Park Vista Care Community

Based on observation, interview and record review, the facility failed to provide homelike dining to all residents in the facility. The facility served all meals since 05/09/25 on paper products with plastic silverware when the dishwasher broke. This affected all 60 residents residing in the facility.

Findings include:

Interview on 06/24/25 at 4:16 P.M. with Resident #9 revealed the facility has not repaired the dishwasher in over six weeks, and all residents have been eating on paper products with plastic silverware. She reported that sometimes residents were unable to cut their meat with plastic silverware and must eat it with their hands.

Observation on 06/24/25 at 4:20 P.M. of residents eating dinner in the main dining room revealed they were being served on paper plates with plastic silverware.

Observation of the dishwasher and interview with Assistant Dietary Manager #503 on 06/24/25 to 4:22 P.M. confirmed residents have been served on paper plates and plastic silverware for the past six weeks. She reported that the dishwasher had a power surge, and it still was not working.

Interview on 06/25/25 at 10:10 A.M. with Maintenance #505 confirmed the dishwasher had a power surge that caused it to stop functioning. He reported the delay in getting it fixed was ordering parts and scheduling of the maintenance service.

Review of the invoices for the dishwasher revealed that the machine went down on 05/09/25. Repairs were not made until 06/20/25, new parts were ordered on 06/23/25, and the machine was still not functional.

This violation is an incidental finding identified during the complaint investigation.

Based on observation, interview, record review and facility policy review, the facility failed to maintain adequate room temperatures for Residents #16, #25, and #53. This affected three (Residents #16, #25, and #53) of four residents reviewed for room temperatures and had the potential to affect all residents. The facility census was 60.

Findings include:

Observation on 06/24/25 at 3:45 P.M. revealed the seventh-floor hallway had a temperature of 83.4 degrees Fahrenheit (F).

1. Review of the medical record for Resident #16 revealed an admission date of 10/13/23. Diagnoses included macular degeneration, a history of falling, and mild cognitive impairment.

Review of the annual assessment dated 08/12/24 revealed Resident #16 was oriented and required set-up assistance to independence for all activities of daily living.

Interview and observation on 06/24/25 at 4:07 P.M. with Resident #16 revealed the temperature in his room was 83 degrees F. Resident #16 had a portable air conditioner in his bedroom, and he reported the facility gave him that months ago because the air conditioner in his bedroom has been broken for a long time. Resident #16 reported it was very hot.

2. Review of the medical record for Resident #25 revealed an admission date of 03/04/25. Diagnoses included asthma, morbid obesity, and incontinence.

Review of the admission assessment dated 03/05/25 revealed Resident #25 had intact cognition and required minimal assistance for activities of daily living.

Interview and observation on 06/24/25 at 4:12 P.M. with Resident #25 revealed her room was extremely hot. She reported she moved into the facility in the winter, and her air conditioner had not worked right since she attempted to turn it on when the weather became warmer. She reported that she was also on oxygen, and the heat makes it even harder to breathe. Resident #25 reported staff have been keeping them hydrated, but she was very uncomfortable and having a hard time breathing due to her diagnoses and being on oxygen. Her room temperature was 87 degrees F.

3. Review of the medical record for Resident #53 revealed an admission date of 11/25/24. Diagnoses included hemiplegia and hemiparesis following a cerebral vascular accident, major depressive disorder, and type two diabetes mellitus.

Review of the admission assessment dated 11/25/24 revealed Resident #53 was not always oriented. Resident #53 required assistance for bathing, dressing, grooming, personal hygiene, toileting, and transferring.

Interview and observation of the room for Resident #53 and her son on 06/24/25 at 3:47 P.M. revealed her room was 87.5 degrees Fahrenheit. Resident #53 reported that they offered her a cooler place to sleep last night but she was unable to get in and out of bed safely, so she was unable to sleep there. She reported that staff have been giving her extra water and ice. She also had ice cream and popsicles. Resident #53 reported they helped, but she was still very uncomfortable in the heat.

Telephone interview on 06/25/25 at 10:00 A.M. with Heating Ventilation and Air Conditioning (HVAC) Technician #504 revealed he does not have a preventative maintenance contract with the facility. He reported that he was hired to fix a few of the facility's units. He reported that he was to have a technician in the facility that morning, but due to an emergency, no technician was in the facility.

Interview on 06/25/25 at 10:10 A.M. with Maintenance #505 confirmed the facility ordered a total of 15 portable air conditioner units for the facility. He was waiting for them to arrive. He confirmed the one heating and air company comes and fixes certain units for the main system, and a third company fixes the issues they are having now. He was unable to provide the names of the second company or invoices from the facility. Maintenance #505 confirmed no one was onsite to fix the air conditioning problems at the moment, but he was waiting for someone to arrive. Maintenance #505 confirmed the residents' rooms were not at the appropriate temperatures.

Review of the facility policy labeled Emergency Preparedness, dated 10/10/17, revealed in the event that there is a loss of function in the cooling system or there is an area in the facility that the system has failed during hot weather, the following procedures should be implemented when the facility temperature reaches 81 degrees Fahrenheit and remains for greater than four hours, set up fans and portable air conditioners, draw all shades, remove residents from direct sunlight, provide ample fluids, and contact the medical director. Central air coolers are maintained at a comfortable temperature range generally between 72-78 degrees F.

This violation represents non-compliance investigated under Complaint Number OH00166927.

Based on review of the facility fire drills, interview and facility policy review, the facility failed to ensure they had 12 fire drills conducted in the last 12 months including one on each shift at least every three months. The facility failed to conduct fire drills during 08/24, 09/24, 10/24, 11/24, and 01/25. This had the potential to affect all 62 residents residing in the facility. Findings include: Review of fire drills completed from 05/24 to 04/23/25 revealed the facility had seven fire drills in the last 12 months that included on 02/27/25 at 12:03 P.M., 03/04/25 at 8:21 P.M., 04/02/25 at 10:47 P.M., 05/29/24 at 8:40 A.M., 06/28/24 at 2:38 P.M., 07/31/24 at 6:15 A.M., and 12/26/24 at 11:34 A.M. There was no documented evidence fire drills were completed in 08/24, 09/24, 10/24, 11/24, and 01/25. Interview on 04/23/25 at 3:33 P.M. with the Administrator verified there were only seven fire drills completed in the last 12 months, and the facility had no documented evidence fire drills were completed in 08/24, 09/24,10/24, 11/24, and 01/25. Review of the facility policy titled Park Vista Emergency Preparedness ProgramBased on review of the facility fire drills, interview and facility policy review, the facility failed to ensure they had 12 fire drills conducted in the last 12 months including one on each shift at least every three months. The facility failed to conduct fire drills during 08/24, 09/24, 10/24, 11/24, and 01/25. This had the potential to affect all 62 residents residing in the facility.

Findings include:

Review of fire drills completed from 05/24 to 04/23/25 revealed the facility had seven fire drills in the last 12 months that included on 02/27/25 at 12:03 P.M., 03/04/25 at 8:21 P.M., 04/02/25 at 10:47 P.M., 05/29/24 at 8:40 A.M., 06/28/24 at 2:38 P.M., 07/31/24 at 6:15 A.M., and 12/26/24 at 11:34 A.M. There was no documented evidence fire drills were completed in 08/24, 09/24, 10/24, 11/24, and 01/25.

Interview on 04/23/25 at 3:33 P.M. with the Administrator verified there were only seven fire drills completed in the last 12 months, and the facility had no documented evidence fire drills were completed in 08/24, 09/24,10/24, 11/24, and 01/25.

Review of the facility policy titled Park Vista Emergency Preparedness Program

Based on observation, interview and policy review, the facility failed to take the temperature of the chicken upon removing it from the oven to ensure it was prepared in a manner to prevent foodborne illness. This had the potential to affect all 52 residents receiving meals from the facility. There were no residents identified as receiving nothing by mouth. The facility census was 52. Findings include: On 01/23/25 at 11:45 A.M. an observation of the tray line for lunch revealed ranch crusted chicken for lunch. The ranch crusted chicken was on the steam table. Interview with Cook #402 at the time of the observation revealed Cook #402 was asked to see the cooking temperature for the chicken. Cook #402 stated they did not take a temperature of the chicken upon removing it from the oven to ensure it was cooked to an appropriate temperature. Cook #402 stated they were not trained to take temperatures of food prior to placing it on the tray line. A review of the policy titled; Minimum Cooking, Holding and Reheating TemperaturesBased on observation, interview and policy review, the facility failed to take the temperature of the chicken upon removing it from the oven to ensure it was prepared in a manner to prevent foodborne illness. This had the potential to affect all 52 residents receiving meals from the facility. There were no residents identified as receiving nothing by mouth. The facility census was 52.

Findings include:

On 01/23/25 at 11:45 A.M. an observation of the tray line for lunch revealed ranch crusted chicken for lunch. The ranch crusted chicken was on the steam table. Interview with Cook #402 at the time of the observation revealed Cook #402 was asked to see the cooking temperature for the chicken. Cook #402 stated they did not take a temperature of the chicken upon removing it from the oven to ensure it was cooked to an appropriate temperature. Cook #402 stated they were not trained to take temperatures of food prior to placing it on the tray line.

A review of the policy titled; Minimum Cooking, Holding and Reheating Temperatures

Based on observation, interview, review of the menu for the week and review of food order receipts, the facility failed to ensure sliced bread was stocked in the kitchen. This had the potential to affect 52 residents receiving dietary services from the facility. There were no residents identified as receiving nothing by mouth. The facility census was 52.

Findings include:

Interview of Resident #55 on 01/23/25 at 9:45 A.M. revealed the facility has had no sliced bread available for weeks.

Review of the weekly menus revealed wheat bread was to be offered two of seven days for breakfast, three of seven days for lunch, and one of seven days for dinner. A grilled ham and cheese sandwich was to be offered one of seven days for dinner, and a turkey sandwich was supposed to be offered one of seven days for dinner. The always available menu included grilled cheese sandwiches and peanut butter and jelly sandwiches.

On 01/23/25 at 10:15 A.M. an initial tour of the kitchen revealed no sliced bread. An interview with the Dietary Director (DD) #280 at the time of the tour verified the lack of sliced bread. The toaster had been broken for one month, so they were serving biscuits and croissants instead of sliced bread. An interview with DD #280 at the time of the tour revealed they had not ordered any bread in January 2025. When asked how they were making grilled cheese sandwiches and peanut butter and jelly sandwiches that were on the always available menu, DD #280 stated they were using hamburger and hot dog buns to make sandwiches.

A review of receipts from the food delivery service dated 01/09/25 and 01/16/25 verified no sliced bread was ordered.

Interview on 01/23/25 at 3:30P.M. with the Administrator revealed there was no policy regarding what foods should be stocked in the kitchen.

This violation represents noncompliance identified while investigating Master Complaint Number OH00161699.

Based on record review and interview the facility failed to provide adequate supervision to prevent Resident #2 from exiting the building for an extended period of time without staff knowledge. This affected one of 59 residents residing in the facility.

Findings include:

Record review revealed Resident #2 was admitted on 08/03/21 with diagnoses of chronic obstructive pulmonary disease, unspecified dementia, and schizoaffective disorder. Review of the Elopement/Wandering Risk Screen dated 07/01/24 revealed Resident #2 was at low risk for wandering. Review of the Senior Living Assessment dated 08/12/24 revealed although Resident #2 was not always oriented, he was not at risk for eloping.

Review of the progress note dated 12/03/24 revealed Resident #2 returned from the hospital on 12/03/24 at 5:50 A.M. after leaving the facility without signing out which was a change in his behavior. Upon his return a wander guard (a device worn by the resident that triggers an alarm when the resident nears/exits an armed door) was placed due to the behavior change. Resident #2's sister/guardian and facility nurse practitioner (NP) were notified.

Interview on 12/04/24 at 1:20 P.M. with Unit Manager (UM) #280 revealed on 12/02/24 at approximately 8:00 P.M. Unit Manager #280, who was in the building, was notified by Licensed Practical Nurse (LPN) #226 that Resident #2 was not in his room for evening medication pass and after checking the floors, staff were unable to locate him. Resident #2 was last seen at approximately 5:30 P.M. UM #280 reported Resident #2 had never left the facility before without staff knowledge and did not sign out or communicate to staff that he was leaving. Upon his return, Resident #2 informed UM #280 he wanted to go for a walk, got cold, so he went to the emergency department and sat in the lobby. Resident #2 was evaluated in the emergency department per the NP's request and was found to be alert and oriented to person, place and time and without injury.

Interview on 12/05/24 at 1:49 P.M. with the Administrator revealed the Director of Nursing (DON) and UM #280 were both present in the building when they were notified staff were unable to locate Resident #2 and he did not sign out. Staff completed a search of the entire building and then notified the Administrator they could not locate Resident #2. Various staff including the DON and the Administrator drove around the neighborhood in an attempt to find him but were unsuccessful. The Administrator contacted the local police department to report Resident #2 was missing but they did not arrive until 9:45 P.M. at which time she provided a description of Resident #2. Approximately 30 minutes later at 10:15 P.M., UM #280 and the Administrator were notified by the police that Resident #2 was found unharmed sitting in the lobby of the local hospital emergency department which was three blocks away from the facility. Police reported another hospital patient advised Resident #2 had been there since about 8:00 P.M.

Interview on 12/05/24 at 1:07 P.M. with Resident #2's guardian/sister revealed she was contacted by LPN #226 the evening of 12/02/24 around 7:00 P.M. or 8:00 P.M. and was told they could not locate Resident #2 in the building. She reported she spoke with Resident #2 sometime after he returned to the facility and when asked how he got out of the assisted living he replied he got on the elevator and walked out. The sister indicated Resident #2 grew up in and was familiar with the area.

Interview on 12/05/24 at 2:50 P.M. with the DON revealed Resident #2 had previously gone on leaves of absence with a friend but that ended when the friend passed away. She denied having knowledge of Resident #2 exiting the facility without staff knowledge prior to 12/02/24.

Interview on 12/05/24 at 3:22 P.M. with Resident #2 revealed he decided to go for a walk to get some air and misjudged the temperature as it was colder than he initially thought and he decided to go somewhere where he would be let in to warm up which was the hospital emergency department approximately three blocks from the facility. Resident #2 was unable to recall what time he left but reported it was after dinner. He acknowledged he did not notify staff he was leaving.

This violation represents non-compliance investigated under Complaint Number OH00160359

Based observation, interview, and policy review the facility failed to ensure residents smoked in designated smoking areas. This had the potential to affect all residents. Census was 52.

Findings include:

Interview on 10/16/24 at 9:25 A.M. with Resident #49 revealed residents smoked outside the main entrance, not in the designated smoking area.

Interview on 10/16/24 at 9:58 A.M. with Resident #48 revealed the smokers were problematic and smoked outside of the main entrance at night. Resident #48 expressed she did not feel the facility had done enough to deter smoking in undesignated areas.

Interview on 10/16/24 at 11:42 A.M. with Resident #37 revealed he did not like going outside because residents smoked outside the main entrance. Resident #37 expressed the smokers disregarded the rights of the non-smokers.

Observation 10/16/24 at 12:10 P.M. revealed Resident #33 smoking outside the main entrance.

Interview on 10/16/24 at 12:12 P.M. with Resident #33 revealed he knew there was a designated smoking area and when asked where it was located, he pointed towards the gazebo. He reported he preferred to smoke outside the main entrance under the canopy when it rained instead of going to the gazebo. Light rain was observed during the interview.

Interview on 10/16/24 at 12:39 P.M. with Resident #6 revealed residents who smoked moved from the front entrance to the gazebo anytime staff requested but returned to the front entrance as soon as the staff returned inside the building.

Observation on 10/16/24 at 1:03 P.M. revealed two unidentified male residents sitting in wheelchairs outside the main entrance under the canopy smoking. When asked if they knew there was a designated smoking area, one of them responded he did not know there was a designated area. The other male remained quiet and proceeded to self-propel in the direction towards the designated smoking area.

Review of the list of smokers provided by the facility revealed there were 22 residents that smoked.

Review of the Smoking Assessments for Residents #4, #6, #20, #33, #34, and #39 revealed the residents were determined to be safe while smoking.

Review of the Smoking Policy, dated August 2021, revealed residents were to smoke at outside designated areas if determined to be a safe smoker as assessed. Violation of the smoking policy could result in immediate or 30 day discharge from the facility.

This violation represents non-compliance investigated under Complaint Number OH00158503.

Based on observation, interview, review of incident log, and review of resident council minutes, the facility failed to maintain a functioning resident activated resident call system. This affected all the residents in the facility. The census was 57.

Findings include:

Review of Resident Council Meeting minutes dated 07/17/24 revealed aides are not responding to calls. Residents are being told the communication radios don't work. Response time is an hour or more. Pendants are not working. Aides are leaving walkie's at the end of the hall unattended. The Solution was identified as the walkie's have been refurbished and antennas have been replaced. More walkie's have been made available. Pendant batteries will be checked. Staff will be addressed regarding monitoring equipment/duties.

Review of the July (2024) Incident Log included on 07/17/24 the walkie talkies were repaired on 07/17/24.

Interview on 09/20/24 at 1:04 P.M. with Resident #54 revealed the staff do not carry the walkie talkies with them. The Lanyards work. Staff just don't always come. The call systems in the rooms don't always work.

Interview on 09/20/24 at 1:40 P.M. with the Administrator included they did an inservice on walkie talkies, not leaving them. They have four or five walkie talkies. There are four assisted living floors. One for each aide. Plus, on the fifth floor the nurse station has the call computer system that will announce when a pendant is pushed.

Interview on 09/20/24 at 2:12 P.M. with State Tested Nurse Aide (STNA) #74 revealed there was a day last week the the call system was not working. The walkie talkie was saying power outage or something like that. She called maintenance and he came up and fixed it on the computer. He resigned and is no longer with the facility. She said the walkie talkies were working this morning but now they are just buzzing.

Interview 09/20/24 at 2:15 P.M. with Business Office Manager (BOM) #77 revealed the pendant system is working. Part of her job is to monitor the system. Checking the computer system there was a 1:44 P.M. call activated from Room 413 unanswered and one at 2:01 P.M. from Room 608. BOM #77 activated Resident #24's pendant and it just buzzed over the walkie talkie. It activated on the computer screen but did not announce location over the walkie talkie. Room 505 was activated resulting in buzzing across the walkie talkie, no announcing which room pressed their pendant would come over the walkie talkies.

Interview on 09/20/24 at 2:43 P.M. with Resident Assistant #80 revealed the pendant call system was not working. He knew Room 608 rang and was waiting for a nurse.

Interview on 09/20/24 at 2:56 P.M. with Resident Assistant #81 revealed the pendant call system was not working. The walkie talkies are buzzing so he was walking up and down the hall. He said they break down at least once a month.

Interview on 09/20/24 at 7:22 P.M. with Resident #49 revealed the call lights were still not working.

Interview on 09/20/24 at 7:54 P.M. with the Administrator revealed the call system was still not activating the walkie talkies. She indicated the system was still being worked on. She said the staff were walking the halls and residents were given bells.

This violation represents non-compliance investigated under Complaint Number OH00156876.

Based on observation and interview, the facility failed to ensure carpets were in good repair. This had the potential to affect all the residents in the facility except for eight residents who reside on the seventh floor (#2, #5, #17, #29, #37, #39, #41, and #42). The facility census was 57.

Findings include:

Observation on 09/20/24 at 2:08 P.M. revealed:

1. The fourth floor hall carpet had dark spots one and a half feet by one foot outside of room 426. The rug outside of the fourth floor elevators was soiled with dirty paths leading to and from. There were soiled paths up and down the hall.

2. The fifth floor hall carpet had darkened soiled paths leading from both elevator doors into the hallway.

3. The carpet outside of the elevators on the sixth floor was soiled with black paths leading from the elevator doors. The carpet outside of the elevator was also heavily spotted with dirt. The carpet exiting the elevator to the left was raised at the seam about a foot area making it a tripping hazard. The carpet down the hall with the raised carpet had the black streaks throughout. There were three different types and colors of carpet on the sixth floor hall.

Interview on 09/20/24 at 2:15 P.M. with Business Office Manager (BOM) #77 said she can not disagree that the carpet is soiled.

Interview on 09/20/24 at 2:46 P.M. with Resident Aide #80 revealed housekeeping cleans the carpet a lot. It just doesn't come clean.

Interview on 09/20/24 at 4:40 P.M. with the Director of Nursing (DON) and the Administrator verified the carpets needed scrubbed or replaced.

This violation represents incidental findings of non-compliance investigated under Complaint Number OH00156876

This violation is evidence of continued non-compliance from the survey completed 07/03/24.

Based on record review and staff interview, the facility failed to maintain an accurate record. This affected one resident (#58) of three residents reviewed. The census was 57.

Findings include:

Review of Resident #58's medical record revealed the resident was admitted to the facility on 08/12/24 with diagnoses including anxiety disorder, depression, type two diabetes, hypothyroidism, hyperglycemia, vitamin D deficiency, alcohol use, cocaine abuse and human immune deficiency, HIV.

Review of the resident's electronic documentation included the resident's clinical profile that identified the resident went on a therapeutic leave on 08/23/24 and was discharged 08/27/24.

Review of the nurse's notes revealed the last note was dated 08/13/24 at 10:43 A.M. when the Nurse Practitioner did an admission note.

There was no explanation in the record of where the resident was discharged. There was no scanned paperwork.

Interview on 09/20/24 at 7:19 P.M. with the Administrator verified there was not information related to the resident discharge in the record. She indicated the resident did not like rules like having to smoke outside. She indicated on 08/23/24 the resident took part of her belongings to a relatives for a leave of absence. When management arrived back on 08/26/24 her apartment had been cleared out over the weekend. When contacted, Resident #58 refused to come back in to sign discharge or Against Medical Advice (AMA) papers. On 08/27/24 the facility signed an AMA paper. The Administrator verified there was not any documentation in the record to indicate where the resident went. She verified they had not uploaded the AMA paper into the medical record.

The facility provided a Release of Responsibility for Discharge Against Medical Advice dated 08/27/24 at 2:00 P.M. for Resident #58 by the Administrator and a witness indicating the resident was discharging herself at her own insistence against the advice of the facility staff and without authority of the physician, The resident has been informed of the dangers to his/her health and safety if he/she leaves. Further, this resident is refusing to sign the above release.

This violation represents incidental findings of non-compliance investigated under Master Complaint Number OH00157146.

Based on review of the facility incident log, policy review, review of resident council meeting minutes, and interview, the facility failed to ensure missing items were included on the facility incident log. This had the potential to affect all 57 residents in the facility.

Findings include:

Review of the July and August 2024 incident log revealed there were no missing resident items included on the log. The facility did not provide a September 2024 incident log.

Review of the Resident Council Minutes dated 07/17/24 revealed items have been listed as missing from resident rooms and cars. The listed Solution included cameras have been used to identify the problem and it has been resolved. Outdoor lights are all changed to brighter LED lights and more fixtures have been added. Overgrowth foliage has bee removed. A stop sign has been installed at the entrance intersection. Youngstown patrol will check parking lots on a regular basis. Corporate is investigating security companies to patrol inside and outside of the facilities. No contracts have been signed to date. It is recommended to lock cars and rooms when they are not occupied and if you see anything happen, report it immediately.

Review of information submitted to the Ohio Department of Health complaint unit revealed allegations that someone stole $20 of marijuana, some pipes, and a mother's ring from Resident #58.

Interview on 09/20/24 at 5:21 P.M. with the Administrator verified the incident logs did not contain any missing items. She was unable to identify what was missing from cars and rooms. The Administrator provided a Report of Concern form dated 08/23/24 related to Resident #58 missing marijuana, mother's ring, and pipes for smoking marijuana, The resolution was unable to replace marijuana and drug paraphernalia, due to illicit drug policy. An attempt was made to help resident look for ring and resident refused. Facility unable to confirm the resident had a ring. Resident voiced understanding. The concern form did not include who received the concern, when it was received, who was assigned to complete the investigation, an executive director review or date of resolution. There was no signature of the person who filled out the form.

Interview on 09/20/24 at 6:11 P.M. with the Director of Nursing verified the Report of Concern form provided to the surveyor was incomplete. The Director of Nursing further verified the complaint of missing items was not listed on the incident log for August 2024.

Review of the facility's Missing Items Policy and Procedure (revised 12/2022) included facility staff will log all missing items.

This violation represents incidental findings of non-compliance investigated under Master Complaint Number OH00157146.

Based on observation, record review, and interview the facility failed to ensure Resident #11's pets had the required vaccinations. This affected one resident (#11) of three residents reviewed for pets and had the potential to affect all residents. The facility census was 56.

Findings include:

Review of the medical record for Resident #11 revealed an admission date of 07/17/23 with diagnoses including depression, hypertension, dementia, and anxiety.

Observation on 08/05/24 at 11:05 A.M. revealed Resident #11 was sleeping on a couch in his room. One cat was observed sitting on a chair.

Review of the vaccination records for a Resident #11's cat revealed he was last seen on 04/12/19 and was overdue for vaccinations and an examination.

Interview on 08/06/24 at 8:13 A.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #11 had a cat. She confirmed the cat was scheduled to see the veterinarian on 08/06/24 which was now cancelled and rescheduled for 08/07/24.

Review of the undated Assisted Living Admission Care Packet revealed pets must be in good health and have all shots and immunization as required by law. An annual examination from a licensed veterinarian must be completed and the animal must be free of pests. The facility was required to retain a copy of the veterinarian examination immunization record.

This violation represents noncompliance investigated under Complaint Number OH00155969 and is a recite to the survey completed on 07/03/24.

Based on observation, interview and record review, the facility failed to ensure concerns were addressed in a timely and adequate manner. This affected two residents (#33 and #34) of five residents reviewed for resident rights and had the potential to affect all residents. The facility census was 56.

Findings include:

Review of the medical record for Resident #33 revealed an admission date of 09/12/18 with diagnoses including hypertension, depression, glaucoma, and hypothyroidism.

Review of the medical record for Resident #34 revealed an admission date of 08/09/23. Diagnoses included hypertension, obesity, asthma, muscle weakness, and overactive bladder.

Review of the concern logs for June and July 2024 revealed call lights were an issue on 06/19/24, and walkie talkie functionality had been an issue since 04/17/24.

Review of the Resident Council minutes dated 05/15/24, 06/19/24, and 07/17/24 revealed repeated concerns about staff call response, walkie talkies not working, and staff leaving walkie talkies unattended.

Interview on 08/05/24 at 7:42 A.M. with Resident #33 revealed she was the Resident Council president. She said there were concerns with call light response for the past several months. Residents were told the lights were being repaired and replaced, and while they have been working recently, call response time was still an issue.

Interview on 08/05/24 at 7:51 A.M. with Resident #34 revealed staff often took a long time to respond to her call light.

Interview on 08/05/24 at 8:01 A.M. with Licensed Practical Nurse (LPN) #201 and State Tested Nurse's Aide (STNA) #202 revealed the call lights often did not work. Both LPN #201 and STNA #202 confirmed their walking talkies were working at the time of the interview.

Interview on 08/05/24 at 10:14 A.M. with the Administrator confirmed concerns were repeatedly brought up regarding call light response and functionality. She revealed management was aware and had been educating and disciplining staff to attempt to correct the situations.

This violation represents noncompliance investigated under Complaint Number OH00155969 and is a recite to the survey completed on 07/03/24.

Based on observation, record review, interview, and facility policy review the facility failed to provide sufficient staffing to meet the supervisory and total care needs of residents residing on the secured memory care unit. This affected one resident (#32), had the potential to affect 17 residents (#21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36 and #37) including the six residents (#24, #25, #31, #32, #36 and #37) identified by the facility as being at risk for elopement residing on the secured memory care unit and had the potential to affect all 59 residents residing in the facility.

Findings include:

Review of the facility survey history revealed the facility had a Real and Present Danger for insufficient staffing that began on 12/07/22. The census at the time of the survey was 33. Part of the facilities abatement plan included on 12/23/22 at 4:00 P.M. the facility indicated residential care staffing would consist of a minimum of four staff (one licensed nurse and three RCA and/or STNA staff) at all times to ensure adequate supervision and assistance was provided for residents who resided on four different floors in the facility. However, from 12/23/22 through 12/28/22 review of the facility staffing revealed these minimum staffing numbers were not met. The Real and Present danger was abated on 12/29/22 when the facility provided evidence of sufficient staffing at that time.

During the onsite survey, completed on 07/03/24, the facility failed to provide evidence how they monitored or adjusted staffing to ensure sufficient staffing was in place to meet the total care and supervisory needs of all residents. Staffing levels at the time of this survey (07/03/24) were noted to be at or below the planned staffing identified in December 2022 with a census of 33. The facility census was now 59. Residents continued to be observed on four floors of the facility, which included a secured memory care unit on the fifth floor.

Observation on 06/25/24 of the facility fifth floor, secured memory care unit revealed there were 17 residents (#21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36 and #37) residing on the unit. Six of the residents (#24, #25, #31, #32, #36 and #37) were identified to be at risk for wandering/elopement. Having only one staff member on this unit had the potential to result in residents being unsupervised or not receiving timely care if this one staff person was involved in providing care for a particular resident.

Review of the facility staffing schedules and unit assignments for April, May, and June 2024 revealed there were three staff members scheduled for the whole facility from 7:00 P.M. until 7:00 A.M. There was also a med tech scheduled from 7:00 P.M. until 11:00 P.M. This included staffing for the secured memory care unit.

Staffing concerns related to Resident #32 were identified as follows:

Review of an elopement assessment for Resident #32 dated 01/24/24, prior to admission, revealed the resident was at risk for elopement due to recent substance abuse or substance abuse history. Record review revealed no safety or elopement interventions were initiated other than placing the resident on the fifth-floor secured memory care unit.

Review of the service plan dated 02/08/24 revealed Resident #32 had a history of wandering and was to remain on a secured unit. The goal was to remain safe while living in the community.

Review of the nursing progress note dated 04/12/24 at 1:00 A.M. revealed at approximately 10:30 P.M. Resident #32, who was diagnosed with dementia and residing on the fifth-floor locked memory care unit, could not be located by staff. The note indicated he was last seen at approximately 9:30 P.M. Assistant Director of Nursing (ADON) #217, the local police, and the resident's daughter were notified. (Record review revealed there was no evidence the physician was notified until after Resident #32 returned to the facility). Resident #32's daughter revealed the resident often liked to wander to bus stations, often frequented a town approximately 15 miles away, and she thought he was a little more confused when she visited him the prior weekend, on 04/04/24. The facility initiated a search for the resident, including both on and off the property, and the resident was located by facility staff at approximately 3:15 A.M. approximately 2.7 miles from the facility, on a busy four lane road, in the rain. The outside temperature was 50 degrees Fahrenheit (F).

Interview on 06/27/24 at 2:45 P.M. with State Tested Nurse Aide (STNA) #208 revealed she was working (on 04/11/24) on the fifth floor the night Resident #32 was reported missing. She revealed she was aware the resident had a history of wandering and came to their facility from another facility where he resided on a locked unit. The STNA indicated the resident often sat in the hallway across from the elevators. STNA #208 revealed she last saw Resident #32 (on 04/11/24) was at approximately 9:30 P.M. at which time she went to another resident's room to provide care. When she emerged approximately 30 minutes later, Resident #32 was not in the hallway nor in his bedroom. There were no other staff working on the fifth floor with her at that time. After identifying Resident #32 was missing, she stated she notified ADON #217, Med Tech #218 and the local police and began searching the facility. ADON #217 was not working in the facility at the time of the incident. Per the STNA, there were three staff (two STNAs and one med tech) working on 04/11/24 at the time the resident was last seen in the facility and at the time of the actual elopement, with STNA #208 being the only staff member assigned to the fifth-floor memory care unit for the shift.

Interview on 07/01/24 at 9:53 A.M. with Licensed Practical Nurse (LPN) #203 revealed there was one nurse and two aides scheduled to work in the facility from 7:00 P.M. to 7:00 AM each day. One employee was expected to remain on the secured memory care unit at all times. There was also a med tech scheduled from 7:00 P.M. until 11:00 P.M. The facility did not account for the personal care and/or supervisory needs of the residents on the memory care unit, if the one staff member on the unit was providing care in a resident room.

Review of the facility policy titled Staffing

Based on record review, review of the police report, interview, and review of the facility policy the facility failed to ensure Resident #32 was supervised during medication administration as required. This affected one resident (#32) of three reviewed for supervised medications. This had the potential to affect all residents who had medications administered by a nurse or a med tech. The facility identified eight residents (#17, #27, #38, #41, #42, #44, #49 and #50) who were assessed to safely administer their own medications. The facility census was 59. Findings include: Review of the medical record for Resident #32 revealed and admission date of 01/25/24 with diagnoses including dementia, schizophrenia, cognitive communication deficit, muscle weakness, alcohol abuse, and cocaine abuse. Resident #32 resided on the fifth-floor secured memory care unit. Review of the self-administration of medications assessment dated 02/08/24 revealed Resident #32 was not able to self-administer his medications. Review of the progress note dated 04/12/24 at 1:00 A.M. revealed Resident #32 was not in his room and was last seen at approximately 10:30 P.M. The local police and Assistant Director of Nursing (ADON) #217 were notified, and a search began for Resident #32. Review of the police report dated 04/11/24 revealed during a search of the facility for Resident #32, a small cup with an unknown dosage of medication in pill form that had not been taken was observed in Resident #32's room. Interview on 07/01/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #203 confirmed Resident #32 should be observed to ensure all medications had been consumed, and medications were not permitted to be left at bedside. Review of the facility policy titled Medication AdministrationBased on record review, review of the police report, interview, and review of the facility policy the facility failed to ensure Resident #32 was supervised during medication administration as required. This affected one resident (#32) of three reviewed for supervised medications. This had the potential to affect all residents who had medications administered by a nurse or a med tech. The facility identified eight residents (#17, #27, #38, #41, #42, #44, #49 and #50) who were assessed to safely administer their own medications. The facility census was 59.

Findings include:

Review of the medical record for Resident #32 revealed and admission date of 01/25/24 with diagnoses including dementia, schizophrenia, cognitive communication deficit, muscle weakness, alcohol abuse, and cocaine abuse. Resident #32 resided on the fifth-floor secured memory care unit.

Review of the self-administration of medications assessment dated 02/08/24 revealed Resident #32 was not able to self-administer his medications.

Review of the progress note dated 04/12/24 at 1:00 A.M. revealed Resident #32 was not in his room and was last seen at approximately 10:30 P.M. The local police and Assistant Director of Nursing (ADON) #217 were notified, and a search began for Resident #32.

Review of the police report dated 04/11/24 revealed during a search of the facility for Resident #32, a small cup with an unknown dosage of medication in pill form that had not been taken was observed in Resident #32's room.

Interview on 07/01/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #203 confirmed Resident #32 should be observed to ensure all medications had been consumed, and medications were not permitted to be left at bedside.

Review of the facility policy titled Medication Administration

Based on record review and interview the facility failed to ensure the written resident agreement/resident handbook was comprehensive to include all required information pertaining to resident equipment/supplies. This affected one resident (#13) of three reviewed for admissions and had the potential to affect all 59 residents residing in the facility.

Findings include:

Review of Resident #13's medical record revealed an admission date of 05/22/24 with diagnoses including dementia, hypothyroidism, cognitive communication deficit, and muscle weakness.

Review of the information contained in the Assisted Living Admission Package revealed Park Vista would provide room, board and services appropriate for health and safety of the resident as part of the basic services add additional supplies upon the resident's request.

Review of the information contained in the handbook revealed it could not be determined which furnishings could be brought from home or purchased by a resident from any store of their choosing. There was no evidence the handbook/agreement was specific to those bedroom furnishings and supplies included under Ohio Administrative Code (OAC) 3701-16-15 (C) (1) through 3701-16-15 (C) (6). This section of the OAC indicated unless the resident chooses to bring his or her own or as specified in the resident agreement, the residential care facility shall provide the following bedroom furnishings and supplies including but not limited to:

3701-16-15 (C) (1) An individual bed equipped with springs and a clean comfortable flame-resistant mattress or a clean comfortable mattress with a flame-resistant mattress cover.

3701-16-15 (C) (2) Bed linen which shall include at least two sheets, a pillow and pillowcase, a bedspread, and one blanket that fit properly and are free of tears, holes and excessive fraying or wear.

3701-16-15 (C) (3) Closet or wardrobe space with a minimum width of twenty-two inches of hanging space sufficient in height and equipped for hanging full length garments and at least one shelf of adequate size within reach of the resident.

3701-16-15 (C) (4) A bedside table, personal reading lamp, adequate bureau, dresser or equivalent space, a mirror appropriate for grooming, and a chair with a padded back and seat, with arms for lateral support.

3701-16-15 (C) (5) Bath linen that includes at least two full towels, two face towels and two washcloths.

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

Interview on 06/26/24 at 1:51 P.M. with the Licensed Practical Nurse (LPN) #203 verified the content of the facility Resident Agreement/Resident Handbook as noted above did not include the required information.

This violation represents non-compliance investigated under Complaint Number OH00154647.

Based on record review and interview, the facility failed to ensure initial health assessments were completed as required. This affected three residents (#6, #13 and #37) of five reviewed for assessments and had the potential to affect all 59 residents in the facility.

Findings include:

1. Review of the medical record for Resident #6 revealed an admission date of 04/30/24 with diagnoses including diabetes, altered mental status, hypertension, anxiety, and cognitive communication deficit.

Review of the record revealed no evidence Resident #6 had a health assessment 90 days prior to admission or within 14 days after admission.

2. Review of the medical record for Resident #13 revealed an admission date of 05/22/24 with diagnoses including dementia, hypothyroidism, stroke, cognitive communication deficit, and muscle weakness.

Review of the record revealed no evidence Resident #13 had a health assessment 90 days prior to admission or within 14 days after admission.

3. Review of the medical record for Resident #37 revealed an admission date of 12/27/23 with diagnoses including dementia, kidney disease, and osteoarthritis.

Review of the document titled Resident Evaluation and Level of Care dated 02/16/24 revealed the assessment for Resident #37 was not comprehensive and did not include all required information.

Interview on 06/26/24 at 1:51 P.M. with Licensed Practical Nurse (LPN) #203 confirmed there were no current health assessment for Residents #6 or #13, and the assessment for Resident #37 was not comprehensive.

Based on record review and interview, the facility failed to ensure annual assessments were completed and comprehensive as required. This affected two residents (#4 and #60) of five reviewed for assessments and had the potential to affect all 59 residents in the facility.

Findings include:

1. Review of the medical record for Resident #4 revealed an admission date of 05/09/23 with diagnoses including hyperlipidemia, spinal stenosis, diabetes, heart failure, and anemia.

Review of the document titled Resident Evaluation and Level of Care dated 02/17/24 revealed the assessment for Resident #4 was not comprehensive and did not include all required information.

2. Review of the medical record for Resident #60 revealed an admission date of 12/30/22 with diagnoses including human immunodeficiency virus (HIV), breast cancer, altered mental status, kidney disease, and seizures.

Review of the medical record revealed Resident #60 did not have a comprehensive annual assessment completed.

Interview on 06/26/24 at 1:51 P.M. with Licensed Practical Nurse (LPN) #203 confirmed the assessment for Resident #4 did not include all required information, and there was no annual assessment for Resident #60.

Based on record review and interview, the facility failed to timely complete fall risk assessments for Resident #60. This affected one resident (#60) of three reviewed for accidents. The facility census was 59. Findings include: Review of the medical record for Resident #60 revealed an admission date of 12/30/22 with diagnoses including human immunodeficiency virus (HIV), breast cancer, altered mental status, kidney disease, and seizures. Review of the service plan dated 02/01/23 revealed Resident #60 was independently mobile. She needed reminders to call for assistance when needed. Review of the medical record revealed no documented evidence Resident #60 had a fall risk assessment completed between admission (02/01/23) and 04/09/24. Review of the nursing progress note dated 04/09/24 at 12:44 P.M. revealed Resident #60's family found her on the floor in her room. When the nurse entered the room, the resident was found sitting on her bed with dried blood on the left side of her face and a lump with a bruise and a small laceration was discovered on the top of her head. The bridge of Resident #60's nose was bruised and swollen. The resident was talking, alert, calm, and cooperative with slight confusion, her vital signs were reported to be within normal limits. Resident #60 was sent to the emergency department. Review of the hospital discharge paperwork dated 04/09/24 revealed a recommendation to follow up with Resident #60's primary care physician within two days. Review of the medical record revealed no documented evidence Resident #60 was assessed upon return from the hospital, had a fall risk assessment completed, or had updates to her service plan after returning from the hospital after the fall on 04/09/24. Review of the fall investigation dated 04/09/24 determined the cause of the fall was gait imbalance. There was no documented evidence that fall prevention interventions were implemented. There was no evidence the facility determined how long Resident #60 was on the floor before being found by her family. Interview on 06/27/24 at 1:51 PM with the Administrator also confirmed there was no evidence an assessment was completed for Resident #60 when she returned from the hospital on 04/09/24, and there was no evidence she was seen by the primary care physician within two days of the 04/09/24 fall as recommended in the hospital discharge instructions. Review of the policy titled Falls and Fall Risk, ManagingBased on record review and interview, the facility failed to timely complete fall risk assessments for Resident #60. This affected one resident (#60) of three reviewed for accidents. The facility census was 59.

Findings include:

Review of the medical record for Resident #60 revealed an admission date of 12/30/22 with diagnoses including human immunodeficiency virus (HIV), breast cancer, altered mental status, kidney disease, and seizures.

Review of the service plan dated 02/01/23 revealed Resident #60 was independently mobile. She needed reminders to call for assistance when needed.

Review of the medical record revealed no documented evidence Resident #60 had a fall risk assessment completed between admission (02/01/23) and 04/09/24.

Review of the nursing progress note dated 04/09/24 at 12:44 P.M. revealed Resident #60's family found her on the floor in her room. When the nurse entered the room, the resident was found sitting on her bed with dried blood on the left side of her face and a lump with a bruise and a small laceration was discovered on the top of her head. The bridge of Resident #60's nose was bruised and swollen. The resident was talking, alert, calm, and cooperative with slight confusion, her vital signs were reported to be within normal limits. Resident #60 was sent to the emergency department.

Review of the hospital discharge paperwork dated 04/09/24 revealed a recommendation to follow up with Resident #60's primary care physician within two days.

Review of the medical record revealed no documented evidence Resident #60 was assessed upon return from the hospital, had a fall risk assessment completed, or had updates to her service plan after returning from the hospital after the fall on 04/09/24.

Review of the fall investigation dated 04/09/24 determined the cause of the fall was gait imbalance. There was no documented evidence that fall prevention interventions were implemented. There was no evidence the facility determined how long Resident #60 was on the floor before being found by her family.

Interview on 06/27/24 at 1:51 PM with the Administrator also confirmed there was no evidence an assessment was completed for Resident #60 when she returned from the hospital on 04/09/24, and there was no evidence she was seen by the primary care physician within two days of the 04/09/24 fall as recommended in the hospital discharge instructions.

Review of the policy titled Falls and Fall Risk, Managing

Based on observation, record review, interview, and review of the Assisted Living Admission Care Packet, the facility failed to ensure pets had the required vaccinations. This affected one resident (#19) of three reviewed for pets and had the potential to affect all residents. The facility census was 59.

Findings include:

Review of the medical record for Resident #19 revealed an admission date of 07/17/23 with diagnoses including depression, hypertension, dementia, and anxiety.

Observation on 06/26/24 at 7:20 A.M. of the laundry room on the fourth floor revealed one cat in a crate on the windowsill behind the closed door to the laundry room and one cat roaming throughout the laundry room.

Interview on 06/26/24 at 7:35 A.M. with Licensed Practical Nurse (LPN) #203 confirmed Resident #19 had a cat. Resident #19 moved to a different room overnight so that his room could be cleaned due to an infestation of fleas. She confirmed when staff entered his room to take his belongings, a second cat was discovered. She revealed the cat was a stray and no one in the facility was aware the cat was in Resident #19's room. Both cats had been placed in the laundry room on the fourth floor until Resident #19 could return to his room.

Review of the vaccination records for a Resident #19's cat revealed he was last seen on 04/12/19 and was overdue for vaccinations and an examination.

Interview on 06/26/24 at 8:38 A.M. with LPN #203 confirmed Resident #19's cat was not up to date with vaccinations and had no evidence the stray cat had received any vaccinations.

Review of the undated Assisted Living Admission Care Packet revealed pets must be in good health and have all shots and immunization as required by law. An annual examination from a licensed veterinarian must be completed and the animal must be free of pests. The facility was required to retain a copy of the veterinarian examination immunization record.

Based on record review and interview, the facility failed to ensure all requirements of fire drills were completed. This had the potential to affect all 59 residents in the facility.

Findings include:

Review of fire drill documentation provided by the facility revealed fire drills were conducted on first shift on 07/21/23, third shift on 08/11/23, second shift on 09/15/23, third shift on 11/24/23, second shift on 12/29/23, third shift on 01/30/24, first shift on 02/29/24, second shift on 03/29/24, third shift on 04/11/24, and first shift on 05/29/24. Except for the fire drill conducted on 11/24/23, no resident evacuations during any of the drills occurred. There was no documented evidence the fire drill conducted on 03/29/24 included a verification the signal was received by the alarm transmission company.

Interview on 06/26/24 at 10:55 A.M. with the Administrator confirmed resident evacuations had not occurred as required, and there was no evidence the alarm company received the signal for the fire drill on 03/29/24.

Based on record review and interview, the facility failed to educate residents regarding fire safety as required. This had the potential to affect all 59 residents in the facility.

Findings include:

Interview on 06/25/24 at 8:50 A.M. with the Administrator revealed she reviewed fire safety procedures with the residents at Resident Council, at least annually.

Review of the Resident Council minutes dated 03/20/24, 04/17/24, and 05/15/24 revealed no documented evidence fire safety education had been provided to residents.

Interview on 06/26/24 at 10:55 A.M. with the Administrator confirmed she had no other documented evidence to verify resident fire safety had occurred.

Based on observation and interview, the facility failed to ensure carpets were in good repair. This had the potential to affect all 12 residents (#38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, and #49) on the sixth floor. The facility census was 59.

Findings include:

Observation on 06/25/24 at 9:32 A.M. of the sixth floor revealed the carpet in the main hallway on the right side of the floor was worn and loose, creating three to four lines of raised carpet in the middle of the hall. Interview at the time of the observation with Housekeeper #206 confirmed the carpet was very loose.

Interview on 06/25/24 at 10:33 A.M. with Resident #49 revealed the carpet had been this way for at least two years.

Based on observation, record review, review of a police report, review of Google map information, facility policy review and interviews the facility failed to provide a safe environment and adequate supervision to prevent the elopement of Resident #32. This resulted in Real and Present Danger and the potential for actual harm on 04/11/24 at approximately 9:30 P.M. when Resident #32, who had a diagnosis of dementia and resided on the facility secured memory care unit was last seen by facility staff. The resident subsequently left the facility without staff knowledge and was found on 04/12/24 at approximately 3:15 A.M. (almost six hours later) 2.7 miles from the facility in a plaza near a busy four-lane roadway. The weather outside was raining and the resident was found cold and wet. This affected one resident (#32) of three residents reviewed for elopement. The facility identified six residents (#24, #25, #31, #32, #36 and #37) at risk for elopement. The facility census was 59.

On 06/27/24 at 9:30 A.M. the Administrator was notified Real and Present Danger began on 04/11/24 when the facility failed to provide a safe environment and adequate supervision to prevent Resident #32 from leaving the facility secured memory care unit unsupervised. The resident was not located until 04/12/24 at approximately 3:15 A.M. 2.7 miles from the facility.

The Real and Present Danger was abated on 04/12/24 when the facility implemented the following corrective actions:

Resident #32 returned to center by Admissions Director #211 and Housekeeping Director #212 and physical assessment completed by the Director of Nursing (DON) on 04/12/24 at approximately 3:20 A.M. On 04/12/24 at 3:22 A.M. the DON notified Resident #32's family and Medical Director (MD) #215 of the elopement incident.

On 04/12/24 at 3:25 A.M. a wander guard bracelet was placed on Resident #32 by Licensed Practical Nurse (LPN) #203. The resident's service plan was also updated on this date by Regional Registered Nurse (RN) #213. An order for checking placement and function (every shift) of the wander guard was initiated by Regional RN #213 on 04/12/24.

Following the incident, on 04/12/24 the facility completed a head count and determined 100% census was obtained for all assisted living. The Interdisciplinary Team (IDT)/management team conducted the head count.

On 04/12/24 following the incident, Licensed Practical Nurse (LPN) #203 completed an audit of wander guard placement and function with no new concerns identified at this time. Wander guards were in place for six residents (#24, #25, #31, #32, #36 and #37) at risk for elopement.

On 04/12/24, following the incident Social Services Designee (SSD) #210 conducted elopement assessments for all facility residents. However, on 07/01/24 during the onsite investigation, the surveyor identified not all re-assessments completed on 04/12/24 were accurate. In addition, two residents (Resident #55 and #59), who did not reside on the fifth-floor secured memory care unit were assessed by SSD #210 to be at risk for elopement with no evidence of safety/elopement interventions being in place.

On 04/12/24 Maintenance Director #209 checked the function of the wander guard system on the fifth floor with no concerns identified.

On 04/12/24 following the incident, LPN #214 checked the elopement books to ensure the book was up to date with accurate information for residents at risk for elopement/wandering. This included Resident #24, #25, #31, #32, #36 and #37.

On 04/12/24 LPN #214 conducted education for staff on the facility elopement policy. Staff included all Assisted Living nurses, State Tested Nursing Assistants (STNAs), resident assistants (RAs), housekeeping and maintenance. Staff not working were called and in-serviced over the telephone. Agency staff were educated with agency policy book when arriving at the facility. Newly hired staff would be educated on the elopement policy and procedure upon hire in orientation and educated on residents with wander guards during floor orientation.

On 04/12/24 LPN #214 provided education to all facility nurses (LPN #204, #221, #222, #223 and #224) to verify wander guards were in place when residents at risk for wandering/elopement were re-admitted and to ensure all residents with wander guards had orders for checking placement and function. A plan was developed for agency staff training and training for newly hired employees.

The facility implemented a plan to conduct elopement drills monthly with staff members scheduled, including agency and new staff that were scheduled, on the day of the drill. Elopement drills would be conducted monthly. If new staff and agency were scheduled on those days, they would be a part of the drill, but no extra drills would be added at this time. Drills were conducted on 05/08/24 and 06/17/24.

The elopement policy was reviewed by the Administrator on 04/12/24 and no changes were made.

Beginning on 04/15/24 the Administrator and IDT team developed a plan for the Administrator, DON, Dietary Manager #202, Maintenance Director #209, Admissions Director #211, Housekeeping Director #212, Assistant Director of Nursing (ADON) #217, Nurse Practitioner (NP) #219, Activities Director (AD) #225, LPNs #214 and #203 (the AL Director), Minimum Data Set (MDS) Nurse #226, Assistant Business Office Manager (ABOM) #227, Business Office Manager (BOM) #228, Therapy Director #229, and Marketing Director #230 to review elopements in morning meeting five days a week for four weeks.

On 05/08/24 a Quality Assurance and Performance Improvement (QAPI) meeting was held to review the elopement incident involving Resident #32. The IDT team determined initiating the actions taken on 04/12/24 including a wander guard for Resident #32, re-assessments of elopement risk for all residents in the assisted living being completed, and the elopement risk book being updated were sufficient to remove further elopements.

On 06/26/24 direct care staff report sheets were updated to reflect which facility residents had wander guard devices. LPN #203 was responsible for updating the aide report sheets when changes occurred.

Between 07/01/24 and 07/02/24 elopement risk assessments were completed for all facility residents by the management team.

Although the Real and Present Danger was removed on 04/12/24, the violation remains as the facility was in the process of implementing corrective actions, re-assessing residents and monitoring actions being taken.

Findings include:

Review of the medical record for Resident #32 revealed an admission date of 01/25/24 with diagnoses including dementia, schizophrenia, cognitive communication deficit, muscle weakness, alcohol abuse, and cocaine abuse. Resident #32 resided on the fifth-floor locked memory care unit.

Review of an elopement assessment for Resident #32 dated 01/24/24, prior to admission, revealed the resident was at risk for elopement due to recent substance abuse or substance abuse history. Record review revealed no safety or elopement interventions were initiated other than placing the resident on the fifth-floor secured memory care unit.

Review of the service plan dated 02/08/24 revealed Resident #32 had a history of wandering and was to remain on a secured unit. The goal was to remain safe while living in the community. There was no documented evidence of any safety or supervisory interventions implemented at this time to prevent elopement except for the resident residing on the secured unit.

Review of the progress notes beginning 04/01/24 revealed the resident was found unresponsive, with labored breathing, skin cool and clammy, his blood sugar was 79. Resident #32 was transferred to the local emergency room where he was admitted and diagnosed with a seizure disorder.

Review of the medical record revealed Resident #32 returned from the hospital on 04/04/24 with new orders for seizure medications. No new elopement assessment was completed upon the resident's return from the hospital.

Review of the nursing progress note dated 04/12/24 at 1:00 A.M. revealed at approximately 10:30 P.M. Resident #32, who was diagnosed with dementia and residing on the fifth-floor locked memory care unit, could not be located by staff. The note indicated he was last seen at approximately 9:30 P.M. Assistant Director of Nursing (ADON) #217, the local police, and the resident's daughter were notified. (Record review revealed there was no evidence the physician was notified until after Resident #32 returned to the facility). Resident #32's daughter revealed the resident often liked to wander to bus stations, often frequented a town approximately 15 miles away, and she thought he was a little more confused when she visited him the prior weekend, on 04/04/24.The facility initiated a search for the resident, including both on and off the property, and the resident was located by facility staff at approximately 3:15 A.M. approximately 2.7 miles from the facility, on a busy four lane road, in the rain. The outside temperature was 50 degrees Fahrenheit (F). The resident was returned to the facility via staff vehicle. He was cold with a body temperature of 96 degrees F. Staff dried him off, changed his clothing and provided blankets, and his body temperature returned to normal. Following the incident, the resident was seen by both Medical Nurse Practitioner (NP) #219 and Psychiatric NP #220 on 04/12/24. Medical NP #219 ordered a urinalysis drug screen, Complete Metabolic Panel (CMP) and Depakote level for the following Monday, 04/15/24.

Review of a local police report (report #24Y015279) dated 04/11/24 revealed local police were called (on 04/11/24) at 11:42 P.M. The report revealed officers responded to a call regarding a missing 65-year-old man with dementia. The report indicated Resident #32 was last seen between the hours of 10:00 P.M. and 11:00 P.M. When staff went to check Resident #32, he was not in his room. Staff indicated it was not normal for him to not be in his room at that hour. Med Tech #218 and several other employees began searching the premises for the resident and contacted the resident's daughter who revealed the resident often walked anywhere from the Youngstown to Warren area. (The facility is located in the Youngstown area). The resident was known to drink alcohol and had not taken his medication. After obtaining a physical description of Resident #32, law enforcement attempted to view the buildings' camera system but were unable to do so due to maintenance log in issues. The search then expanded to local homeless shelters, bars, hospitals and neighborhoods including Warren, Ohio. Resident #32 was found by facility staff in a neighboring town while they were getting coffee for coworkers in a plaza parking lot. Resident #32 got into the car with Housekeeping Director #212 and returned to the facility.

Review of an undated facility investigation completed by the Administrator revealed Med Tech #218 was on a different floor when she was notified Resident #32 was missing from the fifth floor. The investigation did not include whether Med Tech #218 should have been on the fifth floor at the time of the incident or what role Med Tech #218 played in the incident. The investigation revealed STNA #208 stated she had seen Resident #32 in the hallway prior to going into another resident's room on the same unit) to assist with that resident with care and when she came back into the hallway, she noticed Resident #32 was not in the hallway or in his room. She searched the fifth floor and notified the nurse he was missing. All management staff were contacted and arrived at the facility within approximately one hour of receiving the call that Resident #32 could not be located. After searching the facility, managers split into teams of two and searched the surrounding communities. Resident #32 was located at 3:14 A.M. by Housekeeping Director #212, returned to the facility and assessed.

Review of Medical NP #219's note dated 04/12/24 revealed Resident #32 was seen and examined as a result of the resident being found wandering out of the home. A urinalysis, Depakote level and complete metabolic panel were ordered.

Review of the lab report dated 04/15/24 revealed the resident's urinalysis showed abnormal results. The urine clarity was turbid (thick or opaque) with normal value being clear, 2+ ketones (normal value is negative), 1+ protein (normal value is negative), few epithelial cells (normal value is negative) and mucous present (normal value is absent). The CMP blood work showed no abnormal results, and the resident's Depakote level was 104 (normal range 50-100). Medical NP #219 was updated with the lab results and gave no new orders.

On 06/26/24 at 2:00 P.M. Resident #32 was observed on the facility fifth floor secured memory care unit. The resident was observed to have a wander guard device in place to his left ankle at this time. (Wander guard bracelets/systems include a bracelet the resident wears, sensors that monitor doors which result in doors/areas alarming and/or potentially locking when a bracelet is near the area). On the fifth floor memory care unit, the wander guard system was noted to be present on the unit elevator.

Interview on 06/26/24 at 2:08 P.M. with the Administrator and LPN #203 revealed the Administrator received a call on 04/11/24 at approximately 10:40 P.M. notifying her Resident #32 could not be located in the facility. The Administrator revealed the facility elopement protocol was initiated. She contacted the DON as well as other managers who all came to assist in searching for the resident. When the resident could not be located on the facility property, managers split into teams of two and searched the surrounding areas for the resident. She stated she received a call at 3:14 A.M. from Housekeeping Director #212, the resident had been located. At the time of the interview, LPN #203 revealed if a resident with a wander guard device attempted to get on the elevator (on the fifth floor), the elevator would not move, and an alarm would go off until someone typed in a code and deactivated it. At the time Resident #32 eloped from the facility, no alarm sounded, and the resident was not wearing a wander guard bracelet/device.

Interview on 06/27/24 at 2:00 P.M. with Resident #32 revealed he was pleasantly confused. The resident knew where he was but stated he had never left the building at any time, could not recall the incident (on 04/11/24), and did not know what a wander guard was.

Interview on 06/27/24 at 2:45 P.M. with STNA #208 revealed she was working (on 04/11/24) on the fifth floor the night Resident #32 was reported missing. She revealed she was aware the resident had a history of wandering and came to their facility from another facility where he resided on a locked unit. The STNA indicated the resident often sat in the hallway across from the elevators. STNA #208 revealed she last saw Resident #32 (on 04/11/24) was at approximately 9:30 P.M. at which time she went to another resident's room to provide care. When she emerged approximately 30 minutes later, Resident #32 was not in the hallway nor in his bedroom. There were no other staff working on the fifth floor with her at that time. After identifying Resident #32 was missing, she stated she notified ADON #217, Med Tech #218 and the local police and began searching the facility. ADON #217 was not working in the facility at the time of the incident. Per the STNA, there were three staff (two STNAs and one med tech) working on 04/11/24 at the time the resident was last seen in the facility and at the time of the actual elopement, with STNA #208 being the only staff member assigned to the fifth-floor memory care unit for the shift.

Interview on 07/01/24 at 7:43 A.M. with Housekeeping Director #212 revealed she was called at approximately 11:30 P.M. on 04/11/24 and told Resident #32 had eloped. She was asked to come in to aid in a search to find him. After arriving at the facility, she left to look for the resident and stated she found him in a plaza down the road. She described the resident as confused; she stated he was wearing pants, tennis shoes, and a t-shirt. The housekeeping director revealed it was raining at the time of the incident. Resident #32 told her he went looking for his sister. Housekeeping Director #212 stated she believed the resident had been out of the building for approximately one hour before he was found (he was gone for almost six hours). She revealed there was no traffic in the plaza, and stated she thought he was approximately one mile from the facility. (Review of Google maps information revealed the plaza where the resident was located was 2.7 miles from the facility).

Interview on 07/01/24 at 2:37 P.M. with Regional Director of Operations #216 revealed the facility had determined the root cause of the elopement incident on 04/11/24 was that Resident #32 had removed his wander guard. However, there was no documented evidence, order or service plan reflecting Resident #32 had a wander guard device before or at the time of the incident.

Observation of the wander guard system on 07/02/24 at 8:30 A.M. revealed the elevator on the fifth-floor locked if a resident with a wander guard attempted to get on the elevator. A loud beep emitted, and the elevator doors remained open until staff came to the elevator and entered a code on the keypad. The system appeared to be functioning properly at the time of the observation.

Review of the facility Elopement policy dated August 2021 revealed residents at risk for wandering, elopement or other safety issues would have orders which included strategies and interventions to maintain the residents' safety. If a resident was missing, the elopement procedure would be implemented which included initiating a search of the building notifying the Administrator, Director of Nursing, the resident representative, the physician and law enforcement and upon return, the nursing department would examine the resident for injuries, contact the physician and report findings and condition of the resident, notify the residents' representative complete an incident report and document relevant information in the residents' medical record.

Based on record review and interview, the facility failed to timely assess and implement fall prevention interventions for Resident #60. This affected one resident (#60) of three reviewed for accidents. The facility census was 59.

Actual harm occurred on 05/20/24 when Resident #60, who had a history of falls, was found on the floor by family after a fall, resulting in a fracture to her right femur resulting in hospitalization, a partial hip replacement, and subsequent transfer to a skilled nursing facility. At the time of the fall with injury, there was no evidence the facility had identified or implemented safety/fall risk interventions to decrease the resident's risk or prevent the fall.

Findings include:

Review of the medical record for Resident #60 revealed an admission date of 12/30/22 with diagnoses including human immunodeficiency virus (HIV), breast cancer, altered mental status, kidney disease, and seizures.

Review of the service plan dated 02/01/23 revealed Resident #60 was independently mobile. She needed reminders to call for assistance when needed.

Review of the medical record revealed no documented evidence Resident #60 had a fall risk assessment completed between admission (02/01/23) and 04/09/24.

Review of the nursing progress note dated 04/09/24 at 12:44 P.M. revealed Resident #60's family found her on the floor in her room. When the nurse entered the room, the resident was found sitting on her bed with dried blood on the left side of her face and a lump with a bruise and a small laceration was discovered on the top of her head. The bridge of Resident #60's nose was bruised and swollen. The resident was talking, alert, calm, and cooperative with slight confusion, her vital signs were reported to be within normal limits. Resident #60 was sent to the emergency department.

Review of the hospital discharge paperwork dated 04/09/24 revealed a recommendation to follow up with Resident #60's primary care physician within two days.

Review of the medical record revealed no documented evidence Resident #60 was assessed upon return from the hospital, had a fall risk assessment completed, or had updates to her service plan after returning from the hospital after the fall on 04/09/24.

Review of the fall investigation dated 04/09/24 determined the cause of the fall was gait imbalance. There was no documented evidence that fall prevention interventions were implemented. There was no evidence the facility determined how long Resident #60 was on the floor before being found by her family.

Review of the medical record revealed no documented evidence Resident #60 saw the primary care physician within two days as recommended by the hospital and there was no documented evidence the physician was notified that Resident #60 needed follow-up per hospital recommendations.

Review of the nursing progress note dated 05/19/24 at 8:28 P.M. revealed Resident #60's family notified the nurse the resident was on the floor, and they picked her up prior to notifying the nurse. The resident reported a pain level of ten, on a scale of zero to ten, ten being severe and was not able to complete passive range of motion (PROM) exercises to her right leg. The resident stated she was going to the bathroom and fell, and she was not using her assistive ambulation devices. Resident #60 was sent to the emergency department.

Review of the hospital paperwork dated 05/20/24 revealed Resident #60 suffered a right femoral neck fracture as a result of the fall 05/19/24 requiring a partial hip replacement. The resident was transferred to the skilled nursing facility upon discharge from the hospital.

Review of the fall investigation dated 05/20/24 determined Resident #60's fall was caused by gait imbalance, weakness, and not using her assistive devices. However, there was no documented evidence prior to the fall that she used assistive devices; she was assessed as independently mobile. There was no evidence the facility determined how long Resident #60 was on the floor before being found by her family.

Interview on 6/27/24 at 1:49 PM with Licensed Practical Nurse (LPN) #203 confirmed there were no updates to Resident #60's care plan upon her return from the hospital after the fall on 04/09/24.

Interview on 06/27/24 at 1:51 PM with the Administrator confirmed there was no information provided in either fall investigation to determine how long the resident had been on the floor prior to the family finding her, and no evidence she used assistive devices for ambulation. The Administrator also confirmed there was no evidence an assessment was completed for Resident #60 when she returned from the hospital on 04/09/24, and there was no evidence she was seen by the primary care physician within two days of the 04/09/24 fall as recommended in the hospital discharge instructions.

Review of the policy titled Falls and Fall Risk, Managing

Based on observation, interview, record review, and review of the facility self-reported incident (SRI), the facility failed to ensure concerns were adequately addressed in a timely manner. This affected three residents (#6, #38 and #49) of five residents reviewed for concerns and had the potential to affect all residents. The facility census was 59.

Findings include:

Review of the medical record for Resident #6 revealed an admission date of 05/22/24 with diagnoses including dementia, seizures, difficulty walking, and muscle weakness.

Review of the medical record for Resident #38 revealed an admission date of 09/12/18 with diagnoses including hypertension, depression, glaucoma, and hypothyroidism.

Review of the medical record for Resident #49 review on an admission date of 04/01/16 with diagnoses including spinal stenosis, diabetes, kidney disease, depression, and chronic pain.

Observation on 06/26/24 at 7:20 A.M. of the laundry room on the fourth floor revealed one cat in a crate on the windowsill behind the closed door to the laundry room and one cat roaming throughout the laundry room.

Review of the SRI tracking number 247946 dated 05/26/24 revealed Resident #6 left her door unlocked when leaving her room and upon return, found her PlayStation gaming system was missing. She also reported her phone had gone missing a week prior. The facility did a full investigation of the concern, however, could not determine what happened to the items.

Review of the Concern Log dated 04/01/24 through 05/31/24 revealed six items had been reported missing.

Review of the Resident Council minutes dated 03/20/24, 04/17/24, and 05/15/24 revealed repeated concerns about staff call response, housekeeping not completing tasks in a consistent manner, and missing items.

Interview on 06/25/24 at 12:18 P.M. with Resident #38 revealed she was the resident council president. She said there has been concerns with call light response for the past several months. Residents were told the lights were being repaired and replaced, but nothing had changed. Resident #38 also revealed she used to keep her door unlocked when she wasn't home, but in the past year several things have been reported missing in her apartment such as jewelry, money, and phone chargers. Resident #38 also reported there have been many issues with bedbugs, scabies, maggots, and stray cats in the building, and residents had been asking repeatedly for housekeeping to come on a more consistent basis.

Interview on 06/25/24 at 1:29 P.M. with Resident #49 revealed staff often took a long time to respond to her call light. Resident #49 also revealed she has heard many residents complaining of stray cats and missing items in the past few months. Resident #49 stated she used to keep her door unlocked but did not like doing so any longer because of the concerns she heard in resident council and from other residents regarding missing items.

Interview on 06/26/24 at 10:55 A.M. with the Administrator confirmed concerns were repeatedly brought up in Resident Council. She revealed management was aware and had been educating staff to attempt to correct the situations.

Based on observation, record review, interview, and self-reported incident (SRI) review, the facility failed to ensure Resident #6's property was maintained in a reasonable manner. This affected one resident (#6) of three reviewed for missing items and had the potential to affect all residents. The facility census was 59.

Findings include:

Review of the medical record for Resident #6 revealed an admission date of 05/22/24 with diagnoses including dementia, seizures, difficulty walking, and muscle weakness.

Review of the SRI tracking number 247946 dated 05/26/24 revealed Resident #6 left her door unlocked when leaving her room and upon return, found her PlayStation gaming system was missing. She also reported her phone had gone missing a week prior. The facility did a full investigation of the concern, however, could not determine what happened to the items.

Interview on 06/26/24 at 10:03 A.M. with Resident #6 revealed she did not know what happened to her PlayStation or cellular phone, and neither item had been replaced.

Interview on 06/26/24 at 10:03 A.M. with Licensed Practical Nurse (LPN) #204 confirmed Resident #6 did have both a PlayStation and cellular phone which had been reported missing.

Review of the concern log dated 04/01/24 through 05/31/24 revealed six items had been reported missing.

Review of the Resident Council minutes dated 03/20/24, 04/17/24, and 05/15/24 revealed repeated concerns from residents about missing items.

Review of the document titled Resident Rights

Based on interview, observation, record review, and review of the facility policies the facility failed to prevent significant medication errors as medications were not administered in a timely manner. This affected 10 residents (#9, #14, #18, #21, #33, #34, #37, #43, #49, and #56) out of 14 residents observed for medication administration. This had the potential to affect all residents residing at the facility except for Residents #23 and #46 as they self-administered their medications. The facility census was 57.

Findings include:

1. Interview on 04/10/24 at 10:10 A.M. with Licensed Practical Nurse (LPN) #505 revealed she worked from 7:00 P.M. to 7:00 A.M. and had approximately 50 residents to pass medications to. She revealed the medications were to be passed between 7:00 P.M. to 10:00 P.M., but she was often still passing medications until 12:00 A.M. She did not feel it was right as she had to wake up residents to give them their medications.

Interview on 04/10/24 at 10:13 A.M. with the Director of Assistant Living #500 revealed she had only recently started at the facility. She revealed the facility had one nurse on the day shift that worked 7:00 A.M. to 7:00 P.M. and one nurse on night shift that worked 7:00 P.M. to 7:00 A.M. She verified the current census was 57 and that each nurse had over 50 residents to administer medications to on each shift. She verified the form labeled, Patient Centered Care Flexible Med Pass Times stated the morning medications were to be passed from 7:00 A.M. to 10:00 A.M. and the hour of sleep (HS) medications were to be passed from 7:00 P.M. to 10:00 P.M. and if there were specific times they would otherwise be indicated. She stated she had to come in approximately one week ago to administer the morning medications as there was a report off and she was approximately one hour late administering the medications as she felt she did not have a routine because she was new to the facility.

Interview on 04/11/24 at 9:09 A.M. with LPN #506 revealed she worked dayshift from 7:00 A.M. to 7:00 P.M. and that most of the time she was not able to administer the morning medications in a timely manner. At times she was not able to get done until 12:00 P.M. even though the medications were to be administered by 10:00 A.M. She stated the facility used to have one and a half nurses to administer the morning medications in a timely manner but sometime last year (she could not remember when) they had discontinued having a nurse work half of the shift, and now she had to administer medication to over 50 residents.

Interview on 04/11/24 at 10:36 A.M. with Resident #36 revealed the nurses usually administered his medications late. He stated, never know when I will get them.

Interview on 04/11/24 at 10:41 A.M. with Resident #57 revealed she always received her medications late, especially her HS medications. She revealed one night she had not received her HS medications until 1:00 A.M. One of her medications was to assist in her sleeping, and she was having issues getting a good night's sleep as she did not receive her medications timely.

2. Interview, record review, and observation of the evening medication administration on 04/15/24 at 10:24 P.M. with LPN #509 verified the following medications were not administered timely:

a. Resident #9 with an admission date of 01/10/24 revealed an order for Gabapentin 600 milligram (mg) tablet (nerve pain medication) by mouth three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for neuropathy pain. LPN #509 verified it was 10:24 P.M. and she had not passed the 8:00 P.M. dose.

b. Resident #14 with an admission date of 05/15/21 revealed an order for baclofen 10 mg tablet (muscle relaxant) by mouth three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for back pain. LPN #509 verified it was 10:24 P.M. and she had not passed her 8:00 P.M. dose.

c. Resident #56 with an admission date of 03/15/23 revealed an order for gabapentin 300 mg tablet by mouth three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for chronic pain syndrome. LPN #509 verified it was 10:24 P.M. and she had not passed his 8:00 P.M. dose.

. Resident #34 with an admission date of 06/07/23 revealed an order for buspirone 10 mg tablet (antianxiety) by mouth three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for anxiety. LPN #509 verified it was 10:24 P.M. and she had not passed his 8:00 P.M. dose.

e. Resident #37 with an admission date of 07/17/23 revealed an order for gabapentin 300 mg by mouth three times a day at 8:00 A.M., 2:00 P.M., and 8:00 P.M. for neuropathy. LPN #509 verified it was 10:24 P.M. and she had not passed his 8:00 P.M. dose.

3. Record review, observation, and interview on 04/15/24 at 11:02 P.M. with LPN #509 verified the following medications were not administered timely:

a. Review of the medical record for Resident #21 with an admission date of 12/22/22 revealed the following orders: Atorvastatin calcium 40 mg tablet (statin to treat high cholesterol) by mouth in the evening for hyperlipidemia, donepezil 5 mg tablet (cognition enhancing medication) by mouth in the evening for depression, Flomax 0.4 mg give two tablets (urinary retention medication) by mouth in the evening for his enlarged prostate, Remeron 7.5 mg (antidepressant) by mouth in the evening for sleep and appetite, Tresiba flex touch solution pen-injector 200 unit/milliliter (ml) (insulin) inject 28 units subcutaneously (SQ) in the evening for diabetes, bethanechol chloride tablet (urinary retention medication) give 25 mg by mouth two times a day for dysuria, and Eliquis 2.5 mg (blood thinner) tablet give 2.5 mg by mouth two times a day for her circulation. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed his HS medications.

b. Review of the medical record for Resident #34 (as identified above) also had the following orders: Seroquel 25 mg tablet (antipsychotic) by mouth for bipolar disorder, Eliquis 5 mg tablet by mouth twice a day following cerebral infarction, lamotrigine 100 mg tablet (anticonvulsant) by mouth twice a day for seizures, levetiracetam 1000 mg tablet (anticonvulsant) by mouth twice a day for seizures. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed his HS medications as well as she still had not passed his buspirone 10 mg previously identified above that was scheduled at 8:00 P.M.

c. Review of the medical record for Resident #49 with an admission date of 01/24/23 revealed the following orders: Cariprazine (antipsychotic) give one capsule by mouth in the evening for major depression, atorvastatin calcium 20 mg tablet by mouth in the evening for hyperlipidemia, Lantus SQ solution 100 unit/ ml (insulin) Inject 44 units SQ in the evening for diabetes, melatonin 5 mg tablet (hormone to aide in sleep) by mouth give in evening for insomnia, and metformin 1000 mg tablet (anti-diabetic) by mouth two times a day for diabetes. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed her HS medications.

. Review of the medical record for Resident #43 with an admission date of 05/17/23 revealed the following orders: donepezil 10 mg tablet by mouth in the evening due to dementia and anxiety, Remeron 15 mg tablet by mouth in the evening for adjustment disorder with depression, and Eliquis 2.5 mg tablet by mouth two times a day as an anticoagulant. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed his HS medications.

e. Review of the medical record for Resident #18 with an admission date of 12/19/23 revealed the following orders: hydroxyzine 50 mg tablet (antihistamine) by mouth in the evening for anxiety, simvastatin 80 mg tablet (statin to treat high cholesterol) by mouth in the evening for high cholesterol, trazodone 150 mg tablet (antidepressant) by mouth in the evening for sleep, carvedilol 25 mg tablet (beta blocker to treat high blood pressure and heart failure) by mouth two times a day for hypertension, clonidine HCL 0.2 mg tablet (antihypertensive) by mouth two times a day for hypertension, fludrocortisone acetate 0.1mg tablet (steroid) by mouth two times a day, mycophenolate mofetil 250 mg capsule (immunosuppressive to prevent organ rejection after transplant) by mouth two times a day for kidney transplant, and tacrolimus 0.5 mg capsule (immunosuppressive) give three capsules by mouth two times a day for kidney transplant. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed his HS medications.

f. Review of the medical record for Resident #33 with an admission date of 08/08/23 revealed the following orders: lisinopril 40 mg tablet (ACE inhibitor to treat heart failure) by mouth in the evening for heart failure, Norvasc 5 mg tablet (calcium channel blocker to treat high blood pressure and chest pain) by mouth in the evening for heart failure, Risperdal 3 mg tablet (antipsychotic) by mouth in the evening for bipolar disorder, Topamax 25 mg tablet (anticonvulsant and nerve pain medication) by mouth in the evening for mood stabilizer, and gabapentin 600mg tablet by mouth two times a day for neuropathy. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed her HS medications.

g. Review of the medical record for Resident #37 (as identified above) had the following orders: Flomax 0.4 mg tablet by mouth in the evening for urinary flow, and carvedilol 12.5 mg tablet by mouth two times a day. All the above medications were ordered for 7:30 P.M. - [blank] but per the facility procedure medication times per the Patient Centered Care Flexible Med Pass Times HS medication were from 7:00 P.M. to 10:00 P.M. unless specific times were indicated. LPN #509 verified it was 11:02 P.M. and she had not passed his HS medications as well as she still had not passed his gabapentin 300mg that was previously identified above that was ordered at 8:00 P.M.

Interview on 04/15/24 at 11:02 P.M. with LPN #509 revealed she worked 7:00 P.M. to 7:00 A.M. and had over 50 residents to administer medications to and even on a good day, she was not able to administer the medications between 7:00 P.M. to 10:00 P.M. and/or at their specific ordered time. She revealed almost every night she did not get done with her medication pass until between 11:30 P.M. to 12:00 A.M. and sometimes it was later. She verified at times she did wake residents up to administer their medications because they had passed the scheduled time.

4. Interview on 04/16/24 at 8:56 A.M. with the Administrator, Director of Nursing (DON) of the Nursing Home, and Director of Assistant Living #500 verified the above findings as HS medications on 04/15/24 were passed outside of the scheduled times per the Patient Centered Care Flexible Med Pass Times of 7:00 P.M. to 10:00 P.M. and some residents specific ordered times. They revealed they were changing pharmacy to a different delivery system from cards to bags to hopefully decrease the time the nurse was passing the medications so that she was able to pass in the scheduled time frame.

Review of the facility policy labeled, General Guidelines for Medication Administration

Based on interview, record review, and review of the facility policy the facility did not ensure abnormal lab work was timely reported to a physician and/ or nurse practitioner (NP). This affected one resident (#52) out of five residents reviewed for change in condition/ lab work. The facility census was 57.

Findings include:

Review of the medical record for Resident #52 revealed an admission date of 02/10/22 with diagnoses including hypertension, congestive heart failure, atrial fibrillation, and osteoarthritis.

Review of the nursing note dated 03/10/24 at 4:54 P.M. and completed by Licensed Practical Nurse (LPN) #501 revealed Resident #52 was having confusion and hallucinations, and there was an order for a urinalysis and urine culture and sensitivity (c/s) to rule out a urinary tract infection (UTI).

Review of the nursing note dated 03/11/24 at 6:26 P.M. and completed by LPN #501 revealed Resident #52 was found on the floor sitting in an upright position with no injuries. Hospice was notified of the fall and recommended to monitor Resident #52 and notify them of the urinalysis and urine c/s results when available.

Review of the lab report dated 03/11/24 revealed Resident #52's urine specimen was collected on 03/11/24 and the lab reported the results on 03/13/23. The urinalysis indicated there were a few bacteria noted. The urine c/s contained 20,000 -25,000 colony-forming unit (cfu) per milliliter (ml) of Escherichia coli. There was no documented evidence in Resident #52's medical record that NP #504 and hospice were notified of Resident #52's lab work until 03/31/24 when an antibiotic was ordered.

Review of the nursing note dated 03/20/24 at 6:42 A.M. and completed by LPN #505 revealed Resident #52 was found on the floor with no injuries.

Review of the nursing note dated 03/31/24 at 7:43 P.M. and completed by LPN #506 revealed there was a new order for Bactrim (antibiotic) Double Strength (DS) twice a day for seven days for a UTI.

Review of the email dated 04/11/24 at 3:13 P.M. from NP #504 to Director of Assisted Living #500 revealed Resident #52's urine culture was ordered on 03/10/24 and it had resulted on 03/13/24. NP #504 revealed in the email that she had not received the urine results until 03/29/24 and that was when NP #504 sent in the prescription for Resident #52 to be on Bactrim DS for seven days. The email revealed the results only showed Escherichia coli at 20,000 -25,000 cfu/ml which was not typically a count to be treated, but the antibiotic was started due to symptoms and family concerns.

Interview on 04/11/24 at 3:27 P.M. with Director of the Assistant Living #500 verified NP #504 had ordered Resident #52 to have a urinalysis and urine c/s on 03/10/24 and that they had received the results on 03/13/24 but had not reported the results to NP #504 until 03/29/24 at which time NP #504 ordered an antibiotic due to symptoms of UTI. She also verified there was no documented evidence in the medical record that hospice was notified of the urine c/s results. The facility did not have a policy regarding lab work but followed the change in condition policy.

Review of the facility policy labeled, Change in a Resident's Condition

Based on record review and interview, the facility failed to ensure adequate staffing for timely incontinence care. This finding affected one resident (#21) of three residents reviewed for incontinence care.

Findings include:

Review of Resident #21's medical record revealed the resident was admitted to the facility on 09/12/18 with diagnoses including essential hypertension, major depressive disorder, and hemiplegia.

Review of Resident #21's Senior Living Assessment form dated 10/04/22 revealed Resident #21 was alert and oriented.

Review of Resident #21's Service Plan form dated 01/31/23 revealed to equip the bathroom with adaptive devices; bed pan or commode at night; was able to get to and from the toilet; and to report any changes in toileting ability to the nurse.

Interview on 09/26/23 at 2:15 P.M. with Ombudsman #818 indicated she arrived at the facility on 09/22/23 around 10:15 A.M. to 10:30 A.M. and Resident #21 had reported that she was incontinent of stool in the bathroom between 8:00 A.M. and 8:30 A.M., and the caregiver stated she had to pass the trays and would not clean up the resident. Ombudsman #818 denied the resident had odors or signs of incontinence during the interview.

Interview on 09/26/23 at 2:30 P.M. with the Administrator indicated Ombudsman #818 had reported to her that Resident #21 was not provided timely incontinence care. The Administrator confirmed there was a mix-up in staffing and the assisted living (AL) caregiver went to the skilled nursing side (SNF) in error. The Administrator confirmed she sent Housekeeping Supervisor #810 to assist the resident.

Interview on 09/26/23 at 2:36 P.M. with Resident #21 indicated she was incontinent of stool which went through to her pants at breakfast time on 09/22/23, and she was humiliated. Resident #21 indicated she put on the call light to request assistance, and Caregiver #902 came into the room and told her that she was passing trays and could not assist her. Resident #21 indicated she waited, and no staff came, and she cleaned herself up the best she could and changed her clothing. Resident #21 indicated she called the Ombudsman's office and Ombudsman #818 had come to the facility to interview her on 09/22/23 around 10:30 A.M. and no staff had come to assist her with incontinence care. Resident #21 verified that Housekeeping Supervisor #810 came after lunch and cleaned her bathroom and bagged her clothing.

Interview on 09/26/23 at 3:03 P.M. with Resident Care Assistant (RCA) #902 indicated on 09/22/23 she was passing the breakfast trays and went into Resident #21's room to pass the breakfast tray. She confirmed she told Resident #21 the facility was short staffed, and she would be back after the breakfast trays were passed. RCA #902 indicated she passed her partner, RCA #901 in the elevator, who said she would provide incontinence care to Resident #21. RCA #902 indicated she did not go back into Resident #21's room and thought the resident's incontinence care was done by RCA #901.

Interview on 09/26/23 at 4:15 P.M. with RCA #901 indicated she went into Resident #21's room at approximately 9:45 A.M. to see what the resident needed. She stated she made the resident's bed and emptied the bedside commode, and the resident did not report that she needed incontinence care. She stated she did not see the resident after this time because the resident was not on her assignment.

Based on observation, interview, and record review the facility failed to ensure plumbing was well-maintained and free of leaks. This affected two residents (#20 and #35) out of 14 resident rooms observed. The facility census was 48.

Findings include:

Observation during initial tour on 09/22/23 from 10:00 A.M. to approximately 12:00 P.M., Ombudsman #818 revealed numerous leaks from ceiling tiles on the fourth and sixth floors. There were several catch buckets, and some were overflowing.

Interview on 09/22/23 at 11:30 A.M. with the Administrator confirmed the observations.

Observation during initial tour on 09/22/23 from 2:30 P.M. to 3:30 P.M. with Maintenance #950 revealed Residents #20 and #35 had a ceiling tile missing in the hall outside their rooms. Water was leaking and was being caught in a bucket which was placed in an overflow pan. Maintenance #950 confirmed the leaky ceiling.

Interview on 09/22/23 at 4:00 P.M. with the Administrator confirmed the leaky ceiling on the fourth floor.

Review of numerous bids, proposals, and letters of declination to repair the pipes revealed a large job many contractors do not want to accept.

This violation is an example of continued non-compliance from surveys completed on 07/05/23, 08/01/23, and 09/06/23.

Based on observation, resident interviews, and staff interview the facility failed to ensure an operational call system. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Observation during initial tour on 09/22/23 from 10:00 A.M. to approximately 12:00 P.M., Ombudsman #818 found many call lights were not functioning properly. When the call light pendant was used, the wrong room number was being voiced. Ombudsman #818 was told by several staff the problem had been ongoing since last weekend. Maintenance rebooted the system, and the system was calling out the correct room numbers.

Interview on 09/22/23 at 11:30 A.M. with the Administrator confirmed the deficient observations, maintenance correcting the problem, and the call system working correctly.

Observation during initial tour on 09/22/23 from 2:30 P.M. to 3:30 P.M. with Maintenance #950 revealed Residents #14, #16, #17, #26, #29, #38, and #50 all had properly functioning call light pendant systems.

Interviews on 09/22/23 at the time of the observations with Residents #14, #16, #17, #26, #29, #38, and #50 revealed they were relieved the call system was working properly now.

Based on observation, interview and record review, the facility failed to ensure plumbing was well-maintained and free of leaks. This affected two residents (Resident #8 and #11) out of 23 rooms randomly observed. The facility census was 48.

Findings include:

1. Observation during medication administration on 09/06/23 starting at 7:40 A.M. revealed Resident #11 was in the bathroom and there was standing water on the floor heading towards the carpet.

Interview on 09/06/23 at 7:46 A.M. with Licensed Practical Nurse (LPN) #120 revealed she had worked on 09/01/23 and had contacted maintenance that day regarding Resident #11's flooded bathroom. LPN #120 stated the bathroom remained flooded on 09/03/23 and thought Resident #11 may need a room change until the bathroom was repaired.

Follow-up observation of Resident #11's bathroom on 09/06/23 at 10:03 A.M. during the environmental tour revealed staff were sucking water out of the bathroom and a large ring of rust-colored and black debris was noted around the base of the shower.

Interview on 09/06/23 at 10:03 A.M. with Resident #11 revealed her shower had been flooding like this for over two weeks.

Interview on 09/06/23 at 10:03 A.M. with Regional Director of Maintenance (RDOM) #122 revealed the shower needed to be snaked or jetted out and confirmed no plumbing service had been set up to resolve this issue at the time of the interview.

Follow-up interview on 09/06/23 at 12:30 P.M. with RDOM #122 verified no maintenance logs or requests were available to review for the assisted living floors of the facility.

2. Observation on 09/06/23 at 10:07 A.M. revealed Resident #8's shower had at least one inch of rust-colored standing water present.

Interviews on 09/06/23 at 10:07 A.M. and 11:29 A.M. with RDOM #122 indicated Resident #8's bathroom was not usable but he could not state how Resident #8 would bathe until repairs were completed. RDOM #122 confirmed no plumbing service had been set up to resolve this issue at the time of the interview.

Interview on 09/06/23 at 11:54 A.M. with Resident Assistant (RA) #103 revealed Resident #8 and Resident #11 had plumbing issues in their bathrooms for two to three weeks. No plumber had come out to fix the bathrooms yet but the bathrooms would continue to flood.

Interview on 09/06/23 at 12:00 P.M. with RA #101 revealed maintenance staff was notified a few weeks ago regarding the water problems in Resident #8 and Resident #11's rooms but maintenance would just suck up the water and not snake the drains. RA #101 indicated both residents had to utilize a bathroom in a vacant room for bathing.

Follow-up interview on 09/06/23 at 12:30 P.M. with RDOM #122 verified no maintenance logs or requests were available to review for the assisted living floors of the facility.

This violation is an example of continued non-compliance from the complaint survey dated 07/05/23 and the annual survey dated 08/01/23.

Based on observation, interview and record review, the facility failed to ensure a clean, safe and sanitary resident environment. This affected 15 residents (Residents #1, #16, #18, #20, #21, #24, #27, #29, #31, #32, #35, #38, #40, #43 and #44) of 23 rooms reviewed and had the potential to affect all 48 residents in the facility as resident common areas were impacted. The facility census was 48.

Findings include:

The assisted living portion of the facility was on the fourth, fifth, sixth and seventh floors of the building.

1. Observation of the facility on 09/06/23 from 9:25 A.M. to 10:52 A.M. with Housekeeping Supervisor (HS) #121 and Regional Director of Maintenance (RDOM) #122 revealed the following areas of concern:

a. On the fourth floor, a ceiling tile was propped up against the right side of the hallway exposing a leaking pipe that was actively leaking into a trash can below.

b. On one end of the hallway on the fourth floor the air conditioning unit mounted onto the ceiling was leaking into two trash cans.

c. Observation of Resident #32's room revealed there was a ring of scum in the toilet, hair on the floor in the bathroom and the trash was overflowing. Interview on 09/06/23 at 9:43 A.M. with Resident #32 indicated their room had not been cleaned in some time.

. Observation of Resident #38's room revealed debris present on the bathroom floor, the floor of the apartment and in the toilet. Interview on 09/06/23 at 9:46 A.M. with Resident #38 revealed housekeeping had not come into their room in some time.

e. Observation of Resident #35's room revealed a green liquid was on the surface of the vanity and the sink, hair was all over the vanity and sink and the floors in the bathroom and the apartment were not clean. Additionally, medication cups were noted to be left on the table and floor.

f. Observation of Resident #18's room revealed debris all over the floor and the room was in need of vacuuming. Interview on 09/06/23 at 9:50 A.M. with Resident #18 revealed the sweeper housekeeping staff used did not really clean the floors.

g. The laundry room on the fourth floor had debris on the floor including a cookie and a snack wrapper and looked like it had not been swept in some time.

h. Observation of Resident #21's room revealed a strong urine odor, debris all over the floor and an overflowing trash can. In the bathroom, brown matter was on the exterior and interior of the toilet and on the floor.

i. Observation of Resident #27's room revealed the light switch to the bathroom did not work, the floor was in need of vacuuming and flies were noted throughout the apartment.

j. The fifth floor dining room floor needed to be swept.

k. Observation of Resident #16's bathroom revealed the floor was dirty.

l. Observation of Resident #31's room revealed hair was present on the floor in the bathroom and the shower. An empty medication cup was noted behind the toilet on the bathroom floor. Interview on 09/06/23 at 10:14 A.M. with Resident #31 revealed they did not have housekeeping in the facility to clean resident rooms.

m. Observation of Resident #20's room revealed the carpeting was stained in multiple places.

n. The sixth floor laundry room floor was in need of sweeping.

o. The air conditioning unit that was installed in the ceiling on the sixth floor was dripping down into a bucket.

p. Observation of Resident #44's room revealed the bathroom and main apartment floors were dirty. Interview on 09/06/23 at 10:22 A.M. with Resident #44 revealed housekeeping had last been in their room on 08/08/23 and had no idea where housekeeping was.

q. Observation of Resident #29's room revealed the toilet had a ring of scum in it and the bathroom floor was dirty.

r. Observation of Resident #1's room revealed dark brown matter was splattered in the toilet and dried toothpaste was noted in the sink. Interview on 09/06/23 at 10:26 A.M. with Resident #1 revealed their toilet backed up each week and this had been going on for two months.

s. The carpet on the sixth floor was coming up in ridges outside of the elevator. Dark discoloration was noted going down the left side of the hall in the center of the carpet.

t. Observation of Resident #43's room revealed yellow and orange discoloration on the vinyl flooring below the toilet. Interview on 09/06/23 at 10:30 A.M. with Resident #43 revealed the staining below the toilet had been there for seven or eight months and she had tried bleach products and other cleaners but the stain would not go away.

u. The wallpaper on the sixth floor across from Resident #43's room was curled up and peeling away from the wall.

v. The transition strip of trim on the sixth floor was coming up off of the floor and was not secured.

w. The seventh floor laundry room floor was dirty and needed to be swept.

x. Observation of Resident #40's room revealed the floor was dirty and needed to be swept and a towel was noted under the toilet. Interview on 09/06/23 at 10:37 A.M. with Resident #40 revealed housekeeping had not come to her room for at least two weeks and the toilet had an on-going issue where it would leak intermittently.

y. Observation of Resident #24's room revealed there was hair on the floor below the sink and the trim beneath the sink was wavy and not flush with the wall.

Interviews with HS #121 and RDOM #122 throughout the observations verified the above findings. HS #121 stated she started her employment at the facility on 08/30/23 and indicated all resident rooms on the assisted living were cleaned daily. RDOM #122 stated he had estimates for the leaking air conditioning units to be repaired but did not have any dates for the service to actually be completed but reiterated the work had been approved. RDOM #122 indicated the ceiling tile on the fourth floor was to be repaired last week but had not yet followed up to determine what date the service would be completed as this was also dependent on a credit application by the facility. RDOM #122 verified the carpet and transition strip on the sixth floor were tripping hazards.

Interview on 09/06/23 at 11:36 A.M. with Housekeeper (HK) #127 revealed staff were told by (name not shared) that 'cleaning the assisted living was not a priority as the nursing floors are what paid for the building'. HK #127 stated assisted living needed to be cleaned regardless so if residents called the front desk, rooms could be cleaned by requests but ultimately depended on staffing levels. HK #127 stated there was no specified frequency for cleaning the assisted living.

Interview on 09/06/23 at 11:54 A.M. with Resident Assistant (RA) #103 revealed she saw housekeeping no times to one time per week on the assisted living portion of the facility. Housekeeping would half-clean the rooms or only do specific rooms, not all of the rooms on the floor.

Interview on 09/06/23 at 12:00 P.M. with RA #101 revealed she saw housekeeping maybe one to two times per month. If housekeeping staff were told to clean a specific room, they would do that room only then leave the floor.

Interview on 09/06/23 at 12:04 P.M. with HK #126 revealed she usually cleaned the nursing floors but was told to clean the assisted living today. HK #126 stated the assisted living was to be cleaned daily but this also depended on the number of housekeepers working that day.

Interview on 09/06/23 at 12:09 P.M. with RA #107 revealed housekeeping did not clean daily on the assisted living and it would be days before a housekeeper would come over to clean.

Interview on 09/06/23 at 12:17 P.M. with HK #125 revealed she was never assigned to clean the assisted living and shared staff had been told by RDOM #122 that cleaning on the assisted living was to be done as needed. Even if there were four to five housekeepers working that day, no housekeepers would come over to the assisted living to clean.

Follow-up interview on 09/06/23 at 12:30 P.M. with RDOM #122 verified no maintenance logs or requests were available to review for the assisted living floors of the facility.

Review of facility housekeeping procedures dated March 2011 revealed there was no cleaning frequency specified for rooms on the assisted living.

Review of the undated resident agreement revealed housekeeping services were not discussed.

Review of housekeeping schedules for August 2023 revealed HK #125 had been assigned to clean the assisted living four to five days per week. No other staff were assigned to clean the assisted living.

Review of housekeeping schedules for 09/01/23 to 09/16/23 revealed no staff had been scheduled or assigned to clean the assisted living.

Review of the provided documentation revealed it spanned July 2023 though September 2023. Reviewing documentation since the annual survey on 08/01/23, two staff had been assigned to clean the assisted living common areas Monday through Friday from 08/02/23 to 08/18/23. No further documentation was available after 08/18/23. Deep cleaning checklists were available showing some resident rooms were cleaned from 08/02/23 to 08/18/23 minus a sheet for this date 09/06/23.

2. Observation of the fifth floor on 09/07/23 at 11:52 A.M. revealed a cooler was placed under the ceiling-mounted air conditioning unit and the unit was leaking water onto the floor.

Interview on 09/06/23 at 11:54 A.M. with RA #103 verified a cooler was positioned under the ceiling air conditioning unit in the middle of the hallway. RA #103 stated the cooler under the air conditioning unit had been there all summer and the unit would leak every time it was on.

Follow-up interview on 09/06/23 at 12:30 P.M. with RDOM #122 verified no maintenance logs or requests were available to review for the assisted living floors of the facility.

This violation is an example of continued non-compliance from the complaint survey dated 07/05/23 and the annual survey dated 08/01/23.

Based on interview, record review, self-reported incident (SRI) review and policy review, the facility failed to ensure allegations of abuse were thoroughly investigated and failed to follow through on corrective measures. This affected one resident (Resident #48) of one resident reviewed for abuse investigations. The facility census was 48 residents. Findings include: Review of Resident #48's medical record revealed an admission date of 03/15/23 and diagnoses including traumatic brain injury, moderate protein-calorie malnutrition, paraplegia, falls, generalized anxiety disorder, mood disorder and hemiplegia. Review of an assessment dated 03/16/23 revealed Resident #48 was oriented and capable of independent decision making and was independent with transfers. Review of a late-entry nurses' note dated 08/27/23 at 9:31 P.M. revealed Resident #48 had slipped and fallen trying to get into his wheelchair unassisted but did not sustain any injuries. Review of a SRI dated 08/28/23 revealed an allegation of verbal/emotional abuse where on 08/27/23 at 11:30 P.M. Resident #48 reported he fell and when he asked for help, staff cursed at him. An investigation was opened and a staff member was suspended immediately pending investigation. Facility staff were re-educated on verbal abuse. The facility determined the allegation of abuse to be unsubstantiated. Further review of the facility's SRI investigation revealed a blank record of educational program and a copy of the abuse policy. No staff witness statements, resident witness statements or completed education was included in the investigation. Interview on 09/06/23 at 3:28 P.M. with the Director of Nursing (DON) verified there were no other staff or resident witness statements or a completed abuse education available for surveyor review. When asked regarding the expectations for investigating abuse allegations, the DON stated staff were to follow the facility's abuse policy and procedure which included obtaining witness statements. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident PropertyBased on interview, record review, self-reported incident (SRI) review and policy review, the facility failed to ensure allegations of abuse were thoroughly investigated and failed to follow through on corrective measures. This affected one resident (Resident #48) of one resident reviewed for abuse investigations. The facility census was 48 residents.

Findings include:

Review of Resident #48's medical record revealed an admission date of 03/15/23 and diagnoses including traumatic brain injury, moderate protein-calorie malnutrition, paraplegia, falls, generalized anxiety disorder, mood disorder and hemiplegia. Review of an assessment dated 03/16/23 revealed Resident #48 was oriented and capable of independent decision making and was independent with transfers. Review of a late-entry nurses' note dated 08/27/23 at 9:31 P.M. revealed Resident #48 had slipped and fallen trying to get into his wheelchair unassisted but did not sustain any injuries.

Review of a SRI dated 08/28/23 revealed an allegation of verbal/emotional abuse where on 08/27/23 at 11:30 P.M. Resident #48 reported he fell and when he asked for help, staff cursed at him. An investigation was opened and a staff member was suspended immediately pending investigation. Facility staff were re-educated on verbal abuse. The facility determined the allegation of abuse to be unsubstantiated.

Further review of the facility's SRI investigation revealed a blank record of educational program and a copy of the abuse policy. No staff witness statements, resident witness statements or completed education was included in the investigation.

Interview on 09/06/23 at 3:28 P.M. with the Director of Nursing (DON) verified there were no other staff or resident witness statements or a completed abuse education available for surveyor review. When asked regarding the expectations for investigating abuse allegations, the DON stated staff were to follow the facility's abuse policy and procedure which included obtaining witness statements.

Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property

Based on interview, record review, review of resident council minutes and facility policy review the facility failed to ensure physical environment concerns from resident council regarding housekeeping services were addressed in a timely manner. This had the potential to affect all 48 residents residing in the facility. The facility census was 48.

Findings include:

Review of resident council meeting minutes from 01/18/23 to 08/16/23 revealed continued concerns regarding the facility's housekeeping services for seven months out of the last eight months as follows.

Review of the minutes from 01/18/23 revealed Resident #36 (the resident council president) was concerned there was no schedule for cleaning. In response, the assisted living director at the time indicated a new schedule had been made, was to be available soon and deep cleaning of rooms was to start 01/19/23.

Review of the minutes from 02/15/23 revealed there have been no improvements with housekeeping. Some residents stated they have not had a housekeeper in their room for quite some time and housekeepers would do basic cleaning, no dusting or deep cleaning. Residents expressed concerns regarding the carpets. In response, housekeeping was implementing a schedule to ensure deep cleanings occur regularly for each resident and a company was coming to give a quote for the carpet to be replaced.

Review of the minutes from 03/15/23 revealed there have been no improvements with housekeeping. Residents state their toilets are not being cleaned and carpets are not being vacuumed. Residents state they do not see housekeepers on a routine basis. In response, housekeeping was implementing a schedule to ensure deep cleanings occur regularly for each resident and residents could reach out to the housekeeping supervisor with concerns.

Review of the minutes from 04/19/23 revealed housekeeping would improve for a few days then things go back. In response, while the housekeeping supervisor at the time did not attend the meeting but would be spoken with later this week. The supervisor was making changes in the department and held housekeepers responsible for completing assigned duties.

Review of the minutes from 06/21/23 revealed there was no routine schedule for cleaning in the assisted living and residents asked about the sixth floor carpet. In response, the housekeeping supervisor would create and implement a routine schedule for room cleanings and the Administrator stated the carpet on the sixth floor was going to be replaced.

Review of the minutes from 07/17/23 revealed some residents were still having issues getting their rooms cleaned properly and carpet and wallpaper on the sixth floor needed to be replaced. In response, staff was still being trained on proper cleaning procedures and maintenance was to pull up the carpet.

Review of the minutes from 08/16/23 revealed residents would like a deep clean room schedule and there was concern regarding the amount of flies in the facility. In response, staff were being retrained on proper cleaning procedures and exterminators had been out to address the flies.

Interview on 09/06/23 at 8:32 A.M. with the Long Term Care Ombudsman (LTCO) #123 revealed she had concerns regarding no assisted living director or other oversight over the facility as the Administrator was on vacation for two weeks in addition to concerns regarding the physical environment. LTCO #123 indicated she had spoken to the Administrator regarding the August 2023 resident council meeting minutes but had not gotten a response.

Interview on 09/06/23 at 9:43 A.M. with Resident #32 indicated their room had not been cleaned in some time.

Interview on 09/06/23 at 9:46 A.M. with Resident #38 revealed housekeeping had not come into their room in some time.

Interview on 09/06/23 at 9:50 A.M. with Resident #18 revealed the sweeper housekeeping staff used did not really clean the floors.

Interview on 09/06/23 at 10:14 A.M. with Resident #31 revealed they did not have housekeeping in the facility to clean resident rooms.

Interview on 09/06/23 at 10:22 A.M. with Resident #44 revealed housekeeping had last been in their room on 08/08/23 and had no idea where housekeeping was.

Interview on 09/06/23 at 10:30 A.M. with Resident #43 revealed the staining below her toilet had been there for seven or eight months and she had tried bleach products and other cleaners but the stain would not go away.

Interview on 09/06/23 at 10:37 A.M. with Resident #40 revealed housekeeping had not come to her room for at least two weeks and the toilet had an on-going issue where it would leak intermittently.

Interview on 09/06/23 at 11:22 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #124 revealed she was unable to locate concerns or grievances for surveyor review and stated all resident concerns would be discussed at resident council.

During an interview on 09/06/23 at 1:43 P.M. the Director of Nursing (DON) was made aware of the repeated concerns with housekeeping in the facility during 2023 persisting since the annual survey on 08/01/23 which had no documented evidence these concerns were being addressed in a timely manner.

Interview on 09/06/23 at 1:55 P.M. with Social Service Designee (SSD) #128 revealed concerns brought up at resident council would then go to the appropriate department head or the Administrator for resolution. SSD #128 was asked to provide any additional evidence regarding resolution of facility housekeeping concerns, as SSD #128 had nothing to show the surveyor at the time of the interview.

Interview on 09/06/23 at 2:09 P.M. with Resident #36, who served as the facility's resident council president, revealed she never saw housekeepers and indicated facility concerns do not get resolved. Resident #36 stated other residents would provide written concerns to the Administrator and hear nothing back and also shared the Administrator did not provide responses to concerns and was hard to reach. Resident #36 stated there still was no cleaning schedule and there used to be housekeeping services once a week but that had not occurred in quite some time.

Interview on 09/06/23 at 2:50 P.M. with SSD #128 and Housekeeping Supervisor (HS) #121 revealed HS #121 had just started working at the facility on 08/30/23. SSD #128 and HS #121 revealed a deep cleaning schedule was created for August 2023 and September 2023, and HS #121 had plans to implement cleaning tools as guidelines for the housekeeping staff to use when cleaning.

Follow-up interview and record review on 09/06/23 at 3:28 P.M. with SSD #128 and HS #121 revealed they presented to the surveyor all available documentation pertinent to concern resolution for review. Review of the provided documentation revealed it spanned July 2023 though September 2023. Reviewing documentation since the annual survey on 08/01/23, two staff had been assigned to clean the assisted living common areas Monday through Friday from 08/02/23 to 08/18/23. No further documentation was available after 08/18/23 in regard to cleaning of the common areas. Deep cleaning checklists indicated some resident rooms were deep cleaned from 08/02/23 to 08/18/23 and on 09/06/23. Review of undated cleaning tools revealed a deep clean checklist, a blank schedule, a common area schedule and the calendars for August 2023 and September 2023 with two resident rooms listed each day Monday through Friday to be deep cleaned but did not indicate what staff was responsible for this cleaning. Further review of these calendars showed each resident room would be deep cleaned at a frequency of once per month. Documentation did not illustrate when resident rooms would receive routine cleaning if at all. When asked how was it ensured the cleaning had been completed as instructed, SSD #128 stated a deep cleaning checklist would be completed by the staff. When asked if a supervisor or other staff member physically checked rooms to ensure cleaning was completed, neither SSD #128 nor HS #121 responded to the question.

Review of the facility policy and procedure relative to grievances revised August 2023 revealed the grievance committee shall complete an investigation of the resident's grievance. The grievance review will be completed in a reasonable time frame but in no event will exceed 30 days. Upon completion of the review, the grievance committee will complete a written grievance decision and inform the resident of the results of the investigation as soon as possible but no later than seven days.

This violation represents non-compliance discovered during the investigation of Complaint Number OH00145901.

Based on interview and record review the facility failed to evaluate residents receiving dressing changes at least once every seven days to determine appropriateness for continued care in the facility. This affected one of two residents (Resident #27) whose medical records were reviewed for the application of dressings.

Findings include:

Review of Resident #27's medical records revealed an admission date of 02/10/22 with diagnoses including hypertension, congestive heart failure (CHF), osteoarthritis, atrial fibrillation, cataracts, and non-compliance with medication regimen. Further review of the medical record revealed Resident #27 had occasional bladder incontinence and needed some assistance with ambulation to the bathroom.

A review of progress notes in Resident #27's medical record revealed on 02/05/23 the nurse noted a small open area to buttocks that was bleeding. The nurse practitioner was notified and an order was obtained to cleanse the open area with normal saline solution (NSS), apply barrier cream, and a bordered gauze bandage. A new order dated 02/15/23 was noted directing facility nursing to cleanse an open area to the left buttock with NSS, apply Tegaderm every two days and as needed, until resolved.

Review of treatment flowsheets for the months of February, 2023 through July, 2023 revealed Resident #27 received a dressing application a total of 82 times in that time period. Further review of Resident #27's medical record revealed no evaluation of the open area requiring the application of a dressing or a weekly evaluation of her continued appropriateness for care in the assisted living facility.

Interview on 08/01/23 at 5:20 P.M. with the Regional Director of Nursing (RDON) confirmed there was no weekly evaluation of Resident #27's wound or her appropriateness to remain in the assisted living facility noted in the medical record or the treatment sheets during the months of February, 2023 through July, 2023 when the resident was receiving dressing applications.

Based on observation and interview the facility failed to maintain plumbing free of leakage. This affected one Resident (Resident #31) and had the potential to affect all 16 residents residing on the fourth floor (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16).

Findings include:

Observation on 07/31/23 at 11:10 A.M. of Resident #31's room revealed audible running water upon entrance to his apartment. Observation of Resident #31's bathroom revealed constant water running from the faucet which could not be turned off.

Interview on 07/31/23 at 11:15 AM with Resident #31 revealed his shower had been dripping for months and nobody had come to fix it. Resident #31 stated he told the girls that work here and they tried to turn the water off but he had never seen anyone from maintenance.

Observation and interview on 08/01/23 between 9:45 A.M. and 10:15 A.M. with the Regional Director of Environmental Services (RDES) confirmed the continuous running water from the faucet of Resident #31's shower. Further interview revealed the RDES was unaware of the plumbing issue in this room prior to the walk through of the resident's room.

Observation on 07/31/23 between 4:10 P.M. and 4:40 P.M. of the fourth floor revealed water dripping from the ceiling into a black bucket outside of Room 411. The ceiling tile was water stained and there was rust noted on the brackets holding up the ceiling tiles. Further observation revealed a white cloudy stain on the carpet below the leak.

Interview on 07/31/23 between 4:10 P.M. and 4:40 P.M. with Licensed Practical Nurse (LPN) #381 confirmed water dripping into a bucket from the ceiling. During this interview, LPN #381 was unable to indicate how long the ceiling had been leaking, stating she typically worked on another floor but noticed the leak earlier this afternoon when she was passing medications and water dripped from the ceiling onto the medication cart.

Interview on 08/01/23 between 9:45 A.M. and 10:15 A.M. with the RDES confirmed he was aware there was a leak on the fourth floor from the ceiling. He further confirmed this was a plumbing issue and the facility had a plumber evaluate and provide an estimate for repairs but the facility had not yet started any of the repairs. The RDES stated during the facility was waiting on changing insurance prior to being able to make the repairs.

Review of an estimate from an outside plumbing company revealed the facility obtained an estimate for repairs to the leaking pipes on 06/07/23.

This violation is a recite to the complaint survey completed 07/05/23.

Based on interview and record review the facility failed to ensure residents capable of self-evacuation were evacuated in at least two fire drills per shift per year and the facility failed to test the fire alarm signal transmission and receipt when a coded or silent alarm fire drill was initiated. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Review of facility reports for fire drill conducted between 07/10/22 and 06/30/23 revealed no residents were evacuated in any of the 12 fire drills conducted, including fire drills conducted on 07/10/22, 08/31/22, 09/14/22, 10/12/22, 11/15/22, 12/12/22, 01/24/23, 02/23/23, 03/27/23, 04/27/23, 05/18/23, and 06/30/23.

Review of facility fire drill reports for silent drills conducted on 07/10/22, 09/14/22, 10/12/22, and 03/27/23 revealed the facility did not initiate an alarm to test transmission and receipt of the alarm signal within 12 hours of conducting the silent fire drills.

Interview on 08/01/23 at 12:17 P.M. with the Administrator and the Regional Director of Environmental Services (RDES) confirmed there was no evidence of resident evacuation during any of the 12 fire drills conducted between 07/10/22 and 06/30/23. Further interview with the Administrator and the RDES confirmed the silent alarm drills conducted on 07/10/22, 09/14/22, 10/12/22, and 03/27/23 were not followed up with an alarm transmission to verify alarm functionality within 12 hours of completion of these four fire drills.

Based on observation, interview, and record review the facility failed to ensure resident rooms, common areas, community laundry areas, hallways, and air conditioners were maintained in a clean, safe, sanitary manner. This had the potential to affect all 48 residents residing in the facility.

Findings include:

The assisted living residences were located on the fourth, fifth, sixth, and seventh floors of the building.

Observation on 07/31/23 from 9:45 A.M. to 10:40 A.M. of the fourth floor revealed the following:

* The windowsill near the north staircase had 15 dead flies; a medicine cup containing a clear greasy substance smeared on the inside and rim of the medicine cup; a brown hand towel that appeared crinkled and hardened in the center; and a half full water bottle.

* Three stained ceiling tiles near the north side window.

* A table covered with food crumbs, including what looked like scrambled eggs, a dirty napkin and food crumbs were on the floor by the table.

* A trash pail with water collecting drips from the air conditioner hanging from the ceiling.

* The windowsill near the south staircase contained three dead flies and one dead fruit fly. There were two fruit flies flying around near the window.

* The resident laundry room had a sticky floor with gray-black scuffs noted throughout and two small, nickel size brown stains. There were missing floor tiles under the washer. The window curtains had black stains across the bottom. Lint was noted behind the dryer and above the plug and outlet. There was a dryer sheet on floor behind dryer. The wall between the two laundry room windows had a crack about 3.5 feet long with exposed drywall and chipped paint.

* The resident refrigerator that was housed in the laundry area contained a juice pitcher with an identified thick orange liquid that was unmarked and undated and a bowl of fruit that was unmarked, undated, and losing pigmentation. There was a pink stain inside the top door shelf of the refrigerator, brown stains on three of the shelves inside the refrigerator door, brown stains on the bottom shelf and round black spots along the inside of the bottom of the refrigerator.

* The outside of the first aide box/kit was dirty with dust and gray splotches and was in a drawer next to a pair of underwear.

* Room 430 had debris and lint on the carpet.

* Room 410 had debris and lint on the carpet and a tennis ball sized hole in the ceiling near the window and torn paint behind the curtain track.

* Room 417 had fruit flies; house flies; dead flies on the windowsill; large black stains over the carpet; especially alongside the bed; soiled linen, including orange, brown and yellow stains covering the entire exposed area of the exposed mattress pad; a full trash can next to the bed; dirty laundry piled up on the recliner; and multiple open bags of snacks and soda on the bedside table.

Interview on 07/31/23 at 10:05 A.M. with Resident Assistant (RA) #368 revealed there was no designated housekeeper for the Assisted Living. RAs did some of the housekeeping when they were able. RA #368 said a housekeeper sometimes came to the assisted living from the nursing home located on the same property upon request.

Interview on 07/31/23 at 10:16 A.M. with Resident #16 revealed her room did not get cleaned very often and needed vacuumed.

Interview on 07/31/23 at 10:25 A.M. with Resident # 5 revealed the frequency she received housekeeping service was when hell freezes over. Resident #5 was unable to recall the last time her room was vacuumed but may have been a couple weeks ago. During the interview, Resident #5 pointed out a leak above her window and said they fixed it last week, but she did not know if they were coming back to fix the paint.

Interview on 7/31/23 at 10:38 A.M. with Resident #9 revealed fruit flies in his room and crumbs on the floor. Resident #9 stated he did not get laundry done every Monday like he used to, the laundry on his recliner was dirty. Regarding the stains on his bed he stated he did not eat in bed but the brown stains were chocolate from a fudge brownie he dropped.

Observation on 07/31/23 between 10:50 A.M. and 11:20 A.M. of the fifth floor revealed the following:

* The ceiling air conditioner was dripping into a trash can with a second trash can also placed under the air conditioner that was empty.

* Black stains were noted on air conditioner vent cover.

* The windowsill near the south stairs was covered with dust and lint build-up.

* Room 527 had visible loose debris on the carpeting, brown and yellow stains on the bathroom floor, two cup lids on the bathroom floor, a torn up baseboard with soiled, wet flooring underneath between the cabinet and shower, and a black stained shower curtain.

* Room 529 had brown water stains on the shower floor; gray and black stains corner to corner behind toilet and brown stains on the toilet seat.

* Room 515 had a fly swatter on the bedside table.

Interview on 07/31/23 at 10:55 A.M. with Resident #24 revealed housekeeping did not vacuum as often as they used to but her daughter cleaned her room and bathroom, changed her bed linen, and did her laundry. The was a fly swatter next to Resident #24 and Resident #24 said it was for the fruit flies.

Interview on 07/31/23 at 11:05 A.M. with the daughter of Resident #24 revealed she did not see housekeeping much and she liked to make sure her mother's bathroom was kept clean, so she cleaned it herself.

Interview on 07/31/23 at 11:15 AM with Resident #31 revealed maintenance had not addressed the plumbing issues he has had for months, and he did not see housekeeping very often. Further interview revealed someone from housekeeping was just in his room but did not clean anything. Resident #31 reiterated the girl from housekeeping was just there but did not vacuum or clean anything that he could see.

Observation on 07/31/23 between 11:20 A.M. and 11:41 A.M. of the 6th floor revealed the following:

* Stains on the hall carpet. Carpeting was loose and lifting or bubbling coming outside of the elevator and outside Rooms 621 and 625. The carpet was worn, overstretched and creasing upward in some spots.

* The 6th floor resident laundry room had stains on the window sill; stains on the floor; water stains under the dryer; balled-up lint behind the dryer; lint on floor in front of the dryer; and black stains along the bottom of the drapes.

* The windowsill by the south stairwell had a brown rectangular stained area from under and around a plastic planter.

* Three stained ceiling tiles near air the conditioner and one tile over the ceiling air conditioner was loose and hanging. A red bucket was collecting water under the air conditioner.

* A covered cart was noted between the wall and pool table near the north stairwell, leaving only a 2 foot 7 inch width between the cart and the pool table.

Interview on 07/31/23 at 11:28 A.M. with RA #369 revealed the RAs received notes telling them they were responsible for taking trash out of rooms at the end of every shift. Further interview revealed RA #369 did not know when the housekeepers cleaned the resident rooms. During this interview, RA #369 also verified the laundry cart near the north stairs and the floor soiled with lint and other debris in the laundry room.

Interview on 07/31/23 at 11:32 A.M. with Housekeeping Aide #327 revealed she worked on the second floor, not assisted living (AL), but saw an RA from AL and was asked to vacuum Rooms 628, 621, 612. Housekeeping Aide #327 did no know whether there was a specific cleaning schedule for resident rooms or laundry rooms in the AL.

Observation on 07/31/23 between 11:42 A.M. and 12:00 P.M. of the seventh floor revealed the following:

* In the resident laundry room there was lint buildup on wall and floor to the right of the dryer and behind the dryer. There were four open tubs containing Christmas decorations by the window; two water-stained ceiling tiles; and dirty curtains in the windows.

* The resident community refrigerator that was housed in the laundry room contained one cup of a brown liquid on the inside of the door covered in plastic that was unidentifiable; one bowl of fruit with a white crystal-like appearance on top, not labeled or dated; one bowl of what appeared to be a wilting salad unlabeled; brownish stains under both crisper drawers; six Styrofoam cups with lids, unmarked in the freezer and light brown stains in the freezer.

Interview on 07/31/23 at 11:54 AM with Floor Technician #325 confirmed the laundry area issues, including old and unmarked food in the refrigerator and freezer and the condition of the floors and drapes. Floor Tech #325 revealed he swept hallway floors on each floor level weekly and believed the RAs were responsible for cleaning the laundry room floors.

Interview on 07/31/23 at 4:30 PM with Resident #43 revealed they used to get housekeeping services in their rooms weekly, but it had been a while since that happened. Further interview revealed there were stains on her carpet and approximately three weeks ago someone had cleaned the carpet. Resident #43 further stated the housekeeping supervisor used to check on things periodically but had been on vacation for a week or two.

Interview on 07/31/23 at 4:40 P.M. with LPN #381 confirmed the refrigerators in the laundry rooms were for resident use and she did not know who was responsible for cleaning those refrigerators. LPN #381 further revealed she was unaware of the frequency resident rooms were cleaned by housekeeping staff.

Interview on 08/01/23 at 10:25 A.M. with RA #375 revealed multiple residents complained of carpets not being vacuumed and the general lack of bathroom cleanliness, such as floors stained and needing mopped. Further interview revealed housekeeping was supposed to clean the laundry room floors but RA #375 had not witnessed that occurring. When asked about who maintained the refrigerators in the laundry rooms, RA #375 replied, nobody.

Observation and interview on 08/01/23 between 9:45 A.M. and 10:15 A.M. with the Regional Director of Environmental Services (RDES) revealed the previous housekeeping supervisor may not be coming back and he pulled someone from a different facility to start cleaning the assisted living today. During this interview the RDES revealed there was no current environmental service director or maintenance director for the building. During this time a tour and interview with the RDES confirmed the following:

* The plumbing issued in Room 527, soiled floors, and dark spots along walls in bathroom, as well as mold growth on bottom of shower curtain.

* Grayish-black spots on bathroom floor behind toilet in Room 529.

* The carpeting being creased and coming up on the 6th floor.

* Wallpaper coming apart at seems throughout 6th floor.

* Laundry cart blocking the stairwell/fire exit (he moved it at this time).

* Water damage and holes in ceiling in Room 410.

* Flies and soiled bedding, dark stained carpet, and dirty floor in Room 417.

* The soiled table, floor, and windowsills on fourth floor.

* Leaking from ceiling on fourth floor.

* Waste baskets under air conditioners on the fourth, fifth, sixth, and seventh floor to catch water drops.

Review of resident council meeting minutes from 06/21/23 and 07/17/23 revealed residents voiced concerns with rooms being cleaned properly, towels in poor condition, bugs were problematic, the carpet and wallpaper needed replaced on the sixth floor, and a general concern that there was no routine housekeeping schedule being followed by the facility.

Review of the Assisted Living Housekeeping Documentation forms revealed no documentation of cleaning maintained after 07/19/23.

Review of facility undated policy titled Housekeeping Policy revealed a daily cleaning schedule for resident rooms in the nursing home. The policy did not address the Assisted Living. No other housekeeping policy was presented during the survey.

This violation is a recite to the complaint survey completed 07/05/23.

Based on observation, maintenance log review, and interview the facility failed to maintain plumbing in resident bathrooms. This affected two resident's (#29 and #31) of 48 residents in the facility.

Findings include:

The assisted living was located on the fourth, fifth, sixth, and seventh floors of the building.

Observation of the facility 06/30/23 between 6:14 P.M. and 7:30 P.M. revealed the following:

a. Room 527, the toilet bowel was rust colored inside. The bathtub was leaking from the faucet with a steady stream of water faster than a drip. The front one third of the tub was stained rust color. The floor of the tub was blackened. Interview 06/30/23 at 6:35 P.M. with Resident #29 revealed his bathtub had been leaking for a long time.

Review of the maintenance log from 03/29/23 to current revealed on 04/07/23 an entry the shower was not turning off in room 527. On 04/08/23 an entry the shower needs fixed in room 527. An entry on 04/09/23 read the shower is running and will not turn off in room 527. None of the entries were signed off as completed.

Interview 06/30/23 at 6:43 P.M. with Resident Aide #51 included the water does run in the resident's bathroom tub. It will about shut off it you turn the handle in the right position.

Interview 06/30/23 at 7:24 P.M. with Licensed Practical Nurse (LPN) #50 revealed the water coming from the faucet will not turn off.

b. Room 529, the toilet had a dark ring in it. The bathroom smelled like sewage. The front half of the shower was stained rust color. There was black debris on the shower floor spreading about a foot from the drain with the appearance of the shower backing up. The room smelled of sewage.

Review of the maintenance log from 03/29/23 to current revealed no entry related to the shower.

Interview 06/30/23 at 6:41 P.M. with Resident #31 revealed it had been two to three months since she had been able to use her shower. She said maintenance told her he did not have the tools to fix it. She stated she had been taking sponge baths.

Interview 06/30/23 at 7:24 P.M. with LPN #50 revealed she heard about the shower issue around three weeks ago. She was told maintenance was called to look at it. They are short maintenance staff so they are working on emergent request first, but the shower should be important.

This violation represents non-compliance under Master Complaint Number OH00144049.

Based on observation, admission agreement review, and interview the facility failed to ensure the resident rooms, hallways, ceiling, wallpaper, and air conditioners were cleaned and maintained. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Interview 06/30/23 at 5:09 P.M. with Licensed Practical Nurse (LPN) #50 included the nurses and aides help to clean the apartments and bathrooms because they have no housekeeping right now for the assisted living. There are fruit flies on the fourth floor. Occasionally, a housekeeper will come from the nursing home if we call them. They did try and clean Apartment 417 last night, but there was oil in the carpet from the motorized wheelchair and it will not come clean. The air conditioner on the ceiling on the fifth floor, next to the table where the interview took place, had a bucket under it collecting water. LPN #50 stated the air conditioner had been leaking the whole time she had been employed there, over a year.

Interview 06/30/23 at 5:49 P.M. with the Director of Nursing (DON) revealed they were short staffed now in housekeeping. There were two housekeepers and one supervisor for the long-term care and the assisted living. Housekeeping was not here as much as they should be. We have had complaints that housekeeping has not been in room 513. She saw it was dirty with stained carpet. She had housekeeping get carpet cleaner and come up. She verified there was a bucket on the floor, next to the table in the hall where the interview took place, collecting water from the ceiling air conditioner above.

Interview 06/30/23 at 6:43 P.M. with Resident Aide #51 included they take out trash and try to do housekeeping while caring for the residents. There was not enough housekeeping staff to have a housekeeper for assisted living.

The assisted living was located on the fourth, fifth, sixth, and seventh floors of the building.

Observation of the facility 06/30/23 between 6:14 P.M. and 7:30 P.M. revealed the following:

The fourth-floor hall carpet had dark spots and needed scrubbed between rooms 412 and 413 and rooms 410 and 411.

Outside of Room 410 the ceiling tile broke through from water damage leaving a one foot by one foot hole in the ceiling. Beneath there was a trash can in the hall with dried ceiling debris. The carpet was soiled beneath the hole in the ceiling.

Room 402, the kitchen and bathroom floor needed scrubbed. The carpet with visible debris needed the sweeper run. Interview 06/30/23 at 6:46 P.M. with Resident #48 at the time of the observation revealed they had not run the sweeper in weeks.

Room 409, the bathroom floor needed cleaned and the carpet with visible debris needed the sweeper run. Interview 06/30/23 at 6:51 P.M. with Resident #3 revealed the carpet had not been swept for two weeks and the bathroom floor had not been cleaned for two weeks.

Room 408, the carpet with visible debris needed the sweeper run. The bathroom floor and toilet had bowel movement smeared on them. The television stand had thick whitish dust buildup. Interview with Resident #2 revealed they do not clean rooms anymore. They just ask if we need toilet paper. The resident said she cannot get down and clean her bathroom floor.

Room 410 had bowel movement on the toilet. The floor of the shower had rust colored stains and soiled blacken areas. Interview 06/30/23 at 6:54 P.M. with Resident #4 revealed they do not clean the rooms, run the sweeper, or clean the bathroom. She cleans her own bathroom sink.

There was wallpaper coming off the hallway wall between rooms 410 and 412 and 407 and 411.

Room 413, the bathroom floor was soiled in front of the toilet. Interview 06/30/23 at 7:03 P.M. with Resident #7 revealed the rooms were not getting cleaned. Room 417 finally had three people in it yesterday cleaning because it was so bad. The linen closet had not had linen for a month and a half, staff including, aides, housekeeping, and maintenance were quitting. There was no security.

Interview of Resident #6 revealed she had no housekeeping services.

The rug outside of the fourth-floor elevators was soiled with dirty paths leading to and from.

Room 417, the carpet is heavily soiled. There was a three foot blacken path from the door to the bed. The walls were gouged leading to the living room. The bathroom floor was dirty and there was a brown ring in the toilet. The whole living area carpet looked to need replaced it was so heavily damaged with black paths.

There was a bench across from the elevator on the fourth floor. The carpet in front of the bench was visibly soiled.

Room 420 had dark soiled paths in the carpet. The whole living area carpet was heavily soiled with dark spots. The television stand had visible white dust. The bathroom floor needed cleaned. Interview on 06/30/23 at 7:08 P.M. with Resident #11 revealed they go through a lot of housekeepers.

The carpet outside of rooms 422, 423, and 424 was soiled and needed cleaned.

The fifth-floor hall ceiling air conditioner was leaking into a bucket in the hall.

Room 504, the bathroom floor was dirty. A liquid had dried under the toilet. The carpet had not been swept. Interview 06/30/24 at 6:14 P.M. with Resident #17 revealed she collects her own trash and takes it down to dispose. She said they had not run the sweeper in a long time.

Room 502's trash was full.

Room 509, the bathroom floor needed cleaned. There was smeared bowel movement on the floor. The carpet needed the sweeper run. There was a six inch by six-inch dark spot in front of the recliner that needed scrubbed.

The fifth-floor dining room had food on the floor under and around the tables including pasta and sauce, cereal, and lots of crumbs.

Room 511, the bathroom floor was dirty with dried yellow around the toilet. The room smelled like urine. The trash can was full.

Room 513, the carpet had a dark path from the door to bed. There was pasta on the table, chair, and carpet, food debris on the table, straws and silverware were on the floor. The bathroom floor was dirty. Interview 06/30/23 at 6:20 P.M. with Resident #20 included the last time housekeeping came they only cleaned half the room and were supposed to come back.

Room 515 needed the sweeper run.

The fifth-floor hall caret had soiled paths leading from both elevator doors.

Room 520, there was debris scattered on the carpet that needed the sweeper run. There were black areas on the bathroom floor. There was white dust on the furniture. Interview 06/30/23 at 6:25 P.M. with Resident #24 revealed they do not dust the room.

Room 522 had large dark areas to both sides of the recliner measuring three feet by one foot and one foot by one foot. The bathroom floor had dried liquid and loose debris that needed swept and scrubbed.

Room 524, there was thick dust on the television stand. The bathroom floor was soiled and had an odor.

Room 526, the carpet was soiled around the recliner with dark spots of one and a half feet by one foot to the front of the recliner. There was a one foot by six-inch dark soiled spot near the table. There was a bag of trash tied up in the room. Interview 06/30/23 at 6:31 P.M. with Resident #28 revealed she had to take out the trash herself.

Room 528, the carpet was heavily soiled throughout to the point it may not come clean, and needs replaced. There were dark spots in front of the couch. There was a soiled path from the bed and bathroom. Interview 06/30/23 at 6:33 P.M. with Resident #30 revealed her couch needed scrubbed.

Room 527, the toilet bowel was rust colored inside. The bathroom floor was dirty. The carpet was heavily soiled especially in the living area. The furniture had thick visible dust including on the chest of drawers. Interview 06/30/23 at 6:35 P.M. with Resident #29 revealed it had been a long time since his carpet was cleaned.

Room 530, the carpet needed the sweeper run. There were blacked areas on the kitchen floor. The carpet near the bar area was soiled and needed shampooed. The bedroom carpet was soiled all around the bed and needed the sweeper run. The toilet had a dark ring in it. The bathroom smelled like sewage. Interview 06/30/23 at 6:41 P.M. with Resident #31 revealed it had been two weeks since the room was cleaned.

The carpet outside of the elevators on the sixth floor was soiled and rolling making it a trip hazard and needed replaced.

Room 603, the carpet needed scrubbed in front of her chair. The bedroom carpet was spotted with dark areas and need scrubbed. Interview 06/30/24 at 7:16 P.M. with Resident #32 revealed she has been there for six years, and the window curtains and shower curtain have never been cleaned.

Room 609, the carpet to the left of the bed was soiled and needs scrubbed. The path leading from the door into the room needed scrubbed.

Room 611, the carpet needed scrubbed to the left of the bed and from the entry door to living room.

Room 617 had a bag of garbage sitting outside the door in the hall.

The hall carpet outside of room 627 needed scrubbed.

Room 627, the bathroom floor was spotted with rust-colored spots. The hall carpet outside of the entrance door was soiled with a dark path and needed scrubbed.

Room 712, the carpet from the door to the bed had a soil path that needed scrubbed.

Room 710, the carpet needed scrubbed by the dining table.

Room 715, the carpet needed scrubbed, and the kitchen floor was dirty. The dresser and bedside table had visible thick white dust on the top surface.

Review of the facility admission agreement included resident rooms, bathrooms, and halls were cleaned on a weekly basis by the housekeeping staff. Residents are urged to contact maintenance should they have any concerns about the cleanliness of the facility.

Review of the maintenance log from 03/29/23 to current revealed one entry related to carpet. On 05/22/23 room 528 needed carpet cleaned, and the rail by the toilet needed replaced. It was signed 05/22/23 as completed.

Observation 06/30/23 at 6:33 P.M. of Room 528, revealed the carpet was heavily soiled throughout to the point it may not come clean and needed replaced. There were dark spots in front of the couch. There was a soiled path to the bed and bathroom. If the carpet had been cleaned on 05/22/23 it did not come clean, and needs replaced.

Review of the Assisted Living cost sheet revealed there was a $3000.00 nonrefundable community fee on admission. The room rates which included housekeeping services ranged from $2895.00 a month for a studio to $7000.00 a month for a two-bedroom deluxe suite with living/dining room and full kitchen including enhanced care.

Interview 06/30/23 at 7:40 P.M. with the DON verified the rooms had not been cleaned weekly due to lack of housekeeping staff. The DON revealed she notified the head of housekeeping of my arrival and was told they have two housekeeping staff for Assisted Living and the fourth, sixth, and seventh floors had been cleaned on 06/29/23. The DON verified the carpets needed scrubbed or replaced, and there were a lot of complaints about housekeeping not cleaning the rooms. The DON verified the leaking air conditioner in the hall on the fifth-floor hall dripping into the bucket had been there a while.

This violation represents non-compliance under Master Complaint Number OH00144049.

Based on review of Self-Reported incident (SRI), interview, and policy review the facility failed to ensure a resident was free from assault and failed to follow through on corrective measures. This affected Resident #38 and had the potential to affect all the residents in the facility.

Findings include:

Review of SRI #235664 revealed a resident-to-resident altercation between Resident's #9 and #38 was substantiated for physical abuse.

Resident #9 was admitted 06/08/21 with diagnoses including depression, muscle weakness with abnormal posture, benign prostatic hyperplasia, hypercholesterolemia, nicotine dependence, hypertension, atherosclerotic heart disease, cardiomyopathy, congestive heart failure, peripheral vascular disease, gastroesophageal reflux disease, non-traumatic ischemic infarction of muscle, acute kidney failure, difficulty walking, adult failure to thrive, prediabetes, homelessness, and acquired absence of left leg above knee. The resident was oriented to person, place, time, and situation. The resident resided on the fourth floor.

Review of Resident #9's 05/01/23 Service Plan revealed the resident was oriented, needed physical help with bathing and had a history of alcohol and drug abuse.

Resident #38 was admitted 04/23/21 with diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, need for assistance with personal care and cognitive communication deficit. The resident was oriented to person, place, time, and situation. The resident resided on the sixth floor.

On 06/03/23 at 7:25 P.M. there was a resident-to-resident altercation in the parking lot of the facility resulting in Resident #9 verbalizing aggression and Resident #38 had a laceration above his right eyebrow. Staff leaving the building saw Resident #38 come in the front door staff yelled out what happened to your eye and face. The incident report included the resident was bleeding badly from a cut by his right eye. He stated he told Resident #9 he was wearing his pants and he denied it. He stated Resident #9 hit him in the face. The Assisted Living nurse, management and security were called. Resident #38 initially did not want the police called and later changed his mind. The Youngstown police were called and filed report 23Y027468. Resident #38 wanted to press charges. Resident #9 was told to go to his room and stay away from Resident #38. Resident #38 did not want transported to the hospital. Resident #38 said Resident #9 previously threatened to hit him in the head. This was determined to be premeditated because a concrete object was taken by Resident #9's room wrapped in a black cloth and found in his wheelchair. Resident #38 said the object was what was used to hit him. Resident #9 said he acted in self-defense because Resident #38 tried to choke him. Assessment revealed no injury or red marks around neck.

Review of the incident report included Resident #38 noticed his clothes and leather jacket missing from his closet on 05/31/23. On 06/03/23 he saw Resident #9 wearing his pants. He went up to Resident #9's room, the door was opened, and he saw his leather jacket laying on the bed. Resident #38 reported Resident #9 did not say anything just grunted and wheeled away. Resident #38 opened his closet and pointed to holes and said he had nice stuff and now it's gone. He opened his dresser drawers where many articles of clothing were disheveled thrown in drawer around other folded items. Several drawers were empty all together. He reported they were all full and now they are empty. Resident #38 states he felt safe in facility and declined treatment by Emergency Medical Technician and was satisfied with Resident #9 being kept away from him until discharge.

Both residents were educated on appropriate behavior and conduct. Physician and family/guardian notification. Head to toe assessment of residents, abuse policy education initiated with staff and statements gathered. Police and 911 notified with both residents remaining in facility, aggressor (Resident #9) placed on one-on-one supervision. The aggressor was put on one-on-one supervision until discharge. The resident was agreeable to discharge pending location. Resident understanding that aggression is not tolerated and willing to discharge after conversation with the administrator. The Ombudsman was notified and assistance with placement of satisfaction for resident.

No staff reported aggression from other residents in regard to inappropriate behavior from aggressor, Resident #9. Like residents were interviewed. No residents reported altercations or aggression and felt safe within facility. Staff were interviewed. Staff reported alleged perpetrator inappropriate with staff and verbally aggressive. One-on-one supervision remaining until discharge due to these reports.

The final report dated 06/09/23 included Resident #9 was permitted to leave facility to community without one-on-one supervision to get a break from being supervised and staff waits at front lobby for return.

Review of the nurse notes provided evidence of one-on-one for the resident through 06/13/23.

Interview on 06/30/23 at 5:49 P.M. with the Director of Nursing (DON) revealed Resident #9 was still in the facility without a discharge date. The DON verified physical abuse did occur.

Observation on 06/30/23 at 7:06 P.M. during the inspection of room 417 revealed Resident #9 was in his room himself without one-on-one supervision.

Interview on 06/30/23 at 7:24 P.M. with Licensed Practical Nurse (LPN) #50 revealed she thought Resident #9 went off one-on-one after 06/11/23 when there was not enough staff to provide them.

An email dated 07/03/23 at 3:01 P.M. from the Administrator verified the facility did not have a discharge date for Resident #9. The Administrator was hoping for a discharge this month due to one possible facility interested in taking the resident.

An email dated 07/04/23 at 2:44 P.M. from the Administrator revealed they kept the one-on-one for quite a while, and he had no further aggression or previous aggression and after seeing psychiatric services they discontinued the one-on-one.

Interview on 07/05/23 at 8:39 A.M. with Ombudsman #130 revealed she was familiar with the incident but did not receive a copy of a 30-day notice.

Interview on 07/05/23 at 4:28 P.M. with the Administrator included she did give a 30-day notice to the resident a few days after the incident. She said he refused to sign it. He was agreeable to the discharge but was still in the facility due to the facility still attempting to find placement. The Administrator verified she had not emailed the 30-day notice to the Ombudsman because the Ombudsman was on vacation. She stated she asked the DON to send a copy to his case manager. She could not verify it was sent. The Administrator verified she could not provide the psychiatric note from the physician to take the resident of one-on-one. The DON had it in her office and she was off. The Administrator verified it should have been part of the medical record.

On 07/05/23 at 5:06 P.M. the Administrator emailed an unsigned 30-day notice dated 06/09/23 that states it was hand delivered to the resident. The Ombudsman was not provided a copy of the 30-day notice.

The facility had a written note and a card left from the responding police department but were unable to provide the police report. The facility did not provide a psychiatric note indicating it was okay to take the resident off one-on-one.

Review of the facility's undated Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property included willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If a resident is accused or suspected of abuse the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated.

This violation was an incidental finding when investigating an SRI during the investigation of Master Complaint Number OH00144049 and Complaint Number OH00143900.

Based on observation, record review, review of staffing schedules, review of the facility policy and procedure for staffing, and interview, the facility failed to maintain sufficient staffing to meet, in a timely manner, each residents' total care, supervisory and emotional needs and reasonable and appropriate requests for services, including monitoring and supervision of residents with increased emotional needs or presenting behaviors that cause problems for the resident or other residents, or both. This resulted in Real and Present Danger and the likelihood for serious harm, injury or death related to a lack of staff, beginning on 12/07/22 when there were only two staff (one licensed nurse and one State Tested Nursing Assistant) assigned to care for all 33 residential care facility residents who resided on four different floors, which included 13 residents (#2, #3, #4, #6, #9, #11, #14, #16, #18, #19, #21, #27 and #35) with cognitive impairment and mental illness who resided on the fifth floor, a secured floor. In addition, due to a lack of staffing on 12/10/22, Resident #34 who was last observed by staff at 1:00 A.M. was found on the floor at 8:36 A.M. and required hospitalization due to an acute change in condition. The facility failed to have an adequate plan for staffing and to monitor for sufficient staffing to meet the total care needs of all residents on an ongoing basis. This affected all 33 residents residing in the facility.

On 12/20/22 at 1:12 P.M. Regional Director of Operations (RDO) #216, Vice President of Operations #230, Vice President of Clinical Operations #229, the Director of Nursing from the Skilled Nursing Facility (DON/SNF), and Assistant Director of Nursing (ADON/SNF) #214 were notified Real and Present Danger began on 12/07/22 when the facility failed to provide sufficient levels of staff to meet the total care needs of all residents.

The Real and Present Danger was abated on 12/29/22 when the facility implemented the following corrective action:

On 12/20/22 by 3:00 P.M. ADON/SNF #214 provided education to all residential care facility/assisted living (AL) nurses, STNAs, Resident Care Assistants (RCAs) and the scheduler regarding having a designated staff member on the fifth (secured care) floor.

On 12/20/22 at 3:00 P.M. Skilled Unit Manager #231 completed wander assessments for all residents. Four residents, (Resident #11, #16, #19 and #21) were identified with wandering behaviors and a wanderguard (bracelet that sets off an alarm when wander-prone resident attempts to exit a door or area equip with the wanderguard system) was in place. The door alarms were checked on 12/20/22 by Maintenance Director #218 and were noted to be properly functioning. A plan for residents to have wandering assessments completed quarterly by nursing and an at-risk wanderer binder placed at the nurse's station on the fifth floor to identify the residents who were at risk for wandering was implemented.

On 12/20/22 at 3:00 P.M., the exit doors, elevator alarms, and wander alarms for the facility were audited by Maintenance Director #218 to ensure the alarms were properly working. A plan for the alarms to be checked weekly by maintenance was implemented.

On 12/20/22 the facility developed a plan for staffing to be reviewed by the DON/SNF each day. The facility implemented a plan for a staff member to be present on the fifth floor secured care unit at all times.

On 12/20/22 at 8:00 P.M. the DON/SNF re-educated Staffing Coordinator #223 to ensure staff working in the facility were designated as residential care facility and the staffing software was printed out and located on the first floor.

On 12/22/22 the DON/SNF, STNA #204, AL LPN #210, Regional Director of Operations #216, Vice President of Operations #230, and Vice President of Clinical Operations #229 completed resident care profiles for all current residents needs by reviewing cognition, wandering, fall risk, incontinence care needs, medication administration needs, and activities of daily living (ADL)/transfer assistance. A plan for the assessments/profiles to be completed quarterly was implemented.

On 12/22/22 a plan for the DON/SNF or a member of nursing management to review daily the facility staffing and call light response times to ensure there is sufficient staff for resident care needs. Any changes will be communicated in the resident care profile.

On 12/22/22 all staff were educated to call the scheduler or the nurse on call if there was a call off. The contingency staffing policy indicated if the call off was not filled, a nurse manager would cover the call off.

On 12/21/22 a resident council meeting was held to discuss staffing with facility residents. On 12/22/22 LPN #210 and on 12/23/22 LPN #208 interviewed all residents not in attendance at the resident council meeting to discuss staffing and their care needs.

On 12/23/22 the DON/SNF completed a medication administration audit to ensure the timely administration of medication.

On 12/23/22 at 4:00 P.M. the facility indicated residential care staffing would consist of a minimum of four staff (one licensed nurse and three RCA and/or STNA staff) at all times to ensure adequate supervision and assistance was provided for residents who resided on four different floors in the facility. However, from 12/23/22 through 12/28/22 review of the facility staffing, revealed these minimum staffing numbers were not met.

On 12/27/22 three staffing agencies were added to the facility resources to be able to fill all shifts. The facility first provided staffing as planned on 12/29/22 beginning for the 7:00 P.M. shift.

Although the Real and Present Danger was abated on 12/29/22, the violation remains as the facility was in the process of implementing on-going monitoring of the corrective action and monitoring to ensure compliance.

Findings include:

1. Review of the Assisted Living Staffing Assignment sheets, dated 12/04/22 through 12/14/22 revealed on 12/04/22, 12/05/22, 12/06/22, 12/10/22, 12/11/22, and 12/13/22 one nurse and two aides worked from 7:00 A.M. through 7:00 P.M. and from 7:00 P.M. through 7:00 A.M.

Further review revealed on 12/07/22 and 12/12/22 only one nurse and one aide worked from 7:00 A.M. to 7:00 P.M. and one nurse and two aides worked 7:00 P.M. through 7:00 A.M.

Review of the assignment sheets from 12/08/22 and 12/09/22 revealed one aide and one nurse worked from 7:00 A.M. to 7:00 P.M. and one aide and one nurse worked from 7:00 P.M. to 7:00 A.M. (both nights the second aide was pulled to work in the facility nursing home located in the same building).

On 12/14/22 one nurse and two aides worked 7:00 A.M. to 7:00 P.M. and one nurse and one aide worked 7:00 P.M. to 7:00 A.M.

Review of Weekly Shower Schedule for 12/11/22 and 12/12/22 revealed Resident #10, #11, #18, #21 were scheduled to receive showers on Sundays, and Resident #24, #26, and #29 were scheduled to receive showers on Mondays.

Review of the Shower Sheets for 12/11/22 and 12/12/22 revealed no documented evidence Resident #10, #11, #18, #21, #24, #26, and #29 received showers on these days as scheduled.

On 12/14/22 at 8:14 A.M. interview with Receptionist #213 revealed the Director of Nursing for the Assisted Living recently resigned, the Administrator was out of town, and she did not know who was overseeing the Residential Care Facility/Assisted Living (AL).

Review of an Aide Report Sheet (updated 12/16/22) revealed Resident #6, #8, #15, #26, #27, and #35 were assessed to require the assistance of two staff members for care.

Review of the facility policy titled Staffing

Based on interview, record review, and review of food substitution logs the facility failed to ensure residents were provided updated menus for meals served. This affected all 33 residents residing in the facility.

Findings include:

Interview on 12/14/22 at 11:07 A.M. with Northeast Regional Manager (NRM) #232 revealed the current manager for the kitchen called off work today, was not doing his job, had an attendance issue, and probably would not be working in the facility after today. NRM #232 stated the dining room was opened for a short time. There were issues with the kitchen staff, and the dining room was closed for dining. This happened about a month ago and there were plans to reopen the dining room in 01/2023. NRM #232 stated she spoke to the Resident Council via phone in 11/2022; the residents wanted different vegetables and were tired of having the same food over and over. NRM #232 stated she adjusted the menus to accommodate Resident Council requests.

Interview on 12/14/22 at 12:12 P.M. with the Resident Council President (Resident #24) revealed she did not receive what she ordered for her meals. Resident #24 stated the residents were given a menu every week and could preorder from the alternate menu. Resident #24 stated on 12/01/22 she was served chili over a plate of pasta and had to eat her meal with a fork. Resident #24 stated she wanted a bowl of chili. Resident #24 stated on 12/08/22 the menu for dinner stated sloppy joe on a bun, but she was served brown gravy over pasta; it looked terrible, and she did not eat it. Resident #24 stated on 12/09/22 the dinner menu stated hot turkey sandwich with gravy, but she received a horrible looking grilled cheese sandwich. Resident #24 stated on 12/11/22 and 12/12/22 there was no coffee in the facility.

Interview on 12/14/22 at 12:40 P.M. with Ombudsman #217 revealed the dining room was closed for the past two to three years, the food quality was poor, food was cold, and residents did not get the meals they ordered. Ombudsman #217 stated the facility leadership staff did not address the issues.

Interview on 12/15/22 at 12:31 P.M. with Resident #24 revealed every month there was a Resident Council meeting, and every month there was someone different representing the dietary department. Resident #24 stated staff did not stay at the facility. Resident #24 stated the dining room was open for a couple days; it was wonderful while the dining room was open, but the dietary manager had an argument with Administrator #233 and was walked out of the facility.

Interview on 12/19/22 at 10:30 A.M. with Resident #26 revealed things could be better. Resident #26 stated the food was terrible, and the residents were not always served the food documented on the menus. Resident #26 stated for lunch on 12/18/22 she was served meat balls with gravy, mashed potatoes, no vegetables, and the food served was not listed on the menu.

Interview on 12/19/22 at 11:36 A.M. with State Tested Nurse Aide (STNA) #206 revealed sometimes the food served to the residents was not the food documented on the menu.

Interview on 12/20/22 at 10:00 A.M. with Registered Dietitian (RD) #234 revealed there were no substitutions documented on the December 2022 food substitution log. RD #234 confirmed there was no coffee in the facility on 12/11/22 and 12/12/22.

Review of the facility log titled Menu Substitution Log

Based on observation, interview, record review, and review of facility protocol, the facility failed to ensure a sanitary environment free of bed bugs. This affected four residents (#9, #19, #20 and #29) and had the potential to affect all 33 residents residing in the facility. The facility census was 33.

Findings include:

1. Review of Resident #20's medical record revealed an admission date of 10/09/18 with diagnoses including congestive heart failure, cardiomyopathy, and chronic kidney disease.

2. Review of Resident #19's medical record revealed an admission date of 10/17/19 with diagnoses including Alzheimer's disease, esophageal obstruction, other specified diseases of esophagus, acquired absence of other specified parts of digestive tract, and disorientation.

3. Review of Resident #29's medical record revealed an admission date of 05/25/21 with diagnoses including cognitive communication deficit, cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries, and major depressive disorder.

4. Review of Resident #9's medical record revealed an admission date of 01/18/22 with diagnoses including dementia with behavioral disturbance, suicidal ideations, and major depressive disorder.

Interview on 12/14/22 at 12:40 P.M. with Ombudsman #217 revealed the Assisted Living area of the facility had bed bugs since 02/2022. Ombudsman #217 stated it was hard to get the leadership staff of the facility to address issues. Ombudsman #217 stated Resident #29's family called her on 12/10/22 because they visited Resident #29 and found bed bugs crawling on their clothes. Ombudsman #217 stated an unidentified aide told her Resident #29 was getting bit by bed bugs.

Interview on 12/15/22 at 12:31 P.M. with Resident #24 revealed bed bugs were found on the fourth and fifth floor of the Assisted Living area of the facility. Resident #24 stated every month Resident Council had a meeting and things did not get addressed such as the bed bug problem.

Observation on 12/21/22 at 2:00 P.M. of the Resident Council meeting revealed the Resident Council President (Resident #24) stated there were bed bugs found on the fourth floor of the Assisted Living area of the facility.

Review of the Resident Council Meeting Minutes dated 12/21/2, included there were concerns of bedbugs on the fourth floor.

Observation on 12/22/22 at 6:37 A.M. with Resident Assistant (RA) #212 of Resident #19's room revealed a bed bug crawling on a blanket covering Resident #19's upholstered chair in his room. RA #212 confirmed a bed bug was crawling on the blanket and stated the bed bugs were in Resident #19's bed really bad. Observation of Resident #19's bed revealed a plastic cover encased the mattress, and the mattress could not be seen. No bed bugs were observed on the plastic cover of the mattress.

Interview on 12/22/22 at 11:15 A.M. with Vice President of Operations #230 and the Director of Nursing/Skilled Nursing Facility (DON/SNF) revealed Vice President of Operations #230 and the DON/SNF were informed a bed bug was seen crawling on a blanket on Resident #19's upholstered chair in his room.

Review of Resident #9's progress notes dated 12/24/22 at 12:08 P.M included Licensed Practical Nurse (LPN) #208 walked into Resident #9's room to administer his noon medications. Resident #9 was lying in bed. LPN #208 handed Resident #9 his medications and observed bed bugs on the side of his mattress. Maintenance was notified.

Review of Resident #9's progress notes dated 12/24/22 at 2:56 P.M. stated LPN #208 conducted a skin check on Resident #9. LPN #208 asked Resident #9 if she could check his body for bug bites. Resident #9 stated he did not want to get naked in front of LPN #208. LPN #208 explained that he did not have to if he could show her where he had been bitten. There was a small patch of bite marks on Resident #9's upper left thigh near his groin area. Resident #9 stated that the only place he had bites from the bed bugs was on his upper left thigh. Resident #9 stated that they didn't really bother him, but he did kill them when he saw them. There was observation of some spots that looked like bites that had healed around both of Resident #9's ankles. Resident #9 stated he was going to have his guardian buy him a new bed and furniture.

Review of Resident #20's progress notes dated 12/24/22 at 12:06 P.M. included an unidentified State Tested Nursing Assistant (STNA) was in Resident #20's room to get her a blanket because she needed moved to another room due to heat issues. The STNA observed bed bugs on Resident #20's bed and belongings. Maintenance was notified.

Review of the facility pest control company inspection report dated 12/26/22 included room 428 (Resident #20) had bed bugs in the chair and follow up was needed. The report stated room 525 (Resident #9) had bed bugs everywhere and follow up was needed.

Review of an email sent from Regional Director of Operations #216 on 01/03/22 at 12:10 P.M. revealed Resident #19's room was not checked for bed bugs. Regional Director of Operations #216 stated Vice President of Operations #230 and the DON/SNF did not recall being informed of a live bed bug in Resident #19's room, and the room was not treated.

Review of the facility protocol titled Bed Bug Protocol dated 11/21/22 included after initial report, staff would contact the pest control contractor and request a same day service. Staff would remove the residents and staff in the area suspected to be infested and maintenance would spray all areas with approved chemicals. After the pest control contractor completes the industrial application of chemicals, they would inform maintenance of the completion. Housekeeping department would deep clean the areas and the residents and staff would be advised of the readiness to return to the area.

This violation is a recite to the complaint survey completed 11/02/22.

Based on observation, interview and review of resident council minutes, the facility failed to serve palatable and appetizing meals. This affected all 37 residents.

Findings include:

Interview with Resident #125 on 10/20/22 at 11:05 A.M. reported they had complained at every resident council meeting about food not being identifiable, attractive, appetizing, running out of food, and they did not take into account resident preferences for having breakfast meats daily. She showed pictures of food on her cellular phone and the items were not identifiable.

The tray line was observed on 10/20/22 beginning at 11:55 A.M.,. there were five kitchen staff included a new cook. The food temperatures on the tray line were 187 degrees Fahrenheit (F) for the Sloppy Joe, hamburgers were 179 degrees F, peas were 178 degrees F and onion rings were 179 degrees F. There was roast pork on the tray line but the temperature was not taken. The foods were plated and often covered with plastic wrap because there were not enough insulated domes. The majority of the trays were placed into thermal carts and the other trays were placed on a rack with a plastic covering. A test tray was requested. The kitchen provided meals for the assisted living, nursing home and independent living.

The cart with the test tray left the kitchen at 12:23 P.M. and arrived on the second floor of the nursing home at 12:26 P.M. The dietary staff had the nurse sign receipt of the food cart. The aides were observed to deliver all of the meals by 12:42 P.M. at which time the test tray was conducted. Food Service Director (FSD) #425 took the temperatures using a probe thermometer. The Sloppy Joe was 121 degrees F and tasted luke warm but had good flavor, peas were 106 degrees F were hard, wrinkled, and tasted ice cold, the onion rings were 101 degrees F and were not hot. Interview with the FSD #525 on 10/20/22 at 1:00 P.M. reported the food was cold because the facility did not have insulated bases and dome covers for all of the residents and did not have enough staff to open up the dining rooms.

Review of the resident council minutes dated 08/17/22 indicated they had concerns with the quality of food preparation, delivery of food under par, menu problems, and not enough evening snacks. On 09/21/22 they continued to have concerns with the quality of food preparation and delivery was under par, not enough evening snacks and menu problems were addressed. On 10/19/22 they voiced concerns with food not being identifiable and the kitchen not having bacon or orange juice.

Based on interview and document review, the facility failed to maintain records of dated menus with food substitutions. This affected all 37 residents.

Findings include:

Interviews with Resident #125 and #130 on 10/20/22 beginning at 10:20 A.M. reported the menus were not consistently followed because the facility was not able to get the food items. They reported this was discussed at every resident council meeting.

Interview with Food Service Director (FSD) #425 on 10/20/22 at 11:55 A.M. reported the facility was having trouble getting menu items from the food distributor because they did not have them. A food substitution log was requested. FSD #425 reported the facility did not have one.

The facility provided three months of menus as requested but had no accounting of substitutions that were served to the residents.

Review of the October 2022 substitution log revealed substitutions made for 10/20/22 included pork was served instead of hamburger for renal and cardiac diets. The reason for the substitution was marked none. Also for 10/20/22 peach crisp was served instead of apple crisp. The reason for the substitution was marked none.

Review of resident council minutes dated 08/17/22 indicated menu problems and not enough snacks; on 09/21/22 there were menu problems and not enough evening snacks and on 10/19/22 dietary services were discussed again.

Based on observations, interviews and review of resident council minutes, the facility failed to maintain a clean, safe and sanitary environment. This potentially affected all 37 residents.

Findings include:

The tour of the facility began on 10/20/22 at 10:20 A.M. with Assisted Living Director (ALD) #423 on the fourth floor. The fourth floor was one long hallway. Outside Room 410 was a yellow housekeeping bucket fill with about an inch of water. There were two ceiling tiles missing directly above the bucket. Interview with ALD #423 said it had been like that since May 2022 and had yet to be repaired. Observation and interview with Resident #111 revealed she was seated in an over stuffed chair covered in a large white blanket. Resident #111 reported she had a black bug on her hand yesterday and squashed it in her fingers. She didn't report it to anyone but said she did not like them. Observation of the sixth floor revealed wrinkled carpeted hallway that was significant in the center and ran all the way down the halls. Several areas of seams were severely frayed. Interview with Resident #130 who was seated by the elevator and used a walker indicated his walker wheel got caught in the seams and over the large wrinkle. He said he was scared of falling. Interview with Resident #125 reported the residents complained about the same thing month after month and nothing was done about it. She reported that she used to be proud of where she lived but did not feel that way anymore because of the condition of the facility inside and outside.

Review of the resident council minutes dated 08/17/22 indicated they had concerns about bed bugs, lack of hot water and carpets needed repaired or replaced. On 09/21/22 they discussed bed bugs, mice, lack of hot water, carpets needing cleaned or replaced, the sixth floor dryer was not working, and the building entrance was littered with debris and was unkempt. It was noted in the minutes, the administrator indicated they had in house and professional resources to handle pest incidence, he was in process of getting bids for new carpet and ordered parts for the industrial carpet cleaner. On 10/19/22 they discussed bed bugs on the fourth floor, the dryer on the sixth floor still not working.

Interview with Pest Control Service Representative (PCSR) #430 on 10/25/22 at 4:25 P.M. reported he only found dead bed bugs on this date. He reported he could only do so much when the facility was not following through with the protocol. He indicated he texted the Administrator about the staff not following accepted protocols and they continued to do the same thing resulting in continued treatment for bed bugs. He indicated when he arrived on bed bug calls the facility was not prepared. The resident would still be in the room and the linens would be on the bed and their personal items not placed in plastic containers. He watched them take residents out of an infested room, move the residents to another room without changing and bagging their clothes, showering them or applying clean clothes. The next thing he knew he would be a called to treat the room the residents were placed in.

Review of the environmental cleanliness policy revised 08/31/22 indicated the facility must be maintained in a clean and sanitary manner.

This violation represents non-compliance investigated under Complaint Number OH00136410.