Saint Luke Lutheran Home for the Aging

Based on medical record review, observation, and interview, the facility failed to ensure medications were administered in accordance with physician orders. This affected two (Residents #13 and #31) of three residents reviewed for medication administration.

Findings include:

1. Review of Resident #13's medical record revealed diagnoses including hyperlipidemia, atherosclerosis if coronary artery bypass graft and moderate protein-calorie malnutrition. Review of September 2025 and October 2025 Medication Administration Records (MARs) and associated medication administration notes revealed Resident #13 had an order to start ubiquinol (antioxidant) 200 milligrams (mg) every morning on 09/24/25. The MARS and associated notes revealed the ubiquinol was not administered on 09/24/25, 09/25/25, 09/26/25, 09/29/25, 09/30/25, 10/01/25, 10/02/25, 10/04/25, 10/05/25, 10/06/25 or 10/07/25 because it was not available.

Interview of Pharmacy Tech #110 on 10/07/25 at 1:29 P.M. revealed the order for ubiquinol was entered as profiled, meaning Resident #13 would either be using his own supply or the facility's stock supply. There had never been any request for pharmacy to fill the order.

Observations of the medication cart on 10/07/25 at 2:02 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #120 revealed only stock medication was available at 30 mg tablets. LPN #120 stated Resident #13's daughter was going to provide the ubiquinol.

Observations of the main medication room with the DON on 10/07/25 at 2:15 P.M. revealed the facility had 50 mg tablets of the ubiquinol in stock. The DON stated he would take the medication to Resident #13's unit for administration. The DON stated the nurses who did document administration of the ubiquinol must have obtained the medication through stock supply.

2. Review of Resident #31's medical record revealed diagnoses including iron deficiency anemia, hypertension, non-rheumatic aortic valve disorder, and hypercholesterolemia.

a. Review of the August Medication Administration Records (MARs) and associated MAR notes revealed on 08/02/25, 08/03/25 and 08/04/25 atorvastatin calcium (medication used to lower cholesterol) 20 milligrams was not administered but was on order from pharmacy. An eMAR (electronic MAR) note dated 08/04/25 at 7:51 A.M. indicated the atorvastatin was not available. Pharmacy was called.

On 10/07/25 at 1:29 P.M., Pharmacy Tech #110 was interviewed regarding the documentation of atorvastatin not being administered due to it not being available on 08/02/25 through 08/04/25. Pharmacy Tech #110 stated records indicated the pharmacy sent a 30 day supply of atorvastatin to the facility on 07/01/25. The facility requested a refill on 07/27/25 but pharmacy marked it as too early to refill. Pharmacy Tech #110 stated orders could generally be refilled when there were three to four doses remaining. Pharmacy Tech #110 stated the facility again requested a refill on 07/31/25 but pharmacy documented it was too early for a refill although she acknowledged if a 30 day supply was delivered on 07/01/25 the order would have needed refilled. Pharmacy Tech #110 stated the pharmacy delivered the atorvastatin on 08/09/25. Pharmacy Tech #110 stated if the facility withdrew the atorvastatin from the emergency medication supply the nurse withdrawing the medication would be required to complete a withdraw form. There was no evidence of atorvastatin being removed from the emergency drug kit for Resident #31 pending pharmacy delivery of the atorvastatin.

On 10/07/25 at 1:55 P.M., LPN #100 verified documentation revealed Resident #31's atorvastatin was not available for administration from 08/02/25 through 08/04/25. LPN #100 stated she was unable to state where nurses would have obtained atorvastatin for administration between 08/05/25 and 08/09/25 if it had not been delivered by pharmacy.

On 10/07/25 at 2:15 P.M., the information obtained during the interview with Pharmacy Tech #110 was shared with the DON. Observation of the facility's Pyxis (drug dispensing system) revealed atorvastatin 10 milligram (mg) tablets were available. The DON verified through a search of the Pyxis records that atorvastatin was never withdrawn for Resident #31. The DON stated he was unable to determine where staff would have obtained atorvastatin for administration on 08/05/25 through 08/09/25 if pharmacy had not yet delivered it.

b. The October 2025 MAR and eMAR notes indicated ferrous sulfate (iron) 325 milligrams (mg) was not administered on 10/01/25 because it was on order.

On 10/07/25 at 1:55 P.M., LPN #100 stated Resident #31's over the counter medications such as ferrous sulfate was provided from the facility's stock medication supply, not from the pharmacy.

On 10/07/25 at 2:51 P.M., Central Supply Clerk #115 stated the night shift nursing coordinator provided a list of over the counter medications needed and she ordered them if the family chose not to provide them. Iron was one of the medications which was ordered routinely. Central Supply Clerk #115 stated ferrous sulfate was always available. If ferrous sulfate was not available on a medication cart, it was available in the medication supply rooms.

This violation represents non-compliance investigated under Complaint Number OH00168457 and is a recite to the complaint survey completed 09/05/24.

Based on observation, record review, policy review and interview, the facility failed to maintain hot water temperatures in resident rooms between at least one hundred five (105) degrees Fahrenheit (F) and no more than one hundred twenty (120) degrees Fahrenheit F at the point of use. This affected 12 residents (#6, #7, #10, #16, #20, #22, #23, #25, #26, #27, #36 and #40) of 41 residents residing in the facility.

Findings include:

Observations on 08/20/25 with Maintenance Assistant #801 of the assisted living facility revealed the following:

a. At 9:41 A.M., Resident #25's water temperature in the resident's bathroom sink was 85.6 degrees F.

b. At 9:43 A.M., Resident #16's water temperature in the resident's bathroom sink was 100.2 degrees F.

c. At 9:45 A.M., Resident #22's water temperature in the resident's bathroom sink was 100.4 degrees F.

. At 9:48 A.M., Resident #20's water temperature in the resident's bathroom sink was 95.0 degrees F.

e. At 9:51 A.M. Resident #27's water temperature in the resident's bathroom sink was 91.0 degrees F. Interview with Resident #27 at the time of the observation revealed the water was not hot.

f. At 9:53 A.M., Resident #36's water temperature in the resident's bathroom sink was 86.9 degrees F.

g. At 9:55 A.M., Resident #7's water temperature in the resident's bathroom sink was 91.6 degrees F.

h. At 9:58 A.M., Resident #10's water temperature in the resident's bathroom sink was 91.6 degrees F.

i. At 10:00 A.M., Resident #40's water temperature in the resident's bathroom sink was 95.7 degrees F. Interview with Resident #40 at the time of the observation revealed the resident's water was only lukewarm.

j. At 10:01 A.M., Resident #6's water temperature in the resident's bathroom sink was 98.1 degrees F.

k. At 10:03 A.M., Resident #23's water temperature in the resident's bathroom sink was 90.1 degrees F.

l. At 10:07 A.M., Resident #26's water temperature in the resident's bathroom sink was 95.4 degrees F.

Interview on 08/20/25 at 10:09 A.M. with Maintenance Director (MD) #802 revealed he was unaware the water temperatures were not meeting the guidelines. He then stated this had occurred because a valve was left on by housekeeping staff.

Review of the facility Water Temperature Log forms from 05/01/25 to 08/19/25 revealed hot water temperatures were not between 105 and 120 degrees as required on 08/01/25, 08/02/25, 08/14/25, 08/15/25, 08/16/25 or 08/19/25.

Review of the facility undated Hot Water Temperature Policy revealed the resident care areas including the sinks, showers, and tubs were to be maintained between 105 degrees F and 120 degrees F.

This violation represents non-compliance investigated under Complaint Number OH00167892.

Based on observation and interview, the facility failed to ensure the resident rooms were maintained in sanitary and good repair. This affected seven residents (#7, #10, #16, #20, #22, #23 and #25) of 41 residents residing in the facility.

Findings include:

Observations on 08/20/25 with Maintenance Assistant #801 of the assisted living facility revealed the following concerns:

a. At 9:41 A.M., Resident #25's room had rust stains around the toilet bowl.

b. At 9:43 A.M., Resident #16's room had water damage on the bedroom ceiling with stains on the ceiling above the bed.

c. At 9:45 A.M., Resident #22's bathroom had a piece of tile coming off the wall by the shower.

. At 9:48 A.M., Resident #20's toilet had rust stains around the toilet bowl.

e. At 9:55 A.M., Resident #7's bathroom had brown stains and peeling paint on the left side of the toilet.

f. At 9:58 A.M., Resident #10's resident room had two and a half tiles missing from the ceiling by the resident's door. Interview with Resident #10 at the time of the observation revealed the tiles that were missing had been gone for approximately ten days.

g. At 10:03 A.M., Resident #23's room had brown water stains in two of the tiles over the resident's bed.

Interview on 08/20/25 at 10:05 A.M. with Maintenance Assistant #801 confirmed the above findings.

This violation represents non-compliance investigated under Complaint Number OH00167892.

Based on record review, including review of facility billing/financial information, review of email communication, review of the facility Abuse/Neglect policy and procedure and interviews, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. This had the potential to affect all residents residing in the facility.

Findings include:

1. Interview on 06/30/25 at 10:10 A.M. with Former Activities Director (FAD) #624 revealed concern Pastor #733 had not been paid for his services since February 2025.

Interview on 07/01/25 at 4:00 P.M. with Activities Aid # 629 revealed Pastor #733 was the Chaplin/Religious director for the facility, he provided spiritual support for the facility.

Interview on 07/02/25 at 3:16 P.M. with Pastor #733 revealed he was the chaplain in the facility and provided religious services twice a week. Pastor #733 stated he received an email offer for payment of one hundred seventy-five dollars per week. Pastor #733 stated his last payment received from the facility was February 2025. He did not receive payment for services in March, April, May or June 2025 for a total of twelve weeks.

Review of a copy of email exchange dated 04/16/25 revealed the former administrator approved Pastor #733 to provide services twice a week for the residents and was to be paid one hundred seventy-five dollars per week.

Review of a copy of email exchange dated 06/26/25 from Pastor #733 to the Administrator revealed a payment had not been received for services the past four months and requested the matter be addressed urgently.

Interview on 07/07/25 at 4:09 P.M. with the Administrator revealed he was unaware Pastor #733 had not been paid after review of email exchange dated 06/26/25 from Pastor #733 to the Administrator.

2. Interview on 07/01/25 at 1:20 P.M. with Former Activities Director (FAD) #624 revealed lawn care had stopped coming and the landscaping outside the Dementia Unit patio had not been done all year.

Interview on 07/07/25 at 2:30 P.M. with the Director of Maintenance #575 revealed Beadling Lawn care would cut the facility ' s grass, spray for weeds and trim bushes and trees but the facility did not pay Beadling Lawn care bill. The Administrator wanted the facility maintenance crew to provide lawn maintenance instead, but the facility did not provide equipment to maintain the landscaping of the facility.

Observation on 07/07/25 at 2:43 P.M. with the Director of Maintenance #575 revealed grass and weeds were growing from cracks in the parking lot that measured four to sixteen inches long, the grass in the front of the building and along the facility was tall reaching past ankle length. Bushes outside resident ' s rooms were overgrown.

Interview on 07/07/25 at 3:00 P.M. with the owner of Beadling Landscaping revealed the company had stopped services as of April 2024 because the facility did not pay their bill.

Review of document titled Beadling Landscaping, invoice #0006330, dated 05/17/25 revealed nine thousand seven hundred ninety-two dollars and fifty cents was a balance due for the April and May 2025 invoice.

Interview on 07/07/25 at 4:09 P.M. with the Administrator revealed he was unaware Beadling Lawn care company had not been paid and stopped services after review of invoice #0006330.

3. An Interview on 06/30/25 with Registered Dietitian (RD) # 732 revealed the facility had been warned about overdue invoices and the possibility of suspended services.

Interview on 07/01/25 at 2:45 P.M. with RD #730, who received payments and provided overdue notices for Nutri Tech, revealed the facility had an ongoing delay in payments since June 2024. Nutri tech provided contract RD services, and the Administrator was notified of need for payment. RD #730 stated the facility was in breach of contract and owed Nutri Tech sixteen thousand dollars.

Review of document title Nutri Tech invoice number 3218 billed to Saint Luke's dated 05/31/25 revealed a due date of 06/30/25 for the amount of eight thousand sixty-four dollars.

Interview on 07/01/25 at 4:33 p.m. with the Administrator revealed he was not aware of the risk of no further RD services and stated the facility was in the process of paying the debt.

Review of a copy of email exchanges between the parties of Nutri tech and Saint Luke's administration dated 05/27/25 revealed RD #730 copied the Administrator regarding accounts were twenty-seven days past due and Nutri Tech did not permit accounts to exceed thirty days past due without a service hold. A request for current invoice payment was made.

Review of a copy of email exchange between the parties of Nutri Tech and Saint. Luke's administration dated 06/06/25 at 3:19 P.M. revealed RD #730 sent a reminder payment was due by the end of the day as promised to prevent disruption in dietitian services due to nonpayment. Saint Luke's accounts were flagged as high risk and payment links were provided for the facility to pay.

Review of a copy of email exchange between the parties of Nutri Tech and Saint Luke's administration dated 06/11/25 at 3:07 P.M. revealed RD #730 reached out to the Administration regarding Saint Luke's had an outstanding balance of eleven thousand one hundred forty-eight dollars that was forty-two days past due in addition to a balance of eleven thousand two hundred sixty-eight dollars that was twelve days past due. A request for a minimum payment of the balance over thirty days past due be remitted in order to reinstate dietitian services and request the remaining balance that was twelve days past due be resolved prior to reaching thirty days to avoid further disruption in services.

Review of a copy of email exchange between the parties of Nutri Tech and Saint Luke's administration dated 06/20/25 at 9:02 A.M. revealed RD #730 reached out to the Administrator regarding termination of services. The email exchange revealed the Administrator met with RD #730 the Friday prior. The email informed the Administrator that due to ongoing payment delays which resulted in missed compensation to the dietitians, Nutri Tech formally issued a thirty-day notice of termination of services as of 07/18/25. The Administrator was notified that Nutri Tech would continue to provide services throughout 07/18/25 contingent on outstanding invoices did not exceed thirty days past due . Nutri Tech offered to remain past the 07/18/25 deadline if the facility was open to a prepayment model.

Review of a copy of an email exchange between the parties of Nutri Tech and Saint Luke's administration revealed on 06/30/25 at 3:42 P.M. RD CEO #739 reached out the Administration regarding payment was due for dietitian services and Allaire had not honored the payment terms in the contract. The administrator was notified dietitian services were to cease immediately.

Review of a copy of email exchange between the parties of Nutri Tech and Saint Luke's administration dated 07/02/25 at 10:44 A.M. revealed RD CEO #739 reached out to the Administrator regarding a payment reminder and if a minimum payment was received an RD would stay on in limited capacity until the facility found another RD.

An interview on 07/23/25 at 10:43 A.M. with Chief Operating Officer(COO)/RD #730 revealed there had been problems with the facility paying for RD services. The COO/RD revealed services were held for one day in January 2025 and again in June/July 2025. COO/RD #730 verified services were suspended from 06/30/25 until 07/18/25. The facility had to pay the balance owed plus pre-pay until 08/01/25 to resume services. The facility was also required to pre-pay again by 08/01/25 to cover services until 08/20/25 when they reportedly would be hiring a company to provide dietician services.

4. Ombudsman #728 revealed on 07/14/25 at 9:22 A.M. National Data Care company, the company that handles resident funds, had not been paid resulting in residents not having access to petty cash funds.

Interview with the BOM #536 on 07/14/25 at 11:28 A.M. revealed she did not have access to the resident funds account as of 07/14/25 . She stated Allaire was notified that the business office did not have access to resident funds. The BOM #536 stated the issue started 07/03/25 when PNC bank did not cash a two hundred eighteen dollar check because of insufficient funds. The BOM #536 stated the business office tried to keep five hundred dollars on hand for the petty cash box in the facility to ensure residents had access to money at all times. During the month when a resident requests money from the petty cash box a receipt was made with the resident's name, date and amount needed. At the end of the month the business office would tally the receipts and present a check to PNC bank to withdraw the amount of money used for petty cash from an account at PNC. BOM #536 stated Allaire had access and was able to get into resident accounts located in PNC.

Interview on 07/14/25 at 12:05 with National Data Company verified they provided software to the facility to handle resident funds and a fee was involved. Invoices were automatically debited depending on the account attached and could not reveal any more information.

Interview on 07/14/25 at 2:14 with Receptionist #695 revealed residents usually had access to funds from 7:30 A.M. to 7:30 P.M. daily and on weekends. The facility usually kept one hundred dollars daily in the petty cash box for residents to draw from. A slip was kept in the drawer to notify the business office of the amount a resident withdrew. The receptionist and the business office manager would balance the petty cash box at the beginning and the end of each receptionist shift. Receptionist #695 stated she was notified on 07/11/25 by the BOM #536 there was no money to put in the petty cash box for resident withdraw.

Interview on 07/14/25 at 2:42 P.M. with Receptionist # 551 stated there was no petty cash available for residents on 07/12/25. No residents had asked for money greater than one hundred dollars.

Interview on 07/15/25 at 11:00 A.M. with receptionist #619 revealed no petty cash was in the drawer to provide residents on 07/11/25.

Interview on 07/15/25 at 2:26 P.M. with BOM #536 revealed if National Data Company was not paid they would pull money from the account attached. Allaire was responsible for payment to National Data Company. The BOM #536 stated the role of National Data Company was a bookkeeping company that balanced residents' trust accounts to ensure separate interest was paid and bank statements were provided to residents.

Interview on 07/16/25 at 4:01 P.M. with Nurse Supervisor #626 was tearful because residents did not have access to their money. Facility staff bought residents chips and soda pop, and some residents thought they had no money in their accounts.

Interview on 07/16/25 at 4:26 P.M. with the Administrator revealed he was not sure when the payment for NDC was taken out of the PNC bank account and why the funds were not replenished.

Interview on 07/17/25 at 1:30 P.M. with Allaire Chief Financial Officer (CFO) #740 revealed Allaire was the back office functions such as payment to invoices, billing. When the facility receives a bill they will send the bill to a dedicated accounts receivable email , Allaire ' s accounts receivable will then process the payment to the necessary party. Allaire became involved with accounts receivable after CB business solution stepped away 6/01/25. CFO #740 stated PNC bank housed all the resident trust accounts and NDC managed the funds individually regarding quarterly statements and interest. PNC also held a disbursement account that housed petty cash pulled from a resident ' s account if they asked for petty cash the month prior. NDC depleted the disbursement funds account. The disbursement account was a buffer between the resident funds account and the petty cash box. CFO #740 stated the resident fund account was fully insured and protected, because he did not receive the NDC invoice NDC debited their payment from the facility ' s discretionary funds. CFO #740 was not aware residents did not have access to petty cash because the discretionary balance was too low. CFO #740 stated he would send cash from Allaire to replenish the petty cash box in the facility and stated there should always be enough cash to provide for resident needs. CFO #740 stated the administrator should have contacted him immediately when no petty cash was available in the facility box to give to residents and stated there was miscommunication.

Interview on 07/17/25 at 4:48 P.M. with the Administrator, revealed Allaire oversaw operations such as finance. The Administrator stated he was aware a few days ago residents did not have access to petty cash and was not aware facility staff were buying residents chips and pop. The Administrator stated he notified Allaire CFO #740 and CEO #1010 as soon as he heard it was an issue. The Administrator stated Allaire told him they took care of the situation, but the Administrator was not aware of what Allaire did. The Administrator verified the discretionary account was the holding spot for petty cash withdrawal. The Administrator stated CFO #740 and CEO #1010 were the point of contact for facility finances. CEO #1010 was assigned the account payable for the facility.

Interview on 07/17/25 at 5:16 P.M. with BOM #536 revealed she notified the Administrator on 07/06/25 after the holiday weekend when the petty cash drawer had no money to provide for resident requests and an email was sent on 07/03/25 notification PNC could not cash checks to fund the petty cash box in the facility.

Interview on 07/17/25 at 6:10 P.M. with CFO #740 revealed National Data Company was set up with a master account as the billing account to cover unpaid invoices until facility funds the account. This was required by National Data Company. Money was removed from the disbursement account to pay National Data Company because payments were not received. National Data Company would credit the resident account fund and recover the funds from disbursement account. The disbursement account has funds owed to the facility for funds already pre-paid out to residents and fronted by the facility through the facility petty cash box .

CEO #1010 refused interview with the State Survey Agency on 07/21/25.

Interview on 07/21/25 at 2:17 P.M. with the Administrator revealed he was unable to answer how much money was owed to National Data Company and how long it had been owed and why National Data Company had access to remove funds. The Administrator stated he was not sure who approved the funds removal by National Data Company and was not aware if this was the general practice of National Data Company to remove funds from resident accounts and was not aware if National Data Company knew if the funds account belonged to the residents' funds and not the facility's funds. The Administrator stated all invoices go to the back office and National data Company did not make the facility aware of their invoices. The Administrator stated the facility bills did not go through him, the BOM #536 sent all bills to the back office. The Administrator stated he was made aware that bills were not paid if a company called him directly. The Administrator stated it was not appropriate to have resident funds used to pay a bill. The Administrator stated he was not made aware of the petty cash check not clearing prior to the fourth of July holiday weekend, he did not recall an issue prior to the long holiday weekend and stated when he alerted Allaire he was told it was taken care of. The Administrator verified National Data Company was a bookkeeping company for resident accounts.

Interview on 07/22/25 at 11:40 A.M. with BOM #536 revealed bills for the facility can come by mail or email. The BOM #536 would send the bills to CEO #1010 who runs the accounts payable for Allaire, and she paid the bills. CEO #1010 would approve when printing a check to vendors. She went to PNC bank with three checks one check for two hundred eighteen dollars and seventy-five cents, one check for seventy-five dollars and one check for fifty-five dollars. PNC would not cash all three checks on 06/30/25 because of insufficient funds in the disbursement account. PNC bank did cash the seventy-dollar check, and the fifty-five dollars check for the weekend petty cash box. The next day on 07/01/25 the BOM notified the Administrator by verbal communication there was not enough money in PNC to cash the two hundred eighteen-dollar check, and the Administrator was warned about the upcoming long holiday weekend. The Administrator verbally told her he would contact CEO #1010. On 07/02/25 an email was sent by the BOM to the Administrator and CEO #1010 was copied regarding the BOM did not have access resident funds and she needed to cash the two hundred eighteen dollars check to reimburse the petty cash box. They were notified it was a long holiday weekend, and she needed to make sure there was enough money for residents. The BOM stated over the fourth of July holiday weekend residents started to not have access to petty fund cash. The BOM stated CEO #1010 would not reach out to the BOM that week with a plan to fund the petty cash. On 07/17/25 Allaire wired four hundred sixteen dollars and seventy cents into the discretionary account. The BOM was able to take out money for the weekend of 07/19/25.

Review of facility documents titled National Data Care ( NDC) Audit Report for North Canton dated 07/11/25 revealed part of the service National Data care provided was keeping Resident Funds Management Trust (RFMT) account in balance. The document revealed that due to the following items, an audit could not presently balance. Because the account must balance to comply with state regulations, these items must be fixed as soon as possible or National Data care would take the appropriate action to fix it by transferring the items from/to an alternate account, which had the potential of incurring overdraft charges for which the facility would be responsible. Invoice the facility account was debited for the invoice. The facility was notified to fix the problem as soon as possible, such as one send a check payable to the facility which this notice to National Data source for reimbursement. Or make a deposit into the facility trust account for this amount at local NDC affiliated bank. The Resident Trust Account reconciliation placed unpaid RFMS Services Charges after 60 days as outstanding account. Date Amount Description Invoice notice 12/21/24 $218.20 FMS invoice H70237 Notice #5. 0n 01/22/25 $218.20RMS invoice H79315 Notice #4, on 02/22/25 $225.25 RFMS invoice Notice #1.

Review document titled of National Data Care (NDC) Advice of Debit revealed resident fund processing charges. The facility was notified the amount shown would be debited from your Resident Funds Account and Please submit payment to cover this debit.

Review of document titled NDC Advice of Debit #H79315, dated charges for the month of December 2024, revealed the invoice was sent 12/31/24 for a total of two hundred eighteen dollars and twenty cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility document Checking Account Statement from Trust Account-0005528728393, revealed on 01/22/25 a service charge debit #H79315 Resident Funds Management Service invoice of two hundred eighteen dollars and twenty cents was debited from the facility Trust account.

Review of document titled NDC Advice of Debit #H88448, dated charges for the month of January 2025, revealed the invoice was sent 01/31/25 for a total of two hundred twenty-five dollars and twenty-five cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility document Checking Account Statement from Trust Account-0005528728393, revealed on 02/24/25 a service charge debit #H88448 Resident Funds Management Service invoice of two hundred twenty-five dollars and twenty-five cents was debited from the facility Trust account.

Review of document titled NDC Advice of Debit #H97638 , dated charges for the month of February 2025, revealed the invoice was sent 02/28/25 for a total of two hundred forty-one dollars and thirty-seven cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility document Checking Account Statement from Trust Account-0005528728393, revealed on 03/24/25 a service charge debit #H976338 Resident Funds Management Service invoice of two hundred forty-one dollars and thirty-seven cents was debited from the facility Trust account.

Review of document titled NDC Advice of Debit #I06856 , dated charges for the month of March 2025, revealed the invoice was sent 03/31/25 for a total of two hundred forty-seven dollars and fifty-five cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility document Checking Account Statement from Trust Account-0005528728393, revealed on 04/22/25 a service charge debit #I06856 Resident Funds Management Service invoice of two hundred forty-seven dollars and fifty-five cents was debited from the facility Trust account.

Review of document titled NDC Advice of Debit #I16135, dated charges for the month of April 2025, revealed the invoice was sent 04/30/25 for a total of two hundred twenty-nine dollars and sixty-six cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility Checking Account Statement from Trust , revealed on 05/22/25 a service charge debit #I16135 Resident Funds Management Service invoice of two hundred twenty-nine dollars and sixty-six cents was debited from the facility Trust account.

Review of document titled NDC Advice of Debit #I25493, dated charges for the month of May 2025, revealed the invoice was sent 05/30/25 of a total of two hundred thirty-one dollars and sixty-five cents for payment to facility account K963- North Canton. A phone number was provided for questions.

Review of facility Checking Account Statement from Trust Account-0005528728393, revealed on 06/23/25 a service charge debit #I25493 Resident Funds Management Service invoice of two hundred thirty-one dollars and sixty-five cents was debited from the facility Trust account.

Review of facility Trial Balance document dated 07/21/25 revealed Resident #5 had a balance of two hundred thirty dollars and seventy-four cents, Resident #26 had a balance of one hundred three dollars, and forty-four cents and Resident #27 had a balance of fifty dollars and fourteen cents. The facility held a total of three thousand one hundred ninety-one dollars and eighty-four cents total for the Assisted Living residents.

Review of facility document dated 05/21/25 a message correspondence was sent to the facility from National Data Care for account #K963 revealed NDC provided services to keep RFMS Resident Trust Account in balance. The facility's audit did not balance because the account must be balanced to comply with state regulations. The facility was notified to fix this as soon as possible or NDC would take action to fix it by transferring them from an alternate account which could incur overdraft fees. The facility was notified on the debit invoices #H70237, #H79315 and #H88448. NDC requested a check payable to the facility with the notice to National Data Care for reimbursement or make a deposit into the facility trust account at the local NDC bank. The facility was notified that it left unpaid NDC would transfer funds from either the Care Cost or Petty Cash Account.

Interview on 07/07/25 at 11:43 A.M. with the Business Office Manager (BOM) # 536 revealed CB services was previously used as the back office who made arrangements through their procurement team. As of 06/01/25 Allaire did the billing and accounts payable. Allaire was the third-party billing company, and all invoices and bills were sent to Allaire to be paid.

Interview on 07/15/25 at 1:05 P.M. with the Administrator revealed bills that were not on auto pay were sent to the facility then sent to the back office. The Administrator was not able to state what bills were sent to the back office and stated Allaire was the new back-office management as of 06/01/25 that provided staff for accounts receivable and was the Corporate Management company. The old company was CB services.

Review of undated, Residents Bill of Rights policy revealed residents had the right to a clean-living environment, the right to receive care and services need to meet medical treatment , nursing , comfort and sanitation needs and the right to be free from neglect.

Review of policy titled Abuse, Neglect, Exploitation and Misappropriate for Resident Property, dated 11/28/16 defined as the failure of the facility, facility employees or facility service providers to provide the goods and services necessary to remain free from harm, including pain, mental anguish, or emotional distress. Preventative measures were to include accurate assessment of residents' needs, analysis of the physical environment and deployment of sufficient numbers of competent staff and resources to meet resident care needs.

This violation represents non-compliance investigated under Complaint Number OH00167648.

Based on medical record review, resident representative interview, staff interview, observation, resident interview, and review of the facility policy, the facility failed to ensure residents were served diets per the physician's orders. This affected one (Resident #11) of three residents reviewed for therapeutic diets. The facility census was 42 residents.

Findings include:

Review of the medical record for Resident #11 revealed an admission date of 12/23/24 with diagnoses including atrial fibrillation, kidney failure, congestive heart failure, and gastro esophageal reflux disease (GERD).

Review of the admission assessment for Resident #11 dated 12/23/24 revealed the resident was oriented to person, time and place.

Review of the physician's orders for Resident #11 revealed an order dated 12/23/24 for a regular texture, gluten free diet with thin liquids. Resident #11 was noted to be lactose intolerant.

Review of gastroenterology visit note for Resident #11 dated 03/18/25 revealed had diagnoses including diarrhea, dysphagia, GERD, nausea, and ulcerative colitis. Resident #11's allergies included corn, gluten, lactase, and lactose. Resident #11 was referred to speech therapy for dysphagia.

Review of the dietary note for Resident #11 dated 04/22/25 revealed Resident #11's representative, Resident Representative (RR) #709 expressed concerns the facility was not consistently providing foods within the resident's dietary restrictions.

Interview on 05/06/25 at 9:51 A.M. with RR #709 confirmed Resident #11 was allergic to dairy products and could not have wheat products. RR #709 confirmed Resident #11 provided the facility with gluten-free bread and dairy-free cheese to make a grilled cheese sandwich, but the facility refused to make her a grilled cheese sandwich.

Interview on 05/06/25 at 10:13 A.M. with the Director of Nursing (DON) confirmed the kitchen should provide Resident #11 with the appropriate food for a therapeutic diet.

Observation on 05/06/25 at 11:00 A.M. with Dietary Director #543 revealed there gluten free food items available in the kitchen, but the facility did not have dairy free cheese available for Resident #11.

Interview on 05/06/25 at 11:00 A.M. with Dietary Director (DD) # 543 confirmed Resident #11 had asked the kitchen to make a grilled cheese sandwich with gluten free bread and dairy free cheese provided by the resident, but confirmed the facility could not use foods supplied by an outside source. DD #543 confirmed the facility did not have dairy free cheese available to make a grilled cheese sandwich in accordance with Resident #11's dietary restrictions.

Interview on 05/06/25 at 11:42 A.M. with Dietitian # 707 confirmed Resident #11 followed a gluten free diet and dairy free therapeutic diet due to a food allergy. Dietitian #707 confirmed the kitchen should provide Resident #11 with gluten free and dairy free food, and the kitchen had not followed Resident #11's therapeutic diet restrictions.

Interview on 05/06/25 at 2:17 P.M. with Resident #11 confirmed the kitchen did not make her a grilled cheese sandwich using the gluten-free and dairy-free foods she provided, nor did they offer to make her a grilled cheese sandwich using the foods in the kitchen.

Review of facility policy titled Palatable Meals undated revealed special dietary needs, including allergies, and medically prescribed diets, would be accommodated for all residents.

This violation represents noncompliance investigated under Complaint Number OH00165159.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a clean comfortable resident environment. This affected two (Residents #22 and #25) of three residents reviewed for the physical environment. The facility census was 42 residents.

Findings include:

Review of the medical record for Resident #25 revealed an admission date of 9/28/22 with diagnoses including type two diabetes, hypertension, heart failure, edema and allergic rhinitis.

Review of the monthly summary for Resident #25 dated 03/25/25 revealed the resident was oriented to person, time and place, had adequate vision, and needed minimal assistance for bathing.

Observation on 05/06/25 at 8:25 A.M. of Resident #25's room with Licensed Practical Nurse (LPN) # 705 revealed the were a brown stain on a ceiling tile in the upper left corner of the room and another brown stain on the ceiling tile above the bookshelf. The handle to the bathroom door was loose and was coming off the door.

Interview on 05/26/25 at 8:26 A.M. with Resident #25 confirmed the stains in the room had been there for about six months and occurred following a water leak. Resident #25 confirmed the bathroom door handle was loose and coming off the door.

2. Review of the medical record for Resident #22 revealed an admission date of 09/09/24 with diagnoses including Alzheimer's disease, major depressive disorder, and hypertension.

Review of the monthly summary for Resident #22 dated 03/26/25 revealed the resident was oriented to person only, had adequate vision, and required minimal assistance with bathing.

Observation on 05/06/25 at 8:35 A.M. of Resident #22's room with LPN # 705 revealed there was a brown stain on the ceiling above the resident's bed and the windowsill was coated with dust.

Interview on 05/06/25 at 11:12 A.M. with Maintenance Worker (MW) #517 confirmed the facility had multiple ceiling tiles which needed to be replaced due to stains.

Interview on 05/06/25 at 2:16 P.M. with Resident # 27 confirmed her room did not receive basic housekeeping services per a housekeeper on a daily basis. Resident #27 confirmed the stain on the ceiling tile above the bed and the dust to the windowsill.

Interview on 05/06/25 at 3:39 P.M. with Housekeeping Supervisor (HS) # 708 confirmed housekeeping was expected to follow a cleaning checklist daily which included dusting room surfaces.

Interview on 05/06/25 at 4:37 P.M. with the Executive Director (ED) confirmed the facility staff should provide basic housekeeping for the residents' rooms which included emptying trash, dusting surfaces, and cleaning the bathrooms on a daily basis.

Review of the Resident Council minutes dated 12/04/24 revealed residents had concerns regarding ceiling tiles in bathrooms and ceiling tiles needing to be replaced.

Review of the facility cleaning checklist undated revealed the common areas, offices, bathrooms, lobby, resident rooms public restroom, and basement bathroom should be cleaned every morning.

Review of facility policy titled Comfortable Environment undated revealed the facility would provide a comfortable, safe homelike environment for all residents, staff, and visitors. The policy applied to all areas of the facility including resident rooms, common areas, and outdoor spaces. Comfortable environment was defined as an environment that provided physical comfort, emotional security, aesthetic pleasure and made individuals feel at ease and valued. The physical environment in all areas of the facility would be kept clean and well-maintained.

This violation represents noncompliance investigated under Complaint Number OH00165307.

Based on record review, policy review, manufacturer medication information and interview the facility failed to ensure residents received thyroid medication, Synthroid as per manufacturer specifications (before breakfast). This affected three residents (#131, #133 and #136) and had the potential to affect 11 residents identified by the facility who received thyroid medication. The facility census was 71.

Findings include:

During the onsite investigation, information provided by the facility revealed breakfast was served between 7:30 A.M. and 9:00 A.M.

1. Review of Resident #131's medical record revealed an admission date of 10/7/17 with diagnoses including hypertension, chronic atrial fibrillation, depression, anxiety and hypothyroidism.

Record review revealed a physician order dated 09/18/23 for Resident #131 to receive Levothyroxine (Synthroid) 75 micrograms (mcg) by mouth every morning.

Review of medication administration record (MAR) for August and September 2024 revealed Resident #131 received Synthroid 75 mcg 8:00 A.M.

On 09/05/24 at 12:30 P.M. interview with Licensed Practical Nurse (LPN) #102 revealed Resident #131's Synthroid medication was not scheduled to be administered before breakfast.

Review of the facility policy titled Medication Administration dated 04/01/20 revealed to administer medication as ordered in accordance with manufacturer specifications.

Review of manufacturer's full prescribing information (AbbVie) for Synthroid, provided on 09/05/24 at 4:30 P.M. by the facility's contracted pharmacy revealed to administer the medication as a single dose, on an empty stomach, one-half to one hour before breakfast.

Interview with the Director of Nursing (DON) on 09/05/24 at 4:30 P.M. verified the facility was not administering the resident's Synthroid as per manufacturer specifications before breakfast.

2. Review of Resident #136's medical record revealed an admission date of 9/28/22 with diagnoses including hypertensive heart disease, heart failure, atrioventricular block first degree, hypothyroidism and type 2 diabetes.

Record review revealed a physician order dated 09/21/23 for Levothyroxine (Synthroid) 75 mcg by mouth every morning.

Review of medication administration record (MAR) for August and September 2024 revealed Resident #136 received Synthroid 75 mcg at 8:00 A.M.

During an interview with Resident #136 on 09/05/24 at 8:00 A.M., the resident voiced concerns that staff (agency staff specifically) were late bringing him his medications.

On 09/05/24 at 12:30 P.M. interview with Licensed Practical Nurse (LPN) #102 revealed Resident #136's Synthroid medication was not scheduled to be administered before breakfast.

Review of the facility policy titled Medication Administration dated 04/01/20 revealed to administer medication as ordered in accordance with manufacturer specifications.

Review of manufacturer's full prescribing information (AbbVie) for Synthroid, provided on 09/05/24 at 4:30 P.M. by the facility's contracted pharmacy revealed to administer the medication as a single dose, on an empty stomach, one-half to one hour before breakfast.

Interview with the Director of Nursing (DON) on 09/05/24 at 4:30 P.M. verified the facility was not administering the resident's Synthroid as per manufacturer specifications before breakfast.

3. Review of Resident #133's medical record revealed an admission date of 11/05/23 with diagnoses including hypertension, congestive heart failure, paroxysmal atrial fibrillation, hypothyroidism and type 2 diabetes.

Record review revealed a physician order, dated 07/10/23 for Levothyroxine (Synthroid) 112 mcg by mouth every morning.

Review of medication administration record (MAR) for August and September 2024 revealed Resident #133 received Synthroid 112 mcg at 8:00 A.M.

During an interview with Resident #133 on 09/05/24 at 7:50 A.M. the resident voiced concerns she was not receiving her Synthroid until late resulting in her having to wait to eat breakfast and her breakfast being cold. The resident indicated this occurred more frequently on the weekends and when agency staff were working.

On 09/05/24 at 12:30 P.M. interview with Licensed Practical Nurse (LPN) #102 revealed Resident #133's Synthroid medication was not scheduled to be administered before breakfast.

Review of the facility policy titled Medication Administration dated 04/01/20 revealed to administer medication as ordered in accordance with manufacturer specifications.

Review of manufacturer's full prescribing information (AbbVie) for Synthroid, provided on 09/05/24 at 4:30 P.M. by the facility's contracted pharmacy revealed to administer the medication as a single dose, on an empty stomach, one-half to one hour before breakfast.

Interview with the Director of Nursing (DON) on 09/05/24 at 4:30 P.M. verified the facility was not administering the resident's Synthroid as per manufacturer specifications before breakfast.

This violation represents non-compliance investigated under Complaint Number OH00157134.

Based on record review, policy review, and interview, the facility failed to ensure personal care services in the area of showers were provided as preferred. This affected one resident (#16) of three residents reviewed. The facility census was 41.

Findings include:

Review of Resident #16's record revealed a 12/12/18 admission with diagnoses including hypertension, hemiplegia, swelling mass of the lower limb, anxiety disorder, type 2 diabetes, cerebral infarction, cardiac murmur, and edema.

Review of the 11/22/23 Monthly Summary included the resident was alert and oriented to person, time, and place. The resident needed extensive assist for bathing, dressing, toileting, and total assist to walk. The resident had impaired decision making, was incontinent and had partial range of motion of extremities.

Interview on 12/08/23 at 2:19 P.M. with the Director of Nursing (DON) revealed they had one complaint related to Resident #16 who was a waiver payor source resident in assisted living. The resident's case manager said the resident told her she was not getting her showers. The DON indicated the investigation revealed the resident was not able to step into her shower, so staff wheeled her to the memory care unit for showers. The memory care unit was in the long-term care (LTC) facility and had a wheelchair shower level with the ground. The DON indicated the assisted living had a COVID outbreak, so they were not transporting residents through the halls to the LTC memory unit for showers until the outbreak was over, due to the risk of spreading COVID to the memory care unit. The DON indicated Public Consulting Group sent a request for the resident's shower information which he faxed with the facility explanation. The DON indicated the resident received bed baths instead of showers during that period. The DON revealed the showers were documented on shower sheets not in the electronic medical record.

Interview on 12/08/23 at 3:43 P.M. with Registered Nurse (RN) #54 revealed the COVID outbreak started on the assisted living waiver unit 10/19/23 until they went out of outbreak mode on 12/07/23.

Review of the shower schedule revealed Resident #16 was scheduled to receive showers on Sunday and Thursday.

Review of Resident #16's progress notes and shower sheets from 08/24/23 through 12/08/23 revealed there was no evidence of a shower offered or refused on Thursday 08/24/23. The shower sheet read no hot water. The Thursday 10/26/23 shower sheet read no hot water and indicated the resident was provided a bed bath. There was no shower documentation for Sunday 10/29/23. The 11/02/23 shower sheet read shower not working and indicated a bed bath was provided. The resident did not have a shower between 10/22/23 and 11/04/23, 13 days.

Review of the facility's Bathing Resident Policy (dated 12/98) included all residents are bathed as often as necessary to maintain cleanliness, refresh and stimulate circulation. All residents will receive a bath or shower at least once a week and as needed. Staff must be attendance at all times. Residents unable to be transported to the bathing room will receive a bed bath at the direction of the charge nurse.

Interview on 12/08/23 at 2:52 P.M. with Resident #16 revealed she has not used her shower in her room for about nine months. She stated the water pressure was low and was looked at but not fixed. She said they would have to tear out the wall to get to the plumbing. She indicated she needed a bar on the wall to get into the shower in her room. The resident indicated they had been taking her to a different unit to use a shower she did not have to step into. When asked if she had been taking showers, she said she went a period without one. When asked if she received bed baths, she indicated she never had a bed bath at the facility.

The DON checked the water pressure in the shower during the interview. Water did come from the shower head and hand held shower enough to shower in but it was not forceful spray.

Interview on 12/08/23 at 4:24 P.M. with State Tested Nurse Aide (STNA) #55 revealed Resident #16 gets showers on afternoons the shift she works. STNA #55 looked at the shower sheet dated Thursday 08/24/23. The shower sheet read no hot water and was signed by STNA #55. The shower sheet gave no indication as to whether a shower or bed bath was offered or refused. STNA #55 indicated she had never provided Resident #16 a bed bath. She indicated if the water was cold, she would not give the resident a shower or offer a bed bath. The Thursday 10/26/23 shower sheet read no hot water and indicated the resident was provided a bed bath. The shower sheet was signed by STNA #55. STNA #55 indicated she did fill out the shower sheet, but she did not provide the resident a bed bath. She pointed out that bed bath was written in someone else's handwriting. There was no shower documentation for Sunday 10/29/23. The 11/02/23 shower sheet read shower not working and indicated a bed bath was provided. The shower sheet was signed by STNA #55. STNA #55 indicated she did fill out the shower sheet, but she did not provide the resident a bed bath. She pointed out that bed bath was written in someone else's handwriting. STNA #55 verified the resident did not have a shower between 10/22/23 and 11/04/23, 13 days. STNA #55 further verified she had never provided a bed bath to the resident. STNA #55 revealed if the resident attempted to give herself a bed bath, she would not be able to do it except wipe a little on the front of her. STNA #55 indicated she was the only aide on the unit for 28 residents and they do not do bed baths on the assisted living. STNA #55 indicated the shower pressure was not good in the resident's shower. She indicated even if it was it would not be safe to shower her in the shower in her room because she has a weak side and cannot step over the step into the shower. She also indicated the shower would be too small for the resident.

Interview on 12/08/23 at 4:32 P.M. with STNA #56 revealed she has given the resident her showers in the Memory Unit. If someone has COVID on the wing they do not take them to areas without COVID. At times there is no hot water in the building. It doesn't happen very often. You can not give a bed bath with cold water. There is one aide for 28 residents. STNA #56 indicated it is hard for Resident #16 to step over the ledge to the shower in her room. It would be dangerous. Taking her to the Valley Memory Care was the safe way to shower her since she has a weak side.

Interview on 12/08/23 at 5:03 P.M. with the DON revealed when he was given the shower sheets, they had bed bath written on them. He does not know who wrote bed bath on the shower sheets since the STNA who filled out the sheet said she did not give the resident a bed bath or write bed bath on the sheet.

This violation represents non-compliance investigated under Complaint Number OH00148187.