Vitalia Active Adult Community at North Olmsted

Based on medical record review, review of a facility-reported incident (SRI), staff interview, observation of video footage, and policy review, the facility failed to ensure a resident was free from physical abuse. This affected one (#1) of three residents reviewed for abuse. The facility census was 55.

Findings include:

Review of the medical record revealed Resident #1 was admitted to the facility on 11/17/25 with diagnoses including Alzheimer's disease, major depressive disorder, and chronic pain.

Review of the most recent functional assessment dated 11/17/25 revealed Resident #1 was severely cognitively impaired and required hands-on assistance from one staff person for activities of daily living.

Review of an SRI revealed on 03/14/26 at approximately 12:33 A.M., Memory Care Support Partner (MCSP) #100 reported that MCSP #101 placed a towel over Resident #1's face, rubbed the resident's face with the towel, and laughed. Upon notification, the nurse manager immediately removed MCSP #101 from resident care and suspended the staff member pending investigation. The Director of Wellness and the Executive Director (ED) were notified. MCSP #101 was interviewed and provided a written statement. Resident #1 was promptly assessed with no signs or symptoms of injury or distress noted. An interview was attempted with Resident #1 but was unsuccessful due to the resident's severe cognitive impairment. The facility conducted an investigation including staff interviews, written statements, and review of room camera footage. Upon completion of the investigation, the facility confirmed the allegation of abuse and terminated MCSP #101's employment.

Review of a written statement from MCSP #100 dated 03/14/26 revealed she and MCSP #101 were with Resident #1 when the resident began spitting at MCSP #100. MCSP #100 grabbed a towel to block the spit but MCSP #101 took the towel, put it over Resident #1's face, rubbed his face with the towel, and started laughing. MCSP #100 documented she took the towel off the resident's face and notified the nurse.

Review of a written statement from MCSP #101 dated 03/14/26 revealed she was helping MCSP #100 with Resident #1 because he was hitting and spitting at her, and the resident began spitting at MCSP #101 as well. MCSP #101 documented she took a towel to protect MCSP #100 from the resident spitting on her and covered his mouth for a quick second.

Observation of video footage with the ED on 04/09/26 at 9:50 A.M. confirmed the facility's description of the incident as documented in the SRI including MCSP #1 placing a towel over Resident #1's face and rubbing the resident's face with the towel.

Interview with the ED on 04/09/26 at 9:53 A.M. confirmed the events of the SRI and verified the facility concluded the incident involving MCSP #1 and Resident #1 was abuse.

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

Based on record review and interview, the facility failed to ensure Resident #52's acteminophen pain medication was adminsitered as ordered. This finding affected one (Resident #52) of four residents reviewed for medications. The facility census was 59.

Findings include:

Review of Resident #52's medical record revealed an order dated 06/30/25 (discontinued 07/07/25) for acetaminophen (Tylenol) administer 500 mg (milligrams) one tablet every six hours as needed for pain; an order dated 07/02/25 (discontinued 07/07/25) for acetaminophen 500 mg two tablets three times per day; and an order dated 08/25/25 (discontinued 09/04/25) for acetaminophen 500 mg take two tablets by mouth three times a day for 10 days (hold as needed Tylenol while taking this).

Review of the medication administration records (MARS) from 07/02/25 to 07/07/25 revealed documentation on 07/03/25 at 4:00 A.M. which stated the resident was sleeping; on 07/05/25 at 4:00 A.M. which stated the resident was sleeping; on 07/06/25 at 4:00 A.M. which stated to see note (the note stated the pain was zero).

Interview on 10/09/25 at 10:34 A.M. with the Wellness Director (WD) confirmed Resident #52 did not receive the scheduled Acetaminophen for pain as ordered for three doses.

Review of the Medication Administration policy dated 05/13/23 revealed the policy was to ensure medications were properly administered.

This violation represents non-compliance investigated under Complaint Number OH00167764.

Based on record review and interview, the facility failed to ensure adequate monitoring for Resident #52's complaints of right hand pain. This finding affected one (Resident #52) of three residents reviewed for accidents. The facility census was 59.

Findings include:

Review of Resident #52's medical record revealed the resident was admitted on 06/04/25 with diagnoses including Alzheimer's disease, asthma and wandering in diseases classified elsewhere. The resident resided on the secured memory care unit (SMCU).

Review of Resident #52's Brief Interview for Mental Status (BIMS) form dated 06/04/25 revealed the resident had severe cognitive impairment.

Review of Resident #52's Morse Fall Assessment form dated 06/04/25 revealed the resident was identified as a moderate risk for falls.

Review of Resident #52's progress note dated 06/21/25 at 2:20 P.M. revealed the resident was found sitting on the floor next to the bed. No injuries noted and the daughter and nurse practitioner (NP) were notified.

Review of Resident #52's progress note dated 06/29/25 at 4:05 P.M. authored by Licesned Practical Nurse (LPN) #904 revealed a few minutes after a family visit, the resident came out of the apartment complaining of right-hand pain. No redness, edema or bruising were noted. The resident indicated she hit the hand on the door. The resident was able to move the hand and fingers. The nurse indicated she would monitor the resident.

Review of Resident #52's progress note dated 06/29/25 at 7:08 P.M. authored by LPN #904 revealed the husband visited and stated he would take the resident to the emergency room (ER).

Review of Resident #52's transfer note dated 06/29/25 at 7:44 P.M. authored by LPN #902 revealed the resident's right wrist was swollen and the resident could not move it. The resident's husband transported the resident to the ER.

Review of Resident #52's Resident/Family/Provider Communication note dated 06/29/25 at 10:01 P.M. authored by LPN #902 revealed the nurse advised the daughter that Memory Care Director (MCD) #808 did a look back at the Auggie footage from the resident's room and it showed the resident had a fall and got herself up off the floor. The daughter was advised that the facility was unsure what had happened, and an investigation would be initiated.

Review of Resident #52's progress note dated 06/30/25 at 4:00 A.M. revealed the resident arrived back from the hospital transported by the husband. The resident had a soft brace on her right wrist. The X-ray showed an acute right wrist fracture.

Review of Resident #52's Incident Follow-Up Progress Note dated 07/02/25 at 10:10 A.M. authored by the Wellness Director (WD) revealed the resident was observed leaving the bathroom at 3:41 P.M. and immediately exited the apartment. The resident approached the nurse showing the nurse the wrist at 3:41 P.M. Nursing notes revealed the resident complained about hitting her wrist on the door handle. The right wrist and forearm radiographs obtained on 06/29/25 at 11:59 P.M. showed a concern for a forearm fracture at the wrist.

Interview on 10/09/25 at 8:34 a.m. with MCD #808 stated Resident #52 was down for just one frame. If she had fallen half-way out of the bathroom, the Auggie video surveillance system would have caught that. MCD #808 confirmed Resident #52's progress notes did not have evidence the resident was monitored for the right wrist injury from 06/29/25 at 4:05 P.M. until 06/29/25 at 7:08 P.M. when the husband came to the facility to take the resident to the emergency room. The resident left the facility at 7:44 P.M.

Review of the Change in Condition/Behavior Protocol policy revised 05/31/23 revealed the resident's conservator and physician were informed of any change or changes in the residnet's status.

This violation represents non-compliance investigated under Complaint Number OH00167764.

Based on personnel record review and staff interview, the facility failed to provide first-aid training within 60 days of the date of hire. This affected two Caregivers (CGs #878 and #870) of three CGs personnel files reviewed. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Review of the facility personnel files revealed two of three CGs personnel files had no documented evidence that they received first-aid training within 60-days of hire.

1. Review of the facility personnel file for CG #878, revealed a hire date of 05/08/25 and no documented evidence of first-aid training from the date of hire. Sixty days from the date of hire was 07/07/25.

Review of a document titled, Relias Transcript with a print date of 07/14/25 12:07 P.M. for CG #878 revealed no documented evidence of first-aid training.

Review of a document titled, Memory Care Support Partner Training Guide dated 05/25/25 revealed no documented evidence of first-aid training for CG#878.

2. Review of the facility personnel file for CG #870 revealed a hire date of 02/20/25 and no documented evidence of first-aid training from the date of hire. Sixty days from the date of hire was 04/21/25.

Review of a document titled, Relias Transcript with a print date of 07/14/25 3:30 P.M. for CG #870 revealed no documented evidence of first-aid training.

Review of a document titled, New Hire Care Partner Onboarding Training Agenda (revision 04/15/25), revealed no documented evidence of first-aid training for CG #870.

Interview with the Regional Business Office Director (RBOD) #896 on 07/14/25 at 3:30 P.M. verified CGs #878 and #870 did not have evidence of first-aid training in their personnel file.

Interview with the Director of Wellness (DOW) on 07/14/25 at 4:45 P.M. verified CGs #878 and #870 did not have evidence of first-aid training in their personnel files. The DOW did provide a certificate of documentation titled, Certificate of Completion. CPR/AED/First Aid provided by the NationalCPRFoundation for CG #870. The date for the completed renewal of first-aid training was 07/14/25 (85 days after hire) with an expiration date of 07/14/27. The DOW did not provide documentation of initial first-aid training within 60 days of hire for CGs #870 and #878.

Based on observation, review of the lint trap cleaning log and staff interview, the facility failed to keep clothing dryers free of lint buildup and other debris. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Observation on 07/14/25 at 9:35 A.M. of the resident laundry room with the Director of Wellness (DOW) and Plant Operations Director (POD) #800 revealed noticeable lint in the lint trap and underneath the lint trap of the dryer base of one of two dryers.

Review of the facility document of a log titled, Lint trap cleaning log hanging next to the industrial sized dryer door revealed blank spaces on the day shift for the month of July 2025. Empty spaces for day shift included 07/01/25, 07/02/25, 07/03/25, 07/04/25, 07/09/25, and 07/12/25. The log entry dated 07/13/25 revealed four initialed spaces for the day shift. Further, on the same log, there were empty spaces for the evening/overnight shift for the dates 07/01/25 through 07/08/25, and 07/10/25 -through 07/13/25. Observed above the dryer door was a sign titled, Stop check lint trap. Clean before and after every load. There were no clothes in the dryer at the time of observation.

Interview with the DOW and POD #800 verified the findings of the signage and lint trap of the industrial sized dryer at the time of the observation.

Based on record review and staff interview, the facility failed to complete a tuberculosis risk assessment as required. This had the potential to affect all 62 residents residing in the facility.

Findings include:

During the entrance conference of the annual survey on 07/14/25 at 9:30 A.M. evidence of completion of a required tuberculosis risk assessment was requested. The facility provided no evidence of the completion of a tuberculosis risk assessment as required.

Interview on 07/14/25 at 4:30 P.M. with the Director of Wellness (DOW) confirmed and verified the above findings.

Based on observation, staff interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all 62 residents receiving food from the kitchen. The facility census was 62.

Findings include:

Observation during the tour of the kitchen on 07/14/25 between 8:36 A.M. and 9:20 A.M., with Culinary Director (CD) #891 revealed, inside the walk-in refrigerator, the following:

A large pan of mashed sweet potatoes, partially used, uncovered, open to air with multiple areas dried out

One small bowl of red-colored gelatin uncovered, open to air and partially dried out

Nine small bowls of mixed fruit uncovered and open to air partially dried out

One container of sweet, pickled relish, uncovered, open to air, with a large stainless spoon sitting inside

One large bag of mozzarella cheese, one large bag of parmesan cheese, and one large bag of blue cheese, open and not dated

One block of provolone cheese open and not dated

One large container of tomato-based vegetable soup, open to air and not dated

One large pan of sliced meatloaf, open to air and not dated

One large pan of partially used mashed potatoes, open to air, uncovered, partially dried out and not dated

One large container of ground taco meat, open to air, uncovered, dried out, and not dated

One large container of nacho cheese, uncovered, open to air, partially dried out, and not dated

One medium container of sliced tomatoes, uncovered, open to air, and not dated

One medium container of sliced yellow zucchini and/or squash uncovered, open to air, and not dated

Observation of the reach-in refrigerator during the tour of the kitchen revealed the following:

Four baked potatoes in a container, uncovered, open to air and dried out

Observation of the reach-in freezer during the tour of the kitchen revealed the following:

A large bag of frozen French fries, open to air, unsealed with no date

A large bag of frozen peperoni, open to air, unsealed with discoloration and no date

Observation of the kitchen preparation area, during the tour of the kitchen, revealed a container of granulated sugar with the scoop still inside.

Observation of the dry storage area, during the tour of the kitchen, revealed two large bags of barilla penne pasta, open and not dated, and one-pound box of rotini pasta, open, unsealed, and not dated.

Observation of the kitchenette, located in the main dining room, during the tour of the kitchen, revealed a large container of three gallons of chocolate ice cream in the reach-in deep freezer, open to air and not dated.

Observation of the kitchenette, located on the memory care unit, during tour of the kitchen, revealed multiple pieces of lettuce, tomatoes, and cucumbers, and a large pool of spilled clear liquid, located at the bottom of the reach-in cooler.

Interview on 07/14/25 at 9:17 A.M. with CD #891 revealed this was his second week of working in the facility and he was still getting acclimated to how things were run. CD #891 revealed the food items located in the refrigerator were leftovers from a couple of days ago. CD #891 confirmed and verified the above information at the time of the observations.

Review of the undated facility document titled, Storage-Dry Storage revealed the facility had a policy in place that all products would be dated upon arrival, sealed and contain the proper label with date visible. Review of the policy revealed a checklist that included all foods should be covered, labeled, and dated, food bins should be labeled without scoops inside, refrigerators cleaned inside and outside, and leftovers would be handled properly. Review of the document revealed the facility did not implement the policy.

Based on record review and staff interview, the facility failed to verify the receipt of the transmission of the fire alarm signal. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Review of the facility records titled, logbook documentation revealed the receipt of the alarm transmission by the appropriate fire department or monitoring station was missing from documented fire drills for the night shift on 12/24/24, evening shift on 11/28/24, day shift on 10/20/24, night shift on 09/19/24, evening shift on 08/31/24, and day shift on 07/29/24.

Interview with the Plant Operations Director (POD) #800 verified the findings at the time of the observation at 10:45 A.M. and again at 3:00 P.M.

Based on record review and staff interview, the facility failed to provide and maintain records of annual fire prevention training for regularly scheduled staff on all shifts. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Review of the facility records titled, logbook documentation revealed no documentation of annual education from the State Fire Marshal, municipal or local legally constituted fire department.

Interview on 07/14/25 10:45 A.M. with the Plant Operations Director (POD) #800 verified the findings at the time of the observation. POD #800 stated that since COVID-19 there has been no in-person annual training for staff by the fire department.

Based on documentation review and staff interview, the facility failed to provide evidence that the central heating system was checked by a heating contractor every two years. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Review of facility records titled, logbook documentation revealed the absence of documentation that the central heating system was checked by a heating contractor in the last two years.

Interview on 07/14/25 10:45 A.M. with the Plant Operations Director (POD) #800 confirmed at the time of the record review, there was no documentation in the logbook. A second interview with the POD #800 at 3:00 P.M. verified there was no central heating inspection by a heating contractor in the last two years.

Based on closed record review, self-reported incident (SRI) review, staff interview and facility policy review, the facility failed to ensure a completed investigation after an allegation of abuse. This affected one (Resident #63) of one reviewed for abuse. The facility census was 62.

Findings include:

Review of the closed medical record for Resident #63 revealed she was admitted to the facility on 06/30/23 with diagnoses that included type two diabetes, depression, dementia, and hypertension.

Review of the mental status questionnaire dated 06/30/23 revealed Resident #63 had short-and long-term cognitive impairment.

Review of the service plan dated 03/06/24 revealed Resident #63 resided on the memory care unit.

Review of the progress notes dated 04/06/24 through 05/06/24 revealed no documentation regarding the alleged abuse.

Review of the SRI dated 04/15/24 tracking number 246382 revealed Memory Care Support Partner (MCSP) #894 reported MCSP #893 used inappropriate language towards Resident #63. Review of the SRI revealed Resident #63 wanted to continue coloring instead of preparing for the dinner meal, when MCSP #893 stated I don't have [expletive] time for this. Resident #63 was immediately observed to be upset and crying, yelling out that someone had yelled at her. MCSP #893 was immediately suspended pending investigation. Former Executive Director (FED) reviewed video footage, informed Resident #63 family, and gathered witness statements. Review of the video footage revealed Resident #63 was visibly upset after interaction with MCSP #893; however, audio was not available to determine the alleged comment.

Review of the SRI revealed a witness statement dated 04/13/24 written by MCSP #894 that revealed MCSP #893 were setting up dinner, when Resident #63 was seated coloring at a table. MCSP #893 approached Resident #63 and told her to put the coloring away because dinner would be served soon. Resident #63 wanted to continue to color when MCSP #893 became very disrespectful and told Resident #63 Whatever I don't [expletive] care I'm done. Resident #63 then reported to MCSP #894 that she was yelled at, was very upset and did not understand why people were yelling at her.

Review of the SRI revealed a witness statement dated 04/15/24 at 9:07 A.M. vie email correspondence from MCSP #893 revealed Resident #63 was seated at a table coloring in the main dining room, while she prepared for dinner. MCSP #893 revealed she sat some plates down on a table when Resident #63 looked at her. MCSP #893 revealed she then made the comment of Oh boy she looks like she wants to kill me. MCSP #893 denied the allegation.

Review of the current and up-to-date staff roster revealed FED, MCSP #893 and #894 were no longer employed in the facility.

Interview on 07/14/25 at 3:55 P.M. with Regional Wellness Coordinator (RWC) #895 during review of the SRI confirmed the incomplete SRI.

Interview on 07/14/25 at 4:00 P.M. with the Director of Wellness (DOW) revealed all staff involved with the SRI were no longer employed at the facility and she was new as the DOW. She could not provide any additional information related to the SRI. The DOW confirmed and verified the SRI provided was the complete investigation and the above findings at the time of the interview.

Review of the SRI revealed no interviews from subsequent witnesses, outside visitors, other residents, or other direct or indirect care staff regarding the allegation of verbal abuse to rule out if there were other instances that may have occurred.

Review of the facility document titled Abuse and Neglect, Observed or Suspected revised 05/13/23 revealed the facility had a policy in place to complete a full investigation and that residents would not be abused by anyone at any time while residing in the facility. Review of the document revealed the facility did not implement the policy.