Vitalia Senior Residences at Stow

Based on observation, interview with staff, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen. This affected all 56 residents who ate food prepared from the kitchen. Findings included: Observation during the initial tour of the kitchen on 10/29/25 at 7:50 A.M. with Cook #100 revealed the following concerns: a. Cook #100 and Server #101 did not have hair restraints on during the breakfast meal service. b. Two large trash cans did not have lids on them. c. The perimeter of the floor had a buildup of black grime and food debris.. There was a staff members drink in the freezer by the oven. e. The shelf under the steam table was dirty and had a large amount of food debris. f. The warming cart had liquid spilled down the outside and on the inside. g. There was food debris inside the warming cart. h. The reach-in freezer had plastic containers of biscuits, sausage, waffle fries, regular fries, and onion rings with no lids on them and they were open to air. The floor was also dirty with food debris including french fries and onion rings. An interview with Cook #100 during the tour confirmed the above findings. Review of the facility's undated policy titled, Cleaning ScheduleBased on observation, interview with staff, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen. This affected all 56 residents who ate food prepared from the kitchen.

Findings included:

Observation during the initial tour of the kitchen on 10/29/25 at 7:50 A.M. with Cook #100 revealed the following concerns:

a. Cook #100 and Server #101 did not have hair restraints on during the breakfast meal service.

b. Two large trash cans did not have lids on them.

c. The perimeter of the floor had a buildup of black grime and food debris.. There was a staff members drink in the freezer by the oven.

e. The shelf under the steam table was dirty and had a large amount of food debris.

f. The warming cart had liquid spilled down the outside and on the inside.

g. There was food debris inside the warming cart.

h. The reach-in freezer had plastic containers of biscuits, sausage, waffle fries, regular fries, and onion rings with no lids on them and they were open to air. The floor was also dirty with food debris including french fries and onion rings.

An interview with Cook #100 during the tour confirmed the above findings.

Review of the facility's undated policy titled, Cleaning Schedule

Based on review of facility fire drill records and interview with the staff, the facility failed to ensure residents were evacuated two times on each shift for a total of six times per year. This affected all 56 residents in the facility.

Findings included:

Review of the facility fire drills from 11/01/24 to 10/27/25 revealed no residents were evacuated during any of the fire drills.

Interview on 10/29/25 at 9:30 A.M. with Director of Maintenance #102 revealed he thought he only had to evacuate the resident every six months. He verified at this time he had not evacuated the residents two times on each shift for a total of six times per year.

This violation is a recite to the annual surveys completed on 09/13/23 and 12/13/24.

Based on record review, interview, review of the facility self-reported incident (SRI), facility investigation and facility policy review, the facility failed to ensure Resident #58 was free from staff-to-resident abuse and mistreatment. This affected one resident (#58) of three residents reviewed for abuse. The facility census was 60. Findings include: Review of the medical record for Resident #58 revealed an admission date of 12/31/24. Diagnoses included Alzheimer's and muscle weakness. Review of the Brief Interview for Mental Status (BIMS) assessment dated 12/31/24 revealed Resident #58 was severely cognitively impaired. Review of the comprehensive resident evaluation dated 12/31/24 revealed Resident #58 required partial assistance for grooming, bathing, and dressing. Review of the progress note dated 01/12/25 at 7:04 P.M. revealed Care Partner (CP) #207 reported she witnessed abuse of Resident #58 on the morning of 01/11/25. She revealed Resident #58 was sitting on the side of the bed when CP #206 slammed Resident #58's legs and body back onto the bed and used curse words with her. Upon knowledge of the information, Resident #58 was assessed for injury with no areas noted. Her responsible party and physician were notified. Review of the facility SRI tracking number 256034 dated 01/12/25 revealed CP #207 witnessed CP #206 use improper and questionable techniques with a resident (Resident #58) on 01/11/25. The incident was reported to the Director of Wellness, and an investigation was initiated. CP #206 was suspended pending results of the investigation. Review of the investigation revealed upon entering Resident #58's room, CP's #205 and #207 witnessed CP #206 tell Resident #58, who was sitting on the edge of her bed, it was not time to get up yet and put her left hand under Resident #58's legs and her right hand around her back and proceeded to slam her into the bed. CP #206 was described as very abusive and aggressive. Resident #58 was assessed, and no injuries were noted. Resident #58 was unable to provide any meaningful information regarding the interaction. As a result of the investigation, the facility substantiated the allegation of abuse, and CP #206 was terminated on 01/16/25. Interview on 02/18/25 at 9:01 A.M. with Memory Care Director (MCD) #201 revealed she was aware of an incident of abuse involving CP #205 and Resident #58. She confirmed two CP's witnessed the event, and the employee involved had been terminated. Interview on 02/18/25 at 10:31 A.M. with CP #205 revealed she witnessed CP #206 handle Resident #58 very bad. She reported she grabbed Resident #58 by the shoulders and under her legs. CP #205 revealed she reported her concern to the memory care director. Review of the facility policy titled Abuse and Neglect, Observed or SuspectedBased on record review, interview, review of the facility self-reported incident (SRI), facility investigation and facility policy review, the facility failed to ensure Resident #58 was free from staff-to-resident abuse and mistreatment. This affected one resident (#58) of three residents reviewed for abuse. The facility census was 60.

Findings include:

Review of the medical record for Resident #58 revealed an admission date of 12/31/24. Diagnoses included Alzheimer's and muscle weakness.

Review of the Brief Interview for Mental Status (BIMS) assessment dated 12/31/24 revealed Resident #58 was severely cognitively impaired.

Review of the comprehensive resident evaluation dated 12/31/24 revealed Resident #58 required partial assistance for grooming, bathing, and dressing.

Review of the progress note dated 01/12/25 at 7:04 P.M. revealed Care Partner (CP) #207 reported she witnessed abuse of Resident #58 on the morning of 01/11/25. She revealed Resident #58 was sitting on the side of the bed when CP #206 slammed Resident #58's legs and body back onto the bed and used curse words with her. Upon knowledge of the information, Resident #58 was assessed for injury with no areas noted. Her responsible party and physician were notified.

Review of the facility SRI tracking number 256034 dated 01/12/25 revealed CP #207 witnessed CP #206 use improper and questionable techniques with a resident (Resident #58) on 01/11/25. The incident was reported to the Director of Wellness, and an investigation was initiated. CP #206 was suspended pending results of the investigation.

Review of the investigation revealed upon entering Resident #58's room, CP's #205 and #207 witnessed CP #206 tell Resident #58, who was sitting on the edge of her bed, it was not time to get up yet and put her left hand under Resident #58's legs and her right hand around her back and proceeded to slam her into the bed. CP #206 was described as very abusive and aggressive. Resident #58 was assessed, and no injuries were noted. Resident #58 was unable to provide any meaningful information regarding the interaction. As a result of the investigation, the facility substantiated the allegation of abuse, and CP #206 was terminated on 01/16/25.

Interview on 02/18/25 at 9:01 A.M. with Memory Care Director (MCD) #201 revealed she was aware of an incident of abuse involving CP #205 and Resident #58. She confirmed two CP's witnessed the event, and the employee involved had been terminated.

Interview on 02/18/25 at 10:31 A.M. with CP #205 revealed she witnessed CP #206 handle Resident #58 very bad. She reported she grabbed Resident #58 by the shoulders and under her legs. CP #205 revealed she reported her concern to the memory care director.

Review of the facility policy titled Abuse and Neglect, Observed or Suspected

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all 61 residents receiving meals from the kitchen. The facility census was 61.

Findings include:

The initial tour of the kitchen was conducted on 12/11/24 at 8:08 A.M. and revealed multiple areas of concern as followed:

Inside the reach in fridge near the deep fryer there was a container of macaroni salad open to air with the lid lifted up and a package of hot dog buns unsealed and open to air.

The reach in freezer there were onion rings, fries, and chicken patties without a date on their containers. The chicken patties had a lid not fitted correctly and were open to air.

The hood vent covers over the ranges had a moderate build-up of dust, as did the top surface of the warmer cart, and top shelf storage area for dishes near the steam table.

The area behind the range and flat top grill had a heavy build-up of grime, food particles and pieces of old food on the floor.

The range cooking grates, and flat top grill surface were found to have a heavy build of up grease.

The entire perimeter of the kitchen floor where the base of the walls met the floor was a heavy build-up of food particles and moderate build up of brown and black grime to evidence the floor was not being kept swept and mopped which posed a risk of pests in the kitchen.

In the small dry storage room underneath the shelves were two large,white rodent bate boxes and the floor had a heavy build up of crumbs underneath the shelving.

Egg shells were found in the floor drain of a food preparation sink.

Steam table serving pans were discovered being stacked together on a wire shelf and were found to have moisture in between the pans, which could allow for bacterial growth and evidenced the kitchen was not properly air drying the pans.

Interview with Culinary Director #500 on 12/11/24 at 9:00 A.M. verified the above findings.

This violation is a recite to the annual survey completed 09/13/23.

Based on review of facility fire drill documentation and staff interview the facility failed to conduct quarterly fire drills on every shift as required. This had the potential to affect all 61 residents in the facility. The facility census was 61.

Findings include:

Review of fire drill documentation on 12/11/24 at 2:10 P.M. revealed for the months of April 2024, May 2024, and June 2024 there was not a fire drill completed on evening shift and for the months of July 2024, August 2024, and September 2024 there was not a fire drill completed on midnight shift.

Interview with Maintenance Director #400 on 12/11/24 at 3:16 P.M. verified findings.

This violation is a recite to the annual survey completed 09/13/23.

Based on review of the monthly fire safety self-inspections and staff interview the facility failed to complete monthly self-inspections as required. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings include:

Review of the monthly fire safety self-inspections on 12/11/24 at 2:00 PM revealed no evidence the inspections were completed in January and February of 2024.

Interview with Maintenance Director #400 on 12/11/24 at 2:25 P.M. verified the monthly safety self-inspections were not completed as required.

This violation is a recite to the annual survey completed 09/13/23.

Based on observation, staff Interviews, and policy review the facility failed to ensure foods were stored and served in a manner to prevent contamination. This has the potential to affect all 51 residents residing in the facility. The facility census was 51.

Findings Include:

On 09/13/23 during the kitchen tour between 8:50 A.M. and 9:20 A.M., the following was observed:

In the reach in freezer:

1. A bag of onion rings were unsealed and open to air.

2. A bag of frozen carrot sticks were unsealed and open to air.

3. Biscuits located in a container with the lid not closed and open to air.

4. Sausage Patties in a container with the lid not closed and open to air.

In the dry food storage:

1. A bag of uncooked pasta was unsealed.

2. A pack of crackers was unsealed.

3. A measuring cup was located in a container of sugar.

The above was verified at the time of the observations with Dietary Cook (DC) #800.

In the kitchenette on 09/13/23 at 9:35 A.M., located outside the entrance to the to the kitchen the following was observed:

Seven serving bowls of mixed fruit uncovered and open to air.

The above was verified at the time of the findings with Dietary Manager (DM) #805.

Additionally, during the tour of the kitchen, DC #800, Dietary Server (DS) #831, and Care Partner (CP) #850 were present in the kitchen without hair nets, head coverings, or hats. DC #800 verified that they were only required to pull up their hair and pin it up.

Review of the policy titled Food Preparation and Presentation Policy dated 2015, revealed food was to be prepared to promote food quality and to conserve nutritive value, flavor, and appearance.

Based on review of facility fire drill documentation and staff interview the facility failed to conduct quarterly fire drills on every shift at varied times as required and failed to verify the transmission of the fire alarm signal. This had potential to affect all 51 residents residing in the facility. The facility census was 51.

Findings include:

Review of fire drill documentation revealed fire drills were not completed during April, June, July and August of 2023.

In addition, the transmission of a fire alarm signal to the appropriate fire department or monitoring station could not be verified, except for drills conducted 12/23/22 and 05/23/23.

On 09/13/23 at 1:00 P.M. interview with maintenance staff (MS) #975 verified the findings.

Based on review of the monthly fire safety self-inspections and staff interview the facility failed to complete monthly self-inspections as required. This had potential to affect all 51 residents residing in the facility. The facility census was 51.

Findings include:

Review of the monthly fire safety self-inspections revealed no evidence the inspections were completed in September, October, November of 2022 and February, July, and August of 2023.

On 09/13/23 at 1:00 P.M. Maintenance Staff (MS) #975 verified the monthly safety self-inspections were not completed as required.

Based on interview and record review, the facility failed to ensure Resident #1 was thoroughly assessed after an unwitnessed fall and new interventions were immediately implemented to prevent additional falls. This affected one resident (Resident #1) of one resident reviewed for falls. Findings include: Review of the closed medical record for Resident #1 revealed an admission date of 10/07/21 with diagnoses including chronic atrial fibrillation, chronic obstructive pulmonary disease, and Alzheimer's disease. Resident #1 expired on 10/16/22. Review of the assessment titled Arrow Senior Living CBA: Comprehensive Resident Evaluation - V 4Based on interview and record review, the facility failed to ensure Resident #1 was thoroughly assessed after an unwitnessed fall and new interventions were immediately implemented to prevent additional falls. This affected one resident (Resident #1) of one resident reviewed for falls.

Findings include:

Review of the closed medical record for Resident #1 revealed an admission date of 10/07/21 with diagnoses including chronic atrial fibrillation, chronic obstructive pulmonary disease, and Alzheimer's disease. Resident #1 expired on 10/16/22.

Review of the assessment titled Arrow Senior Living CBA: Comprehensive Resident Evaluation - V 4