Alpine House of Maple Heights

Based on closed record review, review of facility video surveillance, review of a facility self-reported incident (SRI), review of a facility investigation, review of an emergency medical services (EMS) run report, review of AccuWeather forecast, review of hospital records, facility policy review and interviews, the facility failed to ensure Resident #90 was provided adequate and appropriate nursing care consistent with resident's identified needs. This resulted in Real and Present Danger and the potential for serious harm, injury, death on 01/28/26 at approximately 3:09 A.M. when Care Aide (CA) #200 assisted Resident #90, a cognitively impaired resident with a diagnosis of dementia to leave the facility unsupervised. At the time of the incident, the CA failed to recognize Resident #90 was a facility resident. On duty staff (two CAs) continued to fail to recognize Resident #90 as a facility resident and at 5:17 A.M. local police were called. At 5:26 A.M. Emergency Medical Services (EMS) arrived, and the resident was transported to the hospital by ambulance. According to the resident's daughter, Resident #90's core body temperature was 95 degrees Fahrenheit (F) upon arrival to the hospital, indicating hypothermia. The facility failure to properly identify the resident, provide adequate supervision/monitoring, respond promptly and appropriately to the resident attempting to re-enter the facility between 3:06 A.M. and 5:09 A.M. placed Resident #90 at increased risk for negative outcome as the resident remained outside for approximately two hours in temperatures ranging from 3 degrees F to 14 degrees F.

On 02/04/26 at 12:07 P.M. Facility Manager #218 was notified Real and Present Danger began on 01/28/26 at approximately 3:09 A.M. when Resident #90 exited the facility unsupervised after being let out the facility main entrance by CA #200, who failed to recognize Resident #90 resided in the facility. The resident remained outside the facility until 5:07 A.M. when a second aide, CA #223 opened the front door and spoke with the resident. The resident did not enter the building at that time; however, CA #223 left the door unlocked, allowing the resident to enter at his discretion without staff supervision. At 5:09 A.M. Resident #90 entered the foyer but did not proceed to the lobby or receive staff assistance. At 5:17 A.M. law enforcement arrived and interacted with the resident. At 5:26 A.M. Emergency Medical Services (EMS) arrived, and the resident was transported to the hospital by ambulance. According to the resident's daughter, Resident #90's core body temperature was 95 degrees F upon arrival to the hospital, indicating hypothermia. Resident #90 was subsequently discharged from the hospital to another facility.

The Real and Present Danger was abated on 02/05/26 when the facility implemented the following corrective actions:

- On 01/28/26 at 5:26 A.M. Resident #90 was transported to the hospital and subsequently discharged to another facility.

- On 01/28/26 at 10:35 A.M. Facility Manager #218 reported the incident of potential neglect of Resident #90 to the State Agency.

- On 01/28/26 Facility Manager #218 gathered statements from the alleged perpetrators, CAs #200 and #223, and notified staff members, witnesses: CA # 207, and Nurse Manager #217, of the incident as well as Resident #90's Medicaid Waiver Case Manager, Physician #224 and Governing Board.

- On 01/28/26, on-shift staff (CA #200 and CA #223) were terminated for not following facility procedures and non-performance of their duties/ responsibilities.

- On 01/28/26, Facility Manager #218 reported the incident to law enforcement, the State agency, Western Reserve Area Office on Aging (case manager), and Adult Protective Services.

- By 01/29/26, all staff were in-serviced by Facility Manager #218 on procedures for Resident Identification, Supervision, and Notification Expectations. Third-shift staff were also notified to conduct hourly checks of hallways and entrances/exits.

- Beginning 02/04/26 the facility implemented a plan for Facility Manager #218 to ensure third-shift staff conducted hourly checks of hallways and entrances/ exits to ensure no residents were outside the building without having signed out prior to exiting.

- By 02/05/26 at 12:00 P.M., Nursing Manager #217 and Licensed Practical Nurse (LPN) #214 re-assessed all facility residents elopement risk. At present, no residents were identified as elopement risks as currently the facility does not have any residents exit seeking. Any changes observed would be reported to the appropriate parties.

- By 02/05/26 the facility implemented a plan for Facility Manager #218 to ensure all staff members were knowledgeable of residents at risk for elopement (if any) by providing a list to staff. Staff would sign acknowledging the receipt of list. All signed acknowledgements would be sent to HR to keep record.

- By 02/05/26 the facility implemented a plan for Facility Manager #218 to ensure all staff had received in-service training on procedures to access resident face-sheets/ resident identification, supervision, and incident reporting expectations. All staff would also receive a copy of the daily census upon the beginning of their shift and would properly dispose of the list at the end of their shift through the provided recycle bin located in facility.

- Beginning 02/05/26 Human Resource staff would include in orientation and would post on agency platform (Clipboard) the new requirements for all new incoming staff and agency workers: Elopement Risk List Acknowledgement form. Electronic signatures would be obtained and records maintained for compliance purposes.

- Beginning the month of March 2026, Facility Manager #218 or designee (supervising staff member) would audit all shifts on a monthly basis to ensure compliance with resident identification, supervision and incident reporting procedures.

Although the Real and Present Danger was abated on 02/05/26, the violation remained as the facility was in the process of monitoring and implementing their corrective action.

Findings include:

Review of the closed medical record revealed Resident #90 was admitted to the facility on 01/03/23 with diagnoses including diabetes, anemia, sleep apnea, Alzheimer's disease, malnutrition, chronic kidney disease, dementia, hypertension, and cerebral infarction.

A service plan, initiated 02/01/23, revealed Resident #90 was at risk for elopement. Intervention included to observe the resident's location in the community.

Record review revealed quarterly Evaluation & Health Assessments - V3 forms were completed on 01/14/25, 04/16/25, 07/16/25, 10/13/25, and 01/12/26. The assessment dated 04/16/25 revealed the resident was at risk for elopement and also noted the resident was combative and aggressive. The other assessments failed to identify the resident's elopement risk.

Although there was no actual written progress note contained in Resident #90's medical record detailing the events of 01/28/26, a facility investigation and timeline of information which included a review of facility surveillance camera footage revealed the following:

On 01/28/26, at approximately 3:06 A.M., Resident #90 entered the facility lobby, obtained a wheeled walker, and informed CA #200 that he did not live at the facility and needed to leave. CA #200 did not recognize the individual, failed to verify his identity or resident status, and unlocked the secured entrance, allowing the individual to exit the facility unsupervised.

External camera footage showed Resident #90 leaving the facility at approximately 3:09 A.M., crossing a street, and traveling East on a sidewalk during the overnight hours. At approximately 3:25 A.M., the resident returned to the facility grounds and attempted to re-enter the locked front door at approximately 3:36 A.M. No staff responded to his attempts to gain entry, and the resident remained outside in cold conditions for an extended period.

At approximately 4:04 A.M., CA #200 was observed to rise from a lying position on a couch in the front lounge area, indicating lack of active supervision. At approximately 4:06 A.M., CA #200 briefly unlocked the front door and interacted with Resident #90 but again closed the door, leaving the resident outside. At approximately 4:23 A.M., the resident again attempted to gain staff attention by waving toward the aide in the front lounge, but no response occurred, and the resident remained outdoors.

At approximately 5:07 A.M., a second aide, CA #223 opened the front door and spoke with Resident #90 but failed to ensure his immediate re-entry, leaving the door unlocked and allowing the resident to decide whether to enter. The resident entered the foyer at approximately 5:09 A.M. and remained there without supervision until law enforcement arrived at approximately 5:17 A.M. Paramedics arrived at approximately 5:26 A.M., and the resident was transported to the hospital.

Review of a facility Incident Report from EMS dated 01/28/26 at 5:19 A.M. revealed an outside temperature of 0.5 degree Fahrenheit (F) and a wind speed of 3.6 miles per hour (MPH). The narrative revealed the resident was treated and transported to the local hospital emergency department (ED).

Review of an EMS Run Sheet dated 01/28/26 at 5:25 A.M. revealed (upon EMS arrival) Resident #90 was found seated, alert to self, with warm dry skin, and no visible complaints. The resident was transported to the local hospital ED by cot. Documented vital signs included a art rate of 86 beats per minute, blood pressure of 155/95, blood oxygen of 98 percent (%), and respirations of 18 per minute. The EMS run sheet did not include evidence the resident's body temperature was obtained.

Review of a facility Self-Reported Incident (SRI) tracking number 270268 created on 01/28/26 at 10:35 A.M. by Facility Manager (FM) #218 revealed, on 01/28/26, Resident #90 requested to exit the building, stating to staff that he did not live at the facility. Prior to requesting to leave, the resident was in the lobby area stating he was looking for his walker. The SRI included in accordance with resident rights and freedom of movement, staff honored the resident's verbal request to go outside and opened the exit door. The resident was subsequently observed leaving the facility grounds heading South. Approximately 30 minutes later, the resident returned to the entrance and knocked to gain staff attention. Staff responded to the door and engaged the resident in conversation. At that time, the resident remained outside the building, seated on his rollator and did not immediately re-enter. When ready, staff escorted the resident into the foyer area and inquired in on his status. The resident indicated he wanted police assistance. Per the resident's request, law enforcement was contacted. Upon arrival, officers evaluated the resident and requested Emergency Medical Services (EMS) for further medical evaluation. EMS transported the resident to the local hospital for assessment where he was admitted for observation. On 01/30/26 at 1:24 P.M. FM #218 concluded the investigation, and abuse/neglect was substantiated by evidence.

Review of the AccuWeather forecast for 01/28/26 revealed a high temperature of 14 degrees F and low temperature of 3 degrees F.

Review of the hospital records dated 01/28/26 revealed Resident #90's rectal temperature was 95.7 degrees F on 01/28/26 at 5:54 A.M. Diagnoses included hypothermia, altered mental status, pain in the right hip, and dementia. Resident #90 was reportedly not recognized as a resident of his facility and was out in the cold elements for a couple hours. Presently, he is no longer hypothermic and appears to be at normal baseline. Uncomfortable discharging back to his facility presently. Will admit locally.

Review of a progress note dated 01/30/26 at 12:41 P.M. revealed Facility Manager #218 noted Resident #90's daughter retrieved the resident's items on 01/29/26 because the resident had been discharged (from the hospital) to another facility.

Interview on 02/02/26 at 9:30 A.M. with Facility Manager #218 verified Resident #90 had left the facility unsupervised on 01/28/26. She stated she and Nurse Manager #217 started an investigation and SRI immediately and substantiated the report. She stated they reviewed the events, reported there was video footage, and a timeline.

Interview on 02/03/26 at 4:27 P.M. with Resident #90's daughter revealed following the incident, when she talked to the hospital nurse on the phone, she was informed the resident's initial temperature upon arrival (taken rectally) was 95 degrees F. She stated she reached out to the facility after the hospital notified her the resident was in the hospital to obtain additional information.

Interview on 02/04/26 at 10:33 A.M. with Resident Satisfaction Manager #219 revealed he had received a call on 01/28/26 at approximately 6:00 A.M. from Resident #90's ex-wife, concerned about the location of the resident. Manager #219 was not sure how the caller was aware of the resident's location or that he had been left outside. He stated he then called Nurse Manager #217 to make her aware of the situation.

Interview on 02/04/26 at 10:37 A.M. with Nurse Manager #217 revealed she received a call from Resident Satisfaction Manager #219 on 01/28/26 and was made aware of the situation involving Resident #90. She confirmed Resident #90 was in the hospital and had been left outside. She stated she spoke to CA #200, who reported the person (Resident #90) was not a resident. Nurse Manager #217 revealed CA #200's story was different every time they reviewed it. Nurse Manager #217 reported the resident was always dressed in multiple layers as he was always cold. She stated in the video surveillance footage, Resident #90 had on long pants, a long coat, hat and gloves.

Interviews were attempted on 02/03/26 at 11:30 A.M. and 2:16 P.M. with CA #200 and #223 with no success. CA #200 had a full voicemail and CA #223 did not have voicemail set up.

Review of facility policy titled Elopement Protocol

Based on medical record review, staff interview and review of a facility policy, the facility failed to ensure Resident #90's family was notified of his leaving the facility and of his discharge to the local hospital. This affected one (Resident #90) of one resident reviewed for adequate and appropriate nursing care. The facility census was 60.

Findings include:

Review of Resident #90's medical record revealed an admission date of 01/03/23 and a discharge date of 01/29/26. Medical diagnoses included diabetes, anemia, sleep apnea, Alzheimer's disease, malnutrition, chronic kidney disease, dementia, hypertension, cerebral infarction, and symbolic dysfunction.

Review of the Evaluation and Health Assessment, dated 01/12/26, revealed Resident #90 was alert and oriented to person only, though he did recognize family and staff.

Review of the progress notes and investigative documents revealed Resident #90 was discharged to a local emergency department on 01/28/26 after leaving the building in the early hours. There was no evidence Resident #90's responsible party, his daughter, was notified of his leaving the facility nor his discharge to the hospital.

Interview with Facility Manager #218 on 02/02/26 at 9:30 A.M. verified Resident #90's daughter was not notified of his leaving the facility and discharge to the hospital because her mother, Resident #90's ex-wife, was already aware.

Review of an undated facility policy titled Change in Condition

Based on observation, interview, record review, and review of the State of Ohio Uniform Food Safety Code, the facility failed to ensure the meals were the appropriate portion sizes and served at an appropriate temperature. This had the potential to affect all 37 residents in the facility.

Findings include:

Observation on 07/09/24 at 5:02 P.M. of the dinner tray line revealed Cook #314 started serving incorrect portions sizes. The cook used a one-third cup measuring scoop for the mashed potatoes and a scoop of one-half to three-fourths cup to cup for the broccoli.

Review of the spreadsheet revealed the portion sizes were listed as one-half cup for the mashed potatoes and one and a half cups for the broccoli.

Interview on 07/09/24 at 5:03 P.M. Cook #314 verified the use of the incorrect measuring scoops based on the spreadsheet portion sizes.

Observation on 07/09/24 at 5:21 P.M. of a test tray after all residents had been served revealed juice taken directly out of the refrigerator and placed on the tray was 48 degrees Fahrenheit (F) (the proper serving temperature is at or below 41 degrees F). In addition, the broccoli was 95 degrees F., an unpalatable serving temperature.

Interview on 07/09/24 at 5:22 P.M., with Facility Manager #323 verified the juice and broccoli temperatures were not what they were required to be.

Review of the State of Ohio Uniform Food Safety Code, chapter 3717-01 of the Ohio Administrative Code, revealed cold foods should be held at or below 41 degrees F to prevent food borne illness.

This violation is a recite of the survey completed 03/13/24.

Based on observation and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 37 residents in the facility.

Findings include:

Observation of the kitchen on 07/09/24 from 4:10 P.M. to 4:26 P.M. with Facility Manager #323 revealed there were frozen country fried chicken, mixed vegetables, and chicken strips opened and unlabeled and/or undated in the freezer. The ice scoop was inside the ice machine. There was a staff member's drink container in the freezer. The raw eggs were not pasteurized as required. The hood vents were greasy and fuzzy with dust.

Interview on 07/09/24 from 4:10 P.M. to 4:26 P.M. with Facility Manager #323 verified the above findings.

This violation is a recite of the survey completed 05/28/24.

Based on interview and record review revealed the facility failed ensure residents capable of self-evacuation were evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift as required. This had the potential to affect all 37 residents at the facility.

Findings include:

Review of the facility record of fire drills during the twelve months from 07/20/23 to 06/24/24 revealed residents were only evacuated during drills held on the first shift.

Review of the fire drill records for the drills conducted on second and third shift revealed no evidence residents capable of self-evacuation were evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on these shifts.

Interview on 07/10/24 at 11:30 A.M. with Facility Manager #323 verified the above findings.

Based on observation, interview, and review of the State of Ohio Uniform Food Safety Code, the facility failed to ensure cold food items were stored and held at or below 41 degrees Fahrenheit (F) prior to service to residents. This had the potential to affect all 33 residents residing in the facility.

Findings include:

On 05/28/24 at 11:24 A.M., observation of food temperatures obtained by Cook #118 using the facility's thermometer revealed the tuna salad was 61 degrees F. Interview at the time of observation with Cook #118 stated the tuna salad should be around 40 degrees F, verified the temperature was 61 degrees F, and stated the temperature was probably out of range because of opening the refrigerator door to get other items.

On 05/28/24 from 12:09 P.M. to 12:27 P.M., observation of the lunch tray line service revealed Cook #118 served the tuna salad on all lunch plates prepared. Cook #118 was not observed obtaining another temperature of the tuna salad prior to serving to residents.

On 05/28/24 at 12:27 P.M., interview with Cook #118 confirmed she did not take the temperature of the tuna salad again prior to serving despite the temperature being above 41 degrees F when the temperature was previously obtained. Cook #118 stated she only takes the temperatures of foods once before meal service and once after the completion of meal service.

Review of the State of Ohio Uniform Food Safety Code, chapter 3717-01 of the Ohio Administrative Code, revealed cold foods should be held at or below 41 degrees F to prevent food borne illness.

This violation represents non-compliance investigated under Complaint Number OH00154083.

Based on record review and interview, the facility failed to ensure the admission agreement included the fees the resident was responsible for and the fees the facility was responsible for in writing. This affected one resident (#13) of three residents reviewed for admission agreement. Facility census was 33.

Findings include:

Review of the medical record for Resident #13 revealed an admission date of 02/15/24 with diagnoses including deficiency of other vitamins, hypertensive heart and chronic kidney disease (CKD) without heart failure, stage five CKD or end stage renal disease, type II diabetes mellitus (DM), and thyrotoxicosis.

Review of the Residency Agreement for Resident #13 revealed for Exhibit 1, (schedule of fees) revealed the document was left blank, none of the boxes regarding the fees were checked. The Residency Agreement was signed by the Administrator and Resident #13.

Interview on 04/29/24 at 12:58 P.M. with the Administrator revealed all new admissions to the facility received a copy (in writing) of the Residency Agreement including the fees the resident was responsible for and the fees the facility was responsible for in writing.

Interview on 04 /29/24 at 2:50 P.M. with the Administrator revealed she had just completed a new Exhibit 1 (schedule of fees) form today for Resident #13; filled it out and had Resident #13 sign it and then provided the updated form to the surveyor for review.

On 04/30/24 at 8:54 A.M. interview with the Ombudsman revealed she had issues with admissions at the facility.

This violation represents non-compliance investigated under Complaint Number OH00152214.

Based on interview and record review the facility failed to follow a resident's service plan regarding leave of absence from the facility. This affected one (Resident #19) of three residents whose service plans were reviewed. The facility census was 33.

Findings include:

Review of Resident #19's medical records revealed an admission date of 01/03/23. Diagnoses included bipolar disorder.

Review of Resident #19's service plan dated 01/12/24 revealed Resident #19 was not to leave the community unattended.

Review of Resident #19's nursing assessment dated 01/19/24 revealed Resident #19 had intact cognition.

Interview on 03/11/24 at 5:40 A.M. with Caregivers #204 and #209 revealed Resident #19 left the facility without staff knowledge. They said Resident #19 went to a fast food restaurant approximately one month ago but they did not know what time Resident #19 had left or how long he was gone. Caregivers #204 and #209 stated Resident #19 was not allowed to leave the facility because he was on probation.

Interview on 03/11/24 at 9:28 A.M. with Resident #19 revealed a few weeks ago he left the facility without supervision. He went next door to the gas station to beg for money and used the money to buy sandwiches from a fast food restaurant. Resident #19 said he exited the facility through the front door around 9:00 P.M. and returned around 10:00 P.M. Resident #19 stated he was aware he was not supposed to leave the facility unattended because he was on probation.

Interview on 03/12/24 at 11:38 A.M. with the administrator confirmed Resident #19's service plan indicated he was not to leave the facility unattended. The administrator was aware Resident #19 had left the facility without supervision. The administrator said Resident #19 waited until staff was not by the front door to exit the facility and he was also known to try and leave via the back door. The administrator stated she had spoken with Resident #19 and he was instructed he was not to leave the facility unattended, and was agreeable. The administrator had also spoken with Resident #19's guardian and they were in the process of looking for a facility with a secured unit.

This violation represents non-compliance investigated under Complaint Number OH00151214.

Based on observation and interview the facility failed to ensure medications were administered appropriately. This affected one (Resident #20) of three residents observed for medication administration. The facility census was 33.

Findings include:

Observation on 03/11/24 at 8:10 A.M. revealed Licensed Practical Nurse (LPN) #214 obtain pre-packaged medications for Resident #20 from the medication cart. LPN #214 opened the package, poured the medications into a cup, handed the cup to Resident #20, and returned to the medication cart. Resident #20 stated to LPN #214 where are the rest of my meds. LPN #214 re-approached Resident #20 and Resident #20 stated he was supposed to have five pills and she only gave him three. LPN #214 took the medications, returned to the medication cart, obtained another pre-packaged pack of medications and stated there was only three pills in that package as well. LPN #214 obtained a third pre-packaged pack of medications and opened the pack and confirmed there were five pills. LPN #214 poured the five medications into a cup and handed them to Resident #20. Interview with LPN #214, at the time of the observation, revealed she did not know what medications were missing in the previous packages. LPN #314 stated I don't know what's missing, I just pulled it out and gave it. Observation of Resident #20's medication package revealed the names of the five medications were listed on the package.

Review of facility's undated policy titled Medication Pass Techniques revealed caregivers were to follow the six rights of medication administration including the right drug and right dose, and to check the name and dose of the medication in the resident's medication record.

This violation represents non-compliance investigated under Complaint Number OH00151214.

Based on interview and review of the Centers for Disease Control and Prevention (CDC) tuberculosis guidelines, the facility failed to ensure staff received tuberculosis (TB) screening prior to or at time of hire. This had the potential to affect all residents. Facility census was 33.

Findings include:

Interview on 03/11/24 at 5:40 A.M. with Caregivers #204 and #209 revealed they received one Tuberculosis (TB) test upon hire. Caregiver #204 and #209 were not aware if the test was part one of a two-step test.

Telephone interview on 03/11/24 at 12:37 P.M. with Caregiver #224 revealed she had not received TB testing upon hire; however, the Administrator had forced her to sign a paper that stated she had.

During interview on 03/12/23 at 10:29 A.M. with the administrator the administrator denied she had asked employees to sign for TB tests that had not been administered.

After multiple requests over the three- day survey, the facility was unable to provide documentation to support Caregivers #204, #209 and #224 received the appropriate TB testing or screening upon hire. The facility was unable to produce personnel files for any staff requested.

Review of the CDC's TB screening and testing of health care personnel dated 08/30/22 revealed the following.

Baseline TB Screening and Testing

All U.S. health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes:

A baseline individual TB risk assessment,

TB symptom evaluation,

A TB test (e.g., TB blood test or a TB skin test), and

Additional evaluation for TB disease as needed.

Information from the baseline individual TB risk assessment should be used to interpret the results of a TB blood test or TB skin test given upon hire (i.e., preplacement). Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results.

Health care personnel with a documented history of a prior positive TB test should receive a baseline individual TB risk assessment and TB symptom screen upon hire (i.e., preplacement). A repeat TB test (e.g., TB blood test or a TB skin test) is not required.

This violation represents non-compliance investigated under Complaint Number OH0015124.

Based on observation and interview the facility failed to provide appropriate portion sizes and palatable meals. This had the potential to affect all residents residing in the facility. The facility census was 33.

Findings include:

Interviews on 03/11/24 at 8:20 A.M. with Resident #4 and Resident #27 revealed their food was often cold, tasted awful and the portions were small. Observation of Resident #4's and Resident #27's breakfast trays, at the time of the interview, revealed a small portion of scrambled eggs, two pieces of bacon and two croissants. Resident #4 and Resident #27 stated their eggs were cold and had no flavor. Resident #18 stated her meals were often cold and did not taste good.

Observation of meal service on 03/12/24 beginning at 7:57 A.M. with Cook #222 revealed scrambled eggs, sausage, biscuits and grits had been prepared. The temperature of the scrambled eggs was 152 degrees Fahrenheit (F), sausage was 158 degrees F, and the grits were 171 degrees F. At 8:15 A.M. Cook #222 began plating the meals with small portions of eggs, sausage and biscuits. Interview with Cook #222, at time of observation, revealed the residents were to receive one cup of scrambled eggs. Cook #222 did not know what portion size the scoop being used to plate the eggs delivered. Cook #222 used the scoop to place scrambled eggs into a measuring cup which indicated the portion size was ½ cup.

A test tray was requested at 8:41 A.M. and was consumed at 8:47 A.M. The scrambled eggs tasted bland and the biscuit was hard and dry. Interview with Cook #222 at time of test tray revealed she had not seasoned the eggs.

This violation represents non-compliance investigated under Complaint Number OH00151933 and OH00151214.

Based on observation, interview and record review the facility failed to ensure residents did not smoke inside the facility. This had the potential to affect all residents residing in the facility. The facility census was 33.

Findings include:

Interview on 03/11/24 at 5:40 A.M. with Caregivers #204 and #209 revealed Resident #31 used marijuana and smoked it in his room.

On 03/11/24 at 7:16 A.M. a strong odor of cigarette smoke was detected and a slight haze of smoke was observed in Resident #4's room. Interview with Resident #4, at the time of the observation, revealed she did not smoke in her room but she was aware of residents who did smoke in their rooms.

Interview on 03/11/24 at 8:20 A.M. with Resident #4 and Resident #27 revealed Resident #31 smoked marijuana in his room.

Observation on 03/11/24 at 9:41 A.M. revealed Resident #19 was in his room and a strong odor of cigarettes was detected. Further observation revealed an ashtray on Resident #19's bedside table that contained cigarette butts. Interview with Resident #19 revealed he did not smoke in his room, he went outside on his balcony to smoke.

Interview on 03/11/24 at 9:51 A.M. with Resident #31 revealed he had a medical marijuana card and was allowed to use marijuana. A strong odor of marijuana was detected in Resident #31's room at the time of the interview.

Interview on 03/12/24 at 11:38 A.M. with the administrator revealed residents were not permitted to smoke inside the facility; however, residents had been caught doing so.

Review of the facility's undated smoking agreement revealed residents were not permitted to smoke inside the facility.

This violation represents non-compliance investigated under Complaint Number OH00151214.

Based on interview and record review the facility failed to ensure residents were treated with respect and dignity. This affected four (Residents #4, #14 , #18 and #27) of eight residents reviewed for respect and dignity. The facility census was 33.

Findings include:

1. Interview on 03/11/24 at 8:20 A.M. with Resident #27 revealed about a month ago Resident #19 was in her room, he stood up and pulled his pants down and had rubbed his genitals. Resident #27 reported the incident to the caregiver and filled out a grievance form.

Review of Resident #27's clinical record revealed no documentation regarding the alleged incident with Resident #19.

Review of Resident #19's medical record revealed a progress note dated 02/09/24 indicating Resident #27 had complained Resident #19 pulled down his pants and grabbed his penis. Resident #27 yelled at Resident #19 to get out of her room and Resident #19 exited Resident #27's room. Further review of the progress note revealed Resident #27 filled out a grievance regarding the situation.

Telephone interview on 03/11/24 at 12:37 P.M. with Caregiver #223 revealed Resident #27 informed her Resident #19 had exposed himself to her. Caregiver #223 gave Resident #27 a grievance form and reported the incident to the administrator and to Caregiver #223's knowledge nothing had happened. Caregiver #223 stated she took a picture of the grievance form Resident #27 had filled out because she had concerns nothing would be done.

Review of grievance/concern logs for January through March 2024 on 03/12/24 at 11:38 A.M. with the administrator revealed no grievances from Resident #27. The administrator stated she was not aware Resident #27 had filled out a grievance regarding Resident #19 exposing himself and rubbing his genitals. The administrator stated she would check through the grievance forms again.

Interview with the administrator on 03/12/24 at 1:39 P.M. revealed she located a grievance form from Resident #27 regarding the incident with Resident #19; it had been filed incorrectly. The administrator had not completed an investigation because she was not previously aware of the incident.

Review of facility policy titled Grievances/Concerns revised 06/2021 revealed all complaints must be resolved within three business days from the date the concern was filed.

2. Interview on 03/11/24 at 8:20 A.M. with Resident #27 and Resident #4 revealed about a week ago Resident #27 turned in a substitution ticket for her dinner and Cook #222 crumpled it up and threw it away. Resident #27 stated Resident #18, Caregiver #211 and Nurse Manager #218 all observed the incident. Resident #27 further stated she had asked Caregiver #203 for milk with her meal about a week ago and Caregiver #203 stated I'll get it when I'm done. Resident #27 also stated Caregiver #203 yelled You can buy your own (expletive) milk. Resident #4 said staff treated them awful and yelled at them. Resident #4 also stated the staff talked down to her and treated her like she was stupid.

Interview on 03/11/24 at 9:28 A.M. with Resident #14 revealed staff was rude to him.

Interview on 03/11/24 at 10:02 A.M. with Resident #18 revealed she had observed Cook #222 crumple up Resident #27's meal substitution request form last week. Resident #18 stated staff was rude to her and sometimes refused to provide her with assistance.

During an interview on 03/12/24 at 7:57 A.M. with Cook #222 she denied throwing away Resident #27's substitution request form.

Interview on 03/12/24 at 11:38 A.M. with the administrator revealed she was aware Resident #27 had complaints regarding Cook #222 crumpling up her meal request form. The administrator stated she had spoken with Cook #222 who stated she had crumpled it up and thrown it away because Resident #27 had requested an item that was not available The administrator stated Cook #222 was educated on the proper way to accept meal request forms. Review of grievance forms with the administrator, at the time of the interview, revealed on 03/05/24 Resident #27 requested coffee from Caregiver #203 during lunch. Caregiver #203 stated to Resident #27 There is coffee up there you can go grab it yourself. The grievance further indicated Resident #27 told Caregiver #203 to get off her phone and do her job and Caregiver #203 responded with I do my job, you're mad because I'm not moving at your pace. The administrator stated Caregiver #203 was educated on proper customer service techniques.

Review of the facility policy titled Personal Rights (Resident Rights, Responsibilities, Guidelines) revised 01/2024 revealed residents were to be treated with dignity.

This violation represents non-compliance investigated under Complaint Number OH00151933 and OH00151214.