Summit of Blue Ash - Senior Living, The

Based on Observation, staff interview, records review, and policy review the facility failed to ensure infection control was maintained during medication administration. This affected one (Resident #78) of two residents observed for medication administration. Facility census was 97.

Findings include:

Review of the medical record for Resident #72 revealed an admission date of 06/30/25. Diagnoses include Type II diabetes, hyperlipidemia, and mild cognitive impairment. The resident was dependent on staff for medication administration.

Review of the medical record for Resident # 78 revealed an admission date of 03/03/22. Diagnoses include Rheumatoid arthritis, depression, Diabetes Mellitus, diverticulitis, hypertension, and spinal stenosis. The resident was dependent on staff for medication administration.

Observation of medication administration on 10/28/2025 at 9:45 A.M. by Licensed Practical Nurse (LPN) #107, revealed she administered medications to Resident #72 then administered medications to Resident #78 without completing any hand hygiene between the two residents.

Interview on 10/28/25 at 10:05 A.M. with LPN #107, verified she did not complete any hand hygiene between the two residents when she administered medications.

Review of policy titled Infection Control dated 06/01/24 revealed individuals working in the facility shall wash their hands vigorously for ten to fifteen seconds before beginning work and upon completing work, and before and after providing personal care services.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and served in a safe and sanitary manner. This directly affected Residents (#01, #10, #16, #17, #18, #29 #30 and #32) but had the potential to affect all 97 residents in the facility as the facility identified all 97 residents received food from the kitchen. The census was 97.

Findings include:

Observation of the kitchen on 10/28/25 at 10:40 A.M. with Dietary Manager (DM) #46 revealed a walk-in cooler which contained an open box of sausage links open to air with no seal and three stacks of sliced cheese wrapped in clear wrapping with no labels or dates. Interview with the DM #46 at the time of discovery verified the sausage and cheese were not labeled, dated, or sealed. Observation of the walk-in freezer revealed two packages of hamburger patties. One package was open to air with no seal and neither package was labeled nor dated. Interview with the DM #46 at the time of discovery verified the hamburger patties were not labeled, dated, or sealed.

Observations of the lunch meal service on 10/29/25 from 11:45 A.M. to 12:00 P.M., revealed Care Manager (CM) #90 washed her hands at the sink with soap and water and donned a pair of gloves. CM #90 touched Resident #20 on the hand with her gloved hands while giving her a beverage to drink. CM #90 then proceeded to serve eight additional residents (#01, #10, #16, #17, #18, #29 #30 and #32) with the same gloved hands. Interview with CM #90 at the same time, verified she did not change gloves, sanitize or wash hands after touching Resident #20 and then passed the additional trays.

Review of policy titled Infection Control dated 06/01/24 revealed individuals working in the facility shall wash their hands vigorously for ten to fifteen seconds before beginning work and upon completing work, before handling food, and at other appropriate times.

Review of policy titled Culinary - Food Storage dated 07/01/24 revealed leftover foods are labeled, dated, immediately placed under refrigeration and used within 72 hours or discarded. All exposed foods should be stored tightly covered.

This violation is a recite to the annual and complaint surveys completed on 11/14/23 and 09/16/24.

Based on record review, policy review and staff interview, the facility failed to ensure fire drills were completed as required. This affected all 97 residents residing in the facility. The facility census was 97.

Findings include:

Review of facility fire drill reports for the previous 12 months revealed fire drills were completed on 01/15/25 on first shift, 02/11/25 on second shift, 03/12/25 on second shift, 04/08/25 on first shift, 05/08/25 on second shift, 06/13/25 on second shift, 07/30/25 on first shift, 08/28/25 on second shift, 09/22/25 on third shift, 10/09/24 on first shift 11/27/24 on second shift, and 12/18/24 on third shift.

Interview on 10/29/2025 at 11:25 A.M. with Maintenance Director (MD) #36 verified fire drills were not completed on third shift from January 2025 to September 2025. He stated he did not understand the fire drills were to be completed between 11:00 P.M. 7:00 A.M.

Review of the facility policy titled Fire Drills dated 08/24, revealed drills should be conducted on a monthly basis; each eight hour shift practices a fire drill four times per year, for a total of twelve drills.

This violation is a recite to the annual survey completed 09/16/24.

Based on observation, interview, record review, facilities investigation review, Self Reported Incident Review (SRI), and facility policy review, the facility failed to ensure residents were free from elopement. This affected two residents (#1, #2) of 31 residents that reside on the locked Memory Care Unit. The facility census was 90 at the time of survey.

Findings include:

1. Review of the medical record revealed Resident #1 was admitted to the facility on 12/03/2024 with diagnoses of Atrial Fibrillation, Status Post Repair of Mohs Defect, Hypoglycemia, Dementia, and Acute Urinary Retention.

Review of the medical record revealed Resident #1 had no prior history of elopement but was on a locked memory care unit related to diagnosis of dementia. He was assessed as being independent with transfers and mobility.

Review of the medical record and facilities investigation including the SRI revealed that On 09/07/25 Resident #1 resided on the locked memory care unit, was last seen on 09/07/25 at 9:24 A.M. walking down hall towards main unit door to the memory care unit. On 09/07/25 at 9:26 A.M. he went out the unit door with another resident's spouse who was visiting, this visitor thought he shut the door, but Resident #1 still had a hold of it which allowed him to leave the locked unit unsupervised. On 09/07/25 at 9:27 A.M., Resident #1 walked around the Bistro area and out the main exit door to the facility, headed towards sidewalk leading to the park (park is located across the street 0.1 miles away). Staff was unaware that he was missing. On 09/07/25 at 10:35 A.M., Resident #1 was seen by a bystander at the park and told Concierge #75 (she knew he lived here due to Resident #1 had an identification arm band on). Then on 09/07/25 at 10:40 A.M., Concierge #75 went outside and brought Resident #1 back inside and took him to the memory care unit and alerted the nurse. There were no injuries noted.

Review of the medical record revealed no further elopement attempts for Resident #1.

Review of the facilities SRI and investigation revealed the facilities interventions would be: In-service staff, Check for a urinary tract infection (UTI), change the code to the memory care unit, speak with the families about being aware of surroundings, and speak with the residents husband who had the incident ( opening the unit exit door) with Resident #1. On 09/07/25, the facility educated the family member about opening the door and being aware of other residents, elopement education was given to nurses and aides.

Review of facilities interventions revealed all staff was not educated on elopement protocols and procedures. Education was only given to nurses and aides and no education to other staff such as housekeeping, receptionist/concierge, bistro/bar worker, etc.

Review of a change in condition assessment dated 09/08/24 for Resident #1 revealed he required occassional cuing,prompting, and reminders and had poor mental status, was independent with transfers and mobility. He was noted to have one elopment off premises on 09/07/25 and required supervision and redirection.

Interview on 09/23/25 at 10:15 A.M. with the Executive Director revealed Resident #1 eloped from the facility on 09/07/25 when he followed a family member out the door that leads to the lobby. He walked around the lobby for a bit and then exited through the front doors. A lady who was at the park noticed he had an armband on and alerted our concierge. The staff went and brought him back in immediately. He was assessed and found to have no injuries. Executive Director stated they filled out an SRI and substantiated neglect on 09/08/25.

Observation on 09/23/25 at 11:15 A.M. of the Memory Care Unit, revealed Memory Care Manager #70 was attempting to gain entry and she had to retrieve the passcode off a piece of paper. She stated that she had just received an email with the new passcode and it was just changed today.

Interview on 09/23/25 at 2:10 P.M. with the Director of Nursing (DON) revealed they educated nurses and care staff on the elopement of Resident #1 and they did not get the name or statement from the bystander that found Resident #1.

Call was made on 09/24/25 at 11:55 A.M. and again on 1:00 P.M. with Licensed Practical Nurse (LPN) # 40 that was working on 09/07/25 at the time of the incident and could not be reached.

Interview on 09/24/25 at 11:59 A.M. with Concierge #75 revealed he was working when Resident #1 had exited the facility on 09/07/25. He stated a woman who was at the nearby park with her family came in and told him of a resident ( Resident #1) being at the park. Concierge #75 then went immediately to the park and retrieved Resident #1. He stated Resident #1 was happy when he met him at the park. He revealed Resident #1 had on appropriate clothing and brought the resident back to the facility to the locked Memory Care Unit and reported to his nurse what happened.

2. Review of the medical record revealed Resident #2 was admitted to the facility on 06/19/2024 with diagnosis of Dementia.

Review of facilities resident assessment dated 07/29/25 revealed Resident #2 had dementia, required occasional cuing, prompting, and reminding. He used a walker and a wheelchair (w/c) for ambulation. He had occasional attempts to wander outside off community premises. He required supervision and redirection.

Review of the medical record and facilities investigation including the SRI revealed on 09/13/25 at 6:22 P.M. Resident #2 who resided on the Memory Care Unit, had history of sundowners and attempts to elope and assessed at risk for elopement, exited the alarmed back door of the unit (alarm did sound, however the door was equipped with a call light alert alarm that did not function due to having dead batteries) staff did not respond or look for anyone that could have opened the door. On 09/13/25 at 6:50 P.M. an employee/nurse who was coming into work saw Resident #2 headed towards the street, he was rolling himself in a w/c and was very aggressive, it was starting to rain, the nurse alerted the Memory Care nurse, and he was brought back inside. Resident #2 was assessed and placed on 30-minute checks.

Review of a physician fax dated 09/13/25 per DON revealed notification that Resident #2 eloped and was found by a staff member coming to work. Resident #2 was in a w/c rolling up the street. He was very aggressive and mean. He was finally redirected back inside facility. Rain drops were starting to fall.

Interview on 09/23/25 at 10:15 A.M. with the Executive Director revealed Resident #2 exited through a door in the Memory Care Unit. He stated a nurse coming into work noticed him and brought him back inside. They gave corrective counseling to the nurses that heard the alarm and did not check on the alarming door. Resident #2 was assessed and found to have no injuries. Executive Director also stated the facility filed an SRI and substantiated neglect.

Interview on 09/23/25 at 2:10 P.M. with the DON revealed they educated all of their nurses and care staff after the first elopement of Resident #1 on 09/07/25 and then they did a training refresher after the second elopement that occurred for Resident #2 on 09/13/25. She verified there was no signed education to staff following the elopement of Resident #2 since they just did education on 09/07/25 so it was reviewed again. The exit door alarm that alerts the nurse call system was found to have dead batteries during the facility's investigation of the elopement. The DON confirmed that they are unaware of how long the batteries had been dead or when the last time they were checked was.

Review of the corrective counseling forms dated 09/18/25 following the elopement of Resident #2 revealed Nursing Assistant #60 ,#61, and #62 were counseled on a resident exiting the Memory Care Unit and failed to initiate the elopement protocol after an exit door was alarming on the unit.

Review of the corrective counseling form dated 09/19/25 revealed Licensed Practical Nurse (LPN) #65 was counseled on a resident exiting the Memory Care Unit and failed to initiate the elopement protocol after an exit door was alarming on the unit.

On 09/24/25 at 10:03 A.M. revealed review of the elopement binder at the receptionist desk revealed no photo of Resident #2. Concierge #76 verified findings.

Observation and interview on 09/24/2025 at 11:30 A.M. with Memory Care Manager #70 of the exit door on the Memory Care Unit that Resident #2 went out revealed the alarm sounded when tested. Memory Care Manager stated the batteries were found to be dead and not sure when they were checked or changed last and New screamer alarm was placed on the door and batteries were changed in the call system alarm.

On 09/24/25 at 2:00 P.M. phone interview with LPN #65 who worked when Resident #2 eloped verified she was the nurse and did not want to comment. She would not talk and stated she was on family medical leave.

Review of the facility policy titled Community Rounds Policy dated 06/01/2024 revealed residents whereabouts will be monitored to minimize the potential for elopement from the Memory Care Unit.

Review of the facility policy titled Missing Person Elopement dated 06/01/2024, revealed staff will respond immediately to door alarms and/or other monitoring alert systems. A personal photo of each resident will be maintained on file along with each resident emergency numbers. An additional photo will be maintained at the receptionist area. The receptionist staff will be familiar with each resident and utilize photos for easy identification if a resident wanders into the main area.

Review of the facility policy titled Elopement revealed elopement precautions will be carried out for residents who have demonstrated previous attempts to elope or have a history of elopement.

This violation represents non-compliance investigated under Master Complaint Number OH00168307 and Complaint Number OH00168290.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This had the potential to affect all 88 residents in the facility. The census was 88.

Findings include:

1. Observation of the kitchen on 09/16/24 at 10:35 A.M. revealed a walk-in cooler which contained a large pan of soup covered with plastic wrap and with no label or or date, a package of green onions wrapped in plastic wrap and with no label or date, and a package of potatoes wrapped in plastic wrap with a discard date of 09/14/24.

Interview with Server #305 at the time of discovery verified the aforementioned items were not labeled or dated appropriately and the potatoes should have been used or discarded by 09/14/24.

2. Continued observation of the kitchen dry storage area on 09/16/24 at 10:40 A.M. revealed two packages of gelatin mix, two packages of spaghetti, one package of macaroni pasta, and one package of penne pasta, opened and wrapped in plastic wrap with no label or date. Further observation revealed a case of water sitting directly on the floor.

Interview with Server #305 at the time of discovery verified the aforementioned items were not labeled and the water should have been stored on a shelf.

3. Observation on 09/16/24 at 10:51 A.M. revealed five trash cans in food preparation areas in the kitchen. None of the trash cans had lids.

Interview with Cook #300 at the time of discovery verified the trash cans in the food preparation areas did not have lids and trash cans in food preparation areas should be covered.

4. Observation on 09/16/24 at 11:35 A.M. revealed a ceiling air conditioner (AC) unit above the food preparation area in the kitchen. The AC unit was on and blowing cold air and the vents of the AC unit were observed to have a grey, fuzzy substance.

Interview with Executive Director (ED) #310 at the time of discovery verified the vents of the AC unit over the food preparation area were dirty and needed to be cleaned.

Review of the facility policy titled, Food Storage

Based on fire drill report review, staff interview, and policy review, the facility failed to ensure fire drills were completed as required, failed to ensure residents were evacuated as required, and failed to verify transmission of the fire alarm signal within 12 hours of the fire drill. This had the potential to affect all 88 residents in the facility. The census was 88.

Findings include:

Review of facility fire drill reports for the prior twelve months revealed fire drills were completed on 09/15/23 at 1:00 A.M. (third shift), 10/13/23 at 8:00 A.M. (first shift), 11/29/23 at 2:00 P.M. (first shift), 12/27/23 at 1:00 A.M. (third shift), 01/18/24 at 5:00 P.M. (second shift), 02/22/24 at 9:00 P.M. (second shift), 03/14/24 at 1:00 A.M. (third shift), 04/29/24 at 3:00 P.M. (second shift), 05/15/24 at 7:00 P.M. (second shift), 06/30/24 at 12:00 A.M. (third shift), 07/31/24 at 10:00 A.M. (first shift), and 08/28/24 at 6:00 P.M. (second shift).

Further review of the fire drill reports dated 09/15/23, 10/13/23, 11/29/23, 12/27/23, 01/18/24, 02/22/24, 03/14/24, 04/29/24, 05/15/24, 06/30/24, and 07/31/24 revealed no evidence of alarm transmission receipts being verified within 12 hours of completing each fire drill and no documentation related to if residents were evacuated or not.

Interview on 09/16/24 at 12:50 P.M. Executive Director (ED) #310 verified there were no first shift fire drills completed on first shift from December 2023 to June 2024, third shift fire drills were not completed at varied times as they all were done between 12:00 A.M. and 1:00 A.M., and the fire drill reports contained no evidence of alarm transmission receipt verification nor resident evacuation.

Review of the facility policy titled, Fire Safety

Based on fire drill reports and staff interview, the facility failed to ensure fire drill reports and evaluations contained all required information related to the fire drill. This had the potential to affect all 88 residents in the facility. The census was 88.

Findings include:

Review of facility fire drill reports and evaluation forms for the previous 12 months revealed fire drills were completed on 11/29/23, 12/27/23, 01/18/24, 02/22/24, 03/14/24, 04/29/24, 05/15/24, 06/30/24, 07/31/24, and 08/28/24. Further review revealed none of the fire drills evaluations indicated whether or not residents were evacuated nor did they contain information on the method of alarm activation.

Interview on 09/16/24 at 12:50 P.M. Executive Director (ED) #310 verified the fire drill evaluations did not contain the required information.

Based on record review and staff interview, the facility failed to ensure regularly scheduled staff members on all shifts received annual fire prevention training conducted by the state fire marshal or township, municipal, or local fire department. This had the potential to affect all 88 residents who resided in the facility. The census was 88.

Findings include:

Review of the documents provided by the facility for review during the annual survey revealed no documented evidence of employees participating in an annual fire prevention course conducted by the state fire marshal or township, municipal, or local fire department as required.

Interview on 09/16/24 at 12:50 P.M. Executive Director (ED) #310 verified there was no documented evidence of staff participating in an annual fire prevention course.

Based on observation, staff interview, and policy review, the facility failed to clearly label hazardous materials and store them appropriately. This had the potential to affect all 88 residents in the facility. The census was 88. Findings include: Observation on 09/16/24 at 10:45 A.M. revealed three spray bottles containing a blue substance and no label to indicate the contents. The bottles were located on a shelf in the drink station in the kitchen. Interview with Cook #300 at the time of the discovery verified the three spray bottles contained a blue substance and were not labeled and were stored in the drink station. Cook #300 stated the bottles contained some type of cleaning solution and verified they should be labeled with their contents. Review of the facility policy titled, Food StorageBased on observation, staff interview, and policy review, the facility failed to clearly label hazardous materials and store them appropriately. This had the potential to affect all 88 residents in the facility. The census was 88.

Findings include:

Observation on 09/16/24 at 10:45 A.M. revealed three spray bottles containing a blue substance and no label to indicate the contents. The bottles were located on a shelf in the drink station in the kitchen.

Interview with Cook #300 at the time of the discovery verified the three spray bottles contained a blue substance and were not labeled and were stored in the drink station. Cook #300 stated the bottles contained some type of cleaning solution and verified they should be labeled with their contents.

Review of the facility policy titled, Food Storage