Senior Suites at Century Farms, LLC

Based on observation, medical record review, and interview the facility failed to implement medical provider orders for weekly weights after the implementation of diuretic medication. This affected one resident (Resident #11) of four residents reviewed for change in condition. The facility census was 41.

Findings Include:

Review of Resident #11's medical record revealed the resident had diagnoses including dysuria (difficulty urinating), edema, hypertension (high blood pressure), depression with anxiety, and generalized weakness.

Review of a physician's order dated 03/25/25 revealed an order to begin Lasix (a diuretic medication) 20 milligrams (mg) by mouth daily and to monitor weekly weights.

Review of Resident #11's treatment administration records (TAR) dated 04/01/25 to 04/30/25 and 05/01/25 to 05/31/25 revealed no weights were obtained as ordered. According to the TAR, weekly weights were to be obtained on Sundays.

Review of Resident #11's progress notes from 03/26/25 to 05/19/25 revealed there was no documentation of the resident's refusal of weights or reason weights were not being obtained as ordered.

Interview with Medication Tech (MT) #13 on 05/19/25 at 2:32 P.M. verified staff had not obtained weekly weights as ordered. MT #13 revealed she was not aware of the order for weekly weights. MT #13 revealed she believed Resident #11 had been ordered Lasix daily for swelling in the lower legs.

This violation represents non-compliance investigated under Complaint Number OH00165654. This violation is also an example of continued non-compliance from the survey dated 04/17/25.

Based on observation and interview the facility failed to ensure each resident room had a resident call system that worked properly. This affected one resident (Resident #12) of 41 residents residing in the facility.

Findings Include:

Interview on 05/19/25 at 9:22 A.M. with Resident #12 revealed she had concerns recently that her call light in her bedroom was not working properly and the call light was paging the Resident Care Assistant (RCA) to another resident's room. Resident #12 reported she does have a pendant call light she can use but stated she does not always wear it regularly and keeps it on her key chain.

Observation on 05/22/25 at 10:50 A.M. revealed RCA #26 activated the box style call light in Resident #12's bedroom. The alarm rang to RCA # 26's pager, reading assistance was needed in Resident #13's room (a room near Resident #12's room, but not Resident #12's room). The RCA verified the call for help was announced to the wrong room through her pager. Maintenance Supervisor (MS) #7 was also present during the observation.

Interview on 05/22/25 at 8:25 A.M. with MS #7 verified he was aware of the call light not functioning properly in Resident #12's room and alerting staff of the incorrect room needing assistance. He stated the previous MS made a switch but never corrected the room numbers in the main computer system associated with the pagers. MS #7 revealed the pagers were how staff were alerted to residents needing assistance.

This violation is an incidental finding to Complaint Number OH00165654.

Based on medical record review, fall investigation review, hospital record review, interview and facility policy review the facility failed to timely identify and provide necessary care to Resident #12 following an unwitnessed fall with major injury.

Actual harm occurred on 01/17/25 when Resident #12, who was alert and oriented, sustained an unwitnessed fall in her apartment without the ability to summon immediate staff assistance as the resident's call pendant was not maintained in a manner accessible for her use. Following the fall, the resident reported she had increased pain and swelling to her ankle and had laid on the floor for over an hour before dragging herself to her telephone to call the facility main phone line to obtain assistance. The resident was subsequently transferred to the hospital and diagnosed/treated for a fractured left ankle.

Findings Include:

Review of the medical record for Resident #12 revealed an admission date of 11/01/24 with diagnoses including type two diabetes, high blood pressure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). Resident #12 had intact cognition and was alert and oriented to self, person, place and time.

Review of Resident #12's admission fall risk assessment dated 11/01/24 revealed Resident #12 was at low risk for falls with a score of four out of a possible ten.

Review of Resident #12's service plan revealed Resident #12 was independent with all activities of daily living (ADL) tasks including transfers and mobility.

Review of Resident #12's progress note dated 01/17/25 at 2:34 A.M. revealed Resident #12 had called the nurse's desk and reported she had fallen in her room and had a possible broken ankle. Registered Nurse (RN) #23 arrived to Resident #12's room at 2:40 A.M. and observed Resident #12 sitting on the floor with her legs out in front of her. Resident #12 reported she was getting ready for bed when she became dizzy, grabbed hold of the chair and fell sideways twisting her left ankle. RN #24 notified the physician and called for Emergency Medical Services (EMS) to transport Resident #12 to the hospital. Resident #12's left ankle was swollen and visibly deformed. Resident #12 reported pain to the left ankle. Resident #12 left the facility at 3:31 A.M. with EMS enroute to the hospital.

Review of Resident #12's fall investigation dated 01/17/25 at 2:34 A.M. completed by RN #23 revealed Resident #12 was sitting in the recliner and got up to get ready for bed. Resident #12 had taken a couple steps and became dizzy, grabbed hold of the chair and fell sideways twisting her left ankle.

There was no additional information provided regarding the resident's call light/pendant not working or evaluation of the resident's call light and/or pendant to determine if functionality was the issue with the resident not receiving timely assistance after her fall.

Review of hospital records dated 01/17/25 revealed the resident required surgical intervention to prevent major morbidity mortality with nonoperative treatment. The resident was admitted to orthopedic services for the surgical application of an external fixator due to a fracture of the left ankle.

Interview on 05/19/25 at 9:22 A.M. with Resident #12 revealed at the time of the fall with fracture she had been sitting in the recliner and went to get up to get ready for bed when she had gotten dizzy, grabbed hold of the chair and fell sideways twisting her left ankle. Resident #12 stated she had laid on the floor for awhile, (the resident stated she thought the fall occurred around 12:00 A.M.) so she laid on the floor for over an hour or more before she was able to summon staff assistance. The resident stated she reported to an aide, a few days prior to her fall, that her call light wasn't working properly. Resident #12 stated she had to crawl over to where her cell phone was located and call the main facility phone number to alert the nurse of her fall and injury. The nurse did come and assess her and then she was transferred to the hospital. The resident also shared she was currently not in the same room she was in when she fell, her room was changed to her current room upon her return from the hospital.

Interview on 05/22/25 at 11:05 A.M. with RN #23 confirmed Resident #12 had fallen and had called the main phone number to notify RN #23 of the fall with injury. RN #23 did not have any knowledge of how long Resident #12 had laid on the floor prior to calling the main phone.

A follow-up interview on 05/27/25 at 3:07 P.M. with Resident #12 revealed the chain for her (call) pendant had been broken for a few weeks prior to her fall with the ankle fracture. The resident described the chain as the part of the pendant that went around her neck and allowed her to keep the pendant on her person. Since the chain had been broken, she stated she often left the pendant on her bathroom sink or on her key chain since she couldn't wear it, making the pendant poorly accessible. Further interview revealed her pendant was on her keychain the night she fell since she was getting ready for bed and she wouldn't have had her keys with her. The resident stated she laid on the floor at least an hour, yelling for help but no staff came. She stated she was able to drag herself to where her phone was charging and she called the nurses' station in order to get assistance in her room. Resident #12 stated RN #23 answered the facility phone and came to her room to help her. Resident #12 shared she had often reported to Aide #100 that her pendant chain was broken and Aide #100 would tell her she would get her a new one but never did. Lastly, Resident #12 revealed the facility finally replaced her chain upon her return from the hospital (but it broke again in March) and they moved her to a different, larger room. The resident stated she was unsure why she was moved but the facility said they would move her belongings into the new room as well.

A follow-up interview with RN #23 on 05/28/25 at 4:08 P.M. revealed she worked the night Resident #12 fell and fractured her ankle. She denied knowledge of the resident's pendant chain being broken but she did not recall pressing the pendant or call light to assess their functionality after the fall. She stated the environmental assessment, if not included on the fall investigation, would have been documented on the fall investigation if she felt it was relevant to the fall. The RN stated she was unaware of any additional investigations that were completed after the incident and denied providing a statement regarding the incident after it had occurred. She revealed Aide #100 was no longer employed by the facility. Lastly, she stated if there were any concerns with the pendants or call lights being broken or not working properly, those would be reported to the maintenance department as they handled call light and pendant concerns.

On 05/28/25 at 6:02 P.M. Personal Care Aide (PCA) #3 returned a call to the surveyor and interview verified she worked the night the resident fell and fractured her ankle. She stated the resident's pendant chain was broken and the pendant was not within the resident's reach. She denied having knowledge of the pendant chain being broken prior to the incident but stated the chain could not be worn around the resident's neck. She stated she offered to fix the chain after the resident's fall and she shared she left a note for maintenance that the resident's chain needed fixed. She verified the chain had been repaired prior to the resident's return to the facility (from the hospital).

Review of the facility's fall policy dated 07/12/20 revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls.

This violation represents non-compliance investigated under Complaint Number OH00165654. This violation is also an example of continued non-compliance from the survey dated 04/17/25.

Based on record review, interview and review of Self Reported Incident (SRI) tracking number 259518 the facility failed to ensure Resident #11 and Resident #12's medications were administered as ordered by the physician. This affected two of three residents reviewed for medication administration. The facility census was 41.

Findings include:

1. Medical record review revealed Resident #11 was admitted on 11/08/23 with diagnoses including chronic obstructive pulmonary disease with emphysema, gastroesophageal reflux disease, head injury, high blood pressure, iron deficiency anemia, lung disease with oxygen dependence, obstructive sleep apnea, vitamin D deficiency and history of right hip joint replacement.

Review of Resident #11's service plan dated 11/08/24 indicated he needed staff assistance with medication administration.

Review of Resident #11's physician orders dated 04/01/25 to 04/30/25 indicated losartan potassium 25 milligram (mg) tablet orally to be administered at 8:00 A.M.

Review of Resident #11's Medication Administration Record (MAR) dated 04/01/25 to 04/30/25 indicated documentation Resident #11 did not receive the losartan potassium medication at 8:00 A.M. on 04/18/25 and 04/19/25.

Review of Resident #11's nursing progress note dated 04/18/25 indicated at approximately 9:17 A.M. Licensed Practical Nurse (LPN) #45 entered Resident #12's and Resident #11's room (roommates) and observed two cups with a resident's name (name was not specified) written on the medication cups with an unspecified number of medications sitting on the bedside table. LPN #45 obtained a photographic picture with her cellular phone of the two medication cups and sent the picture to the Wellness Director (LPN #46) and then immediately deleted the picture from her personal phone. LPN #46 advised LPN #45 to discard the medications in the sharp object disposal box.

2. Medical record review revealed Resident #12 was admitted on 11/08/23 with diagnoses including cerebral aneurysm, dehydration, depression with anxiety, high cholesterol, osteoarthritis, high blood pressure, cognitive communication deficit, edema, dysuria and hypothyroidism.

Review of Resident #12's service plan dated 11/08/24 indicated she needed staff assistance with medication administration.

Review of Resident #12's physician orders revealed the following oral medication to be administered in the morning scheduled at 9:00 A.M.

- acetaminophen 325 mg tablet

- vitamin D3 2,000 units (50 micrograms) tablet

- ezetimibe 10 mg tablet

- furosemide 20 mg tablet

- hydrochlorothiazide 12.5 mg tablet

- hydroxyzine hydrochloride 25 mg tablet

- levothyroxine 100 microgram (mcg) tablet

- losartan potassium 25 mg tablet

- metoprolol tartrate 25 mg tablet

- rosuvastatin 10 mg tablet

- zinc sulfate 220 mg tablet

Review of Resident #12's Medication Administration Record (MAR) dated 04/01/25 to 04/30/25 indicated documentation Resident #12 did not receive the above listed medications at 8:00 A.M. on 04/18/25 and 04/19/25.

Review of Resident #12's nursing progress note dated 04/18/25 indicated at approximately 9:17 A.M. Licensed Practical Nurse (LPN) #45 entered Resident #12's and Resident #11's room and observed two cups with a resident's name (name not specified) written on the medication cups with an unspecified number of medications sitting on the bedside table. LPN #45 obtained a photographic picture with her cellular phone of the two medication cups and sent the picture to the Wellness Director (LPN #46) and then immediately deleted the picture from her personal phone. LPN #46 advised LPN #45 to discard the medications in the sharp object disposal box.

Review of Self-Reported Incident (SRI) tracking number 259518 dated 04/20/25 indicated medications were left at the bedside in a resident's room (Resident #11 and Resident #12) and was not taken as prescribed by the physician. Resident #12 was alert and oriented and was instructed to take medication upon return from the bathroom. The medication was discovered by LPN #45 who alerted LPN #47 who was in charge of the medication administration on the unit. Both nurses destroyed the medications without a directive from the physician. The two nurses did not offer the medications at a later time. The residents were not offered a choice to take the medications at a different time. The physician was notified with no follow-up instructions. LPN #47 was educated on the proper medication administration procedures and policy. Staff were re-educated on abuse policy and proper reporting procedures. Resident #11 and Resident #12 suffered no negative outcome as a result of the incident. The results of the investigation revealed the facility substantiated misappropriation of medications.

Review of the facility policy Medication Administration dated 07/11/20 revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under item numbers 11 to 15 the procedure revealed the nurse was to complete the following.

11. Compare the medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.

b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

c. If other than PO (by mouth) route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.).

12. Identify expiration date. If expired, notify nurse manager.

13. Remove medication from source, taking care not to touch medication with bare hand.

14. Administer medication as ordered in accordance with manufacturer specifications.

a. Provide appropriate amount of food and fluid.

b. Shake well to mix suspensions.

c. Crush medications as ordered. Do not crush medications with do not crush instructions.

15. Observe resident consumption of medication.

This violation represents non-compliance investigated under Complaint Number OH00160538, OH00165303, OH00165103, OH00165106 and OH00165052.

Based on record review and interview the facility failed to respond timely to a change in Resident #43's condition. This affected one of three residents reviewed for change in condition. The facility census was 41.

Findings include:

Review of Resident #43's medical record revealed an admission date of 02/07/25 with diagnoses including sarcoidosis of lung, hypothyroidism, diabetes mellitus, vitamin D deficiency, high cholesterol, hyperosmolality, depression, anxiety, high blood pressure, asthma, pneumonia, gastroesophageal reflux disease with irritable bowel syndrome, osteoarthritis, osteoporosis, kidney disease, urinary retention with urinary tract infection, severe sepsis with septic shock, cognitive communication deficit, and left tibial fracture.

Review of Resident #43's level of care assessment dated 02/14/25 indicated to provide assistance with medication administration, provide cueing, supervision and daily insulin injections and provide prompting, cueing and reminders to eat her meals.

Review of Resident #43's incident investigation revealed on 04/19/25 at approximately 10:41 A.M. Resident #43 was found in her room exhibiting symptoms including pale, clammy skin and was shaking. Resident #43 informed the staff that her blood sugar was 50 milligrams per diluent (mg/dL) and she needed help. Resident Care Assistant (RCA) #49 attempted to call for the nurse on the walkie-talkie system with no response from the nurse (Licensed Practical Nurse [LPN] #47). RCA #48 responded and stated she would look for the nurse (LPN #47). RCA #48 had knocked on the nursing station door to see if LPN #47 was in the nursing station with no answer. Resident #43 told RCA #49 to call her daughter (LPN #45) for instructions on how to treat her low blood sugar level. RCA #49 called LPN #45 (Resident #43's daughter) on the phone and LPN #45 instructed RCA #49 to administer orange juice with sugar and recheck Resident #43's blood sugar. Approximately 15 minutes later Resident #43's blood sugar was rechecked, and the reading was 106 mg/dL. Approximately 20 to 30 minutes later LPN #47 arrived at Resident #43's room and instructed Resident #43 to eat protein to raise her blood sugar. LPN #47 informed LPN #45 that her walkie-talkie had a dead battery and she did not hear a call.

Review of LPN #47's written discipline documentation dated 04/19/25 indicated a verbal warning was issued previously and the current written warning was for LPN #47 to ensure her walkie-talkie radio was fully charged at all times to ensure communication with the other staff in the building including emergent situations.

An interview with LPN #45 on 05/05/25 at 2:09 P.M. revealed her mother (Resident #43) had recently discharged from the facility due to an incident regarding the lack of timely care to address her mother's hypoglycemia (low blood sugar). LPN #45 stated she received a call from RCA #49 on 04/19/25 at approximately 11:00 A.M. and was asked by RCA #49 how to treat her mother's blood sugar level. LPN #45 told RCA #49 to give her mother orange juice and sugar and recheck her blood sugar. LPN #45 stated RCA #49 informed her she was unable to reach LPN #47 using the walkie-talkie radio. LPN #45 stated LPN #47 did not arrive to assist her mother for approximately 30 minutes. LPN #45 stated LPN #47 had informed her the walkie-talkie she was using had a dead battery and she did not hear the call to assist with Resident #43's hypoglycemic reaction.

An interview with LPN #47 on 05/06/25 at 7:15 A.M. verified the walkie-talkie radio she was using on 04/19/25 had a dead battery and she did not hear RCA #49's call for assistance with treatment of Resident #43's hypoglycemic reaction.

An interview with Wellness Director (LPN #46) on 05/05/25 at 3:18 P.M. verified the above findings.

This violation represents non-compliance investigated under Complaint Number OH00165103, OH00165303, OH00165038, and OH00165052.

Based on record review and interview the Administrator failed to ensure faclity policies and procedures were followed regarding documentation of an incident related to medication administration. This affected two (Residents #11 and #12) of seven residents reviewed for documentation. The facility census was 41.

Findings include:

1. Medical record review revealed Resident #11 was admitted on 11/08/23 with diagnoses including chronic obstructive pulmonary disease with emphysema, gastroesophageal reflux disease, head injury, high blood pressure, iron deficiency anemia, lung disease with oxygen dependence, obstructive sleep apnea, vitamin D deficiency and history of right hip joint replacement.

Review of the investigation regarding unsecured medications left on Resident #11's bedside table revealed a written statement by Resident Care Assistant (RCA) #48 dated 04/18/25. The statement indicated she had observed unsecured medications on the bedside table in Resident #11's room and had informed RCA #49 who had also observed the unsecured medications on the floor in Resident #11's room after Resident #11's cat had knocked the pills on the floor.

Review of a second written statement provided by the Wellness Director revealed a different version of the events leading to RCA #48's observation of unsecured medications in Resident #11's room written in a different cursive handwriting style than the original statement. RCA #48 signed the written statement on 04/20/25.

Review of a third written statement provided by the Wellness Director authored and signed by RCA #48 and dated 04/21/25 revealed RCA #48 indicated she was pressured to sign the second statement that the Administrator had fabricated. RCA #48 indicated the Administrator had read her original note and felt it did not make sense, and that the Administrator would re-write the statement. RCA #48 indicated she was frightened and shaking and signed the statement against her will.

An interview with the Wellness Director verified the above information and stated she had kept the original statement in a separate file in the facility.

An interview with the Administrator on 05/07/25 at 1:37 P.M. verified she had written the second version of RCA #48's written statement regarding finding unsecured medications in Resident #11's room because RCA #48 had asked the Administrator to write the statement because she (RCA #48) was a poor writer. The Administrator stated RCA #48 read the statement and then signed the statement. The Administrator stated the police had investigated the incident as a possible misappropriation of medication and removal of Resident #11's nursing progress notes from the facility without the resident's permission.

2. Resident #12 was admitted on 11/08/23 with diagnoses including cerebral aneurysm, dehydration, depression with anxiety, high cholesterol, osteoarthritis, high blood pressure, cognitive communication deficit, edema, dysuria and hypothyroidism.

Review of a nursing progress note dated 04/18/25 timed 9:30 A.M., provided by the Wellness Director, revealed Resident #12 was scheduled for a neurology appointment and did not attend the appointment due to illness. The note also indicated that Licensed Practical Nurse (LPN) #45 observed two medication cups with Resident #12's name on them containing oral tablets. LPN #45 obtained a picture of the medications and notified the Wellness Director and sent the Wellness Director the pictures of the oral tablets. The Wellness Director advised LPN #45 to discard the medications in the sharp container waste receptacle.

A review of Resident #12's medical record revealed the nursing dated 04/18/25 timed 9:30 A.M. regarding the unsecured medications was not in the medical record.

An interview with the Wellness Director on 05/05/25 at 3:18 P.M. verified the nursing note dated 04/18/25 timed 9:30 A.M. was missing from Resident #12's medical record. The Wellness Director was told the Administrator had told LPN #47 to remove the nursing note from Resident #12's medical record and to shred the nursing note. The Wellness Director stated the nursing progress note was not shredded; she (the Wellness Director) had kept the original nursing progress note in a file to ensure it was in a safe place.

An interview with LPN #47 on 05/06/25 at 7:15 A.M. verified the Administrator had told her to remove LPN #45's nursing progress note in Resident #12's medical record that was dated 04/18/25 and timed 9:30 A.M.

An interview with the Administrator on 05/07/25 at 1:37 P.M. revealed that LPN #45 was instructed by the Wellness Director to remove the nursing progress dated 04/18/25 and timed 9:30 A.M. from Resident #12's medical record. The Administrator stated she felt LPN #45 had removed the documentation on her own will.

A review of the police investigation dated 04/23/25 revealed that an investigation regarding the removal of Resident #11's and Resident #12's documents from the facility without the residents' permission was ongoing and the outcome had not been determined.

Review of the facility policy Documentation in Medical Record dated 07/11/25 indicated that each resident's medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

The policy explanation and compliance guidelines indicated:

1. Licensed staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

2. Documentation would be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

3. Principles of documentation included, but were not limited to:

a. Documentation would be factual, objective, and resident centered; false information would not be documented; staff were to record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided, and subjective information would be recorded only as relevant, such as the resident's verbalizations, in quotation marks.

b. Documentation would be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

c. Documentation would be timely and in chronological order.

d. Staff were to write legibly in black ink.

e. Staff were to record date and time of entry.

f. Staff were to sign each entry with name and credentials of the person making the entry.

g. Only standardized terminology, acronyms, and symbols were to be used.

h. Staff were to avoid generalizations and vague phrases or expressions.

i. Staff were only to document conclusions that could be supported by data and avoid bias, labels, and value judgments.

4. When documentation occurred after the fact, outside acceptable time limits, the entry was to be clearly indicated as late entry.

5. Corrections to a medical record would be made to clarify inaccurate information.

a. Only the individual who made the original entry could correct the entry.

b. The original content was to remain legible, with a notation that the entry had been corrected.

c. The date and time of the new entry was to be recorded, and annotated as a correction or addendum.

6. Contradictory information could be clarified by a new entry in the medical record.

a. Staff were to date and time the entry.

b. Staff were to provide sufficient details to support that the current information was accurate.

c. Staff were to sign each entry with name and credentials.

The violation represents non-compliance investigated under Complaint Number OH00165387, OH00165303, and OH00165052.

Based on record review and interview the facility failed to ensure a safe living environment free of accident hazards. This affected affected one (Resident #42) of three residents reviewed for falls. The facility census was 41.

Findings include:

Review of Resident #42's medical record revealed an admission date of 10/26/23 with diagnoses including senile degeneration of the brain, severe dementia, Wegener's granulomatosis with renal involvement, skin cancer, heart attack, depression with agitation and anxiety, high cholesterol, colon polyps and macular degeneration.

Review of Resident #42's annual service plan dated 10/25/24 revealed a need for assistance with medical equipment (unspecified type of medical equipment), assistance to the use the bathroom and protective garment change, assistance with transfers, and use of a wheelchair for mobility.

Review of a fall investigation revealed Resident #42 sustained a fall on 04/16/25 at approximately 6:30 P.M. The Resident Care Assistant (RCA) #48 found Resident #42 lying on the floor in the bathroom. Resident #42's wheelchair was found in the hallway. It was suspected Resident #42 had used the wheelchair as a walker to ambulate to the bathroom independently. Resident #42's raised toilet seat was lying on the floor next to the left side of the toilet. Resident #42 was confused and in and out of consciousness but arousable and complained of generalized pain. Resident #42 was sent to the the hospital for evaluation and treatment.

An interview with Licensed Practical Nurse (LPN) #45 on 05/05/25 at 3:05 P.M. revealed Resident #42 had a hospitalization following a fall and was sent to a skilled nursing facility. Resident #42 returned to the assisted living facility after completing her rehabilitation at the skilled nursing facility and was admitted to a different room closer to the nursing station. A raised toilet seat was placed improperly on the toilet in her room; it was not secured. LPN #45 stated Resident #42 independently used the toilet and on 04/16/25 Resident #42 fell off the toilet because the raised toilet seat was not secured properly on the toilet. LPN #45 was unaware who had placed the raised toilet seat on the toilet in Resident #42's room.

An interview with the Maintenance Director (MD) on 05/05/25 at 4:42 P.M. revealed he was notified Resident #42's raised toilet seat was improperly installed and had fallen off the toilet seat when Resident #42 used the toilet, causing her to fall. The MD stated he inspected the raised toilet seat and found the toilet seat was not designed to be placed on the type of toilets used in the facility. The MD stated the raised toilet seat should not be used on the toilets in the facility.

Review of the facility policy titled Fall Risk Assessment dated 07/12/20 indicated it was the policy of the facility to ensure an environment that was free from accident hazards over which the facility had control, and to provide supervision and assistive devices to each resident to prevent avoidable accidents.

The policy explanation and compliance guidelines revealed the risk assessment would identify environmental hazards and individual risks, including the need for supervision, and evaluate and analyze hazards and risks. An At Risk for Fall care plan would be completed for each resident to address each item identified on the risk assessment and would be updated accordingly. The At Risk for Fall care plan would include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Staff were to monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

This violation represents non-compliance investigated under Complaint Number OH00165387, OH00165103, and OH00164997.

Based on observation, record review, and interview, the facility failed to provide sufficient staff to meet resident needs. This affected six residents (#6, #21, #35, #39, #41 and #42) of six sampled residents and had the potential to affect all 43 residents in the facility.

Findings include:

Medical record review for Residents #21, #39, and #41 for evidence that bathing of the resident was provided revealed no evidence that showers twice a week were provided to these residents according to the needs of the residents as outlined in the resident service plan.

Medical record review for Residents #6, #39, #35, and #42 including Level of Care information revealed the facility did not have the required staff to provide Memory Programs as per the resident service plans.

Observation on 04/10/25 at 5:58 P.M. revealed the March 2025 Activity calendar was hanging in the lobby area. An April calendar was not provided to the residents. Interview with the Executive Director at the time of the observation revealed the facility did not currently have any activity staff.

Review of facility documents revealed the facility had positions open for a part time activities assistant (full time activities was hired and had not yet started), two full time Personal Care Assistants (PCA) for 12 hour days and two PCA's for 12 hour night shift, a full time cook, full time housekeeper and a full time Licensed practical Nurse for 12 hour night shift. On 04/14/25 at 3:22 P.M., interview with the Executive Director revealed that for the facility to meet the requirements of the Medicaid Assisted Living Memory Care Program the facility needed an additional 20 percent staffing, four and a half hours a day and were unable to meet the requirements of the program at this time.

Observation on 04/14/25 at 3:00 P.M. revealed the facility had unlocked exit doors 24 hours a day on all three levels of the facility. The facility did not have a wanderguard system and the doors were not alarmed. With two staff on 12 hour night shift and four hours of dayshift with only two staff there were not enough staff to monitor all three levels of the facility that housed cognitively impaired residents with dementia, Alzheimer's and short term memory loss.

Interview on 04/14/25 at 3:22 P.M. with the Executive Director revealed she was hoping to hire a part time activity assistant to help with the Memory Program. The full time Activity Director started 04/14/25 and she was going through onboarding before starting activities. Current staff were trying to provide some activities. The facility was short a night shift nurse but had two aides on nights when there was not a nurse. The kitchen manager quit and was replaced by a cook leaving a cook opening. The facility needed aides because of resignations and an aide who works an eight hour shift instead of a 12 hour shift and has some other responsibilities. She verified there were days with an aide working 12 hours and an aide working eight hours leaving one aide on duty as the only aide for four hours on dayshift with 43 residents. The Executive Director further verified the facility had a Memory Program and exit doors unlocked 24 hours a day.

This violation represents non-compliance investigated under Complaint Number OH00161808 and Complaint Number OH00161411.

Based on record review and interview the facility failed to ensure the written resident agreement/resident handbook was comprehensive to include all required information pertaining to resident equipment/supplies. This had the potential to affect all 43 residents residing in the facility.

Findings Include:

Review of the information contained in the Resident Service Agreement regarding Resident Responsibilities under Section 10 (b) revealed Resident is responsible for purchase of soap, shampoo and/or personal toiletries and incontinence items. The Resident Agreement was silent on the following:

Review of the information contained in the Resident handbook revealed it could not be determined which furnishings could be brought from home or purchased by a resident from any store of their choosing. There was no evidence the handbook/agreement was specific to those bedroom furnishings and supplies included under Ohio Administrative Code (OAC) 3701-16-15 (C) (1) through 3701-16-15 (C) (6). This section of the OAC indicated unless the resident chooses to bring his or her own or as specified in the resident agreement, the residential care facility shall provide the following bedroom furnishings and supplies including but not limited to:

3701-16-15 (C) (1) An individual bed equipped with springs and a clean comfortable flame-resistant mattress or a clean comfortable mattress with a flame-resistant mattress cover. Rollaway beds and cots, double deck beds, stacked bunk beds, hide-a-bed couches, or studio couches do not meet the standards of this rule. If the resident chooses to sleep on an alternate piece of furniture, such as a reclining chair, the facility is obligated to ensure that a bed meeting the standards of this rule remains available to the resident;

3701-16-15 (C) (2) Bed linen which shall include at least two sheets, a pillow and pillowcase, a bedspread, and one blanket that fit properly and are free of tears, holes and excessive fraying or wear. The residential care facility is obligated to:

(a) Ensure that the mattresses of incontinent residents are protected with an intact waterproof material unless contraindicated or otherwise ordered by a physician or other licensed healthcare professional working within their scope of practice; and

(b) Provide each resident with additional blankets and pillows upon request and ensure that two sets of bed linens are available for each bed at all times. Residential care facilities are obligated to ensure that bed linen is changed weekly and more often if soiled or requested by the resident;

3701-16-15 (C) (3) Closet or wardrobe space with a minimum width of twenty-two inches of hanging space sufficient in height and equipped for hanging full length garments and at least one shelf of adequate size within reach of the resident.

3701-16-15 (C) (4) A bedside table, personal reading lamp, adequate bureau, dresser or equivalent space, a mirror appropriate for grooming, and a chair with a padded back and seat, with arms for lateral support. If a resident has a wheelchair, the wheelchair may meet this standard unless the resident indicates he or she wants a comfortable chair in addition to the wheelchair;

3701-16-15 (C) (5) Bath linen that includes at least two full towels, two face towels and two washcloths.

3701-16-15 (C) (6) A shower curtain and appropriate hanging devices; and

3701-16-15 (C) (7) Basic toiletry items and paper products.

The resident service agreement did not include information specific to these furnishings/supplies and/or who would provide or how they would be provided.

On 04/10/25 at 11:58 A.M., an interview with the Executive Director verified the content of the facility Resident Service Agreement as noted above. The Executive Director indicated she did not know the facility was to offer basic toiletries to all residents. She was unaware of the need for the resident agreement to outline the specifics of what was to be provided to residents.

This violation represents non-compliance investigated under Complaint Number OH00163059.

Based on record review and interview, the facility failed to ensure personal care services including showers were provided per the resident service agreement. This affected three residents (#21, #39 and #41) of four residents reviewed for showers.

Findings include:

1. Review of the closed record review for Resident #41 revealed a 04/21/23 admission with diagnoses including hereditary idiopathic neuropathies, hearing loss, chronic kidney disease, amnesia, and history of falling. The resident was a Memory Program Tier 3 level of care. Specialized services included supervision and monitoring due to confusion. She had a hearing aid and eyeglasses. The 04/22/24 annual assessment included the resident had a walker for mobility, and needed reminders for orientation. She was at lower risk for falls. The resident was discharged to a long term care facility on 04/07/25.

Review of the resident admission agreement revealed two showers a week were provided to residents at no extra charge.

Review of shower documentation revealed the staff completed shower sheets for bathing, showering or refusal. The shower sheets for Resident #41 revealed there was no evidence of bathing or hair washing between 02/03/25 and 02/10/25 (received a sponge bath), seven days and between 03/20/25 and 03/31/25, 11 days between bathing.

Interview on 04/14/25 at 1:18 P.M. with Licensed Practical Nurse (LPN) #71 revealed she had no evidence of showers being provided for the seven and 11 day periods when the resident had no shower sheets.

2. Review of the record for Resident #39 revealed a 09/10/24 admission with diagnoses including anemia, hypothyroidism, insomnia, heart failure, gastroesophageal reflux disease, muscle weakness, history of falling, and cardiac pacemaker. Review of the resident's individualized level of care service plan indicated she required a one person physical assist for bathing. The resident was incontinent of bladder and wore incontinence briefs. Review of the resident's monthly summary revealed that she needed assistance with incontinence briefs at night. The resident used a walker and a wheelchair. She had a good appetite. She was to be bathed twice a week, a shower and as needed.

Review of the resident's shower sheets revealed between 02/03/25 and 02/10/25, 02/10/25 and 02/17/25 and 02/17/25 to 02/24/25, seven days between showers or baths.

Interview on 04/14/25 at 1:18 P.M. with LPN #71 revealed she had no evidence of showers being provided to Resident #39 twice a week for the weeks of 02/03/25 and 02/10/25, 02/10/25 and 02/17/25 and 02/17/25 to 02/24/25.

3. Review of the record for Resident #21 revealed a 08/30/24 admission with diagnoses including cerebral vascular accident and incontinence. The resident's admission level of care indicated he required a moderate assist for bathing. He was incontinent. He was to receive two showers a week and as needed.

Review of shower documentation revealed between 02/11/25 and 02/25/25 there was 14 days between baths or showers, 03/04/25 and 03/15/25, 11 days between baths and 03/15/25 and 03/3025, 15 days between baths. On 02/15/25 the resident refused a shower and on 02/18/25 he said he wanted an evening shower. There was no evidence of the resident being reproached after refusing a shower. There was no evidence the resident received an evening shower on 02/18/25 as requested. On 03/11/25 the resident said he wanted an evening shower. There was no evidence he received an evening shower on 03/11/25 as requested.

Interview on 04/14/25 at 1:18 P.M. with Licensed Practical Nurse (LPN) #71 revealed she had no evidence of showers being provided twice a week for the weeks of 02/11/25 and 02/25/25, there was 14 days between baths or showers, 03/04/25 and 03/15/25, 11 days between baths and 03/15/25 and 03/30 25, 15 days between baths. LPN #71 indicated the resident was to be reproached three times and if the resident refused the nurse was to call the case manager to inform of the resident's refusal to bathe.

This violation represents non-compliance investigated under Master Complaint Number OH00164559.

Based on review of incident reports, record review and interview, the facility failed to ensure professional standards were met when a resident fell and hit his head. This affected one resident (#21) of six sampled residents.

Findings include:

Review of Resident #21's medical record revealed a 08/30/24 admission with diagnoses including cerebral vascular accident and incontinence. His admission level of care indicated he required a moderate assist for bathing. The resident was incontinent. The resident was independent for transferring and utilized a walker when out of the room. The resident was a fall risk.

Review of a fall incident dated 02/04/25 at 8:19 P.M. revealed Resident #21 was in his bathroom and he was found lying on the bathroom floor. The resident said he lost his balance and fell backwards. The resident hit the back of his head on the counter. He went to the emergency room and returned. The resident had a score of 12 for falls which identified the resident was a high risk for falls due to the number of falls in the past three months and for his balance problem while standing, and walking. The resident required an assistive device, a walker. The resident had three or four medications and three or more diseases that can contribute to falls.

Review of Resident #21's Fall Check Off Sheet for the fall on 02/04/25, revealed the form included to fill out the form and pass the form on until completed, then turn into the Wellness Director. The first item on the checklist included to initiate neurological checks if resident hit their head or a fall was not witnessed and the resident had any confusion. Further review revealed no evidence neurological checks were completed for Resident #21 after his fall on 02/04/25.

Review of the schedule revealed there was a nurse on duty 24 hours a day on 02/04/25 and 02/05/25. On 02/06/25 there was a nurse on duty until the evening medications were administered. On 02/07/25 there was a nurse on duty starting at 6:00 A.M. and then 24 hours a day through 02/12/25.

Interview on 04/09/25 at 6:34 P.M. with Registered Nurse (RN) #57 revealed she was told by the previous administrator since they are assisted living, they do not have to do neurological checks. Registered Nurse #57 did verify the fall checklist sheet instructed to initiate neurological checks if the resident hit their head and it was identified that Resident #21 hit his head.

This violation represents an incidental finding of non-compliance investigated under Master Complaint Number OH00164559.

Based on resident agreement review, record review and interview the facility failed to ensure residents who were private pay residents were provided basic toiletry items. This affected one of six sampled residents (#39) and had the potential to affect the additional six residents (#15, #24, #32, #34, #38, and #43) private pay residents in the facility. The facility census was 43.

Findings include:

Review of Resident #39's medical record revealed a 09/10/24 admission with diagnoses including anemia, hypothyroidism, insomnia, heart failure, gastroesophageal reflux disease, muscle weakness, history of falling, and cardiac pacemaker. Review of the resident's individualized level of care service plan indicated she required a one person physical assist for bathing. The resident was incontinent of bladder and wore incontinence briefs. Review of her monthly summary revealed that she needed assistance with incontinence briefs at night. She used a walker and a wheelchair. She had a good appetite. She was to be bathed twice a week, a shower and as needed.

Interview on 04/09/25 at 6:02 P.M. with Resident #39 revealed she was told she had to buy her own toiletry items because she was a private pay resident.

Interview on 04/10/25 at 12:40 P.M. with Personal Care Assistant (PCA) #54 revealed she was told the residents had to buy their own toiletry items. The supply room has toilet paper, tissues and hand sanitizer, There was no toothbrushes, toothpaste, shampoo, conditioner, deodorant, shaving cream or razors available to the aides. PCA #54 revealed she thought they had some of those items locked in the front lobby but they were not available after business hours or on weekends. She indicated they used to be unlocked to provide to waiver residents.

Review of the information contained in the Resident Service Agreement regarding Resident Responsibilities under Section 10 (b) revealed Resident is responsible for purchase of soap, shampoo and/or personal toiletries and incontinence items.

Review of the Ohio Administrative Code (OAC) 3701-16-15 (C) (1) through 3701-16-15 (C) (6) indicated unless the resident chooses to bring his or her own or as specified in the resident agreement, the residential care facility shall provide the listed bedroom furnishings and supplies. The OAC included but was not limited to:

3701-16-15 (C) (7) Basic toiletry items and paper products.

On 04/10/25 at 11:58 A.M., an interview with the Executive Director verified the content of the facility Resident Service Agreement as noted above. The Executive Director indicated she did not know the facility was to offer basic toiletries to all residents. She thought private pay residents were to get their own toiletry items. She was unaware of the need for the resident agreement to outline the specifics of what was to be provided to residents. She verified the toiletry items in the facility were locked and not assessable to staff. The Executive Director indicated she would have the items taken down to the storage area where the clean laundry is located.

This violation represents non-compliance investigated under Complaint Number OH00163059.

Based on observation, staffing schedule review, and interview the facility failed to ensure a safe environment for memory impaired residents. This affected four residents (#6, #29, #35 and #42) identified by the facility to have memory impairment and part of the facility Medicaid Assisted Living Memory Program of 43 residents residing in the facility.

Findings include:

On 04/09/25 observation of the facility revealed the facility was built into the hillside. The main entrance was on the top floor, third floor. The front door led to a vestibule then into the facility where there was a reception desk.

Interview on 04/09/25 at 4:52 P.M. with Receptionist #58 revealed she works 8:00 A.M. till 4:00 P.M. Monday through Friday. She sits at the reception desk but does leave to visit the residents to collect payments and help the personal care aides. There was no one at the reception desk after business hours and weekends.

Observation revealed the second floor had a door past the dining room that led to an outdoor patio. The patio had steps that led to the parking lot and was not secured. The first floor had a door to a smoking area. The patio smoking area was under cover with chairs with an unsecured grass courtyard in front of the sitting area. There were three additional unlocked exit doors on the back end of the first floor. Two exited to parking areas and one door to a nearby grassy courtyard.

Interview on 04/09/25 at 2:57 P.M. with the Director of Nursing revealed the exit doors were opened 24 hours a day. There was no wanderguard system and not enough staff to monitor the doors. There were residents with dementia. They go outside in the parking lot. She was fearful they would walk toward the busy street. They do have residents who walk to local businesses. She indicated the Area Agency on Aging had residents benchmarked to be in Memory Programs.

Interview on 04/10/25 at 11:32 A.M. with the Executive Director revealed the facility currently had four residents (#6, #29, #35 and #42) on a Memory Program. They were to have 20% more staff due to the Memory program which she determined was four and a half hours more staff a day.

Interview on 04/11/25 at 9:49 A.M. with Area Agency on Aging Region 9 Contract Compliance Specialist #80 stated there were residents in the facility on a Medicaid Assisted Living Memory Program. The residents have diagnoses of dementia or Alzheimer's disease and are to have 1:1 activities and have call lights answered within 10 minutes. The Area Agency on Aging was at the facility in March (2025) and cited the facility for not having a safe outdoor space for residents.

Review of staffing schedules and observation of staffing on 04/09/25 revealed there were only two staff, a nurse and aide, on duty from 6:00 A.M. till 8:00 A.M. and 4:00 P.M. till 6:00 P.M. The night shift had two aides once the nurse left after passing evening medications. On 04/10/25 the surveyor was onsite and observed there was one nurse and one aide on duty from 6:00 P.M. till 6:00 A.M. The surveyor returned onsite 04/14/25 and observed there were only two staff, a nurse and aide, on duty from 6:00 A.M. till 8:00 A.M. and 4:00 P.M. till 6:00 P.M. There was one nurse and one aide on duty from 6:00 P.M. till 6:00 A.M. Review of the staffing schedule revealed they had a nurse for 12 hours on day shift with two aides and a nurse and aide or two aides on night shift. On day shift, one of the aides may only be an eight hour shift and not a 12 hour shift leaving four hours of the dayshift with two staff. The 12 hour night shift had two staff. All days had 12 hours with two staff to monitor three floors. Many days there were 16 hours a day and only two staff were on duty to monitor three floors.

Interview on 04/14/25 at 7:23 P.M. with Licensed Practical Nurse (LPN) #64 revealed she was concerned that all the doors were unlocked and they had residents with memory issues and cognitive impairment. Many days there were 16 hours a day with only two staff on duty to monitor three floors. Residents #11, #24, #32, #33, #35, are #38 were confused. It concerned her that Residents #11, #33 and #38 were confused and like to be outside when it is nice; she was concerned about them going to the outside without supervision. She felt they should have an enclosed courtyard or all memory impaired residents on the same hall with staff on the hall. She verified there were frequently two staff on duty and three levels of residents with memory issues and access to unsecured exits.

This violation represents non-compliance investigated under Master Complaint Number OH00164559, Complaint Number OH00161808, Complaint Number OH00161411.

Based on observation, record review, review of Area Agency on Aging documents, and interview the facility failed to ensure residents were receiving services according to the contracted Memory Program. This affected four residents (#6, #29, #35, and #42) identified on the Medicaid Assisted Living Memory Program of the 43 residents residing in the facility. The facility census was 43.

Findings include:

Review of the facility's documents for resident Level of Care revealed there were four residents (#6, #29, #35, and #42) with a Level of Care of three (3). The diagnoses of dementia or Alzheimer's disease would make these residents eligible for a Memory Program.

Interview on 04/09/25 at 2:40 P.M. with Licensed Practical Nurse (LPN) #71 revealed the staff were not trained to provide the services for residents on the contracted Memory Program. LPN #71 revealed the Director of Nursing would do the initial assessment. LPN #71 thought there were three residents on the Memory Program but she didn't know which three residents.

Interview on 04/09/25 at 3:42 P.M. with Personal Care Assistants (PCA) #60 and #61 revealed they did not know which residents were on the Memory Program.

Interview 04/10/25 at 11:32 A.M. with the Executive Director revealed she did not know who was on the Memory Program. She ran a list of residents on the program and identified the facility currently had four residents (#6, #29, #35 and #42) on the Memory Program. Resident #41 had been on the program but had been discharged. Per the Executive Director, they were to have 20% more staff due to the Memory program which she determined was four and a half hours more staff a day. The resident call lights were to be answered within 10 minutes and they were to have three 1:1 visits each daily. Per the Executive Director, the Former Activity Director was informed of their program and was to provide the 1:1 visits daily with the residents but she had resigned and the new Activity Director had not started. The residents in the Memory Program resided on all three levels of the facility.

The facility had been receiving the increased income for Resident's #6 and #42 to be on the Memory Program since 04/25/24. Resident #35 was on the program since 09/01/24. Resident #29 had been on the program since 12/09/24.

Interview on 04/11/25 at 9:49 A.M. with Area Agency on Aging Region 9 Contract Compliance Specialist #80 and review of the Agency documentation regarding the Memory Program revealed there were residents in the facility on a Memory Program. These residents have diagnoses of dementia or Alzheimer's disease and are to have 1:1 activities and have call lights answered within 10 minutes. The Area Agency on Aging Region 9 had been at the facility in March (2025) and cited the facility for not having a safe outdoor space for residents, the staff not having the five required trainings for the program and not all 1:1 activities were completed. Compliance Specialist #80 revealed the facility received ten dollars more a day for each resident on the program.

Interview on 04/14/25 at 3:22 P.M. with the Executive Director verified the staff did not have the five classes required for the Memory Program. She verified the staff should know who was on the program. The Executive Director thought everyone's call light was already answered within 10 minutes so she thought the 10 minute stipulation was being met. The Executive Director verified the facility could not be implementing the Memory Program they were being paid to implement for over a year if the staff did not have the required training and did not know who was on the program in order to provide the contracted services to.

This violation represents non-compliance investigated under Complaint Number OH00161411.

Based on record review and interview the facility failed to ensure all staff had been examined by a physician or other health care professional acting within their applicable scope of practice within thirty days before commencing work or on the first day of work as required. This had the potential to affect all 41 residents residing in the facility.

Findings include:

1. Record review revealed Licensed Practical Nurse (LPN) #325 had a start date of 06/07/23. Record review revealed no evidence a physical exam had been completed within 30 days before commencing work or on the first day of work.

Interview on 12/11/24 at 4:30 P.M. with Wellness Coordinator #310 confirmed LPN #325's physical examination had not been completed as required.

2. Record review revealed Personal Care Assistant (PCA) #317 had a start date of 07/23/24. Record review revealed no evidence a physical exam had been completed within 30 days before commencing work or on the first day of work.

Interview on 12/11/24 at 4:30 P.M. with Wellness Coordinator #310 confirmed PCA #317's physical examination had not been completed as required.

Based on record review and interview the facility failed to complete all required pre-employment screening/checks to ensure no staff member had a finding of abuse or neglect of a resident or misappropriation of the property of a resident on the nurse aide registry established by another state where the home believes or has reason to believe the person resides or resided. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Review of the personnel file for Maintenance Personnel #308 revealed the employee had a start date of 03/01/24. Record review revealed no evidence the employee was checked against the nurse aide registry (NAR) at the time of hire to ensure the employee did not have a finding of abuse or neglect of a resident or misappropriation of the property of a resident on the nurse aide registry as required.

Interview on 12/211/24 at 3:37 P.M. with Wellness Coordinator (WC) #310 confirmed Maintenance #308 had started on 03/01/24 and was not checked against the NAR before hire. The WC revealed she was aware someone in this job role would need to be checked against the NAR.

Based on record review and interview the facility failed to complete a comprehensive annual health assessment for Resident #7 as required. This affected one resident (#7) of five sampled residents.

Findings include:

Record review revealed Resident #7 was admitted to the facility on 11/05/21 with a past medical history (PMH) of Alzheimer's disease, polyneuropathy, insomnia, and dementia.

Record review revealed an annual health assessment was due on 11/06/24. However, as of 12/11/24, the annual assessment, service plan, medication self-administration evaluation and fall assessment had not been completed.

Interview on 12/11/24 at 4:35 P.M. with Wellness Coordinator (WC) #310 confirmed Resident #7's annual functional assessment, service plan, medication self-administration evaluation and fall assessment were due on 11/06/24 but had not yet been completed. WC #310 indicated the assessments must have been missed.

Based on record review and interview, the facility failed to ensure resident personal fund accounts were attested to by a witness who was not connected in any manner whatsoever with the residential care facility or its administrator as required. This affected four residents (#32, #37, #6, and #8) of five sampled residents reviewed.

Findings include:

1. Review of Resident #32's Resident Fund Account

Based on record review, interview and policy review the facility failed to ensure three residents (#7, #12 and #11) who resided in the facility with pets had evidence of annual pet physical exams and updated vaccinations. This affected three residents (#7, #12 and #11) of four sampled residents reviewed with pets.

Findings include:

1. Record review revealed Resident #12's dog had a physical examination and rabies vaccination due on 11/05/24 that had not been completed as of 12/11/24.

2. Record review revealed Resident #7's cat had not had a visit to the veterinarian since 2022 and was out of compliance for required vaccinations and annual physical exams as of 12/11/24.

3. Record review revealed Resident #11's dog was not up to date on a rabies vaccination and there were no records of previous rabies vaccinations administered.

Interview on 12/11/24 at 12:27 P.M. with the Administrator confirmed Resident #12, #7 and #11's pets did not have up to date vaccinations and/or annual physical exams completed as completed. The Administrator revealed the facility pet policy was in the process of being revised.

Review of the current facility Pet Policy dated 05/09/24 revealed dogs were required annually to have a physical examination, every three years distemper adenovirus parvovirus (DA2PP) vaccination, yearly Bordetella vaccination, yearly leptospirosis, every three years rabies vaccination, biannual fecal exam, and to be spayed and neutered. For cats the policy indicated they must have an annual exam with a biannual fecal exam, yearly rabies vaccination, and feline viral rhinotracheitis (FVRCP) vaccination very three years.

Based on record review and interview the facility failed to have a tuberculosis (TB) control plan and failed to ensure all employees received TB testing prior to their start date. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Interview on 12/11/24 at 4:30 P.M. with Wellness Coordinator (WC) #310 revealed the facility did not have a TB control plan. The WC revealed the facility did complete a risk assessment but had not fully completed a control plan. Record review revealed the facility did not have a TB control plan.

Review of the personnel file for Receptionist #315 revealed a start date of 07/23/24. However, the first step of the employee's TB test was not read until 07/26/24.

Review of the personnel file for Personal Care Assistant (PCA) PCA #307 revealed a start date of 07/23/24. However, the employee's first step of the TB test was not read until 07/24/24.

Interview on 12/11/24 at 4:30 P.M. with Wellness Coordinator #310 confirmed Receptionist #315 and PCA #315 had the first step of their TB skin test read after their first day worked.

Based on record review, interview and policy review the facility failed to ensure monthly fire drills were completed, failed to ensure residents capable of self-evacuation were evacuated during drills as required and failed to maintain record of alarm transmission receipts from the receiving entity. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Review of the facility monthly fire drill log revealed there were no fire drills conducted in January, February, March or September 2024. In addition, there was no fire drill conducted in December or November 2023.

In addition, review of the monthly fire drill log revealed no 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 during the previous 12 months.

Lastly, review of the monthly fire drill log revealed no evidence of any signal transmission receipt from alarms were received from the facility's alarm company for any alarm sounded in the past twelve months.

Interview on 12/11/24 at 10:12 A.M. and 10:22 A.M. with Maintenance Personnel (MP) #308 confirmed fire drills had not been completed as required; one conducted on each shift at least every three months to familiarize staff members and residents with signals, evacuation procedures and emergency actions under varied times and conditions. In addition, MP #308 verified no 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 during the previous 12 months. Lastly, MP #308 verified the lack of written evidence to ensure signal transmission receipt from alarms were received from the facility's alarm company for any alarm sounded in the past twelve months.

Review of the facility undated policy titled Fire Drills and Fire Safety Plan revealed transmission form the monitoring company was to be verified.

This violation is a recite to the survey dated 02/22/23.

Based on record review and interview the facility failed to perform monthly fire safety inspections as required. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Review of the facility monthly fire safety self-inspections revealed no inspection had been completed for January or February 2024.

Interview on 12/11/24 at 10:12 A.M. and 10:22 A.M. with Maintenance Personnel #308 confirmed there were no monthly self-inspections completed in January or February 2024 as required.

Based on record review and interview the facility failed to establish a grievance committee comprised of the appropriate ratio of not more than one staff member to every two residents, sponsors, or outside representatives. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Review of the grievance committee log revealed one resident (Resident #30) and one staff (Recreation Director #311) were the only members of the committee.

Interview on 12/11/24 at 11:20 A.M. with the Administrator confirmed Resident #30 and Recreation Director #311 were the only members of the committee. She stated she was unaware of the need for the ratio of not more than one staff member to every two residents, sponsors, or outside representatives

Based on observation, recipe review, and interview, the facility failed to serve proper portion sized according to the approved menu. This had the potential of affecting all 19 residents residing in the facility.

Findings Include:

Observation during noon meal service on 02/22/23 at 11:00 AM revealed the use of a slotted spoon being used to plate lima beans and meatball sub sandwich being prepared with inconsistent number of meatballs.

Recipe review of noon meal of 02/22/23 revealed the scoop size of four ounces to be used for plating of vegetables and four meatballs to be served to make a meatball sub sandwich.

Interview with Dietary Cook #109 on 02/22/23 at 10:50 A.M. confirmed food was not served using recommended portion size related to the menu dated 02/22/23.

Based on observation, dietary record review and interview, the facility failed to maintain records of any food substitutions from the menu. This had the potential to affect all 19 residents residing at the facility.

Findings Include:

Observation of meal service on 02/22/23 at 11:00 AM revealed vegetable substitution of lima beans for the noon meal.

Review of dietary records revealed no food substitute records kept by dietary staff for the past year.

Interview with Dietary Cook #111 on 02/22/23 at 11:35 AM confirmed no food substitute records being kept by dietary staff for the past year.

Based on maintenance record review and interview, the facility failed to perform disaster drills in the past year. This had the potential to affect all 19 residents residing in the facility.

Findings Include:

Review of maintenance records revealed no disaster drills being performed at the facility during the past twelve months.

Interview with Administrator on 02/22/23 at 2:30 P.M. confirmed the facility did not perform disaster drills during the past twelve months.