Scarlet Oaks Care Center

Based on observation, staff interview, and review of the facility policy, the facility failed to prepare and store food in a sanitary manner and in a way that prevented spoilage. This had the potential to affect all of the residents residing in the facility. The facility census was 76 residents.

Findings include:

1. Observation on 07/08/25 at 11:30 A.M revealed Service Dining Staff (SDS) #180 cooked two hamburger patties. The Dining Director (DD) took the temperature of the two hamburger patties which were at a temperature of 131 degrees Fahrenheit (F.)

Interview on 07/08/25 at 11:31 A.M. with the DD confirmed the temperature of the two hamburger patties was 131 degrees F.

Review of the facility policy titled Food Safety and Quality undated revealed hamburger patties should be cooked to an internal temperature of at least 145 degrees F.

2. Observation on 07/08/25 at 11:35 A.M. with the DD revealed the following items in the dry storage area: an open box biscuit mix with a hairnet laying on top of the biscuit mix, an open and unlabeled package of icing mix, two packages of undated and unlabeled taco shells, a single cheese puff sitting in the box of liquid thickener, an open and unlabeled packet of gravy mix.

Interview on 07/08/25 at 11:40 A.M with the DD confirmed the unlabeled and undated items in the dry storage area.

3. Observation on 07/08/25 at 11:41 A.M. of kitchen prep station #1 with the DD revealed the following items: a pink jacket hanging over the prep station, a dirty fork and napkin on the clean prep station cart, 2 used masks, a napkin, and lid on top of the plastic cups.

Interview on 07/08/25 at 11:43 A.M with the DD confirmed the pink jacket hanging over the prep station, the dirty fork and napkin on the clean prep station cart, and the two used facemasks were improperly stored in the prep station.

4. Observation on 07/08/25 at 11:50 A.M. with the DD revealed the following concerns in the kitchen prep station #3: the deep fryer hood had built up grime, there was a container of flour under the prep station that was unlabeled and undated, the flour was stored next to a bottle of sanitizer used to clean surfaces, above the prep station there was an open and undated container of brown sugar and an open and undated packet of gravy mix.

Interview on 07/08/25 at 11:55 A.M with the DD confirmed the deep fryer hood had built up grime, the flour under the prep station was unlabeled and undated, the container of flour was being stored next to a bottle of sanitizer, and above the prep station there was an open and undated container of brown sugar and an open and undated packet of gravy mix.

Review of facility policy titled Food Receiving and Storage dated October 2017 revealed food should be covered, labeled, and dated.

5. Observation on 07/08/25 at 12:05 P.M of the kitchen with Dietary Staff Member (DSM) #160 revealed a large number of gnats flew out of the front of kitchen supply storage refrigerator upon opening.

Interview on 07/08/25 at 12:05 P.M with DSM #160 confirmed a large number of gnats flew out of the front of the kitchen supply storage refrigerator upon opening.

Review of the facility policy titled Food Receiving and Storage dated October 2017 revealed food storage areas should be free from pests.

This violation represents noncompliance investigated under Master Complaint Number OH00165047 and Complaint Number OH00165032 and Complaint Number OH00163283.

Based on record review and staff interview, the facility failed to ensure residents capable of self-evacuation were evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift. This had the potential to affect all of the residents residing in the facility. The facility census was 76 residents.

Findings include:

Review of the facility fire drill reports dated May 2024 to June 2025 revealed there was no record of completion of resident evacuations for any of the drills.

Interview on 07/08/25 at 3:10 P.M. with Maintenance Staff (MS) #35 confirmed the facility had not completed resident evacuations for any of the fire drills in the previous 12 months.

Based on record review and staff interview, the facility failed to ensure employees attended a fire prevention training course. This had the potential to affect all of the residents residing in the facility. The facility census was 76 residents.

Findings include:

Review of the fire safety binder for the facility revealed none of the employees had attended a fire prevention training course from June 2024 to June 2025.

Interview on 07/08/25 at 3:15 P.M. with Maintenance Staff (MS) #35 confirmed the facility had not provided employees with a fire prevention training course for 2024 or 2025.

Based on observation and staff interview the facility failed to ensure facility dryers were maintained in a safe manner with lint traps free of excessive lint build up. This had the potential to affect all of the residents residing in the facility. The facility census was 76 residents.

Findings include:

Observation on 07/08/25 at 9:16 A.M. of dryer #2 with Licensed Practical Nurse Supervisor (LPNS) #10 revealed there was lint buildup of approximately one half of an inch in the lint trap.

Interview on 07/08.25 at 9:17 A.M with LPNS #10 confirmed there was lint buildup of approximately one half of an inch in the lint trap of dryer #2.

Observation on 07/08/25 at 9:20 AM with LPNS #10 revealed there was lint buildup of approximately one half of an inch in the lint trap.

Interview on 07/08/25 at 9:21 A.M with LPNS #10 reconfirmed there was lint buildup of approximately one half of an inch in the lint trap of dryer #3.

Based on personnel record review and staff interview, the facilty failed to ensure Certified Nurse Aides (CNAs) completed first aid training. This had the potential to affect all residents residing in the facility . The facilty census was 69.

Findings include:

Review of the personnel records for CNAs #90 and #91 revealed they did not include evidence of first aid training.

Interview on 06/04/24 at 4:40 P.M. with Assisted Living Director (ALD) #95 confirmed CNAs #90 and #91 had not completed first aid training.

Based on review of fire drill records and staff interview the facility failed to complete the required fire drills. This had the potential to affect all residents residing in the facility. The facility census was 69.

Findings include:

Reivew of the fire drills records for June 2023 to May 2023 revealed fire drills were not completed for the following months: June 2023, July 2023, August 2023, September 2023, October 2023, December 2023, February 2024, March 2024, April 2024.

Interview on 06/04/24 at 4:24 P.M. with Maintenance Director (MD) #76 confirmed the facility had not completed fire drills for the following months: June 2023, July 2023, August 2023, September 2023, October 2023, December 2023, February 2024, March 2024, April 2024.

Based on observation, resident and staff interviews, review of pest control records, and review of a facility policy, the facility failed to maintain a pest free environment. This directly affected two (#18 and #26) of eight residents reviewed with potential to affect all 65 residents residing in the facility. The census was 65.

Findings include:

Observation on 03/03/23 at 11:15 A.M. revealed Resident #18 sitting in his recliner eating snacks. There were crumbs of food on the flood with and ants walking around near the crumbs.

Interview with Resident #18 on 03/03/23 at 11:17 A.M. confirmed he did not want staff to clean his room and verified the ants in his room at that time.

Observation on 03/03/23 at 11:42 A.M. revealed a smashed cockroach in the second flood hallway.

Interview with Resident #21 on 03/03/23 at 11:42 A.M. confirmed she smashed the cockroach with her wheeled walker as she saw it come out from underneath Resident #18 room door. Resident #21 stated that was not the first time she saw pests come from underneath Resident #18's door.

Observation and interview with Resident #26 on 03/03/23 at 2:35 P.M. revealed cockroaches inside one of his miniature refrigerators in his room and gnats in the another miniature refrigerator in the room. Resident #26 confirmed he was aware there were cockroaches and gnats in his miniature refrigerators, but it did not bother him. Resident #26 stated facility staff have offered to clean his room, including the miniature refrigerators, but he would rather do it himself.

Interview with Director of Assisted Living (DAL) #101 on 03/03/23 at 12:42 P.M. confirmed there are a few residents who choose not to have their rooms cleaned by the facility staff. DAL #101 confirmed Resident #18 and Resident #26 have both indicated they did not want staff going through their rooms. DAL #101 confirmed the facility had a pest control company to their facility multiple times in the last two months for bed bugs and cockroaches.

Review of facility pest control records, dated 12/01/22 to 03/01/23, revealed resident rooms, offices, and common areas were treated for bed bug activity on 02/08/23, 02/10/23, 02/17/23, 02/22/23, 02/24/23, and 02/27/23. Additionally, on 02/17/23, resident rooms, including Resident #26's room, was baited for cockroaches and was noted to have gnats. On 02/27/23, a resident room was treated for cockroaches and would need follow up.

Review of a facility pest control policy, dated May 2008, revealed the facility will maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services will assist, when appropriate and necessary, in providing pest control services.

Based on medical record review, resident and staff interview, review of a missing items log, and review of a facility policy, the facility failed to review and respond to requests and grievances in a timely manner. This affected four (#7, #21, #27, and #65) of five residents reviewed for missing items and grievances. The census was 65.

1. Review of Resident #7's medical record revealed and admission date of 03/31/17. Diagnoses included asthma, low back pain, muscle weakness, basil cell carcinoma of the skin, anemia, paranoid schizophrenia, hyperparathyroidism, bipolar disorder, hyperkalemia, chronic kidney disease, hypothyroidism, dementia. Review of Resident #7's assisted living quarterly review, dated 02/06/23, revealed Resident #7 had no cognitive issues.

Review of Resident #7's progress notes, dated 02/15/23, revealed during a care conference meeting, the facility was made aware of missing clothing items. Further review of Resident #7's entire medical record revealed no further follow up about her missing items.

Review of an undated facility missing items log revealed Resident #7 was missing shirts, jeans, and Capri pants.

2. Review of Resident #21's medical record revealed an admission date of 09/08/21. Diagnoses included chronic kidney disease, diabetes mellitus type II, major depressive disorder, bipolar disorder, atherosclerotic heart disease, insomnia, hypertension, anemia, and osteoarthritis. Review of Resident #21's assisted living quarterly review, dated 11/11/22, revealed Resident #21 had no cognitive issues.

Review of Resident #21's progress notes, dated 01/09/23, revealed she made a statement that people were stealing her things and missing other items from her room, but was not specific to what was missing from her room at that time. Further review of Resident #21's entire medical record revealed no further follow up about her missing items.

Review of an undated facility missing items log revealed Resident #21 was missing a comforter, laptop computer, and a tablet.

3. Review of Resident #27's medical record revealed an admission date of 02/09/22. Diagnoses included chronic obstructive pulmonary disease (COPD), convulsions, alcohol dependence with alcohol induced persisting dementia, altered mental status, insomnia, and hypokalemia. Review of Resident #27's assisted living quarterly review, dated 02/09/23, revealed Resident #27 had no cognitive issues.

Review of an undated facility missing items log revealed revealed Resident #27 was missing a beanie type hat, three big gray towels, and gray washcloths.

Further review of Resident #27's entire medical record revealed no further follow up about any missing items.

4. Review of Resident #65's medical record revealed an admission date of 01/27/17. Diagnoses included hypertension, anxiety disorder, bipolar disorder, myalgia, hypothyroidism, osteoporosis, chronic migraines, overactive bladder, edema, and benign neoplasm of bladder. Review of Resident #65's assisted living quarterly review, dated 01/23/23, revealed Resident #65 had no cognitive issues.

Review of Resident #65's progress notes, dated 02/15/23, revealed during a care conference meeting, Resident #65 indicated she was still missing pillows from when the building was treated for bed bugs. The note also confirmed the facility would replace the missing pillows. Further review of Resident #65's entire medical record revealed no further follow up about the missing items.

Review an undated facility missing items log revealed Resident #65 had two orthopedic pillows and a lounge pillow that were missing.

Interview with Resident #21 on 03/03/23 at 11:42 A.M. confirmed she was missing items from her room, and made it know the items were missing to the facility managers, but they had not done anything about it.

Interview with Resident #27 on 03/03/23 at 12:53 P.M. confirmed he is missing some towels, wash cloths, and a couple hats. Resident #27 confirmed he told the nurses and managers about the missing items, but had no idea where in the process they were of investigating the missing items or replacing them. Resident #27 could not remember how long the items were missing, but indicated it was probably a couple of months.

Interview with Director of Assisted Living (DAL) #101 on 03/03/23 at 2:10 P.M. stated there was no documentation to support an investigation was completed for Resident #7, #21, #27, and #65's missing items. DAL #101 confirmed the facility did not do any inventory or labeling with the items that were removed from resident rooms when they treated the building for bed bugs, and could not confirm if everything got back to the residents.

Interview with the Administrator on 03/03/23 at 2:25 P.M. confirmed she will be replacing all the missing items in the next week. The Administrator stated when she found out about the missing items, they could not confirm where the missing items went or who was responsible for misplacing them, so the facility was going to replace all the missing items. The Administrator stated there was no documentation of an investigation into the missing items.

Review of an undated facility grievance and complaints policy revealed residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

This violation substantiated complaint number OH00139641.

Based on medical record review, observations, resident and staff interviews, the facility failed to ensure No Smoking signs posted on doors where oxygen was in use. This affected three (#11, #20 and #39) of three residents observed for oxygen usage. The census was 68.

Findings include:

Review of the medical record for Resident #11 revealed an admission date on 02/10/22. Diagnoses for Resident #11 included bipolar, chronic pain and depression. Review of functional assessment for Resident #11, dated 02/10/22, revealed she was independent with walking, eating and toilet use. Resident #11 needed reminders for socialization.

Observation on 01/04/23 at 3:54 P.M., revealed Resident #11 had oxygen in use, in her room with no sign on the door indicating, No smoking oxygen in use.

Interview on 01/04/23 at 3:56 P.M., with Resident #11 reported she use the oxygen during the day if she did not feel well and she uses it at night. Resident #11 reported she was not feeling well and needed oxygen.

Interview on 01/04/23 at 4:00 P.M., with Licensed Practical Nurse (LPN) #9 verified the resident was utilizing oxygen and no signage was posted. LPN #9 reported Residents #20 and #39 have oxygen in their rooms.

Review of the medical record for Resident #20 revealed an admission date on 10/11/19. Diagnosis for Resident #20 included chronic obstructive pulmonary disease repeated falls, heart failure, opioids use with withdrawal, and chronic pain. Review of functional assessment for Resident #20, dated 09/25/22, revealed she was independent with walking, eating and toilet use. Resident #20 needed reminders for socialization.

Review of the medical record for Resident #39 revealed an admission date on 03/10/20. Diagnoses for Resident #39 included chronic obstructive pulmonary disease, hypertension, gastro esophageal reflux disease without esophagitis and acute kidney failure. Review of functional assessment for Resident #39, dated 11/12/22, revealed she was independent with walking, eating and toilet use. Resident #39 needed reminders for socialization.

Interview on 01/04/23 at 4:10 P.M., with LPN #5 confirmed Residents #11 and #20 are on oxygen and the tanks are in their rooms.

Interview on 01/04/23 at 4:15 P.M. with Resident #20, who was using oxygen , revealed there was not a no smoking sign posted on front of door. Resident #20 reported she was in hospital and needs her oxygen.

Observation on 01/04/22 at 4:20 P.M., revealed Resident #39 had oxygen running with no signage on door.

Interview on 01/04/22 at 5:00 P.M., with the Assisted Living Director (ALD) verified there was no signage on the doors for no smoking when residents used oxygen. ALD then placed signs on the doors after deficient practice had been identified.

Based on observation and staff interview, the facility failed to ensure residents and family had access to review the survey results. This had potential to affect all 68 residents in the facility. The census was 68.

Findings include:

Observation on 01/04/23 from 11:10 A.M. to 11:50 A.M., revealed no survey results posting or book or anything indicating where survey results could be located.

Interview on 01/04/23 at 11:55 A.M., with Administrative Assistant (AA) #405 denied seeing survey results book since she has been employed with facility. AA #405 reported she has been working in the facility at the front desk for over three years.

Interview on 01/04/23 at 12:15 P.M., with Assisted Living Director (ALD) verified there was no information posted where the survey results could be located and no results were available.

Based on medical record review, observations, staff and resident interview, review of pest control invoices and policy review, the facility failed to provide an effective pest control program for the facility. This affected seven (#18, #21, #22, #23,# 24, #34, and 35) out of eight residents reviewed for effective pest control and had the potential to affect all 67 residents residing in the facility. The facility census was 67.

Findings include:

Tour of the facility was completed on 10/24/22 from 9:55 A.M. to 10:55 A.M. revealed there were roaches in the dinning room in the corner and bedbugs seen on multiple chairs, verified with staff. There were roaches and bedbugs on each floor in various rooms.

Observation of resident rooms (130, 220, 310, 331, 417, 420, and 429) , during facility initial tour revealed bedbugs, roaches and mice. Facility was spot treated on Friday, 10/21/22 but it did not kill all of the bugs. Live bedbugs were seen through out the facility.

Interview was conducted with Resident #22 on 10/24/22 at 10:17 A.M. and resident states rooms are disgusting, and he wants to move because nothing is being fixed.

Interview was conducted with Resident #34 on 10/24/22 at 10:24 A.M. revealed a mouse in resident's room. Resident denies issues with bedbugs and roaches.

Interview was conducted with Resident #18 on 10/24/22 at 10:33 A.M. revealed that resident used chair more than his bed because bedbugs had infested his room and had not been taken care of by the time of the survey.

Interview was conducted with Resident #24 on 10/24/22 at 10:45 A.M. revealed that resident was moved from room 231 two days prior to survey for infestation and still has not received his belongings, resident stated that he lived in the room under those conditions for over three months without getting things cleaned up.

Interview was conducted with Resident #23 on 10/24/22 at 11:00 A.M. and resident asked that surveyor accompany her to her room and she showed surveyor multiple roach traps full of both live and dead bugs. Resident stated that it has been an ongoing problem although she had not personally experienced the bedbugs.

Interview with Licensed Practical Nurse (LPN) #211 on 10/24/22 at 11:10 A.M. revealed that the facility had issues with bedbugs and roaches throughout the facility including the nursing station and dining room.

Interview with LPN #224 on 10/24/22 at 11:22 A.M. revealed bedbugs in the nursing office, chairs covered with plastic bags and nurses using alcohol spray to keep bugs of and to kill them on contact. During med pass observation at this time to Resident #18 revealed bed bugs were crawling on the bed.

Interview with LPN #207 on 10/24/22 at 11:40 A.M. revealed that the facility has had issues with bedbugs and roaches for months and has not been resolved.

Review of the facility pest control invoices from March 2022 through October 2022 revealed the following residents rooms had been treated sporadically and the activity on the lower level. No record of the dining room or offices being treated for bed bugs, roaches or mice.

Review of the facility policy titled, Pest Control, undated, revealed it is the policy of the facility to maintain an effective pest control program.

This violation substantiates Complaint Number OH00136470.