility dated 11/05/25 revealed the resident had diagnoses including alcohol and cannabis abuse, chronic pain, low back pain, artificial eye, hemiplegia, blindness left eye, dehydration, and chronic embolism. The resident had a return appointment to pain management scheduled 11/24/25 at 12:30 P.M. The report included the resident was non-ambulatory, needed assistance with activities of daily living, and used a wheelchair for mobility.

Review of Resident #235's progress note dated 11/05/25 at 2:57 P.M. authored by Licensed Practical Nurse (LPN) #104 revealed the resident arrived via wheelchair and was alert and oriented times four when assessed. The resident preferred Adobe Care Partners as physician.

Review of Resident #235's pain assessment dated 11/05/25 authored by LPN #104 revealed the resident reported his pain was constant, the pain made it hard to sleep at night and limited his day-to-day activities. The resident had pain daily and was able to verbalize pain. The resident uses Oxycodone (narcotic) and Tylenol as needed daily.

Review of Resident #235's admission agreement dated 11/05/25 revealed two alcoholic drinks per day at evening happy hour. The resident was permitted to use alcohol unless restricted by physician order or if alcohol was contraindicated with physician prescribed medication. Other residents may not be disturbed as a result of alcohol use. All illegal drugs and paraphernalia were prohibited on the premises for resident and visitors.

Resident #235's admission agreement continued to include transportation could and would be provided for residents to physician appointments under the following conditions: Senior Suites must schedule resident appointments. Staff would be managing the transportation schedule and thus would know when they were available to transport residents to an appointment. Staff would set up transportation to an appointment that is within 15 miles of the facility. For all day appointments, it may be necessary for family to accompany residents.

Resident #235's admission agreement continued and identified the facility shall provide the following services on as needed basis as determined in the resident support plan: ongoing oversight, securing transportation, making and keeping appointments, securing healthcare, provide staff monitoring management of medication. and managing healthcare. The residents are required to sign in and out anytime a resident leaves the facility for any period of time. The facility should refer residents to an appropriate assessment agency if resident needs cannot be met by facility. Residents should not disturb the quiet environment of others or perform any act that is injurious to the facility or others. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise necessary and appropriate care consistent with the program for which the resident contracted. This care shall be provided without regard to considerations such as race, religion, national origin, age, or source of payment for care. The resident will be provided with a copy of the resident's rights. The residents have the right to a safe and clean-living environment, right to adequate and appropriate medical treatment and nursing care, the right to consume a reasonable amount of alcoholic beverages.

Review of Resident #235's Brief Interview for Mental Status dated 11/05/25 authored by LPN #104 revealed the resident's cognition score was 10 out of 15 indicating the resident had moderate cognition impairment.

Review of Resident #235's Wandering Risk Assessment dated 11/05/25 authored by LPN #104 revealed the resident was at moderate risk for wandering.

Review of Resident #235's fall assessment dated 11/05/25 authored by LPN #104 revealed the resident was at moderate risk for falls related to confined to chair, exhibits loss of balance while standing, uses short discontinuous steps and/or shuffling steps, exhibits jerking or instability when making turns, and decrease in muscle coordination.

Review of Resident #235's pain assessment dated 11/05/25 authored by LPN #104 revealed the resident reported his pain was constant, the pain made it hard to sleep at night and limited his day-to-day activities. The resident had pain daily and was able to verbalize pain. The assessment included the resident used Oxycodone (narcotic) and Tylenol as needed daily.

Review of Resident #235's functional assessment dated 11/05/25 authored by LPN #104 revealed the resident depended on someone else for travel and he was unable to make arrangements. The resident was oriented in person, place, and times but may have occasional forgetfulness. The resident occasionally had problems with sleep, agitated at nights, falls asleep during the day.

Review of Resident #235's senior living assessment dated 11/05/25 (un-authored) revealed the resident was capable of independent decision making. The resident reported pain. The resident was not ambulatory and used a wheelchair for mobility. The resident was not at risk for elopement and no known history of alcohol or marijuana abuse. The resident was dependent for arranging transportation.

Review of Resident 235's service plan dated 11/05/25 revealed Resident #235 was non- ambulatory and mobile with assistive device (wheelchair). The resident needed help with managing transportation/appointments. The resident needed assistance and/or appointment reminders as needed 1-2 times per month.

There was no service plan for Resident #235's pain, alcohol abuse, or cannabis abuse. In addition, there was no service plan to address Resident #235's safety and/or supervisory needs.

Review of Resident #235's care plan from the assisted living (AL) waiver program (a separate document from the resident's service plan) dated 11/05/25 to 09/30/26 revealed the AL would make or arrange transportation as needed. AL staff to monitor changes in health status, the resident would have access to transportation to meet the resident's needs for community integration, the AL would inform the case manager of any changes in needs or if any modification was needed to ensure health and safety.

Review of Resident #235's orders dated 11/05/25 to 01/05/26 revealed the resident had an active medication order for Oxycodone five milligrams (mg) every 12 hours as needed for pain and an order to return to pain management on 11/24/25 at 12:30 P.M. This return to pain management appointment was discontinued on 11/24/25 and reordered for 12/11/25 at 10:30 A.M.. This order for the pain management was then discontinued on 12/11/25 and rewritten for 12/18/25 at 2:00 P.M.

There was no documentation that identified the reason for Resident #235's pain management appointments being discontinued/changed.

On 12/11/25 new orders were written for ViaQuest (psych consult). There was no documentation that identified the reason for the ViaQuest consult.

There was no evidence of orders for alcohol/non-alcohol beverages per the residents' admission orders.

Review of Resident #235's progress note dated 11/10/25 authored by Registered Nurse (RN) #116 revealed Adobe Nurse Practitioners (NP) nurse was notified the resident refused to take scheduled medication. The resident only takes Aspirin. The NP nurse reported the resident was not in the system yet. Faxed consent and resident information to direct patient intake.

Review of Resident #235's initial evaluation authored by Nurse Practitioner (NP) #146 dated 11/18/25 (13 days after the resident's admission to the facility) revealed the resident was being seen today for initial evaluation. The evaluation indicated the resident was alert and oriented times four and answered questions appropriately during the visit although his voice was sometimes difficult to understand. The resident was noted to have a history of artificial left eye as a result of a gunshot wound, lower back pain, blindness in left eye, acute embolism in upper extremity, acute kidney failure, hemiplegia on left side, dehydration, alcohol and cannabis abuse, and chronic pain syndrome. Staff reported he was refusing his ferrous sulfate, Senna, Eliquis, and Vitamin B1 since arriving at the facility but continued on Tylenol 650 milligrams (mg) every six hours as needed, Oxycodone 5/325 mg every 12 hours as needed, and aspirin 81 mg daily. The resident had a wheelchair he was able to self-propel around the facility and had left-sided weakness. Staff reported the resident followed up with pain management and that was who prescribed his Oxycodone. The resident would be monitored for any signs of withdrawal or complication related to alcohol and cannabis dependence and continue Tylenol and Oxycodone for pain management as well as physical therapy to address pain and improve function. The evaluation revealed the resident had chronic medical conditions or high-risk diagnoses which made it necessary for increased medical oversight related to his conditions. There was a potential for decline, or severe illness, or re-hospitalization should this patient not have access to timely care.

Review of Resident #235's medical record revealed no evidence the resident had a return visit to the pain management clinic on 11/24/25 as identified in the transfer report from the skilled nursing facility (dated 11/05/25) or evidence of monitoring for withdrawal per NP noted dated 11/18/25.

Review of Resident #235's progress note dated 11/24/25 authored by RN #116 revealed the facility called the skilled nursing facility the resident was transferred from to inquire who the resident saw for pain management. After verifying with the skilled nursing facility, the facility called and rescheduled the appointment to 12/11/25 at 10:30 A.M.

Review of Resident #235's progress note dated 11/26/25 authored by LPN #104 revealed Abode and pain management was notified for a script for as needed Oxycodone due to the Oxycodone was no longer available. Pain management returned the call and reported that they treat the resident without narcotics and they cannot order the medication. The NP from Abode was notified the last script was from the physician at the skilled nursing home.

Review of Resident #235's progress note dated 12/01/25 authored by RN #116 revealed the staff faxed Abode for refill on Oxycodone for the resident. This medication was never received.

Review of Resident #235's progress note dated 12/04/25 authored by LPN #108 revealed the resident arrived at the nurse's station with complaints of severe pain to right lower extremity. Upon assessment the resident described pain to be throbbing and constant, getting much worse upon movement. Resident requested to be sent to the hospital. Emergency Medical Services (EMS) was called, and report was called to the hospital, physician, and power of attorney. The resident returned at 5:22 P.M., with no new orders.

Review of Resident #235's progress note dated 12/05/25 at 10:23 A.M. authored by LPN #104 revealed the resident was educated that staff here had no issues giving as needed narcotic (to resident) if ordered by physician and the facility staff would assist in any way possible. The resident stated I need them sometimes, not all the time, some days I don't take any. When I am really hurting, I need them. LPN #104 told the resident she was waiting for the resident's appointment on 12/11/25 (for the pain management facility), advised the resident to inform staff if he requested a change in provider. The resident voiced understanding.

On 12/11/25 there was an order for ViaQuest, however, no progress note or indication of why. There was no evidence that the ViaQuest referral was made.

Review of Resident #235's Via Quest (psychiatric note) dated 01/12/26 revealed the resident denied depression but reports his anxiety was a six out of ten due to being told he had to come to assisting living. He reported I don't want to be here. The resident had adjustment disorder with anxiety and discussed the use of Vistaril as needed for anxiety. Plan included Vistaril 25 mg every six hours as needed for 14 days for anxiety and mental health services.

Interview on 01/05/26 at 6:39 A.M., with Personal Care Assistant (PCA) #124 confirmed the facility currently does not have a Wellness Director. The PCA reported on night shift there was not adequate staffing to evacuate residents in an emergency. The building was four stories, and some residents need assistive devices for ambulation. The staff have voiced concerns numerous times but no changes in staffing have been made. The PCA reported she tries to check all residents every two hours, however there are some residents that sign waivers not to be checked. PCA #124 reported she checks Resident #235 every two hours, but she was not sure if he requested to be checked or not. The PCA reported the resident is alert and oriented, but she doesn't feel he would be safe on the main road in a wheelchair. The PCA reported the resident usually pushes himself backwards in the wheelchair instead of going forward.

Interview on 01/05/26 at 11:00 A.M., with Resident #235 revealed on 12/05/25 he told staff he wanted to go to the cannabis store to get marijuana for his pain. The staff kept telling him someone was coming to take him, but no one ever showed up. He stated he was tired of waiting so he left on his own and started hitch hiking. Motorists stopped to help but some of them couldn't fit his wheelchair in their cars. He stated he made it down to the bridge (0.9 miles from the facility) and tried crossing the road to get on the sidewalk that crossed the bridge. Prior to that he was on the main road (three lanes) due to there were no sidewalks. The police showed up and told him the road was dangerous to walk on due to it being a busy road and cars drove fast. He then stated he got a ride to the main entrance of the mall (1.9 miles from the facility) and saw the restaurant and decided to have a drink. The next thing he knew was he was intoxicated and he spent the week in jail. The resident confirmed he had smoked marijuana at the facility near the smoking area. The resident confirmed he was discharged from a skilled nursing facility last year for leaving the facility unsupervised and got intoxicated. The resident reported he was not happy at this facility because there was nothing for him to do and he had no access to the community. The resident reported he had no common interest with the current residents, and he would like to be somewhere closer to activities he likes.

Additional interview on 01/06/26 at 1:55 P.M., with Resident #235 revealed a motorist picked him up at the bridge on Common Mall Crossing Road (on 12/05/25). As the motorist was loading his wheelchair in the truck a police officer arrived. He rode to the mall with the motorist. Resident #235 reported there were not enough staff to answer call lights timely.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 confirmed Resident #235 had voiced concerns about leaving several times prior to the incident on 12/05/25 to go the cannabis dispensary. The day of the incident he was upset and was talking about his opioid addiction and the doctor had cut his pain medication off. The resident was agitated with nursing staff because they would not give him anything but Tylenol for pain. He told her he needed to get weed if staff wasn't going to give him opioids.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 revealed confirmed the facility did not have a Wellness Director to oversee nursing. LPN #104 revealed Resident #235 was alert but had behaviors such as drug seeking. Her concern was that once he left he wouldn't return.

Interview on 01/06/26 at 3:43 P.M., with Resident #235's Case Manger #147 revealed she was just assigned the facility in November (2025). She stated she had had issues with communication since the facility had not had a Wellness Director. The facility had not reported concerns timely and most of the time she has to go into the resident electronic medical record to find information. The case manager reported she didn't feel Resident #235 was safe to be unsupervised in the community due to his impulsive behaviors. The resident reported to the case manager during their first visit he didn't like this place because it was not near a cannabis dispensary. The case manager reported the root cause for the resident leaving on 12/05/25 was because he was in pain and the Tylenol was not relieving his pain and he needed marijuana. The case manger reported she met with the facility today regarding the resident being transferred to the sister facility, however her supervisor and herself didn't feel it was a good decision because the resident may get into more trouble as the sister facility had a younger population and described the facility as a frat house.

Interview on 01/06/26 at 4:15 P.M., with Resident #235's Nurse Practitioner (NP) #146 reported she had only seen Resident #235 once. The NP reported she didn't have previous records to review; however, she was aware the resident had been seen by pain management in the past and was upset he wasn't getting narcotics.

Interview on 01/07/26 at 11:51 A.M., with Administrator #141 confirmed Resident #235 did not go to the pain management appointment on 11/24/25 but staff didn't know why. The resident didn't go on 12/11/25 because he was in jail. The resident went on 12/18/25; however, the facility didn't have the progress notes and didn't know the resident treatment plan.

Interview on 01/12/26 at 12:30 P.M., with LPN #109 confirmed Resident #235's admission orders was for one 12-ounce non-alcoholic beer daily as needed. The LPN confirmed the order was never entered.

2. Record review revealed Resident #231 was admitted to the facility on 10/15/25 with diagnoses including macular degeneration, diabetes, and peripheral vascular disease. The resident was transferred on 12/12/25 to a skilled facility after being hospitalized on 12/07/25.

Review of Resident #231's transfer form dated 10/15/25 from the skilled nursing facility indicated the resident had diagnoses including atrial fibrillation, depression, polymyalgia rheumatica, chronic kidney disease, anxiety, insomnia, chronic kidney disease, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.

Review of Resident #231's wandering risk assessment dated 10/15/25 revealed the resident moderate risk for wandering.

Review of Resident #231's senior living assessment dated 10/15/25 revealed the resident required nighttime care (safety checks/comfort checks).

Review of Resident #231's assisted living waiver program referral dated 11/04/25 revealed the resident was accepted in Tier 3 (memory program).

Review of the Resident #231's police report dated 11/25/25 revealed at 4:29 A.M., a caller called and reported an elderly female in a wheelchair on Common Mall Crossing. The female was Resident #231, she attempted to leave the facility, stating she's receiving abuse from visiting family member. The staff came out and convinced her to come inside. The alleged abuse will be investigated internally by the facility; they will reach out if they find anything of merit.

Review of Resident #231's service plan dated 10/15/25 revealed no evidence of a service plan for dementia, wandering, or behaviors.

Interview on 01/12/26 at 12:30 P.M., with Licensed Practical Nurse (LPN) #109 confirmed Resident #231 did not a service plan for interventions including dementia, wandering, or behaviors.

3. Record review revealed Resident #246 was admitted to the facility on 02/13/25 with diagnoses including insomnia and urine retention.

Review of Resident #246's wandering assessment dated 05/18/25 revealed the resident was low risk for wandering. He was noted to be forgetful/short attention span.

Review of Resident #246 assisted living assessment dated 05/20/25 revealed the resident was oriented and on safety checks. The resident was independent for decision making and was being monitored for behaviors, however no behaviors where checked or documented. The resident can't manage his own medications. The resident requires assistance with medication due to cognitive loss.

Review of Resident #246 progress note dated 10/18/25 authored by LPN #103 revealed the resident was drunk, crawling on floor looking for his wallet.

Review of Resident #246 progress note dated 11/09/25 authored by LPN #133 revealed the resident had been on several floors trying to get into resident rooms as he had been drinking wine this shift and he had his evening medications. He had been staggering and was confused and had been taken to his room several times via wheelchair by staff. He was found lying on his back on the floor in the hallway outside of his room. No injury noted. He was assisted off the floor into wheelchair by two staff and was taken into his room and was asked to please use his pendant if he wanted to get up.

Review of Resident #246 progress note dated 11/13/25 at 9:47 P.M. authored by LPN #102 revealed the nurse was informed by the aide the resident appeared to be off balance while walking out of the building prior to leaving facility in own vehicle.

Review of Resident #246 progress note dated 11/19/25 at 3:39 P.M. authored by LPN #150 revealed the resident had left the building last night and has not returned or contacted the facility. Attempted to call the son but no answer, also contacted the resident's clinic who have not seen him today.

Review of Resident #246 progress note dated 12/24/25 authored by LPN #129 revealed the resident was drinking after he received his nighttime medication. Resident #246 was previously found wandering the hall by this nurse and aide. The staff members talked with the resident about needing to have clothes on before he could be in the common areas. The resident stated he was fine. The resident could barely hold himself up when he was being redirected the first time. The resident was helped back to his room and back to bed by this nurse and aide. This nurse had already seen and smelled alcohol on the resident's breath and so this nurse took his car keys to make sure that the resident would be safe and not out on the road. The resident got up in the time staff had left at 10:00 P.M. and went and got into his neighbor's bed. The door was locked and staff were not sure how he got into the room. The resident was in the bed resting when staff found him because he pulled the pull cord. The resident had been spoken to several times about drinking and wandering the halls. The resident was noncompliant. The administrator and son were notified. 911 was called after searching for the resident and nothing had turned up nothing. The resident was helped from the other room back to his room and to bed.

Review of Resident #246 incident/investigation report and progress note dated 01/08/26 authored by LPN #103 revealed without evidence of the resident drinking alcohol Ambien was given at 10:36 P.M. At 12:29 A.M. the resident was not in his room, and an empty bottle of wine was on his sink. This nurse was concerned the resident maybe driving under the influence. The resident's car was gone from the parking lot.

Review of Resident #246 service plan dated 02/26/25 revealed the resident needed help with medication due to cognitive loss. Further review revealed there was no evidence in the resident serviced plan regarding behaviors including wandering and behaviors related to drinking alcohol.

Interview on 01/12/26 at 12:30 P.M., with Licensed Practical Nurse (LPN) #109 confirmed Resident #246 did not have a service plan with interventions related to wandering or behaviors related to drinking alcohol.

This violation represents non-compliance from survey completed on 11/04/25.

This violation represents non-compliance investigated under Complaint Number OH00169265.

Based on medical record review, review of the facility's incident and accident log, interview and policy review, the facility failed to ensure incidents were investigated and documented on the incident log. The facility also failed to ensure the incident log contained all the required information. This affected three residents (#231, #235, and #246) of three residents with the potential to affect all 66 residents residing in the facility.

Findings included:

1. Review of the incident log dated 10/01/25 to 01/05/26 revealed the residents' name, date, time, and if it was an elopement or fall. There was no evidence of a general description of the incident, place, or care provided, or action taken.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 confirmed the incident log did not include the general description of the incident, place, or care provided or action taken as required.

2. Record review revealed Resident #231 was admitted to the facility on 10/15/25 with diagnoses including macular degeneration, diabetes, and peripheral vascular disease. The resident was transferred on 12/12/25 to a skilled facility after being hospitalized on 12/07/25.

Review of Resident #231's wandering risk assessment dated 10/15/25 revealed the resident was moderate risk for wandering.

Review of the Resident #231's police report dated 11/25/25 revealed at 4:29 A.M., a caller called and reported an elderly female in a wheelchair on Common Mall Crossing. The female was Resident #231, she attempted to leave the facility, stating she's receiving abuse from visiting family member. The staff came out and convinced her to come inside. The alleged abuse will be investigated internally by the facility; they will reach out if they find anything of merit.

Review of Resident #231's progress note dated 11/25/25 at 6:40 A.M. authored by Licensed Practical Nurse (LPN) #103 revealed at 4:32 A.M. 911 called to see if we could pick the resident up at the end of the sidewalk. The resident was last seen at 2:45 A.M., by aide. The resident had her coat/gloves/hat on. She was taking herself to the police station to report abuse allegations of her family, was able to convince her to come back inside for the night. Administrator notified at this time.

Review of the incident log dated 10/01/25 to 01/05/26 revealed no evidence of the incident that occurred on 11/25/25 when the resident eloped.

There was no evidence an investigation was completed.

Interview on 01/05/26 at 9:30 A.M., with Executive Director (ED) #145 confirmed there was no investigation completed nor was the elopement documented the incident log for Resident #231. ED #145 reported she was not aware of the incident even though staff had charted she was notified.

3. Review of Resident #235's medical record revealed Resident #235 was admitted to the facility on 11/05/25 from a skilled nursing facility with diagnoses including hemiplegia, dehydration, alcohol abuse, cannabis abuse, chronic pain syndrome, low back pain, blindness in left eye (artificial eye), acute kidney failure, and acute embolism and thrombosis of unspecified veins.

Review of Resident #235's Wandering Assessment authored by LPN #104 revealed the resident was a moderate risk for wandering.

Review of Resident #235's progress note dated 12/05/25 at 10.00 P.M. authored by LPN #133 revealed received a 911 call that a man saying he lived at the facility was inebriated at restaurant and the police were needing to know his name. After description was given it was determined to be Resident #235. He was brought back by two deputies, and he was lying down in the back seat of the cruiser. He had emesis on his shoes. When they tried helping the resident out of the car he yelled and cursed. Deputies' finally sat him up and assisted him out of the cruiser into his wheelchair. When they tried helping the resident out of the car he yelled and cursed. Deputies' sat him up and assisted him out of cruiser into his wheelchair. After he came into the lobby he said he wanted to go to the hospital. He ran over aides' foot with his wheelchair and gave inappropriate hand signals and telling LPN to go away. He vomited all over the floor. EMT's came and he refused to get onto the stretcher for quite a while. Finally, he said he wanted to go to the restroom where he voided onto the floor and then fell off the toilet onto the floor. Administrator (#141) heard most of this as she was on the phone with the nurse. EMT's loaded the resident onto the stretcher and transported him to the hospital.

Review of Resident #235's progress note dated 12/06/25 at 12:55 A.M. authored by LPN #133 revealed the police called and reported the resident was arrested for persistent disorderly in front of medical facility. Administrator #141 was called and updated.

Review of Resident #235's police report dated 12/05/25 at 10:44 P.M., revealed the resident was arrested for disorderly conduct. The narrative included on 12/05/25, approximately 7:57 P.M., the police responded to the mall to assist the sheriff's office regarding having an elderly male in a wheelchair removed from the restaurant for being intoxicated and disorderly. Upon arrival to the mall, the resident had vomited on the floor inside the restaurant. While on scene another officer radioed and reported he had dealt with the same gentleman earlier in the day. He stated the resident was trying to get to the mall from the assisted living and was found on Common Mall Crossing in his wheelchair. The officer stated the resident was given a ride. After receiving that information the male resident was taken back to the assisted living. At approximately 8:35 P.M., the officer arrived back to the assisted living to the EMS regarding the same male. Staff reported the male was intoxicated and was being disrespectful to them. The officer was told the male had urinated multiple times on the lobby floor and kept changing his mind about going to the hospital. Shortly after that, the male resident went to the bathroom and fell onto the floor and urinated on himself again. The male was transported to the hospital. At approximately 10:44 P.M. the officer was dispatched to the hospital regarding the same male giving hospital staff issues. The hospital was going to discharge the resident; however, the assisted living was contacted and stated the male was responsible for his own transportation. After a short while, the hospital was able to contact a taxi service and pay for the cost. The male continued to disrespectful to staff and was highly intoxicated. He stated he wanted to go to jail multiple times, and he was not going back to the assisted living. The resident reported he was going to leave, and no one was going to stop him. He got out of bed and onto the floor and began crawling out of the room into the hallway. He was advised to get back in bed or he would be arrested. Due to ignoring the warning, the male resident was placed under arrest for persistent disorderly conduct due to being voluntarily intoxicated and inside of a medical facility. He was transported to jail and booked.

Review of Resident #235's fall investigation dated 12/05/25 revealed the resident was brought back by the deputies drunk and very argumentative and combative. He requested to go to the hospital, EMT staff helped the resident to the restroom, and he voided onto the floor then fell off toilet onto floor. EMT's, nurse, and two aides were outside the restroom door and heard him in restroom. No injuries were observed at the time of the incident. EMT's loaded him and transported him to the local hospital in town. The predisposing factor was wanderer. The Administrator and Hospital were notified.

There was no evidence Resident #235's medical provider was notified, root cause, or interventions implemented.

Further review revealed the investigation didn't include the resident leaving the facility unsupervised, being intoxicated, and arrested.

Review of the incident log dated 10/01/25 to 01/05/26 revealed the resident had a fall on 12/05/25 at 10:00 P.M. There was no general description, place, or care or action taken.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 confirmed the incident log did not include the general description of the incident, place, or care provided or action taken per regulation.

Interview on 01/05/26 at 9:30 A.M., with Executive Director (ED) #145 confirmed the facility did not investigate the incident when Resident #235 left the facility unsupervised or the incident with the police.

4. Record review revealed Resident #246 was admitted to the facility on 02/13/25 with diagnoses including insomnia and urine retention.

Review of Resident #246 progress note dated 11/09/25 authored by LPN #133 revealed the resident had been on several floors trying to get into resident rooms as he had been drinking wine this shift and he had his evening medications. He had been staggering and was confused and had been taken to his room several times via wheelchair by staff. He was found lying on his back on the floor in the hallway outside of his room. No injury noted. He was assisted off the floor into wheelchair by two staff and was taken into his room and was asked to please use his pendant if he wanted to get up.

Review of Resident #246 fall investigation dated 11/09/25 revealed the resident was in the hallway on his back outside his room. He had bent down to unlock his door and fell. The resident had been drinking wine and took his evening medication. There were no injuries noted. Staff assisted resident in wheelchair and wheeled him into his room. The resident was slurring his words and had been staggering around trying to get into other rooms this evening.

There was no evidence that any interventions were implemented.

Review of the incident log dated 10/01/25 to 01/05/26 revealed Resident #246 had a fall on 11/09/25 at 12:25 A.M. There was no general description, place, or care or action taken noted.

Review of Resident #246's progress note dated 12/23/25 authored by LPN #129 revealed the resident was drinking after he received his nighttime medication. The resident was previously found wandering the hall by this nurse and aide. The staff members talked with the residents about needing to have clothes on before he could be in the common areas. The resident stated he was fine. The resident could barely hold himself up when he was being redirected the first time. The resident was helped back to his room and back to bed by this nurse and aide. This nurse had already seen and smelled alcohol on the resident's breath and so this nurse took his car keys to make sure that the resident would be safe and not out on the road. The resident was later found in another resident's room. The door was locked and we are not sure how he got into the room. The resident was in the bed resting when staff found him because he pulled the pull cord. The resident had been spoken too several times about drinking and wandering the halls. The resident was non-compliant. The administrator and son were notified. 911 was called after searching for the resident turned up nothing. The resident was helped from the other room back to his room and to bed.

Review of the police report dated 12/23/25 revealed at 11:13 P.M., the caller reported an intoxicated 81-year-old male may have eloped from the facility in his underwear only. The resident was searching for alcohol and may have walked towards the gas station. The staff has his car keys. At 11:21 P.M., the caller called back and reported resident was found in bathroom and was okey denied EMS to evaluate resident.

Review of the incident log dated 10/01/25 to 01/05/26 revealed the resident had an elopement on 12/23/25 at 10:20 A.M. There was no general description, place, or care or action taken noted.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 confirmed the incident log did not include the general description of the incident, place, or care provided or action taken per regulation.

Review of the facility's policy titled Incident Reports (undated) revealed injury and unusual incidents will be reported in compliance with state regulatory requirements. The incident form is used to document and report any incidents which is a threat to a resident's health, safety, welfare, or rights. This included, but is not limited to occurrences such as falls, injury, psychiatric crisis, unexplained absences, violation of rights, any incident that threatens the health, welfare, or safety of the residents. The nursing staff will complete the incident log and incident report.

This violation represents evidence of continued non-compliance from survey completed on 11/04/25.

This violation represents non-compliance investigated under Complaint Number OH00169265.

Based on infection control review of infection control log, interviews, and policy review the facility failed to maintain a comprehensive infection prevention and control program and failed to ensure the facility had an infection preventionist (IP). This had the potential to affect all 66 residents residing in the facility.

Findings included:

1. Interview on 01/06/26 at 8:14 A.M., with the Administrator #141 and 12:41 P.M., with the Executive Director (ED) #145 confirmed the facility has not had an infections preventionist since 10/19/25.

Review of the facility's policy titled Infection Preventionist (dated 07/07/20) revealed the facility would employ one or more individual with responsibility for implementing the facility's prevention and control program. The Infection Preventionist (IP) will work at least part-time at the facility and adequately qualified and meets the eligibility requirements. The IP will report to the Wellness Director.

2. Review of the infection control log dated 10/2025 to 01/2026 revealed the log the residents' name, the site of the infection, antibiotic, start date and resolved date. There was no evidence of the organism or evidence the infection/organism were being tracked to determine trends. Further review revealed there was no tracking or trending for the months of December 2025 or January 2026.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 and 12:41 P.M., with the Executive Director (ED) #145 confirmed the facility did not have tracking or trending records for the months of December 2025 or January 2026. The Administrator confirmed the log was not comprehensive to include the organism nor was there evidence the facility was tracking to ensure trends of infections.

Review of the facility's policy titled Infection Control (undated) revealed the Wellness Director, IP, or designee will monitor and track all infections and review with the clinical care committee to review and monitor for trends, equipment evaluation, and make recommendations for staff education. The facility will follow the Center of Disease Control (CDC) guideline on specimen collection and treatment under the guidance of the Medical Director. Every reasonable attempt would be made to prevent the spread of infection at the facility. The policy didn't include how to track and trend infection to prevent the spread of organisms.

This violation represents non-compliance from survey completed on 11/04/25.

This violation represents an incidental finding of non-compliance investigated under Complaint Number OH00169265.

Based on observation, interview, and review of resident council minutes the facility failed to make accommodation for residents who smoke during adverse weather conditions and ensure the residents had containers to dispose of cigarette butts. This had the potential to affect all 66 residents residing in the building.

Findings included:

Review of Resident Council Minutes dated 12/17/25 revealed residents reported the smokers needed a better shelter. The resolution was the Administrator ordered on 12/18/25.

Review of the invoice dated 12/18/25 revealed a 10 by 10 pop up canopy tent was ordered and would arrive on 12/22/25.

Observation on 01/05/26 at 6:32 A.M., with Personnel Care Assistant (PCA) #136 revealed there was no shelter for the smoker to use in adverse weather conditions. Resident #260 was observed behind a shed (not in the designated area) smoking a cigarette and flipping ashes on the ground. The bench for residents to sit on was blown over as well as the four ashtrays. The bench and ash trays were covered with snow and frozen to the ground. Cigarette butts were observed all over the ground. PCA #136 confirmed findings.

Interview on 01/05/26 at 6:39 A.M., with PCA #124 confirmed the residents have no shelter to protect them from the weather when they smoke. The canopy they had blew away months ago.

Interview on 01/05/26 at 7:21 A.M., with Licensed Practical Nurse (LPN) #109 confirmed the canopy for the smokers that blew away was probably around November (2025).

Interview and observation on 01/05/26 at 7:30 A.M., with Administrator #141 confirmed the residents had no shelter to protect them against adverse weather. The Administrator confirmed the bench was flipped over and the four ashtrays were blown over near the weeds and covered with snow. The Administrator confirmed there was cigarette butts on the ground and behind the shed where Resident #260 was observed smoking earlier. The Administrator reported she had ordered a new canopy a few weeks ago, but maintenance had not put it up. The Administrator reported that the ashtrays need sand or something to hold them down to prevent them from blowing away.

Interview on 01/06/26 at 1:48 P.M., with Resident #263 confirmed there had not been a shelter for residents to smoke for months. The resident reported that the ashtrays blow away frequently as well.

Review of the facility's policy titled Smoking Policy dated 06/18/25 revealed the designated smoke area was at the end of patio on left side. Smokers must keep designated smoking areas litter-free, which includes properly extinguishing and disposing of cigarette butts and remaining ashes into the appropriate waste receptacles.

This violation represents non-compliance investigated under Complaint Number OH00169265.

Based on observation, medical record review, review of police reports, review of hospital records, review of online accuweather data, review of personnel files, review of the Wellness Director job description, policy review, and interview the facility failed to provide a safe environment to meet the total care and safety/supervisory needs of residents to ensure all residents attained/maintained their highest practicable physical, mental, and psychosocial well-being. This resulted in Real and Present Danger and the potential for serious harm, injury and/or death beginning on 10/20/25 when the absence of adequate nursing oversight and Wellness Director resulted in residents (#231, #235 and #246) not being adequately assessed or provided comprehensive, individualized and effective safety/supervisory interventions to ensure the residents were provided a safe environment and to prevent the residents from being unsafe in the community. Beginning on 11/05/25 Resident #246 was identified to have safety concerns related to self-administration of medications combined with alcohol consumption and subsequent concerns when leaving the facility independently; however, the facility failed to implement individualized and effective interventions to ensure the resident ' s safety. On 11/25/25 at 4:32 A.M. the facility was notified Resident #231 was unsupervised outside the facility and needed staff to pick her up; staff were unaware the resident was missing at the time they were called by police/emergency medical services (EMS). On 12/05/25 Resident #235 left the facility unsupervised and without staff knowledge and was subsequently assessed to be intoxicated and arrested. This affected three residents (#231, #235, #246) of three sampled residents reviewed for safety. The facility census was 66.

On 01/07/26 at 12:58 P.M., Executive Director (ED) #145 and Administrator in Training (Administrator #141) were notified Real and Present Danger began on 10/20/25 when the facility failed to have comprehensive nursing systems in place to ensure oversight of the nursing department and failed to ensure residents (#231, #235 and #246) were assessed and provided effective intervention to maintain a safe environment.

The Real and Present Danger was abated on 01/15/26, when the facility implemented the following corrective action:

On 01/08/26 Licensed Practical Nurse (LPN) #109 was identified to be the Interim Wellness Director. On 01/12/26 LPN #109 signed the Wellness Director job description. The facility indicated a new Wellness Director had been hired with a start date of 01/26/26.

On 01/08/26 from 9:00 A.M. to 4:30 P.M. the Administrator, Executive Director and Interim Wellness Director completed a comprehensive review of 30 days of progress notes on all 65 residents. All progress notes were reviewed to ensure incident reports were completed, investigations done, and Case Managers/Family notified as applicable. The Incident Report log was updated to include all required fields and all incidents from the last 30 days were entered into the log by the Wellness Director. Further review was completed to ensure all incident reports, when applicable, were followed up with a post-incident resident assessment and recommendations to ensure immediate safety.

On 01/08/26 Resident #246 was reassessed by the Interim Wellness Director to ensure the resident was safe to reside at the facility and the facility could meet his needs. The resident was also reassessed for safety risks, psychosocial needs, behavioral indicators, cognitive status and wandering risk.

On 01/08/26 Resident #235 was reassessed by the Interim Wellness Director for safety risks, psychosocial needs, behavioral indicators, cognitive status, pain assessment and wandering risk. The resident was also reassessed to determine appropriate placement of the resident at the facility.

On 01/08/26 the Administrator reached out to local public transportation to discuss making Senior Suites a daily pick-up area and the possibility of having a representative come to the campus to assist residents in attaining bus passes on a scheduled day. These modes of transportation could also accommodate resident wheelchairs upon request. The front desk would assist all residents in setting up transportation.

On 01/09/26 education was sent to nine (9) nurses, 16 Personal Care Assistants (PCA ' s) nine (9) dietary employees, one (1) Administrative Assistant, two (2) Administrators, one (1) Activity Director, three (3) Housekeeping employees, and one (1) Maintenance Director through the facility Paycom Application on the following policies: Abuse, Neglect & Misappropriation and reporting requirements, Elopement and the procedures to follow should it occur; and Falls and the procedures to follow should it occur. All staff signed acknowledging understanding of the policies/training. Beginning on 01/15/26, the Administrator would interview a random sample of six employees to ensure they can answer questions regarding the trainings/policies they have signed. Anyone who was identified to not understand the policies would be trained in person at that time. Any instances of employees not following the policies will result in disciplinary action.

On 01/09/26 from 8:00 A.M. until 5:00 P.M. the Interim Wellness Director, RN #116 and LPN #102 reassessed all 58 in-house residents for proper placement, safety risks, psychosocial needs, behavioral indicators, cognitive status, fall risks and wandering risk. Individualized interventions were implemented immediately, including increased supervision as warranted, environmental modifications as needed, staff cueing/redirection and behavioral supports. Interventions communicated to staff in the same shift.

On 01/12/26 the Administrator met with Resident #235 to discuss the facility admission agreement was discussed in relation to his elopements, and his alcohol and drug use. Resident #235 was assessed by Viaquest for psych services on 01/12/26.

As of 01/12/26 Resident #231 continued to reside in a skilled nursing facility. Prior to re-admission, the Interim Wellness Director would determine if the resident ' s needs could be met in the facility. If determined to be appropriate, upon the resident ' s return, assessments would be completed and service plan updates would be emailed to the resident ' s case manager as warranted. Assessments would include safety risks, psychosocial needs, behavioral indicators, cognitive status and any other assessments identified to be needed upon return. Resident #231 ' s service plan would be updated to reflect any needs at that time.

On 01/12/26 the Administrator entered into an agreement with Resident #246 that the resident would give the nurse his car keys upon receipt of his Ambien/Trazadone or any other sedating medication at night to ensure his safety. Resident #246 also agreed to give the nurse his keys if he does not take his Ambien or Trazadone and was found to be drinking alcohol for his safety.

On 01/12/26 the facility Incident Reporting policy was updated by the Administrator to include that all incidents would be entered onto the Incident Reporting log by the Wellness Director and would be utilized for tracking purposes. Incident Report Policy update training was sent to nine (9) nurses, 16 PCA ' s nine (9) dietary employees, one (1) Administrative Assistant, two (2) Administrators, one (1) Activity Director, three (3) Housekeeping employees, and one (1) Maintenance Director through the facility Paycom Application.

On 01/13/26 the Administrator reviewed all current facility policies with no changes made.

On 01/14/26 Resident #246 signed a Risk Agreement, and his service plan was updated by the Interim Wellness Director to address his noncompliance and include the resident would not combine narcotics and alcohol. Resident #246 ' s service plan was updated to include the resident had agreed to give staff his car keys during the night for safety reasons.

Beginning on 01/14/26 at 10:00 P.M. the facility implemented a plan for all (exterior) doors to be locked to ensure resident safety. The doors would be unlocked at 6:00 AM each day. The doors would be monitored between the hours of 4:00 P.M. and 10:00 P.M. and 6:00 A.M. and 8:00 A.M. with an alarm system. The aides pagers would beep when a door was opened. This would alert the aide to check the door. Residents and visitors would be permitted entrance/exit by the nurse or aide on duty. The Maintenance Director would be responsible for ensuring all door alarms were in working order. All aides were trained on this process through the Paycom application.

Beginning on 01/14/26 the Interim Wellness Director was to ensure all shifts were covered with appropriate staffing ratios to meet the needs of the residents. The staffing ratios were determined by the Administrator, Executive Director, and Interim Wellness Director based on the needs of the residents. Beginning on this date, a schedule was created, and a running schedule would be maintained by the Interim Wellness Director. Should there be a need for additional staffing or a call-off the Interim Wellness Director or designee would work to fill the shifts. This would be re-evaluated daily as the needs of the residents ' changed.

On 01/15/26 Resident #246 was seen by his primary care physician. The Interim Wellness Director/designee would follow up with Resident #246 ' s physician to discuss recommendations following the appointment and document the follow-up in the resident ' s progress note. The Interim Wellness Director and Administrator would implement any recommendations from the physician.

On 01/15/26 the Interim Wellness Director and facility licensed nurses assessed all current facility residents for appropriate placement in the facility. Moving forward a Level of Care would be completed on each resident quarterly and when there was a change in condition. Anyone identified to not being appropriately placed would be given 30-day notice. During those 30 days the Interim Wellness Director and Administrator would meet to discuss the resident's specific needs and how the facility would meet them.

Beginning on 01/15/26 the facility implemented a plan for all perspective residents to be assessed prior to admission. The Administrator would request a copy of the history and physical, current medication list, and an order from their primary care physician assessing the resident was appropriate for assisted living placement. In addition, if the resident was in a skilled nursing facility (prior to admission) 60 days of documentation to include progress notes, nursing notes and any behavior related notes would be requested. The information would be reviewed by the Administrator and Interim Wellness Director. Following the paperwork review and an in-person assessment, the Administrator and Wellness Director would decide if the needs of the resident could be met by the facility.

Beginning on 01/15/26 the facility identified the following audits would be implemented:

The Interim/Wellness Director or designee would ensure all Incident Reports were entered on the Incident Reporting Log daily. This would be audited and documented by the Wellness Director/Designee daily for two weeks and weekly for two months.

The Interim/Wellness Director/Designee would ensure appropriate assessments were completed following the completion of an Incident Report. For instance, after a fall a Fall Assessment would be completed. This would be monitored and documented by the Wellness Director/Designee daily for two weeks and weekly for two months.

The Maintenance Director would ensure the door alarms were working and alerting the aide ' s pagers to ensure resident safety. Audits would be completed and documented weekly for two months.

The Wellness Director would complete the staffing schedule monthly to ensure coverage, and staffing would be monitored and amended daily based on resident needs. The schedule would be signed off by the Administrator monthly to ensure coverage prior to distributing to the staff. Copies of the schedule would be maintained by the Wellness Director with shift changes and call offs documented. The Administrator would monitor the schedule daily for two weeks and monthly for two months to ensure changes were being documented.

The Wellness Director/designee would audit a random sample of 10 progress notes weekly to ensure documentation was complete, incident reports were complete, any required assessments were complete and that incident reports were entered on the Incident Report log. A random sample of 10 progress notes would be audited and documented weekly for two months.

The facility administrative staff would meet every Friday to review and ensure audit completion.

Although the Real and Present Danger was abated on 01/15/26, the facility remains out of compliance as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings included:

Interview on 01/05/26 at 6:18 A.M., with Licensed Practical Nurse (LPN) #120 revealed she usually works night shift and as long as there were no incidents there was adequate staffing on night shift. If there was an incident sometimes her medication administration must be put on hold, which puts her behind. The LPN revealed the facility currently doesn ' t have a Wellness Director to oversee nursing or nursing staff. Night shift has asked Executive Director #145 for additional staffing on nights but administration declines requests for additional staff. LPN #120 reported she had worked the night (12/05/25) when an incident had occurred involving Resident #235. She was not notified from the previous shift the resident had left and was unaware until the police had called. During the interview the LPN reported the facility had a similar incident a few weeks ago with Resident #231 eloping in the early morning.

Interview on 01/05/26 at 6:32 A.M., with Personal Care Assistant (PCA) #136 confirmed the facility currently did not have a Wellness Director to oversee nurse staffing or nursing in the facility.

Interview on 01/05/26 at 6:39 A.M., with PCA #124 confirmed the facility currently does not have a Wellness Director. The PCA reported on night shift there was not adequate staffing to evacuate residents in an emergency. The building was four stories, and some residents need assistive devices for ambulation. The PCA stated staff had voiced concerns numerous times but no changes in staffing had been made. The PCA reported she tried to check all residents every two hours, however there were some residents who sign waivers not to be checked.

Interview on 01/05/26 at 7:21 A.M. and 11:47 A.M., with LPN #109 revealed the facility had not had a Wellness Director since October (2025) and there had not been any oversight for nursing to ensure incident logs, infection control logs, and investigation reports were completed accurately. The LPN revealed the facility had asked nursing staff to fill in until a Wellness Director was hired; however, all the nursing staff declined to fill in.

Interview on 01/05/26 at 7:30 A.M., with Administrator #141 confirmed she was working under the direct supervision of ED #145 who was the facility ' s Administrator prior to her employment on 12/01/25. Administrator #141 revealed she spent the first two days in orientation at the main office. Administrator #141 confirmed the facility did not have a Wellness Director currently.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 confirmed the facility did not have a Wellness Director to oversee nursing. The LPN revealed (floor) staff were to start an incident report; however, there was no one to follow up on them after they were started to ensure interventions were implemented and incidents were logged. The LPN revealed today she was the only licensed nurse working after the other LPN left around 9:00 A.M. to care for the 60 some residents residing in the facility.

Interview on 01/06/26 at 3:43 P.M. with Resident #235 ' s Case Manger #147 revealed she was just assigned the facility in November (2025). She stated she had had issues with communication since the facility had not had a Wellness Director. The facility had not reported concerns timely and most of the time she had to go into the resident electronic medical record to find information.

Interview on 01/08/26 with Anonymous Staff Member #128 revealed the facility doesn ' t have a Wellness Director to refer to if you have clinical/nursing questions.

Information provided during the onsite survey revealed the facility had been without a Wellness Director since 10/20/25.

Review of the undated Wellness Director job description revealed the purpose of the job position was to plan, organize, develop and direct the overall operations of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest degree of quality care was maintained at all times. Duties include developing, maintaining, and periodically update written policies and procedures that govern the day to day functions of the nursing service department, perform administrative duties such as competing medical forms, reports, evaluation, charting and etc., determine the staffing need of the nursing service department necessary to meet the total nursing needs of the residents, make daily rounds to ensure all nursing services personnel are performing their work assignments in accordance with acceptable nursing standards, develop written care plans, report and investigate all allegation of abuse, assist with infection control.

The following concerns were identified related to the facility failure to provide a safe environment to meet the total care and safety/supervisory needs of residents to ensure all residents attained/maintained their highest practicable physical, mental, and psychosocial well-being.

1.Review of Resident #235's medical record revealed the resident was admitted to the facility on 11/05/25 from a skilled nursing facility with diagnoses including hemiplegia, dehydration, alcohol abuse, cannabis abuse, chronic pain syndrome, low back pain, blindness in left eye (artificial eye), acute kidney failure, and acute embolism and thrombosis of unspecified veins.

Review of Resident #235's pre-screening questionnaire dated 11/05/25 completed by the skilled nursing facility revealed the resident needed assistance with medication administration. The questionnaire revealed the resident drinks one alcoholic beverage daily. The resident had a history of smoking and marijuana use. This was completed prior to Resident #235 ' s admission to the assisted living facility.

Review of Resident #235 ' s Transfer Discharge report from the skilled nursing facility dated 11/05/25 revealed the resident had diagnoses including alcohol and cannabis abuse, chronic pain, low back pain, artificial eye, hemiplegia, blindness left eye, dehydration, and chronic embolism. The report included the resident was non-ambulatory, needed assistance with activities of daily living, and used a wheelchair for mobility.

Review of Resident #235 ' s progress note dated 11/05/25 at 2:57 P.M. authored by Licensed Practical Nurse (LPN) #104 revealed the resident arrived via wheelchair and was alert and oriented times four when assessed.

Review of Resident #235's admission agreement dated 11/05/25 revealed two alcoholic drinks per day at evening happy hour. The resident was permitted to use alcohol unless restricted by physician order or if alcohol was contraindicated with physician prescribed medication. Other residents may not be disturbed as a result of alcohol use. All illegal drugs and paraphernalia were prohibited on the premises for resident and visitors.

Resident #235 ' s admission agreement continued to include transportation could and would be provided for residents to physician appointments under the following conditions: Senior Suites must schedule resident appointments. Staff would be managing the transportation schedule and thus would know when they were available to transport residents to an appointment. Staff would set up transportation to an appointment that is within 15 miles of the facility. For all day appointments, it may be necessary for family to accompany residents.

Resident #235 ' s admission agreement continued and identified the facility shall provide the following services on as needed basis as determined in the resident support plan: ongoing oversight, securing transportation, making and keeping appointments, securing healthcare, provide staff monitoring management of medication. and managing healthcare. The residents were required to sign in and out anytime a resident leaves the facility for any period of time. The facility should refer residents to an appropriate assessment agency if resident needs cannot be met by facility. Residents should not disturb the quiet environment of others or perform any act that is injurious to the facility or others. Upon admission and thereafter, the right to adequate and appropriate medical treatment and nursing care and to other ancillary services that comprise necessary and appropriate care consistent with the program for which the resident contracted. This care shall be provided without regard to considerations such as race, religion, national origin, age, or source of payment for care. The resident would be provided with a copy of the resident ' s rights. The residents have the right to a safe and clean-living environment, right to adequate and appropriate medical treatment and nursing care, the right to consume a reasonable amount of alcoholic beverages.

Review of Resident #235's Brief Interview for Mental Status dated 11/05/25 authored by LPN #104 revealed the resident's cognition score was 10 out of 15 indicating the resident had moderate cognition impairment.

Review of Resident #235's Wandering Risk Assessment dated 11/05/25 authored by LPN #104 revealed the resident was at moderate risk for wandering.

Review of Resident #235's fall assessment dated 11/05/25 authored by LPN #104 revealed the resident was at moderate risk for falls related to being confined to chair, exhibiting loss of balance while standing, using short discontinuous steps and/or shuffling steps, exhibiting jerking or instability when making turns, and decrease in muscle coordination.

Review of Resident #235's pain assessment dated 11/05/25 authored by LPN #104 revealed the resident reported his pain was constant, the pain made it hard to sleep at night and limited his day-to-day activities. The resident had pain daily and was able to verbalize pain. The assessment included the resident used Oxycodone (narcotic) and Tylenol as needed daily. (A violation related to Resident #235 ' s pain and lack of effective pain management were cited during this survey at R333.

Review of Resident #235's functional assessment dated 11/05/25 authored by LPN #104 revealed the resident depended on someone else for travel and he was unable to make arrangements. The functional assessment included the resident was oriented in person, place, and times but may have occasional forgetfulness. The resident occasionally had problems with sleep, agitated at nights, falls asleep during the day.

Review of Resident #235's senior living assessment dated 11/05/25 (unauthored) revealed the resident was capable of independent decision making. The resident reported pain. The resident was not ambulatory and used a wheelchair for mobility. The resident was not at risk for elopement and no known history of alcohol or marijuana abuse. The resident was dependent for arranging transportation.

Review of Resident 235's service plan dated 11/05/25 revealed Resident #235 was non- ambulatory and mobile with assistive device (wheelchair). The resident needed help with managing transportation/appointments. The resident needed assistance and/or appointment reminders as needed 1-2 times per month.

Record review revealed there was no nursing service plan developed for Resident #235 ' s pain, alcohol abuse, or cannabis abuse. In addition, there was no nursing service plan to address Resident #235 ' s safety and/or supervisory needs and/or safety when leaving the facility independently.

Review of Resident #235's care plan from the assisted living (AL) waiver program (a separate document from the resident ' s service plan) dated 11/05/25 to 09/30/26 revealed the AL would make or arrange transportation as needed. AL staff to monitor changes in health status, the resident would have access to transportation to meet the resident ' s needs for community integration, the AL would inform the case manager of any changes in needs or if any modification was needed to ensure health and safety.

On 12/11/25 new orders were written for ViaQuest (psych consult). There was no documentation that identified the reason for the ViaQuest consult.

There was no evidence of orders for alcohol/non-alcohol beverages per the residents ' admission orders.

Review of Resident #235's initial evaluation authored by Nurse Practitioner (NP) #146 dated 11/18/25 (13 days after the resident ' s admission to the facility) revealed the resident had a wheelchair he was able to self-propel around the facility and he had left-sided weakness. The evaluation revealed the resident had chronic medical conditions or high-risk diagnoses which made it necessary for increased medical oversight related to his conditions. There was a potential for decline, or severe illness, or re-hospitalization should this patient not have access to timely care.

Review of Resident #235 ' s progress note dated 12/05/25 at 3:52 P.M., authored by LPN #104 revealed the resident left facility at this time, reported I am going to the store, right up there. Resident signed out of the facility. Executive Director (ED) #145 notified, and this nurse was advised by ED #145 that no further action was needed. Interview on 01/06/26 at 10:24 A.M.. with LPN #104 confirmed the documentation on 12/05/25 at 3:52 P.M., was inaccurate. The LPN reported she was not notified the resident had left until a motorist had called into the facility and reported there was a resident hitch hiking on Mall Crossing Road. The LPN revealed she was concerned about (the resident) and reported the incident to ED #145 and was told (by ED #145) there was no further action needed.

Review of Resident #235 ' s progress note dated 12/05/25 at 10.00 P.M. authored by LPN #133 revealed LPN #133 received a 911 call that a man saying he lived at the facility was inebriated at a local restaurant and the police were needing to know his name. After a description was given, it was determined to be Resident #235. The resident was brought back to the facility by two deputies, and he was lying down in back seat of the cruiser. The resident had emesis on his shoes. When they tried helping the resident out of the car he yelled and cursed. Deputies ' final sat him up and assisted him out of the police cruiser into his wheelchair. After he came into the lobby he said he wanted to go to the hospital. He ran over an aides ' foot with his wheelchair and gave inappropriate hand signals and was telling LPN #133 to go away. He vomited all over the floor. EMT ' s came and he refused to get onto the stretcher for quite a while. Finally, he said he wanted to go to the restroom where he voided onto the floor and then fell off the toilet onto the floor. Administrator #141 heard most of this as she was on the phone with the nurse. EMT ' s loaded the resident onto the stretcher and transported him to the hospital.

Review of Resident #235 ' s progress note dated 12/06/25 at 12:55 A.M. authored by LPN #133 revealed the police called and reported the resident was arrested for persistent disorderly conduct in front of the medical facility. Administrator #141 was called and updated.

Review of Resident #235 ' s hospital notes dated 12/05/25 revealed the resident was brought to the hospital by the squad and law enforcement because he was unruly and intoxicated. The resident was lying in bed sleeping and would not let staff do anything to him. His home medications listed included Senna two tablets at bedtime, Oxycodone 5 milligrams (mg) every 12 hours as needed for chronic back pain, Eliquis 5 mg daily, Ferrous Sulfate 325 mg daily, and Vitamin B-1 100 mg daily. Patient instructions were given for drug induced (disorder) and for alcohol use disorder. The resident became unruly, police were called and the resident was discharged to law enforcement as he had been very disruptive.

Review of Resident #235 ' s police report dated 12/05/25 at 10:44 P.M., revealed the resident was arrested for disorderly conduct (intoxicated, annoy or alarm). The narrative included on 12/05/25 at approximately 7:57 P.M., the police responded to the mall to assist the sheriff ' s office regarding having an elderly male in a wheelchair removed from the restaurant for being intoxicated and disorderly. Upon arrival to the mall the resident had vomited on the floor inside the restaurant. While on scene another officer radioed and reported he had dealt with the same gentleman earlier in the day. He stated the resident was trying to get to the mall from the assisted living and was found on Common Mall Crossing in his wheelchair. The officer stated he was given a ride. After receiving that information the male resident was taken back to the assisted living. At approximately 8:35 P.M., the officer arrived back to the assisted living to find EMS (being on scene) regarding the same male. Staff reported the male was intoxicated and was being disrespectful to them. The officer was told the male had urinated multiple times on the lobby floor and kept changing his mind about going to the hospital. Shortly after that the male (Resident #235) went to the bathroom and fell onto the floor and urinated on himself again. The resident was transported to the hospital. At approximately 10:44 P.M. the officer was dispatched to the hospital regarding the same male giving hospital staff issues. The hospital was going to discharge the resident; however, the assisted living was contacted and stated the male was responsible for his own transportation. After a short while, the hospital was able to contact a taxi service and pay for the cost. The male continued to be disrespectful to staff and was highly intoxicated. The resident stated he wanted to go to jail multiple times, and he was not going back to the assisted living. The resident reported he was going to leave, and no one was going to stop him. He got out of bed and onto the floor and began crawling out of the room into the hallway. He was advised to get back in bed or he would be arrested. Due to ignoring the warning, the male resident was placed under arrest for persistent disorderly conduct due to being voluntarily intoxicated and inside of a medical facility. He was transported to jail and booked.

Review of AccuWeather revealed on 12/05/25, the high was 32 degrees and the low was 13 degrees.

Review of MapQuest revealed from the facility to the restaurant (where Resident #235 was taken to on 12/05/25) revealed it was two miles and a 30-minute walk.

Review of Resident #235 ' s fall investigation dated 12/05/25 revealed the resident was brought back by the deputies drunk and very argumentative and combative. He requested to go to the hospital, Emergency Medical Technicians (EMTs) helped the resident to the restroom, and he voided onto the floor then fell off the toilet onto the floor. EMTs, nurse, and two aides were outside the restroom door and heard him in the restroom. No injuries were observed at the time of the incident. EMTs loaded the resident and transported him to the local hospital in town. The predisposing factor listed on the fall investigation was wanderer . The investigation noted the Administrator and hospital were notified.

Record review revealed there was no evidence Resident #235 ' s medical provider was notified in the investigation report nor was a root cause of the incident completed. No new interventions were implemented for the resident ' s safety/supervision following this incident.

Further review revealed no incident report was completed regarding the resident ' s intoxication or incident with the police.

Review of the incident log dated 10/01/25 to 01/2026 revealed no evidence of Resident #235 ' s incident with the police was recorded on the log and fall incident only included the date and time. There was no general description of the fall, place, or action taken.

Review of Resident #235 ' s progress notes revealed no evidence when the resident returned from jail.

Review of the resident sign in and out book dated 12/2025 revealed someone had documented the resident returned on 12/11/25 at 9:40 A.M.

Review of Resident #235 ' s late entry progress note dated 01/06/26 and authored by ED #145 revealed she had spoken to the resident in his apartment to follow up on the incident from 12/05/25. The resident reported he was taken to Walmart by the police and then he went to the restaurant and had some drinks and paid for them. He reported he was arrested for failure to pay for his drinks. The resident stated he didn ' t have recollection of the incident and did not remember going to the hospital. The resident reported he did not want any more pain medications and reported he has all that s--- out of his system and doesn ' t want it anymore. The ED educated the resident that psych services could help him with his past alcohol use by speaking to the counselor. Resident agreed to meet with psych services to meet with a counselor and appeared to understand his options.

Review of MapQuest revealed Walmart was 1.1 miles from the restaurant and a 24-minute walk.

Review of Resident #235 ' s service plan on 01/12/26 revealed no evidence the resident ' s service plan was updated to reflect the resident ' s safety needs following this incident.

Review of Resident #235 ' s safety checks revealed safety checks were not initiated until 01/08/26.

Review of Resident #235 ' s Via Quest (psychiatric note) dated 01/12/26 revealed the resident denied depression but reported his anxiety was a six out of ten due to being told he had to come to assisting living. He reported I don ' t want to be here . The resident had adjustment disorder with anxiety and discussed the use of Vistaril as needed for anxiety. Plan included Vistaril 25 mg every six hours as needed for 14 days for anxiety and mental health services.

Interview on 01/05/26 at 6:18 A.M. with LPN #120 revealed she had worked the night (12/05/25) the incident occurred with Resident #235. She stated she was not notified from the previous shift the resident had left and was unaware of the incident until the police had called. The police had brought the resident back from the restaurant and the resident was intoxicated and spitting and hitting staff. The resident was vomiting and requested to go to the hospital and then fell in the bathroom. LPN #120 reported it was her understanding that the resident had an alcohol issue and was not supposed to be around alcohol. The LPN reported in her opinion the resident was not safe to be outside the facility unsupervised on the main road in a wheelchair. The LPN reported she was not aware if the resident was on two-hour checks prior to or after the incident. The LPN reported the facility had a similar incident a few weeks ago with Resident #231 eloping in the early morning.

Interview on 01/05/26 at 6:39 A.M. with PCA #124 revealed she checks Resident #235 every two hours, but she was not sure if he requested to be checked or not. The PCA reported the resident was alert and oriented but stated she didn ' t feel he would be safe on the main road in a wheelchair. The PCA reported the resident usually pushes himself backwards in the wheelchair instead of going forward.

Interview on 01/05/26 at 7:21 A.M. and 11:47 A.M. with LPN #109 confirmed there was an incident with Resident #235 last month. The resident had gone to a restaurant and drank alcoholic beverages and refused to pay. The police were called and they brought him back to the facility and then he fell and went to the hospital. The hospital discharged the resident; however, he became combative and the hospital called the police and the resident was arrested. LPN #109 confirmed the resident was assessed on admission to have mild cognition impairment and was a moderate risk for wandering/elopement and history of alcohol and cannabis use. The LPN reported the facility only had a wandering assessment and not one just specific for elopements. If a resident was moderate risk for wandering staff should keep a better eye on the resident . LPN #109 revealed Resident #235 was not capable of going to the mall unsupervised by wheelchair on the road due to the distance to the mall and the hills. The LPN confirmed prior to the incident the resident had voiced he was going to leave the facility to get alcohol and cannabis but never acted on it until 12/05/25.

Interview on 01/05/26 at 7:30 A.M., with Administrator #141 revealed it was her expectation that if a resident was assessed to be a moderate risk for wandering she would have staff watch them closely in common areas during the day, conduct two-hour checks at night, and may consider increasing staff for supervision.

Interview on 01/05/26 at 9:30 A.M. with ED #145 revealed the facility did not complete an investigation for Resident #235 regarding the incident at the restaurant (12/05/25) which later resulted in the resident being arrested.

Interview on 01/05/26 at 10:18 A.M. with the Administrator #141 confirmed the only incident reports/investigation she had for Resident #235 was the one staff started for the fall on 12/05/25. The facility had cameras; however, they had not worked for some time per the Regional Maintenance Director.

Interview on 01/05/26 at 11:00 A.M. with Resident #235 revealed on 12/05/25 he told staff he wanted to go to the cannabis store to get marijuana for his pain. The staff kept telling him someone was coming to take him, but no one ever showed up. He stated he was tired of waiting so he left on his own and started hitch hiking. The resident stated motorists stopped to help but some of them couldn ' t fit his wheelchair in their cars. He stated he made it down to the bridge (0.9 miles from the facility) and tried crossing the road to get on the sidewalk that crossed the bridge. Prior to that he was on the main road (three lanes) because there were no sidewalks. The resident shared that police showed up and told him the road was dangerous to walk on due to it being a busy road and cars drove fast. He then stated he got a ride to the main entrance of the mall (1.9 miles from the facility), saw the restaurant and decided to have a drink. The next thing he knew was he was intoxicated and he spent the week in jail. The resident revealed he had smoked marijuana at the facility near the smoking area. The resident confirmed he was discharged from a skilled nursing facility last year for leaving the facility unsupervised and getting intoxicated. The resident reported he was not happy at this facility because there was nothing for him to do and he had no access to the community. The resident reported he had no common interests with the current residents, and he would like to be somewhere closer to activities he liked. An additional interview on 01/06/26 at 1:55 P.M., with Resident #235 revealed a motorist picked him up at the bridge on Common Mall Crossing Road (on 12/05/25). As the motorist was loading his wheelchair in the truck a police officer arrived. He rode to the mall with the motorist. During the interview, Resident #235 reported there were not enough staff to answer call lights timely.

Interview on 01/05/26 at 1:00 P.M. and 1:44 P.M. with Administrator #141 and ED #145 revealed they were not aware of Resident #235 ' s past history at the previous skilled nursing facility. The Administrator reported on 12/05/25 she had gone looking for the resident after he did not return for about 40 minutes. She stated she had even gone to the cannabis dispensary. She did not notify the police when he didn ' t return because ED #145 said he had signed himself out. The ED reported it was not her business where residents went because it was their right to come and go as they pleased. During the interview the ED and Administrator revealed the previous Wellness Director ' s last day was 10/19/25.

Interview on 01/06/26 at 8:14 A.M. with Administrator #141 confirmed Resident #235 had voiced concerns about leaving several times prior to the incident on 12/05/25 to go the cannabis dispensary. The day of the incident he was upset and was talking about his opioid addiction and the doctor had cut his pain medication off. The resident was agitated with nursing staff because they would not give him anything but Tylenol for pain. He told her he needed to get weed if staff wasn ' t going to give him opioids. The Administrator reported she thought he told someone he was leaving and signed himself out. The Administrator reported it was only her second or third day at the facility and she really didn ' t know the residents yet. The Administrator confirmed the resident was assessed to have cognitive impairment and was at moderate risk for wandering per the admission assessments. The Administrator reported on 12/05/25 she did happy hour because the interim activities person was not available. Resident #235 had attended happy hour from 3:00 P.M. to 4:00 P.M. and drank two cans of Bud Light. Staff had reported around 4:00-4:30ish the resident had signed himself out; however, she could not recall which staff member reported he had signed himself out. The Administrator confirmed the sign out sheet didn ' t indicate a time or place it was just two initial that were not legible; however, appeared to be an B and O. Around 5:00 P.M, the resident didn ' t return and it was getting dark out and it was cold and the sidewalks were covered in snow on the lane into the facility. The main road (Common Mall Crossing Road) that led to the mall didn ' t have sidewalks and the resident would have had to travel on the main road which was three lanes, which would have not been safe to be on with a wheelchair and the cold weather, so she stated she went out looking for the resident but was not able to find him. The Administrator revealed ED #145 reported to her the resident was an adult and signed out, so she didn ' t notify the police; however, she verified the facility didn ' t know his whereabouts. The Administrator confirmed she was not aware the police had already encountered the resident earlier that day and may have known his whereabouts if she had contacted them earlier that day after she could not locate the resident. Later that day the police were called because the resident didn ' t pay his bill and he became combative at the restaurant. The police returned the resident to the facility; however, the resident wanted to go to the hospital. The resident was vomiting and changing mind about going to the hospital. The resident was left in the bathroom unattended and fell off the toilet. A fall incident (form) was started by nursing staff but was not completed. The resident was taken to the hospital and then to jail. The Administrator confirmed there was no incident report for the incident that occurred before the fall regarding the resident being intoxicated. The Administrator confirmed the resident was not being monitored for wandering prior to or after the incident.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 revealed Resident #235 was alert but had behaviors such as drug seeking. The LPN revealed she was concerned that if the resident left he wouldn ' t return, but would not be safe on the road in the cold hitch hiking. The LPN reported the progress note she authored on 12/05/25 was not accurate. She stated she was not aware the resident had signed out and left until a motorist had called the facility to report a male resident was on Common Mall Crossing Road and needed assistance. She believed Administrative Assistant #140 had taken the call. The LPN reported she was concerned and reported the call to ED #145 and was told no action was needed since the resident signed himself out. The LPN reported this was an incident that would have been nice to have had a nursing Wellness Director to talk to because in her clinical opinion the resident was not safe to be out on the road in a wheelchair.

Interview on 01/06/26 at 11:00 A.M. with Administrative Assistant (AA) #140 revealed she had received a call from two motorists on 12/05/25 regarding Resident #235. The first call was around 3:30 P.M. a motorist reported a man was hitch hiking on the end of Dorthy Lane (the road the facility was located on). Shortly after the first call she received another call from a motorist asking if someone from the facility could help the resident and she stated she was told by ED #145 the facility could not help the resident. The motorist then asked if he could help the resident. ED #145 told AA #140 that was up to the motorist. AA #140 reported she usually monitored the facility door and resident sign in and out book; however, she was helping the Administrator with Happy Hour and was not at the front desk to monitor the door or book. AA #140 confirmed she had seen Resident #235 during Happy Hour from 3:00 P.M. to 4:00 P.M., and he had two beers and left after that. AA #140 revealed it would not have been safe for the resident to be on the road in the cold weather.

Interview on 01/06/26 at 3:43 P.M. with Resident #235 ' s Case Manger #147 revealed she did not feel Resident #235 was safe to be unsupervised in the community due to his impulsive behaviors. The resident reported to the case manager during their first visit he didn ' t like this place because it was not near a cannabis dispensary. The case manager reported the root cause for the resident leaving on 12/05/25 was because he was in pain and the Tylenol staff were providing was not relieving his pain and he needed marijuana. The case manager reported she met with the facility today regarding the resident being transferred to the sister facility, however both she and her supervisor felt this was not a good decision because the resident may get into more trouble as the sister facility had a younger population and described the facility as a frat house .

Interview on 01/06/26 at 4:15 P.M. with Resident #235 ' s Nurse Practitioner (NP) #146 revealed she was employed by Abode which had a contract with this facility and their sister facility along with several Intermediate Care Facilities. NP#146 reported she had only seen Resident #235 once. The NP was aware the resident had a police report blown up and in a picture frame from an incident that happened at another facility. The NP reported the resident could make his own decisions; however, he had poor judgement and impulsive behaviors. He had been noted to be inappropriate with staff as well. The NP reported she didn ' t have previous records to review; however, she was aware the resident had been seen by pain management in the past and was upset he wasn ' t getting narcotics.

Interview on 01/07/26 at 10:16 A.M., with Administrator #141 and Administrator Assistant (AA) #140 revealed the facility front doors are not monitored from 4:00 P.M. to 8:00 A.M. during the week. The Administrator confirmed Resident #235 had returned to the facility from jail on 12/11/25 in the afternoon not the morning per the resident sign in and out book; however, staff never assessed or documented the resident ' s return. The police brought the resident back due to the facility not having a transport vehicle. The administrative staff revealed the facility would help residents find transportation if needed.

Interview on 01/08/26 with Anonymous Staff Member #128 revealed Resident #235 drinks during Happy Hour on Fridays and starts acting goofy . The staff member also felt Resident #235 was mad at staff because he doesn ' t have narcotics for his pain. Staff had sent out a text message informing all staff the resident had eloped on 12/05/25. Resident #235 had voiced prior to the incident on 12/05/25 he didn ' t want to be at the facility. The staff member revealed there weren ' t enough staff to supervise residents especially on night shifts due to resident behaviors. Residents had also voiced concerns they were not getting medication timely. Sometimes there was only one nurse for days and nights shift for 60 residents. On day shift there were supposed to be three aides and usually one calls off leaving only two aides. The facility doesn ' t have an activity director, and they are using one of the PCA staff to fill the position.

Interview on 01/08/26 at 1:28 P.M., with Occupational Therapist (OT) #148 revealed she had provided OT services to Resident #235. The OT revealed the resident had poor judgement when he was drinking and had impulsive behaviors. The OT reported she was aware of the incident that happened at the skilled facility when the resident left the facility and was intoxicated. The OT reported Resident #235 was not safe to leave the building unsupervised.

Interview on 01/12/26 at 12:30 P.M., with LPN #109 confirmed Resident #235 ' s admission orders were for one 12-ounce non-alcoholic beer daily as needed. The LPN confirmed the order was never entered.

Observation on 01/05/26 at 1:30 P.M. revealed the road in front of the facility was a two-lane road that had one side walk along the side of the road and was 0.3 miles and intersected with a three-lane road (Common Mall Crossing Road). To the right the road led to the mall and to the left the road led to Route #40. Both roads were hilly. The road to the mall had no sidewalks, however the road to Route 40 had one sidewalk. The road was observed to be well-traveled, and cars were not following the 25 miles per hour speed limit.

2. Record review revealed Resident #246 was admitted to the facility on 02/13/25 with diagnoses including insomnia and urine retention.

Review of Resident #246 ' s assisted living assessment dated 05/20/25 revealed the resident was oriented and on safety checks. The resident was independent for decision making and was being monitored for behaviors; however, no behaviors were checked or documented. The assessment revealed the resident can ' t manage his own medications. The resident required assistance with medication due to cognitive loss. The resident required nighttime care (safety checks/comfort check). The resident required assistance with evacuation. The assessment revealed the resident was independent with transportation.

Review of Resident #246 ' s admission agreement dated 02/13/25 revealed the resident must not exhibit behavior problems that disturb others and must not be a safety risk to self or others. The facility would provide assistance with ongoing oversight and general direction, providing staff monitoring and management of medication, and managing health care. The grounds for discharge or transfer of a resident for the following conditions: if a resident was a danger to themselves or others, the facility can ' t meet the resident ' s needs, or documented, repeated violation of the home rules.

The resident ' s responsibility included complying with home rules, not disturbing the quiet environment of others, and should not perform any act or permit or encourage anyone else to perform any act that was injuries to the facility or to other residents or staff.

Review of the house rules revealed the resident was permitted to use alcohol unless restricted by physician order of if alcohol was contraindicated with physician prescribed medication. Other residents may not be disturbed as a result of alcohol use. Resident and/or designated persons were required to sign in and out anytime a resident was leaving the facility for any period of time. No resident was permitted to enter another resident ' s apartment without permission of the resident occupying the unit.

Review of Resident Rights revealed residents had the right to a safe and clean environment.

Review of Resident #246 ' s progress note dated 02/13/25 authored by LPN #129 revealed the resident arrived via self and stated he was going want help with administering his medication because he has some memory issues. The resident stated he takes Ambien at night but sometimes if he was not careful he would wake up and take another one. The resident reported he had peripheral neuropathy at bedtime, and he took a pain pill (stating it ' s a narcotic but he can ' t remember what he takes). He stated he drives to Cleveland and Toledo for work, but sometimes his car ends up somewhere he was not going. He stated he drinks up to a glass and half of wine a night. He wanted to keep his physicians because they were friends. The resident reported he does have a history of wandering around at night.

Review of Resident #246 ' s admission self-administration assessment dated 02/13/25 authored by resident physician revealed the resident was deemed able to safely administer his own medications.

Review of Resident #246 service plan dated 02/26/25 revealed the resident needed help with medication due to cognitive loss. The resident cognition service plan dated 02/27/25 revealed the resident goal was to provide support to make appropriate decisions about his care and environment. The intervention was to make safe judgment and function appropriately in social situations.

Review of Resident #246 ' s fall assessment dated 05/18/25 revealed the resident was low risk for falls.

Review of Resident #246 ' s wandering assessment dated 05/18/25 revealed the resident was low risk for wandering. He was noted to be forgetful/short attention span.

Review of Resident #246 ' s progress note dated 06/11/25 (author unknown) revealed the resident was given three days of medication on Monday (because he was leaving the facility for a few days). The resident reported he took two Ambien one night while he was away because he was treating crying babies and he was stressed out. The resident ' s physician was notified about incident.

Review of Resident #246 ' s progress note dated 11/03/25 authored by RN #116 revealed the resident was leaving the facility for leave of absence until 11/08/25. Resident #246 requested that Ambien to be sent with him and he refused other medication to be sent. Five Ambien were sent with the resident.

Review of Resident #246 ' s progress note dated 11/05/25 authored by LPN #103 revealed the resident reported he took five Ambien in one night. The nurse explained to the resident that it could be very dangerous, and we needed to put precautions in place, so this doesn ' t happen again. However, there was no evidence the resident ' s service plan was updated and/or his safety related to self-medication administration was re-assessed at this time.

Review of Resident #246 progress note dated 11/09/25 authored by LPN #133 revealed the resident had been on several floors trying to get into resident rooms as he had been drinking wine this shift and he had his evening medications. The resident had been staggering and was confused and had been taken to his room several times via wheelchair by staff. The resident was found lying on his back on the floor in the hallway outside of his room. The resident was assisted off the floor into wheelchair by two staff and was taken into his room and was asked to please use his pendant if he wanted to get up. There was no evidence the resident ' s safety needs were assessed at this time or a service plan for safety was implemented.

Review of Resident #246 fall investigation dated 11/09/25 revealed the resident was in the hallway on his back outside his room. He had bent down to unlock his door and fell. The resident had been drinking wine and took his evening medication which included Ambien (a sedative-hypnotic medication). There were no injuries noted. Staff assisted resident in wheelchair and wheeled him into his room. The resident was slurring his words and had been staggering around trying to get into other rooms this evening. There was no evidence of any new intervention(s) being implemented at this time to ensure the resident (or other facility residents) safety.

Review of Resident #246 progress note dated 11/10/25 authored by Registered Nurse (RN) #116 revealed the physician was going to fax over a paper stating the resident could no longer self-administer medications.

Review of order scanned into the electronic medical record dated 11/10/25 revealed the resident should no longer administer his own medication. However, there was no evidence the order was entered into the resident ' s orders in the electronic medical record and Resident #246 continued to administer his own medication.

Review of Resident #246 ' s progress note dated 11/13/25 at 9:47 P.M. authored by LPN #102 revealed the nurse was informed by the aide the resident appeared to be off balance while walking out of the building prior to leaving facility in his own vehicle. This nurse called Executive Administrator #145 and was informed to call the resident ' s emergency contact. The nurse attempted to contact the resident ' s emergency contact (the resident ' s son) but was unsuccessful. The son called back and stated this was an ongoing issue and he planned to contact the doctor about future options. The nurse attempted to call the resident four times and the calls went to voicemail. The son reported he would try to make contact with the resident. The nurse made contact with the resident at 10:36 P.M. and he stated he had patients in the morning, and he headed to work to get things in order for tomorrow. The resident ' s son was contacted and stated the resident does work tomorrow, informed the nurse they weren ' t worried about the situation, the resident rented a house, and the resident would be there while away from the facility.

Review of Resident #246 ' s progress note dated 11/19/25 at 3:39 P.M. authored by LPN #150 revealed the resident had left the building last night and had not returned or contacted the facility. Attempted to call the son but no answer, also contacted the resident ' s clinic who had not seen him today.

Review of a physician ' s order, written on paper, which was not part of the electronic medical records, dated 11/19/25 revealed it was brought to the medical providers attention that Resident #246 had been consuming alcohol while also receiving medication including Ambien and hydrocodone (narcotic). This combination presented significant and immediate health risk including severe respiratory depression, excessive sedation or loss of consciousness, increased risk for fall, injury, and aspiration, dangerous impairment of judgement and coordination, and potentially life-threatening overdose. Because of this risk the resident must not be given Ambien, hydrocodone, or any other sedating medication at times when he has consumed alcohol or was suspected of having consumed alcohol.

Review of Resident #246 ' s behavior monitoring dated 12/05/25 to 01/05/25 revealed the resident had no documented behaviors.

Review of Resident #246 ' s progress note dated 12/24/25at 1:15 A.M., authored by LPN #129 revealed the resident was drinking after he received his nighttime medication. The resident was previously found wandering the hall by this nurse and aide. The staff members talked with the resident about needing to have clothes on before he could be in the common areas. The resident stated he was fine. The resident could barely hold himself up when he was being redirected the first time. The resident was helped back to his room and back to bed by this nurse and aide. This nurse had already seen and smelled alcohol on the resident ' s breath and so this nurse took the resident ' s car keys to make sure the resident would not go out on the road. The resident got up in the time we had left at 10:00 P.M. and went and got not his neighbor ' s bed. The door was locked and staff were not sure how he got into the room. Resident #246 was in bed resting when staff found him because he pulled the pull cord. The note included Resident #246 had been spoken to several times about drinking and wandering the halls. The resident was noncompliant. The administrator and son were notified that the resident was missing. 911 was called after staff had been searching turned up nothing. The resident was found and was helped from the other room back to his room and to bed.

Review of a facility elopement investigation dated 12/23/25 revealed around 10:20 P.M., staff alerted the nurse Resident #246 was not in his room. Previously, the resident was helped back to his room at 10:00 P.M. by a PCA and nurse. The resident had been drinking. 911 was called around 11:13 P.M. after looking several times around the facility. Resident #246 was found at 11:18 P.M, in another residents locked room asleep in her bed only in his underpants. The resident had no idea how he got into the other resident ' s room and thought he was in his room. The resident ' s son was notified, and son reported his dad had a history of doing this; leaving where he was to go and look for Ambien on the streets. The resident was assisted back to bed and 911 notified he was found. The resident was confused because he was drinking. The resident had a history of alcohol consumption and wandering in the facility. The resident also had over the counter medications all over his counter in his room.

Review of the police report dated 12/23/25 revealed at 11:13 P.M., the caller reported an intoxicated male may have eloped from the facility in his underwear only. The caller reported the resident was searching for alcohol and may have walked towards the gas station. The staff had his car keys. At 11:21 P.M., the caller called back and reported the resident was found in the bathroom and was okay and denied EMS to evaluate resident.

Review of Resident #246 ' s safety checks dated 12/23/25 revealed the resident was only checked at 1:42 A.M., 4:20 A.M., 4:23 A.M., and 1:42 P.M. Record review revealed no new safety assessment or service plan was initiated following this incident.

Review of Resident #246 ' s functional assessment dated 01/03/26 revealed the resident required complete supervision and administration of all medication and had mild cognition impairment. Record review revealed no service plan or safety/supervisory interventions were implemented following the completion of this assessment.

Review of Resident #246 ' s incident/investigation report and progress note dated 01/08/26 authored by LPN #103 revealed without evidence of the resident drinking alcohol Ambien was given at 10:36 P.M. At 12:29 A.M. the resident was not in his room, and an empty bottle of wine was on his sink. This nurse was concerned the resident maybe driving under the influence. The resident ' s car was gone from the parking lot. The staff checked the entire building until 1:12 A.M. Staff had driven to the gas station at 12:45 A.M. and the resident was not there. The resident had signed out twice today but not since the Ambien was given. Administrator #141 was notified at 1:16 A.M. and advised staff to call the police. The resident ' s son was notified at 1:20 A.M. and was okay with calling the police. The resident ' s phone went straight to voicemail. 911 was called at 1:26 A.M. The police arrived at 1:43 A.M. to get report. About 2:00 A.M. the police came into the building with the resident. The resident drove back to facility, and the officers watched him pull in and hit the curb. The police interviewed him and found he could not make sense, they requested a urine test which the resident consented to. The resident told cops he had left at 11:00 P.M. to go see patients. The resident then reported he was at a wedding with cocaine. Staff collected a urine sample, and the officers gave the resident citation papers with a court date on them and left. The resident gave the nurse his car keys and staff assisted the resident to his room.

Review of Resident #246 safety checks dated 01/07/26 revealed the resident was checked 6:13 A.M., 9:48 A.M., and 6:21 P.M.

Review of Resident #246 safety checks dated 01/08/26 revealed the resident was checked 1:22 A.M., 3:18 A.M., 6:21 A.M., 3:43 P.M., and 4:11 P.M.

Record review revealed no new safety assessment or service plan was initiated following this incident.

Review of Resident #246 physician orders for 01/2026 revealed medication orders for Aspirin 325 mg two tablets daily in the evening for prevention, Duloxetine 60 mg daily for mood, Hydrocodone-Acetaminophen 5-325 milligrams every six hours as needed for pain, melatonin 3 mg two tablets every 24 hours as needed for insomnia, Oxybutynin 10 mg daily for muscle spasms, Tamsulosin 0.4 mg at bedtime for retention, Trazodone 50 mg at bedtime for insomnia, and Ambien 12.5 mg every 24 hours as needed for insomnia.

There was no evidence of an order to hold sedative medication if resident was drinking or suspected of drinking or evidence of an order that the resident could not self-medicate.

Review of Resident #246 Ambien narcotic control sheets dated 08/26/25 to 01/04/26 revealed the facility had sent Ambien with the resident during leave of absences: On 09/24/25 three tablets, on 09/08/25 four tablets, on 10/02/25 three tablets, on 10/06/25 three tablets, on 10/30/25 three tablets, on 11/03/25 five tablets, on 12/04/25 four tablets, on 12/08/25 four tablets and on 01/01/26 three tablets. Further review revealed the resident had received an Ambien almost nightly.

Further review revealed there was no evidence in the resident service plan regarding behaviors including wandering, alcoholism, or holding sedative medication when drinking.

Review of the incident log dated 10/01/25 to 01/2026 revealed Resident #246 had a fall on 11/09/25 at 12:25 A.M., there was no general description of the fall, no action taken, or no place the incident occurred. Further review of the log indicated the resident had eloped on 12/23/25 at 10:20 P.M., however there was no general description of the incident, no action taken, or place it occurred. The incident that resident reported on 11/05/25 regarding taking five Ambien at one time was not noted on the incident log nor was an incident report completed.

Review of Resident #246 ViaQuest note (psych services) dated 01/12/26 revealed the resident had insomnia and mood disorder. The resident had been found in other residents ' room and noticed the resident was drinking alcohol. The service note revealed the resident would be assessed for alcohol disorder at next visit. Must not be given Ambien, Hydrocodone, or any other sedating medication at times when alcohol had been consumed or has been suspected to have been consumed.

Interview on 01/05/26 at 9:30 A.M. with ED #145 confirmed she did not complete an investigation on 12/23/25 for Resident #246 because he was later found in his room.

Interview on 01/05/26 at 10:18 A.M., with Administrator#141 confirmed the facility only had an incident/investigation report for Resident #246 for a fall on 11/09/25 which was not comprehensive.

Interview on 01/05/26 at 11:47 A.M., with LPN #109 revealed Resident #246 was a chiropractor and was still practicing which was concerning to her because he had a problem with alcoholism. The LPN revealed the resident had recently found in a female resident ' s room; however, the female resident was currently at a skilled nursing home when the incident happened.

Interview on 01/06/26 at 8:14 A.M., with Administrator #141 confirmed she was not aware of Resident #246 taking five Ambien at one time until the surveyor brought it to her attention. The Administrator confirmed there was no incident report completed or documented on the incident log. The Administrator confirmed Resident #246 ' s behaviors were not being addressed, and the resident continued to have behaviors related to alcohol abuse and taking medication that were contraindicated to be used with alcohol. The resident had fallen on 11/09/25 because he was intoxicated; however, the incident report was not comprehensive to include intervention. The resident was not able to be found on 11/13/25 or 11/29/25; however, there was no incident report or intervention implemented. On 12/23/25 the resident was missing and was later found in a female resident room. There was no evidence an incident form was completed or any safety intervention(s) being implemented. The Administrator was not sure if the female resident or her family was notified the resident was in her room because there was not documentation to support they were notified.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 revealed Resident #246 had behaviors especially at night. He drinks and takes Ambien with alcohol. She thought there was an order not to give alcohol with Ambien, but she couldn ' t find it. The surveyor reviewed Resident #246 ' s current orders with the LPN and there was no such order. The LPN reported she didn ' t know what the regulations were for oversight for residents with behaviors in an assisting living.

Interview on 01/06/26 at 11:00 A.M. with Administrative Assistant (AA) #140 revealed Resident #246 leaves the facility daily to buy wine. AA #140 revealed she was aware the resident had been involved in previous car accidents and stated she was concerned about his drinking and driving.

Interview on 01/08/26 with Anonymous Staff Member #128 revealed Resident #246 started drinking at 10:00 A.M., and drinks until he decides to go to bed. The resident drinks and drives and the facility was aware. On Tuesday (01/06/26) he let his car running in the parking lot from 9:30 A.M. to 4:00 P.M. One night he left with someone and didn ' t tell anyone or sign out. The resident was unaccounted for for 24 hours. The facility tried to call around, and no one knew where he was. Once he returned, staff told him they were worried about him, and he responded he was worried about himself and someone made him snort some white stuff. A couple months ago the resident hit the stop sign at the end of the road (Dorthy Lane), flattened the tires on his car and broke the front axle. The staff member stated staff have reported these concerns to ED #145; however, nothing gets done and the resident was going to hurt himself or others.

Interview on 01/08/26 at 9:19 A.M. with Administrator #141 confirmed last night Resident #246 left the facility and didn ' t sign out or tell staff. He took his Ambien and staff found an empty wine bottle in his room. His car was gone and he wouldn ' t answer his phone. The son had not seen him as well, so the facility called the police. The police had found him and followed him back to facility and had the facility collect a urine sample from his catheter bag. The resident had court on 01/15/26 but she wasn ' t sure if it was for this incident or when he hit the stop sign.

Interview on 01/12/26 at 2:00 P.M., with Administrator #141 confirmed Resident #246 had an order written on 11/19/25 to hold Ambien, hydrocortisone, or any other sedating medications at times when he had consumed alcohol or was suspected of having consumed alcohol, however it was never entered into the resident ' s medical record. Staff had just hung the order on the wall in the nurse ' s station. However, the order was not being implemented.

3. Record review revealed Resident #231 was admitted to the facility on 10/15/25 with diagnoses including macular degermation, diabetes, and peripheral vascular disease. The resident was transferred on 12/12/25 to a skilled facility after being hospitalized on 12/07/25 and had not returned to the facility as of the time of the survey.

Review of Resident #231 ' s transfer form dated 10/15/25 from the skilled nursing facility indicated the resident had diagnoses including atrial fibrillation, depression, polymyalgia rheumatica, chronic kidney disease, anxiety, insomnia, chronic kidney disease, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.

Review of Resident #231 ' s Brief Interview for Mental Status (BIMS) assessment dated 10/15/25 revealed the resident was cognitively intact.

Review of Resident #231 ' s wandering risk assessment dated 10/15/25 revealed the resident was at moderate risk for wandering.

Review of Resident #231 ' s fall assessment dated 10/15/25 revealed the resident was at moderate risk for falls.

Review of Resident #231 ' s senior living assessment dated 10/15/25 revealed the resident required nighttime care (safety checks/comfort checks). The resident required a walker for ambulation and was dependent on staff for assistance with travel.

Review of Resident #231 ' s service plan dated 10/15/25 revealed the resident required a wheelchair for long distances. There was no evidence of a service plan for dementia, wandering, or behaviors and/or to address any safety/supervisory needs of the resident.

Review of Resident #231 ' s assisted living waiver program referral dated 11/04/25 revealed the resident was accepted in Tier 3 (memory program).

Review of Resident #231 ' s care plan from the assisted living waiver program dated 10/15/25 to 07/31/26 revealed the resident had dementia and the facility was to provide a memory care service. Ensure safe access to outdoor space and provide assistance in fewer than 10 minutes when resident ' s call system is utilized. This assessment was noted to conflict with the facility BIMS assessment dated 10/15/25.

Review of Resident #231 ' s progress note dated 11/24/25 at 4:16 P.M., authored by RN #116 revealed the resident had returned from the hospital. The resident had complaints of soreness to abdominal area. Four laparoscopic incisions seen on abdomen, bruising noted on both sides of abdomen. Resident returned with no paperwork. Per report from hospital the resident had a cholecystectomy two days ago, four lap incisions that are to left open to air, resident may resume regular diet, states there were no new orders.

Review of Resident #231 ' s progress note dated 11/25/25 at 6:40 A.M. authored by LPN #103 revealed at 4:32 A.M. EMS called the facility to see if facility staff could pick a resident (#231) up at the end of the sidewalk. The resident was last seen at 2:45 A.M., by the aide. The resident had her coat/gloves/hat on. The resident stated she was taking herself to the police station to report an abuse allegation of her family. Facility staff were able to convince her to come back inside for the night. Administrator #141 was notified at this time.

Review of the Resident #231 ' s police report dated 11/25/25 revealed at 4:29 A.M., a caller called and reported an elderly female in a wheelchair on Common Mall Crossing. The female was Resident #231, she attempted to leave the facility, stating she ' s receiving abuse from visiting family member. The staff came out and convinced her to come inside. The alleged abuse would be investigated internally by the facility; they would reach out (to police) if they find anything of merit.

Review of AccuWeather revealed on 11/25/25 in St. Clairsville, Ohio the high was 56 and the low was 45.

Interview on 01/05/26 at 6:18 A.M. with LPN #120 revealed she had worked the night Resident #231 had eloped. The LPN revealed the resident recently had surgery and just returned to the facility on pain medications. Staff had assisted the resident into a chair, and she had her gown on, and she had administered the resident her medications. The resident was ambulatory by wheelchair. In the early morning, she had received a call from the police department that they found the resident at the stop sign at the end of Common Mall Crossing (three lane road) and Route 40 (main road 1.9 miles from the facility). The LPN stated the resident must have planned to leave because she had changed her clothes and had gloves and a jacket on.

Interview on 01/05/26 at 7:21 A.M. with LPN #109 confirmed Resident #231 had eloped (on 11/25/25) and the police had found her and brought her back to the facility. The resident told the cops she left because she wanted to go to the police department to report abuse. The LPN confirmed the resident was at moderate risk for wandering but felt her cognition was intact.

Interview on 01/05/26 at 9:30 A.M., with ED #145 revealed she was not aware of Resident #231 ' s elopement until the time of this interview and stated she had not been notified even though staff had documented she was notified. The ED revealed the facility did not complete an investigation into the elopement incident because she was unaware of the incident.

Interview on 01/06/26 at 4:15 P.M. with Resident #231 Nurse Practitioner (NP) #146 revealed she was not aware Resident #231 had eloped on 11/25/25. NP #146 revealed it would not be safe for anyone to be out in the cold at 4:00 A.M.

Interview on 01/08/26 at 1:28 P.M., with Occupational Therapist (OT) #148 revealed Resident #231 would not be safe unsupervised when leaving the building by herself. The OT reported she used to have a monthly meeting with the Wellness Director to discuss the watch program (this program is typically a program for two-hour checks but can be different depending on the incident); however since there had not been a Wellness Director there had not been any meetings. She stated she had discussed some of the cases with the aides.

Review of the facility ' s policy titled Change in Condition (undated) revealed when a resident exhibited a change in condition, actions would be taken to coordinate appropriate care. When a resident displayed a change in condition, caregivers notify the Administrator. If a change in status progresses to an emergency at any time, call 911. Examples of change in condition may include, but were not limited to change in level of consciousness, unusual behaviors, nausea, vomiting, complaints of pain or discomfort, and falls. If there was an actual change in condition the residents ' physician was notified. Document the date and time of contacts and whom you spoke to. Clearly document any new orders and enter the new order on the resident ' s service plan and/or medication administration record. Notify the residents responsible party of the change in status and action taken. If the resident ' s status change results in prohibited health condition (the policy does not establish what prohibited health conditions are), a conference would take place with the administrator to determine the resident ' s suitability for retention. The administrator would file for an exception if required. The administrator documents, schedules and follows through with any continuing physician appointments and medical care. If the resident status change is more than a transient problem, a resident care conference is arranged.

Review of the facility policy titled Elopements and Wandering Residents (dated 07/10/20 and last reviewed on 07/10/20 by an Administrator that had not been employed by the facility for three years), revealed the facility ensured residents who exhibit wandering behavior and/or who were at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy defined wandering as a random or repetitive locomotion that may be goal-directed or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. The facility was equipped with door locks/alarms to help avoid elopements. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and managing resident at risk for elopement or unsafe wandering include assessing the resident for risk of elopement and unsafe wandering upon admission and throughout the stay by the interdisciplinary care plan team. The team would evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident ' s risk, modify the resident ' s behavior, or to minimize risk associated with hazards would be added to the resident ' s care plan and communicated to appropriate staff. Adequate supervision would be provided to help prevent accidents and elopements. Charge nurses and unit managers will monitor and implementation of interventions, response to interventions, and document accordingly. Any changes or new interventions would be communicated to relevant staff.

The procedure for locating a missing resident included any staff member becoming aware of a missing resident would alert personnel using facility approved protocol. The designated facility staff would look for the resident. If the resident was not located in the building or on the ground, Administrator or designee would notify the police department and serve as the designated liaison between the facility and policy department. The administrator or designee should also notify the company ' s corporate office. The director of Nursing (DON) or designee should notify the physician and family member or legal representative. All parties would be notified of the outcome once the resident was located. Appropriate reporting requirements to the State Survey agency should be conducted.

The procedure post- elopement includes a nurse who would perform a physical assessment, document, and reporting findings to the physician. A social service designee would reassess the resident and make any referrals for counseling or psychological/psychiatric consults. The residents and family/authorized representatives would be included in the care plan. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred to for alternative placement in an appropriate facility. Documentation in the medical record will include findings from nursing and social service assessment, physician/family notification, care plan discussions, and consultants note as applicable.

Review of the facility ' s policy and procedure titled Incident Reports (undated) revealed an injury and unusual incident would be reported in compliance with state regulatory requirements. The incident form was used to document and report any incident which was a threat to a resident ' s health, safety, welfare, or rights. This includes fall, injury, psychiatric crisis, unexplained absence, any violation of resident rights, and any incident that threatens the health, welfare, or safety of the resident. The nursing staff would complete the incident log and incident report. If an incident was considered abuse it would be reported to the state agency within 24 hours and would require a full investigation to be completed by the DON or Administrator.

The facility did not have a policy on completing an incident report or log.

This violation represents non-compliance from survey completed on 11/04/25.

This violation represents non-compliance investigated under Complaint Number OH00169265 and OH00169061.

Based on record review, review of a police report, review of self-reported incident investigation, interview, and policy review the facility failed to ensure residents were free from abuse. This had the potential to affect all 66 residents residing in the building.

Findings included:

1. Record review revealed Resident #231 was admitted to the facility on 10/15/25 with diagnoses including macular degeneration, diabetes, and peripheral vascular disease. The resident was transferred on 12/12/25 to a skilled facility after being hospitalized on 12/07/25.

Review of Resident #231's transfer form dated 10/15/25 from the skilled nursing facility indicated the resident had diagnoses including atrial fibrillation, depression, polymyalgia rheumatica, chronic kidney disease, anxiety, insomnia, chronic kidney disease, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.

Review of Resident #231's ViaQuest (psych note) dated 05/01/25 (prior to admission) revealed the 87-year-old was a resident of a skilled nursing facility seen for psychiatric evaluation for medication management. The resident had historical mental health diagnoses of anxiety, depression, and dementia. The resident reported she was sad and had a history of depression for several years. She denies delusions, hallucinations, signs and symptoms mania. The resident was tearful during conversation and stated that it was hard to talk about her past. The resident stated that after her husband had open heart surgery he had issues with stuff in the bedroom, she stated that she would have to do stuff to him for years that was very traumatic for her. She had a poor relationship with her daughter.

Review of Resident #231's BIMS assessment dated 10/15/25 revealed the resident was cognitively intact.

Review of Resident #231's Nurse Practitioner (NP) note dated 10/29/25 revealed the resident was seen to establish as a new patient. The resident was previously at a skilled facility after she had a hip fracture. The patient does get teary-eyed at times when talking about her family.

Review of Resident #231's progress note dated 11/25/25 at 6:40 A.M. authored by Licensed Practical Nurse (LPN) #103 revealed at 4:32 A.M. 911 called to see if we could pick the resident up at the end of the sidewalk. The resident was last seen at 2:45 A.M., by an aide. The resident had her coat/gloves/hat on. She was taking herself to the police station to report abuse allegation of her family, was able to convince her to come back inside for the night. The Administrator was notified at this time.

Review of the Resident #231's police report dated 11/25/25 revealed at 4:29 A.M., a caller called and reported an elderly female in a wheelchair on Common Mall Crossing. The female was Resident #231, she attempted to leave the facility, stating she's receiving abuse from a visiting family member. The staff came out and convinced her to come inside. The alleged abuse will be investigated internally by the facility; they will reach out if they find anything of merit.

There was no evidence the facility had completed an investigation regarding the allegation of abuse the resident had reported to police and staff on 11/25/25.

Interview on 01/05/26 at 6:18 A.M. LPN #109 confirmed Resident #231 had eloped and the police had found her and brought her back to the facility recently. She told the cops she left because she wanted to go to the police department to report abuse. LPN #109 confirmed the resident was at moderate risk for wandering and cognition intact.

Interview on 01/05/26 at 9:30 A.M., with Executive Director (ED) #145 revealed she was not aware of Resident #231's elopement until now and she was not notified even though staff had documented she was notified. ED #145 confirmed Resident #231 had reported allegations of abuse regarding her husband, but she didn't complete an investigation or report the concerns because the resident reported her husband shaved her eyebrows off, but they were still intact.

Interview on 01/05/26 at 10:18 A.M., with Administrator #141 confirmed the facility did not have any incident/investigation reports for Resident #231's allegation of abuse.

Interview on 01/05/26 at 11:47 A.M., with LPN #109 revealed that in regard to Resident #231 she had reviewed the resident's old records, and the resident's husband must have been abusive to her in the past and drank alcohol. The resident's husband did visit her but spent most of the time in the common area of the facility. After her husband visits the resident would say he shaved her eyebrows, but they were still intact.

Interview on 01/06/26 at 10:24 A.M. with LPN #104 revealed Resident #231 was alert and oriented but was delusional. She would say she didn't want her family to visit but when they showed up she would say it was okay. The resident had horrible things to say about her family, and it did sound like they had abused her. She reported her husband wasn't good to her and her daughter made her sick.

Interview on 01/08/26 with Anonymous Staff Member #128 confirmed Resident #231 and reported an allegation of abuse (by her family) to staff including nursing and administration, however nothing gets done. The management keeps saying they will just send her for a psych evaluation. Resident #231 reported her husband was abusive to her in the past. He cut her eyebrows and pulled her finger nails off and her daughter would cut her hair. The resident was scared when her husband would visit and her behavior would change. She would tell her husband she didn't want him there and to get the F out. Some of the nurses let her husband visit and some wouldn't. The facility said it was just her dementia, but you could tell she was fearful of her husband. She didn't know what to do since there was inconsistency with staff whether he could visit or not. The facility doesn't have a Wellness Director to refer to if you have questions clinically.

Interview on 01/08/26 at 1:28 P.M., with Occupational Therapist (OT) #148 confirmed Resident #231 was emotional and cried at times about her family life. She had reported her husband was abusive and it was very traumatic for her. The OT reported she had mentioned to the nurses, and she was told it was something that happened in the past. The resident seemed okay when the husband visited.

Interview on 01/08/26 at an undisclosed time with two anonymous staff members revealed Resident #231 had also verbalized allegation of abuse from her husband. Sometimes she was fine when he visited and other times she would freak out. When staff report allegation of abuse to ED #145 she would say it was just one of the resident's dementia fits.

2. Review of self-reported incident (SRI) #269575 dated 01/08/26 and closed 01/12/26 revealed the facility had reported the incident that occurred on 11/25/25 regarding Resident #231 (see above). As part of the investigation staff interviewed residents regarding abuse. Each form had a resident room number; however, it was difficult to determine the residents due to each of the floors having the same room numbers. There were 15 residents that had reported that they didn't feel safe or had been abused by a resident, visitor, or staff member in the facility. There was no evidence that these residents' abuse allegations were investigated by the facility.

Further review of the SRI revealed no evidence of staff interviews related to the abuse allegation.

Interview on 01/14/26 at 7:59 A.M., with PCA #132 confirmed she was one of the staff members assigned to interview residents regarding abuse. The PCA confirmed she had a few residents report abuse or they didn't feel safe, but she did not follow up with the residents. She was just instructed to ask the three yes and no questions on the form and put the name of the person they would report abuse to.

Interview on 01/14/26 at 11:15 A.M., with Administrator #141 confirmed there were 15 residents that had reported concerns with abuse, however there was no evidence the Executive Director (ED) #145 had followed up with those residents. The Administrator reported she knew staff had written statements because she had seen them drop them off to the ED, but she can't locate them and the ED has not returned her text. The Administrator reported she was going to have LPN #109 follow up the resident and have her obtain new statements.

Interview on 01/14/26 at 2:56 P.M., with LPN #109 confirmed she was following up with the 15 residents, however three were not available to interview yet. The LPN also confirmed she was working on obtaining statements from staff regarding the abuse allegation for the SRI.

3. Record review revealed Resident #246 was admitted to the facility on 02/13/25 with diagnoses including insomnia and urine retention.

Review of Resident #246's progress note dated 03/12/25 authored by LPN #149 revealed the nurse witnessed a grey dodge ram drive onto the property, there was a man and a woman inside. The woman got out of the truck and walked into the building. Once the woman realized there were people at the front desk she turned around and walked out. A few minutes after this Resident #246 went outside and gave the woman money. Once the woman got the money she left the facility.

Review of Resident #246 progress note dated 05/03/25 authored by LPN #150 revealed she was alerted by aides that the resident received a concerning phone call from Amber. Resident #246 was visibly stressed after the call. Ten minutes after call the resident walked outside to parking lot and met a woman in the white SUV and was seen to give her money. Resident #246 stated the woman was not a family member and she had been here before requesting money.

Review of Resident #246's service plan dated 05/15/25 indicated to observe resident when with visitors of non-relations due to resident request of certain individuals' not come into the facility. The goal was the resident will continue to not have visits from individuals noted in the complaint with police and he will notify staff/police if individual shows up to facility or contacts him. There were no interventions.

Interview on 01/08/26 with two anonymous staff members at an undisclosed time revealed Resident #246 left the facility about a month and half ago with a visitor he was not supposed to be in contact with around 9:00 P.M., drunk and didn't sign out or tell staff. He was gone over 15 hours.

Interview on 01/14/26 at 2:56 P.M. with LPN #109 revealed there was a concern with a female coming and getting money from Resident #246. The LPN recalls the resident was upset when the woman would visit. Staff had spoken to the resident, and he said he had to give her money because she knew things about his past. Staff encouraged him to tell her not to visit because the facility was not permitted to tell the female visitor she couldn't visit because of resident rights. The LPN reported the staff had posted pictures of the women's car at the nurse's station to alert staff, but she doesn't know if the pictures are still posted and she has not seen the woman again. The facility did not report the incident to police, and the resident didn't want to file a police report. LPN #109 confirmed the service plan was not comprehensive to include interventions.

Review of the facility's policy titled Abuse, Mistreatment, Neglect, and/or Misappropriation of Resident Property (undated) revealed the facility would not tolerate mistreatment, abuse, or neglect. The facility's policy was to investigate all allegations, suspicions, and incidents of abuse, mistreatment, neglect and misappropriation of resident property, and report the results of any such investigation as required by state law. If a person not on staff is accused of abuse the facility would take action to protect the residents including, but not limited to, contracting the third party and addressing the issue directly with him/her, preventing access to residents during the investigation, and/or referring the matter to the appropriate authorities. The incident would be documented in the nurses' notes. All allegations must be reported within 24 hours and a facility incident report completed. Once the Administrator and department of health are notified a quality assurance investigation of the allegation or suspicion would be conducted. The person investigating the incident shall take the following action: interview the residents, the accused, and all witnesses, obtain written statements, obtain all medical reports, and review the residents' records. The investigation should be completed within five working days after the incident.

This violation represents an incidental finding of non-compliance investigated under Complaint Number OH00169265.

Based on record review, interview, personnel file review, and job description review the facility failed to ensure the administrator provided necessary oversight to ensure the needs of the residents were met. This affected all 67 residents residing in the facility. The facility census was 67.

Findings Include:

On 08/28/25 at 9:39 AM, interview with the facility Administrative Assistant/Business Office Manager (BOM) revealed that she had started working at the facility at the end of May (2025). She is responsible for resident billing at the facility to include printing off the bills for the residents, mailing them to residents or their guardians, and then collecting the payment. In regard to the training she received to perform her job duties, the BOM stated that she received on the job training and it was a learn as I go training process. Her training was received from the Administrator at this facility and the business office manager from a sister facility. In addition, the BOM stated she could call someone in the corporate office if she needed help.

Review of BOM's personnel file revealed a start date of 05/27/25. The BOM had previous work experience in a local casino, retail, and gas station attendant. She obtained a high school GED. There was no disciplinary action noted in her personnel file. Contained within the personnel file was a document titled Accounts Payable Process, this document was signed by the BOM but not dated. This document identified the process for placing orders to vendors, receiving invoices from vendors, and then payments submitted to vendors. There was no documentation in the BOM's personnel file that pertained training for managing resident accounts and billing practices and protocols that would follow standard accounting principles.

On 08/28/25 at 1:28 P.M., additional interview with the BOM revealed the document in her personnel file titled Accounts Payable Process is really just a checklist of what she does with the accounts to pay vendors. The BOM verified she signed the document but did not sign it. The BOM thought she had received the document about a month after she started working at the facility. The BOM stated the Administrator had looked at the document with her and told her that she had already been trained on all of that and to just sign the document.

On 09/02/25 at 11:18 A.M., telephone interview with the Koorsen Fire and Security (the facility's fire and security vendor) Office Manager revealed that the facility is mostly current with their payments. The facility still owes $5487.72 in an outstanding balance, however only $774 of that amount is greater than 60 days out (it is at 76 days out). The Office Manager identified there is currently no hold on the facility account. The last payment was made 08/27/25 for the amount of $984.02 for the invoice dated 07/17/25. When asked where the invoices are being sent to for payment, the Office Manager identified that the invoices are being sent to the email address of the administrator at the facility.

Review of the Administrator's job description (signed by the Administrator 11/08/24) revealed the primary purpose of the job position is to direct the day to day functions of the facilities with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality can be provided to residents at all times. Under the section titled, Budget and Planning Functions, the job description revealed the administrator will assist in the establishment and maintenance of an adequate accounting system that reflects the operating cost of the facilities and oversight of operations for facilities.

In addition to the identified issue with outstanding payment to Koorsen Fire and Security vendor, the Administrator failed to develop and implement a comprehensive training program for resident accounts and billing to follow established accounting principles as evidenced by the following resident billing issues:

Review of Resident #26's billing statements for March 2025, April 2025, May 2026, July 2025, August 2025 revealed Resident #26 did not receive a billing statement for the month of June 2025.

Interview on 09/02/25 at 9:02 A.M. with Administrative Assistant/Business Office Manager (BOM) verified Resident#26 did not receive a billing statement for the month of June 2025.

Review of Resident #23's billing statements for July, August and September 2025 revealed an additional charge of $917 monthly including the Assisted Living Waiver amount ($1137) which totaled $1708.24.

Interview on 09/02/25 at 10:10 A.M. with Resident #23's daughter revealed she has attempted to get clarification regarding the additional charges and is unable to get answers.

Interview on 09/02/25 at 2:00 P.M. with Administrator and Administrative Assistant stated Resident #23 had a past due amount is why her charges are $1708.24 each month. The Administrator and Administrative Assistant/BOM were unable to provide an explanation for the extra $917 each month being charged to Resident #23. Per the Administrator and Administrative Assistant/BOM the reports are autogenerated and we just print them off.

This violation represents non-compliance investigated under Master Complaint Number OH00168066 and Complaint Number OH00167876.

This violation is evidence of continued non-compliance from the surveys completed 05/23/25 and 06/25/25.

Based on record review, observation, policy review, job description review, personnel file review, and interview, the facility failed to treat residents with dignity and respect. This affected all 67 of 67 residents residing in the facility. The facility census was 67.

Findings Include:

On 08/28/25 and 09/02/25 observations revealed the Administrator was present in the facility.

On 08/28/25 at 9:23 A.M. interview with the local Ombudsman revealed the residents were dissatisfied with the Administrator. Residents had reported to her that the Administrator refuses to speak with them and often tells them she doesn't have time for them.

On 08/28/25 at 3:55 P.M., interview with Patient Care Aide (PCA) #18 revealed she had seen the Administrator be disrespectful to residents. The Administrator was observed telling the residents she didn't have time for them. PCA #18 stated she had reported this to the Corporate Chief Operating Officer (COO) and reported it to the facility director of nursing (DON) as well.

On 09/02/25 at 8:44 A.M., interview with PCA #4 revealed that talking with the Administrator was a battle. The Administrator was not approachable. PCA #4 had observed the Administrator refer to a resident as a fata$$. This occurred in front of staff and PCA #4 didn't think this occurred in front of other residents, but was unsure.

On 09/02/25 at 8:44 A.M., interview with facility Staff #9 revealed they had observed Administrator be mean to the residents, same to staff. Staff #9 revealed they had observed the Administrator be verbally abusive to residents. Staff #9 reported they did not report this as the Administrator's actions and behaviors had been reported before and nothing had happened. When asked who this had been reported to in the past, Staff #9 replied multiple people including the director of nursing, and corporate.

On 09/02/25 at 8:51 A.M., interview with Licensed Practical Nurse (LPN) #14 revealed the Administrator is constantly refusing to talk with specific residents because those residents will report her to state. LPN #14 reported she had observed the Administrator tell residents that she didn't have time for them. LPN #14 reported she had told her concerns the Administrator including her actions, behaviors, and her treatment of residents to the COO and the Corporate Human Resources (HR) staff.

On 09/02/25 at 8:58 A.M., interview with PCA #20 revealed she had observed the Administrator call a resident Bitc* as the resident walked by. PCA #20 revealed she had also heard the Administrator make rude comments about a resident regarding the way the resident smells. These comments were made in front of staff and PCA #20 didn't think other residents had heard this but can't be sure.

On 09/02/25 at 9:02 A.M., interview with two residents who wished to remain anonymous revealed that they don't often see the Administrator out on the floor but when they do, the Administrator just walks around and doesn't stop to speak with the residents, she struts around.

On 09/02/25 at 9:25 A.M., interview with the Administrator revealed she was not aware of anyone accusing her of verbal abuse against residents. The Administrator reported that she knows residents had reported that she didn't take the time to talk with her, but that was not true.

On 09/02/25 at 1:03 P.M., telephone interview with the Corporate COO and Corporate HR staff revealed they had received concerns, complaints, and calls from facility staff regarding the Administrator and her treatment of residents and staff. When asked the process to address these concerns, they replied that the first step is to speak directly to the staff making the complaint and try and figure out what has happened. They stated they had a meeting with the Administrator last week (no specific date identified) to address these concerns. The Administrator was instructed to have time for residents, and the Administrator needed to adjust her demeanor when she was in the building. The Administrator needed to work on how she presented herself to staff and residents. When the COO and Corporate HR staff were asked what the process would be if staff and residents reported verbal abuse from the Administrator, they replied that if the abuse or mistreatment involved the Administrator the director of nursing (DON) would be responsible for investigating allegations of abuse against the Administrator, make a determination, and then review with HR. The COO and Corporate HR staff denied that the concerns they had received regarding the Administrator's behaviors, actions, and treatment of residents raised to the level of abuse.

On 08/28/25 review of the Administrator's personnel file revealed no documented evidence of a meeting having occurred with the Administrator, COO and Corporate HR staff to address concerns with the Administrator's treatment of residents or staff. The Administrator's personnel file contained the Executive Director of Ohio Facilities Job Description (signed by the Administrator 11/08/24). The Job Description revealed the primary purpose of the position is to direct the day-to-day functions of the facilities with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. In the area of resident rights, the Administrator is to ensure that the Administrator treats all residents fairly, and with kindness, dignity, and respect; communicate respectfully and appropriately. In the area of Specific Requirements, the Administrator must be a supportive team member, contribute to and be an example of teamwork and the team concept.

Review of the facility Abuse, Neglect, and Exploitation policy (implemented 03/05/18 and reviewed/revised 07/10/20) revealed it is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent abuse, neglect, exploitation, and misappropriation of resident property. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

This violation represents non-compliance investigated under Complaint Number OH00167876.

This violation is evidence of continued non-compliance from the survey completed 06/25/25.

Based on interview, record review and review of facility billing statements, the facility failed to ensure Resident #26 received accurate monthly billing statements. This affected one resident (#26) of ten residents reviewed for resident billing.

Findings include:

Review of the medical record for Resident #26, revealed an initial admission date of 02/03/25 and a readmission date of 08/09/25. Diagnoses included chronic obstructive pulmonary disease, hypertension, major depressive disorder and type 2 diabetes mellitus.

Review of Resident #26's Medicaid Waiver program referral sheet revealed the resident had no Medicaid liability and her total cost of living at the facility was $917.00 per month.

Review of Resident #26's billing statements for March 2025, April 2025, May 2026, July 2025, August 2025 revealed Resident #26 did not receive a billing statement for the month of June 2025

Interview on 09/02/25 at 9:02 A.M. with Administrative Assistant/Business Office Manager (BOM) verified Resident#26 did not receive a billing statement for the month of June 2025.

This violation represents non-compliance investigated under Master Complaint Number OH00168066 and Complaint Number OH00167876.

Based on record review, Resident Council Minute review, interview and job description review the facility failed to ensure the administrator provided at least 20 hours of service in the facility per calendar week and provided necessary oversight to ensure the needs of the residents were met. This affected all 60 residents residing in the facility.

Findings include:

a. During the onsite survey, interviews with six anonymous residents revealed they don't see the Administrator at the facility often and are told she is at the other facility owned by the company. The residents shared when she is working, she is unavailable, primarily in her office and does not engage with the residents. In addition, interviews with two anonymous staff members (Anonymous Staff Member #115 and #144) revealed the Administrator is not at the facility the alternating two days one week and three days the next week since she is currently responsible for both facilities owned by the company. The staff members stated the Administrator is not working the minimum 20 hours per week in the facility.

There was no documented evidence of the hours worked at the facility by the Administrator.

On 06/09/25 at 2:36 P.M. interview with the Administrator revealed she did not keep record of the hours she worked at the facility weekly but she would work two days one week and three days the next week since she was responsible to be the Administrator of both facilities owned by the corporation.

b. Review of the Resident Council Minutes dated 05/28/25 revealed old business (from the prior Resident Council Meeting) for water temperatures required follow-up. The follow up note from the Administrator read: I emailed (the) plumber (on) 05/23/25. Its 05/27/25 still waiting on response about the part. Review of the new business for the Resident Council Minutes dated 05/28/25 revealed everyone asking about any word when we are going to get the hot water fixed? This is too long. We don't like taking cold water baths and sponge baths. Please note, this inquiry was not responded to by the Administrator. There were 16 residents in attendance for this meeting (Resident #7, #8, #9, #12, #16, #17, #25, #29, #34, #43, #49, #51, #53, #55, #57 and #60).

An interview on 06/09/25 at 9:15 A.M. with Resident #25 revealed she currently had hot water in her room; however, it had only been fixed for three or four days. Resident #25 reported for the past month she had no hot water and had to bird bath because there was no way she would shower in the cold water. She believed it had been an extensive amount of time to get the hot water repaired.

On 06/09/25 at 11:15 A.M. interview with Resident #57 revealed the facility had recent issues with the hot water and the facility just got the hot water back but it took about a month to get it fixed but no one will tell us why it took so long to get it fixed. The resident stated that some residents took sponge baths, and some residents refused to bathe due to the cold water temperatures.

On 06/09/25 at 11:50 A.M., a phone interview with Plumber #204, who was employed with Kucera Plumbing revealed the facility had a plumber at the facility previously, who was from Moundsville (Plumber #203). Plumber #203 had installed a new mixing valve, but the valve installed was for one emergency shower, like what is used in places for decontamination, not for an entire building. The incorrect mixing valve was just tempering the water. Plumber #204 stated the facility had not asked him to do any work after his initial visit, but he had informed the facility to notify him if they wanted to proceed with the repairs. Due to past experiences with the facility and the facility not paying his company (for work completed), payment for the order and invoice was needed before service would be provided to replace the mixing valve at the facility.

On 06/09/25 at 3:30 P.M., an interview with Resident #50 revealed she had been without hot water for over a month and had just got it back a few days prior to this interview. She had to sponge bathe in the sink when the water was cold. She was disappointed because she did not feel the facility had kept her up to date on what was happening.

c. Review of State Fire Marshal (SFM) Fire Safety Inspection, dated 06/09/25 and conducted by SFM #209, revealed violations were noted for the following systems (including but not limited to): Hood Suppression Systems, Fire Alarm Systems, and Smoke Detectors. There were violations issued because the sprinkler system is not being maintained as installed; the smoke and fire dampers throughout the ventilation system of the facility have not been maintained as required. There was no evidence of required periodic inspection, testing or maintenance of the smoke and fire dampers; the level of protection afforded by the fire protection system in the facility is not being maintained. The fire protection system, required to be maintained by the Ohio Fire Code, is not operational. The Fire Protection system has not been inspected, tested and maintained as required; Inspection reveals the fire pump is not maintained as required. A weekly test of the fire pump assemblies is not conducted.

On 06/10/25 at 12:15 P.M., an interview with Maintenance Director #127 revealed Gutridge Fire Suppression company was scheduled to come to facility to help get the fire codes up to standards but he was advised by administration he could not schedule them until the balance with Gutridge was paid. He was new to the facility and did not know the history of the company, but the administration told him the invoice and payment had been sent, and he was waiting for the approval to schedule.

On 06/11/25 at 8:07 A.M. a phone interview with SFM #209 revealed that all systems in the facility needed inspected. He stated all quarterly assessments and testing were past due and needed completed before everything could be determined operational.

Review of Gutridge (a fire system vendor) Invoices from 11/01/25 through 11/21/24 revealed the vendor was owed $6,808.68 without evidence of payment made.

Review of an email sent to the surveyor from Service Controller #205 from Gutridge dated 06/11/25 at 9:57 A.M. revealed Gutridge would not service the facility at the time of the survey. The email read, We have an outstanding balance of $6,808.68 dated back from last year October and November (2024). As of right now, they are not a customer we can service. If the balance is caught up, I will leave it up to (Gutridge #207), who I have copied on this email. I haven't heard from anyone (from the facility) about payment.

. On 06/11/25 at 5:30 P.M. interview with the Administrator verified she was responsible to ensure the facility operated to meet the needs of the residents in the facility but she denied any knowledge of non-payment to vendors or disruption in services. However, the Administrator shared that when she assumed the role as Administrator of this facility, there was a stack of bills that had not been paid and she directed staff to get the bills submitted to corporate to ensure they were paid timely.

On 06/18/25 at 3:30 P.M. interview with the Administrator verified there was no tracking mechanism, on her part, to ensure all financials and invoices were paid timely. The Administrator verified she did not track to ensure invoices were received from vendors or utilities, she just made sure invoices were submitted to corporate for payment.

On 06/18/25 at 6:55 P.M., an interview with the Administrator revealed the facility did not have a heating and cooling company under contract.

Review of the Executive Director (Administrator) Job description, signed by the Administrator on 11/08/24 revealed the primary purpose of the job is to direct the day-to-day functions of the facilities with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Under budget and planning functions the Administrator is to keep abreast of the economic condition/situation and make arrangements as necessary to assure the continued ability to provide quality care.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

This violation is an example of continued non-compliance from the 05/23/25 survey.

Based on record review, interview and observation, the facility failed to provide personal care services that were in accordance with acceptable standards of care. This affected two residents (#19 and #40) of three residents reviewed. This had the potential to affect all residents of the facility. The facility census was 60.

Findings include:

1. Review of document titled Standing Orders revealed a document with a faxed date of 11/09/2023. These orders did not contain an approving physician signature, or date approved for use by any medical staff. The orders indicated if an item was not covered on the orders, the nurse should call the on-call provider for assistance. The standing orders did not address what to do in the event of a burn. The contents of the standing orders, as well as the absence of burn orders, a physician signature or medical staff approval was confirmed by the Director of Nurses.

Review of Resident #19's medical record revealed she was admitted to the facility on 02/03/25. She was admitted with diagnoses of chronic obstructive pulmonary disease, hypertension, and major depressive disorder.

The record further revealed a Functional Assessment dated 02/03/25, which was the day of admission. This functional assessment determined Resident #19 scored a five on a one to five scale. A score of five indicated the resident required complete supervision and administration of all medications.

The record also revealed a Level of Care Assessment dated 03/11/25. This assessment indicated the resident scored a one on a zero to three scale for personal hygiene. A score of one indicated Resident #19 needed prompting and cueing measures to complete personal hygiene. She scored a two on a zero to three scale for medication administration, which indicated she required staff administration of medications.

Record review of Resident #19 revealed a progress note dated 06/02/25. The progress note read: Resident came to nurses station at approx :45 A.M. States that she burned her left hand with hot water, while trying to pour hot water into her cup, the water got on her hand causing a burn mark. On assessment, area on left hand between thumb and first finger is reddened. Resident denies pain or discomfort. No open areas noted. This nurse applied triple antibiotic ointment. Notified the NP. No new orders yet. Will continue to monitor.

On 06/09/25 at 3:29 P.M., during an interview with Resident #19, she was observed to have a unit dose of Triple Antibiotic Ointment in her pocket. She reported a nurse told her to use it on her burn to take the sting away.

On 06/11/25 at 10:18 A.M., interview with Director of Nurses (DON) confirmed that Resident #19's medical record did not contain any follow up, as indicated in the incident report from 06/02/25, following being burned. She agreed that Resident #19 was assessed to need assistance with medication administration. She confirmed RN #145 did not complete any follow up notes in the resident's medical record for Resident #19 nor was there any follow up past the initial note, and there were no orders written for triple antibiotic ointment for the resident. She confirmed the standing orders the facility nurses refer to did not include orders for the treatment of burns. She was unsure where the standing orders had generated from or what physician had approved them, and acknowledged the standing orders were unsigned.

On 06/12/25 at 10:23 A.M., telephone interview with RN #145 revealed Resident #19 presented to her with a burn on her left hand. The resident told her she was making a cup of tea and spilled the water on herself. She noted the area of the resident's hand to be red but not blistered, so she applied triple antibiotic ointment and then called the nurse practitioner, who gave no new orders. She knew to put on triple antibiotic ointment because, I just knew, but there is also a standing order list to follow. She confirmed she left at least one additional package of the triple antibiotic ointment with Resident #19 in the event she needed to reapply to the affected area later. RN #145 reported she checked in on the resident later in the day and her hand was no longer red and the resident did not complain of any discomfort.

On 06/14/25 at 2:43 P.M., interview with Resident #19 revealed she was burned on her left hand while trying to heat water to bathe in on 06/02/25. She could not recall the exact time, but she knew it was between breakfast and lunch. She had been trying to heat water to be able to take a sponge bath. She could not shower because there was not any hot water in her room. She placed a one quart plastic bowl covered with images of candy canes in her microwave to heat, and when she tried to get it out, the bowl tipped and splashed onto her hand, on the wall and on the floor. She ran it under cold water and rang her call light. She did not recall which two aides came to her room, and then the aides called the nurse. When the nurse came the resident asked her if she should just put some butter on it because that was what her mother taught her. At that time, the resident noted her entire thumb, third and fourth finger into her had were all bright red and very painful. She indicated the nurse gave her some ointment in a package and three additional packages and instructed her to apply the ointment whenever it started hurting. She said the nurse checked back on her a couple times throughout the day and then there was no further follow up. It remained red but the triple antibiotic ointment had helped to take out the sting of the burn. The resident's left hand was observed to have brown discoloration over her thumb, and into her fourth finger and hand. She reported it occasionally still was sensitive to touch. She reported she had no follow up with a physician for this injury.

2. Review of Resident #40's medical record revealed she was admitted to the facility on 06/21/24. She was admitted with diagnosis of Type 2 diabetes mellitus, hypothyroidism, and Stage Four pressure ulcer of the left hip.

Further review of Resident #40's medical records revealed she expressed urinary urgency, frequency and pressure on 06/02/25, and an order for a urinalysis (UA) was obtained. The urine sample was not collected until 06/04/25. The results were received on 06/05/25 and sent to the provider. New orders for antibiotics were not obtained until 06/07/25 and the resident did not start antibiotic therapy until 06/08/25. It took six days from the onset of symptoms for treatment to begin.

On 06/18/25 at 11:50 A.M. interview with the DON verified treatment for the UTI was not initiated for six days after the onset of symptoms.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

This violation is also an example of continued non-compliance from the surveys dated 04/15/25 and 05/23/25.

Based on record review and interview, the facility failed to, with consideration given to resident preferences, provide or arrange for varied activities of sufficient quantity so that residents' lives may be more meaningful, to stimulate physical and mental capabilities and to assist residents in attaining their optimal social, physical, and emotional well-being. This affected four residents (#19, #40, #50 and #54) of four residents reviewed. This had the potential to affect all residents of the facility. The facility census was 60.

Findings include:

Record review of Resident #50 revealed she was admitted on 06/03/24. She had admission diagnoses of hyperlipidemia; HTN; anxiety disorder, allergic rhinitis, postherpetic nervous system involvement, hypothyroidism; GERD; constipation, diarrhea; vertigo, disorder of thyroid. Her record did not contain an activities assessment or assessment revealing her likes, dislikes or hobbies.

Record review of Resident #40 revealed she was admitted on 06/21/24. She had an admission diagnoses of Type 2 diabetes mellitus, hypothyroidism, and Stage 4 pressure ulcer left hip. Her record did not contain an activities assessment or assessment revealing her likes, dislikes or hobbies.

Record review of Resident #54 revealed he was admitted on 04/12/24. He had an admission diagnoses of Type 2 diabetes with diabetic peripheral angiopathy with gangrene, hyperlipidemia, nicotine dependence, major depressive disorder, hypertension, and left below knee amputation. His record did not contain an activities assessment or assessment revealing her likes, dislikes or hobbies.

Record review of Resident #19 revealed she was admitted on 02/03/25. She had an admission diagnosis of chronic obstructive pulmonary disease, hypertension, and major depressive disorder. Her record did not contain an activities assessment or assessment revealing her likes, dislikes or hobbies.

On 06/14/25 at 2:43 P.M., interview with Resident #19 revealed she believed the activities of the facility are subpar and no one had ever asked what she wanted or liked to do. She reported she found the activities at the facility boring. She reported the Activities Director had told her she was willing to do other activities but did not have a budget to support doing crafts, and that was what Resident #19 found most enjoyable. She indicated she believed the current activities were for the elderly and she believed she still had lots of energy to spend.

On 06/18/25 at 5:47 P.M., interview with the Activity Director (AD) confirmed the activity budget had been decreasing since she took the position in March of 2024. Her original budget at that time was $400.00 per month. It dropped to $200 per month, and then to $100 per month. She was unsure of the dates of the decreases. If she wanted to do a craft project it would have to come out of her own pocket. She reported she paid for alcohol for the bar for resident Happy Hour, if she could not get donations, out of her own money. The AD also reported that no formal activity assessment was completed for new residents or on an ongoing basis. She reported she met with residents when they were admitted to get to know them, but nothing was documented or implemented to be sure residents had activities they enjoyed offered to them.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review, resident fund review, policy review and interview, the facility failed to ensure resident fund authorizations were witnessed as required. This affected one resident (#54) of four residents sampled for resident fund accounts. The facility identified 14 residents with resident fund accounts. The census was 60.

Findings include:

Review of the record revealed Resident #54 was admitted on 04/12/24 with diagnoses including anxiety disorder, diabetes mellitus and hypertension.

Review of the Resident Fund Management Service dated 07/02/24 revealed Resident #54's authorization for the facility to manage his funds was witnessed by Administrator #201. There was no other witness to the authorization that was not affiliated with the facility.

On 06/16/25 at 4:58 P.M., interview with the Administrator verified Resident #54's fund authorization was only witnessed by the previous Administrator #201.

Review of the policy: Resident Personal Funds revised 07/10/2020 revealed the facility will not require residents to deposit their personal funds with the facility. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review and interview, the facility failed to take immediate steps to see that residents received necessary intervention when there was a change in health status. This affected one resident (#40) of three residents reviewed. This had the potential to affect all residents of the facility. The facility census was 60.

Findings Include:

Review of Resident #40's medical record revealed she was admitted to the facility on 06/21/24. She was admitted with diagnoses of Type 2 diabetes mellitus, hypothyroidism, and Stage Four pressure ulcer of the left hip.

Further review of Resident #40's medical records revealed she expressed urinary urgency, frequency and pressure on 06/02/25, and an order for a urinalysis (UA) was obtained. The urine sample was not collected until 06/04/25. The results were received on 06/05/25 and sent to her primary care provider. New orders for antibiotics were not obtained until 06/07/25 and the resident did not begin antibiotic therapy until 06/08/25. It took six days from the onset of symptoms for treatment to begin. Director of Nurses confirmed this record on 06/17/25.

On 06/16/25 at 4:10 P.M., interview with Resident #40 revealed she had been a resident of the facility for one year. She reported she felt very frustrated because she did not feel like the facility was concerned about her health. She indicated one week ago, she was diagnosed with a UTI and reported concerns of delay in treatment and felt like it took too long to take care of it. She indicated after her results were positive it took several days for the facility to get orders for antibiotics.

On 06/18/25 at 11:50 A.M. interview with the Director of Nursing (DON) verified treatment for the UTI was not initiated for six days after the onset of symptoms.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on infection control information review, interview and policy review the facility failed to provide a comprehensive infection prevention and control program. This had the potential to affect all 60 residents residing in the facility.

Findings include:

Review of the facility's infection control surveillance program revealed the facility used a document titled Antibiotic Tracking which contained the resident's name, medication, symptoms/infection and the start/end date. There was no other infection control surveillance or monitoring used by the facility.

Review of the infection control policies provided by the facility revealed no written policy or procedure regarding infection prevention and control, investigation of infections or implementation of appropriate infection control interventions. Further review of the infection control procedures revealed the only infection control policy and procedure provided was the Influenza Exposure Control dated 07/11/20.

On 06/11/25 at 10:30 A.M. interview with the Director of Nursing verified the only surveillance for infections the facility completes is the antibiotic tracking.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on review of the State Fire Marshal (SFM) Fire Safety Inspection, interview, observation, review of vendor invoices, review of the facility sprinkler system testing and maintenance records, and review of the facility fire alarm interfaced equipment system testing and maintenance records, the facility failed to comply with all applicable state fire code standards.

Findings include:

Review of State Fire Marshal (SFM) Fire Safety Inspection, dated 06/09/25 and conducted by SFM #209, revealed violations were noted for the following systems (including but not limited to): Hood Suppression Systems, Fire Alarm Systems, and Smoke Detectors. There were violations issued because the sprinkler system was not being maintained as installed; the smoke and fire dampers throughout the ventilation system of the facility had not been maintained as required. There was no evidence of required periodic inspection, testing or maintenance of the smoke and fire dampers; the level of protection afforded by the fire protection system in the facility was not being maintained. The fire protection system, required to be maintained by the Ohio Fire Code, was noted to be not operational. The Fire Protection system had not been inspected, tested and maintained as required; Inspection revealed the fire pump was not maintained as required. A weekly test of the fire pump assemblies was not conducted.

On 06/10/25 at 12:15 P.M., an interview with Maintenance Director (MD) #127 revealed Gutridge Fire Suppression company was scheduled to come to facility to help get the fire codes up to standards but he was advised by administration he could not schedule them until the balance (owed) to Gutridge was paid. He stated he was new to the facility and did not know the history of the company, but the administration told him the invoice and payment had been sent, but he was currently waiting for the approval to schedule.

On 06/11/25 at 8:07 A.M. a telephone interview with SFM #209 revealed all systems in the facility needed inspected. He stated all quarterly assessments and testing were past due and needed completed before everything could be determined operational.

On 06/11/2025 at 11:26 A.M., observation of the facility kitchen with MD #127 revealed the Ansul hood suppression had not been inspected and tagged since August 2024. This inspection is required every six months. MD #127 verified the findings at the time of the observation.

On 06/11/2025 at 1:12 P.M., observation revealed the main fire panel located by the main entrance door had a trouble light on indicating the system was not normal. The trouble light was found to be a smoke detector removed from the ceiling in the 300 hallway. MD #127 verified the finding at the times of observation.

Review of the invoices from Gutridge (fire service company) revealed the following invoices:

Invoice Number (#)FS-4321 Dated 10/02/24 with a due date of 11/01/24 for an annual fire hydrant inspection with the balance due $125.00.

Invoice #FS-4332 Dated 10/03/24 with a due date of 11/02/24 for an annual fire pump inspection with the balance due $500.00.

Invoice #FS-4333 dated 10/03/24 with a due date of 11/02/24 for a semi-annual inspection of the wet systems, main riser, dry system and first floor mechanical room with the balance due $1,200.00.

Invoice #FS-4711 Dated 11/21/24 with a due date of 12/21/24 for an identified busted sprinkler pipe and parts list for repair with the balance due $4,483.68.

All invoices had terms of 30 (days) net. All invoices were marked as scanned and were all signed and entered an account number on 01/20/25 by Employee #500.

The facility provided no evidence the invoices were paid.

On 06/11/25 at 9:40 A.M. an interview with Service Coordinator #205 from Gutridge Mechanical-Electrical-Plumbing company revealed no services had been scheduled for the facility as of this date.

Review of an email sent to the surveyor from Service Controller #205 from Gutridge dated 06/11/25 at 9:57 A.M. revealed Gutridge would not service the facility at the time of the survey. The email read, We have an outstanding balance of $6,808.68 dated back from last year October and November (2024). As of right now, the facility is not a customer we could service. If the balance is caught up, I will leave it up to (Gutridge #207), who I have copied on this email. I haven't heard from anyone (from the facility) about payment.

Review of the facility sprinkler system testing and maintenance records revealed the facility was unable to provide documentation showing completion of the following required testing:

·12 months of consecutive wet sprinkler system pressure logs. The facility could only provide December 2024 to March 2025.

·Weekly dry sprinkler system pressure logs for 12 months reviewed.

·Quarterly sprinkler inspections since 10/02/2024

·3-year pressure leak testing.

·3-year full trip test.

·Annual private fire hydrant testing.

Review of the facility fire alarm interfaced equipment system testing and maintenance revealed the facility was unable to provide documentation showing completion of the following required testing:

· Annual Electronic smoke damper testing.

·Four-year mechanical fire damper testing/inspection.

·Two-year smoke detector sensitivity testing.

On 06/15/25 at 8:50 A.M., a telephone interview with Representative #211 from Protex LLC (the facility smoke detection company) revealed the facility had an outstanding balance over 90 days. The current balance was $7,577.03.

On 06/16/25 at 9:48 A.M., an email was received from Representative #211 to confirm communication with Chief Operating Officer (COO) #214 and Director of Finance (DOF) #210 for the facility. The email dated 06/11/25 at 12:05 P.M. notified COO #214 and DOF #210 that outstanding invoices needed paid immediately because they were too outdated. The email advised that services would be suspended until all invoices were paid.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on fire drill record review and interview the facility failed to ensure a fire drill was conducted on each shift at a minimum of every three months This had the potential to affect all 60 residents residing in the facility.

Findings include:

Review of the fire drills revealed only two fire drills had been completed from May 2024 to May 2025. The fire drills were held on 01/29/25 at 11:00 P.M. and 03/26/25 at 3:24 P.M.

On 06/18/25 at 5:11 P.M. interview with Maintenance Director #127 verified only two fire drills had been completed during the last 12 months.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review and interview the facility failed to ensure monthly fire inspections were completed. This had the potential to affect all 60 residents residing in the facility.

Findings include:

Review of the monthly Fire Safety- Self-Inspection Form for 2024 and 2025 revealed no evidence the 2024 inspections were completed. Review of the 2025 inspections revealed there was no monthly inspection completed during the month of May.

On 06/18/25 at 5:04 P.M. interview with Maintenance Director #127 verified the monthly inspections were not completed as required.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on review of the facility Admission Packet, policy review, record review, interview and observation, the facility failed to permit smoking only in designated areas, to take reasonable precautions to ensure the safety of all residents when permitting smoking, or to not allow smoking in areas where oxygen was in use. The facility also failed to make accommodations for residents who smoked during adverse weather conditions. This had the potential to affect all residents of the facility. The facility census was 60.

Findings Include:

Review of the facility Admission Packet, which was undated, revealed a smoking policy on page 12 of 15. The smoking policy read as follows: Smoking guidelines-Smoking is prohibited in any area of the property, including parking lots and outdoor seating areas.

Review of a separate policy, which was undated and titled Smoking Policy revealed a different smoking policy. This policy was as follows: Senior Suites at St. Clair Commons does not allow smoking of any kind, including electronic cigarettes within this facility. All residents who are labeled as smokers are required to have a Smoking Assessment completed upon admission and quarterly. Residents are to smoke only within the designated smoking area located behind the facility.

Record review of Resident #11 revealed she was admitted on 04/14/25. She had admission diagnoses of chronic obstructive pulmonary disease, major depressive disorder and gastroesophageal reflux. The resident's medical record failed to reveal a Smoking Safety Assessment. On 06/18/25 at 12:00 P.M., Director of Nurses confirmed resident was identified as a smoker.

Record review of Resident #59 revealed he was admitted on 03/01/23. He had a diagnoses on admission of chronic obstructive pulmonary disease, hereditary idiopathic neuropathy, solitary pulmonary nodule and major depressive disorder. His record indicated orders for continuous oxygen by nasal cannula (through the nose) at two to four liters per minute.

On 06/09/25 at 3:30 P.M., an interview with Resident #59 revealed he could no longer enjoy being outside on the back patio by the dining room. He did not feel like he could go outside and enjoy the patio because people smoke wherever they wanted to and with his oxygen he could not safely be around them.

On 06/14/25 at 1:20 P.M., interview with the son of Resident #59, revealed his father had expressed some concerns to him. He explained his father had breathing issues and wore oxygen; however, he liked to go outside in the evenings. Resident #59 had expressed to him there was no seating in the outside area, and that other residents were smoking all over the place, so it had not been safe for him to go out and socialize with other residents due to his oxygen.

On 06/14/25 at 2:38 P.M., observation of patio area revealed cigarette butts scattered all over the patio area, in the cracks of the concrete, and all around the black wrought iron fencing area. There was noted to be two Smokers Outposts for cigarette disposal inside the fenced area. One was directly beside the entrance door, and the second was near the edge of the patio beside the fence. Near the parking lot, outside the fenced in area, was a bench and another Smokers Outpost that had a sign indicating it was the smoking area. There was not any covering over this area or protection from the weather. These findings were confirmed by Licensed Practical Nurse (LPN) #105 at the time of the observation.

On 06/15/25 at 6:18 P.M., observation revealed Resident #11 sitting just outside the door of the pub, under the awning, smoking a cigarette. It was raining at that time. This was confirmed by Patient Care Support Staff (PCSS) #118 at the time of the observation.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review, interview, policy review, and observation, the facility failed to maintain a clean, healthy environment for all residents. This had the potential to affect all residents of the facility. The facility census was 60.

Findings include:

Review of undated policy titled Routine Cleaning and Disinfection, revealed routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Interview on 06/12/25 at 12:00 P.M. interview with the Director of Nurses confirmed this was the current policy.

Review of housekeeping logs failed to reveal any cleaning of Resident #54's room. The logs showed only cleaning of bathroom for Resident #40's room.

Review of Resident #40's medical record revealed she was admitted to the facility on 06/21/24. She was admitted with diagnosis of Type 2 diabetes mellitus, hypothyroidism, and Stage Four pressure ulcer of the left hip.

Record review of Resident #54 revealed he was admitted on 04/12/24. He had an admission diagnosis of Type 2 diabetes with diabetic peripheral angiopathy with gangrene, hyperlipidemia, nicotine dependence, major depressive disorder, hypertension, and left below knee amputation.

On 06/09/25 at 12:00 P.M., an interview with Resident #57 revealed he wanted to change his room. He indicated there was an overwhelming odor coming from that guy across the hall (Resident #54). Resident #57 stated, The guy across from me smells horrible. I can't open my door without smelling him. He has never showered the whole time he has lived here.

On 06/10/25 at 10:05 A.M., observation was made of Resident #54's room, accompanied by Housekeeper #109. Foul odor could be smelled from the hallway before the door was opened. Upon entering the room, it was found to be disarrayed. The countertop in the entryway was completely covered with clutter and other detritus. There was a sign hanging that said boil order dated from two months ago. There was cigarette butts noted on the floor. There were no sheets on the bed, and a large brownish stain covered the middle of the mattress, and the bottom of the mattress had a large black stain on it. The floor beside the bed was covered in what appeared to be vomit. There were three unidentified pills on the floor near the nightstand and one unidentified pill on the floor on the other side of the bed. There was a full urinal hanging from the nightstand. The toilet was covered in feces, and the bowl was stained. The floor surrounding the toilet in the bathroom had black stains on it, and there were feces on the floor of the bathroom. The condition of the room was confirmed by the Director of Nurses at 11:00 A.M. on 06/10/25.

On 06/14/25 at 2:04 P.M., observation revealed a strong smell of urine in the hallway outside of Resident #40's room. At the time of the observation, Patient Care Support Staff (PCSS) #118 confirmed that the resident did not allow the staff to assist her with laundry, all the laundry of the resident was done in her sink. She did not allow housekeeping services in her room, and staff was only allowed to remove her trash.

On 06/14/25 at 2:38 P.M., observation of patio area revealed cigarette butts scattered all over the patio area, in the cracks of the concrete, and all around the black wrought iron fencing area.

On 06/16/25 at 4:10 P.M., observation of Resident #40's room revealed a pungent odor of urine about the room. There was a significant amount of dirty dishes in the sink and trash in the trash cans.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on interview and observation, the facility failed to provide each resident with basic toilet items and paper products. This had the potential to affect all residents of the facility. The facility census was 60.

Findings include:

On 06/10/25 at 12:00 P.M., observation of supplies and interview with Housekeeping #109 confirmed he was advised not to provide paper towels to residents. He revealed the facility had only five rolls of paper towels available, which he reported were only for emergencies and he did not like that he could no longer provide residents with paper towels like he had done in the past. He confirmed he had not been able to provide towels for (Resident #6) or (Resident #8) in the past week.

On 06/10/25 at 12:05 P.M., interview with Resident #6 revealed she had asked for paper towels from housekeeping but had been advised they could not provide them to her. She reported Housekeeping #109 had given her three or four of the loose kind to get her through, but that was it.

On 06/10/25 at 12:06 P.M., interview with Resident #7 revealed he had been out of paper towels in his room for over a month. Usually, he would ask the female housekeeper for paper towels, however when she would come back to his room, she would only bring toilet paper and never paper towels. He reported when he initially came to the facility, he could get them whenever he wanted, however on the date of interview he could not get them at all.

On 06/10/25 at 12:15 P.M., interview with Maintenance Supervisor #139 revealed he had been instructed by Maintenance Supervisor #200 not to supply paper towels to any of the residents. He had been advised only to put paper towels in public restrooms.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review, resident council meeting review, policy review, and interview, the facility failed to ensure residents were free from misappropriation. This affected two residents (#43 and #46) of four residents reviewed for missing items. In addition, the facility failed to treat residents with dignity. This affected all 60 of 60 residents residing in the facility. The facility census was 60.

Findings include:

1. Record review revealed Resident #43 was admitted on 10/18/24 with diagnoses including major depression, anxiety and spinal stenosis.

Review of the Resident Council Meeting dated 03/26/25 revealed Resident #43 reported the laundry aides had lost her comforter and sheets and the items had not been located. The Director of Nursing (DON) addressed the above laundry concerns voiced indicating she was going to educate staff on proper laundry use and requesting a concern/complaint form be filled out immediately so she can resolve the issues. Further review of the Resident Council Minutes revealed no evidence staff/residents were educated on the above. There were no missing item or complaint forms filled out after discovery of the above missing items for Resident #43.

On 06/16/25 at 5:00 P.M., interview with the Administrator and DON stated they were unaware of any concerns regarding lost or missing items. Resident Council Meeting minutes were reviewed with both the Administrator and the DON who stated they were unaware of the lost or damaged clothing, and were unable to state what happened to the items. The DON verified there was no education completed to date regarding proper laundry use.

2. Record review revealed Resident #46 was admitted on 12/27/23 with diagnoses including major depressive disorder, anxiety and osteoporosis.

On 06/09/25 at 3:29 P.M. interview with Resident #46 revealed the facility does her laundry and staff needed to learn how to wash clothing. The resident stated she has had about $200 worth of clothing ruined or lost by the staff including pants and a blouse, a track/jogging suit and one other outfit.

On 06/16/25 at 5:00 P.M., interview with the Administrator and the DON revealed neither were aware of the missing personal items for Resident #46.

Review of the Grievance Log dated 2025 revealed no evidence the above missing items reported in the Resident Council Meetings were documented or investigated. There was one grievance on the log; however, the grievance was not in regards to missing resident property.

Review of the undated policy: Abuse, Mistreatment, Neglect and/or Misappropriation of Resident Property revealed the facility would not tolerate abuse, neglect and/or misappropriation of resident property. Residents, families or other persons may contact a member of the administration team or nursing staff at any time with concerns regarding abuse, neglect and/or misappropriation of resident property. A grievance could be filed with the facility or with the Ohio Department of Health with any instance or suspicion of abuse, neglect or misappropriation of resident property.

Review of the undated policy: Resident Missing Items revealed when an item is missing a Missing_ Item report should be filled out by the person who discovers the item is missing. Residents, family members or staff may file. the report. This report should be turned into Administrator or Director of Wellness, who will route it to the proper department. An investigation will be assigned to the appropriate staff. An investigation will be conducted and will not last longer than 5 days, at which time a determination is made. If the item is not found, Administrator or assigned staff member will

re-evaluate for thoroughness of the investigation. Within 10 days progress report will be given to resident and/or responsible person. Missing items report will be signed by resident and/or responsible party.

Based on observation, record review, including review of facility billing/financial information, review of email communication, review of the State Fire Marshal report, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. This resulted in Real and Present Danger beginning on 11/01/24, when the lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization, and/or displacement due to potential interruption of services from outside service providers. This had the potential to affect all 60 residents residing in the facility.

On 06/11/25 at 5:09 P.M., the facility Administrator (Administrator #216), Director of Nursing (DON) and Maintenance Director (MD) #127 were notified Real and Present Danger began on 11/01/24 when the onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by having outstanding balances with vendors and providers. This included, but was not limited to, disruption in maintenance of the fire system rendering the fire system non-operational, monthly utility disconnection notices, delinquent food service invoices, and the lack of timely and effective hot water heater repairs to maintain comfortable water temperatures for resident use due to historical delays with invoice payments.

The Real and Present Danger was abated on 06/25/25 when the facility implemented the following corrective actions:

On 6/11/25 at 11:50 P.M. Licensed Practical Nurse (LPN) #117 was educated by Administrator #216 and to implement fire watch.

On 06/12/25 at 12:45 A.M. Administrator #216 implemented the fire watch procedure which continued through 06/17/25 at 4:30 P.M. Staff were assigned fire watch duty during that time.

On 06/12/25 at 1:15P.M.- Koorsen Sales Representative #208 evaluated the facility and provided a contract for Koorsen to assume the fire and safety services at the facility. A contract was signed on 06/12/25 for Koorsen to take over the fire and security services at the facility effective 07/01/25.

On 06/12/25 (no time identified) an electronic payment was made to Gutridge in the amount of $9,872.40.

Beginning 06/12/25 (no time identified) monthly fire safety training for all staff, including evacuation procedures, fire watch protocols, and emergency roles. This training was provided by Maintenance Director (MD) #127.

On 06/12/25 (no time identified) Director of Finance #210 categorized bill/payment method: autopay (utilities), manual check (supplies), ACH (payroll) for facility vendors/suppliers.

On 06/12/25 (no time identified) Backup payments (e.g., credit card) were established for key utilities as identified by facility administrator in collaboration with the corporate office.

On 06/13/25 at 3:45 P.M. the DON educated the following staff on fire watch procedures: Patient Care Support Staff (PCSS) #118, PCSS #123, PCSS #122, LPN #155, and Registered Nurse (RN) #145.

On 6/13/25 (no time identified) a notification was sent via Paycom for all staff acknowledgment of fire watch training.

On 06/13/25 (no time identified) US Foods was paid $24,835.55 through First Merchants with a resulting zero balance due.

On 06/13/25 (no time identified) three invoices were paid to IceBox (the portable outdoor refrigeration system used in place of the Walk-In cooler that did not maintain temperature): Invoice Number (#) 20250273 for $5,357.14; Invoice #20250166 for $900.90 and Invoice #20250315 for $1,071.43 via Quicken Books.

On 06/14/25 at 2:31P.M. the DON notified the local fire department of the facility fire watch procedures in place.

On 06/16/25 at approximately 10:30 A.M.- State Fire Marshal #209 visited the facility for another inspection and awaiting the report from Koorsen to place the facility back into compliance with the fire system requirements.

On 06/17/25 at 8:00 A.M. MD #127 was trained on temperature monitoring and safe water temperatures by Corporate Maintenance Director #200.

On 06/17/25 at 2:35 P.M. -Koorsen cleared the fire panel and stated there were no current alarm system warnings on the panel.

On 06/17/25 (no time identified) Administrative Assistant #131 was educated by the Administrator #216 on the Accounts Payable process and to monitor the Accounts Payable Tracking Log weekly. The Administrator/Designee would complete a report through the accounts payable system in Point Click Care (PCC) to ensure nothing was delinquent moving forward.

Beginning 06/17/25 (no time identified) MD #127/Designee would oversee issues with the fire monitoring system by reviewing the fire panel weekly. Administrator #216 would audit this review randomly using an audit report.

Beginning 06/17/25 (no time identified) reminders would be set for Administrator #216/MD #127 for all fire system inspections and when those inspections are due through the PayCom system. This would ensure all inspections have been scheduled.

Beginning 06/20/25 (no time identified) the Administrative Assistant/Designee would time-stamp, code and scan invoices to corporate accounts payable by the end of the day on Fridays. Administrator #216/Designee would complete an accounts payable review beginning on 06/20/25.

Beginning 06/20/25 centralized invoice repository and weekly tracking utilizing a new tracking log created was implemented. This would ensure a thorough review of all invoices and assist with monitoring the process of timely submission at the facility level and submitted to corporate for review/payment. The Administrator would monitor weekly for compliance.

On 6/20/25 (no time identified) all residents were trained on the evacuation procedures by the DON. The DON would re-educate all staff on fire preparedness. Staff were educated to reach out to DON/Administrator/Designee to ensure the message is followed up on through corporate accounts payable. Maintenance issues should be directed to the MD #127 or Corporate Maintenance Director #200

On 06/20/25 (no time identified) Kucera reinstalled the correct mixing valve by Plumber #204 to address the water temperatures throughout the facility.

Beginning on 06/25/25 (no time identified) a contract was obtained with Kucera for the facility's heating and cooling needs.

Beginning on 06/30/25 Administrator #216/Designee would audit completion of the facility corrective actions weekly for four weeks and monthly for two months to ensure ongoing compliance.

Although the Real and Present Danger was abated on 06/25/25, the violation remained as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance.

Findings include:

Review of the facility survey history revealed on 05/23/25 a complaint survey was completed which resulted in concerns related to the facility's hot water heater not being repaired timely resulting in water temperatures not meeting the required range of 105 to 120 degrees Fahrenheit (F) and the facility did not have a water management program to prevent the spread of Legionella. The hot water heater had not been repaired as of the time the survey was completed.

Review of the Resident Council Minutes dated 05/28/25 revealed old business (from the prior Resident Council Meeting) revealed water temperatures required follow-up. The follow-up note from the administrator read: I emailed (the) plumber (on) 05/23/25. Its 05/27/25 still waiting on response about the part. Review of the new business for the Resident Council Minutes dated 05/28/25 revealed everyone asking about any word when we are going to get the hot water fixed? This is too long. We don't like taking cold water baths and sponge baths. Please note, this inquiry was not responded to by the Administrator. There were 16 residents in attendance for this meeting, Resident #7, #8, #9, #12, #16, #17, #25, #29, #34, #43, #49, #51, #53, #55, #57 and #60.

An interview on 06/09/25 at 9:15 A.M. with Resident #25 revealed she currently had hot water in her room; however, she indicated it had only been hot/fixed for three or four days. Resident #25 reported for the past month she had no hot water and had to bird bath because there was no way she would shower in the cold water. The resident reported it had been an extensive amount of time to get the hot water repaired.

On 06/09/25 at 10:31 A.M., an interview with Corporate Maintenance Director #200 revealed the water mixing valve had been replaced the week before (the week of 06/02/25); however, the water continued to be cold in resident rooms. He indicated the plumber who had replaced it (Plumber #203) refused to come back to correct the issue. A new plumber, identified as Plumber #204, was contacted and came to the facility the next day (06/06/25). The director revealed it was identified by the second plumber that the mixing valve which had been replaced by Plumber #203 was for a ten-room shower system and was for emergencies only. The second plumber ordered the correct mixing valve and adjusted the emergency valve to allow water temperatures to reach appropriate levels until the new mixing valve arrived.

On 06/09/25 at 11:15 A.M. interview with Resident #57 revealed the facility had recent issues with the hot water and just got the hot water back but it took about a month to get it fixed and no one would tell us why it took so long to get it fixed. The resident stated that some residents took sponge baths, and some residents refused to bathe due to the cold water temperatures.

On 06/09/25 at 11:50 A.M., a telephone interview with Plumber #204, who was employed with Kucera Plumbing revealed the facility had a plumber at the facility previously, who was from Moundsville (Plumber #203). Plumber #203 had installed a new mixing valve, but the valve installed was for one emergency shower, like what was used in places for decontamination, not for an entire building. The incorrect mixing valve was just tempering the water. Plumber #204 stated the facility had not asked him to do any work after his initial visit, but he had informed the facility to notify him if they wanted to proceed with the repairs. During the interview, Plumber #204 revealed that due to past experiences with the facility and the facility not paying his company (for work completed), payment for the order and invoice were needed before service would be provided to replace the mixing valve at the facility.

On 06/09/25 at 2:36 P.M. an interview with Administrator #216 revealed Plumber #203 required pre-payment before he started repairs (no reason provided by the Administrator). However, when issues were identified with the hot water heater after his repairs were complete, Plumber #203 would not return to the facility, so Plumber #204 was contacted. Plumber #204 identified the wrong mixing valve was installed by Plumber #203. Administrator #216 stated Plumber #204 ordered the correct mixing valve and it was on its way.

On 06/09/25 at 3:30 P.M., an interview with Resident #50 revealed she had been without hot water for over a month and had just got it back a few days prior to this interview. She stated she had to sponge bathe in the sink when the water was cold. She stated she was disappointed because she did not feel the facility had kept her up to date on what was happening.

On 06/11/25 at 11:19 A.M., a telephone interview with Plumber #203 revealed he was no longer servicing the facility. He stated he installed a mixing valve on 06/02/25 and on 06/03/25 he received a phone call that the system was not working. When he arrived at the facility, he met with three maintenance men (from the facility). He discovered the return pump was only giving two to three gallons of water per minute and needed to be seven to eight gallons per minute so he believed there was a cross connection somewhere in the system, which would be hard to isolate. He stated he was given approval to order the new return pump and told the facility it would not be available until Friday (06/06/25). Further interview revealed he received a phone call on 06/05/25 from Maintenance Director (MD) #127, who asked if Plumber #203 was coming to the facility that day. Plumber #203 advised MD #127 the pump was not available until the following day (06/06/25) so he would not be coming until then. MD #127 informed him if he could not be at the facility on 06/05/25, to not return to provide service.

In addition to the facility's failure to ensure timely and necessary repairs were completed due to a lack of vendor payment for plumbing services, the following concerns related to financial solvency were also identified placing all facility residents at risk for serious harm, injury, hospitalization, and/or displacement due to potential interruption of services from outside service providers:

a. Review of State Fire Marshal (SFM) Fire Safety Inspection, dated 06/09/25 and conducted by SFM #209, revealed violations were noted for the following systems (including but not limited to): Hood Suppression Systems, Fire Alarm Systems, and Smoke Detectors. There were violations issued because the sprinkler system was not being maintained as installed; the smoke and fire dampers throughout the ventilation system of the facility had not been maintained as required. There was no evidence of required periodic inspection, testing or maintenance of the smoke and fire dampers; the level of protection afforded by the fire protection system in the facility was not being maintained. The fire protection system, required to be maintained by the Ohio Fire Code, was noted to be not operational. The Fire Protection system had not been inspected, tested and maintained as required; Inspection revealed the fire pump was not maintained as required. A weekly test of the fire pump assemblies was not conducted.

On 06/10/25 at 12:15 P.M., an interview with Maintenance Director (MD) #127 revealed Gutridge Fire Suppression company was scheduled to come to facility to help get the fire codes up to standards but he was advised by administration he could not schedule them until the balance (owed) to Gutridge was paid. He stated he was new to the facility and did not know the history of the company, but the administration told him the invoice and payment had been sent, but he was currently waiting for the approval to schedule.

On 06/11/25 at 8:07 A.M. a telephone interview with SFM #209 revealed all systems in the facility needed inspected. He stated all quarterly assessments and testing were past due and needed completed before everything could be determined operational.

On 06/11/2025 at 11:26 A.M., observation of the facility kitchen with MD #127 revealed the Ansul hood suppression had not been inspected and tagged since August 2024. This inspection is required every six months. MD #127 verified the findings at the time of the observation.

On 06/11/2025 at 1:12 P.M., observation revealed the main fire panel located by the main entrance door had a trouble light on indicating the system was not normal. The trouble light was found to be a smoke detector removed from the ceiling in the 300 hallway. MD #127 verified the finding at the times of observation.

Review of the invoices from Gutridge (fire service company) revealed the following invoices:

Invoice Number (#)FS-4321 Dated 10/02/24 with a due date of 11/01/24 for an annual fire hydrant inspection with the balance due $125.00.

Invoice #FS-4332 Dated 10/03/24 with a due date of 11/02/24 for an annual fire pump inspection with the balance due $500.00.

Invoice #FS-4333 dated 10/03/24 with a due date of 11/02/24 for a semi-annual inspection of the wet systems, main riser, dry system and first floor mechanical room with the balance due $1,200.00.

Invoice #FS-4711 Dated 11/21/24 with a due date of 12/21/24 for an identified busted sprinkler pipe and parts list for repair with the balance due $4,483.68.

All invoices had terms of 30 (days) net. All invoices were marked as scanned and were all signed and entered an account number on 01/20/25 by Employee #500.

The facility provided no evidence the invoices were paid.

On 06/11/25 at 9:40 A.M. an interview with Service Coordinator #205 from Gutridge Mechanical-Electrical-Plumbing company revealed no services had been scheduled for the facility as of this date.

Review of an email sent to the surveyor from Service Controller #205 from Gutridge dated 06/11/25 at 9:57 A.M. revealed Gutridge would not service the facility at the time of the survey. The email read, We have an outstanding balance of $6,808.68 dated back from last year October and November (2024). As of right now, the facility is not a customer we could service. If the balance is caught up, I will leave it up to (Gutridge #207), who I have copied on this email. I haven't heard from anyone (from the facility) about payment.

Review of the facility sprinkler system testing and maintenance records revealed the facility was unable to provide documentation showing completion of the following required testing:

·12 months of consecutive wet sprinkler system pressure logs. The facility could only provide December 2024 to March 2025.

·Weekly dry sprinkler system pressure logs for 12 months reviewed.

·Quarterly sprinkler inspections since 10/02/2024

·3-year pressure leak testing.

·3-year full trip test.

·Annual private fire hydrant testing.

Review of the facility fire alarm interfaced equipment system testing and maintenance revealed the facility was unable to provide documentation showing completion of the following required testing:

· Annual Electronic smoke damper testing.

·Four-year mechanical fire damper testing/inspection.

·Two-year smoke detector sensitivity testing.

On 06/15/25 at 8:50 A.M., a telephone interview with Representative #211 from Protex LLC (the facility smoke detection company) revealed the facility had an outstanding balance over 90 days. The current balance was $7,577.03.

On 06/16/25 at 9:48 A.M., an email was received from Representative #211 to confirm communication with Chief Operating Officer (COO) #214 and Director of Finance (DOF) #210 for the facility. The email dated 06/11/25 at 12:05 P.M. notified COO #214 and DOF #210 that outstanding invoices needed paid immediately because they were too outdated. The email advised that services would be suspended until all invoices were paid.

b. Review of the invoice for Account Number A15-70010-01 from St. Clairsville Municipal Utilities, with a due date of 06/23/25 revealed a past due balance of $9,872.40 and a current balance of $18,616.23. The invoice indicated the previous balance of $9,872.40 was due before 06/11/25. If not received by 4:30 P.M. on the due date, the facility would have a ten percent penalty added to the bill. This bill was for service from 04/30/25 through 05/31/25. It was provided by Administrator #216 for review during the onsite survey.

On 06/10/25 at 8:36 A.M., a phone interview with St. Clairsville Municipal Utilities #219 revealed the facility had an outstanding balance of $18,616.23 which included a past due balance of $9,872.40. She reported the facility had only been current in April of 2025, and had been past due in January, February, March, and May of 2025. She reported the facility had been at risk of disconnection, and when this happened, a phone call was placed to the facility and then a letter of disconnection would be sent. If a facility does not pay the balance owed by the 23rd of each month, a 10 percent penalty is assessed. If the utility bill is not paid by the 11th of the following month, the utilities would be disconnected on the 17th of that month. She indicated the utilities department of St. Clairsville try to be generous because they are aware there are residents who live at the facility, so disconnection had not occurred.

A follow-up interview on 06/13/25 at 11:20 A.M., with St. Clairsville Municipal Utilities #219 revealed the facility paid the past due amount of $9,872.40 on 06/12/25 online (following surveyor intervention) but continued to have a current balance of $8,743.83.

c. Review of IceBox Invoices (a mobile freezer unit being used by the facility) that were due on receipt revealed the following:

Review of Invoice #20251066 dated 04/21/25 revealed $900.90 was overdue.

Review of Invoice #20250315 dated 06/03/25 revealed $1,071.43 was overdue.

On 06/11/25 at 10:14 A.M., an interview with Administrator #216 revealed the facility was using a mobile freezer for food because the existing facility freezer was not operational as it would not hold freon. She reported National Equipment (a contracted company) had come out and advised her the compressor (on the freezer) was bad and could not be repaired, so the unit would require a new compressor. She asked National Equipment to send someone out for an estimate. The vendor returned and provided estimates for a replacement compressor and a new freezer, but she was unsure of the corporation plans to replace the freezer. She stated while she was on vacation, someone authorized the use of the IceBox Mobile Refrigeration, and it had been in use ever since (specific dates not provided).

On 06/13/25 at 10:45 A.M., a telephone interview with Icebox Mobile Refrigeration Representative #218 revealed the facility had an outstanding balance of $7,329.47 (this included a rental amount of $5,357.14 dated 05/28/25 and the facility was given 30 net days to pay with a due date of 06/27/25) with service beginning on 03/23/25. Further interview revealed the only payment that had been made was on 04/01/25 with a credit card. The representative verified they had not received another payment since. The representative stated she had been in contact with the facility administrator, who advised her that all invoices had been sent to the corporate office, which was how IceBox would get paid, and the administrator said it was out of her hands.

On 6/13/25 at 12:18 P.M., an email received from Representative #218 revealed she had reached out to the Administrator (#216) but did not reach her, and was told no one who worked in accounts payable was available. She explained to whomever she was talking to that there was an overdue balance of over $7K ($7,000). She advised the facility that if a payment was not made that day (06/13/25) she would start the process of removing the box.

. Review of invoices sent from Climatech (Heating and Cooling Vendor/Contractor) revealed invoices that were unpaid and resulted in discontinued heating and cooling services for the facility. The invoices included:

Invoice #205767 dated 01/06/25 for $1,731.98

Invoice #208679 dated 04/07/25 for $602.00.

Invoice #208798 dated 04/10/25 for $1,731.98.

Invoice #209409 dated 05/05/25 for #1,731.98.

Invoice #210470 dated 06/04/25 for $1,731.98.

On 06/15/25 at 9:06 A.M., a telephone interview with Representative #212 from Climatech revealed the facility had an outstanding balance with the company of $7,529.92. The company had a contract for heating and cooling with the facility, however, effective the previous week (the week of 06/09/25), Representative #212 reported Climatech had stopped service for non-payment.

On 06/18/25 at 6:55 P.M., an interview with Administrator #216 revealed the facility did not currently have a heating and cooling company under contract.

e. Review of the US Foods Invoice dated 05/31/25 revealed the facility had a current balance of $28,532,71 with $4,009.92 past due greater than 30 days.

On 06/12/25 at 12:21 P.M. an interview with Corporate Controller #212 and DOF #210 confirmed the open balance with US Foods.

During an interview on 06/09/25 at 2:36 P.M., Administrator #216 reported all bills were submitted to the corporation and then corporate would pay the bills. She stated she was not certain of the method in which all bills were paid, if by check, credit card, or auto pay. However, she did know that some of the bills were paid on the corporate credit card. She also shared that since Medicaid payment had been on hold due to the facility Medicaid Waiver application not being submitted timely (resulting in no payment for residents receiving the Medicaid Waiver program), it had been difficult to make some payments since many residents were on the waiver program.

On 06/11/25 at 2:44 P.M., a telephone interview with Corporate Controller #211 revealed he worked for the financial contracted company responsible for the financial services of the buildings owned by Danan Healthcare, which included this facility, Senior Suites at St. Clair Commons. He stated he had been working in his current position for under a month and had been trying to familiarize himself with each of the facilities (under the Danan Healthcare umbrella). He stated he was not certain who the owner of the facility was. He revealed he was aware there had been a flood at the facility that created some issues with things being paid and some vendor issues, but as far as he had been aware, all of the issues and bills were current as of this date (06/11/25). Corporate Controller #211 stated, I don't think it's a surprise that Senior Suites, well, I mean the skilled nursing industry in general, has some financial issues, and I think the whole flood issue just made it worse.

During the interview, the controller explained that he managed the accounts payable team, which was responsible for entering the approved invoices into the system and getting them paid. He was also responsible for preparing financial statements for the facility each month. He managed Revenue and Expenses, Profits and losses, and satisfying all external regulatory services such as Medicare/Medicaid, the banking relations, and creating the annual budget.

When discussing the status of the outstanding bills and disruption of services, the controller reported it was hard to know an answer to what the systemic failure would be that kept bills from being paid on time since he had only been with the company for two weeks. However, he stated he knew some things were paid by check and some things were paid by electronic funds transfer (ACH). He reported that ultimately it was his responsibility for bills to be paid but if he did not receive the bills, he would not know what needed paid. He shared he would like the administrator to sign off on the correctness of the invoice and then send them to the corporate office to be paid.

At the time of the interview, the controller indicated he did not have access to the facility accounts. He reported the Director of Finance (DOF) #210, who worked in the same office, would have access to them and she was the one who would reconcile bank statements and do any ACH when necessary and she would be available for interview on 06/12/25.

On 06/12/25 at 12:21 P.M., a telephone interview with Corporate Controller #211 and DOF #210 revealed the DOF answered the questions throughout the interview. She indicated she helped with anything financially related, which included all vendor payments and invoices due, which were to be sent to the corporate office at a minimum of once a week. The second and third weeks of the month were the weeks that very little came in. The first and the last week of the month, invoices were to be sent daily via email to the accounts payable (AP) email address. The entire team in that office had access to the files that came to the AP email address. She indicated her staff then would go through AP on a bi-weekly basis and then, as they got money in, they would pay for the open AP. She also shared the finance group would take the most important bills, which would affect the residents first and then work from there. According to DOF #210, the following were considered the most important: Food, utilities, insurance, employee benefits, any supplies (such as Medline), linens, and anything else related to care of residents. At the end of month, when the company received their Medicaid Waiver payment, all the remaining outstanding bills were to be paid. The DOF reported there had been no pause or delay of the facility receiving any of their Medicaid Waiver payments and the payments always arrived on time.

According to DOF #210, some of the billing was behind because the corporation did not receive the invoices from the facility timely and there was no system in place to track the invoices. She shared, at the corporate level, they (meaning the financial department) were unaware of what the facility was ordering or what needed paid and unless the invoices were timely sent to the department, there was no method of tracking or ensuring all invoices were paid timely. The DOF denied knowledge of services being discontinued or held due to nonpayment until 06/10/25 but stated if the facility received a delinquent notice, it would be her expectation that an email and follow-up phone call from the facility to her department would be received immediately.

On 06/17/25 at 12:32 P.M., interview with Administrator #216, Consulting Administrator #217, and Chief Operating Officer (COO) #214 (via phone) revealed they did not believe there were any issues with financial solvency and all bills/invoices were paid timely. However, during the interview COO #214 stated that if the facility Medicaid waiver application could be processed faster (the facility was delinquent in renewing the application within the required timeframe to avoid penalty or disruption in services), then bills would get paid faster.

During the onsite survey, an interview with an anonymous staff member revealed the company credit card would sometimes be shut off despite being told to use the card to purchase items for the residents. The staff member did not know if it was specific to a certain time of the month, if there was an unpaid balance or what the reason may be. The anonymous staff member stated it was embarrassing to try and purchase things for the facility to only be told at the counter the card was declined.

An additional interview with a staff member who wished to remain anonymous revealed they had received calls from vendors indicating payments were not received or payments were late. The staff stated they had received calls from the utility office about disconnect notices and other vendors were unhappy about not being paid. The anonymous staff member stated these concerns were shared with management, but the calls were still coming to the facility by vendors.

Review of the facility undated policy titled Abuse, Mistreatment, Neglect and/or Misappropriation of Resident Property revealed the facility would not tolerate abuse, neglect and/or misappropriation of resident property. The policy stated under federal law, neglect meant the failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness. Under Ohio law, neglect meant recklessly failing to provide a resident with any treatment, care, goods, or services necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident.

This violation represents non-compliance investigated under Complaint Number OH00166182.

Based on review of resident council minutes, record review, interview, and observation, the facility failed to respond to resident reasonable requests and inquiries promptly. This had the potential to affect all residents of the facility. The facility census was 60.

Findings include:

Review of 04/30/25 Resident Council Minutes revealed multiple residents (note says Everyone) voiced concerns of water temperatures. The note read our hot water is not consistently hot in our rooms. The written reply from the Administrator was as follows: Two emails out; I'm in touch with the plumber company. The part is not a stock item and has been order. The same complaint was noted in old business in the Resident Council Meeting notes dated 05/28/25 for follow up. The follow up note from the administrator read: I emailed plumber 05/23/25 its 05/27/25 still waiting on response about the part. A note from 05/28/25 resident council meeting listed everyone asking any word when we are going to hot water fixed? This is too long. We don't like taking cold water baths and sponge baths. This note was not responded to by the Administrator.

Review of Resident Council Meeting minutes dated 04/30/25 revealed concerns about safety of patio furniture. Documented as a concern by everyone, the question posed was is there any word on getting back patio new furniture for the chairs are damaged? Someone is going to get hurt. The response to the question, made by Administrator #216 was will look into new furniture in the next couple months.

At this same meeting, Resident #48 expressed concerns over missing items from laundry. Resident #48 indicated the facility should be responsible for paying back residents because they are on a fixed budget. The answer from the Administrator on the minutes was the facility does not reimburse for missing or damaged items. Resident #57 requested quarters to be awarded for prizes during bingo. Administrator #216's reply was no, this is gambling. We cannot support this.

Review of Resident Council meeting minutes, dated 05/28/25 revealed a report from the grievance committee. The committee reported it did not like the response from Administrator #216 from the last meeting in which she indicated she would look into new patio furniture in the next few months. The residents wanted it on record as a grievance. There was no noted response to this.

Record review of Resident Council Meeting minutes dated 05/28/25 revealed further discussion regarding patio furniture. Listed as everyone, the records indicated the following That is too long summer will be over by then. Right now, we are using dining room chairs. They will get ruined, then they will have to replace them. There are not enough chairs up front for us to sit in. No Administrator response was noted on these minutes.

During the course of the survey, interview with Employee #115 revealed concern that resident complaints were not being listened to. The residents have voiced concerns over water temperatures and patio furniture for months, and Administrator #216 had done nothing to address those issues until people start calling State.

On 06/09/25 at 12:00 P.M., an interview with Resident #57 revealed the Administrator at this time was Administrator #216, but they are looking for a new one. He reported residents had filed a grievance to get new outside furniture, but who knows when that will happen.

On 06/09/25 at 1:22 P.M., an interview with Resident #58 revealed multiple concerns for residents of the facility. The residents had been bringing up new patio furniture but the Administrator just says no. The resident reported the old furniture had been taken away because it was unsafe. Resident #58 indicated Administrator #216 had advised the grievance committee there needed to be quotes for the new furniture, but the old furniture was removed before that happened.

During an interview on 06/09/25 at 2:36 P.M., with Administrator #216 revealed she didn't address resident concerns or complaints directly with the residents as she always wrote her response on the resident concern forms. The Administrator stated she would sometimes go to Resident Council Meetings if she was invited by the residents. The administrator described the process as follows: The resident would complete a concern form and give it to the Activities Director. The Activities Director would give her the concern forms, she would respond or give the form to the appropriate manager to respond, and then the form would be returned to the Activities Director, who would present the response to the resident.

During the interview, Administrator #216 reported that on 06/06/25, multiple residents had asked her about the patio furniture. She reported she had been getting estimates for replacement furniture. She had approval from the corporate office to get estimates for new patio furniture and the owner of the facility told her to get estimates for the remote sun setter (a motorized awning system that can be extended or retracted using a remote control). At the time of interview, the administrator had obtained no estimates. She reported all old furniture that had been on the patio was discarded due to being in poor condition.

On 06/09/25 at 3:00 P.M., an interview with Employee #155 revealed they had been employed at the facility for more than a year. The employee expressed concerns over the patio furniture not being replaced. They indicated Administrator #216 had advised the staff there was no budget for any purchases.

On 06/09/25 at 3:15 P.M., interview with Employee #145 revealed they had worked at the facility for over ayear. They have had residents complain to them that Administrator #216 had been rude to them. The residents were asking for patio furniture and were told by Administrator #216 that someone would look into it, but that it could be a couple months, which seemed too long.

On 06/09/25 at 3:29 P.M., interview with Resident #46 revealed concerns the outdoor patio furniture had been falling apart for months and it was thrown away. She indicated the residents had to sit on their walkers and there were only four chairs on the patio. If there were more residents outside, they would have to bring out dining room chairs.

On 06/09/25 at 3:30 P.M., an interview with Resident #59 revealed the residents have asked for patio furniture for months. He did not believe what they had was safe, but the administrator would not discuss it with anyone. He also reported he did not feel like he could go outside and enjoy the patio because people smoke wherever they wanted to and with his oxygen he could not safely be around them. The residents have had to take their own chair out of the dining room if they want a safe seat outside. Resident #59 shared that all I keep hearing is they (the facility) don't have the money.

On 06/10/25 at 9:46 A.M., interview with Ombudsman #220 revealed Administrator #216 does not want to spend additional money. She had told Ombudsman #220 we have to cut the bleed, when discussing reasons for cutting back on purchasing.

On 06/09/25 at 6:00 P.M., observation revealed the old patio furniture with holes, cuts and in obvious disrepair beside the dumpster. At the time of the observation, the Director of Nursing confirmed the furniture had been placed at the dumpster for pick up.

On 06/14/25 at 1:20 P.M., interview with the son of Resident #59, revealed his father had expressed some concerns to him. He reported his father would like to do some out of the facility trips, but his real concern had been not being able to get outside and enjoy the patio as he would like. He explained his father had breathing issues and wore oxygen; however, he liked to go outside in the evenings. Resident #59 had expressed to him that there was no seating in the outside area, and that other residents were smoking all over the place, so it had not been safe for him to go out and socialize with other residents due to his oxygen.

On 06/22/25 at 1:05 P.M., observation of the patio off of the dining room revealed there were four dining room chairs pulled out onto the patio. There was one wicker chair, a wicker foot rest and side table, one round dining table without chairs and a glass top side table.

On 06/22/25 at 1:05 P.M., interview with Residents #46, #29, #28, #19, and #21, who were sitting outside, revealed they had pulled dining room chairs out because there was no furniture to sit on. They said more people would sit outside if there was furniture. They said they have asked for furniture but can't get anything done.

On 06/22/25 at 1:09 P.M., interview with the Director of Nurses revealed Administrator #216 had spoken about bringing outdoor furniture from her other facility in Carrollton because they did not use it.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00166182.

Based on record review, resident council meeting review and interview, the facility failed to ensure resident personal property was safeguarded and in good condition. This affected three residents (#46, #48 and #49) identified in resident council meeting minutes and had the potential to affect all residents residing within the facility. The facility census was 60.

Findings include:

Record review revealed Resident #46 was admitted on 12/27/23 with diagnoses including major depressive disorder, anxiety and osteoporosis.

Record review revealed Resident #49 was admitted on 12/17/24 with diagnoses including diabetes mellitus and hypertension.

Record review revealed Resident #48 was admitted on 12/17/24 with diagnoses including myasthenia gravis and chronic obstructive pulmonary disease.

Review of the Resident Council Meeting minutes dated 03/26/25, 04/30/25 and 05/28/25 revealed the following:

a. Resident #46 asked what to do when you have lost clothes or clothes that were ruined when washed. Resident #46 stated they (staff) have damaged her clothes 'a lot' and could not wear them.

b. Resident #48 stated when people have missing clothes the facility should be responsible for paying back residents. We are on a fixed income. The Administrator's response to Resident #48's statement was ' We do not reimburse for missing items damaged.

c. Resident #49 stated 'they need to quit washing clothes in hot water and drying them on hot'. The Director of Nursing was to provide education to staff; however, there was evidence this had been completed.

On 06/16/25 at 5:00 P.M., interview with the Administrator and Director of Nursing verified the above statements and facility responses to the resident council concerns. The Administrator stated when resident clothing was damaged from staff doing their laundry, it should be replaced.

This violation represents non-compliance investigated under Master Complaint Number OH00166384.

Based on resident fund review, resident agreement review, resident fee review, record review, policy review and interview, the facility failed to provide paid services as listed in the resident agreement, failed to ensure residents received their monthly Medicaid personal needs allowance and failed to accurately bill a resident for room and board. This affected one resident (#25) of four residents reviewed for billing and one resident (#54) of four residents reviewed for resident funds. This had the potential to affect all 60 residents residing within the facility.

Findings include:

1. Record review revealed Resident #25 was admitted on 05/25/21 with diagnoses including cerebral infarction and lymphedema.

a. Review of the Resident Agreement dated 05/25/21 revealed the Ohio Revised Code provides certain resident rights for assisted living facilities and these rights were included in this agreement.

Review of the 2025 Living Unit Resident Fees description revealed the cost of a private, All-Inclusive-Rate was $268.16 per day. All Inclusive Rates allowed the prices to stay the same if the resident's level of care changed, as well as, getting two free haircuts per month.

Review of the facility Admission policies-Level of Care revealed the daily rate also included two alcoholic drinks per day at the evening happy hour.

Review of the resident billing Statement dated April 2025 and May 2025 revealed Resident #25 continued to be charged the daily an All-Inclusive-Rate.

On 06/12/25 at 10:45 A.M., interview with Resident #25 revealed she has not had her hair cut at the facility salon since March 2025 and this was an included service (two haircuts a month) per her agreement. Resident #25 also stated she has been overcharged for other things but could not specify the items.

On 06/12/25 between 3:10 P.M. and 3:53 P.M., interview with Administrator #216 revealed the beautician was terminated on 04/03/25 and verified there had been no salon services for any resident since the end of March 2025. The Administrator verified Resident #25 had an All-Inclusive-Rate including two free haircuts per month and two daily alcoholic drinks but has not been receiving these per the Resident Agreement.

b. Review of the resident billing Statement dated 12/01/24 revealed Resident #25's daily rate for Room and Board (R/B) was $255. Further review revealed Resident #25 was charged for 12 days of $255 for a total R/B of $3,060 between 11/01/24 and 11/12/24.

Review of the resident billing Statement dated 04/01/25 revealed Resident #25 was billed for the following:

i. R/B during Flood- payable to third party for 18 days effective date 11/13/24 at the daily rate of $255 for a total amount of $4,590.

ii. R/B during Flood-payable to third party for 15 days effective date 12/01/24 at the daily rate of $255 for a total amount of $3,825.

On 06/11/25 at 1:46 P.M., phone interview with Beautician #112 revealed she had stopped coming to the facility after the first of the year (2025) because they did not have a current beauty shop license and failed to pay her as agreed upon.

On 06/12/25 at 10:18 A.M., interview with Administrator #216 revealed residents had to be relocated to other living arrangements due to a pipe bursting and flooding the facility around 11/13/24. The Administrator stated residents were to pay the same daily rate they normally would pay-per-day and if the relocated location had any additional room/board differences, those charges would be covered by the facility's insurance company and not charged to the residents.

On 06/16/25 between 4:45 P.M. and 5:45 P.M., interview with the Administrator verified Resident #25 was charged the daily rate of $255 in both November 2024 and then again in April 2025 totaling an excess of $8,415.00. The Administrator stated she was unaware the resident had been billed twice stating the billing was done at the corporate level.

2. Record review revealed Resident #54 was admitted on 04/12/24 with diagnoses including anxiety, major depressive disorder, diabetes mellitus and hypertension.

Review of the Fund Management Service Authorization dated 07/02/24 revealed Resident #54 authorized the facility to manage his personal funds.

Review of the Resident Statement Landscape dated 04/01/25 through 06/05/25 revealed no evidence Resident #54 was paid his $50.00 personal needs allowance from Medicaid for April 2025.

On 06/12/25 at 5:20 P.M., interview with the Activity Director stated there had been no beautician at the facility since March 2025 when the beauty salon closed on 03/23/25. The Activity Director also stated the resident agreement indicated the daily rate included two alcoholic drinks per day at evening happy hour and this was only being offered on Monday-Wednesday-Friday and it has never been daily. Now they told the residents it will be cut down to once a week next month and the residents are not happy about this.

On 06/16/25 between 4:45 P.M. and 5:30 P.M., interview with the Administrator and the Director of Nursing verified there was no evidence of a signed receipt for the above cash withdrawals at the time of the review. The Administrator stated it was her expectation that signed receipts for cash were placed in the resident funds binder at the time of the cash withdrawal.

Review of the undated policy: Beauty Shop/Salon revealed the facility was committed to providing access to professional grooming and personal care services through an on-site beauty shop/salon operated in compliance with all state and federal requirements.

Review of the policy: Resident Personal Funds revised 07/10/2020 revealed the if the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf.

This violation represents non-compliance investigated under Master Complaint Number OH00166384.