Woodlands of Findlay

Based on observation, staff interview, review of the menu spreadsheet, the facility failed to follow the approved menu at lunch time. This had the potential to affect all 52 residents that received lunch from the kitchen. The facility census was 52.

Findings include:

Review of the menu for day two, week one for lunch revealed steak fajitas, chicken and sausage gumbo soup, Mexican corn, banana pudding, and beverage of choice was on the lunch menu.

Review of the spreadsheet for the lunch menu revealed toppings were to be served with the steak fajita included: salsa, sour cream, shredded cheese, diced tomatoes, and shredded lettuce.

Observation of lunch trayline on 06/01/26 at 12:20 P.M. revealed the steak fajita was served without the following toppings: shredded cheese, diced tomatoes, and shredded lettuce.

Interview on 06/01/26 at 1:00 P.M. with the Executive Director verified the lunch meal was served without offering the toppings of shredded cheese, diced tomatoes, and shredded lettuce.

Interview on 06/01/26 at 2:09 P.M. with the Executive Director revealed the facility does not have a policy related to following the menu.

This violation represents non-compliance investigated under Complaint Number OH00170510, Complaint Number OH00168965, Complaint Number OH00168562, Complaint Number OH00168353, and Complaint Number OH00167230.

Based on observation, staff interview, and review of the policy, the facility failed to maintain a clean and sanitary environment throughout the facility. This had the potential to affect all 52 residents. The facility census was 52.

Findings include:

Observation on 06/01/26 at 9:04 A.M., revealed accumulation of food, dirt, and dried liquid throughout all the facilities hallway floors.

Interview on 06/01/26 at 10:30 A.M. ,with the Administrator confirmed there was food, dirt, and dried liquid throughout the hallways of the facility. Administrator further stated that housekeeping typically worked a Monday through Friday schedule and that the night shift staff were supposed to help keep the facility clean.

Review of the facility policy titled Environmental Cleanliness and Maintenance Policy dated 02/01/24, revealed all facility areas shall be maintained in a clean, sanitary, orderly, and safe condition. Floors, walls, ceilings, furnishings, fixtures, and equipment shall be maintained free from excessive dirt, dust, stains, debris, and other conditions that negatively impact cleanliness or safety.

This violation represents non-compliance investigated under Complaint Number OH00170510, Complaint Number OH00169003, Complaint Number OH00167650, Complaint Number OH00167230, and complaint Number OH00166604.

Based on observation and staff interview, the facility failed to ensure a first-aid kid was readily available. This had the potential to affect all 52 residents. The facility census was 52.

Findings include:

Observation on 06/01/26 at 9:00 A.M. of the nurse's station revealed there was no visible first-aid kit.

Interview on 06/01/26 at 9:18 A.M. with Licensed Practical Nurse (LPN) #104 confirmed there was no first- aid kit available.

Based on resident interview, medical record review, staff interview and review of the facility policy, the facility failed to ensure qualified staff were available to provide residents, who required medication administration services, with medications at physician ordered medication administration times. This affected three (#33, #43, and #58) of three residents reviewed medication administration. The facility census was 57.

Findings include:

1. Review of Resident #33's medical record revealed an admission date of 08/05/24. Diagnoses included anxiety, bipolar disorder, chronic kidney disease, chronic obstructive pulmonary disease (COPD) and major depressive disorder.

Review of the Self-Medication Assessment, dated 08/05/24, revealed Resident #33 was unable to safely self-administer medications.

Review of a physician order dated 10/03/24 revealed that Resident #33's medications were to stay in the (pharmacy) pill pack and staff must watch the resident take her medications. Additional review of the physician orders revealed Resident #33 had the following bedtime (HS) medications ordered: simvastatin (cholesterol medication) 80 milligrams (mg), take one tablet by mouth at bedtime and doxepin (used to treat depression, anxiety and insomnia) 75 mg, take one tablet by mouth at bedtime.

Interview on 06/09/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #133 confirmed the facility did not have staff available to administer medications after 7:00 P.M. LPN #133 verified HS medications were left with any resident who did not want to take their HS medications during the evening medication pass to take later in the evening, including Resident #33.

Interview on 06/09/25 at 3:47 P.M. with Assistant Director of Nursing (ADON) #140 revealed that Resident #33 had an order to watch her take all medications. ADON #140 verified Resident #33 should not administer her own medications.

Interview on 06/10/25 at 8:15 A.M. with Certified Medication Aide (CMA) #141 revealed staff sometimes left Resident #33's HS medications with her to take before bedtime because she would refuse to take them with the last medication pass before the nurses left the facility at 7:00 P.M., due to it being too early.

A follow-up interview on 06/10/25 at 8:16 A.M. with LPN #133 revealed Resident #33 sometimes refused to take her HS medications before the nurses left for the day at 7:00 P.M. because she felt it was too early to take them. LPN #133 stated nursing staff could not force residents to take their medications before they left for the day, so the only option was to leave them with the resident to self-administer later.

Interview on 06/10/25 at 12:00 P.M. with the Director of Nursing (DON) confirmed Resident #33 was not assessed to safely self-administer her medications and further verified the facility did not have nursing staff available for any medication administration after 7:00 P.M.

2. Review of Resident #43's medical record revealed an admission date of 09/25/24. Diagnoses included anxiety disorder, depression, chronic renal failure, neurocardiogenic syncope, cerebrovascular accident (stroke), seizure disorder, lesions on the brain, uterine cancer, migraine, and Postural Orthostatic Tachycardia Syndrome (POTS - causes rapid increase in heart rate and other symptoms when a person stands up from a sitting or lying position).

Review of the Self-Medication Assessment, undated, revealed the instructions stated the resident must be able to perform each step indcated prior to beginning self-administration of medication. The steps included, but not limited to, correctly state what each medication was for, correctly state the proper dosage, and correctly state the common side effects of each medication. Further review revealed Resident #43's Self-Medication Assessment was not completed and a handwritten note at the bottom of the assessment stated Does not desire to self-med.

Review of a facsimile (fax), dated 10/03/24, revealed the facility sent a request to Resident #43's physician requesting an order for the resident to self-administer HS medications with medication set-up and reminders from staff. The fax stated the resident was requesting this due to the facility only having a nurse on duty until 7:00 P.M. and the resident wanted to take them later in the evening.

Review of the current physician orders revealed Resident #43 had the following HS and as needed (PRN) medication orders: buspirone (used to treat anxiety) 10 mg one tablet by mouth at HS, butalab-acetamin-caff 50-300-44 (used to treat tension headaches) take one or two capsules by mouth every eight hours PRN, not to exceed six capsules in 24 hours; cyclobenzaprine (muscle relaxer) five mg take one tablet by mouth at bedtime as needed; hydroxyzine HCL (used to treat anxiety) 10 mg tablet take one tablet by mouth every six hours as needed; loperamide (treats diarrhea) two mg capsule, take two capsules by mouth after first loose stool, then take one capsule after each subsequent loose stool, not to exceed eight mg in 24 hours; Excedrin migraine caplet, 250-250-65 mg take one tablet by mouth every six hours as needed; ropinrole HCL (treats restless leg syndrome) one mg tablet, take one tablet by mouth at HS; simvastatin (used to treat high cholesterol) 20 mg tablet, one tablet by mouth at bedtime; and Systane nighttime eye ointment (treats dry eyes), apply 1/8 inch ribbon to each lower eyelid at bedtime.

Interview on 06/09/25 at 12:06 P.M. with Resident #43 revealed that facility staff did not administer her bedtime medications, but administered all other medications. Resident #43 stated the facility did not have nurses after 7:00 P.M. and she did not want to take her bedtime medications at dinnertime because they made her sleepy and she preferred to go to bed around 10:00 P.M. to 11:00 P.M. Resident #43 stated that during the dinnertime medication pass, around 5:00 P.M., the nurse provided her with evening medication doses in one cup and placed her HS medications in a second cup for her to take later. Resident #43 stated facility staff did not reminder her to take her HS medication and that her roommate, Resident #44, reminded her to take her HS medications when it was time so that she did not forget. Additionally, Resident #43 stated she had frequent migraines and, while the medication was ordered PRN, she typically requested the nurse provide her a dose because there would be no one available to provide her PRN medications if she needed them after 7:00 P.M. Concurrent interview with Resident #44 confirmed he provided Resident #43 with reminders to take her HS medications and not facility staff.

Interview on 06/09/25 at 1:09 P.M. with Certified Medication Aide (CMA) #141 confirmed the facility had no nursing staff available to administer medications, including PRN medications, after 7:00 P.M. so nursing staff had to provide Resident #43 with her HS medications during the last medication pass of the day, which occurred between 5:00 P.M. and 7:00 P.M.

Interview on 06/09/25 at 2:55 P.M. with LPN #133 confirmed the facility did not have nursing staff available to administer medications, including PRN medications, after 7:00 P.M. LPN #133 verified HS medications were left with any resident who did not want to take their HS medications during the evening medication pass to take later in the evening, including Resident #43.

Interview on 06/09/25 at 3:00 P.M. with the DON verified Resident #43 did not have a Medication Self-Administration Assessment completed to determine the resident's ability to safely administer medications with or without assistance. The DON stated she was unaware nursing staff were leaving medications with residents to take at HS and she thought the residents were taking their HS medications before the nurses left at 7:00 P.M.

Interview on 06/10/25 at 9:21 A.M. with Assistant Director of Nursing (ADON) #140 revealed a request was faxed to Resident #43's physician on 10/03/24 requesting an order for the resident to self-administer her HS medications, with staff assistance. ADON #140 stated the resident requested to self-administer medications at bedtime because she did not want to take them before 7:00 P.M., when the nurses left for the day, because that time was too early for the resident. ADON #140 stated she viewed this as a resident request but confirmed the request for Resident #43 to self-administer her bedtime medications was the result of the facility having no staff available after 7:00 P.M. to administer medications to residents.

Interview on 06/10/25 at 12:00 P.M. with the DON confirmed she had never come to the facility between 7:00 P.M. and 7:00 A.M. to administer a PRN medication to a resident who needed one and further verified nursing staff would not come to the facility after the nurses left at 7:00 P.M. to administer a PRN medication, if a resident needed it.

A follow up interview with the DON on 06/10/25 at 3:44 P.M. confirmed the facility did not have staff available for medication administration from 7:00 P.M. to 7:00 A.M. The DON stated they facility explained to residents prior to admission that they did not offer medication administration during those hours. Further interview with the DON verified the facility admitted residents who required medication administration, including HS medications.

3. Review of Resident #58's medical record revealed an admission date of 12/09/24. Diagnoses included anxiety disorder, bipolar disorder, atrial flutter (a condition that causes the heart to beat irregularly), chronic obstructive pulmonary disease (COPD), Myasthenia Gravis (a chronic condition where the body's immune system attacks the nerves to the voluntary muscles leading to fluctuating weakness and fatigue), and adult-onset diabetes.

Review of the Self-Medication Assessment, undated, revealed the assessment was not completed. A handwritten note at the top of the document stated the resident did not have a self-administration order.

Review of the Wellness Baseline assessment, dated 12/10/24, revealed Resident #58 required assistance with medications.

Review of a physician order dated 05/14/25 revealed Resident #58 had an order for levetiracetam (used to treat seizures) 750 mg, one tablet by mouth every 12 hours. Resident #58 did not have an order to self-administer medications.

Observation on 06/09/25 at 10:15 A.M. of medication administration with LPN #133 revealed she was completing the morning medication pass for Resident #58. LPN #133 removed the resident's medications from the medication cart and provided the medications to the resident. Included in the medications administered was levetiracetam.

Review of the Medication Administration Record (MAR) for June 2025 revealed none of Resident #58's levetiracetam administrations were documented as 12 hours apart, per physician order. On 06/07/25, the morning dose of levetiracetam was documented as administered at 11:48 A.M., while the second dose was documented as administered at 6:50 P.M. (approximately seven hours after the morning dose). On 06/08/25, the morning dose was documented as administered at 11:56 A.M. (approximately 17 hours after the last dose on 06/08/25) and the second dose was documented as administered at 5:55 P.M. (approximately six hours after the morning dose).

Interview on 06/09/25 at 2:55 P.M. with LPN #133 verified the physician order for levetiracetam was to be administered every 12 hours. LPN #133 confirmed she administered Resident #58's levetiracetam at 10:15 A.M., approximately 16 hours and 20 minutes after the last dose was administered on 06/08/25 at 5:55 P.M., and the resident would receive the second dose before the end of her shift at 7:00 P.M. (maximum possible time of eight hours and 45 minutes from the morning dose). LPN #133 stated nursing staff only worked from 7:00 A.M. to 7:00 P.M. and all medications had to be administered within that time.

Interview on 06/10/25 at 9:21 A.M. with ADON #140 confirmed Resident #58 did not self-administer her medications. Further interview revealed she was unaware the physician order for Resident #58's levetiracetam specified the medication doses were to be administered 12 hours apart. ADON #140 stated the facility did not have nursing staff available after 7:00 P.M. to ensure the medication was administered within the timeframe indicated in the physician order.

Review of the facility policy titled, Medication Services, dated 12/20/22, revealed the Executive Director (ED) would ensure that medication related services required or requested by each resident was provided. Residents would be determined to be in one of three assistance categories; Independent: able to safely self-manage their own medications, including storage, administration, and re-ordering; Assistance: required and needed coaching, reminding, assistance with containers, was aware that they were taking medication, and needed/requested assistance with storage and re-ordering. Assistance with administration for residents in this category were performed by nurses and CMAs (under nurse delegation); and Administration: resident was completely incapable of self-directing their medication care. Medication administration for residents in this category were performed by nurses and CMAs (under nurse delegation).

Review of the facility policy titled, Basic Care, dated 12/20/23, revealed that medications were to be given on schedule and PRN medications were to be passed as requested, according to physician orders and Ohio rules.

This violation was issued relative to incidental findings that were discovered during the complaint investigation completed on 06/10/25.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure initial Self-Medication Assessments were completed. This affected two (#43 and #58) of three residents reviewed for self-medication assessments. The facility census was 57.

Findings include:

1. Review of Resident #43's medical record revealed an admission date of 09/25/24. Diagnoses included anxiety disorder, depression, chronic renal failure, neurocardiogenic syncope, cerebrovascular accident (stroke), seizure disorder, lesions on the brain, uterine cancer, migraine, and Postural Orthostatic Tachycardia Syndrome (POTS - causes rapid increase in heart rate and other symptoms when a person stands up from a sitting or lying position).

Review of the Self-Medication Assessment, undated, revealed the assessment was not completed and a handwritten note at the bottom of the assessment stated Does not desire to self-med.

Interview on 06/09/25 at 3:00 P.M. with the Director of Nursing (DON) verified a Self-Medication Assessment was not completed for Resident #43, and further stated one was not required because the resident did not have a physician order to self-administer medications. The DON stated she was unaware a Self-Medication Assessment was required for all residents upon admission and annually thereafter.

2. Review of Resident #58's medical record revealed an admission date of 12/09/24. Diagnoses include anxiety disorder, bipolar disorder, atrial flutter (a condition that causes the heart to beat irregularly), chronic obstructive pulmonary disease (COPD), Myasthenia Gravis (a chronic condition where the body's immune system attacks the nerves to the voluntary muscles leading to fluctuating weakness and fatigue), and adult-onset diabetes.

Review of the Self-Medication Assessment, undated, revealed the assessment was not completed for Resident #58. Further review revealed a handwritten note at the top of the document stating the resident did not have a self-administration order.

Interview on 06/10/25 at 12:00 P.M. with the DON verified a Self-Medication Assessment was not completed for Resident #58 upon admission. The DON stated the assessment was only completed for residents who had a physician order to self-administer medications. The DON confirmed she was unaware how a determination was made regarding a resident's ability to safely self-administer medications or what assistance may be needed to self-administer medications without the assessment being completed to determine resident needs.

Review of the facility policy titled, Medication Services, dated 12/20/22, revealed residents would be determined to be in one of three assistance categories; Independent: able to safely self-manage their own medications, including storage, administration, and re-ordering; Assistance: required and needed coaching, reminding, assistance with containers, was aware that they were taking medication, and needed/requested assistance with storage and re-ordering. Assistance with administration for residents in this category were performed by nurses and Certified Medication Aides (CMAs) (under nurse delegation); and Administration: resident was completely incapable of self-directing their medication care. Medication administration for residents in this category were performed by nurses and CMAs (under nurse delegation).

This violation was issued relative to incidental findings that were discovered during the complaint investigation completed on 06/10/25.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were administered per physician orders to residents who required medication administration. This affected one (#58) of three residents reviewed for medication administration. The facility census was 57.

Findings include:

Review of Resident #58's medical record revealed an admission date of 12/09/24. Diagnoses included anxiety disorder, bipolar disorder, atrial flutter (a condition that causes the heart to beat irregularly), chronic obstructive pulmonary disease (COPD), Myasthenia Gravis (a chronic condition where the body's immune system attacks the nerves to the voluntary muscles leading to fluctuating weakness and fatigue), and adult-onset diabetes.

Review of the Self-Medication Assessment, undated, revealed the assessment was not completed. A handwritten note at the top of the document stated the resident did not have a self-administration order.

Review of a physician order dated 03/26/25 revealed Resident #58 was ordered Breo Ellipta (treats respiratory conditions) 100-25, inhale one puff by mouth every day. Further review revealed an order dated 05/14/25 for levetiracetam (used to treat seizures) 750 milligrams (mg), one tablet by mouth every 12 hours. Resident #58 did not have an order to self-administer medications.

Observation on 06/09/25 at 10:15 A.M. of medication administration with Licensed Practical Nurse (LPN) #133 revealed she was completing the morning medication pass for Resident #58. LPN #133 removed the resident's medications from the medication cart and provided the medications to the resident. Included in the medications administered was levetiracetam. LPN #133 did not administer Breo Ellipta.

Review of the Medication Administration Record (MAR) for June 2025 revealed none of Resident #58's levetiracetam administrations were documented as 12 hours apart, per physician order. On 06/07/25, the morning dose of levetiracetam was documented as administered at 11:48 A.M., while the second dose was documented as administered at 6:50 P.M. (approximately seven hours after the morning dose). On 06/08/25, the morning dose was documented as administered at 11:56 A.M. (approximately 17 hours after the last dose on 06/08/25) and the second dose was documented as administered at 5:55 P.M. (approximately six hours after the morning dose).

Interview on 06/09/25 at 2:55 P.M. with LPN #133 verified she did not administer Resident #58's Breo Ellipta during the morning medication pass. LPN #133 stated the Breo Ellipta was kept in the resident's room and she was unable to confirm if the resident had taken the medication. Further interview confirmed the physician order for levetiracetam was to be administered every 12 hours. LPN #133 verified she administered Resident #58's levetiracetam at 10:15 A.M., approximately 16 hours and 20 minutes after the last dose was administered on 06/08/25 at 5:55 P.M., and the resident would receive the second dose before the end of her shift at 7:00 P.M. (maximum possible time of eight hours and 45 minutes from the morning dose). LPN #133 stated nursing staff only worked from 7:00 A.M. to 7:00 P.M. and all medications had to be administered within that time.

Interview on 06/10/25 at 9:21 A.M. with Assistant Director of Nursing (ADON) #140 revealed she was unaware the physician order for Resident #58's levetiracetam specified the medication doses were to be administered 12 hours apart. ADON #140 stated the facility did not have nursing staff available after 7:00 P.M. to ensure the medication was administered within the timeframe indicated in the physician order.

Review of the facility policy titled, Medication Services, dated 12/20/22, revealed medications could be given up to one hour before or up to one hour after the prescribed time to accommodate resident schedules unless otherwise indicated by the physician.

This violation represents non-compliance investigated under Master Complaint Number OH00166462 and Complaint Numbers OH00166256 and OH00166154.

Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were not left unsecured in resident rooms, to take at a later time. This affected three (#33, #43 and #58) of three residents reviewed for medication administration. Additionally, the facility failed to ensure the medications were stored to prevent unauthorized access when the facility failed to lock the medication room. This had the potential to affect all 57 residents residing in the facility. The facility census was 57.

Findings include:

1. Review of Resident #33's medical record revealed an admission date of 08/05/24. Diagnoses included anxiety, bipolar disorder, chronic kidney disease, chronic obstructive pulmonary disease (COPD) and major depressive disorder.

Review of the Medication Self-Administration assessment, dated 08/05/24, revealed Resident #33 was unable to safely self-administer medications.

Review of a physician order dated 10/03/24 revealed that Resident #33's medications were to stay in the (pharmacy) pill pack and staff must watch the resident take her medications. Additional review of the physician orders revealed Resident #33 had the following bedtime (HS) medications ordered: simvastatin (cholesterol medication) 80 milligrams (mg), take one tablet by mouth at bedtime and doxepin (used to treat depression, anxiety and insomnia) 75 mg, take one tablet by mouth at bedtime.

Review of the care plan, dated 12/13/24, revealed Resident #33 required staff to provide supervision and assistance with self-administration (of medication).

Interview on 06/09/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #133 revealed the facility did not have staff available to administer medications after 7:00 P.M. LPN #133 verified HS medications were left with any resident who did not want to take their HS medications during the evening medication pass to take later in the evening, including Resident #33.

Interview on 06/10/25 at 8:15 A.M. with Certified Medication Aide (CMA) #141 revealed staff sometimes left Resident #33's HS medications with her to take before bedtime because the resident would refuse to take them with the last medication pass before the nurses left the facility at 7:00 P.M.

Interview on 06/09/25 at 3:00 P.M. with the Director of Nursing (DON) revealed she was unaware nursing staff were leaving unattended/unsecured medications with residents to take at night. Additionally, the DON stated residents who were assessed to self-administer medications independently or with assistance should have a lockbox in their apartment for storage.

A follow-up interview on 06/10/25 at 8:16 A.M. with LPN #133 revealed Resident #33 sometimes refused to take her HS medications before the nurses left for the day at 7:00 P.M. LPN #133 stated nursing staff could not force residents to take their medications before they left for the day, so the only option was to leave them with the resident to self-administer later. LPN #133 verified Resident #33 did not have a lockbox in her apartment to secure her medications.

2. Review of Resident #43's medical record revealed an admission date of 09/25/24. Diagnoses included anxiety disorder, depression, chronic renal failure, neurocardiogenic syncope, cerebrovascular accident (stroke), seizure disorder, lesions on the brain, uterine cancer, migraine, and Postural Orthostatic Tachycardia Syndrome (POTS - causes rapid increase in heart rate and other symptoms when a person stands up from a sitting or lying position).

Review of the Self-Medication Assessment, undated, revealed the instructions stated the resident must be able to perform each step indicated prior to beginning self-administration of medication. The steps included, but not limited to, ability to correctly read aloud instructions for use on the medication container, state what each medication was for, correctly state what time medications were to be taken, and demonstrate secure storage for medication kept in their apartment. Further review revealed Resident #43's Self-Medication Assessment was not completed and a handwritten note at the bottom of the assessment stated Does not desire to self-med.

Review of a facsimile (fax), dated 10/03/24, revealed the facility sent a request to Resident #43's physician requesting an order for the resident to self-administer HS medications with medication set-up and reminders from staff. The fax stated the resident was requesting this due to the facility only having a nurse on duty until 7:00 P.M. and the resident wanted to take them later in the evening. Further review revealed the physician responded on 10/03/24 and stated the resident could administer her medications with set up by the pharmacy.

Review of the current physician orders revealed Resident #43 had the following HS and an needed (PRN) medication orders: buspirone (used to treat anxiety) 10 mg one tablet by mouth at HS, butalab-acetamin-caff 50-300-44 (used to treat tension headaches) take one or two capsules by mouth every eight hours PRN, not to exceed six capsules in 24 hours; cyclobenzaprine (muscle relaxer) five mg take one tablet by mouth at bedtime as needed; hydroxyzine HCL (used to treat anxiety) 10 mg tablet take one tablet by mouth every six hours as needed; loperamide (treats diarrhea) two mg capsule take two capsules by mouth after first loose stool, then take one capsule after each subsequent loose stool, not to exceed eight mg in 24 hours; Excedrin migraine caplet, 250-250-65 mg take one tablet by mouth every six hours as needed; ropinrole HCL (treats restless leg syndrome) one mg tablet, take one tablet by mouth at HS; simvastatin (used to treat high cholesterol) 20 mg tablet, one tablet by mouth at bedtime; and Systane nighttime eye ointment (treats dry eyes), apply 1/8 inch ribbon to each lower eyelid at bedtime.

Interview on 06/09/25 at 12:06 P.M. with Resident #43 revealed that facility staff did not administer her bedtime medications but administered all other medications. Resident #43 stated the facility did not have nurses after 7:00 P.M. and she did not want to take her bedtime medication at dinnertime because they made her sleepy. Resident #43 stated that during the dinnertime medication pass, around 5:00 P.M., the nurse provided her with evening medication doses in one cup and placed her HS medications in a second cup for her to take later. Resident #43 stated she kept the medication cup with her bedtime medication in her apartment and her roommate reminded her of when to take them. Resident #43 indicated she likes to go to bed around 10 or 11 o'clock at night.

Interview on 06/09/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #133 revealed the facility did not have staff available to administer medications after 7:00 P.M. LPN #133 verified HS medications were left with any resident who did not want to take their HS medications during the evening medication pass to take later in the evening, including Resident #43.

Interview on 06/09/25 at 3:00 P.M. with the DON revealed she was unaware nursing staff were leaving unattended/unsecured medications with residents to take at night. Additionally, the DON stated residents who were assessed to self-administer medications independently or with assistance should have a lockbox in their apartment for storage.

A follow-up interview on 06/10/25 at 8:16 A.M. with LPN #133 revealed Resident #43 did not want to take her HS medications before the nurses left for the day at 7:00 P.M. LPN #133 stated nursing staff could not force residents to take their medications before they left for the day, so the only option was to leave them with the resident to self-administer later. LPN #133 verified Resident #43 did not have a lockbox in her apartment to secure her medications.

3. Review of Resident #58's medical record revealed an admission date of 12/09/24. Diagnoses included anxiety disorder, bipolar disorder, atrial flutter (a condition that causes the heart to beat irregularly), chronic obstructive pulmonary disease (COPD), Myasthenia Gravis (a chronic condition where the body's immune system attacks the nerves to the voluntary muscles leading to fluctuating weakness and fatigue), and adult-onset diabetes.

Review of the Self-Medication Assessment, undated, revealed the assessment was not completed. A handwritten note at the top of the document stated the residents did not have a self-administration order.

Review of the Wellness Baseline assessment, dated 12/10/24, revealed Resident #58 required assistance with medications.

Interview on 06/09/25 at 3:00 P.M. with the DON revealed she was unaware nursing staff were leaving unattended/unsecured medications with residents to take at night. Additionally, the DON stated residents who were assessed to self-administer medications independently or with assistance should have a lockbox in their apartment for storage.

Interview on 06/10/25 at 8:15 A.M. with Certified Medication Aide (CMA) #141 revealed that Resident #33 sometimes refused to take her HS medications prior to nursing staff leaving at 7:00 P.M., so there were times the medications were left for the resident to take later.

Interview on 06/10/25 at 8:16 A.M. with LPN #133 confirmed Resident #58 would refuse to take her medications before nursing staff left at 7:00 P.M. and that staff could not force the residents to take her medications. LPN #133 stated the only option was to leave the medications with the resident to take later. LPN #133 verified Resident #58 did not have a lockbox in her apartment to secure her medications.

4. Observation on 06/10/25 at 1:52 P.M. of the medication storage room revealed the door was unlocked and no staff were present in the room. The room contained two medication refrigerators and medications were observed stored on shelves on the wall. A sign was posted on the door stating the door was to be locked.

Interview on 06/10/25 at 2:00 P.M. with the DON verified the medication room door was unlocked, the room contained medications, and the door was to always be locked.

Review of the facility policy titled, Medication Storage of Centrally Stored Medications, dated 12/20/22, revealed medications would be stored in a manner that ensured maintenance of both the integrity of the medication and the safety of all residents. Further review revealed all medications, including over-the-counter medications, were to be kept in locked storage at all times.

This violation was issued relative to incidental findings that were discovered during the complaint investigation completed on 06/10/25.

Based on resident interviews, staff interviews, review of the medical record and review of facility policy, the facility failed to ensure resident medications were not repackaged, when staff removed medications from pharmacy packaging and placed in a medication pill cup for administration later in the day. This affected two (#33 and #43) of three residents reviewed for medication storage. The facility census was 57.

Findings include:

1. Review of Resident #33's medical record revealed an admission date of 08/05/24. Diagnoses included anxiety, bipolar disorder, chronic kidney disease, chronic obstructive pulmonary disease (COPD) and major depressive disorder.

Review of a physician order dated 10/03/24 revealed that Resident #33's medications were to stay in the (pharmacy) pill pack and staff must watch the resident take her medications. Additional review of the physician orders revealed Resident #33 had the following bedtime (HS) medications ordered: simvastatin (cholesterol medication) 80 milligrams (mg), take one tablet by mouth at bedtime and doxepin (used to treat depression, anxiety and insomnia) 75 mg, take one tablet by mouth at bedtime.

Review of the care plan, dated 12/13/24, revealed Resident #33 required staff to provide supervision and assistance with self-administration (of medication).

Interview on 06/09/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #133 revealed the facility did not have staff available to administer medications after 7:00 P.M. LPN #133 verified HS medications were left with any resident who did not want to take their HS medications during the evening medication pass to take later in the evening, including Resident #33.

Interview on 06/10/25 at 8:15 A.M. with Certified Medication Aide (CMA) #141 revealed staff sometimes left Resident #33's HS medications with her to take before bedtime because the resident would refuse to take them with the last medication pass before the nurses left the facility at 7:00 P.M. CMA #141 stated the residents' HS medications were removed from the pharmacy packaging, placed in a medication cup, and given to Resident #33 for later self-administration.

Interview on 06/09/25 at 3:00 P.M. with the DON revealed she was unaware nursing staff were repacking medications and placing them in a medication cup and left with residents for HS self-administration.

A follow-up interview on 06/10/25 at 8:16 A.M. with LPN #133 revealed Resident #33 sometimes refused to take her HS medications before the nurses left for the day at 7:00 P.M. LPN #133 stated nursing staff could not force residents to take their medications before they left for the day, so the only option was to leave them with the resident to self-administer later. LPN #133 verified Resident #33's medications were removed from the pharmacy packaging, placed into a medication cup and left with the resident for HS self-administration.

2. Review of Resident #43's medical record revealed an admission date of 09/25/24. Diagnoses included anxiety disorder, depression, chronic renal failure, neurocardiogenic syncope, cerebrovascular accident (stroke), seizure disorder, lesions on the brain, uterine cancer, migraine, and Postural Orthostatic Tachycardia Syndrome (POTS - causes rapid increase in heart rate and other symptoms when a person stands up from a sitting or lying position).

Review of the current physician orders revealed Resident #43 had the following HS and an needed (PRN) medication orders: buspirone (used to treat anxiety) 10 mg one tablet by mouth at HS, butalab-acetamin-caff 50-300-44 (used to treat tension headaches) take one or two capsules by mouth every eight hours PRN, not to exceed six capsules in 24 hours; cyclobenzaprine (muscle relaxer) five mg take one tablet by mouth at bedtime as needed; hydroxyzine HCL (used to treat anxiety) 10 mg tablet take one tablet by mouth every six hours as needed; loperamide (treats diarrhea) two mg capsule take two capsules by mouth after first loose stool, then take one capsule after each subsequent loose stool, not to exceed eight mg in 24 hours; Excedrin migraine caplet, 250-250-65 mg take one tablet by mouth every six hours as needed; ropinrole HCL (treats restless leg syndrome) one mg tablet, take one tablet by mouth at HS; simvastatin (used to treat high cholesterol) 20 mg tablet, one tablet by mouth at bedtime; and Systane nighttime eye ointment (treats dry eyes), apply 1/8 inch ribbon to each lower eyelid at bedtime.

Interview on 06/09/25 at 12:06 P.M. with Resident #43 revealed that facility staff did not administer her bedtime medications but administered all other medications. Resident #43 stated the facility did not have nurses after 7:00 P.M. and she did not want to take her bedtime medication at dinnertime because they made her sleepy. Resident #43 stated that during dinnertime medication pass, around 5:00 P.M., the nurse provided her with her evening medication doses in one medication cup and placed her HS medications in a second medication cup for her to take later. Resident #43 stated the HS medication cup did not have her name or the names of the medications it contained on it. Resident #43 indicated she likes to go to bed around 10 or 11 o'clock at night.

Interview on 06/10/25 at 8:15 A.M. with Certified Medication Aide (CMA) #141 revealed staff left Resident #43's HS medications with her to take before bedtime because the resident did not want to take her HS medications before the nurses left the facility at 7:00 P.M. CMA #141 stated the resident's HS medications were removed from the pharmacy packaging, placed in a medication cup, and given to Resident #43 for later self-administration.

Interview on 06/09/25 at 3:00 P.M. with the DON revealed she was unaware nursing staff were repacking medications and placing them in a medication cup and left with residents for HS self-administration.

A follow-up interview on 06/10/25 at 8:16 A.M. with LPN #133 revealed Resident #43 did not want to take her HS medications during the evening medication pass that was completed before the nurses left the facility at 7:00 P.M. LPN #133 stated nursing staff could not force residents to take their medications before they left for the day, so the only option was to leave them with the resident to self-administer later. LPN #133 verified Resident #43's medications were removed from the pharmacy packaging, placed into a medication cup and left with the resident for HS self-administration.

Review of the facility policy titled, Medication Storage of Centrally Stored, dated 12/20/22, revealed medications would be stored to ensure the safety of all residents. Further review revealed the facility would assure the labeling of prescription medicine and drugs met the following criteria: every container of medicine and drugs prescribed for a resident for self-administration or assistance by non-licensed healthcare personnel shall be labeled with the resident's name, the proprietary or generic name of the medication dispensed and its strength, the name and address of the dispensing pharmacy, the name or initials of the dispensing pharmacist, the prescription number, the date dispensed, the name of the prescribing physician or the name of the individual authorized under state law to prescribe medications, and the instructions for use including any cautions that may be required under federal or state laws.

This violation was issued relative to incidental findings that were discovered during the complaint investigation completed on 06/10/25.

Based on staff interviews, resident interviews, and record review, the facility failed to ensure physicians were notified as ordered for changes in resident health status. This affected one (#35) of three residents reviewed for medication administration. The facility census was 57.

Findings include:

Review of Resident #35's medical record revealed an admission date of 11/06/24. Diagnoses included chronic obstructive pulmonary disease (COPD), dysphagia (trouble swallowing), migraines, hypertension (high blood pressure), and a history of a stroke.

Review of a physician order dated 01/31/25 revealed Resident #35's blood pressure and pulse were to be checked daily in the afternoon and update the physician if the resident's blood pressure (BP) was persistently over 140/90 millimeters of mercury (mmHg). The order did not define persistently or specify if both the systolic (top number) and the diastolic (bottom number) both needed to exceed the parameters or if one of the measurements being elevated required physician notification.

Review of the Vitals History from 05/10/25 through 06/10/25 revealed Resident #35 had the following BP readings exceeding the parameters identified in the physician order: 161/92 mmHg on 05/12/25; 150/79 mmHg on 05/14/25; 150/89 mmHg on 05/16/25; 154/80 mmHg on 05/17/25; 167/94 mmHg on 05/22/25; 152/102 mmHg on 05/24/25; 157/92 mmHg on 05/28/25; 170/90 mmHg on 05/29/25; 159/100 mmHg on 05/31/25; 164/90 mmHg on 06/06/25; and 164/96 mmHg on 06/10/25.

Review of the progress notes from 05/01/25 through 06/03/25 revealed no evidence the facility notified the physician of Resident #35's BP readings or requested clarification of the order. On 06/04/25, a facsimile (fax) was sent to the physician for more specific parameters for the resident's ordered BP and pulse checks.

Interview on 06/10/25 at 8:54 A.M. with Resident #35 revealed his BP had been fluctuating and was not under control. The resident stated the facility staff checked his BP daily.

Interview on 06/10/25 at 2:00 P.M., with the Director of Nursing (DON) verified the facility had not notified Resident #35's physician regarding his elevated BP readings, as ordered. The DON stated it was not clear what persistently meant in the order and further confirmed the facility had not contacted the physician for clarification of the order since the initiation on 01/31/25. The DON stated the facility reached out to the physician via fax on 06/04/25 for clarification, after it was brought to their attention by an outside agency, but the facility had not received a response yet.

Review of the facility policy titled, Basic Care, dated 12/20/23, revealed that resident status changes should be reported to the DON, physician, and the resident's responsible party.

This violation represents non-compliance investigated under Complaint Number OH00166368 and the continued non compliance from the 06/02/25 survey.

Based on resident interviews, staff interviews and review of the facility call light audit report, the facility failed to provide timely assistance to residents who activated their call light to receive assistance with incontinence care and were dependent on staff to provide care. This affected two (#46 and #65) of three residents reviewed for call light response. The facility census was 57.

Findings include:

Review of the facility call light audit report revealed the document showed the room number and the length of time it took for the call light to be reset (turned off). On 06/08/25, Resident #46 activated his call light, and the call light was not reset for 1 hour, 22 minutes, and 22 seconds.

Interview on 06/09/25 at 4:42 P.M. with Assistant Director of Nursing (ADON) #140 revealed that at times, there were long waits for staff to respond to resident call lights. ADON #140 stated some of the residents were repeat offenders and staff had already been in the resident's apartment several times.

Interview on 06/10/25 at 2:50 P.M. with Resident #46 confirmed on Saturday night (06/07/25 into the morning of 06/08/25), he needed assistance with cleaning up following a bowel movement. Resident stated he pressed his call light, and after approximately 25 minutes no one came so he pressed it again. The resident stated after approximately one hour, he put on a pair of shorts and went to find staff to assist him. Resident #46 stated agency staff were working and when he approached the aide, she stated she did not have a phone or tablet in order to get the call light notification. Resident #46 stated there were times call lights were not responded to timely because the call light system was connected through the internet and staff reported if there was an issue with the internet connectivity, they did not receive the notifications.

Further review of the call light audit report revealed on 06/08/25, Resident #65 activated his call light, and it was not reset for 57 minutes and 38 seconds.

Interview on 06/10/25 at 3:10 P.M. with Resident #65 confirmed on Saturday night (06/07/25 into the morning of 06/08/25), he needed assistance with incontinence care. Resident #65 explained he had a colostomy bag (pouch used to collect fecal matter through an opening in the abdominal wall) that he needed help emptying and was also incontinent of urine and required assistance with changing his incontinence brief. The resident could not recall what time he needed assistance, but confirmed it was during the night, and he waited quite a while for staff to come to assist him. Resident #65 stated it happened sometimes that staff did not respond timely, but if it were a real emergency, he would call 911 for assistance.

Interview on 06/10/25 at 2:07 P.M. with the Executive Director (ED) revealed that he expected facility staff to respond to call lights in 20 minutes or less. The ED verified the facility had some long call light response times, including the one hour, 22 minute, and 22 second response for Resident #46 on 06/08/25 and the 57 minute and 38 second response for Resident #65 on 06/08/25. The ED confirmed the start time for Resident #46's call light was at 1:45 A.M. and Resident #65's call light was activated at 2:16 A.M. The ED stated he thought the staff were probably busy providing showers during that time, resulting in delayed responses, but he was not certain. The surveyor asked if agency staff worked on 06/08/25, the ED responded yes, and he was familiar with the staff who would have told Resident #46 that she did not have a phone or tablet to receive the call light notification. The ED stated that staff walked out because the residents of the facility required more care than she was used to. The ED denied any concerns related to the functionality of the call light system creating delayed responses and stated the Internet connection was monitored and checked frequently.

This violation represents non-compliance investigated under Complaint Number OH00166110 and the continued noncompliance from the 06/02/25 survey.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to ensure that documentation in the resident record was complete and accurate. This affected one (#58) of three residents reviewed for documentation accuracy. The facility census was 57.

Findings include:

Review of Resident #58's medical record revealed an admission date of 12/09/24. Diagnoses included anxiety disorder, bipolar disorder, atrial flutter (a condition that causes the heart to beat irregularly), chronic obstructive pulmonary disease (COPD), Myasthenia Gravis (a chronic condition in which the body's immune system attacks the nerves of voluntary muscles leading to fluctuating weakness and fatigue), and adult-onset diabetes.

Review of initial assessments stored in the hard chart for Resident #58 revealed an undated self-medication assessment that was not completed. Additional review showed a notation at the top stating, no self-admin order.

Review of the Wellness Baseline dated 12/10/24 for Resident #58 indicated that the resident required assistance with medications. Further review of the Area Office on Aging Consumer Report dated 12/20/24 also documented that Resident #58 required assistance with medications.

Review of the current physician orders for June 2025 revealed Resident #58 ordered Breo Ellipta (treats respiratory conditions) 100-25, inhale one puff by mouth every day. Further review revealed Resident #58 had an order for Duoneb (breathing medication administered through a nebulizer) 2.5 milligrams (mg)/0.5 mg four times daily.

Review of the May 2025 Medication Administration Record (MAR) revealed Duoneb was scheduled to be administered upon rising, at 11:00 A.M., evening, and at bedtime (HS). From 05/01/25 through 05/21/25, Duoneb administration was documented as follows: on 05/03/25, the 11:00 A.M. and HS doses were documented as refused and the evening dose was administered; on 05/04/25, the upon rising and evening doses were documented as administered; on 05/06/25, the upon rising and the 11:00 A.M. doses were documented as refused; on 05/12/25, the HS dose was documented as refused; on 05/13/25, the evening and HS doses were documented at administered; on 05/16/25, the upon rising and evening doses were documented as administered; and on 05/17/25, the 11:00 A.M. dose was documented as refused and the evening dose was administered. All other opportunities for Duoneb administration during this time were documented at other.

Observation on 06/09/25 at 10:15 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #133 prepared and administered medications for Resident #58. LPN #133 did not administer Resident #58's Breo Ellipta.

Review of June 2025 MAR revealed Resident #58's Breo Ellipta was documented as administered upon risking by nursing on 06/09/25.

Interview on 06/09/25 at 2:55 P.M. with LPN #133 verified she did not administer Resident #58's Breo Ellipta during the morning medication pass. LPN #133 stated Resident #58 kept the Breo Ellipta in her room and she had no way to confirm if the resident took the medication even though it was documented as administered on the MAR.

Interview on 06/10/25 at 3:35 P.M. with Certified Medication Aide (CMA) #141 revealed Resident #58 was ordered Duoneb for administration through a nebulizer; however, there was an insurance issue, and the resident did not receive the nebulizer until around 05/21/25. CMA #141 stated other was documented on May 2025 MAR because it was unavailable for administration. CMA #141 verified the entries on the Mary 2025 MAR for resident refusals and the documented administrations from 05/01/25 through 05/17/25 were inaccurate as the medication could not be administered. CMA #141 stated other should have been documented.

Interview on 06/10/25 at 3:37 P.M. with the Director of Nursing (DON) confirmed Resident #58's MAR reflected inaccurate documentation of duoneb administration as the nebulizer was unavailable. The DON confirmed medications should only be documented on the MAR when nursing staff administer medications to the residents.

2. Review of Resident #43's medical record revealed an admission date of 09/25/24. Diagnoses included anxiety disorder, depression, chronic renal failure, neurocardiogenic syncope, cerebrovascular accident (stroke), seizure disorder, lesions on the brain, uterine cancer, migraine, and Postural Orthostatic Tachycardia Syndrome (POTS - causes rapid increase in heart rate and other symptoms when a person stands up from a sitting or lying position).

Review of the current physician orders for June 2025 revealed Resident #43 had the following HS and an needed (PRN) medication orders: buspirone (used to treat anxiety) 10 mg one tablet by mouth at HS, butalab-acetamin-caff 50-300-44 (used to treat tension headaches) take one or two capsules by mouth every eight hours PRN, not to exceed six capsules in 24 hours; cyclobenzaprine (muscle relaxer) five mg take one tablet by mouth at bedtime as needed; hydroxyzine HCL (used to treat anxiety) 10 mg tablet take one tablet by mouth every six hours as needed; loperamide (treats diarrhea) two mg capsule take two capsules by mouth after first loose stool, then take one capsule after each subsequent loose stool, not to exceed eight mg in 24 hours; Excedrin migraine caplet, 250-250-65 mg take one tablet by mouth every six hours as needed; ropinrole HCL (treats restless leg syndrome) one mg tablet, take one tablet by mouth at HS; simvastatin (used to treat high cholesterol) 20 mg tablet, one tablet by mouth at bedtime; and Systane nighttime eye ointment (treats dry eyes), apply 1/8 inch ribbon to each lower eyelid at bedtime.

Review of the MAR from 05/18/25 through 06/09/25 revealed the following HS medications were documented as administered to Resident #43 by nursing: buspirone 10 mg, ropinirole one mg, and simvastatin 20 mg on 05/18/25, 05/23/25, 05/26/25, 05/27/25, 05/31/25, 06/01/25, 06/04/25 and 06/09/25.

Interview on 06/09/25 at 12:06 P.M. with Resident #43 revealed that facility staff did not administer her bedtime medications but administered all other medications. Resident #43 stated the facility did not have nurses after 7:00 P.M. and she did not want to take her bedtime medication at dinnertime because they made her sleepy. Resident #43 stated that during the dinnertime medication pass, around 5:00 P.M., the nurse provided her with her evening medication doses in one cup and placed her HS medications in a second cup for her to take later. Resident #43 stated facility staff did not reminder her to take her HS medication and that her roommate, Resident #44, reminded her to take her HS medications when it was time so that she did not forget. Concurrent interview with Resident #44 confirmed he provided Resident #43 with reminders to take her HS medications and not facility staff.

Interview on 06/09/25 at 1:09 P.M. with CMA #141 confirmed the facility nurses provided medication set-up for Resident #43 to self-administer her HS medications. This included placing the residents' HS medications in a medication cup and giving them to the resident, but Resident #43 took them later.

A follow-up interview on 06/10/25 at 3:26 P.M. with CMA #141 verified she documented Resident #43's medication as administered on 05/18/25, 05/23/25, 05/26/25, 05/27/25, 05/31/25, 06/01/25, 06/04/25 and 06/09/25. Further interview with CMA #141 revealed the MAR was used to verify medications were administered and further verified nursing staff did not administer Resident #43's HS medications.

Interview on 06/10/25 at 3:36 P.M. with LPN #133 verified Resident #43's medications were documented as administered by nursing staff on the MAR even though nursing only provided the residents with the HS medications in a medication cup for later self-administration. LPN #133 stated she questioned this practice but was uncertain of what else to do.

Interview on 06/10/25 at 3:44 P.M. with the DON confirmed medications should only be documented on the MAR when nursing staff administered medications to a resident, unless there was a comment to indicate they only provided set-up assistance. The DON verified Resident #43's medications were documented as administered and stated staff should have documented a comment that the medications were provided to the resident for self-administration at HS. The DON verified Resident #43's MAR included no comments or documentation to indicate nursing staff only provided, and not administered, the resident's HS medications.

This violation represents non-compliance investigated under Master Complaint Number OH00166462.

Based on record review, staff interviews, review of the fall policy, resident interviews, and review of staff job descriptions, the facility administration failed to ensure the daily operations of the facility were conducted appropriately in regards of ensuring all residents' care and needs were being provided for. This has the potential to affect all 66 residents. The facility census was 66.

Findings include:

1. Ohio Revised Code 3721.13 (A) (3) Rights of Resident was not met when the facility failed to ensure the safety and well-being of the residents in the facility. This resulted in Real and Present Danger and actual harm/resident death on 05/05/25 at 1:45 P.M., when Resident #01 was found deceased in a state of advanced decomposition, with discoloration to his body, fluids coming from his nose and mouth, and no signs of life. Resident #01 did not receive any meals after 05/02/25 (Friday) at 11:30 A.M., to the time he was found deceased on 05/05/25 (Monday) at 1:45 P.M., by agency Licensed Practical Nurse (LPN) #175 during a scheduled quarterly nursing assessment. Additionally, the facility failed to provide timely assistance to Resident #10 on 04/23/25, when he had an incontinent episode in his wheelchair while visiting another resident on their outside patio, and then activated his call light pendent when he had fallen out of his wheelchair onto the ground outside at 12:28 A.M., and laid on the ground for over two hours while attempting to clean himself up on his own, placing the resident at risk for potential serious physical harm.

2. Ohio Administrative Code (OAC) 3701-16-09 (D) Personal Care Services was not met when the facility administration failed to ensure staff observed residents completing Activities of Daily Living tasks independently prior to documenting all tasks were completed by residents.

a. Review of the Service Plan (SP) dated December 2024 for Resident #01 revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan the resident was unable to make his own meals and required the facility to provide all his meals.

Review of Resident #01's Activities of Daily Living (ADL) sign-off documentation worksheet dating from 05/01/25 to 05/05/25 revealed on 05/01/25, 05/02/25, 05/03/25, 05/04/25, and 05/05/25 from 7:00 A.M. to 7:00 P.M., dayshift, and 7:00 P.M. to 7:00 A.M., night shift was marked 'S', indicating the resident completed the task by themselves, for dressing, grooming, mobility, transfers, and incontinence. Per the documentation the tasks of bathing, housekeeping, and laundry were crossed off with no documentation noted per the staff.

Further review of the task worksheet revealed the staff documented on the 05/05/25 7:00 P.M. to 7:00 A.M. shift as the resident completing the tasks by himself after he had passed away in the facility and the body had been removed to the funeral home on 05/05/25 at 5:54 P.M.

Interview on 05/12/25 at 9:02 A.M., with Certified Nurse Aide (CNA) #100 revealed the aide was working on Friday 05/02/25 from 7:00 A.M. to 7:00 P.M. and Monday 05/05/25 from 7:00 A.M. to 7:00 P.M. CNA #100 stated the last time she remembered seeing Resident #01 was on Friday (05/02/25) around 10:00 A.M., when she offered the resident a shower, but the resident refused. Per CNA #100 Resident #01 was independent with most ADL's but required assistance with bathing. CNA #100 stated she did not document any refusals of the showers for Resident #01 and marked the ADL sign off worksheet with dash for bathing on 05/02/25 for the day shift (7:00 A.M. to 7:00 P.M.). CNA #100 verified she had documented Resident #01 was completing his ADL tasks himself on 05/02/25 and 05/05/25 day shifts. CNA #100 verified the documentation on the ADL sign off sheet and verified she did not visually see Resident #01 complete any task on 05/02/25 or 05/05/25 by himself.

Interviews on 05/13/25 from 4:33 P.M., with CNA #105 via the telephone, revealed CNA #105 was assigned Resident #01's hall on 05/03/25 and 05/04/25 day shifts. Per CNA #105 she had not seen or checked on Resident #01 on 05/03/25 or 05/04/25. CNA #105 verified she filled out Resident #01's ADL worksheet and marked 'S' for tasks she did not see the resident complete himself.

b. Review of Resident #11's service plan dated 12/2024 revealed the resident required assistance with bathing, incontinence, housekeeping, dressing, and safety with smoking while using oxygen.

Review of Resident #11's ADL sign-off worksheet dated 05/01/25 to 05/15/25 revealed from 05/01/25 to 05/06/25 staff documented the resident was not available. On 05/07/25 from 7:00 P.M. to 7:00 A.M. nightshift staff documented the resident as 'S' self-completing tasks for dressing, grooming, mobility, transfers, and incontinence. On 05/08/25 the staff documented the residents as 'S' for dressing, grooming, transfers, and incontinence, and needs assistance for mobility for the nightshift. No documentation was noted for 05/12/25 7:00 A.M. to 7:00 P.M., or on 05/16/25 from 7:00 P.M. to 7:00 A.M. No refusals of showers or bed baths were marked on the worksheet. On 05/10/25 and 05/13/25 the staff documented the resident received a bed bath. On 05/16/25, 05/17/25, and 05/18/25 the bathing task was left blank.

3. OAC 3701-16-12 (A) Changes in Resident Health Status; Incidents was not met when the facility administration failed to ensure staff were notifying the residents' responsible parties in the events of incidents, missed care provided, or residents' refusals of care.

a. Review of the Service Plan (SP) dated December 2024 for Resident #01 revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan the resident was unable to make his own meals and required the facility to provide all his meals.

Resident #01 received lunch on 05/02/25, when he came to the dining room and never returned for another meal. Resident #01 was found deceased on 05/05/25.

Further review of Resident #01's medical records including progress notes and care history revealed no documentation the resident's responsible party was being notified of the resident's refusals or missing meals.

Interview on 05/12/25 at 9:02 A.M. with Case Manager (CM) #20 revealed she was a responsible party for Resident #01. CM #20 stated she had created the service plan with the facility and Resident #01 upon his admission in December 2024. Per CM #20, Resident #01 was to get assistance with bathing, meals, and housekeeping at least twice a week. CM #20 stated she had educated the staff to contact her if Resident #01 refuses care required to be completed by the service plan. CM #20 stated she did not receive any notifications of the residents' refusal or non-completion of any care from the facility in the months in April and May 2025.

Interview on 05/12/25 at 9:09 A.M. with Certified Nurse Aide (CNA) #100 revealed the aide had cared for Resident #01 on Friday, 05/02/25. Per CNA #100, Resident #01 was mostly independent with his needs but required assistance with housekeeping and bathing. CNA #100 stated the resident was scheduled to get a shower on Tuesdays and Fridays but stated Resident #01 refused his shower on 05/02/25. CNA #100 verified she did not report to the nurse the resident had refused his shower on 05/02/25. CNA #100 verified if residents refuse care the nurse is to be notified.

b. Review of Resident #10's service plan dated 03/2025 revealed the resident required assistance with bathing, incontinence, housekeeping, and fall prevention.

Further review of Resident #10's fall/incident log dating from 04/23/25 to 04/24/25 revealed no documentation regarding a fall on 04/23/25 at 12:00 A.M. to 3:00 A.M.

Further review of Resident #10's records and fall log revealed on 04/24/25 at 8:35 A.M. the resident had an unwitnessed fall in his room and was found on the floor. Per the incident report the resident suffered no injuries from the unwitnessed fall on 04/24/25.

Review of the facility's call light response time log dating from 04/23/25 to 04/24/25 revealed on 04/23/25 at 12:28 A.M., Resident #10 activated his call light. Per the log, the call light was responded to 2 hours 22 minutes and 36 seconds after activation.

Interview on 05/15/25 at 8:49 A.M. with Resident #10 revealed the resident reported on 04/23/25 around 12:00 A.M., he fell outside of another resident's room in the patio area. Resident #10 stated he was on the ground for over 4 hours until the Emergence Medical Services (EMS) squad came to the facility to help him off the ground and back into his wheelchair. Resident #10 stated he used his call light, and no staff responded for over 3 hours to his call light. Resident #10 stated he had no injuries from the fall. Resident #10 stated he reported the fall to the DON and the Administrator and stated the DON erased the call light audits and they claimed to the resident they had no records of his call lights.

Interview on 05/19/25 at 9:00 A.M. with Case Manager (CM) #25 revealed the case manager was the party responsible for Resident #10 and was to be notified of all falls and changes in the residents' condition. CM #25 verified she had not been contacted by the facility on 04/23/25 after Resident #10's fall. CM #25 stated she had not been notified by the facility of any falls for Resident #10 including the daytime fall on 04/23/25.

c. Review of Resident #11's service plan dated 12/2024 revealed the resident required assistance with bathing, incontinence, housekeeping, dressing, and safety with smoking while using oxygen.

Review of Resident #11's ADL sign-off worksheet dated 05/01/25 to 05/15/25 revealed from 05/01/25 to 05/06/25 staff documented the resident was not available. On 05/07/25 from 7:00 P.M. to 7:00 A.M. nightshift staff documented the resident as 'S' self-completing tasks for dressing, grooming, mobility, transfers, and incontinence. On 05/08/25 the staff documented the residents as 'S' for dressing, grooming, transfers, and incontinence, and needs assistance for mobility for the nightshift. No documentation was noted for 05/12/25 7:00 A.M. to 7:00 P.M., or on 05/16/25 from 7:00 P.M. to 7:00 A.M. No refusals of showers or bed baths were marked on the worksheet. On 05/10/25 and 05/13/25 the staff documented the resident received a bed bath. On 05/16/25, 05/17/25, and 05/18/25 the bathing task was left blank.

Interview on 05/15/25 at 2:33 P.M. and on 05/19/25 at 9:20 A.M. with the ADON verified Resident #11 was refusing showers but was receiving bed baths. The ADON verified the aides were not documenting any refusals of bathing for Resident #11 in the records. The ADON verified there was no documentation of any notifications to the resident's party responsible for refusals of care since Resident #11 was receiving bed baths.

Interview on 05/20/25 at 10:06 A.M. with CM #25 revealed she is the responsible party for Resident #11. Per CM #25 she had not been notified of any refusals of care or any incidents for Resident #11 from the facility. CM #25 stated she was aware the staff were documenting care being provided by the residents themselves on the ADL sign-off sheets and stated Resident #11 was to be assisted with toileting, bathing, and mobility per his service agreement. CM #25 stated she had not been notified that the resident was completing the tasks himself, or the tasks were not being completed including bathing which she was unaware the resident was refusing showers and getting bed baths instead.

4. OAC 3701-16- 12 (B) Changes in Resident Health Status, Incidents was not met when the facility administration failed to ensure staff were documenting and investigating falls for a resident.

Review of Resident #10's service plan dated 03/2025 revealed the resident required assistance with bathing, incontinence, housekeeping, and fall prevention.

Further review of Resident #10's fall/incident log dating from 04/23/25 to 04/24/25 revealed no documentation regarding a fall on 04/23/25 at 12:00 A.M. to 3:00 A.M.

Further review of Resident #10's records and fall log revealed on 04/24/25 at 8:35 A.M., the resident had an unwitnessed fall in his room and was found on the floor. Per the incident report the resident suffered no injuries from the unwitnessed fall on 04/24/25. There was no fall documented for 04/23/25.

Review of the facility's call light response time log dating from 04/23/25 to 04/24/25 revealed on 04/23/25 at 12:28 A.M. Resident #10 activated his call light. Per the log the call light was responded to 2 hours 22 minutes and 36 seconds after activation.

Interview on 05/15/25 at 8:49 A.M. with Resident #10 revealed the resident reported on 04/23/25 around 12:00 A.M., he fell outside of another resident's room in the patio area. Resident #10 stated he was on the ground for over 4 hours until the Emergence Medical Services (EMS) squad came to the facility to help him off the ground and back into his wheelchair. Resident #10 stated he used his call light, and no staff responded for over 3 hours to his call light. Resident #10 stated he had no injuries from the fall. Resident #10 stated he reported the fall to the DON and the Administrator and stated the DON erased the call light audits and they claimed to the resident they had no records of his call lights.

Interview on 05/15/25 at 10:00 A.M. with the DON verified Resident #10 had an unwitnessed fall when he was outside of another resident's room in the patio area. Per the DON, the EMS squad was called when the staff could not lift Resident #10 and put him back into his wheelchair. The DON verified the call light response time was 2 hours 22 minutes and 36 seconds per the log. The DON verified Resident #10 was on Resident #56's patio and Resident #56 also activated her call light on 04/23/25 in the morning and the response was 21 minutes and 15 seconds. The DON verified there was no fall investigation or documentation for Resident #10's fall on 04/23/25.

5. OAC 3701-16-10 (H) (4) Dietary Services, Supervision of Therapeutic Diet was not met when the facility administration failed to ensure a resident who required assistance with meals was provided with meals.

Review of the Service Plan (SP) dated December 2024 for Resident #01 revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan the resident was unable to make his own meals and required the facility to provide all his meals.

Resident #01 received lunch on 05/02/25, when he came to the dining room and never returned for another meal. Resident #01 was found deceased on 05/05/25.

6. OAC 3701-16-15 (I) (7) Building Maintenance, Equipment, Supplies was not met when the facility administration failed to ensure the facility was maintained in good repair and in a clean manner. Observations on 05/12/25 through 05/14/15 revealed broken, bubbling and missing floor tile was observed throughout the facility. Outside the facility, there were broken eaves spouts, an orange cord laying on top of the ground along the building, across resident patios, and a blue tarp with piles of rocks on the tarp. An excessive buildup of cigarette butts was observed outside of Resident #01's room near the patio area.

Interview on 05/15/25 at 10:09 A.M. with Housekeeper #555 revealed there were multiple areas where the floor tiles were missing or bubbled up. Housekeeper #555 did verify some residents had complained about the flooring at the facility and the maintenance team had received reports from residents requesting the flooring be repaired. Housekeeper #555 stated residents are educated to keep cigarette butts off the ground and containers are provided; however, the housekeeping staff are responsible for cleaning resident rooms and patios as needed.

Interview on 05/19/25 at 11:00 A.M. with Director of Maintenance (DOM) #441 verified the areas of the flooring where the tiles were missing or bubbling up. DOM #441 verified there was a hanging gutter, trash debris, chords, and a blue tarp in the residents' courtyard near the patio areas of B-hall and C-hall. DOM #441 verified there was work orders to repair the flooring and gutters but due to the contacts being with private contractors no repairs had been completed as of the date of the survey.

Review of the facility policy titled, Fall Response Procedures dated 12/20/23, revealed if a resident falls the facility staff will notify the Director of Nursing (DON). The DON will conduct an assessment for injuries, the physician, and the party responsible will be notified of the fall.

Review of the Director of Nursing's job description signed by the facility's DON on 01/05/24 revealed the duties of the Director of Nursing will be led by the team to deliver quality care to residents, timely reporting and investigating concerns, and monitoring daily care of the residents. The Director of Nursing will also create and monitor service plans with quarterly updates.

Review of the Executive Director's job description signed by the facility's ED on 01/05/24 revealed the duties of the Executive Director shall include overseeing all daily operations and to ensure the building, grounds, and properties are up to standards. The Executive Director may advise and create service plans and provide direct care as needed.

This violation represents non-compliance found during the complaint survey investigations for Complaint Numbers OH00165775, OH00165698, OH00165531, OH00165549, OH00165318, OH00163141, OH00163073, OH00162435, and OH00162437.

Based on record reviews, resident interviews, and staff interviews, the facility failed to ensure staff observed residents completing Activities of Daily Living tasks independently prior to documenting all tasks were completed by residents. This affected two (#01 and #11) of seven residents reviewed for documentation. The facility census was 66.

Findings include:

1. Record review for Resident #01 revealed the resident was admitted to the facility on 12/02/24 and was found deceased on 05/05/25. Diagnoses for Resident #01 include constipation, dysphagia, and use of tobacco.

Review of the Service Plan (SP) dated December 2024 for Resident #01 revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan the resident was unable to make his own meals and required the facility to provide all his meals.

Review of Resident #01's Activities of Daily Living (ADL) sign-off documentation worksheet dating from 05/01/25 to 05/05/25 revealed on 05/01/25, 05/02/25, 05/03/25, 05/04/25, and 05/05/25 for the 7:00 A.M. to 7:00 P.M., dayshift, and 7:00 P.M. to 7:00 A.M., night shift was marked 'S', indicating the resident completed the task by themselves, for dressing, grooming, mobility, transfers, and incontinence. Per the documentation, the tasks of bathing, housekeeping, and laundry were crossed off with no documentation noted per the staff.

Further review of the task worksheet revealed the staff documented on the 05/05/25 7:00 P.M. to 7:00 A.M. shift as the resident completing the tasks by himself after he had passed away in the facility and the body had been removed to the funeral home on 05/05/25 at 5:54 P.M.

Interview on 05/12/25 at 9:02 A.M. with Certified Nurse Aide (CNA) #100 revealed the aide was working on Friday 05/02/25 from 7:00 A.M. to 7:00 P.M. and Monday 05/05/25 from 7:00 A.M. to 7:00 P.M. CNA #100 stated the last time she remembered seeing Resident #01 was on Friday (05/02/25) around 10:00 A.M., when she offered the resident a shower, but the resident refused. Per CNA #100, Resident #01 was independent with most ADL's but required assistance with bathing. CNA #100 stated she did not document any refusals of the showers for Resident #01 and marked the ADL sign off worksheet with dash for bathing on 05/02/25 for the day shift (7:00 A.M. to 7:00 P.M.). CNA #100 verified she had documented Resident #01 was completing his ADL tasks himself on 05/02/25 and 05/05/25 day shifts. CNA #100 verified the documentation on the ADL sign off sheet and verified she did not visually see Resident #01 complete any task on 05/02/25 or 05/05/25 by himself.

Interviews on 05/13/25 from 4:33 P.M., with CNA #105 via the telephone, revealed CNA #105 was assigned Resident #01's hall on 05/03/25 and 05/04/25 day shifts. Per CNA #105 she had not seen or checked on Resident #01 on 05/03/25 or 05/04/25. CNA #105 verified she filled out Resident #01's ADL worksheet and marked 'S' for tasks she did not see the resident complete himself.

2. Record review for Resident #11 revealed he was admitted to the facility on 10/24/24. Diagnoses for Resident #11 included heart disease, emphysema, chronic obstructive pulmonary disease, and lesions of the lungs.

Review of Resident #11's service plan dated 12/2024 revealed the resident required assistance with bathing, incontinence, housekeeping, dressing, and safety with smoking while using oxygen.

Review of Resident #11's ADL sign-off worksheet dated 05/01/25 to 05/15/25 revealed from 05/01/25 to 05/06/25 staff documented the resident was not available. On 05/07/25 from 7:00 P.M. to 7:00 A.M. nightshift staff documented the resident as 'S' self-completing tasks for dressing, grooming, mobility, transfers, and incontinence. On 05/08/25 the staff documented the resident as 'S' for dressing, grooming, transfers, and incontinence, and need assistance for mobility. No documentation was noted for 05/12/25 7:00 A.M. to 7:00 P.M., or on 05/16/25 from 7:00 P.M. to 7:00 A.M.

Interview on 05/19/25 at 10:03 A.M. with CNA #105 revealed if an aide assists the residents with any tasks they are to document which task they assist with, and all other tasks can be observed as self if the resident did not require any assistance. CNA #105 verified there was documentation on the ADL sign-off sheets marking 'S' as the residents completing the tasks by themselves without the aide seeing the resident during the shift.

Interview on 05/20/25 at 10:06 A.M. with CM #25 revealed she is the responsible party for Resident #11. Per CM #25, she had not been notified of any refusals of care or any incidents for Resident #11 from the facility. CM #25 stated she was not aware the staff were documenting care being provided by the residents themselves on the ADL sign-off sheets and stated Resident #11 was to be assisted with toileting, bathing, and mobility per his service agreement. CM #25 stated she had not been notified the resident was completing the tasks himself or the tasks were not being completed at all.

Interview on 05/12/25 at 10:02 A.M. with the Director of Nursing (DON) verified the aides who are documenting on the ADL sign off sheet may not be checking on the residents due to the residents being independent with their ADLs. The DON stated it was facility policy to not have any blanks on the documentation for residents' ADL worksheets.

There was no policy provided for review.

Based on record reviews, family interviews, resident interviews, review of incident logs, review of the fall policy, and staff interviews, the facility failed to ensure staff were notifying the residents' responsible parties in the events of incidents, missed care provided, or residents' refusals of care. This affected three (#01, #10, and #11) of three residents reviewed for notifications. The facility census was 66.

Findings include:

1. Record review for Resident #01 revealed the resident was admitted to the facility on 12/02/24 and was found deceased on 05/05/25. Diagnoses for Resident #01 included constipation, dysphagia, and use of tobacco.

Review of the Service Plan (SP) dated December 2024 for Resident #01 revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan the resident was unable to make his own meals and required the facility to provide all his meals.

Further review of Resident #01's medical records including progress notes and care history revealed no documentation the resident's responsible party was being notified of the resident's refusals or missing meals.

Interview on 05/12/25 at 9:02 A.M. with Case Manager (CM) #20 revealed she was a responsible party for Resident #01. CM #20 stated she had created the service plan with the facility and Resident #01 upon his admission in December 2024. Per CM #20, Resident #01 was to get assistance with bathing, meals, and housekeeping at least twice a week. CM #20 stated she had educated the staff to contact her if Resident #01 refuses care required to be completed by the service plan. CM #20 stated she did not receive any notifications of the residents' refusal or non-completion of any care from the facility in the months in April and May 2025.

Interview on 05/12/25 at 9:09 A.M. with Certified Nurse Aide (CNA) #100 revealed the aide had cared for Resident #01 on Friday, 05/02/25. Per CNA #100, Resident #01 was mostly independent with his needs but required assistance with housekeeping and bathing. CNA #100 stated the resident was scheduled to get a shower on Tuesdays and Fridays but stated Resident #01 refused his shower on 05/02/25. CNA #100 verified she did not report to the nurse the resident had refused his shower on 05/02/25. CNA #100 verified if residents refuse care the nurse is to be notified.

Interview on 05/12/25 at 9:36 A.M. with Resident #01's Power of Attorney (POA) revealed the POA stated she was not notified of any decline in Resident #01's condition prior to 05/05/25. The POA stated she questioned staff why no one had checked on Resident #01 to see if he was eating or getting his meals and she was given no answer from staff. The POA stated per the police Resident #01's last meal was Friday lunch, and he was found after lunch on Monday.

2. Record review for Resident #10 revealed the resident was admitted to the facility on 03/11/25. Diagnoses for Resident #10 included iron deficiency, diabetes type two, bilateral leg amputations, psychoactive substance abuse, and mood affective disorder.

Review of Resident #10's service plan dated 03/2025 revealed the resident required assistance with bathing, incontinence, housekeeping, and fall prevention.

Further review of Resident #10's fall/incident log dating from 04/23/25 to 04/24/25 revealed no documentation regarding a fall on 04/23/25 at 12:00 A.M. to 3:00 A.M.

Further review of Resident #10's records and fall log revealed on 04/24/25 at 8:35 A.M. the resident had an unwitnessed fall in his room and was found on the floor. Per the incident report the resident suffered no injuries from the unwitnessed fall on 04/24/25.

Review of the facility's call light response time log dating from 04/23/25 to 04/24/25 revealed on 04/23/25 at 12:28 A.M., Resident #10 activated his call light. Per the log, the call light was responded to 2 hours 22 minutes and 36 seconds after activation.

Interview on 05/15/25 at 8:49 A.M., with Resident #10 revealed the resident reported on 04/23/25 around 12:00 A.M., he fell outside of another resident's room in the patio area. Resident #10 stated he was on the ground for over 4 hours until the Emergence Medical Services (EMS) squad came to the facility to help him off the ground and back into his wheelchair. Resident #10 stated he used his call light, and no staff responded for over 3 hours to his call light. Resident #10 stated he had no injuries from the fall. Resident #10 stated he reported the fall to the DON and the Administrator and stated the DON erased the call light audits and they claimed to the resident they had no records of his call lights.

Interview on 05/19/25 at 9:00 A.M. with Case Manager (CM) #25 revealed the case manager was the responsible party for Resident #10 and was to be notified of all falls and changes in the residents' conditions. CM #25 verified she had not been contacted by the facility on 04/23/25 after Resident #10's fall. CM #25 stated she had not been notified by the facility of any falls for Resident #10 including the daytime fall on 04/23/25.

Interview on 05/15/25 at 9:18 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #10 had a history of putting himself on the ground and needing help from staff to get back into his wheelchair. The ADON verified there was no documentation of the incident for Resident #10 on 04/23/25 from 12:00 A.M. to 3:00 A.M. and verified there was no documentation the resident's responsible party had been notified.

3. Record review for Resident #11 revealed he was admitted to the facility on 10/24/24. Diagnoses for Resident #11 include heart disease, emphysema, chronic obstructive pulmonary disease, and lesions of the lungs.

Review of Resident #11's service plan dated 12/2024 revealed the resident required assistance with bathing, incontinence, housekeeping, dressing, and safety with smoking while using oxygen.

Review of Resident #11's ADL sign-off worksheet dated 05/01/25 to 05/15/25 revealed from 05/01/25 to 05/06/25 staff documented the resident was not available. On 05/07/25 from 7:00 P.M. to 7:00 A.M. nightshift staff documented the resident as 'S' self-completing tasks for dressing, grooming, mobility, transfers, and incontinence. On 05/08/25 the staff documented the residents as 'S' for dressing, grooming, transfers, and incontinence, and needs assistance for mobility for the nightshift. No documentation was noted for 05/12/25 7:00 A.M. to 7:00 P.M., or on 05/16/25 from 7:00 P.M. to 7:00 A.M. No refusals of showers or bed baths were marked on the worksheet. On 05/10/25 and 05/13/25 the staff documented the resident received a bed bath. On 05/16/25, 05/17/25, and 05/18/25 the bathing task was left blank.

Interview on 05/15/25 at 2:33 P.M. and on 05/19/25 at 9:20 A.M. with the ADON verified Resident #11 was refusing showers but was receiving bed baths. ADON verified the aides were not documenting any refusals of bathing for Resident #11 in the records. ADON verified there was no documentation of any notifications to the resident's responsible party for refusals of care since Resident #11 was receiving bed baths.

Interview on 05/20/25 at 10:06 A.M. with CM #25 revealed she is the responsible party for Resident #11. Per CM #25, she had not been notified of any refusals of care or any incidents for Resident #11 from the facility. CM #25 stated she was aware the staff were documenting care being provided by the residents themselves on the ADL sign-off sheets and stated Resident #11 was to be assisted with toileting, bathing, and mobility per his service agreement. CM #25 stated she had not been notified that the resident was completing the tasks himself, or the tasks were not being completed including bathing which she was unaware the resident was refusing showers and getting bed baths instead.

Review of the policy titled, Fall Response Procedures, dated 12/20/23 revealed that if a resident falls the facility staff will notify the Director of Nursing, (DON). The DON will conduct an assessment for injuries, the physician, and the responsible party will be notified of the fall.

This violation represents non-compliance found during the complaint investigation for Complaint Number OH00165775.

Based on record review, review of the facility's incident log, review of call light log, review of policy, resident interview and staff interview, the facility failed to document and investigate falls for residents. This affected one (#10) of three residents reviewed for falls and incidents. The facility census was 66.

Findings include:

Record review for Resident #10 revealed the resident was admitted to the facility on 03/11/25. Diagnoses for Resident #10 included iron deficiency, diabetes type two, bilateral leg amputations, psychoactive substance abuse, and mood affective disorder.

Review of Resident #10's service plan dated 03/2025 revealed the resident required assistance with bathing, incontinence, housekeeping, and fall prevention.

Further review of Resident #10's fall/incident log dating from 04/23/25 to 04/24/25 revealed no documentation regarding a fall on 04/23/25 at 12:00 A.M. to 3:00 A.M.

Further review of Resident #10's records and fall log revealed on 04/24/25 at 8:35 A.M., the resident had an unwitnessed fall in his room and was found on the floor. Per the incident report the resident suffered no injuries from the unwitnessed fall on 04/24/25. There was no fall documented for 04/23/25.

Review of the facility's call light response time log dating from 04/23/25 to 04/24/25 revealed on 04/23/25 at 12:28 A.M. Resident #10 activated his call light. Per the log, the call light was responded to 2 hours 22 minutes and 36 seconds after activation.

Interview on 05/15/25 at 8:49 A.M. with Resident #10 revealed the resident reported on 04/23/25 around 12:00 A.M., he fell outside of another resident's room in the patio area. Resident #10 stated he was on the ground for over 4 hours until the Emergence Medical Services (EMS) squad came to the facility to help him off the ground and back into his wheelchair. Resident #10 stated he used his call light, and no staff responded for over 3 hours to his call light. Resident #10 stated he had no injuries from the fall. Resident #10 stated he reported the fall to the DON and the Administrator and stated the DON erased the call light audits and they claimed to the resident they had no records of his call lights.

Interview on 05/19/25 at 9:00 A.M. with Case Manager (CM) #25 revealed the case manager was the responsible party for Resident #10 and was to be notified of all falls and changes in the residents' condition. CM #25 verified she had not been contacted by the facility on 04/23/25 after Resident #10's fall.

In an additional interview on 05/19/25 at 9:22 A.M. with Resident #10 revealed on 04/23/25 in the morning of the fall incident, the resident stated he had an episode of incontinence before he fell out of his wheelchair, and he was attempting to clean himself while he was on the ground. Resident #10 stated he did not obtain any injuries from the fall.

Interview on 05/15/25 at 9:18 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #10 had a history of putting himself on the ground and needing help from staff to get back into his wheelchair. The ADON denied any knowledge of the 04/23/25 fall for Resident #10.

Interview on 05/15/25 at 10:00 A.M. with the DON verified Resident #10 had an unwitnessed fall when he was outside of another resident's room in the patio area. Per the DON, the EMS squad was called when the staff could not lift Resident #10 and put him back into his wheelchair. The DON verified the call light response time was 2 hours 22 minutes and 36 seconds per the log. The DON verified Resident #10 was on Resident #56's patio and Resident #56 also activated her call light on 04/23/25 in the morning and the response was 21 minutes and 15 seconds. The DON verified there was no fall investigation or documentation for Resident #10's fall on 04/23/25.

Interview on 05/15/25 at 10:12 A.M., with a visitor in the facility revealed the visitor reported to the surveyor they were in the facility on 04/23/25 visiting another resident. Per the visitor, Resident #10 was observed outside sitting on the ground in another resident's patio area. The visitor stated she was unsure how long the resident was sitting outside but stated she did know it was over an hour.

Interview on 05/15/25 at 3:00 P.M. with Resident #56 revealed Resident #10 was visiting her room on 04/23/25 when Resident #10 was scooching around in his wheelchair and fell to the ground. Resident #56 stated Resident #10 sat on the ground for a couple of hours before any staff responded to his call light. Resident #56 verified she also activated her call light for staff to come assist Resident #10.

Review of the policy titled, Fall Response Procedures dated 12/20/23 revealed if a resident falls the facility staff will notify the Director of Nursing, (DON). The DON will conduct an assessment for injuries, the physician, and the responsible party will be notified of the fall.

This violation represents non-compliance found during the investigation for Complaint Numbers OH00165775 and OH00162437.

Based on observation, resident interviews, and staff interviews, the facility failed to maintain the inside and outside of the building in a safe clean and orderly manner. This has the potential to affect all 66 residents residing in the facility. The facility census was 66.

Findings include:

Observations on 05/12/25, upon entry at 7:30 A.M., revealed two missing broken tiles on the floor in the front lobby near the front door reception area. During the observation there was one tile missing along the floor located in front of the administration offices in the main dining room area. Multiple missing tiles were noted in the dining room near the serving window. Observation at 8:00 A.M., of the flooring in the hallway leading to the B-hall, C-hall, and D-halls revealed two areas of missing tiles on the floor. Observation on 05/12/25 at 8:10 A.M., of the floor area around the medication cart storage and the visitor bathroom in the dining room area revealed 4-5 spaces the tiles were bubbled up and raised off from the floor.

Further observations on 05/13/25 at 3:00 P.M., revealed there were broken eaves spouts hanging off the roof in the courtyard of the B-hall and C-hall areas in plain view of the residents' patios and windows. During the observation debris was noted all around the courtyard area near the hanging eaves spouts. An orange cord was observed laying on the ground from the wall of the facility to the outside of the courtyard, crossing over resident patio access. A blue tarp was observed with rocks on top of it at the bottom of a window in view of the B-hall windows.

Observation on 05/14/25 at 7:30 A.M. of Resident #01's room revealed a large amount of cigarette butts were noted on the outside patio ground area. Resident #01 was no longer a resident at the facility at the time of the observation.

Interview on 05/15/25 at 10:09 A.M. with Housekeeper #555 revealed there were multiple areas where the floor tiles were missing or bubbled up. Housekeeper #555 did verify some residents had complained about the flooring at the facility and the maintenance team had received reports from residents requesting the flooring be repaired. Housekeeper #555 stated residents are educated to keep cigarette butts off the ground and containers are provided; however, the housekeeping staff are responsible for cleaning resident rooms and patios as needed.

Interview on 05/19/25 at 11:00 A.M., with Director of Maintenance (DOM) #441 verified the areas of the flooring where the tiles were missing or bubbling up. DOM #441 verified there was a hanging gutter, trash debris, chords, and a blue tarp in the residents' courtyard near the patio areas of B-hall and C-hall. DOM #441 verified there were work orders to repair the flooring and gutters but due to the contacts being with private contractors no repairs had been completed as of the date of the survey.

This violation represents non-compliance found during the complaint investigation for Complaint Numbers OH00163073, OH00162435, and OH00162437.

Based on observations, open and closed medical record reviews, staff interviews, resident interviews, visitor interviews, coroner office staff interviews, Emergency Services Director interview, review of a police report, review of the Emergency Medical Squad (EMS) report, review of call light response time log, review of the facility resident agreement, review of the facility's Resident Handbook, review of the time/date and weather report website, and review of the policy for Daily Resident Safety Checks, the facility failed to ensure the safety and well-being of the residents in the facility. This resulted in Real and Present Danger and actual harm/resident death on 05/05/25 at 1:45 P.M., when Resident #01 was found deceased in a state of advanced decomposition, with discoloration to his body, fluids coming from his nose and mouth, and no signs of life. Resident #01 did not receive any meals after 05/02/25 (Friday) at 11:30 A.M., to the time he was found deceased on 05/05/25 (Monday) at 1:45 P.M., by agency Licensed Practical Nurse (LPN) #175 during a scheduled quarterly nursing assessment. This affected one (Resident #01), resident with the potential to affect 12 (#03, #04, #08, #11, #20, #24, #26, #32, #33, #38, #49, and #69) additional residents who the facility identified as needing little to no assistance with activities of daily living (ADL) and who self-isolated. Additionally, the facility failed to provide timely assistance to Resident #10 on 04/23/25, when he had an incontinent episode in his wheelchair while visiting another resident on their outside patio, and then activated his call light pendent when he had fallen out of his wheelchair onto the ground outside at 12:28 A.M., and laid on the ground for over two hours while attempting to clean himself up on his own, placing the resident at risk for potential serious physical harm. Seven additional residents (#02, #03, #04, #06, #08, #09, and #11) were reviewed who required staff assistance with transfers when activating the call light. The facility identified all 66 residents required assistance with care for at least two ADLs per their service plans. The facility census was 66.

On 05/14/25 at 12:52 P.M., the Executive Director (ED) and Director of Nursing (DON) were notified Real and Present Danger began on 05/02/25 at 5:00 P.M., when Resident #01 failed to come to the dining room for the supper meal on 05/02/25 and no staff checked on the resident to inquire why he missed his meal. Consequently, the resident was found dead three days later by LPN #175 in a decomposing state in his apartment on 05/05/25 at 1:45 P.M. during a scheduled quarterly nursing assessment. Resident #01's service plan indicated the resident was unable to provide or cook any of his meals and all meals will be provided to Resident #01 by the facility.

The Real and Present Danger was abated on 05/15/25, when the facility implemented the following corrective actions:

On 05/05/25, Resident #01 was transported from the facility.

On 05/08/25 at 12:00 P.M., the facility added an additional task in the medical records for all residents to ensure safety checks are completed on the dayshift and will be documented and signed by caregivers and nurses.

On 05/14/25, at 2:22 P.M. and 2:26 P.M., a mass text including the new policy to complete daily safety checks of residents was sent to each staff member at the facility by the DON to inform staff of the new daily task to be completed to ensure the safety of all residents. Per the text, the staff will ensure the daily task is completed to ensure care staff have checked in on each resident on the day shift and documented in the care task portion of the electronic medical record. Staff roster sign-in was initiated to ensure all staff received the mass text and verified by the DON.

On 05/14/25 at 2:25 P.M., a sign-off sheet for agency staff was sent to the staffing agency by the DON, to ensure each agency staff that comes into the facility has signed off on the document, to ensure they are aware each resident needs to be checked on at some point throughout the day. An agency binder was created by the ED to remind all agency staff to complete and sign daily safety checks. An audit of the binder will be conducted at random by a member of administration to ensure the agency staff sign off on the documentation.

Beginning on 05/14/25, three times a week for 4 weeks an audit of the daily safety checks completion will be conducted by a member of the administration. The safety check audits will consist of an audit of the daily safety checks for 6 random residents for a 1-week span, for a total of 4 weeks.

On 05/14/25 at 2:19 P.M., for each new resident admitted to the facility, the staff who complete the individual care plans will ensure the daily safety check is added to the daily tasks for every resident moving forward.

On 05/15/25 at 7:55 A.M., a new policy titled, GP 37 Daily Resident Safety Checks was created and added to the nursing policies and procedures binder. Staff have been notified of the change via photos of the policy in the group text messages and verified with acknowledgments by the DON. A copy of the new policy was added to the agency binder.

As of 05/15/25 at 7:55 A.M., a member of the facility's administration will check with 6 random residents, audited to ensure their daily safety checks were completed by staff. This will continue for 4 weeks 3 times per week. An audit book will be created and located with administration.

On 05/15/25 at 11:59 A.M., interviews with LPN #115 and LPN #125 revealed the nurses could verify via their telephones they received a text message with the training to start daily checks on 05/08/25. Observation of the nurses ' phones revealed there was an additional mass text sent on 05/15/25, including the information regarding the requirement of daily checks for all residents and the new policy for the safety checks.

On 05/15/25 at 12:30 P.M., an additional daily task was added to the electronic records for all residents to ensure safety tasks are completed on the day shift and night shift and will be documented by caregivers or nurses. Audits will continue as stated above on 05/14/25.

Beginning on 05/15/25 at 1:00 P.M., a member of the kitchen staff at the facility will verify each resident has received breakfast, lunch, and dinner and will document if the meal was accepted or refused or not applicable. Administration will train all new employees to properly track meal documentation. If kitchen staff are not in the building the meal tracking documentation will fall on nursing responsibilities.

On 05/15/25 at 1:59 P.M., the facility has had one applicant for the additional role of dietary aide for kitchen staff. Per the plan the facility will hire enough staff to schedule an additional dietary aide for each shift. The role of the dietary aide will be to ensure the meals tracking is complete and will report any refusals to the nursing department for further investigation and to complete the safety checks.

Beginning on 05/15/25 at 2:00 P.M., the DON will audit the meal tracker book to ensure the meal tracker is complete and up to date. The audits will continue for 3 times a week for 4 weeks.

On 05/15/25 at 2:22 P.M., a mass text was sent out to all staff by the DON to inform them they are required to ensure the daily safety checks on the day shift and night shift are completed and documented in electronic records. A staff roster was made via text message to acknowledge the staff member accepted the text message; this was verified by the DON.

On 05/15/25 at 3:45 P.M., interview with Certified Nurse Aide (CNA) #100 and CNA #105 verified they received the mass text message to their phones on 05/15/25 regarding the required daily checks of all residents. CNA #105 stated she was educated regarding the aides must visually see all residents for the daily checks prior to documenting in the records that the checks were completed.

On 05/19/25 from 8:13 A.M. to 10:10 A.M., Resident #33, Resident #06, Resident #04, and Resident #12, were interviewed and verified staff had been checking in with them daily since 05/15/25. Review of the daily checks in the electronic records revealed staff were documenting the safety checks for the residents interviewed.

On 05/19/25 at 8:33 A.M., interview with LPN #175 verified she is an agency nurse who works frequently in the facility. LPN #175 stated on 05/15/25 she received a text informing her of the required visual daily checks of all residents, the new policy for safety checks, and the location of a binder for the education to be provided to the agency staff regarding the changes in the tasks and policies.

Although Real and Present Danger was abated on 05/15/25, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings include:

Review of the closed medical record for Resident #01 revealed an admission date of 12/02/24, with diagnoses of constipation, dysphagia, and use of tobacco.

Review of the Service Plan (SP) dated December 2024 for Resident #01, revealed the resident required hands-on assistance with bathing, laundry, and housekeeping as needed. Per the service plan Resident #01 was unable to make his own meals and required the facility to provide all his meals.

Review of Resident #01's observation documentation revealed no documentation from 12/06/24 to 05/04/25.

Review of Resident #01's observation documentation dated 05/05/25 at 1:44 P.M., revealed agency LPN #175 approached the Assistant Director of Nursing (ADON) and stated when LPN #175 entered Resident #01's room to complete a quarterly resident survey (assessment) she noted the resident was not breathing, skin noted to be blue/gray, and unresponsive on the bed. ADON directed LPN #175 to dial 911 at 1:46 P.M. Upon entering the room, Resident #01 was noted to be cold to touch, sitting on the edge of the bed with the upper torso laid back on to the bed and slumped over to the right. The room was noted to have a foul smell upon entering. LPN #175 reported the condition of Resident #01 to the 911 operator, who stated to not perform Cardiopulmonary Resuscitation (CPR) due to the condition of the resident's body. The DON was notified at 1:46 P.M. and shortly after, the police, Emergency Medical Squad (EMS), and fire department staff arrived at the facility. The EMS was given Resident #01's Face Sheet. The police questioned staff regarding when Resident #01 was last seen. Multiple staff members noted to have seen Resident #01 Saturday afternoon. Staff assisted police with retrieving next of kin contact information. The Executive Director (ED) arrived and spoke with police and was able to contact the resident's niece. Resident #01's niece and nephew came to the facility and were notified of the death by police. The funeral home was contacted, and Resident #01 was transported at approximately 4:15 P.M.

Review of Resident #01's Activity of Daily Living (ADL) sign-off records dated May 2025 revealed a grid documentation sheet with categories of bathing, dressing, grooming, mobility, transfers, incontinence, housekeeping, and laundry. Documentation of completion of tasks dated each day of the month for 2 shifts from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. On 05/01/25, 05/02/25, 05/03/25, and 05/04/25, for both shifts, the staff documented a slash through the task (indicating not completed) for bathing, housekeeping, and laundry; and marked a S for self-done by resident for dressing, grooming, mobility, transfers, and incontinence care. On 05/05/25 (after the resident had been found deceased), the staff marked a slash for bathing, housekeeping, and laundry and marked S for dressing, grooming, mobility, transfers, and incontinence care for the 7:00 P.M. to 7:00 A.M. shift.

Review of EMS report dated 05/05/25 at 1:50 P.M., revealed EMS was dispatched to the facility with a report of deceased male. Per the EMS report Resident #01 was found with obvious signs of death. Per the EMS report Resident #01 was found lying in bed with obvious signs of death. Resident #01 had mottling (blueish-red or purplish discoloration of the skin) and lividity (the pooling of blood in the body due to gravity and lack of blood circulation as the result of cessation of cardiac activity) to his face, torso, and legs. Per the EMS, housekeeping staff reported the last time staff had seen Resident #01 alive was Friday, 05/02/25, in the morning.

Review of the police report dated 05/05/25 at 1:58 P.M., revealed the officer arrived at the facility for a report of a deceased male. Per the report upon entry to the facility the officer arrived at Resident #01's room and found Resident #01 to be blue and cold to the touch. The officer reported that when he approached Resident #01's room he could smell distinct odor of decomposition. When the officer entered the room, he immediately smelled a very strong odor of decomposition. The officer described Resident #01 as being found on his back in bed with his legs on the floor and his head towards the northeast and his feet pointed to the west. Per the report, the resident was only wearing boxers and was noted to be dark purple and black. The officer reported seeing blood and other fluids around his nose and mouth. Per the officer's report, the resident was pronounced deceased at 1:55 P.M. The officer began investigating by talking with staff to see who was in charge of checking on the resident. The officer reported the staff members stated residents were independent and were never checked on. Per the staff interviews the officer documented Resident #01 did not receive medications and he was not checked on by staff. The officer investigated the scene and determined Resident #01 passed away sometime after Friday, 05/02/25, due to the food remaining in the resident's room being baked cod and review of the menu provided by facility staff.

Interview on 05/12/25 at 9:02 A.M. with Certified Nurse Aide (CNA) #100 revealed the aide was working on Friday 05/02/25 from 7:00 A.M. to 7:00 P.M. and Monday 05/05/25 from 7:00 A.M. to 7:00 P.M. CNA #100 stated the last time she remembered seeing Resident #01 was on Friday (05/02/25) around 10:00 A.M., when she offered the resident a shower, but the resident refused. Per CNA #100, Resident #01 was independent with most ADL's but required assistance with bathing. CNA #100 stated she did not document any refusals of the showers for Resident #01 and marked the ADL sign off with a dash for bathing on 05/02/25 for the day shift (7:00 A.M. to 7:00 P.M). CNA #100 verified she had marked Resident #01 was completing his ADL tasks himself on 05/02/25 and 05/05/25 day shifts. CNA #100 verified the documentation on the ADL sign off sheet and verified she did not visually see Resident #01 complete any task on 05/02/25 or 05/05/25 by himself.

Interview on 05/12/25 at 9:19 A.M. with Resident #01's Case Manager (CM) #20 for Medicaid revealed the case manager had created Resident #01's service plan with the facility staff and Resident #01, upon his admission in December 2024. Per CM #20, Resident #01 was to get assistance with bathing, and housekeeping at least twice a week and as needed. CM #20 stated the resident was unable to make his own meals, so he required the facility to provide all meals and snacks for him. CM #20 stated she had educated the staff to contact her if Resident #01 refused any care required to be completed according to the service plan. CM #20 stated she did not receive any notifications of the resident's refusal or non-completion of any care from the facility in the months of April and May 2025. CM #20 stated she was notified via email on 05/05/25 after 5:00 P.M. of Resident #01's passing and she followed up with the facility the following day.

Interview on 05/12/25 at 9:36 A.M. with Resident #01's Power of Attorney (POA) revealed the POA was notified of Resident #01's passing on 05/05/25 around 2:00 P.M., by facility staff. Per the POA, the family came to the facility and spoke with police and staff regarding the death of Resident #01. The POA stated she was not notified of any decline in Resident #01's condition prior to 05/05/25. The POA stated Resident #01 was unable to cook or prepare any of his meals, so he required the facility to provide all 3 meals a day for him. The POA stated she knew Resident #01 was able to ambulate by himself safely and would always go down to the dining room to get his meals himself. The POA stated she was told the resident had not received any meals after lunch on Friday 05/02/25 and was found on Monday, 05/05/25. The POA stated she questioned staff why no one had checked on Resident #01 to see if he was eating or getting his meals and she was given no answer from staff. The POA stated per the police, Resident #01's last meal was Friday lunch, and he was found after lunch on Monday.

Interview on 05/12/25 at 9:42 A.M. with LPN #111 revealed the nurse was in the facility on 05/05/25 when Resident #01 was discovered in his room deceased. Per LPN #111, she was not assigned the hallway Resident #01 resided on since 05/02/25, dayshift. LPN #111 stated she could not recall the last time she saw Resident #01 prior to 05/05/25. LPN #111 stated Resident #01 had no medications to pass and did not require any nursing care, so the nurse did not provide any care for Resident #01.

Interview on 05/12/25 at 10:02 A.M. with the DON verified the aides who are documenting on the ADL sign off sheet may not be checking on the residents due to the residents being independent with their ADLs. The DON verified Resident #01 was considered independent and did not require hands-on care by the staff except for housekeeping and bathing. The DON stated on Friday, 05/02/25, Resident #01 was cared for by CNA #100 and Housekeeper #555 when they provided the care to Resident #01 per his service plans. The DON verified Resident #01 did receive all his meals from the facility's kitchen. The DON stated Resident #01 could push his call light and request help from staff but was independent and would isolate himself in his room except when he came to the dining room for meals.

Interview on 05/12/25 at 10:15 A.M. with Housekeeper #555 verified the interaction between Resident #01 and CNA #100 on Friday morning (05/02/25). Housekeeper #555 stated she was in the resident's room and asked him if he had any laundry and the resident stated he did not have any dirty laundry he wanted cleaned. Housekeeper #555 stated she did some light housekeeping and left the resident sitting on his bed. Housekeeper #555 stated Resident #01 appeared well and without distress. Housekeeper #555 verified the resident was wearing his call light pendant when she left the room on 05/02/25.

Two attempts were made to contact and interview Resident #01's primary care physician on 05/12/25 at 1:50 P.M. and 05/19/25 at 3:30 P.M. but were unsuccessful. Per the coroner's office secretary, the primary care physician for Resident #01 is also the coroner for the county, and he is currently unavailable for interview, as he is on vacation.

Interview on 05/12/25 at 3:22 P.M. with the ED and the DON verified there was no policy or procedure at the facility to perform routine safety or wellness checks on residents. The DON stated per the Resident Handbook, the facility promotes independence for the residents and if the residents' service plans do not require hands-on care, the facility staff do not check on residents.

Interview on 05/13/25 at 8:20 A.M. with Medication Technician (MT) #188 revealed the last time MT #188 saw Resident #01 was on Friday 05/02/25 around lunchtime when he came to the dining room for his meal. MT #188 stated she was assigned to the resident's hall on 05/03/25 and 05/04/25 dayshifts, but Resident #01 received no medications and he did not require any nursing care, so MT #188 did not provide him with any care.

. Interview on 05/13/25 at 1:30 P.M. with Cook #333 revealed the cook had worked from 05/02/25 to 05/04/25 on the day shift. Per Cook #333, the last time she saw Resident #01 was on 05/02/25 at 11:30 A.M., around lunchtime. Cook #333 verified she saw Resident #01 come to the kitchen window and she gave him his lunch, which is a regular meal order, in a to-go box as always. Cook #333 stated she remembered the interaction because Resident #01 had a dirty glass he liked to re-use for his milk and the cook convinced him to use a clean glass for his lunch drink. Cook #333 stated she did not recall seeing Resident #01 come back to the kitchen for any more meals on 05/02/25, 05/03/25, 05/04/25, or 05/05/25. Cook #333 verified there was no list of residents who required meals, just diet orders in the kitchen, and stated there is no protocol for when residents miss meals at the facility. Cook #333 stated she did not report Resident #01 missing any meals to any other staff in the building.

Interview on 05/13/25 at 3:15 P.M. with the DON and ED verified no staff checked on Resident #01 after he was seen Friday around lunchtime due to the resident being independent and not requiring any care. The DON stated the resident was able to use his call light and ask for help but usually remained isolated in his room per his choice. The ED stated there were no scheduled or required checks on residents who did not require any hands-on care at the facility. The DON and ED verified there were no policies in place for safety checks of the residents at the facility

Interview on 05/13/25 at 4:33 P.M. with CNA #105 via the telephone, revealed CNA #105 was assigned to Resident #01's hall on 05/03/25 and 05/04/25 day shifts. Per CNA #105, she had not seen or checked on Resident #01 on 05/03/25 or 05/04/25. CNA #105 stated Resident #01 was independent and did not require any care from the nurse aide. CNA #105 stated Resident #01 was independently ambulatory and would go to the dining room to get his meals in a to-go container and eat them in his room. CNA #105 stated she could not recall if the last time she saw the resident was on Saturday 05/03/25 or the previous Wednesday 04/30/25 when she last worked. CNA #105 verified she did provide a statement upon request of the DON after the resident was found deceased. CNA #105 verified in her statement, she did not identify the resident or date she last saw Resident #01. CNA #105 stated due to her poor recollection of when she saw Resident #01 alive, she was hesitant to write down any information regarding names and dates. CNA #105 verified at no time did she see Resident #01 after lunch on 05/03/25 or any time on 05/04/25.

Interview on 05/13/25 at 4:45 P.M. with Caregiver (CG) #300 verified she worked on 05/03/25 and 05/04/25 day shift. CG #300 stated she was not assigned to Resident 01's hall and could not recall the last time she saw Resident #01. CG #300 stated she was not asked to write a witness statement and was not interviewed by anyone at the facility regarding Resident #01's death.

Interviews on 05/14/25 at 7:20 A.M. with LPN #115 and at 7:56 A.M. with LPN #125, verified neither nurse could recall seeing Resident #01 after 05/02/25 around lunch time. Per the nurses, Resident #01 did not receive any medications or nursing care. Both nurses stated there are no protocols for checking on residents who are considered independent. Both nurses stated there are no protocols or policies for checking on residents who miss meals at the facility.

Observation on 05/14/25 at 7:30 A.M. of Resident #01's room revealed the room door was locked. Upon entry, no smell was noted, and the room appeared to have been partially cleaned. No trash was noted in the trash can and no food was noted in the kitchen area. There was no mattress on the twin bed. The mini fridge had no food containers observed. A large amount of cigarette butts were noted on the outside patio ground area. Clothes and shoes were observed all over the floor area around the bed. No call-light pendant was noted in the room during the observation.

Interview on 05/14/25 at 9:39 A.M. with agency LPN #175 revealed the nurse had been scheduled to work in the facility on 05/05/25 for the dayshift. Per LPN #175, she was informed by the DON the facility was overstaffed for 05/05/25, day shift. The nurse reported that the DON notified LPN #175 and asked her to still come to the facility to complete nursing assessments such as the quarterly assessments and complete other nursing tasks. LPN #175 stated on 05/05/25 she had not seen Resident #01 earlier in the day around any of the mealtimes (breakfast or lunch). LPN #175 stated she had not seen Resident #01 in the facility since 04/27/25, which is when she last worked in the facility. Per LPN #175, she remembered Resident #01 was independent and did not receive any medications or nursing care. LPN #175 stated she did not know of any policies or protocols at the facility to do any well-checks on the residents. LPN #175 stated on 05/05/25, she was given a list of residents requiring a nursing assessment. LPN #175 stated she knocked on Resident #01's room around 1:45 P.M. to complete his quarterly nursing assessment and she said she did smell a faint odor. LPN #175 stated she tried to open the door and found it unlocked and stated Resident #01 usually locked his door. LPN #175 stated she went into the apartment and smelled a very strong odor and saw Resident #01 laying on the bed. LPN #175 stated she saw Resident #01 was contorted in a position with his knees and legs bent in one direction and his torso and head facing the other direction. LPN #175 stated she saw Resident #01 was discolored looking very black and blue with no response to her calling his name. LPN #175 stated she did not observe any details except the state of the body and did not recall where the resident's call light pendant was.

Interview on 05/14/25 at 10:38 A.M., with the ED revealed Resident #01 was considered independent except for the required care provided per the service plans which included showers twice a week (Tuesday and Fridays), dressing and housekeeping as needed. Per the ED, unless Resident #01 pressed his call light pendant for help it was not required of the facility staff to check on the resident for any reason. The ED stated the facility follows the Resident Rights and Admission Agreements regarding ensuring resident safety, and they do not complete any checks of residents unless required by the service plans.

Review of the Resident Agreement revealed the facility will provide three meals a day and will be included in the rent charged to the resident and if a resident is ill the facility will deliver the meals to the resident's room. The facility will provide ongoing wellness assessments for the residents.

Review of the Resident Handbook revealed the facility believed each resident has the right to plan their day that fits their lifestyle. Per the handbook, the facility believed each resident to be as independent as they wish and make choices to fit their day to day living. Per the handbook, the facility made no mention of assessing the safety and well-being of the residents at the facility.

2. Review Resident #10's medical record revealed the resident was admitted to the facility on 03/11/25. Resident #10 had diagnoses which included iron deficiency, diabetes type two, bilateral leg amputations, psychoactive substance abuse, and mood affective disorder.

Review of Resident #10's service plan dated March 2025 revealed the resident required assistance with bathing, incontinence, fall risks, and housekeeping. The plan did not address transfers and assistance with ambulation.

Review of Resident #10's observation documentation from 03/27/25 to 05/06/25, revealed there were no observations documented from 04/23/25 to 04/24/25 regarding any unwitnessed falls.

Review of Resident #10's fall investigations revealed there was no documentation regarding any falls on 04/22/24 or 04/24/25 from 12:00 P.M. to 4:00 A.M.

Review of the facility's call light response time log from 04/23/25 to 04/24/25, revealed on 04/23/25 at 12:28 A.M., Resident #10 activated his call light. Per the log, the call light was not responded to for 2 hours, 22 minutes, and 36 seconds after activation.

Review of the EMS Patient Care Report dated 04/23/25 revealed EMS was called on 04/23/25 at 3:03 A.M. The EMS responded to the facility on 04/23/25 at 3:07 A.M. Per the report, Resident #10 required a lift assist. No injuries were noted in the report. Per the report Resident #10 refused care and services and signed an Against Medical Advice form. The EMS left the facility on 04/23/25 at 3:17 A.M.

Interview on 05/15/25 at 8:49 A.M. with Resident #10 revealed the resident reported to the surveyor, while he was visiting another resident and was outside on the resident's patio he had fallen out of his wheelchair onto the ground on 04/23/25 after midnight. Resident #10 stated he pushed his call lights and waited for over 3-4 hours before any staff came to his assistance. Resident #10 stated the staff called EMS to assist him getting off the ground and back into his wheelchair. Resident #10 stated there was no nurse to assess him after fall but stated he did not obtain any injuries from the fall. Resident #10 stated he reported the fall to the DON and the ED the next day and stated the ED claimed there was no call light log from Resident #10's pendant showing the times he activated the call light when he fell.

Interview on 05/15/25 at 9:18 A.M. with the ADON revealed Resident #10 had a history of putting himself on the ground and needing help from staff to get back into his wheelchair. The ADON denied any knowledge of the 04/23/25 fall for Resident #10.

Interview on 05/15/25 at 10:00 A.M. with the DON verified Resident #10 had an unwitnessed fall when he was outside of another resident's room (Resident #56) in the patio area. Per the DON, the EMS squad was called when the staff could not lift Resident #10 and put him back into his wheelchair. The DON verified the call light response time was 2 hours, 22 minutes, and 36 seconds per the log. The DON verified Resident #10 was in Resident #56's patio area outside when he was on the ground. The DON verified there was no fall investigation or documentation for Resident #10's fall on 04/23/25.

Interview on 05/15/25 at 10:12 A.M. with a visitor in the facility revealed the visitor reported to the surveyor they were in the facility on 04/23/25 visiting another resident. Per the visitor, Resident #10 was observed outside sitting on the ground in another resident's patio area. The visitor stated she was unsure how long the resident was sitting outside but stated she did know it was over an hour.

Interview on 05/15/25 at 3:00 P.M. with Resident #56 revealed Resident #10 was visiting her room on 04/23/25. When Resident #10 was scooching around in his wheelchair, he fell to the ground. Resident #56 stated Resident #10 sat on the ground for a couple of hours before any staff responded to his call light. Resident #56 verified she also activated her call light for staff to come assist Resident #10.

Interview on 05/19/25 at 9:00 A.M. with CM #25 revealed she was the responsible party for Resident #10. Per CM #25 she was not notified of any falls or incidents for Resident #10 regarding the fall on 04/23/25. CM #25 stated she has educated the facility staff she is to be notified of any falls or incidents or changes in condition for Resident #10. CM #25 stated she learned of the fall during a visit with Resident #10, where he informed her, he had fallen and sat on the ground for hours until EMS arrived to help.

Interview on 05/19/25 at 9:22 A.M. with Resident #10 revealed on 04/23/25, on the morning of the fall incident, the resident stated he had an episode of incontinence before he fell out of his wheelchair, and he was attempting to clean himself while he was on the ground. Resident #10 stated he did not obtain any injuries from the fall.

Interview on 05/19/25 at 3:30 P.M. with the ED stated there was no policy regarding call light response times.

Interview on 05/21/25 at 11:15 A.M. with Emergency Services Director (ESD) #01, revealed per the dispatch records and the report the only time EMS was dispatched to the facility for Resident #10 on 04/23/25 was at 3:03 A.M. ESD #01 verified there was no narrative or documentation of where the EMS squad found Resident #10 when they arrived at the facility on 04/23/25 at 3:07 A.M. Per ESD #01, the squad had been called out to the facility on numerous occasions to provide lift assist for Resident #10. ESD #01 stated he reviewed the reports and verified there were no injuries reported by the staff or the resident at the time the squad left the facility on 04/23/25 at 3:17 A.M.

Review of the weather forecast on the website, https://www.timeanddate.com/weather/@5153924/historic?month=4&year=2025, revealed the temperature ranged from 57 degrees to 52 degrees Fahrenheit on 04/23/25.

Review of the policy titled GP37: Daily Resident Safety Checks dated 05/14/25, revealed a daily safety check will be conducted by a member of the care staff and documented in the electronic medical record. If the resident is not in the building an observation will be made in the notes section and the nursing department will be notified to see if the resident is out of the building for medical appointments, hospitalization or with family. Also, a check of the Resident Sign Out Sheet will be looked at. If the resident has not signed out or no notifications of appointment or hospitalization or with family, the facility will refer to the Emergency Preparedness Binder. Notifications will be made to the family, case managers, and all appropriate agencies, after 24 hours of no contact.

This violation represents the noncompliance discovered during the investigation of Complaint Numbers OH00165775, OH0016549, OH00165531, and OH00165437.

Based on record review and staff interview, the facility failed to ensure Resident #18's pet was seen by a veterinarian yearly. This affected one resident's pet of four resident pets reviewed. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Review of the pet records of Resident #18's cat revealed the last veterinarian visit was 05/29/19. The rabies vaccination was recommended for 07/17/19. There was no documentation as to when the last rabies vaccination had been completed.

Interview on 01/21/25 at 1:05 P.M., with Administrator provided verification of the date of the last veterinarian visit for Resident #18's cat.

Based on observation, record review, and staff interview, the facility failed to ensure the dishwasher sanitation levels were regularly measured and recorded at least daily for proper sanitation. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Observation on 01/21/25 at 7:15 A.M., revealed no recordings of dishwasher sanitation levels. Observation of the dishwasher running revealed the wash and rinse temperature reached 120 degrees Fahrenheit after four cycles.

Interview at the time of the observation, with Cook #220, revealed no dishes had been washed with the dishwasher as of this morning. Cook #220 ran a test strip of the sanitation level after the fourth cycle to reveal a 100 parts per million reading. The sanitation was a chlorine-based solution. Cook #220 verified no sanitation levels had been recorded for the months of December 2024 or January 2025 to date.

Interview on 01/21/25 at 1:00 P.M., with the Director of Nursing revealed no food-borne illness had been experienced in the facility.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted with resident involvement, staff involvement, evaluations of drills completed, and conduct drills on the third shift. Furthermore, the facility failed to ensure the alarm company had received the alarms. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Review of the fire drills for the previous months revealed no residents had been evacuated during any of the six months of residence. Residents began moving into the facility in July 2024. The drills further revealed only the Administrator, the Director of Nursing, and the former Maintenance Manager were the only staff listed on the form as having participated in the drills. The forms had no evaluations as to the effectiveness of the drills. The forms were absent for any drills conduct on third shift. The forms were absent for any indications the alarm system had been notified and receipts received for alarm transmission.

Interview on 01/22/24 at 2:00 P.M., with the Administrator provided verification of the above findings.

Based on record review and staff interview, the facility failed to ensure a disaster drills had been conducted to train staff and residents on what to do in a disaster. This had the potential to affect all 46 residents residing in the facility.

Findings include:

Review of the disaster drills revealed there was no tornado drills conducted in the facility. There were other disaster drills but the only staff member documented as participating was the former Maintenance Manager and no residents participated.

Interview on 01/22/24 at 2:00 P.M. with Administrator provided verification of the lack of disaster drills.

Interview on 01/22/25 at 2:00 P.M., with Administrator revealed the facility opened in March 2024 with the first residents being admitted in July 2024. Administrator verified no disaster drills had been conducted with residents. The only staff member listed as participating in the disaster dills was the former Maintenance Manger.