Ohio Living Swan Creek

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the resident laundry room was maintained in a clean and safe manner. This had the potential to affect all 40 residents in the facility. The census was 40.

Findings Include:

Observation on 10/09/25 at 10:22 A.M. revealed the resident laundry room had an excessive amount of lint build up behind the washers and dryers, a 20-count package of disposable briefs was located on the floor behind the dryer and a disposable brief was located on the floor, outside of the package, under the dryer exhaust pipe, and both lint traps were noted to have an excessive build-up of lint contained in them.

Interview on 10/09/25 at 10:25 A.M. with the Administrator verified the resident laundry room had an excessive amount of lint build up behind the washers and dryers, a 20-count package of disposable briefs was located on the floor behind the dryer and a disposable brief was located on the floor, outside of the package, under the dryer exhaust pipe, and both lint traps were noted to have an excessive build-up of lint contained in them.

Review of the undated facility policy titled, Dryer Vent Cleaning

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure the facility kitchen was maintained in a sanitary manner. This had the potential to affect all 40 residents in the facility. The census was 40.

Findings Include:

Observation on 10/09/25 at 8:31 A.M. revealed the floor under the facility dishwasher was coated in an unidentified thick substance that was black and brown in color.

Interview on 10/09/25 at 8:34 A.M. with Assistant Director of Culinary and Food Services (ADCFS) #201 verified the floor under the facility dishwasher was coated in an unidentified thick black and brown colored substance. ADCFS #201 stated dietary staff do not have access to housekeeping supplies and they rely solely on housekeeping to ensure the facility kitchen floors are maintained in a sanitary fashion.

Review of an undated facility policy titled, Cleaning and Sanitation of Dining and Food Service Areas

Based on review of fire drill documentation and staff interview, the facility failed to ensure facility fire alarm signals were transmitted and received by the alarm company as required. This had the potential to affect all 40 residents in the facility. The census was 40.

Findings Include:

Review of the facility fire drill documents and fire alarm transmission receipts revealed no alarm transmissions were received by the alarm company for fire drills conducted in June, July, August, and September 2025.

Interview on 10/14/25 at 10:59 A.M. with Director of Environmental Services (DES) #202 revealed no alarm transmissions were received by the alarm company for June, July, August, and September 2025 fire drills. DES #202 confirmed the facility should send an alarm signal and receive a transmission receipt for each fire drill conducted.

This deficiency is a recite to the annual survey completed 11/13/24.

Based on review of personnel files and staff interview, the facility failed to ensure pre-employment physicals were completed on or within 30 days before the first day of work. This had the potential to affect all 41 residents in the facility.

Findings include:

Review of the personnel file for Licensed Practical Nurse (LPN) #202 revealed a hire date of 05/28/24. Review of the Pre-Employment Physical form revealed it was completed 08/08/24.

Review of the personnel file for LPN #203 revealed a hire date of 08/07/24. Review of the Pre-Employment Physical form revealed it was completed 08/08/24.

Review of the personnel file for Certified Nurse Aide (CNA) #101 revealed a hire date of 09/17/24. Review of the Pre-Employment Physical form revealed it was completed 09/18/24.

Interview on 11/13/24 at 4:49 P.M., with Human Resources Director (HRD) #503 and concurrent review of the personnel files confirmed the Pre-Employment physicals for LPN #202, LPN #203 and CNA #101 were not completed before the first day of work.

Based on observation, staff interview, and review of the medical record, the facility failed to ensure physician orders were clarified. This affected one (#52) of two residents reviewed for medication administration. The facility census was 41.

Findings include:

Review of the medical record for Resident #52 revealed an admission date of 10/21/21 with a diagnosis of hypertension.

Review of a physician order dated 08/28/24 revealed Resident #52 should receive artificial tear drops; preserved; amount: one gtt (drop), ophthalmic (in the eye), instill into eye once daily.

Observation on 11/13/24 at approximately 9:10 A.M., revealed Licensed Practical Nurse (LPN) #201 administering one eye drop into each of Resident #52's eyes. Concurrent interview with LPN #201 confirmed she administered one eye drop per eye. Concurrent observation of the eye drop prescription label revealed instructions to administer one drop to each eye once daily.

Interview on 11/13/24 at 5:39 P.M., with Unit Manager (UM) #502 confirmed Resident #52's physician order for the eye drops did not define which eye should receive the drops. UM #502 further confirmed the prescription label on the eye drops indicated one drop should be placed in each eye and confirmed the order should have been clarified.

Based on review of personnel files, review of the Tuberculosis (TB) Risk Assessment Worksheet, and staff interview, the facility failed to ensure staff were screened annually for TB. This had the potential to affect all 41 residents in the facility.

Findings include:

Review of the personnel file for Certified Nurse Aide (CNA) #102 revealed a hire date of 09/19/14.

Review of the personnel file for Resident Assistant (RA) #103 revealed a hire date of 03/10/22.

Interview on 11/13/24 at 4:49 P.M., with Human Resources Director (HRD) #503 and concurrent review of the personnel files confirmed no annual TB screening was completed for CNA #102 or RA #103. HRD #503 stated the facility did not complete annual TB screening for staff.

Interview on 11/13/24 at approximately 5:00 P.M., with the Executive Director (ED), and concurrent review of the facility's TB Risk Assessment Worksheet, confirmed the facility was at low risk of acquiring a case of TB. The ED further confirmed the TB Risk Assessment Worksheet stated the facility's healthcare workers would be tested yearly or as ordered for TB infection.

Based on observation, staff interview, and review of the medical record, the facility failed to ensure hand hygiene was practiced during medication administration. This affected one (#52) of two residents reviewed for medication administration. The facility census was 41.

Findings include:

Review of the medical record for Resident #52 revealed an admission date of 10/21/21 with a diagnosis of hypertension.

Review of a physician order dated 08/28/24 revealed Resident #52 should receive artificial tear drops; preserved; amount: 1 gtt (drop), ophthalmic (in the eye), instill into eye once daily.

Observations on 11/13/24 beginning at 9:00 A.M., revealed Licensed Practical Nurse (LPN) #201 dispensing medication for Resident #52 by opening drawers of the medication cart and touching medication packets, bottles, and the box of eye drops for Resident #52. LPN #201 picked up a pair of disposable gloves and walked to Resident #52 in the common area of the facility. No other residents were present during the medication administration. LPN #201 poured three tablets into Resident #52's mouth and assisted Resident #52 with drinking a glass of water. LPN #201 then set down the water cup and medication cup and put on the gloves she had been holding in her hand. LPN #201 administered one eye drop into each of Resident #52's eyes.

Interview on 11/13/24 at 9:13 A.M., with LPN #201 confirmed she did not wash her hands after touching the medication cart and administering oral medications, and before donning gloves to administer Resident #52's eye drops. LPN #201 stated she should have washed her hands before donning the gloves.

Based on observation, staff interview, and review of policy, the facility failed to ensure appropriate hand hygiene was practiced during meal service. This has the potential to affect all 41 residents in the facility. Findings include: Observations during meal service on 11/13/24 beginning at 11:55 A.M., revealed Cook #300 wearing disposable gloves while plating a meal of hamburger, soup, and French fries. Cook #300 held open the bag of buns with her left hand while removing a bun with her right. Cook #300 then opened the bun on the plate, used a spatula to place a burger on the bun, used a serving utensil to place sauteed mushrooms on top of the burger, used the same gloved hand to place the top of the bun on the burger, then placed a bowl on the plate and used a ladle to spoon soup into the bowl, then opened the oven drawer and used tongs to place fries on the plate. Cook #300 then began the process again, without change her gloves, and touched a hamburger bun, placed it on the plate with her gloved hands, and continued to touch surfaces in the kitchen before placing the top of the bun on the burger. Interview on 11/13/24 at 11:59 A.M., with Cook #300 confirmed she touched multiple surfaces in the kitchen then touched a ready-to-eat hamburger bun without changing gloves. Continued observations on 11/13/24 beginning at 11:59 A.M., revealed Dietary Manager (DM) #301 wearing disposable gloves and preparing meals for residents. DM #301 was observed to touch the bag of hamburger buns, utensils, oven drawers, and the plastic wrap box without changing gloves or washing her hands before touching hamburger buns. Continued observation revealed Cook #300 changing gloves between touching utensils and ready-to-eat items without washing her hands. Further observation revealed Certified Dietary Manager (CDM) #302 wearing disposable gloves and touching multiple surfaces in the kitchen before plating food and touching ready-to-eat hamburger buns. CDM #302 changed her gloves without washing her hands before proceeding to prepare the next plate. Interview on 11/13/24 at 12:17 P.M., with Cook #300 confirmed she did not wash her hands between changing gloves and confirmed she was aware she should wash he hands when changing gloves. Interview on 11/13/24 at 12:19 P.M., with CDM #302 confirmed she touched multiple surfaces in the kitchen before touching a hamburger bun on a plate served to a resident. CDM #302 confirmed she should not touch ready-to-eat food with gloves soiled by touching other surfaces in the kitchen. Review of the policy titled, Bare Hand Contact with Food and Use of Plastic GlovesBased on observation, staff interview, and review of policy, the facility failed to ensure appropriate hand hygiene was practiced during meal service. This has the potential to affect all 41 residents in the facility.

Findings include:

Observations during meal service on 11/13/24 beginning at 11:55 A.M., revealed Cook #300 wearing disposable gloves while plating a meal of hamburger, soup, and French fries. Cook #300 held open the bag of buns with her left hand while removing a bun with her right. Cook #300 then opened the bun on the plate, used a spatula to place a burger on the bun, used a serving utensil to place sauteed mushrooms on top of the burger, used the same gloved hand to place the top of the bun on the burger, then placed a bowl on the plate and used a ladle to spoon soup into the bowl, then opened the oven drawer and used tongs to place fries on the plate. Cook #300 then began the process again, without change her gloves, and touched a hamburger bun, placed it on the plate with her gloved hands, and continued to touch surfaces in the kitchen before placing the top of the bun on the burger.

Interview on 11/13/24 at 11:59 A.M., with Cook #300 confirmed she touched multiple surfaces in the kitchen then touched a ready-to-eat hamburger bun without changing gloves.

Continued observations on 11/13/24 beginning at 11:59 A.M., revealed Dietary Manager (DM) #301 wearing disposable gloves and preparing meals for residents. DM #301 was observed to touch the bag of hamburger buns, utensils, oven drawers, and the plastic wrap box without changing gloves or washing her hands before touching hamburger buns. Continued observation revealed Cook #300 changing gloves between touching utensils and ready-to-eat items without washing her hands. Further observation revealed Certified Dietary Manager (CDM) #302 wearing disposable gloves and touching multiple surfaces in the kitchen before plating food and touching ready-to-eat hamburger buns. CDM #302 changed her gloves without washing her hands before proceeding to prepare the next plate.

Interview on 11/13/24 at 12:17 P.M., with Cook #300 confirmed she did not wash her hands between changing gloves and confirmed she was aware she should wash he hands when changing gloves.

Interview on 11/13/24 at 12:19 P.M., with CDM #302 confirmed she touched multiple surfaces in the kitchen before touching a hamburger bun on a plate served to a resident. CDM #302 confirmed she should not touch ready-to-eat food with gloves soiled by touching other surfaces in the kitchen.

Review of the policy titled, Bare Hand Contact with Food and Use of Plastic Gloves

Based on review of the facility's fire drills, staff interview, and review of policy, the facility failed to ensure fire drills were completed monthly. This had the potential to affect all 41 residents in the facility.

Findings include:

Interview on 11/13/24 at 12:59 P.M., with Director of Environmental Services (DES) #500 and concurrent review of the facility's monthly fire drills confirmed no fire drill was conducted during the month of September 2024. DES #500 confirmed the facility should perform fire drills every month.

Review of the undated policy titled, Fire Drill Policy & Procedure revealed fire drills are to be conducted on a quarterly basis on each of the three shifts according to Ohio statutes. In order to meet this requirement, fire drills are scheduled on a monthly basis.

Based on record review and staff interview, the facility failed to provide a transfer agreement. This had the potential to affect all 41 residents in the facility.

Findings include:

Interview on 11/13/24 at 4:25 P.M., with Director of Environmental Services (DES) #500, confirmed she could not find a written, signed transfer agreement between the facility and another facility to implement if a situation arose in which the health and safety of residents was potentially affected by conditions in the facility.

Based on observation and staff interview, the facility failed to ensure required postings were posted in the facility. This had the potential to affect all 41 residents in the facility.

Findings include:

Observation on 11/13/24 at 4:28 P.M. and concurrent interview with Director of Social Services (DSS) #501 revealed the facility's rules and regulations and a list of residents rights advocates were not posted in the facility. Further interview and observation with DSS #501 revealed the survey results were in a drawer and no signage was posted indicating the availability or location of previous survey results.