Greenview Senior Assisted Living

Based on observation, interview and record review, the facility failed to properly count available controlled substances. This had the potential to affect all residents on the memory care unit. The memory care census was 26. The facility census was 88.

Findings include:

On 10/09/25 at 9:18 A.M., an observation of a binder on the medication cart labeled Narcotics D-Hall Room 1-14 revealed narcotic count sheets. The sheets were titled shift verification of narcotics sign out. There was a line with the date of 10/09/25 and the time of 1:00 P.M. It was already signed by Licensed Practical Nurse (LPN) #196. This signature was confirmed by LPN #196 on 10/09/25 at 9:32 A.M.

On 10/09/25 at 9:31 A.M., an observation of binder on medication cart labeled Narcotics D-Hall Room 15-28 revealed narcotic count sheets. The sheets were titled shift verification of narcotics sign out. There was a line with the date of 10/09/25 and the time of 1:00 P.M. It was already signed by LPN #196. This signature was confirmed by LPN #196 on 10/09/25 at 9:32 A.M.

On 10/09/25 at 9:26 A.M., an interview with LPN #196 revealed she had signed the out-going narcotic sheet for 10/09/25. She confirmed she had signed it before any narcotic counts were done and also that it was timed for 1:00 P.M. She said, I messed up and signed it this morning.

On 10/09/25 at 9:50 A.M., an interview with Director of Nursing (DON) #122 revealed narcotics were to be counted between each in-coming and out-going nurse at shift change. The nurses should count the narcotics, write the number remaining on each sheet, and then sign, date and time the shift verification of narcotics sign out form. She confirmed these should not be signed, dated or timed prior to the shift change.

Review of an undated facility policy titled Medication Policy revealed controlled substances should be ordered, dispensed, administered and disposed of in accordance with state and federal laws.

This policy was confirmed by DON #122 on 10/09/25 at 9:50 A.M.

Based on record review, interview and review of facility policy, the facility failed to take immediate action to ensure residents received necessary care in the event of a significant adverse change in a resident's condition. In addition, the facility failed to make a notation of the change in health status and any intervention taken in the resident's record. This affected one (#8) of one resident reviewed for change in condition. The facility census was 88.

Findings include:

Review of medical record of Resident #8 revealed an admission date of 12/18/24. The resident was admitted with diagnoses that included, but were not limited to, unspecified protein-calorie malnutrition, hyperlipidemia, vascular dementia, with other behavioral disturbance, Alzheimer's Disease, encephalopathy, glaucoma, hypertensive heart and chronic kidney disease with heart failure, dysphagia following other cerebrovascular disease, and peripheral vascular disease.

Review of the medical record for Resident #8 revealed a form titled Resident Care Profile. This form indicated the resident needed care giver assistance to walk, to dress, for oral care, bathing, and toileting.

Review of a progress note for Resident #8, dated 01/27/25 at 5:30 P.M., revealed the resident's son called the nurse to the resident's room. The note read, R [resident] eyes fluttered, but no response to verbal or physical stimuli, 911 called. 911 transported to Akron City main campus. R had per squad BP (blood pressure) 206/116, son present who called siblings. The note was signed by Licensed Practical Nurse (LPN) #107.

On 10/09/25 at 2:45 P.M. Director of Nursing (DON) #101 confirmed there were no vital signs documented in the medical record other than those reported by the emergency squad staff.

Review of a progress note for Resident #8, dated 01/27/25 at 10:00 P.M., revealed the resident had been admitted to Akron City Hospital diagnosed with an acute ischemic stroke. The physician, director and administrator were notified.

Review of a progress note for Resident #8, noted as a late entry 01/28/25, with no time, revealed the resident left with the squad. The resident had complained of a headache in her right ear. The note indicated the son was present and aware. The progress note was signed by LPN #107.

Review of a document titled GV Change in Resident Condition, dated 01/27/25 at 5:30 P.M., revealed Resident #8 had a change in condition related to abnormal vital signs. The document indicated the son of Resident #8 had called staff to the room when his mother complained of a headache, then she was not responding.

The summary indicated the following: Assessed. VSS [Vital Signs Stable] unstable. [Increase indicated by an upwards arrow] BP (blood pressure). Called 911. Transported to Akron City. The document was signed by LPN #107 on 01/27/25 and Director of Nursing (DON) #101 on 01/28/25.

Review of a document titled Complaint Investigation, dated 01/30/25, revealed the facility received a complaint on 01/28/25 from the family of Resident #8, regarding unprofessional behavior by LPN #107. According to the document, the incident occurred on 01/27/25 during a change in medical condition for Resident #8, at which time the resident's son felt LPN #107 had a cool demeanor and did not keep him informed of what was happening with the care of his mother.

Further review of the document revealed a post investigation recommendation. The recommendation indicated staff would bring concerns to the nurse on duty as soon as possible and assessment of a resident must be done quickly to prevent a delay in care.

An interview with DON #101 on 10/09/25 at 2:30 P.M. confirmed she prepared this document and educated nursing staff regarding preventing a delay in care in a medical emergency, however she did not have documentation to support the staff education.

On 10/09/25 at 2:54 P.M., an interview with Director of Nursing (DON) #122 revealed she had assisted with an investigation regarding the care and treatment when Resident #8 had a change in condition. Regarding the incident of 01/27/25, the daughter called and complained to the Administrator, who forwarded the information to the Director's of Nursing. DON #101 and #122 talked with the daughter and the son. They did not express any concerns. The daughter expressed she did not believe anything was done wrong, just that her brother was very anxious and did not feel the nurse kept him informed of what was happening with his mother. DON #122 reported an investigation was completed on all residents who were hospitalized.

On 10/14/25 at 10:50 A.M., an interview with a family member of Resident #8 revealed concern over the time between Resident #8's son notifying LPN #107 of a change in the resident's condition and the time emergency medical staff was called. The family member reported the incident happened on 01/27/25 on the memory care unit of the facility. The family member reported on 01/27/25, Resident #8 had visitors and was talking and laughing, telling them about an upcoming dance to be held at the facility. The visitors had not seen any changes in Resident #8's condition. Resident #8's son arrived at the facility at around 4:00 P.M. He entered Resident #8's room where he found her sideways on the bed, face down. He tried to arouse her, with no response. He notified an aide (name unknown), who had LPN #107 come to the resident's room. The son advised the nurse of his concern for his mother, and LPN #107 responded by telling the resident's son the resident was playing opossum. When he advised LPN #107 the situation was more serious, LPN #107 told him to get out of her way and let her do her job. She advised him the resident's vital signs were fine, and if he wanted to, he could call 911, but she (LPN #107) had no reason to call. The family member advised Resident #8's son had been in a panic and did not know what to do to help his mother. At that time, two aides (unknown) came into the room and assisted him to get the resident into a wheelchair. He reported she was dead weight. The aides told Resident #8's son it appeared the resident had a stroke, and they went to get the nurse. At this time, about 45 minutes had passed from the initial contact with LPN #107 and she then called 911 for assistance, left the room, and did not explain anything happening to the son.

The family member reported Resident #8 was admitted to the hospital with a diagnosis of a massive stroke, and died in hospice a few days later. The family member was not concerned the delay would have changed the outcome, but was concerned about the delay in care and how it may have affected both Resident #8, her son, and could affect someone else in the future.

On 10/14/25 at 12:09 P.M., an interview with Nurse Aide (NA) #400 revealed she was present on 01/27/25 when Resident #8 had a change in condition on the memory care unit of the facility. She reported checking on Resident #8 briefly when she arrived on shift, around 3:00 P.M., and she did not have any concerns or noticeable changes. Approximately 45 minutes later, the resident's son arrived at the facility. At that time, the aides were getting residents ready for dinner. LPN #107 asked her to assist in getting Resident #8 into a chair. The resident's son was reporting something was wrong with his mother. At that time, LPN #107 told the son there was nothing wrong with the resident, she was playing opossum and had this behavior frequently. NA #400 advised LPN #107 she did not want to get the resident up in the wheelchair, however the LPN insisted. LPN #107 was saying loudly (Resident #8), your son is here repeatedly. Resident #8 would open her eyes briefly and they were unfocused, then would close again. Resident #8 was not talking and her face appeared droopy. At that time, LPN #107 advised the son there was no reason to send the resident to the hospital, but he could take her himself if he wanted to. NA #400 was not certain who called 911. She reported no vital signs were taken during this time until the ambulance was on the way. She believed there was 30 to 35 minutes at least from the time the son notified LPN #107 of the change in Resident #8's condition until 911 was called.

On 10/14/25 at 12:46 P.M., an interview with NA # 600 revealed she was present on 01/27/25 when Resident #8 had a change in condition on the memory care unit of the facility. She reported the incident occurred at dinner time when aides were getting residents ready for dinner. NA #600 revealed she was sitting at the desk, when another aide (she thought NA #400) went to get (Resident #8) out of bed. A couple minutes later, NA #400 came to get LPN #107 and the two returned to Resident #8's room. About ten minutes passed. LPN #107 returned to the desk and asked if NA #600 was a dayshift aide. LPN #107 asked her to go to the room and tell the family Resident #8 pretended to sleep in the mornings, and would do that all the time. NA #600 advised LPN #107 she did not believe she should tell the family that information, however she went to Resident #8's room to check on the situation.

NA #600 reported on arrival to the room, she found Resident #8 to be slumped and sliding out of her wheelchair and her skin color was greenish yellow. NA #400 was present in the room also and told NA #600 she was advised by LPN #107 to get the resident out of bed, even though she was so limp and unresponsive. Resident #8's son was also present in the room and was crying and freaking out and told them his mother had been unresponsive since he arrived at the facility. LPN #107 had advised him she was not calling the Emergency Room or calling for an ambulance. The son told NA #600 he wanted his mother to go to the Emergency Room. NA #600 advised LPN #107 either she had to call 911 or the family was going to. NA #600 reported after LPN #107 called an ambulance and sent the resident to the hospital, she spent the remainder of the shift complaining about having to call 911 because she did not believe anything was wrong with (Resident #8).

On 10/14/25 at 1:45 P.M., an interview with Licensed Practical Nurse (LPN) #106 revealed upon change in condition of a resident, the nurse was to immediately do an assessment and determine what the resident needs were. If the resident had a change in condition that required emergency medical treatment, the nurse would have to leave the memory care unit, because the only place to call for help was the nurse's station. One nurse would get any transfer paperwork together, while the other nurse would tend to the resident. This assessment would need to be documented in the resident record. That would include what the change in condition was, what the resident's vital signs were, who was contacted and anything else the nurse noted was important.

On 10/14/25 at 2:30 P.M., an interview with DON #122 revealed no formal training had been done for nursing staff following the 01/27/25 incident of Resident #8. She reported Licensed Practical Nurse (LPN) #107 was educated on 01/30/25 to be more informative to resident's and families when there was a change in condition.

Review of an undated facility policy titled Emergency Procedure revealed in the event of an emergency, the nurse would document all pertinent information in the Resident's nursing note. This policy was confirmed by DON #107 on 10/14/25 at 2:30 P.M.

Review of an undated facility policy titled Incident Procedure, revealed the purpose was to document events of a resident incident. The policy indicated the staff should provide immediate intervention and/or medical care for the resident. Emergency Medical Staff (EMS) should be called for care and transportation to the hospital, and the nurse was to document accident/incident information in the resident record. This policy was confirmed on 10/09/25 at 2:54 P.M. by DON #122.

This violation represents non-compliance investigated under Complaint Number OH00164219

Based on review of facility policy and interview, the facility failed to establish and implement appropriate written policies and procedures to assure a safe, sanitary and comfortable environment for the residents. Further the facility failed to establish an infection prevention and control program to monitor compliance with the facility's infection prevention and control policies and procedures to prevent, investigate, and control infections in the home. This had the potential to affect all residents of the facility. The facility census was 88.

Findings include:

Review of facility policies failed to reveal any infection control policies or procedures. The facility failed to provide policies for a written surveillance plan for monitoring/tracking infections. The facility failed to provide policies to institute interventions to implement standard and transmission-based precautions to be followed to prevent the spread of infection. The facility failed to provide policies regarding when and whom to report possible incidents of communicable disease or infections.

Further review of the facility policies failed to reveal infection control policies which would ensure staff training. No policy was available to ensure all staff were appropriately trained on the home's infection prevention and control protocol. No policies were received regarding the establishment and implementation of an effective water management program to identify hazardous conditions, and take steps to manage the risk of occurrence and transmission of waterborne pathogens, including but not limited to Legionella, in building water systems.

On 10/09/25 at 11:00 A.M., an interview with the Director of Nursing (DON) #101 revealed the facility did not have infection policies or surveillance plans in place. Infection control was previously managed by the former Maintenance Director in conjunction with DON #101, and they only tracked Tuberculosis.

Based on observation and interview, the facility failed procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This had the potential to affect all residents of the facility. The facility census was 88.

Findings include:

On 10/09/25 at 11:20 A.M., an observation of the facility walk in cooler revealed a ten pound box labeled egg pasta which contained an open blue bag of pasta. The cooler also held a five pound box labeled dried apricots which contained an open blue bag of apricots. These findings were confirmed by Dietary Director (DD) #180 at the time of the observation.

On 10/09/25 at 11:32 A.M., an observation of the walk in freezer revealed a half empty, two pound bag of onion rings which was not closed. There was a four and a half pound bag of 3/8 inch, crinkle cut sweet potato fries which was open, with fries sticking out of the bag. There was a box of frozen, over-ripened bananas which were not labeled or covered in any way. There were three separate four and a half pound bags of French fries which were half empty and not sealed. There was a five pound bag of tater tots which was open and undated. These findings were confirmed by DD #180 at the time of the observation.

On 10/09/25 at 12:07 P.M., an observation of the ice cream cooler revealed a 24 ounce bottle of Hershey Syrup, which was half empty, on top of the cooler. The bottle was labeled to refrigerate after opening. At the time of the observation, Server #192 confirmed the bottle was never placed in the refrigerator.

On 10/09/25 at 12:08 P.M., an interview with the Dietary Manager confirmed the contents of the walk in cooler and freezer were improperly stored. She confirmed she was unaware the Hershey syrup required refrigeration.

Based on record review and interview, the facility failed to provide records of three months of food substitutions from the menu. This had the potential to affect all residents of the facility. The facility census was 88.

Findings include:

Review of a facility log titled Menu Substitution Log, revealed the facility was tracking resident requests for alternate menu items. When a resident requested to change what was on the menu, the facility would track this. The facility failed to track internal changes made to menus based on what was published to residents versus what was prepared and served. This was confirmed by Dietary Director (DD) #108 on 10/09/25 at 12:08 P.M.

On 10/09/25 at 12:08 P.M., an interview with DD #108 revealed the facility tracked changes requested by individual residents. She was not aware she should be tracking changes made by the facility.

Based on observation and interview, the facility failed to provide accessible means of egress that opened to a hard surface leading to a public way. This had the potential to affect all residents of the facility. The facility census was 88.

Findings include:

On 10/08/25 at 12:40 P.M., observation of emergency floor plan in the hallway closest to the salon revealed an emergency exit door beside the salon. The floor plan had a path identified by arrows which led to the exit. There were emergency exit signs which also were in the hallway and over the door beside the salon. Outside the external door, located just outside of the door to the salon, was a poured concrete slab. Beyond the concrete slab, there was no firm path of egress which led to a public way.

On 10/08/25 at 12:40 P.M., interview with Director of Nursing (DON) #122, during the facility tour, revealed the door outside the salon did not have a path beyond the concrete slab. The slab just opened into a grassy area.

Based on observation, interview and record review, the facility failed to store and maintain poisonous and hazardous materials in order to maintain the safety of all residents. This had the potential to affect all cognitively impaired residents on the open unit of the facility. The facility identified 17 residents (Resident #90, #70, #21, #61, #55, #94, #35, #4, #42, #32, #75, #80, #67, #85, #40, #83, and #34) on the open unit with cognitive impairment. The facility census was 88.

Findings include:

On 10/08/25 at 12:30 P.M., an observation revealed an unlocked room, identified as the clean laundry room by Director of Nursing (DON) #122. The room contained a 15-ounce spray bottle of DC-7, a 15-ounce aerosol can of Virosol surface disinfectant and deodorant, a 32-ounce bottle of Pro-link enzyme spotter and odor eliminator, and a 32-ounce spray bottle of Stainworx blood buster. These findings were confirmed by DON #122 at the time of observation.

On 10/08/25 at 12:42 P.M., observation revealed empty an empty beauty salon, unlocked. Inside the salon on the open counter tops, there was a 15-ounce aerosol can of Steriphene disinfectant deodorant, two 15-ounce aerosol cans of Matrix Vavoom freezing spray, and a one pound, 13 ounce container of Barbicide disinfecting towelettes. In a drawer between the two shampoo bowls were two pairs of cutting shears. These findings were confirmed by DON #122 at the time of the observation.

On 10/08/25 at 12:50 P.M., an interview with DON #122 revealed the laundry room doors were never locked, and she confirmed there were residents on the unit who were cognitively impaired. She further confirmed the salon doors should have been locked when there was no stylist present.

Review of a Safety Data Sheet (SDS) for StainWorx Blood Buster revealed the label held a signal word Danger. The stain remover was harmful if swallowed or if it came in contact with the skin. It could cause serious skin or eye irritation. Instructions were to flush eyes and/or skin with water for at least 15 minutes and if irritated seek medical attention, and if ingested seek medical attention.

Review of a SDS for DC-7 revealed the product was a disinfectant which was hazardous, keep away from children. First aid for DC-7 for the skin and eyes was to flush for 15 minutes with water and seek doctor if necessary. If ingested, the treatment was to drink large amounts of water and seek medical attention immediately. If inhaled, the treatment was to seek fresh air immediately.

Review of a SDS for Pro-link enzyme spotter and odor eliminator revealed the label to call poison control if ingested. The SDS indicated although low to moderated toxicity, an ingestion of large amounts could cause gastrointestinal irritation, nausea, vomiting, and diarrhea. The product was known to cause eye irritation, skin irritation with prolonged contact or repeated contact. The first aid for Pro-link enzyme spotter and odor eliminator was to flush eyes with plenty of water and get medical attention if irritation persisted. Wash skin with soap and water and get medical attention if irritation developed or persisted. If the chemical was ingested, it was advised to get medical attention immediately, and do not induce vomiting unless instructed to do so by the poison center or a physician.

Review of SDS for Matrix vavoom hairspray revealed eye contact could cause mild to severe irritation and potential for corneal injury. In the even of eye contact, the SDS indicated the eyes should be rinsed well with water for several minutes or until irritation subsided and seek medical attention.

Review of SDS for Virosol revealed the product had potential adverse human health effects and symptoms, and the label had a Danger warning on it. It was known to have endocrine disrupting properties. Personal protective equipment, which included chemical goggles or safety glasses, suitable protective clothing, and gloves, was to be worn when using Virosol. Contact with the product could cause severe skin burns and serious eye damage. First aid measures included if contact with skin, remove affected clothing and wash all exposed skin area with mild soap and water, followed by warm water rinse. If the product came into contact with the eyes, the instructions were to rinse immediately with plenty of water, and to obtain medical attention if pain, blinking or redness persists, and if ingested to rinse mouth, do not induce vomiting and obtain emergency medical attention.

Review of SDS for Barbicide wipes revealed the product was acutely toxic if ingested or came in contact with the skin. The product should only have been used in outdoor or well-ventilated areas, with eye protection. If ingested, the person should contact a physician or poison control If the product came into contact with the eyes, the instructions were to rinse cautiously with water for several minutes, remove contact lenses, and if eye irritation persisted, to seek medical attention.

Based on personnel file review and interview, the facility failed to ensure employees were checked for a finding of abuse, neglect, or misappropriation of the property of a resident on the nurse aide registry (NAR) upon hire. This had the potential to affect all 87 residents in the facility.

Findings include:

Review of the personnel file for certified nurse aide (CNA) #210 revealed a hire date of 07/11/24. There was no documented evidence CNA #210 was checked against the NAR to be free of a finding of abuse, neglect, or misappropriation of the property of a resident upon hire.

Review of the personnel file for CNA #211 revealed a hire date of 02/16/24. There was no documented evidence CNA #211 was checked against the NAR to be free of a finding of abuse, neglect, or misappropriation of the property of a resident upon hire.

Review of the personnel file for Registered Nurse (RN) #212 revealed a hire date of 05/06/24. There was no documented evidence RN #212 was checked against the NAR to be free of a finding of abuse, neglect, or misappropriation of the property of a resident upon hire.

Review of the personnel file for CNA #213 revealed a hire date of 12/01/23. There was no documented evidence CNA #213 was checked against the NAR to be free of a finding of abuse, neglect, or misappropriation of the property of a resident upon hired.

Interview on 11/04/24 at 1:59 P.M. with the Administrator confirmed the above employees were not checked against the NAR upon hire.

Interview on 11/05/24 at 12:40 P.M. with the Director of Nursing (DON) confirmed checks against NAR for all employees were completed on 11/05/24, and no findings of abuse were identified.

Review of the facility self-reported incidents (SRIs) revealed no allegations of abuse had been substantiated since their last annual survey dated 03/14/22.

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 affected one resident (Resident #28) and had the potential to affect all 87 residents in the facility.

Findings include:

Review of Resident #28's medical record revealed the resident was admitted to the facility on 06/01/24 with diagnoses including diabetes, hypothyroidism, depression and dementia.

Record review revealed the Resident Agreement and Resident Handbook were signed by Resident #28's sister and Power of Attorney (POA) on 05/08/24.

Review of the information contained in Residency Agreement regarding basic services revealed the facility would provide bathroom tissue. The facility did not provide any personal items such as clothing, toiletries, hygiene items or furnishings. The facility would not accept any funds from agencies or personal funds to purchase items for new or current residents.

Review of the information contained in the handbook revealed no evidence the facility would provide or not provide additional blankets or pillows if requested, shower curtain hanging devices, a chair with a padded back and seat, with arms for lateral support, a lamp, mirror, closet or shelf. 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) (2) (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.

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, a waste basket with liners, and a chair with a padded back and seat, with arms for lateral support.

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

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

Interview on 11/05/24 at 9:01 A.M. with the Administrator verified the content of the facility Resident Agreement/Resident Handbook as noted above.

This violation represents noncompliance investigated under Complaint Number OH00154640.

Based on observation, interview and facility policy review, the facility failed to ensure food was stored and dated appropriately in a manner that protects it against contamination and spoilage. This had the potential to affect all 87 residents in the facility.

Findings include:

Observation of the kitchen on 11/04/24 at 7:47 A.M. revealed the refrigerator had two stacks of boxes for a total of 11 boxes on the floor in the middle of the refrigerator, one tub identified by the cook as butternut squash dated 10/29/24, five packs of hot dog buns, two packs of raisin bread, eight bags of either white wheat, or rye bread and four hamburger buns all undated. There were also two bags of brussels sprouts, and one bag of thawed, diced potatoes opened and undated. There was one bag of diced ham dated 08/09/24. The freezer contained two stacks of boxes for a total of ten boxes on the floor. There were approximately 11 frozen slabs of meat, identified by the cook as either top roast or other types of beef, which were undated. The dry storage contained three stacks of boxes four of 16 boxes on the floor, one bag of couscous open and undated, three bags of spaetzle noodles, one box of biscuit mix and two bags of rice Krispies undated.

Interview at the time of the observation with Cook #202 confirmed the food delivery had just come that morning and he had not yet had time to place the boxes on shelves. He confirmed all food should be dated with an open or use by date and used within seven days of the open by date.

Review of the undated facility policy titled Prepared Food Storage revealed all food would be covered and properly labeled with either an open buy or use by date. Any open products would be used within seven days of that date or discarded.