Hines Hill Senior Living

Based on observations, medical record review, review of the facility's incident log, review of resident funds accounts, review of the resident handbook, review of the resident agreement, review of the Medicaid waiver addendum to the resident agreement, review of facility policies, and interviews, the facility failed to have effective administration to oversee the provision of adequate care and services to meet the needs of residents, maintain resident safety, and ensure residents were fully informed of the facility's resident agreement prior to admission. This affected all 44 residents in the facility.

Findings include:

1. Review of the invoice dated 09/17/25 revealed parts were ordered from Guardian Protection and the Executive Director (ED) identified this invoice as being for new call lights. The invoice had a stamp applied indicating it was received 09/22/25.

There was no evidence of communication from the facility requesting parts or assistance with the call light system between 09/22/25 and 03/31/25.

Review of the email dated 03/31/26 at 10:03 A.M., sent from ED to the facility's owner's son, revealed an additional 15 to 20 call light pull stations were requested for residents who did not have pendant call lights.

Review of the invoice dated 04/22/26 revealed 15 wireless pull cord stations were ordered from Guardian Protection, approximately 22 days after ED requested to order the call light stations.

On 04/23/26 at 8:29 A.M., an interview with Medication Technician #506 stated the facility wifi was not functioning properly and the resident call system worked using wifi.

On 04/23/26 at 8:56 A.M., an interview with Wellness Director #521 stated the resident call system was working intermittently due to wifi issues and aides were conducting hourly checks on residents.

On 04/23/26 at 11:59 A.M., an interview with Hospice Registered Nurse (RN) #523 stated she provided care for former Resident #45, who discharged on 04/11/26. Hospice RN #523 stated Resident #45's call light did not work while she was in the facility. Hospice RN #523 further stated Resident #45's call light came off the wall and the facility instructed the resident to just carry the pull cord call light around the facility with her, however, the call light did not work when activated.

On 04/27/26 at 9:16 A.M., an interview with ED stated the facility had ordered new call lights twice. She stated the first box that was delivered did not work and they were still waiting on the second shipment.

On 04/27/26 at 9:45 A.M., an observation with ED of the call light system monitor revealed the screen displayed no results when looking at historical call light data from 04/20/26 to current. Interview at the time of observation with ED confirmed there was no historical call light data available for 04/20/26 through 04/27/26. The ED further confirmed there was historical call light data for the week prior and she was unable to provide an explanation for the lack of data beginning on 04/20/26.

On 04/27/26 at 10:53 A.M., an interview with ED stated the facility had issues with call lights since September 2025 and new call lights had been delivered on 09/22/25. ED further stated that those new call lights did not work and were sitting in a box in the staff area. ED was unable to state why no additional orders had been placed for new call lights between 09/22/25 and 04/22/26 other than claiming the owner's son was responsible for ordering and he ran on his own time.

On 04/27/26 from 11:06 A.M. to 1:18 P.M., an environmental tour with Wellness Director #521 revealed there were 60 pull cord call lights in the facility and 13 pendants. Testing of all 60 call lights and all 13 pendants throughout the building during the environmental tour revealed none of the devices transmitted a signal to the call light system when activated. During the environmental tour, Residents #2, #3, #5, #6, #8, #9, #11, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #28, #30, #31, #35, #37, #40, and #42 did not have call lights in required areas. The concerns identified during the environmental tour were verified by Wellness Director #521 at the time of observation.

On 04/27/26 from 11:06 A.M. to 1:18 P.M., during the environmental tour, interviews with Residents #2, #3, #6, #7, #8, #9, #11, #15, #17, #18, #24, #26, #31, #32, #35, #38, and #44 expressed concerns with call lights working properly, staff responding when the call light was activated, or having reasonable access to a call light. Residents #15, #17, and #26 stated they had to use their cell phones to call the facility's front desk for assistance because their call lights did not work.

On 04/27/26 at 3:26 P.M., an observation of the call light system monitor in the employee office area by the front desk indicated the most recent call light request was on 04/19/26 at 11:07 P.M. An interview at the time of observation with Wellness Director #521 verified the date and time of the last call light that was displayed on the call light system monitor.

On 04/27/26 at 5:00 P.M., an interview with ED claimed the call light system report indicating the last call light signal received was 04/19/26 was invalid; however, ED was unable to provide evidence that the call light system was working after that time and verified a second time that when the ED reviewed the historical call light data earlier in the day there was no data available beginning 04/20/26 through 04/27/26.

On 04/29/26 at 11:47 A.M., an interview with ED stated it was facility policy to provide residents with personal alarms when the call light system was not working properly and to conduct rounding every 10 minutes during the call light system failure. ED verified during the current call light system failure, residents were not provided personal alarms and staff rounded every hour instead of every 10 minutes.

On 04/29/26 at 1:00 P.M., an interview with Wellness Director #521 stated she was unaware of the facility's emergency call light system failure policy. Upon reviewing the policy, Wellness Director #521 stated she did not know residents were supposed to be provided with personal alarms and rounding should be conducted every 10 minutes for the duration of a call light system failure. Wellness Director #521 further stated that policy needed to be restructured and indicated rounding every 10 minutes was unrealistic. Wellness Director #521 also stated as far as monitoring the call light system for proper functioning, they changed all the batteries in call light devices in January 2026 and the system would alert them if the batteries were running low. Wellness Director #521 was unable to provide any insight related to audits or documentation of testing the functionality of the call light system.

On 04/29/26 at 4:25 P.M., an interview with ED stated she had access to the call light system on her tablet and she audited the call light system quarterly to ensure it was functioning properly. ED stated she did not document those audits anywhere and it consisted of her reviewing the historical call light data in the system.

The facility was unable to provide any evidence the call light system had been audited for functionality prior to 04/27/26.

Review of the facility policy titled Emergency Call Light Failure Policy

Based on review of the resident handbook and interview, the facility failed to ensure use of resident call systems was not limited to emergencies only. This affected all 44 residents in the facility.

Findings include:

Review of the resident handbook, dated 08/22/25, revealed each suite was equipped with an emergency call system which alarmed a caregiver to a resident's need for assistance. Pull stations were also available in the toilet and shower areas. The handbook indicated the call system was only to be used for emergencies, during temporary sickness, or when requiring assistance to transfer.

On 04/30/26 at 10:05 A.M., an interview with Executive Director verified the resident handbook indicated the call system was only to be used in emergencies, during temporary sickness, or when needing transfer assistance.

This violation represents non-compliance investigated under Complaint Number OH00170455 and Complaint Number OH00170262.

Based on record review and interview, the facility failed to provide Residents #27 and #52 with a written residency agreement prior to admission. This affected two residents (#27 and #52) out of two reviewed for resident agreements. The facility census was 44.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 29/26/25 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, malfunction of tracheostomy stoma, type two diabetes mellitus, and hypertension.

Review of the admission paperwork for Resident #27 revealed there was no signed resident agreement, just a signed Medicaid waiver addendum to the Resident Agreement.

Review of the Medicaid waiver addendum to the resident agreement revealed it explicitly stated This Medicaid Waiver Addendum (the Addendum) shall supplement the Assisted Living Residency Agreement and It is the intention of the parties that this Addendum be read in conjunction with the terms and condition of the aforementioned Agreement, and that the two documents constitute a single instrument evidencing the terms and conditions of the parties' relationship.

On 04/30/26 at 12:30 P.M., an interview with Executive Director (ED) revealed residents who were Medicaid waiver recipients only received the Medicaid waiver addendum and not the full resident agreement. ED confirmed Resident #27 was not provided the full resident agreement, just the Medicaid waiver addendum.

On 04/30/26 at 12:37 P.M., an interview with ED confirmed the Medicaid waiver addendum indicated it was supplemental to the resident agreement and was to be provided in conjunction with the agreement.

On 04/30/26 at 4:25 P.M., an interview with ED stated the facility's attorney claimed Medicaid waiver recipients could not sign both the resident agreement and the Medicaid waiver addendum to the resident agreement.

2. Review of the medical record for Resident #52 revealed an admission date of 04/24/26 with diagnoses including morbid obesity, hypertension, peripheral vascular disease, and drug induced subacute dyskinesia.

Review of the admission paperwork for Resident #52 revealed there was no signed resident agreement, just a signed Medicaid waiver addendum to the resident agreement.

Review of the Medicaid waiver addendum to the resident agreement revealed it explicitly stated This Medicaid Waiver Addendum (the Addendum) shall supplement the Assisted Living Residency Agreement and It is the intention of the parties that this Addendum be read in conjunction with the terms and condition of the aforementioned Agreement, and that the two documents constitute a single instrument evidencing the terms and conditions of the parties' relationship.

On 04/30/26 at 12:30 P.M., an interview with ED confirmed residents who were Medicaid waiver recipients only received the Medicaid waiver addendum and not the full resident agreement.

On 04/30/26 at 12:37 P.M., an interview with ED confirmed the Medicaid waiver addendum indicated it was supplemental to the resident agreement and was to be provided in conjunction with the agreement.

On 04/30/26 at 3:55 P.M., an interview with ED verified Resident #52 was not provided the full resident agreement, just the Medicaid waiver addendum.

On 04/30/26 at 4:25 P.M., an interview with ED stated the facility's attorney claimed Medicaid waiver recipients could not sign both the resident agreement and the Medicaid waiver addendum to the resident agreement.

Based on record review and interview, the facility failed to ensure the residency agreement provided to Medicaid Waiver recipients included all necessary components. This affected two residents (#27 and #52) of two reviewed for Resident Agreements. The facility census was 44.

Findings include:

1. Review of the medical record for Resident #27 revealed an admission date of 29/26/25 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, malfunction of tracheostomy stoma, type two diabetes mellitus, and hypertension.

Review of the admission paperwork for Resident #27 revealed there was no signed resident agreement, just a signed Medicaid waiver addendum to the Resident Agreement.

Review of the Medicaid waiver addendum to the resident agreement revealed it explicitly stated This Medicaid Waiver Addendum (the Addendum) shall supplement the Assisted Living Residency Agreement and It is the intention of the parties that this Addendum be read in conjunction with the terms and condition of the aforementioned Agreement, and that the two documents constitute a single instrument evidencing the terms and conditions of the parties' relationship. The addendum did not include a statement that all charges, fines, or penalties that would be assessed against the resident were included in the resident agreement; a statement that the basic rate would not be changed unless 30 days written notice was given; an explanation of the residential care facility's policy for refunding charges in the event of the resident's absence, discharge, or transfer from the facility and the facility's policy for refunding security deposits; and a statement that the facility was obligated to discharge or transfer a resident when a resident needs skilled nursing care beyond the limitations of an assisted living facility.

On 04/30/26 at 12:30 P.M., an interview with Executive Director (ED) revealed residents who were Medicaid waiver recipients only received the Medicaid waiver addendum and not the full resident agreement. ED confirmed Resident #27 was not provided the full resident agreement, just the Medicaid waiver addendum.

On 04/30/26 at 12:37 P.M., an interview with ED confirmed the Medicaid waiver addendum indicated it was supplemental to the resident agreement and was to be provided in conjunction with the agreement.

On 04/30/26 at 4:25 P.M., an interview with ED stated the facility's attorney claimed Medicaid waiver recipients could not sign both the resident agreement and the Medicaid waiver addendum to the resident agreement.

2. Review of the medical record for Resident #52 revealed an admission date of 04/24/26 with diagnoses including morbid obesity, hypertension, peripheral vascular disease, and drug induced subacute dyskinesia.

Review of the admission paperwork for Resident #52 revealed there was no signed resident agreement, just a signed Medicaid waiver addendum to the resident agreement.

Review of the Medicaid waiver addendum to the resident agreement revealed it explicitly stated This Medicaid Waiver Addendum (the Addendum) shall supplement the Assisted Living Residency Agreement and It is the intention of the parties that this Addendum be read in conjunction with the terms and condition of the aforementioned Agreement, and that the two documents constitute a single instrument evidencing the terms and conditions of the parties' relationship. The addendum did not include a statement that all charges, fines, or penalties that would be assessed against the resident were included in the resident agreement; a statement that the basic rate would not be changed unless 30 days written notice was given; an explanation of the residential care facility's policy for refunding charges in the event of the resident's absence, discharge, or transfer from the facility and the facility's policy for refunding security deposits; and a statement that the facility was obligated to discharge or transfer a resident when a resident needs skilled nursing care beyond the limitations of an assisted living facility.

On 04/30/26 at 12:30 P.M., an interview with ED revealed residents who were Medicaid waiver recipients only received the Medicaid waiver addendum and not the full resident agreement.

On 04/30/26 at 12:37 P.M., an interview with ED confirmed the Medicaid waiver addendum indicated it was supplemental to the resident agreement and was to be provided in conjunction with the agreement.

On 04/30/26 at 3:55 P.M., an interview with ED verified Resident #52 was not provided the full resident agreement, just the Medicaid waiver addendum.

On 04/30/26 at 4:25 P.M., an interview with ED stated the facility's attorney claimed Medicaid waiver recipients could not sign both the resident agreement and the Medicaid waiver addendum to the resident agreement.

Based on interview and record review, the facility failed to obtain witness authorizations to manage resident funds. This affected four residents (Resident #5, #22, #37, and #43) of five residents reviewed for resident funds. The facility census was 44.

Findings include:

Review of Resident Funds Spreadsheet revealed Resident #5, #22, #37, and #43 had personal funds managed by the facility. There was no evidence of authorized witness statements to manage the funds.

On 04/27/26 at 10:10 A.M., an interview with Executive Director (ED) #500 confirmed the facility did not have witnessed authorizations to manage resident funds as the facility only sends paperwork to social security to manage the resident's funds.

Based on interview and record review, the facility failed to provide individualized interest bearing accounts for residents with personal funds managed by the facility. This affected four residents (Resident #5, #22, #37, and #43) of five residents reviewed for personal funds. The census was 44.

Findings include:

Review of Resident Funds Spreadsheet revealed Resident #5, #22, #37, and #43 had funds managed by the facility. Review of the resident fund statements revealed it was in one account and non-interest bearing.

On 04/27/26 at 10:06 A.M., an interview with Corporate Worker #522 revealed the residents' funds were all in one account and the account was non-interest bearing. Corporate Worker #522 revealed they keep track of funds on a spreadsheet monthly.

Based on interview and record review, the facility failed to make provisions for the conveyance of any remaining funds after a residents discharge. This affected one resident (Resident #49) of three residents reviewed for final disbursement of funds.

Findings include:

Review of Resident #49's medical record revealed the resident was discharged from the facility on 08/29/25. The resident had a final balance of $2,012 at the time of discharge. The final disbursement of resident funds to Social Security was not made until 03/20/26.

On 04/30/26 at 11:33 A.M., an interview with Corporate Worker #522 revealed resident funds remain in a joint account until the facility hears from Social Security or resident's family to designate where to send the funds.

Review of Financial Affairs Policy revealed that in the event of a resident's transfer, discharge, or death, Hines Hill Assisted Living shall close the resident's account. The policy also revealed that for residents who are transferring or being discharged, all remaining funds shall be returned to the resident or their authorized sponsor. In case of a resident's death, all remaining funds shall be handled in accordance with the provisions outlined in section 5162.22 of the Revised Code.

Based on medical record review, review of the facility's incident log, and interview, the facility failed to maintain a complete and accurate incident log with all required information separate from the medical record. This affected three residents (#10, #24, and #45) out of five reviewed for falls. The facility census was 44.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 09/26/25 with diagnoses including Alzheimer's, dementia, chronic obstructive pulmonary disease, and hypertension.

Review of the incident report in the electronic health record dated 04/21/26 at 4:17 P.M. revealed Resident #10 had an unwitnessed fall in his room by the bathroom and complained of pain to the right shoulder and elbow. Facility staff observed Resident #10 favoring his right arm. Resident #10's family and hospice were notified of the incident.

Review of the progress note dated 04/21/26 at 9:30 P.M. revealed Resident #10 was sent to the emergency room per orders from the hospice nurse.

Review of the hospital after visit summary dated 04/21/26 revealed Resident #10 was evaluated for fall with shoulder injury and diagnosed with a proximal humerus fracture. Resident #10 was sent back to the facility with education for fall prevention.

Review of the facility's incident log revealed the log only included the date of the incident, the name of the resident involved, and what type of incident occurred. There was no indication as to the time the incident occurred, location where the incident occurred, or what actions the facility took following the incident.

On 04/28/26 at 10:36 A.M., an interview with Wellness Director #521 verified the incident log did not include the time of day the incidents occurred, the location where the incidents occurred, or what actions the facility took after the incident occurred.

2. Review of the medical record for Resident #24 revealed an admission date of 01/09/25 with diagnoses including hypertension, atrial fibrillation, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, history of falling, and need for assistance with personal care.

Review of the incident report in the electronic health record dated 04/14/26 at 3:45 P.M. revealed Resident #24 had an unwitnessed fall in her bathroom and was complaining of 10 out of 10 pain to her back. Tylenol was administered as ordered. Resident #24 was assessed with no skin impairments noted. Resident #24's family and hospice were notified.

Review of the incident report in the electronic health record dated 04/16/26 at 7:40 A.M. revealed Resident #24 had an unwitnessed fall in her room by her bed and was complaining of nine out of 10 pain to her back. Hydromorphone was administered as ordered. Resident #24 was assessed and no skin injuries were identified. Resident #24's family and hospice were notified, as well as Wellness Director #521.

Review of the facility's incident log revealed the log only included the date of the incident, the name of the resident involved, and what type of incident occurred. There was no indication as to the time the incident occurred, location where the incident occurred, or what actions the facility took following the incident.

On 04/28/26 at 10:36 A.M., an interview with Wellness Director #521 verified the incident log did not include the time of day the incidents occurred, the location where the incidents occurred, or what actions the facility took after the incident occurred.

3. Review of the medical record for Resident #45 revealed an admission date of 02/28/26 with diagnoses including presence of left artificial hip joint, hypertension, insomnia, muscle weakness, difficulty in walking, need for assistance with personal care, reduced mobility, fibromyalgia, Bell's palsy, overactive bladder, and disorientation. Resident #45 discharged from the facility on 04/11/26 to another care facility.

Review of the incident report in the electronic health record dated 03/28/26 at 6:44 A.M. for Resident #45's fall revealed the report was incomplete and only included the nurse's note stating Resident #45 was found on the floor with a laceration to the forehead. There was no pain evaluation, no vital signs, and no evidence of notification to the facility director, physician, or family. Emergency Medical Services (EMS) was called.

Review of the progress note dated 03/28/26 at 11:14 A.M. revealed Resident #45 returned to the facility after being sent out earlier that morning for evaluation after a fall. Resident #45 had an abrasion of the forehead and Morphine was administered as ordered due to complaints of pain.

Review of the facility's incident log revealed Resident #45's unwitnessed fall on 03/28/26 was not included on the incident log.

On 04/28/26 at 3:18 P.M., an interview with Resident Care Coordinator (RCC) #501 verified Resident #45's unwitnessed fall on 03/28/26 was not included on the incident log.

On 04/28/26 at 3:50 P.M., an interview with Wellness Director #521 verified the nurse on duty did not complete Resident #45's incident report in its entirety for the unwitnessed fall that occurred on 03/28/26. Wellness Director #521 stated the entire report should have been completed, not just the nurse's note.

This violation represents non-compliance investigated under Complaint Number OH00170262.

Based on record review and interview, the facility failed to complete an annual tuberculosis risk assessment of the facility. This had the potential to affect all 44 of the residents in the facility.

Findings include:

Review of the facility Tuberculosis Exposure Plan revealed the last tuberculosis (TB) risk assessment for the facility was completed on 05/17/23. The facility was listed as being at a low risk for transmission at that time.

On 04/27/26 at 9:16 A.M., an interview with Executive Director (ED) #500 confirmed the facility had not updated the TB risk assessment since 05/17/23.

Based on interview and record review, the facility failed to conduct one fire drill on each shift at least every three months and failed to document alarm transmission/receipt confirmation. This had the potential to affect all 44 residents of the facility.

Findings include:

Review of Fire Drill reports revealed the facility conducted the following drills: 04/11/25 on day shift, 05/14/25 on day shift, 06/11/25 on day shift, 07/14/25 on night shift, 08/12/25 on day shift, 09/12/25 on day shift, 10/10/25 on day shift, 11/12/25 on day shift, 12/15/25 on day shift, 01/16/26 on night shift, 02/13/26 on night shift and 03/13/26. The time of the drill was not documented. There was no verification of receipt of the fire alarm signal to the fire department.

On 04/27/26 at 11:05 A.M., an interview with Executive Director (ED) #500 revealed that there was only two shifts for the facility, day shift 7:00 A.M. to 7:00 P.M. and night shift 7:00 P.M. to 7:00 A.M.

On 04/27/26 at 12:05 P.M., an interview with ED #500 revealed that they were not aware of conducting fire drills on each shift at least once every three months. An additional request of receipt of fire alarm transmissions was made at the time of interview. The facility did not provide this evidence.

Review of Fire Safety and Disaster Plan Book revealed a document stating fire drills must be conducted once per quarter on each shift.

Based on interview and record review, the facility failed to conduct monthly fire safety inspections in the facility. This had the potential to affect all 44 of the residents of the facility.

Findings include:

Review of Maintenance Binder revealed monthly inspections of the sprinkler system for the facility. There was no evidence of monthly fire safety inspections.

On 04/27/26 at 2:22 P.M., an interview with Executive Director #500 confirmed there was no documentation for the facility monthly fire safety inspections at this time.

Based on closed record review and interview, the facility failed to ensure safe smoking practices and interventions were in place for Resident #46 to prevent injury while smoking. This affected one resident (#46) of one resident reviewed for smoking. The census was 44.

Actual harm occurred on 11/10/25 when Resident #46 burned the right side of his face, experiencing second degree burns, and requiring treatment at the burn center as a result of smoking in his room while wearing oxygen. Prior to the incident, the facility failed to ensure the resident was assessed to smoke safely and interventions were in place to prevent the resident from igniting a cigarette in his room while wearing oxygen.

Findings include:

Review of Resident #46's closed medical record revealed the resident was admitted 08/20/25 with diagnoses including bipolar disorder, schizophrenia, anxiety, depression, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and nicotine dependence. Resident #46 expired at the facility 01/11/26.

Review of Resident #46's Semi-Annual Evaluation dated 11/03/25 revealed the resident received oxygen.

Review of Resident #46's medical record revealed no evidence of a care plan related to safe smoking practices or an assessment to determine the resident's ability to safely smoke independently.

Review of Resident #46's medical record revealed an incident report dated 11/10/25 at 6:28 A.M. which was incomplete. Resident #46 was observed to have burns to the right side of the face when the nurse opened the door to the resident's room. Resident #46 told the nurse that he was trying to light a wax figure and showed the nurse the wax figure (later discovered to be the resident was lighting a cigarette). Hospice was notified and Resident #46 was sent to the hospital to be evaluated. The incident report only contained the incident summary with no evidence of an assessment of the residents' burns or pain experienced.

Review of the emergency room after visit summary dated 11/10/25 revealed Resident #46 arrived to the emergency room on 11/10/25 at 7:06 A.M. via ambulance for evaluation and treatment after smoking while wearing oxygen and suffering burns to the face. There was no indication as to the severity of the burns. New orders were given for mineral oil-hydrophilic petrolatum ointment and a follow-up appointment at the burn clinic was recommended for 11/13/25.

Review of Resident #46's medical record revealed no evidence the facility implemented intervention to ensure the resident's safety when smoking until 11/14/25.

Review of Resident #46's observation note dated 11/12/25 at 9:00 A.M., authored by Wellness Director #521 revealed the resident came out of the elevator, started going outside, and he was witnessed lighting a cigarette with his oxygen on and in his nose. Wellness Director #521 ran up to him yelling him to stop, don't light the cigarette and the resident disregarded the warnings and lit it anyway. Wellness Director #521 immediately turned off the oxygen and took it off the resident and placed the oxygen inside the door.

Review of Resident #46's care plan, updated 11/14/25, revealed the resident was educated about the smoking policy and about smoking in his room and the hazards while he was on oxygen. Special instructions included the resident endured facial burns to the right side of his face related to smoking in his room while on his oxygen. He was educated on the hazards and risks of his decision to smoke. He was also educated on safety precautions/policy. The plan included the resident understands and agrees that he would no longer be allowed to have lighters or matches in his room. He understands he would have to come and ask for a lighter and cigarettes from staff and then return it when finished. Resident #46 also has been abusing alcohol which might have contributed to his poor decision making and was educated on alcohol abuse.

Review of Resident #46 New Patient History and Physical from the outpatient burn center dated 11/19/25 revealed the resident's nose had second degree .05% burns, lips second degree .05% burn, and mouth had second degree .05% burn. The date of burn was identified to be 11/10/25 with a treatment of bacitracin. Resident #46 presented with a flash burn to the face while smoking with oxygen. The resident was smoking in his room in the senior living facility in which he resides with oxygen and sustained flash burns to his face and mouth and soot around his nose with singe burns to his eyebrows and facial hair. He was taken to the emergency department where they performed an assessment and sent him home with bacitracin to apply daily. The resident has COPD at baseline but has not noted any increased shortness of breath or sputum since the injury. The resident received Morphine at 8:00 A.M. this morning before leaving the building as states that he has some pain but it is well-controlled. Resident #46 reported he has not been eating as much due to pain around mouth.

Review of Resident #46's observation note dated 12/18/25 at 1:24 P.M. revealed when the nurse went to administer medicine to the resident the nurse smelled a strong odor of cigarette and observed smoke in the resident's room. The nurse educated the resident there was no smoking allowed in rooms nor around oxygen tanks. Resident #46 expressed that he would not do it again and the Assistance Director of Nursing (ADON) was notified.

Review of Resident #46's medical record and care plan reviewed no further interventions were implemented as a result of the resident smoking in his room again.

On 04/29/26 at 12:55 P.M., an interview with Wellness Director #521 confirmed the incident report (for the incident on 11/10/25) was not complete to include a full assessment of Resident #46 after he burned himself. Wellness Director #521 revealed it was unknown what treatments the resident received after sustaining the burns. Wellness Director #521 revealed Resident #46 was smoking while wearing oxygen, not lighting a wax figure, which ignited and caused him burns to his face. Wellness Director #521 confirmed the details of the incident were not documented accurately in the medical record or incident log. Wellness Director #521 revealed Resident #46 was then caught outside smoking with oxygen a few days later and an incident report was not filed. Wellness Director #521 confirmed there were no interventions implemented after the resident burned his face on 11/10/26 prior to being found smoking outside with oxygen on 11/12/25. After the 11/12/25 incident, Wellness Director #521 indicated Resident #46's lighter and cigarettes were taken and held at the front desk. Resident #46 had to ask for his cigarettes and lighter, so staff could make sure he was not wearing oxygen.

On 04/29/26 at 1:44 P.M., an interview with Residential Care Coordinator (RCC) #501 revealed on 11/10/25, the nurse was passing morning medications when, RCC #501 was called to come to Resident #46's room. RCC #501 revealed upon her arrival to the room, Resident #46's face was singed from being burned. RCC #501 identified Resident #46 was caught smoking in his room again on 12/18/25 at 1:24 P.M., after an odor of smoke was in the vicinity of Resident #46's room.

On 04/29/26 at 4:10 P.M., an interview with Wellness Director #521 confirmed Resident #46 did not have an assessment or care plan related to safe smoking, and the facility did not assess any residents in their ability to safely smoke independently. Wellness Director #521 revealed Resident #46 was educated on safe smoking practices and the hazards of smoking while on oxygen through review of the smoking policy. Wellness Director #521 revealed cigarettes and lighters were removed from the resident's room, but Resident #46 would obtain cigarettes and lighters from other residents, so they would make rounds to check the resident's room daily. Resident #46 had to go to the front desk before and after smoking to receive and return the lighter and cigarettes.

Review of Smoking Policy revealed smoking was permitted only outside of the house. It is expected that any smoker will discard cigarette butts appropriately and not simply drop on porch or ground. The policy did not include education on safe smoking practices.

Based on observation, record review, review of the Resident Handbook, facility policy review and interview, the facility failed to maintain a working call light/signal system as required for residents to request/obtain timely and necessary assistance from staff. This resulted in Real and Present Danger and the potential for actual harm for all 44 residents residing in the facility beginning on 04/20/26 when the resident call signal/system became inoperable and residents were unable to call for assistance utilizing the resident call system. Additionally, Actual Harm occurred on 04/21/26 (while the call system was inoperable) when Resident #10, who was at high risk for falls and required assistance from staff for bowel and bladder elimination, experienced a fall near his bathroom, was unable to obtain staff assistance through the call signal system (prior to or after the fall) and was subsequently transferred to the hospital where he was diagnosed with a fractured arm.

On 04/28/26 at 12:21 P.M., the Executive Director (ED) and Wellness Director #521 were notified Real and Present Danger began on 04/20/26 when the resident call system became inoperable without evidence the facility implemented immediate and effective alternative measures for residents to obtain timely and necessary staff assistance.

The Real and Present Danger was abated on 04/29/26 when the facility implemented the following corrective actions:

On 04/22/26 Executive Director reached out to IT department to get the call light system inspected on 04/22/2026.

On 04/24/26 a service tech arrived at facility to fix the call light system but was unable to resolve it. The system remained down over the weekend into the following week.

On 04/27/26 all residents were placed on every one-hour checks with a staffing sign-off form for completion.

On 04/27/26 all staff members were educated by the Executive Director to monitor the call light system to ensure it was turned on and operational.

Between 04/27/26 to 04/29/2026, an IT tech continued to work on the call light system remotely until a tech arrived to the facility on 04/29/26.

On 04/29/26, the ED and Certified Medication Aide (CMA) #506 assessed all residents, including Resident #10 to determine any unmet needs as a result of the lack of call system in place.

On 04/29/26, the ED and CMA #506 educated all residents on proper use of the call system, including how to use resident pendants and wall pull stations for assistance.

On 04/29/26 IT was able to restore the call light system and the facility call light system was functioning.

On 04/29/26, the Executive Director conducted a full house audit of the call light system by checking every call light to identify all call pendants/pull stations that showed low battery or dead battery. During this audit, it was identified 15 call lights had batteries that were not working or were low. Once identified, maintenance director was given a count of batteries to purchase, and they were purchased on rooms noted to be missing a pull station in the living area and/or bathroom.

On 04/29/26 at 4:07 P.M., observation of the call light system electronic monitor revealed the system was functional at this time and facility staff were testing the call light devices and auditing battery levels.

Beginning on 05/04/26, the ED would audit the call light system and devices weekly for the next four weeks by testing 10 call lights weekly to ensure proper working order as well as reviewing call light data. After the next four weeks, monthly call light audits would be conducted to ensure the call light system is functioning properly.

By 05/10/26 the ED would conduct an entire staff interview on policies and procedures of call light system failure including personal pendants to ensure all staff understand steps to take if the system should go down in the future. If additional training was needed it would be provided by the Executive Director.

The facility Quality Assessment and Performance Improvement (QAPI) committee would be actively involved in oversight of plan and audit findings on an ongoing basis to ensure sustained compliance and patient safety.

Although the Real and Present Danger was abated on 04/29/26, the violation remained 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 medical record for Resident #10 revealed an admission date of 09/26/25 with diagnoses including Alzheimer's, dementia, chronic obstructive pulmonary disease, and hypertension.

Review of the fall risk assessment dated 01/28/26 revealed Resident #10 was at high risk for falls with a score of 10. The assessment indicated a score of five or greater was considered high risk.

Review of the Mini Mental State Examination (MMSE) dated 01/28/26 revealed Resident #10 had mild cognitive impairment with a score of 18. The MMSE interpretive guidelines revealed a score of 18 to 23 was indicative of mild cognitive impairment.

Review of the quarterly evaluation and care plan dated 04/09/26 revealed Resident #10 was ambulatory with minimal assistance utilizing a walker and required minimal assistance for bowel and bladder elimination, which the care plan specified meant the resident completed the task with the physical presence of staff for safety or hands on assistance.

Review of an incident report dated 04/21/26 at 4:17 P.M. revealed Resident #10 had an unwitnessed fall in his room by the bathroom and complained of pain to the right shoulder and elbow. Facility staff observed Resident #10 favoring his right arm. Resident #10's family and hospice were notified of the incident.

Review of the staffing schedules for 04/21/26 revealed there was one nurse, LPN #505, and two aides, Certified Nursing Assistant (CNA) #511 and Caregiver #518, working at the time of Resident #10's fall.

Review of the progress note dated 04/21/26 at 9:30 P.M. revealed Resident #10 was sent to the emergency room by order from the hospice nurse.

Review of the hospital after visit summary dated 04/21/26 revealed Resident #10 was evaluated for fall with shoulder injury and diagnosed with a proximal humerus fracture. Resident #10 was sent back to the facility with education for fall prevention.

On 04/23/26 at 2:08 P.M., Resident #10 was observed lying in bed yelling out for help and no staff were visible in the vicinity. Resident #10 was not interviewable at the time of this observation due to confusion the resident was exhibiting.

On 04/23/26 at 2:14 P.M., Wellness Director #521 was notified of Resident #10 calling out for help. Wellness Director #521 immediately went to Resident #10's room but was unable to locate Resident #10's call pendant in his room.

On 04/23/26 at 2:25 P.M., an interview with Wellness Director #521 verified she was unable to locate Resident #10's call pendant.

On 04/27/26 at 8:38 A.M., an interview with Wellness Director #521 revealed Resident #10 was pretty independent prior to last week when he fell and broke his arm. Wellness Director #521 revealed there were some rooms that did not have a call light and the facility's owner had yet to respond to their request for ordering new call lights.

On 04/27/26 at 3:38 P.M., an interview with Licensed Practical Nurse (LPN) #505 revealed Resident #10 was able to utilize his call light prior to the fall and said he would call for assistance when needed.

On 04/27/26 at 3:57 P.M., an interview with LPN #505 revealed Resident #10 required minimal assistance from staff prior to his fall last week. LPN #505 said Resident #10 was taking himself to the bathroom at the time of the fall and she thinks he lost his balance. LPN #505 said Resident #10's walker was in the bathroom and unlocked, which she clarified Resident #10 was good about locking his walker when he was going from standing to sitting.

On 04/27/26 at 4:01 P.M., an interview with Certified Nursing Assistant (CNA) #511 revealed Resident #10 lost his balance in his bathroom. CNA #511 did not witness the fall, stating she was in the laundry room at the time of the fall. CNA #511 revealed she observed Resident #10 on the floor while walking in the hallway with another resident. CNA #511 revealed Resident #10 was by his bathroom door and his brief was around his knees. CNA #511 revealed LPN #505 was the one who saw Resident #10 prior to the fall.

On 04/27/26 at 4:07 P.M., an interview with LPN #505 revealed she last saw Resident #10 in his room between 2:30 P.M. and 3:00 P.M. when she was heading to administer medications to Resident #32.

On 04/27/26 at 4:10 P.M., review of the medication administration record (MAR) for Resident #32 with LPN #505 confirmed the medication administration occurred on 04/21/26 at 2:08 P.M. and LPN #505 verified that was the last time she saw Resident #10 prior to his fall.

Review of the facility undated policy titled Fall Prevention and Response Policy

Based on interview and record review, the facility failed to ensure the grievance committee consisted of at least two residents to every staff member. This had the potential to affect all 44 residents of the facility.

Findings include:

Review of Resident Council/ Grievance Committee document revealed there were three residents and three staff members on the committee.

On 04/28/26 at 9:36 A.M., an interview with Executive Director (ED) #500 revealed there are currently only three residents on resident council/grievance committee and three staff members. There were four other residents on the list, but they no longer live at this facility.

Based on record review and interview, the facility failed to ensure the electronic health record was maintained in a complete and accurate manner to include a comprehensive list of medical diagnoses. This affected one resident (#31) out of five reviewed for complete medical records. The facility census was 44.

Findings include:

Review of the medical record for Resident #31 revealed an admission date of 02/05/25. There were no diagnoses listed in the electronic health record for Resident #31.

Review of Resident #31's face sheet revealed there were no primary or secondary diagnoses listed.

Review of the initial health evaluation dated 02/05/25 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

Review of the 30 day health evaluation dated 03/07/25 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

Review of the nurse practitioner's new patient progress note dated 04/15/25 indicated Resident #31 had medical diagnoses including hyperglycemia, recent staph aureus infection, heart block, moderate aortic stenosis, cellulitis of the right leg, class III obesity, nonrheumatic aortic valve stenosis, chronic heart failure with preserved ejection fraction, mild intermittent asthma, obstructive sleep apnea, stage three chronic kidney disease, hypothyroidism, and uncontrolled type two diabetes mellitus with hyperglycemia.

Review of the quarterly health evaluation dated 06/06/25 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

Review of the quarterly health evaluation dated 09/05/25 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

Review of the quarterly health evaluation dated 12/04/25 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

Review of the quarterly health evaluation dated 02/04/26 for Resident #31 revealed there were no medical diagnoses listed on the health evaluation.

On 04/29/26 at 10:12 A.M., an interview with Wellness Director #521 verified there were no diagnoses listed in the electronic health record or on the health evaluations for Resident #31.

Based on record review, interview, and facility policy review, the facility failed to ensure there were physician's orders in place for an injectable prescription medication pen prior to providing pen needles to Resident #48 for self-administration. This affected one resident (#48) of three reviewed for medications. The facility census was 48.

Findings include:

Review of the medical record for Resident #48 revealed an admission date of 02/01/25 with diagnoses including chronic back pain, osteoarthritis of unspecified hip, contracture of left knee, intervertebral disc displacement, and intervertebral disc degeneration.

Review of the physician's progress note dated 04/23/25, written by Resident #48's outside primary care physician, revealed Resident #48 had a diagnosis of pre-diabetes and there were no active orders for Victoza at that time. Resident #48 had previously been ordered Victoza and suffered severe side effects leading to a cholecystectomy. Resident #48's primary care physician discussed the possibility of trialing Victoza again depending on lab results. The new physician's orders included comprehensive metabolic panel, hemoglobin A1c, complete blood count, and vitamin B12. Medication orders included Flexeril 10 milligrams (mg) tablet to take 5 to 10 mg daily at night as needed, Ibuprofen 600 mg tablet to take one tablet three times daily as needed for pain, Melatonin 10 mg tablet to take one tablet daily at night as needed for insomnia, and Prilosec 40 mg capsule to take one capsule twice daily before meals. There were no medication changes at this visit.

Review of the physician's orders for Resident #48 revealed there were no active or discontinued orders for Victoza in the facility's electronic health record.

Review of the progress note dated 10/13/25 at 12:30 P.M., written by Medication Technician (Med Tech) #103, revealed Resident #48 approached the nurse's station in search of needles for his Victoza pen. Resident #48 was educated on his responsibility to order appropriate supplies and his option to have his medications managed by the facility. Med Tech #103 provided Resident #48 with two needles to address his insulin need for the day. Approximately two hours later, Resident #48 reported his blood sugar was low and he had stomach pains. Resident #48's blood sugar was checked with a reading of 100 milligrams per deciliter (mg/dl), which was not indicative of hypoglycemia.

Review of the progress note dated 10/14/25 at 12:50 P.M., written by Wellness Director #101, indicated Resident #48 approached the nurse's office area asking to have his blood sugar checked. There was no diagnosis of diabetes in Resident #48's medical record at that time. Resident #48 told Wellness Director #101 that his doctor ordered Victoza which he had in his refrigerator.

Review of the medication orders provided by Resident #48's primary care physician, faxed on 10/16/25, revealed there were no orders for Victoza and an allergy to Metformin had been added 08/21/25 with reaction symptoms listed as diarrhea.

Review of the progress note dated 10/17/25 at 8:00 A.M., written by Wellness Director #101, revealed Resident #48's outside primary care physician had discontinued the Victoza in April 2025 and the resident should not have been taking that medication.

On 10/30/25 at 8:51 A.M., an interview with Wellness Director #101 revealed Resident #48 self-administered medications.

On 10/30/25 at 2:04 P.M., an interview with Med Tech #103 revealed Resident #48 came to the nurse's station stating he was out of needles for his insulin pen. Med Tech #103 verified she provided Resident #48 with a needle for an insulin pen at his request and explained to him that he would have to order them in the future. Med Tech #103 said when the facility followed up with Resident #48's primary care physician, it was discovered Resident #48 did not have current orders for insulin or Victoza.

On 10/30/25 at 12:55 P.M., an interview with Resident #48 stated he had run out of needles for his Victoza pen and the lancet device for his glucometer was not working, and that was why he asked facility staff for them. Resident #48 confirmed the Victoza order had been discontinued but he kept taking it.

On 10/30/25 at 4:17 P.M., an interview with Wellness Director #101 stated Resident #48 did not have a diagnosis of diabetes in their electronic health record, and confirmed there were no orders for Victoza. Wellness Director #101 stated Resident #48 self-administered his medications and paperwork from his primary care physician indicated the Victoza had been discontinued in April 2025.

Review of the facility's policy titled Medication Delivery

Based on observation, interview, and review of facility policy, the facility failed to store medications in a secured area. This affected one resident (#19) of four reviewed for medication administration. The facility census was 48.

Findings include:

Review of the medical record for Resident #19 revealed an admission date of 05/09/25 with diagnoses including chronic obstructive pulmonary disease (COPD), vascular dementia, delusional disorder, disorganized schizophrenia, and nicotine dependence.

Review of the physician's orders for Resident #19 revealed an order for Fluticasone Salmetorol (Advair) Diskus 250/50 micrograms (mcg) to give one puff by mouth one time daily at 8:00 A.M. for COPD (ordered 06/04/25).

Review of the Medication Administration Record (MAR) for Resident #19 revealed the Advair inhaler was administered on 10/30/25 at 7:53 A.M. by Medication Technician (Med Tech) #103.

On 10/30/25 at 9:43 A.M., an observation of the dining room revealed a round Advair 250/50 inhaler laying on the table closest to the dining room entrance. There was no box and no prescription label to indicate who the inhaler belonged to.

On 10/30/25 at 9:45 A.M., an interview with Licensed Practial Nurse (LPN) #102 verified the Advair inhaler was laying on the table in the dining room and there was no indication of who the inhaler belonged to. LPN #102 said Med Tech #103 must have accidentally left it on the table during medication pass.

On 10/30/25 at 10:25 A.M., an interview with Wellness Director #101 stated the Advair inhaler that was in the dining room belonged to Resident #19. Wellness Director #101 confirmed Resident #19 did not self-administer medications and the inhaler should have been secured in the medication cart. Wellness Director #101 verified the MAR documentation indicated the inhaler had been administered on 10/30/25 at 7:53 A.M., which meant the Advair inhaler was left in the dining room from 7:53 A.M. until 9:43 A.M. (110 minutes).

Review of the facility's policy titled Medication Delivery

Based on observation and interview, the facility failed to store food items to prevent contamination and obtain the temperature of all foods prior to meal service to ensure palatability. This had the potential to affect all 48 residents in the facility.

Findings include:

On 10/30/25 at 11:56 A.M., an observation of the lunch meal service revealed Cook #104 did not obtain the temperature of the chopped salad prior to service. The chopped salad consisted of chopped lettuce, cut tomatoes, shredded cheese, and ranch dressing mixed in with the salad. An interview at the time of observation with Cook #104 verified she did not obtain the temperature of the salad, stating she usually did not obtain the temperature of salads because it was mixed with the dressing and the dressing was ice cold straight out of the refrigerator.

On 10/30/25 at 12:12 P.M., an observation of the kitchen revealed both the flour bin and sugar bin stored in the food prep area had scoops in the bins with handles touching the flour and sugar. An interview at the time of observation with Cook #104 verified the scoops were in the bins. Cook #104 stated the scoops were placed in the bins every morning, staff used them throughout the day, and then they were removed and washed every night.

This violation represents non-compliance investigated under Complaint Number OH00168617 and is an example of continued non-compliance from the survey dated 10/21/25.

Based on observation, interview, record review, and review of facility policy, the facility failed to serve all food in a manner that protects it against contamination and spoilage. This affected 15 residents (Resident #7, #8, #11, #15, #16, #18, #22, #26, #29, #30, #31, #34, #39, #45 and #50) of 15 residents observed during meal service with potential to affect all residents receiving meals from the facility kitchen. The facility census was 46.

Findings include:

Review of the Resident Council meeting minutes for July 2025 revealed residents were concerned with food temperatures and in September 2025 the food was cold.

Record review for Resident #26 revealed an admission date of 02/01/25. Diagnoses included sacroiliitis and lordosis of the lumbosacral region. Review of the Service Plan dated 03/3/25 revealed Resident #26 was alert and oriented to person, place and time. Resident #26 required total assistance for meal preparation and received a regular diet.

An interview on 10/20/25 at 1:47 P.M. with Resident #26 revealed the food served by the facility was always cold. Resident #26 confirmed he had a microwave in his room and revealed the food did not taste as good due to having to be reheated in a microwave every day.

An interview on 10/20/25 between 2:19 P.M. and 2:55 P.M. with Residents #8, #11 and #50 revealed their hot food was not hot by the time it was served to them.

Interviews on 10/20/25 between 3:12 P.M. and 6:17 P.M. with Certified Nursing Assistant (CNA) # 210, Caregiver #230, Med Tech #205, Resident Care Companion #200, Administrator, and Activity Director #201 confirmed the residents had been complaining of hot food not being served hot but instead being served cold.

An observation on 10/20/25 at 5:09 P.M. of the dinner meal service in the kitchen revealed the hot foods were cooked to the appropriate final cooking temperatures then moved to a long metal table. A pot of white rice, a pot of fried cabbage, a container of egg rolls and a container of shredded chicken were sitting directly on the metal table. The metal table felt cold to touch and there were no heating devices to keep the food warm while on the table. The kitchen did not have a steam table for hot food holding. Cook #227 was present during the observation and verified the metal table was very cold and there was nothing to keep the pots of food warm while preparing the resident's plates of food. Kitchen Assistant (KA) #226 began to plate up 14 resident plates of the rice, chicken, cabbage and egg roll for room trays and also one test tray. Plate warmers were placed under nine of the 15 plates then those 15 plates went onto an open food delivery cart. The last plate was placed on the cart at 5:20 P.M. and delivered to the resident area at 5:30 P.M.

Further observation at 5:32 P.M. of KA #226 revealed meal tray delivery to Resident #7, #8, #15, #16, #18, #22, #26, #29, #30, #31, #34, #39, #45 and #50. During this meal delivery, KA #226 was also removing dirty dishes, plates, cups and silverware from these resident rooms that had been used at a prior meal, and was setting the dirty items next to or above the dinner meals to be served to the next resident. Cook #227 was present during this observation and verified the dirty dishes should not be mixed in with the meals that are ready to serve to the residents. At 5:52 P.M. the last meal was served. Observation revealed KA #226 served all meals to each resident and at no time during the process performed hand hygiene or used hand sanitizer.

Observation of the test tray food temperatures on 10/20/25 at 5:54 P.M. revealed Cook #227 tested the temperatures of each food item served. The white rice was served at 82.8 degrees Fahrenheit (F). The chicken was 83.8 degrees F, the veggie egg roll was 82.4 degrees F and the fried cabbage was 76.8 degrees F. Cook #227 confirmed each food item tasted cold and stated the temperature served should have been at least 120 degrees F.

Interview on 10/20/25 between 6:03 P.M. and 6:14 P.M. with Resident #15, #29, and #45 confirmed their dinner was served to them cold.

Interview on 10/20/25 at 6:30 P.M. with KA #226 confirmed he passed all the resident trays who were served in their room. KA #226 confirmed he picked up the previous meal dirty dishes after serving each tray and placed the dirty dishes on the same cart next to or near the food prepared to be served. KA #226 revealed he washed his hands before leaving the kitchen to serve the trays then again when he returned to the kitchen after serving the trays and picking up the dirty dishes. KA #226 confirmed he never washed his hands or used hand sanitizer after picking up dirty dishes or before delivering or setting up resident meals on the resident unit.

Review of the facility document titled, Food Storage, undated, revealed food should be cooked to minimum safe internal temperatures and minimal time in the food danger zone of 41 degrees F to 135 degrees F. Ready to eat food (vegetables, grains and cooked foods) should be at 135 degrees and raw poultry should be at 165 degrees F for 15 seconds.

Review of the facility policy titled, Universal Precaution Guidelines, undated, revealed in addition to body fluids, all instruments, surfaces, and materials that have the potential to be with blood or other infectious materials should also be treated as if they are infectious. To provide proper protection against infectious diseases, team members must follow established guidelines for washing their hands and wearing protective clothing/equipment. Team members should wash their hands immediately and thoroughly with soap and water, for ten to fifteen seconds, in the following situations: After any contact with blood or other potentially infectious body fluids or materials, or after contact with items that may have been contaminated by blood or other body fluids. Before handling items in the food preparation and handling area. Before beginning work and upon completing work, before and after eating, after using bathroom, after covering mouth when sneezing and coughing, before and after personal care or skilled nursing care, when there's physical contact, when there's contact with bodily substances, after contact with contaminated materials, before handling food and other appropriate times. When hand washing facilities and/or supplies are not immediately available, team members may use a hand sanitizer in place of hand washing. When a sanitizer is used, wash hands with soap and water as soon as possible and/or in accordance with the manufacturer.

This violation represents non-compliance investigated under Complaint Number OH00168486.

Based on record review, interview, and policy review the facility failed to ensure resident health assessments included all required information. This affected eight residents (#5, #18, #23, #27, #29, #40, #45 and #46) out of 12 resident records reviewed for assessments. Facility census was 49.

Findings include:

1. Review of Resident #5's medical record revealed an admission date of 03/13/25 and diagnoses including generalized anxiety disorder, dementia, postpartum mood disturbance, schizoaffective disorders, asthma, peripheral vascular disease and impulse disorder.

Further review of Resident #5's paper and electronic medical records revealed no service plan was available for review.

Interview on 07/30/25 at 10:01 A.M. with the Administrator verified Resident #5's service plan could not be located.

2. Review of Resident #18's medical record revealed an admission date of 05/29/25 and diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, lumbago with sciatica, chronic pain syndrome, generalized anxiety disorder, depression, memory deficit following cerebral infarction and atrial fibrillation. Resident #18 discharged to the hospital on 07/22/25 and did not return to the facility.

Further review of Resident #18's paper and electronic medical records revealed no service plan, medication self-administration assessment or mini-mental state examination (MMSE) assessment were available for review.

Interview on 07/30/25 at 9:55 A.M. with the Administrator verified Resident #18's service plan, MMSE assessment and medication self-administration assessment could not be located.

3. Review of Resident #23's medical record revealed an admission date of 01/31/25 and diagnoses including suicide attempt, hyperlipidemia, schizoaffective disorder, depression, borderline personality disorder and COPD.

Further review of Resident #23's paper and electronic medical records revealed an incomplete service plan dated 03/12/25.

Interview on 07/30/25 at 10:14 A.M. with the Administrator verified Resident #23's service plan was incomplete and a complete plan could not be found.

4. Review of Resident #27's medical record revealed an admission date of 01/09/25 and diagnoses including chronic kidney disease, depression, COPD, hypertension, asthma, adjustment disorder and glaucoma.

Further review of Resident #27's paper and electronic medical records revealed no service plan was available for review.

Interview on 07/30/25 at 10:15 A.M. with the Administrator verified Resident #27's service plan could not be located.

5. Review of Resident #29's medical record revealed an admission date of 09/12/24 and diagnoses including schizoaffective disorder, moderate protein-calorie malnutrition, post-traumatic stress disorder, dementia and leukemia.

Further review of Resident #29's paper and electronic medical records revealed an incomplete service plan dated 09/11/24.

Interview on 07/30/25 at 10:15 A.M. with the Administrator verified Resident #29's service plan was incomplete and a complete plan could not be found.

6. Review of Resident #40's medical record revealed an admission date of 04/01/25 and diagnoses including alcohol abuse, COPD, severe protein-calorie malnutrition and osteoporosis with current pathological fracture.

Further review of Resident #40's paper and electronic medical records revealed no service plan was available for review.

Interview on 07/30/25 at 10:11 A.M. with the Administrator verified Resident #40's service plan could not be located.

7. Review of Resident #45's medical record revealed an admission date of 10/17/24 and diagnoses including schizoaffective disorder bipolar type, history of traumatic brain injury, anemia, atrial fibrillation and vitamin D deficiency.

Further review of Resident #45's paper and electronic medical records revealed no service plan was available for review.

Interview on 07/30/25 at 9:59 A.M. with the Administrator verified Resident #45's service plan could not be located.

8. Review of Resident #46's medical record revealed an admission date of 06/03/25 and diagnoses including stimulant abuse, cognitive communication deficit, hyperlipidemia, alcohol abuse and myocardial infarction.

Further review of Resident #46's paper and electronic medical records revealed no service plan, medication self-administration assessment or MMSE assessment were available for review.

Interview on 07/30/25 at 10:13 A.M. with the Administrator verified Resident #46's service plan, MMSE assessment and medication self-administration assessment could not be located.

Review of the facility policy, Service Plans and Assessment

Based on interview, record review and review of the facility policy, the facility failed to provide appropriate assistance with self-administration of medications. This affected one resident (#18) out of 10 residents reviewed for medication administration. Facility census was 49.

Findings include:

Review of Resident #18's medical record revealed an admission date of 05/29/25 and diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, lumbago with sciatica, chronic pain syndrome, generalized anxiety disorder, depression, memory deficit following cerebral infarction and atrial fibrillation. Resident #18 discharged to the hospital on 07/22/25 and did not return to the facility.

Review of Resident #18's physicians' orders as of 07/29/25 revealed no order for self-administration of medications and revealed orders for controlled medications, including an order dated 06/10/25 for Hydromorphone tablet four milligrams (mg) every four hours (timed 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.) and an order dated 05/29/25 for Pregabalin capsule 50 mg three times daily (timed 4:00 A.M., 12:00 P.M. and 4:00 P.M.).

Further review of Resident #18's paper and electronic medical records revealed no service plan, medication self-administration assessment or mini-mental state examination (MMSE) assessment were available for review.

Interview on 07/29/25 at 3:01 P.M. with Registered Nurse (RN) #61 revealed there were times she had left Resident #18's medications at bedside. When asked how she knew Resident #18 took the medications, RN #61 indicated Resident #18 was of sound mind and only a few residents at the facility could have their medications left at bedside. RN #61 indicated Resident #18 always took her medications.

Interview on 07/30/25 at 9:55 A.M. with the Administrator verified Resident #18's service plan, MMSE assessment and medication self-administration assessment could not be located for further review.

Interview on 07/30/25 at 11:51 A.M. with Licensed Practical Nurse (LPN) #60 revealed licensed nursing personnel worked at the facility from 7:00 A.M. to 7:00 P.M. daily. Resident #18 received medications outside of these times, so she would put her Hydromorphone tablet 4 mg in baggies within a lockbox and each designated administration time (8:00 P.M., 12:00 A.M. and 4:00 A.M.) was written on the bags. The caregiver staff would then go in, unlock the box and oversee the administration at the designated times. When asked if Resident #18 was capable of self-administering her medications, LPN #60 stated if all of the medication bottles and/or containers were provided to Resident #18, she would not be able to self-administer the medications but Resident #18 could self-administer the timed medications within the lockbox. When asked who determined if a resident could self-administer medications, LPN #60 shared whoever did the initial assessment made that determination.

Interview on 07/30/25 at 12:09 P.M. with Resident Care Coordinator (RCC)/Medication Technician (MT) #63 revealed Resident #18 was not able to self-administer her medications. RCC/MT #63 stated nursing staff made the decision regarding who could or could not self-administer their medications which did not include herself. For overnight medications such as with Resident #18, the nurse would put the medications in a lock box and a caregiver could unlock the box and the resident would take the medication at the ordered times.

Follow-up interviews on 07/30/25 at 12:53 P.M. and 3:14 P.M. with the Administrator revealed caregivers would get the key for the lockbox at the designated medication times when licensed personnel were not in the facility, tell the resident it is [designated time] do you know what medication you are taking and the resident should state the medication and the dose and the caregiver would watch the resident take the medication. The Administrator confirmed the caregiver staff had access to the residents' Medication Administration Records (MARs) to verify the medication and dosage and did not indicate a separate process for the administration of controlled substances. During the interviews the Administrator was made aware that facility staff described a process of self-medication administration for Resident #18; however, there was no assessment, service plan or other documentation to capture Resident #18's cognitive status or ability to perform the needed tasks for self-medication administration and to determine if this practice was appropriate to which the Administrator did not disagree.

Review of the undated facility policy, Medication Delivery

Based on observation, interview, record review and review of the facility policy, the facility failed to administer medications per physician's orders. This affected one resident (#27) of two residents observed for medication administration. Facility census was 49.

Findings include:

Review of Resident #27's medical record revealed an admission date of 01/09/25 and diagnoses including chronic kidney disease, depression, COPD, hypertension, asthma, adjustment disorder and glaucoma.

Review of Resident #27's physician's orders revealed an order dated 05/20/25 for Omeprazole capsule 20 milligrams (mg) give one capsule by mouth one time a day in the morning, one hour before meal and scheduled for 6:00 A.M. daily.

Observation on 07/29/25 at 7:58 A.M. revealed Licensed Practical Nurse (LPN) #60 prepared nine oral medications for Resident #27 including Omeprazole 20 mg, Aspirin 81 mg, Buspirone 5 mg, Citalopram 20 mg, Duloxetine delayed release 30 mg, Losartan tablet 25 mg (a half-tablet), Metoprolol 25 mg, Myrbetriq extended release 50 mg and Oxybutynin extended release 15 mg. At 8:02 A.M. LPN #60 provided the medications to Resident #27, who was seated in the dining room having breakfast. Resident #27 took the medications whole with water without issue.

Interview on 07/29/25 at 9:50 A.M. with LPN #60 revealed qualified staff for medication administration did not arrive at the facility until 7:00 A.M. daily. LPN #60 verified Resident #27's Omeprazole 20 mg was given with the breakfast meal as observed and not one hour before meal as ordered which constituted a medication error.

Review of the undated facility policy, Medication Delivery

Based on observation, interview and record review, the facility failed to store and manage controlled substances to comply with Board of Pharmacy and drug enforcement agency regulations. This affected one resident (#18) out of 10 residents reviewed for medication administration. The facility census was 49.

Findings include:

Review of Resident #18's medical record revealed an admission date of 05/29/25 and diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, lumbago with sciatica, chronic pain syndrome, generalized anxiety disorder, depression, memory deficit following cerebral infarction and atrial fibrillation. Resident #18 discharged to the hospital on 07/22/25 and did not return to the facility.

Review of Resident #18's physicians' orders as of 07/29/25 revealed no order for self-administration of medications and revealed orders for controlled medications, including an order dated 06/10/25 for Hydromorphone tablet four milligrams (mg) every four hours (timed 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.) and an order dated 05/29/25 for Pregabalin capsule 50 mg three times daily (timed 4:00 A.M., 12:00 P.M. and 4:00 P.M.).

Further review of Resident #18's paper and electronic medical records revealed no service plan, medication self-administration assessment or mini-mental state examination (MMSE) assessment were available for review.

Interview on 07/30/25 at 9:55 A.M. with the Administrator verified Resident #18's service plan, MMSE assessment and medication self-administration assessment could not be located.

Interview on 07/30/25 at 11:51 A.M. with Licensed Practical Nurse (LPN) #60 revealed nurses/medication technicians worked at the facility from 7:00 A.M. to 7:00 P.M. daily. Resident #18 received medications outside of these times, so she would put her Hydromorphone tablets in baggies within a lockbox and each designated administration time (8:00 P.M., 12:00 A.M. and 4:00 A.M.) was written on the bags. LPN #60 stated she then filled out the controlled substance logs at the time she filled the lock box and confirmed this was not done at the time of actual narcotic administration. In the evening, caregiver staff would then go in, unlock the box and oversee the administration at the designated times. LPN #60 stated she would sign off the applicable doses on the Medication Administration Record (MAR) the next morning when she came in to work.

Interview on 07/30/25 at 12:09 P.M. with Resident Care Coordinator (RCC)/Medication Technician (MT) #63 revealed for overnight medications such as with Resident #18, the nurse would put the medications in a lock box and a caregiver could unlock the box and the resident would take the medication at the ordered times. RCC/MT #63 stated medications should not be signed off as passed until the resident swallowed the medications.

Follow-up interviews on 07/30/25 at 12:53 P.M. and 3:14 P.M. with the Administrator revealed caregivers would get the key for the lockbox at the designated medication times when licensed personnel were not in the facility, tell the resident it is [designated time] do you know what medication you are taking and the resident should state the medication and the dose and the caregiver would watch the resident take the medication. The Administrator confirmed the caregiver staff had access to the residents' Medication Administration Records (MARs) to verify the medication and dosage and did not indicate a separate process for controlled substances. During the interviews the Administrator was made aware that facility staff described a process leaving controlled substances not double-locked as required and accessible to unlicensed staff in addition to documentation being done ahead on narcotic count sheets and being done not timely after administration on MARs which did not follow standards of practice for medication administration or management of controlled substances and she did not disagree.

Review of the undated facility policy, Medication Delivery

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure medications were labeled and stored properly until the point of administration. This affected six residents (#5, #17, #23, #40, #45 and #46) of 10 residents reviewed for medication administration. Facility census was 49.

Findings include:

Observation on 07/29/25 at 7:43 A.M. revealed in the front office, there were two medication carts. One medication cart had three cups labeled with room numbers (belonging to Residents #5, #40 and #46) with medications inside the cups on top of the cart.

Interview on 07/29/25 at 7:43 A.M. with Licensed Practical Nurse (LPN) #60 verified the observed medications were pre-poured. When asked if any additional medications were pre-poured, she opened one of the medication carts and three additional cups were observed to be labeled with room numbers (belonging to Residents #17, #23 and #45) and had medications inside. LPN #60 confirmed licensed nursing personnel were not supposed to pre-pour medication and stated the other nurse had called off of work today and she only pre-poured medication when she worked alone.

Review of the facility policy, Medication Delivery

Based on observation, interview and record review the facility failed to ensure a fully functional call system. This affected three residents (#29, #40 and #51) out of seven resident rooms observed for call system functionality. Facility census was 49.

Findings include:

1. Review of Resident #40's medical record revealed an admission date of 04/01/25 and diagnoses including alcohol abuse, COPD, severe protein-calorie malnutrition and osteoporosis with current pathological fracture.

Interview on 07/29/25 at 10:24 A.M. with Resident #40 revealed other residents reporting waiting hours for staff to come and answer their call lights. Resident #40 stated he did not have a call pendant but a pull station in the bathroom and gave the surveyor permission to press the pull station which was thus activated at 10:28 A.M.

Observation and interview on 07/29/25 at 10:40 A.M. with the Administrator in front of the screen where call lights would register revealed Resident #40's call light did not register on the screen. At 10:44 A.M., the Administrator and the surveyor went back to Resident #40's room, shut the bathroom pull station off and re-activated the call light. Upon returning to the screen, Resident #40's call light still did not register on the screen which the Administrator verified at the time of observation.

2. Review of Resident #29's medical record revealed an admission date of 09/12/24 and diagnoses including schizoaffective disorder, moderate protein-calorie malnutrition, post-traumatic stress disorder, dementia and leukemia.

Observation and interview on 07/29/25 at 10:58 A.M. with the Administrator revealed Resident #29's call pendant was activated. Upon returning to the screen where call lights registered, Resident #29's call pendant was not on the screen. At 11:02 A.M. Licensed Practical Nurse (LPN) #60 went to deactivate and reactivate Resident #29's call pendant and upon returning to the screen, Resident #29's call light still did not register on the screen which the Administrator verified at the time of observation.

Interview on 07/29/25 at 1:42 P.M. with Resident #29 revealed she was unsure about if her call light was functioning correctly or not.

3. Review of Resident #51's medical record revealed an admission date of 04/03/24 and diagnoses including chronic kidney disease, type two diabetes, spinal stenosis, insomnia, glaucoma and right eye blindness.

Observation and interview on 07/29/25 at 10:56 A.M. with the Administrator revealed Resident #56's call pendant and bathroom pull station were activated. Upon returning to the screen where call lights registered, Resident #56's call pendant was not on the screen. At 11:02 A.M. Licensed Practical Nurse (LPN) #60 went to deactivate and reactivate Resident #56's call pendant and upon returning to the screen, Resident #56's call pendant still did not register on the screen which the Administrator verified at the time of observation.

Interview on 07/29/25 at 1:47 P.M. with Resident #51 revealed her call light did not work all of the time and when it was not working, she could not get assistance.

Review of the undated resident handbook revealed each suite was equipped with an emergency call system, which alarms a caregiver to the resident's need for assistance.

This violation is an example of noncompliance investigated under Complaint Number OH00167731.

Based on closed medical record review, review of hospital documentation, review of emergency medical services (EMS) run sheet, review of facility policies, review of video camera footage and interviews, the facility failed to maintain effective systems to ensure Resident #18 received adequate, necessary and timely care and treatment to promote the resident's highest level of well-being. The facility failed to ensure controlled medications were properly secured and administered appropriately by qualified personnel for Resident #18, whose cognition and ability to self-administer medications were not assessed, resulting in the resident having a change in condition without timely care and treatment. This resulted in Real and Present Danger and actual harm beginning on 07/22/25 at 4:00 A.M. when unlicensed Caregiver #65 entered Resident #18's room to administer 4:00 A.M. medications, including narcotic medication without the qualifications to administer medications and assess the resident before and after the administration. When Caregiver #65 walked in, Resident #18 was lying face down in her blanket in a sitting position. The caregiver proceeded to administer the medications to the resident. Continued observation of camera footage from 07/22/25 revealed Caregiver #65 entered the resident's room again at 6:20 A.M., Dietary Aide (DA) #72 entered the room at 8:37 A.M., Licensed Practical Nurse (LPN) #69 entered the room at 9:03 A.M. and LPN #60 entered the room at 9:27 A.M. Upon LPN #60's entry to the room, the LPN proceeded to call down the hallway for assistance. Emergency Medical Services (EMS) was subsequently called and Resident #18 was transferred to the hospital where she received Narcan (a prescription medication that can reverse an opioid drug overdose), was admitted to the Intensive Care Unit (ICU) and was intubated. The resident did not return to the facility. This affected one resident (#18) of 10 residents reviewed for quality of care/medication administration. The facility census was 49.

On 08/04/25 at 2:10 P.M. the Administrator was notified that Real and Present Danger began on 07/22/25 at 4:00 A.M., when Caregiver #65 found Resident #18 in an abnormal position but proceeded to administer medication and did not report the change in condition until 7:00 A.M. to the nurse (name not divulged). LPN #69 entered the resident's room at 9:03 A.M. but it was not until LPN #60 entered the room at 9:27 A.M. that assistance was sought from EMS personnel related to the resident's change in condition. Resident #18 was subsequently admitted to the ICU and required intubation and Narcan administration as part of life-sustaining measures.

The Real and Present Danger was abated on 08/05/25 when the facility implemented the following corrective actions:

On 07/22/25 at approximately 9:36 A.M. EMS and local police department responded. Resident #18 was transported to the hospital and did not return to the facility.

On 08/05/25 and 08/06/25 LPN #60 and Registered Nurse (RN) #61 educated night shift nursing and medication techs. The facility implemented a staffing plan for one nurse and three caregivers seven days per week. In the event a night shift nurse calls off the facility implemented a plan for an on-call schedule for nursing. The Administrator would monitor call off's and would ensure on call nursing reported to the shift needing coverage.

Beginning 08/05/25 the facility implemented a plan for only licensed nurses or medication techs to administer medications.

On 08/05/25 RN #61 completed a thorough chart audit for Resident #18 and all other facility residents. During this review several residents were identified to have missing service plans and medication administration orders. Each nurse was called in and re-educated about reviewing and maintaining complete/accurate charts. Nursing staff were currently in the process of updating every resident's chart to ensure all orders, documentation and resident demographics are correct. This would be completed by 8/18/25 and reviewed by the Administrator for accuracy on 8/19/25.

On 08/05/25 RN #61 completed teaching and reeducating of facility nursing staff, caregivers and med techs related to medication administration and documentation. The facility implemented a plan for as needed (PRN) staff to be educated by 08/15/25. Any new staff hired after 08/15/25 would be educated as part of their orientation.

On 08/08/25 RN #61 provided staff training to licensed nurses, caregivers, dietary staff and maintenance staff on timely identification/reporting of resident changes in condition. Any change in condition was to be reported to nursing staff or to the Administrator. Changes in condition would be documented in Alis (facility's electronic medical record). The facility also implemented a system for securing narcotics and appropriate narcotic count sheet/MAR documentation and self-administration of medication. Narcotic counts would only be conducted nurse to nurse at all times. Caregivers were no longer to open any medication lockboxes or help residents to administer any meds included narcotics.

Beginning on 08/15/25 the Administrator would interview four residents weekly for four weeks to ensure nursing staff were following policies and procedures of medication administration.

Beginning on 08/15/25 the Administrator will interview four staff members on policies and procedures of medication administration for the next four weeks.

Beginning on 08/15/25 the Administrator would conduct a whole house audit on medication administration. This audit will be completed by 08/19/25 and then would be conducted quarterly thereafter. Each resident would also be assessed by their primary care physician (PCP) related to their ability to self-administer medications. All residents assessed for self- administration would have lockboxes in their rooms with a key to obtain their medication. All other residents would have their medication stored in facility medication carts and would have medication administered by licensed nurses or medication techs.

All findings of audits will be reviewed by the facility Quality Assessment and Performance Improvement (QAPI) committee for the next three months.

On 08/19/25 a medication administration assessment would be completed for all residents with the medical director present. Any resident found to be capable of self-administering medication during the assessment would have written orders to do so and would follow facility procedures to ensure medications were properly secured.

On or before 08/29/25 facility policies and procedures would be revised related to medication delivery/administration, caregiver's duties, change in condition, nursing check list and new admissions documentation. All staff would be given new policies to review during the facility's monthly staff meeting on 09/03/25. Staff would be required to sign acknowledgement of revised policies.

Although the Real and Present Danger was abated on 08/05/25, the violation remains as the facility was in their process of implementing additional corrective actions and monitoring for compliance.

Findings include:

Review of Resident #18's closed medical record revealed an admission date of 05/29/25 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, lumbago with sciatica, chronic pain syndrome, generalized anxiety disorder, depression, memory deficit following cerebral infarction and atrial fibrillation. Resident #18 discharged to the hospital on 07/22/25 and did not return to the facility.

Review of Resident #18's paper and electronic medical records revealed no service plan, medication self-administration assessment or mini-mental state examination (MMSE) assessment were available for review. A pharmacy admission order form dated 05/30/25 revealed the resident required assistance with medication but the physician did not sign the form.

Review of Resident #18's physicians' orders as of 07/29/25 revealed no order for self-administration of medications and revealed orders for controlled medications, including an order dated 05/29/25 for pregabalin (Lyrica, a controlled substance used to treat nerve or widespread pain) capsule 50 milligrams (mg) three times daily (timed 4:00 A.M., 12:00 P.M. and 4:00 P.M.); an order dated 06/10/25 for hydromorphone (Dilaudid, a controlled opioid or narcotic medication used to treat pain) tablet four mg every four hours (timed 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.) and an order dated 06/10/25 for lorazepam (Ativan, a controlled substance used to treat anxiety) 0.5 mg every six hours (timed 4:00 A.M., 8:00 A.M., 4:00 P.M. and 8:00 P.M.).

Review of the Medication Administration Record (MAR) for July 2025 revealed documentation Resident #18 was received Dilaudid 4 mg on 07/21/25 at 8:00 P.M. and on 07/22/25 at 12:00 A.M., 4:00 A.M. and 8:00 A.M. The MAR indicated Resident #18 was documented to receive Ativan 0.5 mg on 07/21/25 at 8:00 P.M. and on 07/22/25 at 4:00 A.M. and 8:00 A.M. as well as Lyrica 50 mg on 07/22/25 at 4:00 A.M.

Review of a progress note dated 07/22/25 at 9:30 A.M. and authored by LPN #60 revealed this nurse went into (resident's) room to pass morning medication when Resident #18 was observed sitting Indian-style (legs crisscrossed) face down in lap not responding to this nurse. This nurse laid resident back and observed resident had hyperhidrosis (excessive sweating) and gasping for breath with periods of apnea (temporary cessation of breathing). The note included Resident #18 still had a heartbeat and responded to sternal rub. This nurse assisted other nurse with vitals and calling 911. EMS took Resident #18 to the hospital and notifications made. Vitals included oxygen, 65%; respirations nine breaths per minute (bpm); blood pressure 66/44 millimeters mercury (mmHg) (hypotensive) and pulse 34 beats per minute (bpm) (bradycardic).

Review of the next available progress note dated 07/22/25 at 6:19 P.M. and authored by LPN #60 revealed this nurse called Resident #18's daughter for an update on the resident. Resident #18 was admitted to the ICU for acute hypercapnic respiratory failure and was in a medically induced coma and the hospital was going to try to take Resident #18 off the medically-induced coma tomorrow to see how she responded. The daughter stated no employee should call to receive updates on her mother as daughter would call with any information if she wants to update the community.

Review of a written (email) statement dated 07/29/25 at 12:20 P.M. and authored by Caregiver #65 revealed the following information: On 07/21/25 Resident #18 received her 8:00 P.M. medications from Caregiver #70 and around 10:30 P.M. going on 11:00 P.M. Resident #18 let them know she was still hungry so they made her a ham and cheese sandwich. After she was done eating they gave her a shower which was around 11:20 P.M. to 11:30 P.M. Once they were done with her shower it was about 11:50 P.M. and they gave her 12:00 A.M. medications and watched her take them. Caregiver #65 went back up around 4:00 A.M. to give her 4:00 A.M. medications and when they walked in Resident #18 was laying face down in her blanket in a sitting position. Caregiver #65 said her name and she sat up and was asked if she was okay and she (the resident) said yes. The email included Caregiver #65 watched her (the resident) take her medications and included the resident laid back down.

Review of an EMS run sheet dated 07/22/25 revealed a call was received at 9:32 A.M. regarding Resident #18 being unconscious and/or fainting. EMS was on site at 9:41 A.M. Resident #18 was grunting with irregular, shallow and slow breaths and had cool, diaphoretic and cyanotic skin. Vitals obtained from EMS included blood pressure, 82/45 mmHg, pulse 116 bpm, respirations 24 bpm and oxygen 82%. Narrative from EMS personnel revealed staff stated Resident #18's last known normal was at 4:00 A.M. this morning. While in the back of the squad Resident #18 started to wake up and move around the cot. Resident #18 would open her eyes to verbal stimuli and make incomprehensible sounds.

Review of hospital records revealed on 07/22/25 Resident #18 was seen in the emergency department (ED) for altered mental status with a last known well at 4:00 A.M. this morning when she received her medications. Before arriving to the ED, Resident #18 was found slumped over unresponsive only responsive to painful stimuli and with vomit on her shirt. Resident #18 received two of Narcan in the resuscitation bay and was responsive to it; however, she was combative, not compliant and not redirectable. Resident #18 was using accessory muscles for breathing as well as abdominal muscles and was intubated after being on nonrebreather mask during her entire time in the ED. Differential diagnoses included acute hypercapnic respiratory failure and opioid overdose secondary to chronic pain, low suspicious for opioid overdose that may have caused aspiration pneumonia for this patient which was consistent with her pupils being pinpoint as well as vomit noted on her shirt. Review of a discharge summary dated 07/30/25 revealed Resident #18 was on Dilaudid and Ativan and responded to Narcan so oversedation may have been part of her presentation. Resident #18 followed with outpatient palliative care and was on these medications to improve her air hunger and symptoms as a result of her serious COPD thus the timing of the Dilaudid and Ativan were adjusted for discharge.

Review of hospital urinalysis results from 07/22/25 revealed Resident #18 was positive for opiates.

Interview on 07/29/25 at 9:06 A.M. with the Administrator during the entrance conference revealed there was not an investigation into Resident #18's episode of unresponsiveness and subsequent hospitalization on 07/22/25.

Interview on 07/29/25 at 3:01 P.M. with Registered Nurse (RN) #61 revealed there were times in the past she left Resident #18's medications at the bedside. When asked how she knew Resident #18 took her medications, RN #61 stated Resident #18 was of sound mind and only a select few residents at the facility could have their medications left at bedside.

Interview on 07/29/25 at 3:12 P.M. with LPN #60 revealed on 07/22/25, she got to the facility around 7:00 A.M. and passed medications on the first floor then went to the second floor to help LPN #69 with his medication pass. She stated she knocked on Resident #18's door a little after 9:00 A.M. and there was no answer. As the door was locked, she got LPN #69's master key and opened Resident #18's door. Resident #18 was sitting cross-legged, face down in a pillow and LPN #69 said her name and shook Resident #18 with no response. LPN #60 noticed Resident #18 had uneven breathing and a light heart rate and told LPN #69 to get vital equipment and called 911. EMS arrived to the facility 15 minutes later and Resident #18 was taken to the hospital. Resident #18 had not returned to the facility from the hospital. LPN #60 stated residents did not have routine orders for vital sign monitoring so vitals were only done if a resident had a change in condition. LPN #60 reported Caregivers #65 and #70 told her Resident #18 was groggy but holding a conversation when medications were given at 4:00 A.M. that morning. During the interview LPN #60 shared no nurse worked at the facility from 7:00 P.M. to 7:00 A.M., there were only (unlicensed) caregivers on duty. Further interview revealed related to medication administration for Resident #18 from 7:00 P.M. to 7:00 A.M., she pre-poured and labeled medications with the times the medications scheduled at 8:00 P.M., 12:00 A.M. and 4:00 A.M. and the medications went into a lockbox the caregivers had the key to. The caregivers would unlock the box at the designated time, give the resident the bag with the appropriate time and the resident would take the medication. When asked how it was known if the resident took one dose or several doses of medications at any one of these scheduled times, LPN #60 stated the resident did not have the key to the lock boxes so they could not administer their own medications without a caregiver unlocking the lockbox. The LPN revealed this was the same process for other residents as well who received medications between 7:00 P.M. and 7:00 A.M.

A telephone interview on 07/29/25 at 3:48 P.M. with Resident #18's daughter revealed Resident #18 did not receive Narcan until she was in the ER and per Resident #18's pulmonologist (not identified), the way Resident #18 responded to the Narcan was indicative of an overdose. The daughter indicated Resident #18 was still hospitalized as of the time of the call but would be discharging to a skilled nursing facility once stable and would not be returning to this facility.

Interview on 07/29/25 at 4:28 P.M. with Caregiver #64 revealed she worked with Resident #18 on 07/21/25 and the resident appeared at her baseline status. Caregiver #64 did not work on 07/22/25.

Interview on 07/30/25 at 6:54 A.M. with Caregiver #65 revealed she worked the shift from 7:00 P.M. on 07/21/25 to 7:00 A.M. on 07/22/25. Caregiver #65 explained Caregiver #70 provided Resident #18 with her 8:00 P.M. medications but she provided Resident #18 with the 12:00 A.M. and 4:00 A.M. medications, unlocking the lockbox and making sure Resident #18 took her medications that had been prepared. Caregiver #65 reported giving Resident #18 her shower before midnight. When asked if she rounded on residents overnight, Caregiver #65 stated she rounded on her incontinent residents, but Resident #18 was not a check and change thus was not routinely rounded on. Caregiver #65 indicated if Resident #18 needed something she would call the facility or use her call pendant. Caregiver #65 confirmed she did not go back into Resident #18's room after 7:00 A.M.

Interview on 07/30/25 at 9:04 A.M. with Caregiver #67 revealed she worked on 07/22/25 starting around 7:15 A.M. Caregiver #67 stated LPN #69 went into Resident #18's room when he came in (time unknown). Caregiver #67 reported during the morning both LPN #60 and LPN #69 went into Resident #18's room and then EMS arrived; Resident #18's chest was rising and falling but Resident #18 was not talking.

A telephone interview on 07/30/25 at 9:17 A.M. with Caregiver #70 revealed she did not go in Resident #18's room on 07/21/25 or 07/22/25 as the other caregiver had given Resident #18 her medications.

Interview on 07/30/25 at 9:55 A.M. with the Administrator revealed Resident #18's service plan, MMSE assessment and medication self-administration assessment could not be located.

Follow-up interview on 07/30/25 at 10:17 A.M. with the Administrator while she reviewed facility camera footage revealed the following activities regarding Resident #18:

-On 07/21/25 at 8:09 P.M. Resident #18 went out of her room to go smoke.

-On 07/21/25 at 9:30 P.M. a caregiver went into Resident #18's room.

-On 07/21/25 at 10:23 P.M. a caregiver went into Resident #18's room.

-On 07/21/25 at 11:24 P.M. Resident #18 went out of her room to go smoke, returning at 11:57 P.M.

-On 07/22/25 at 1:15 A.M. a caregiver went into Resident #18's room and took out trash.

-On 07/22/25 at 3:46 A.M. a caregiver went into Resident #18's room with a cup of ice.

-On 07/22/25 at 3:59 A.M. Caregiver #65 went into Resident #18's room for medication pass.

-On 07/22/25 at 6:20 A.M. Caregiver #65 went into Resident #18's room to remove a dirty clothes basket. Resident #18 was in the same position.

-On 07/22/25 at 8:37 A.M. DA #72 went into Resident #18's room to provide a meal.

-On 07/22/25 at 9:03 A.M. LPN #69 went into Resident #18's room to deliver morning medication.

-On 07/22/25 at 9:27 A.M. LPN #60 went into Resident #18's room then was observed calling down the hallway.

-On 07/22/25 at 9:37 A.M. LPN #69 and Caregiver #67 went in to assist LPN #60 in Resident #18's room.

-On 07/22/25 at 9:41 A.M. EMS personnel entered Resident #18's room.

-On 07/22/25 at 9:52 A.M. EMS left with Resident #18.

Interview on 07/30/25 at 10:38 A.M. with DA #72 revealed the morning of 07/22/25, he went into Resident #18's room to offer her breakfast. DA #72 stated Resident #18 refused the tray, which he stated she did sometimes. When asked if DA #72 reported the refusal of the meal to nursing staff, DA #72 stated he did not know.

Interviews on 07/30/25 at 11:51 A.M. and 1:52 P.M. with LPN #60 verified for Resident #18, she put the resident's overnight medications in a baggie with the administration time on them and these went into a lock box. LPN #60 confirmed she documented the administration of the medications on the controlled substance log at the time of pre-portioning them (and not at the time of administration). LPN #60 stated she would then document on the resident's MAR the administration of the medications the next day (even though she did not personally administer the medications) unless the medication was still in the lockbox. LPN #60 verified she was not present when these medications were administered. When asked if Resident #18 could safely self-administer her medications, LPN #60 stated Resident #18 could not obtain the pre-poured medications directly out of medication containers but felt she did well with the medication lockboxes. The caregivers would sit there and ensure she took the medications then relock the lockbox. When asked who was responsible for determining if a resident could safely self-medicate, LPN #60 stated whoever did the assessment would make that call. During the interview, LPN #60 also revealed when she worked alone, she counted the narcotics and checked the narcotic count book alone. When RCC/MT #63 came in between 9:00 A.M. and 10:00 A.M. they would do a count together at that time and then again when she left, between 6:00 P.M. and 7:00 P.M.

Interviews on 07/30/25 at 12:09 P.M. and 1:57 P.M. with Resident Care Coordinator (RCC)/Medication Technician (MT) #63 revealed Resident #18 was not able to self-administer medications. The RCC revealed nursing staff made that judgement, which did not include her. RCC/MT #63 described how staff put medications in a lockbox for Resident #18 as the medication carts were locked at night. The caregiver would open the lockbox for the resident, the resident would take the medication and then consume it. RCC/MT #63 stated only certain residents could follow this process. RCC/MT #63 also stated medications should not be documented or signed off ahead of time, as the resident had not yet taken the medications. RCC/MT #63 revealed when the previous Health and Wellness Director (HWD) worked at the facility, she would help count narcotics at the start of the day at 7:00 A.M. But the last two weeks, there had not been someone else to do narcotic counts with until 9:30 A.M. to 10:00 A.M. when she came in. RCC/MT #63 also helped do the evening count at 6:30 P.M.

Interview on 07/30/25 at 12:53 P.M. with the Administrator revealed there was not a nurse at the facility overnight, so caregivers were responsible for medication administration oversight. The Administrator revealed the process should include the caregiver going to the resident (including Resident #18) at the time medication was to be given with a key for the lockbox. If a resident was not capable of unlocking the lockbox, the caregiver would unlock it for them. Caregiver staff were to say to the resident what time it was and ask them what medication they were taking. The resident was to say the medication and the dose and the caregiver staff would watch the resident consume the medication. The caregivers had access to resident MARs to verify the medication and dosage and did not indicate a separate process for controlled substances. When the nursing staff came in for the day at 7:00 A.M. the caregivers would let them know if any medication was refused and the staff were to sign the controlled log and the MAR at that time.

During a follow-up interview on 07/30/25 at 3:14 P.M. the Administrator was made aware that facility staff described a process leaving controlled substances not double-locked as required and accessible to unlicensed staff in addition to documentation being done ahead on narcotic count sheets and being done not timely after administration on MARs which did not follow standards of practice for medication administration or management of controlled substances and she did not disagree. During the interviews the Administrator was made aware that facility staff described a process of self-medication administration for Resident #18, however, there was no assessment, service plan or other documentation to capture Resident #18's cognitive status or ability to perform the needed tasks for self-medication administration and to determine if this practice was appropriate to which the Administrator did not disagree.

Interview on 08/04/25 at 7:04 A.M. with RN #61 revealed for Resident #18, if she (the RN) was in the facility late she would administer her 8:00 P.M. medications at 7:00 P.M. RN #61 stated Resident #18 received Dilaudid at 12:00 A.M. and 4:00 A.M. and there would be a cup or a baggie in a lock box with the date, medication, the dose and the time. RN #61 stated she would sign on the controlled substance log and MAR before she left at the end of her shift and confirmed this was before the medications were administered. RN #61 stated if caregiver staff had questions or there was a change in condition, they were to contact the nurse on-call as no nurse was in the facility from 7:00 P.M. to 7:00 A.M.

Interview on 08/04/25 at 7:40 A.M. with Caregiver #66 revealed before the HWD left, they had to help with medications, which included opening lock boxes at specific times and taking out prepared medications in a cup or baggie with the time to take the medications placed on it. Caregiver #66 stated she worked with Resident #18 on 07/21/25 and denied knowledge of any change in condition during that time. When asked how night shift staff addressed resident changes in condition, Caregiver #66 stated staff were to call the HWD or a supervisor and if it was really bad they were to call 911 after that. Caregiver #66 also shared the nurses would verbally tell caregivers if a resident was not supposed to get medications.

A telephone interview on 08/04/25 at 9:41 A.M. with Caregiver #65 verified her written statement from 07/29/25 and shared on 07/22/25 around 4:00 A.M. when she went into Resident #18's room for medication administration, Resident #18 was seated with her legs crossed leaning forward into a pillow. Caregiver #65 stated Resident #18 did not normally lay like that but took her medicine and laid back down. Caregiver #65 confirmed she did not report this change in condition until the nurse (not named) came on shift at 7:00 A.M. Caregiver #65 stated she did not obtain vital signs as Resident #18 was talking to her and she asked Resident #18 if she was okay, she said yes, and then Caregiver #65 gave her medication. When asked what medications Resident #18 received at 4:00 A.M. Caregiver #65 could not say and just said it was a packet that said 4:00 A.M. on it. Caregiver #65 confirmed caregiver staff did not have training on what to look for before or after medication administration concerning if a resident should not take medication and reiterated if Resident #18 did not talk to her, she would have sat her up and called the nurse.

A telephone interview on 08/04/25 at 10:09 A.M. with Caregiver #79 revealed she worked night shift from 7:00 P.M. to 7:00 A.M. at the facility. Caregiver #79 stated at times she assisted with medications where she would go into a resident's room and unlock a lockbox, but then the resident would get the medication themselves and staff would watch the resident take it. Caregiver #79 stated staff do not assess residents before or after medication administration but if a resident was lethargic, she would not give the medications and would call someone above her scope of practice. Caregiver #79 recalled Resident #18 as someone who normally knows what is going on and got medications at 12:00 A.M. and 4:00 A.M. but she was not routinely the staff who did Resident #18's medication reminders.

Interview on 08/04/25 at 10:59 A.M. with the Administrator revealed the facility never had nurses scheduled overnight but this was slated to start on 08/05/25. During the interview, the Administrator was asked about Caregiver #65's statement regarding Resident #18 and stated what Caregiver #65 was observing was how she sleeps. When asked if there was any documentation that illustrated this, there was no response. The Administrator was also asked about Resident #18's change in medication orders on 06/10/25 from as needed (PRN) to scheduled for her Ativan and Dilaudid and stated she did not know but would find out.

Review of staffing schedules for July 2025 and August 2025 revealed one to two nurses were scheduled on day shift (7:00 A.M. to 7:00 P.M.) with two to three caregivers. On nights (7:00 P.M. to 7:00 A.M.), no nurses were scheduled until 08/05/25 and two to three caregivers were scheduled.

A telephone interview on 08/05/25 at 11:55 A.M. with Family Nurse Practitioner (FNP) #74 revealed she had only seen Resident #18 once while she was at the facility from May 2025 through July 2025 and this was on 06/20/25. FNP #74 stated she ordered occupational therapy, physical therapy and speech therapy at this time. When asked about Resident #18's Ativan and Dilaudid, FNP #74 stated her records included Resident #18 was ordered Ativan 0.5 mg every 12 hours PRN and Dilaudid 4 mg every four hours PRN which did not match Resident #18's facility physician's orders for these medications. When asked if Resident #18 was capable of safely self-administering her own medications, FNP #74 stated she did not feel anyone in a facility should be self-administering their own medications. During the interview FNP #74 looked into the Ohio Automated Rx Reporting System (OARRS) and indicated it appeared palliative staff changed the orders for the Ativan and Dilaudid on 06/10/25 and reiterated she did not change any medications for Resident #18 since she was involved with her care.

A telephone interview on 08/05/25 at 1:12 P.M. and 08/06/25 at 3:08 P.M. with Palliative Practice Manager (PPM) #82 confirmed one of their providers changed Resident #18's Ativan order on 06/10/25 to 0.5 mg Ativan every six hours and also changed Resident #18's Dilaudid order on 06/10/25 to 4 mg every four hours.

A telephone interview on 08/07/25 at 9:45 A.M. with LPN #69 revealed he no longer worked for the facility. LPN #69 stated on 07/22/25, he was still in training with LPN #60 and came up during the breakfast meal to work on medication administration on the second floor as they were splitting the cart. LPN #69 stated LPN #60 went into Resident #18's room that morning and found her unresponsive and then asked him to get the vital sign machine and obtain Resident #18's vital signs. LPN #69 stated he got Resident #18's blood pressure and pulse oxygen and stated her vitals were all very low which was not good. LPN #69 stated Resident #18 was shaking too much to obtain a blood sugar and described Resident #18 as warm, sweaty and grunting trying to breathe and had her eyes closed with her legs crossed and face down into her chest which did not look right. LPN #60 called 911 and they arrived about 10 to 15 minutes later. LPN #69 confirmed no staff reported to him any change in Resident #18's condition and no staff called him prior to his shift at 7:00 A.M. to report any concerns with Resident #18. LPN #69 explained he was previously an emergency medical technician (EMT) and had the change been reported to him, he would have gone into Resident #18's room right away to assess her. LPN #69 also confirmed he had not been in Resident #18's room prior to LPN #60 calling him into the room that morning.

Review of the facility undated Resident Agreement revealed Hines Hill Senior Living would make personal care and health-related services available to the resident, within the service capacity of Hines Hill Senior Living and as required and as allowed by State regulation. Such services include, but were not limited to, assistance with dressing, bathing, hygiene, toileting, eating, ambulation, transferring, supervision of medication administration, monitoring health care, and arranging for health services. The charge for such care and assistance would be included in the resident's monthly fee, as set forth in Section IV of this agreement...Team members would be available 24 hours per day to provide residents with needed services, as determined by house team members in conjunction with the Resident. Health-related assistance or supervision may be provided by licensed nurses, licensed nursing assistants or by unlicensed team members through nurse-delegated assistance. The level of team member assistance provided would be adapted to changing resident needs based on assessments conducted by the Executive Director or nurse prior to move in, 30 days post move in, semi-annually, and/or when there was a change in the resident's health status, which would require a reassessment.

Review of the undated policy titled Significant Change in Physical or Behavioral Status and Incidents revealed staff were to take immediate and proper steps needed to see that the resident received necessary interventions including if needed medical attention or transfer to an appropriate medical facility. The policy included: If you are in doubt about whether or not something should be considered an emergency call 911...provide appropriate treatment for the resident within your scope of practice...Investigate any significant incidents and document the incident and investigation. Incidents include hospitalizations.

Review of the undated facility policy titled Medication Delivery revealed all medications shall be given only to the individual resident for whom they were prescribed given in accordance with the directions on the prescription or the physician's or other prescribers' orders and recorded on the resident's medication record ...pre-pouring of medications was allowed only directly prior

to the time of the medication pass and in accordance with House policy and state regulations. A resident's ability to consistently, appropriately self-administer his/her medications would be evaluated in accordance with the Self-Administration of Medication policy/procedure. Medication assistance would be categorized as either self-administration or assistance with self-administration and would occur in accordance with physicians' orders, resident preference and ability, state regulations and house policy. Assistance with self-administration did not address controlled substances. Medications prepared by team member would be passed by the same team member. The medications were recorded as given, documenting the name of the medication, date and time given, route of administration and signed by the individual administering the medication.

Review of a facility undated and untitled policy regarding controlled substances revealed the facility would ensure the proper handling of controlled substances. Controlled medications would be subject to special receipt, record-keeping, medication assistance, change of shift-count verification, storage and disposal procedures ...controlled medications for a resident who was self-administering would be delivered directly to the resident by the delivery person. All controlled medications were to be logged on a narcotic record form. All narcotics would be stored under a double lock system.

This violation is an example of noncompliance investigated under Complaint Number OH00167731.

Based on record review, interview, police report review and facility investigation review, the facility failed to prevent, timely report and thoroughly investigate resident to resident misappropriation. This affected one resident (#18) of three residents reviewed for financial exploitation. Facility census was 49.

Findings include:

Review of Resident #18's medical record revealed an admission date of 05/29/25 and diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes, lumbago with sciatica, chronic pain syndrome, generalized anxiety disorder, depression, memory deficit following cerebral infarction and atrial fibrillation. Resident #18 discharged to the hospital on 07/22/25 and did not return to the facility.

Further review of Resident #18's paper and electronic medical records revealed no service plan or mini-mental state examination (MMSE) assessment were available for review.

Review of a progress note dated 07/17/25 at 11:57 A.M. and authored by Licensed Practical Nurse (LPN) #60 revealed Resident #18's daughter called and informed staff that she was going to make a police report for the items missing from her mother's room and was going to press charges on the resident that went into residents room. This nurse made facility Administrator know about phone call and what resident's daughter stated.

Review of a progress note dated 07/18/25 at 2:59 P.M. and authored by LPN #60 revealed the police came and took statement from Resident #18 about her missing items and also talked with staff involved. Police also talked to other resident involved in incident.

Review of Resident #5's medical record revealed an admission date of 03/13/25 and diagnoses including generalized anxiety disorder, dementia, postpartum mood disturbance, schizoaffective disorders, asthma, peripheral vascular disease and impulse disorder. Further review of Resident #5's paper and electronic medical records revealed a MMSE score of eight indicating severe cognitive impairment. No service plan was available for review.

Review of a nurses' note dated 07/10/25 at 12:16 P.M. and authored by LPN #60 revealed this nurse was doing lunch medication pass when caregiver (not identified) came to me and stated resident was seen coming out of Resident #18's room with items in hands that belonged to Resident #18. This nurse went and notified Resident Care Coordinator (RCC) #63 and Administrator and when cameras were checked they confirmed her going in there and retrieving items. Both staff educated resident on not going in other resident's room.

Review of a police report dated 07/16/25 revealed Resident #5 was being charged with theft of Resident #18's belongings. The report listed the belongings as a plant, two books, a carton of cigarettes, a lock box with $327.00, four unopened wipes, pull ups, a bottle of mouthwash, two big cups, a box of tarot cards, a dream catcher, random clothing, a 12-pack of soda, three packs of Swiss Miss hot cocoa, a six-pack of toilet paper, $20.00 in cash and seven pairs of socks. Resident #18 reported missing items on 07/16/25 at 5:10 P.M. as she had been in the hospital for the past week and when she came home, she noticed many of her belongings were misplaced and some items were missing. Resident #18 stated she thought her items were stolen as she never gave anyone permission to enter her room while she was gone. Resident #18 voiced she'd had issues with Resident #5 who had the tendency to come to her room to ask for cigarettes and that she came to her room while she was in there without knocking or asking and this had happened on a few occasions. Police then went to Resident #5's room to ask about Resident #18's missing items. Resident #5 admitted to going into Resident #18's room last Wednesday (07/09/25) around 10:30 A.M. and taking the items while Resident #18 was gone at the hospital. Resident #5 permitted police to enter her room to look for the missing items and three books, a potted plant, a skull t-shirt and a bar of soap were returned to Resident #18. The lockbox was still missing. Resident #5 was given a citation for petty theft and had a court date regarding the matter on 07/22/25 at 3:30 P.M. Investigation remained on-going.

Review of the facility's investigation regarding Resident #18's misappropriation consisted of Resident #18's nurses' notes and an incident report dated 07/16/25 at 11:02 A.M. Further review of the incident report revealed Resident #18 reported to the nurse items were missing from her room when she was at the hospital and the Administrator was made aware. The nurse requested Resident #18 make a list of items missing and she'd have staff keep an eye out for items. Resident #18's family and police were notified. Under the section, determination of cause staff and residents were marked as being interviewed, but the rest of the report was blank. No determination of cause or prevention of similar incidents was provided. No witness statements from staff or residents was included in the provided materials.

Review of a second incident report dated 07/29/25 for 07/18/25 at 11:05 A.M. revealed the Administrator spoke with Resident #5 and Resident #18 to follow up with items missing from Resident #18's room. Resident #5 stated she had gone in Resident #18's room and took several items but when police came she gave them all back. Resident #18 stated she's still missing a black lock box with at least $300.00 in it. The Administrator stated she would obtain video footage to see if Resident #5 in fact had the lock box which would take a few days to work on and Resident #18 stated that's fine.

Interview on 07/29/25 at 12:28 P.M. with the Administrator regarding the misappropriation of Resident #18's property revealed when she spoke with Resident #5, Resident #5 had admit she had went into Resident #18's room to take soda, books and shampoo and said she had given the items back when the police were present. The Administrator stated as part of the investigation she spoke to Resident #5 and Resident #18 along with the caregiver at the time who since was deceased. The Administrator stated the caregiver normally would have initiated the incident report but had died unexpectedly so the documentation available was what LPN #60 and herself had completed. The Administrator verified she did not report the alleged misappropriation to the State Agency (SA) as required as there was not an injury to the resident and staff were not identified as stealing the property. During the interview, the Administrator was made aware the above incident was reportable to the SA as the allegation concerned misappropriation and the police report indicated Resident #5 actually took Resident #18's property and she did not disagree. The Administrator also indicated the provided policy on incidents is what they had regarding abuse and did not have a separate abuse policy and procedure at the facility.

Interview on 07/29/25 at 12:47 P.M. with Resident #5 confirmed she took items from Resident #18, including lotion and a mat. Resident #5 stated she could not remember what else she took from Resident #18. When asked why she took Resident #18's items as they did not belong to her, Resident #5 stated she did not know why and indicated it was an impulse. Resident #5 stated she had the items for two days then Resident #18 got everything back. Resident #5 stated there was a lockbox but she did not take it.

Interview on 07/29/25 at 4:06 P.M. with RCC #63 revealed while Resident #18 was at the hospital on 07/10/25 the cleaners cleaned her room but it was not until staff saw Resident #5 walking down the hallway with a Pepsi in a basket that staff suspected something was amiss. Resident #5 had Pepsi cans in her fridge and did not normally have these items of her own. RCC #63 stated she asked the Administrator for camera footage which showed Resident #5 by Resident #18's door. RCC #63 stated she went to Resident #18's door, which was unlocked, and put the soda back into her refrigerator. While in the room she noticed Resident #18's carton of cigarettes was empty and Resident #5 denied taking her cigarettes. RCC #63 locked Resident #18's door. Later that day, Resident #18 came back from the hospital and was upset her room looked like someone had ransacked it. RCC #63 told staff to have Resident #18 write down what was missing so they could follow up. Resident #18's daughter came to the facility on 07/11/25 and indicated the police were going to come out due to the missing items. When the police came to the facility, Resident #18 got some of her missing items back but the lockbox with over $300.00 cash remained missing and unaccounted for. RCC #63 also stated a few days later, Resident #5 gave another resident (not identified) some of Resident #18's makeup.

Follow-up interview on 07/30/25 at 9:55 A.M. with the Administrator revealed as part of the facility's investigation she had spoken with Resident #5, Resident #18, Resident #21 and Resident #38. When asked if there was documentation pertaining to these statements, the Administrator stated no. The Administrator verified no staff witness statements were collected as part of the investigatory process. The Administrator was made aware during the interview the provided nurses' notes and incident reports were not evidence of a complete investigation and she did not disagree.

Review of the facility policy, Incident-Occurrence Reporting