Inniswood Village

Based on observation, staff interview, and dietary policy and procedure review, this facility failed to to ensure hand hygiene was completed as required when preparing plates of food for residents. This had the potential to affect all residents residing at the facility at this time. Facility census was 73.

Findings include:

Observation completed on 02/03/2026 at 12:30 P.M. of lunch time revealed multiple infection control and hand hygiene concerns. Server #300 was observed putting on a pair of gloves without completing hand hygiene followed by placing seven bowls on a table in front of the salad bar. Server #300 continued to touch multiple surfaces around the salad bar including the handle to the salad bar and the storage door under the salad bar. Server #300 was then observed using the same gloved hand to reach in and grab a handful of lettuce, tomatoes, cucumber, eggs, onions and then peppers. This was completed seven different times. At no point was serving utensils used or gloves changed.

Dishwasher #310 was observed grabbing a cart from the dishwashing area and moving it to another part of the kitchen follower by putting a pair of gloves on, grabbing two plates of dessert. Dishwasher #310 then proceeded to unwrap the plates of dessert and using the gloved hands, grab each dessert and place then in separate plastic containers. At no point was hand hygiene completed or was gloves changed.

Sous Chef #340 was observed using gloved hands and grabbing two pieces of bread followed by touching multiple surfaces near the stove. Then Sous Chef #340 was observed using the same gloved hand to grab a pickle from the storage container and place it on a plate. At no time was hand hygiene completed, gloves changed, or serving utensils used.

Line Cook #350 was observed putting on a pair of blue gloves while waiting for meal tickets to come in. During this time, Line Cook #350 was observed picking up a damp cloth and wiping his gloved hands and then wiping multiple surfaces near the steam table and oven. While wearing the same blue gloves Line Cook #350 grabbed a roll and placed it on a meal plate. At no time was hand hygiene or glove change completed.

Review of the facility policy titled Hand Hygiene dated 01/2026 revealed Hands are washed with soap and water at the following times: before putting on gloves, before handling food, after removing gloves, and after any other activity that may contaminate the hands.

This violation is a recite to the complaint survey completed 09/15/2025.

Based on review of facility documented fire drills and staff interview, the facility failed to ensure 12 fire drills, and each shift as required. This had the potential to affect all resident residing at the facility at this time. Facility census was 73.

Findings include:

Review of the fire drill documented from January 2025 through January 2026 revealed there was no drill conducted on June 2025 or July 2025 now did the facility ensure fire drill that were completed were on a different shift each month.

Interview on 02/04/2026 at 2:00 P.M. with the Executive Director verified the above findings.

This violation is a recite to the annual survey completed 07/02/2025.

Based on medical record review, staff interview and facility abuse policy and procedure, this facility failed to ensure resident to resident physical and verbal abuse did not occur. This affected Resident #102 and #110 of the five residents reviewed for abuse. The facility census was 73.

Findings include:

Review of the medical record for Resident #102 revealed an admission date of 12/16/2023. Diagnoses included type two diabetes, dementia, and inter-vertebral disc degeneration of the lumbar region.

Review of the Mini Cognitive Assessment dated 12/15/2025 revealed a score of 0 indicating suspected dementia for Resident #102.

Review of the medical record for Resident #110 revealed an admission date of 12/16/2025. Diagnoses included dementia, hyperlipidemia and heart disease.

Review of the Mini Cognitive Assessment dated 12/15/2025 revealed a score of 0 indicating suspected dementia for Resident #110.

Review of multiple progress notes for both residents revealed both resident resided in the same room and were husband and wife. Between 08/15/2025 to 01/27/2026 there have been numerous documented incidents of Resident #102 displaying verbal and/or physical abuse to Resident #110.

-08/15/2025 at 1:42 P.M. Resident #102 was noted to yell at Resident #110 and tell her it was time for lunch. At this time, Resident #110 raised her hands as to protect herself from being hit.

-10/16/2025 at 3:16 P.M. Resident #102 was noted to be walking behind Resident #110 and observed hitting her in the back while walking. Resident #102 claimed she was just shoving her and not punching her.

-12/02/2025 at 11:54 A.M. Resident #102 was observed by facility staff grabbing a hold of Resident #110's wheeled walker and pulling on it. Resident #102 was then heard by a facility staff member telling Resident #110 that she needed to sit the hell down. Resident #102 voiced that he did not like Resident #110, he did not want to be with her, and it was her fault that they were there.

-12/03/2025 at 8:30 A.M. Resident #102 was reported to become aggressive with facility staff when they attempted to assist Resident #110 with bathing care. Resident #102 was noted to pull staff members hair while providing care. Staff had to assist Resident #102 out of the bathroom and lock the door where he proceeded to hold onto the door handle and refuse to let staff members and Resident #110 out of the bathroom. Later that same day, Resident #102 was noted to refuse Resident #110 go to the dinning room to staff where staff had to intervene.

-12/04/2025 at 2:23 P.M. Resident #102 was observed by facility staff hitting Resident #110 in the legs with his cane as to tried her along or make her move faster.

-12/06/2025 at 9:30 P.M. Resident #110 approached a facility staff member and accused Resident #102 of hitting her.

-12/13/2025 at 8:14 A.M. Resident #102 became physically aggressive with staff while attempting to provide care to Resident #110.

-12/18/2025 at 8:14 A.M. Resident #102 was blocking facility staff members from coming into the room and claiming Resident #110 was not going anywhere and she did not need to eat.

-12/29/2025 at 2:00 P.M. Resident #102 was observed by facility staff pulling Resident #110's walker down the hallway while she was actively using it. When Resident #110 was attempting to eat a muffin Resident #102 smacked it out of her hand claiming she did not need to eat that.

-01/08/2026, time not noted, Resident #102 was observed by facility staff attempting to force Resident #110 back to their room, when resident refused, Resident #102 was observed hitting Resident #110 in the back multiple times.

-01/27/2026, time not noted, Resident #102 was observed by facility staff members pushing his walker into Resident #110's legs while sitting at the table.

Observation on 02/03/2026 at 3:30 P.M. of Resident #102 and Resident #110 in their room revealed that the door was closed and the television was very loud. Upon entering the room with facility staff, Resident #102 was noted to be sitting on the couch watching television and the door to the bedroom was closed. When staff entered the bedroom, Resident #110 was sitting on the side of the bed, wearing own clothing and appeared clean and well groomed. Resident #102 was friendly at first until the staff member started to talk to Resident #110 and asked her if she wanted to come to the lobby area and hang out. Resident #110 at first said yes, all while sitting with arms crossed in from of chest and side looking at Resident #102. Resident #102 came up to this surveyor and asked what was going on. Replied everything was going well. Resident #102 stared to yell Bullshit I want to know what the charges are, Resident #110 immediately changed her mind and ended up saying she did not want to go down to the lobby any more and wanted to lay in bed. Staff assisted Resident #110 to lay down.

Interview shortly after with Licensed Practical Nurse (LPN) #116 claimed Resident #102 has yelled at Resident #110 and pushed her in the back and pulled the her walker multiple times. Facility staff try to keep Resident #110 out in the common area to monitor her but Resident #102 always wants to take her back to their room. When Resident #110 is in the room, facility staff try to complete frequent checks on her but this can sometimes cause Resident #110's agitation. When both residents first moved into this facility they were in the assisted living section where Resident #102 would provide most of Resident #110's care and left staff know if they needed anything. Since Resident #102 started to display dementia, they both were moved to the memory care unit for safety concerns. LPN #116 claims she reaches out to the power of attorney (POA) with all incidents and changes. Most of the time, she has to leave a message and does not receive a return call. Claims she does feel like Resident #110 is intimidated by Resident #102 but per her knowledge he has not caused any injuries.

Interview on 02/04/2026 at 1:18 P.M. with the Executive Director (ED) revealed staff have attempted to reach out to the POA multiple times to see about getting a camera put into the room but he never gives them a answer, permission nor has he returned their calls or text. Claimed a phone call was placed about two weeks ago and is yet to hear back. Claims they have attempted to provide 1:1 care or supervision for both residents but this just seems to increase Resident #102's agitation and cause behaviors because the Resident #102 wants to know why they are there and wants them out of his room. The physician has been notified and constantly updated about all of Resident #102's behaviors. The ED requested to send Resident #102 to the emergency room for a evaluation but was told he would just be sent back because his behaviors are not constant and he has not actually harmed anyone. Also there are a lot of time where he does seem alert and orient.

Interview on 02/04/2026 at 1:42 with Resident #102 and #110's POA revealed he receives messages from the facility all the time and they are very good at keeping him updated. He is aware of the behaviors but feels that Resident #102 would never hurt Resident #110. The only issues is when they are coming from the room to the common area, Resident #110 moves slowly and Resident #102 tries to hurry her along. The POA claimed he did not feel like there was a safety concerns while they are in the room and was informed of the facility and CNP wanting to install a camera in the room for safety but feels this is an invasion of their privacy and has not agreed to it. When updated on his aggression towards this surveyor and facility staff, the POA said well you are a stranger and he becomes that way with strangers.

This violation represents non-compliance investigated under Complaint Number OH00169643.

Based on observation, staff interview, and review of facility policy, the facility failed to complete wound dressing changes in a manner consistent with infection control practices. This affected two residents (#2 and #22) out of two residents reviewed for wound care. The facility identified nine residents who received dressing changes. The facility census was 70.

Findings include:

1. Review of the medical record for Resident #2 revealed an admission date of 11/23/20. Diagnoses included Alzheimer's dementia, arthritis, pain in the right hip, major depressive disorder, and other specified hearing loss.

Review of the physician order dated 09/11/25 revealed to cleanse Resident #2's right inner elbow wound then apply a foam dressing once weekly and as needed.

Observation on 09/11/25 at 1:05 P.M. revealed Licensed Practical Nurse (LPN) #86 took a photo of Resident #2's exposed right elbow wound using an iPhone while holding the device with gloved hands. Further observation at the time revealed LPN #86 placed the iPhone down on a nearby medication cart, then opened a new dressing and applied it to Resident #2's wound without changing gloves.

Interview on 09/11/25 at approximately 1:15 P.M. with LPN #86 verified not changing gloves after using an iPhone to take a picture of Resident #2's wound prior to opening and applying the clean dressing. LPN #86 stated the mobile device used to take photos was a potential source of contamination to the gloved hands used to perform Resident #2 dressing change.

2. Review of the medical record for Resident #22 revealed an admission date of 04/02/24. Diagnoses included Alzheimer's dementia, anxiety, and arthritis. Review of the last mini-cognition assessment completed on 04/18/25 revealed Resident #22 had significant cognitive impairment.

Review of the physician order dated 07/24/25 revealed to cleanse Resident #22's left upper lateral (at the side) shin skin tear then apply a foam dressing once weekly and as needed.

Observation on 09/11/25 at 12:53 P.M. revealed LPN #86 donned a glove to the left hand but not to the right hand, then placed a wound measurement sticker on Resident #22's left shin wound using the ungloved right hand. Further observation at this time revealed LPN #86's index and middle fingers appeared to make direct contact with Resident #22's wound during the process.

Interview on 09/11/25 at approximately 1:15 P.M. with LPN #86 verified not using a gloved hand to apply the wound measurement sticker on Resident #22's left shin wound. LPN #86 stated gloves would normally worn on both hands whenever completing wound care, along with hand hygiene performed with each glove change.

Review of the facility policy, Infection Control-Standard Precautions

Based on observation, interview, record review and facility policy review, the facility failed to maintain infection control measures when administering medication. This affected one (Resident #2) of five residents reviewed for medication administration. The facility census was 72.

Findings include:

Review of the Senior Living Level of Care Assessment dated 02/12/25 revealed Resident #2 could not manage her own medications and relied on staff to dispense medications two times a day.

Observation of medication administration on 07/02/25 at 10:00 A.M. for Resident #2 revealed Licensed Practical Nurse (LPN) #1 pulled medications for Resident #2, while attempting to remove a pills from blister pack, LPN #1 dropped the pills onto the counter of the medication cart and picked it up with an ungloved hand and placed it in medication cup.

Interview on 07/02/25 at 10:10 A.M. LPN #1 verified she dropped Resident #2's pills onto the medication cart, picked them up with an ungloved hand, placed them into the medication cup and administered the medication to Resident #2. LPN #1 stated she would normally throw the medication in the sharps container and contact the pharmacy to replace the medications that were thrown away.

Review of the Medication Administration policy, dated 06/2014, stated keep medications and equipment free from contamination.

This violation was an incidental finding identified during the complaint investigation.

Based on observation, interview and facility policy review, the facility failed to safely store food in the kitchen. This had the potential to affect all 72 residents residing in the facility.

Findings include:

1. Observation of the dry storage in the kitchen on 07/01/25 at 10:51 A.M., revealed gnats in the dry storage area, used bag of croutons (no open date, no expiration date), a large container of maraschino cherries (no open date) that stated the bottle should be refrigerated after opening, and complete powder (no open date, no expiration date).

Interview with the Dietary Manager on 07/01/25 at 10:53 A.M., verified the items should be labeled and dated, and maraschino cherries should be refrigerated.

2. Observation of the walk-in refrigerator on 07/01/25 at 10:56 A.M., revealed a bucket of chocolate chip muffin mix (no open date, expiration date of 06/24/25).

Interview with the Dietary Manager on 07/01/25 at 10:56 A.M., verified the chocolate chip muffin mix should have been thrown away by the date on the label.

3. Observation of the reach- in freezer on 07/01/25 at 11:09 A.M., revealed uncovered containers of turkey sausage, beef hamburgers patties, onion rings, breakfast sausages, sweet potato fries, French fries, and chicken patties.

Interview with the Dietary Manager on 07/01/25 at 11:10 A.M. verified the items were not covered in the freezer although there were lids in the freezer, and all items were disposed of and replaced.

4. Observation of lunch service of 07/01/25 at 11:22 A.M., revealed a cold storage log was not completed. Temperatures of the cold storage items were checked, tuna salad was 43 degrees Fahrenheit (F), marinara sauce 45 degrees F, sausage crumbles 43 degrees F, shredded cheese 46 degrees F, chopped ham 42 degrees F, and red onion (had use by date of 06/28/25).

Interview with the Dietary Manager on 07/01/25 at 11:25 A.M., verified the items of the cold storage by the fryer were not at safe holding temperature, were removed and replaced. The Dietary Manager verified no log had been filled out prior to being asked for a log on 07/01/25. The Dietary Manager verified items from the cold storage table should be replaced every Monday and Wednesday each week if not used.

5. Observation on 07/01/25 at 11:45 A.M. revealed a large container of cauliflower salad outside of the refrigerator.

Interview with the Dietary Manager on 07/01/25 at 11:45 A.M., verified the container should be on ice during service. The Dietary Manager checked the temperature of the cauliflower salad and revealed a temperature of 47 degrees F. The cauliflower salad was thrown out by the Dietary Manager.

6. Observation of lunch service on 07/01/25 at 11:36 A.M. revealed the hamburger patties and the grilled chicken temperatures were not checked prior to plating for service.

Interview with the Dietary Manager on 11:39 A.M. revealed the expectation for food temperature checks prior to plating is required only for the chicken being prepared in the fryer.

Interview on 07/02/25 at 11:25 A.M. with the Dietary Manager verified each prepared item by a cook such as hamburger patties, grilled chicken, and fried chicken should have the temperature checked prior to plating and serving to verify item is at proper temperature.

This violation represents non-compliance investigated under Complaint Number OH00166392.

Based on observation, interviews, review of maintenance work orders and facility policy review, the facility failed to maintain a clean and safe environment. This had the potential to affect all 72 residents residing in the facility.

Findings include:

1. Observation on 07/01/25 at 10:51 A.M. revealed gnats in the dry storage area of the kitchen.

Interview with the Dietary Manager on 07/01/25 at 10:58 A.M. verified gnats in the dry storage of the kitchen.

2. Observation of lunch service on 07/01/25 at 11:46 A.M., and 12:32 P.M., revealed flies and gnats flying in kitchen.

Interview with the Dietary Manager on 07/01/25 at 12:33 P.M. verified gnats and flies in kitchen.

3. Observation on 07/02/25 at 8:15 A.M., revealed the Dietary Manager shaking a box of potatoes with many gnats flying out of box, stating I think I have a bad potato.

Review of maintenance work orders revealed no open or closed orders for gnats or flies in the kitchen.

Interview with the Maintenance Director on 07/01/25 at 3:30 P.M. verified kitchen staff did not report a problem with gnats and flies in the kitchen.

Review of the Insects- Pests Resident Safety Policy, dated 06/2012, it is the responsibility of all staff members to detect and report immediately the present or potential presence of pests to the Administrator and Director or Nursing/ Nurse Manager.

This violation represents non-compliance investigated under Complaint Number OH00166392.

Based on record review and staff interview the facility failed to complete quarterly fire drills on each shift and at varied times as required. The facility also failed to ensure residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift. This had the potential to affect all 73 residents residing in the facility.

Findings Include:

Review of the facility's monthly fire drills from 02/22/2024 through 02/13/2025 revealed the following completed drills:

-02/22/2024 at 3:58 P.M., no shift indicated,

-04/03/2024 at 6:46 P.M., was noted to be third shift and this was a late drill from 03/2024,

-04/18/2024 at 10:25 A.M. no shift indicated,

-06/06/2024 at 12:59 P.M. no shift indicated and noted to be a late drill from 05/2024,

-07/24/2024, no time or shift noted,

-09/03/2024, 1:26 P.M. noted as a late drill for 08/2024,

-09/19/2024 at 10:33 A.M. and noted to be first shift,

-10/01/2024 at 8:00 P.M. noted to be third shift and a late drill for 09/2024,

-10/23/2024 at 10:35 A.M. no shift noted,

-11/13/2024 at 2:05 P.M., no shift noted,

-12/17/2024 at 8:00 P.M. no shift noted,

-01/10/2025 at 1:07 P.M. no shift noted,

-02/13/2025 at 7:00 P.M. and noted to be for second shift.

Further review of the facility's fire drills from 02/22/2024 through 02/13/2025 revealed no documented evidence those residents capable of self-evacuation were actually evacuated to safe areas or to the exterior of the facility during any of the fire drills conducted.

On 03/04/2025 at 3:30 P.M.. interview with the Executive Director (ED) verified the fire drills were not conducted quarterly on each shift and at varied times. Additionally the ED verified the lack of documented evidence those residents capable of self-evacuation

were evacuated to a safe area at least two fire drills a year on each shift.

This citation is a recite to the annual survey completed 01/22/24.