Tapestry Senior Living Springboro

Based on observation, interview, and record review, the facility failed to ensure food items and kitchen equipment were maintained in a manner to prevent foodborne illness. This affected 116 out of 116 residents that resided in the facility. The facility census was 116.

Findings Include:

Observation of the ice machine on 10/22/25 at 8:13 A.M. with the Director of Nursing (DON) revealed there was a black substance on the inside ledge of the ice machine. The DON was observed to wipe the ledge of the ice machine with a white paper towel, and the black substance was observed to transfer to the paper towel. Further observation of the ice machine revealed there was grayish colored debris on the vent on the front of ice machine. Interview with the DON at the same time, verified there was a black substance on the inside ledge of the ice machine that transferred to a paper towel when wiped and gray debris on the vent on the front of the ice machine.

Observation of the facility's kitchen on 10/22/25 at 8:14 A.M. with DON, revealed there was an open and updated jar of mayonnaise, an open and undated jar of ranch dressing, and an open and undated jar of vinaigrette dressing in the reach in refrigerator and an open and undated bag of chicken strips, an open and undated bag of hash browns and an open and undated bag of sweet potato nuggets in the reach in freezer. Interview with the DON at the same time verified the findings.

Observation of Cook #72 on 10/22/25 at 8:50 A.M. revealed the Cook #72 cracked an egg with her gloved hand and then proceeded to flip eggs with a spatula with the same gloved hand. Cook #72 then picked up cheese using the same gloved hands and placed the cheese on the eggs without changing her gloves. Cook #72 proceeded to pick up bacon and placed the bacon in a resident's Styrofoam container without changing her gloves. Cook #72 did not change her gloves after cracking the egg, flipping the eggs, picking up the cheese, or picking up the bacon.

Interview with Cook #72 on 10/22/25 at 8:50 A.M. verified Cook #72 picked up the bacon with her gloved hand, and she did not use tongs or any type of utensil.

Review of the facility's equipment and supplies cleaning policy dated 11/06/19 revealed ice machines shall be cleaned and maintained on a regular schedule.

Review of the facility's food handling and storage dated 11/06/19 revealed food should remain covered when unattended and food items should be handled minimally by staff. When food handing is necessary, gloves or utensils shall be used. Food items should be appropriately contained and labeled with a date.

This violation represents non-compliance investigated under Complaint Number OH00168624.

Based on staff interview and record review, the facility failed to provide and obtain written acknowledgements that staff received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program. This affected four (Licensed Practical Nurse [LPN] #28, Resident Aide [RA] #41, RA #46, and Housekeeper #92) out of four newly hired employees reviewed for required written acknowledgements. The facility census was 116.

Findings include:

1) Review of LPN #28's personnel file revealed LPN #28 was hired at the facility on 06/02/25. Further review of LPN #28's personnel file revealed no documentation that LPN #28 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program.

2) Review of RA #41's personnel file revealed RA's #41 was hired at the facility on 09/26/2025. Further review of RA #41's personnel file revealed no documentation that RA #41 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program.

3) Review of RA #46's personnel file revealed RA #46 was hired at the facility on 09/11/2025. Further review of RA #46's personnel file revealed no documentation that RA #46 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program.

4) Review of Housekeeper #92's personnel file revealed Housekeeper #92 was hired at the facility on 08/13/2025. Further review of Housekeeper #92's personnel file revealed no documentation that Housekeeper #92 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program.

Interview with Business Office Director #14 on 10/22/25 at 10:00 A.M. verified LPN #28, RA #41, RA #46 and Housekeeper #92 were not provided and did not sign a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local Offices of the Department of Aging, and the Ombudsman program.

Based on interview and record review, the facility failed to ensure residents were free from medication errors. This affected one #109 resident out of 100 residents that required assistance with medication administration at the facility. The facility census was 113.

Findings include:

Review of the Resident #109's chart revealed Resident #109 admitted to the facility on 03/15/24 with diagnoses including type two diabetes mellitus, diverticulosis of small intestine, hypercholesterolemia, paroxysmal atrial fibrillation, chronic kidney disease, and malignant neoplasm of the skin.

Review of Resident #109's assisted living level of care evaluation dated 02/12/25 revealed Resident #109 was cognitively impaired, and Resident #109 required assistance with dressing, grooming, toileting, and showering. Resident #109 was independent with transfers, ambulation and eating. Resident #109 also required assistance medication management.

Review of Resident #109's incident report dated 04/08/25 at 11:00 P.M. revealed Resident #109 was given the wrong medication and received Clonazepam (antianxiety) 0.5 mgs and Mirtazapine (antidepressant) 15 mgs. Licensed Practical Nurse (LPN) #163 had Resident #109's medication ready to walk to her room when LPN #163 was distracted by the telephone ringing and dealing with another issue. LPN #163 sat the medication down and proceeded to prepare the next resident's medications while handling the telephone call. When the telephone call was complete, LPN #163 took the cup with the two medications and walked in to give them. As soon as LPN #163 walked out of Resident #109's room, LPN #163 saw the cup she had prepared for Resident #109 with her medication. Resident #109 was notified on 04/08/25 at 11:00 P.M. of the medication error, NP #800 was notified on 04/09/25 at 12:15 A.M. and Resident #109's son was notified on 04/09/25 at 1:20 A.M. The report was signed by Director of Nursing (DON) #133 and Executive Director #115.

Review of Resident #109's progress note dated 04/09/25 at 2:24 A.M. revealed Resident #109 was given the wrong medication of Clonazepam 0.5 mgs.

Review of Resident #109's progress note dated 04/09/25 at 12:28 P.M. revealed DON #133 completed an assessment of Resident #109. Resident #109's gait was normal and steady. Resident #109 was in good spirits and reported just feeling a little tired. Resident #109's daughter was educated to use a transport chair for her eye appointment on 04/09/25 to be safe. Resident #109's daughter did not want to cancel the appointment.

Telephone interview with LPN #163 on 04/11/25 at 1:49 P.M. revealed LPN #163 was passing medications on 04/08/25 at night and she had a lot of distraction. LPN #163 stated she pulled Resident #109's medication and set them aside and she got a telephone call. LPN #163 reported she started to pull the next resident's medication while she was on the telephone. LPN #163 stated that after she got off the telephone and she went into Resident #109's room and accidentally gave Resident #109 the medications that she pulled for the other resident. LPN #163 verified she gave Resident #109 a Clonazepam 0.5 mgs and Mirtazapine 15 mgs that were not prescribed to Resident #109. LPN #163 stated she realized the error immediately upon walking out of Resident #109's room and she contacted the physician. LPN #163 reported she checked on Resident #109 multiple times throughout the shift and Resident #109 appeared fine.

Interview with NP #800 on 04/11/25 at 1:57 P.M. revealed she received a report that Resident #109 received Clonazepam 0.5 mgs and Mirtazapine 15 mgs in error on 04/08/25.

Observation of Resident #109 on 04/11/25 at 1:58 P.M. revealed Resident #109 was walking around her room.

Interview with Resident #109 on 04/11/25 at 1:58 P.M. revealed Resident #109 was given the wrong medications three nights ago. Resident #109 stated the incident was an accident and she felt fine.

Interview with DON #133 and ED #115 on 04/11/25 at 3:06 P.M. revealed LPN #164 notified DON #133 of a medication error that occurred on 04/08/25. DON #133 reported that LPN #163 stated that she was distracted during medication pass and was dealing with multiple issues when she accidentally gave Resident #109 the Clonazepam 0.5 mgs and Mirtazapine 15 mgs that were not prescribed to her. DON #133 stated that NP #800 was also notified. DON #133 reported that she assessed Resident #109 on 04/09/25 and Resident #109 had no issues.

Review of the facility's medication administration policy dated 08/07/19 revealed the facility staff will provide safe and accurate medication administration to residents. Staff will review each resident's MAR to determine which medications need to be administered at the given time. The staff will also observe the six rights in administering each medication including the right resident, the right time, the right medication, the right dose, the right method of administration and the right documentation.

This deficiency represents non-compliance investigated under Complaint Number OH00162900.

Based on record review and staff interview, the facility failed to ensure resident evacuations were completed during fire drills as required. This had the potential to affect all 119 residents in the facility.

Findings include:

Review of the fire drills conducted during the past year, revealed fire drills were conducted on the following dates: 01/31/24 (second shift), 02/23/24 (third shift), 03/29/24 (first shift), 04/24/24 (second shift), 05/30/24 (third shift), 06/19/24 (first shift), 07/31/24 (second shift), 08/30/24 (third shift), 09/27/24 (first shift), 10/31/24 (second shift), 11/24/24 (third shift), and 12/26/24 (first shift). Further review revealed residents were evacuated during drills conducted on first shift on 09/27/24, second shift on 07/31/24, and on third shift on 02/23/24 and 11/24/24. All remaining drills indicated there were no residents evacuated.

Interview on 01/08/25 at approximately 1:30 P.M., Executive Director #300 verified there was only one resident evacuation on the first and second shifts during 2024 and residents should be evacuated twice per year on each shift.