Department of Health Report - · PDF fileohio dept health form approved statement of...

Ohio Dept Health FORM APPROVED

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETEDA. BUILDING

B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICICIENCY MUST BEPRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

ID

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COMPLETION

DATE

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

WOODLANDS AT EASTLAND THE 2469 KIMBERLY PARKWAY EAST

COLUMBUS OH, 43232

06/03/20152072R

R 0000 R 0000Initial Comments

Total Capacity: 75

Total Census: 49

County: Franklin

Administrator:

Survey Type: Master Complaint Number

OH00079229 and Complaint Number

OH00078698

Completed by: 34299

At the time of the complaint survey,

completed on 06/03/15 the business

office manager identified the current

owner was the administrator. However,

there was no personnel file for this person

and he was not observed during the

onsite investigation on 05/27/15,

06/01/05, 06/02/15 or 06/03/15.

R 0098 R 0098O.A.C. 3701-13-07 (C), (D) Criminal

Records Check

3701-13-07 (C), (D)

(C) Attestation. The DCP shall, upon

request, provide to the director, written

confirmation of compliance with the

provisions of this rule in a format that is

specified by the director and is consistent

with state law.

(D) Documentation of compliance. The

DCP shall maintain an applicant log

separate from the personnel record that

shall be accessible to the director and

shall contain the following information:

(1) The name of each applicant;

(2) Application date;

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Ohio Department of Health

STATE FORM Event:HOFR11 of 71If continuation sheet6899








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R 0098 Continued From page 1 R 0098

(3) The date the applicant starts work;

(4) The date the criminal records check

request is submitted to BCII,;

(5) The type(s) of criminal records checks

requested (BCII, FBI, or both);

(6) The date(s) the BCII and FBI checks

are received or, for referred applicants or

applicants employed pursuant to a

contract, the date a copy of the report of

the criminal records check is provided to

the DCP for its records;

(7) The date the report is completed by

BCII, "date of original record check";

(8) Whether the applicant was hired

pursuant to the personal character

standards listed in rule 3701-13-06 of the

Administrative Code;

(9) Final disposition of the applicant; and

(10) Whether the applicant was

terminated pursuant to paragraph (D)(1),

paragraph (D)(2) or paragraph (E) of rule

3701-13-04 of the Administrative

Code.

This STANDARD is not met as evidenced

by:

Based on record review and staff

interview the facility failed to maintain a

complete criminal background check log

for all employees. This affected four

employees of four employees hired within









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the past year and had the potential to

affect all 49 residents residing in the

facility.

Findings include:

On 06/02/15 a request was made to

review the facility background log. On

06/02/15 at 9:47 A.M. interview with

business office manager (BOM) revealed

the facility had not maintained a criminal

background check log for all employees

and that all employees were not on the

log. The BOM indicated the background

checks had been completed, however

again verified the facility did not have a

current log which included all employees.

On 06/02/15 the facility provided a list of

current employees and their hire dates.

Review of a sample of current staff

including two licensed staff and two life

enhancement caregivers revealed the

following:

Licensed practical nurse (LPN) #15 was

hired on 04/13/15. Record review

revealed this LPN was not included on the

criminal background check log.

LPN #21 was hired on 05/11/15. Record

review revealed this LPN was not

included on the criminal background

check log.

Life Enhancement Caregiver #30 was


revealed this caregiver was not included

on the criminal background check log.









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Life Enhancement Caregiver #37 was


revealed this caregiver was not included

on the criminal background check log.

This violation substantiates Complaint

Number OH00078698.

R 0100 R 0100O.A.C. 3701-17-54 (A) Personnel

Requirements

O.A.C. 3701-17-54 (A) Each residential

care facility shall arrange for the services

of an administrator who shall:

(1) Meet the applicable requirements of

rule 3701-17-55 of the Administrative

Code;

(2) Be responsible for the daily operation

of the residential care facility including,

but not limited to, assuring that residents'

ongoing or changing service needs, as

identified in the resident assessments,

and services ordered by a licensed health

care professional are acted upon by the

appropriate staff member. If the facility

does not provide for the needed service, it

shall be discussed with the resident as

required by paragraph (H) of rule

3701-17-58 of the Administrative Code;

(3) Provide not less than twenty hours of

service in the facility during each calendar

week during the hours of eight a.m. and

six p.m. If the administrator is unable to

provide at least twenty hours of service in

the residential care facility in a given

calendar week because of a vacation,









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illness, or other temporary situation, the

administrator shall designate a staff

member, who shall not be less than

twenty-one years of age and who meets

the requirements of paragraphs (D) and

(K) of rule 3701-17-55 of the

Administrative Code, to serve as acting

administrator;

The administrator or acting administrator

shall be accessible at all other times when

not present at the residential care facility.

A residential care facility located in the

same building as a nursing home, or on

the same lot as a nursing home, both of

which are owned and operated by the

same entity, shall be considered to have

met this requirement if the nursing home

has a full-time administrator licensed

under Chapter 4751. of the Revised Code

who is responsible for both the residential

care facility and nursing home. For the

purposes of this paragraph, "full-time"

means no less than thirty-two hours per

calendar week.


by:

Based on observation, record review and

interview the facility failed to arrange for

the services of an administrator as

required. This had the potential to affect

all 49 residents.

Findings include:









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On 05/27/15 at 3:48 P.M. upon entrance

to the facility, interview with the activities

director/community director (Employee

#11) revealed there was no administrator

onsite. Employee #11 revealed the

previous administrator, who had

functioned as both the administrator and

director of nursing "walked out" on

04/15/15 and no one had been in the role

since that time.

On 06/01/15 at 11:35 A.M. interview with

the business office manager (BOM)

revealed the current owner of the facility

was functioning as the administrator and

had been doing so since the previous

administrator was terminated on 04/15/15.

The BOM indicated the

owner/administrator would not be in on

this date, but would be in tomorrow, on

06/02/15.


the BOM revealed the


this date and that he would be in on

Thursday or Friday. Additional interview

revealed the facility did not have any type

of personnel file for the

owner/administrator to determine he was

qualified to function as the administrator.

There was no written evidence as to when

the owner/administrator had been present

in the facility between 04/15/15 and

06/03/15 to ensure he provided not less

than twenty hours of service in the facility

during each calendar week during the









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hours of 8:00 A.M. and 6:00 P.M.

During the onsite investigation on

06/01/15, 06/02/15 and 06/03/15

interviews were conducted with residents.

Interview with Resident #23, Resident #7

and Resident #48 revealed they were

unaware of who the administrator of the

facility was, had not met the owner and/or

never saw the owner in the facility.

On 06/02/15 at 4:49 P.M. a telephone

interview with the owner revealed his

company, owned by his father had owned

the facility since 2004. He stated in 2009

the facility was sold via land contract and

an asset purchase agreement to the

previous administrator/director of nursing.

The owner stated in 2014 he began

receiving "tips" from different agencies

that there were financial concerns and

delinquent property taxes that created a

"red flag". He stated he requested

financial records/documentation from the

previous administrator, but nothing was

provided. The owner indicated the

decision was made to evict the previous

administrator/director of nursing on

04/15/15 at which time he assumed

administrative responsibility. When asked

how he was qualified to be the

administrator of record, he stated it was

based on his knowledge of the facility

prior to 2009. The owner indicated he

had never functioned as the administrator

of the facility in the past. During the

telephone interview, the concern was

shared there was no evidence the owner

was qualified to be the administrator of









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the facility and no evidence the owner

was present in the facility between

04/15/15 and 06/02/15 to ensure he

provided not less than twenty hours of

service in the facility during each calendar

week during the hours of 8:00 A.M. and

6:00 P.M. No additional information was

provided during the on-site complaint

investigation.

On 06/03/15 at 8:00 A.M. no

owner/administrator was observed onsite

in the facility. As of 06/03/15 at 2:00 P.M.

there was no evidence the

owner/administrator was available onsite.

On 06/03/15 at 4:15 P.M., an exit

conference conducted with facility staff

revealed the owner was not present at the

conference.

This violation substantiates Master

Complaint Number OH00079229 and

Complaint Number OH00078698.

R 0128 R 0128O.A.C. 3701-17-55 (E)(2) Qualifications

And Health of Personnel

O.A.C. 3701-17-55 (E)(2) Staff

members who provide personal care

services in a residential care facility,

except licensed health professionals

whose scope of practice include the

provision of personal care services, shall

meet the following training requirements:

(2) Have documentation that, prior to

providing personal care services without

supervision in the facility, the staff

member met one of the following









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requirements:

(a) Successfully completed training or

continuing education that shall cover, as

is necessary to meet the needs of

residents in the facility, the following:

(i) The correct techniques of providing

personal care services as required by the

staff member's job responsibilities;

(ii) Observational skills such as

recognizing changes in residents' normal

status and the facility's procedures for

reporting changes; and

(iii) Communication and interpersonal

skills.

The training or continuing

education shall be provided by a

registered nurse or a licensed

practical nurse under the direction of a

registered nurse and be sufficient to

ensure that the staff member

receiving the training can demonstrate an

ability to provide the personal care

services. The facility may utilize other

health care professionals acting within the

scope of the professional's

practice as part of the training or

continuing education; or

(b) Successfully completed the

training and competency evaluation

program and competency evaluation

program approved or conducted by the

director under section 3721.31 of the

Revised Code; or









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(c) Successfully completed the

training or testing requirements in

accordance with the medicare

condition of participation of home health

aide services, 42 C.F.R. 484.4 and

484.36;


by:

Based on record review and interview the

facility failed to ensure all life

enhancement caregiver staff, who

provided personal care were properly

trained and/or qualified to provide such

care. This has the potential to affect all

49 residents residing at the facility.

Findings include:

1. Review of life enhancement caregiver

(LEC) #30's personnel file revealed the

employee was hired on 02/02/15. Record

review revealed the employee was not a

licensed health professional, had not

successfully completed the training and

competency evaluation and competency

evaluation program, and had not

successfully completed the training or

testing requirements of a home health

aide.









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Review of the personnel file revealed no

evidence of training in the correct

techniques of providing personal care

services, no training related to

observational skills such as recognizing

changes in residents' normal status and

the facility's procedures for reporting

changes and no training related to

communication and interpersonal skills

provided by a registered a registered

nurse or a licensed practical nurse under

the direction of a registered nurse.

On 06/02/15 at 4:55 P.M. interview with

the business office manager verified there

was no further training information

documented for LEC #30 to ensure she

had received the above training as

required prior to working independently

with residents in the facility.











aide.


evidence of training in the correct

techniques of providing personal care

services, no training related to

observational skills such as recognizing

changes in residents' normal status and









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the facility's procedures for reporting

changes and no training related to

communication and interpersonal skills

provided by a registered a registered

nurse or a licensed practical nurse under

the direction of a registered nurse.






required prior to working independently

with residents in the facility.


Number OH00078698.

R 0129 R 0129O.A.C. 370-17-55 (E)(3) Qualifications

And Health of Personnel

O.A.C. 370-17-55 (E)(3) Staff

members who provide personal care

services in a residential care facility,

except licensed health professionals

whose scope of practice include the

provision of personal care services, shall

meet the following training requirements:

(3) If the residential care facility provides

accommodations to individuals, other then

those identified in paragraph (C) of rule

3701-17-52 of the Administrative Code,

with increased emotional needs or

presenting behaviors that cause problems

for the resident or other residents, or both,

each staff member shall have

documentation that the staff member

successfully completed training or

continuing education in the appropriate









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interventions for meeting these needs and

for handling and minimizing such

problems. The documentation required by

this paragraph shall be signed and dated

by the provider of the training.


by:


facility failed to ensure life enhancement

caregiver (LEC) #37 received training to

provide the necessary care and

intervention to residents with increased

emotional needs and/or behaviors. This

had the potential to affect all 49 residents

residing at the facility.

Findings include:

Review of LEC #37's personnel file

revealed the employee was hired on

05/18/15. Review of the employee's

personnel file revealed no evidence of

training related to caring for residents with

increased emotional needs or behavioral

needs to ensure the staff member was

trained to appropriately handle and

minimize such problems that might occur

as a result.



verified LEC #37 had not received training









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related to caring for residents with

increased emotional needs or behavioral

needs to ensure the staff member was

trained to appropriately handle and

minimize such problems that might occur

as a result. During the complaint

investigation, record review and interview

with the BOM verified there were

residents who resided in the facility who

had increased emotional and/or

behavioral needs.


Number OH00078698.

R 0136 R 0136O.A.C. 3701-17-55 (K)(1)(2)

Qualifications And Health of Personnel

O.A.C. 3701-17-55 (K)(1)(2) The

administrator shall meet either of the

following qualifications:

(1) The individual is licensed as a nursing

home administrator under Chapter 4751.

of the Revised Code; or

(2) The individual meets one of the

following criteria at the time of

employment:

(a) Has three thousand hours of direct

operational responsibility for a senior

housing facility, health care facility,

residential care facility, adult care facility

or any other group home licensed or

approved by the state;

(b) Has successfully completed one

hundred credit hours of post high school

education in the field of gerontology or









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health care;

(c) Holds a baccalaureate degree; or

(d) Is a licensed health professional as

that term is defined in rule 3701-17 07.1

of the Administrative Code.


by:


facility failed to ensure the owner of the

facility was properly qualified to be the

administrator. This had the potential to

affect all 49 residents.

Findings include:

On 05/27/15 at 3:48 P.M. upon entrance

to the facility, interview with the activities

director/community director (Employee

#11) revealed there was no administrator

onsite. Employee #11 revealed the

previous administrator, who had

functioned as both the administrator and

director of nursing "walked out" on

04/15/15 and no one had been in the role

since that time.



revealed the current owner of the facility

was functioning as the administrator and

had been doing so since the previous









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administrator was terminated on 04/15/15.

The BOM indicated the


this date, but would be in tomorrow, on

06/02/15.


the BOM revealed the


this date and that he would be in on

Thursday or Friday. Additional interview

revealed the facility did not have any type

of personnel file for the

owner/administrator to determine he was

qualified to function as the administrator.

During the onsite investigation on

06/01/15, 06/02/15 and 06/03/15

interviews were conducted with residents.

Interview with Resident #23, Resident #7

and Resident #48 revealed they were

unaware of who the administrator of the

facility was, had not met the owner and/or

never saw the owner in the facility.

On 06/02/15 at 4:49 P.M. a telephone

interview with the owner revealed his

company, owned by his father had owned

the facility since 2004. He stated in 2009

the facility was sold via land contract and

an asset purchase agreement to the

previous administrator/director of nursing.

The owner stated in 2014 he began

receiving "tips" from different agencies

that there were financial concerns and

delinquent property taxes that created a

"red flag". He stated he requested

financial records/documentation from the

previous administrator, but nothing was









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provided. The owner indicated the

decision was made to evict the previous

administrator/director of nursing on

04/15/15 at which time he assumed

administrative responsibility. When asked

how he was qualified to be the

administrator of record, he stated it was

based on his knowledge of the facility

prior to 2009. The owner indicated he

had never functioned as the administrator

of the facility in the past. During the

telephone interview, the concern was

shared there was no evidence the owner

was qualified to be the administrator of

the facility. No additional information was

provided during the on-site complaint

investigation.

On 06/03/15 at 8:00 A.M. no

owner/administrator was observed onsite

in the facility. As of 06/03/15 at 2:00 P.M.

there was no evidence the

owner/administrator was available onsite.

On 06/03/15 at 4:15 P.M., an exit

conference conducted with facility staff

revealed the owner was not present at the

conference.




R 0138 R 0138O.A.C. 3701-17-55 (L) Qualifications And

Health of Personnel

O.A.C. 3701-17-55 (L) The operator or

administrator shall ensure that each staff

member, other than a volunteer who does

not provide personal care services,

receives and completes orientation and









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training applicable to the staff member's

job responsibilities within three working

days after beginning employment with the

residential care facility. The orientation

and training required by this paragraph

shall include at least orientation to the

physical layout of the residential care

facility, the staff member's job

responsibilities, the residential care

facility's policies and procedures, training

in how to secure emergency assistance,

and residents' rights. A staff member shall

not stay alone in the residential care

facility with residents until the staff

member has received the orientation and

training required under this paragraph and

the general staff training in fire control and

evacuation procedures required under

paragraph(P) of rule 3701-17-63 of the

Administrative Code.


by:


facility failed to ensure all life

enhancement caregiver staff received

orientation and training as required. This

had the potential to affect all 49 residents

residing at the facility.

Findings include:














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aide.


evidence of training related to the resident

bill of rights, facility policy and procedures,

transfer/discharge requirement for

residents or how to contact the

ombudsman. Record review also

revealed no evidence the employee

received orientation/training related to the

facility layout, the home's policy and

procedures and resident evacuation

procedures.






required.











aide.










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evidence of training related to the resident

bill of rights, facility policy and procedures,

transfer/discharge requirement for

residents or how to contact the

ombudsman. Record review also

revealed no evidence the employee

received orientation/training related to the

facility layout, the home's policy and

procedures and resident evacuation

procedures.






required.


Number OH00078698.

R 0312 R 0312O.A.C. 3701-17-58 (C) Resident Health

Assessments

O.A.C. 3701-17-58 (C) The initial health

assessment shall include documentation

of the following:

(1) Medical diagnoses, if applicable;

(2) Psychological history, if applicable;

(3) Health history and physical, including

cognitive functioning and sensory and

physical impairments;

(4) Developmental diagnosis, if

applicable;

(5) Prescription medications,









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over-the-counter medications, and dietary

supplements;

(6) Dietary requirements, including any

food allergies;

(7) Height and weight;

(8) A functional assessment which

evaluates how the resident performs

activities of daily living and instrumental

activities of daily living. For the purposes

of this paragraph, "instrumental activities

of daily living" means using the telephone,

acquiring and using public and private

transportation, shopping, preparing own

meals, performing housework, laundering,

and managing financial affairs;

(9) Type of care or services, including the

amount, frequency, and duration of skilled

nursing care the resident needs as

determined by a licensed health

professional in accordance with the

resident's assessment under paragraph

(C) of this rule;

(10) A determination by a physician or

other licensed healthcare professional

working within their scope of practice, as

to whether or not the resident is capable

of self-administering medications. The

documentation also shall specify what

assistance with self-administration, as

authorized by paragraph (F) of rule

3701-17-59 of the Administrative Code, if

any, is needed or if the resident needs to

have medications administered in

accordance with paragraphs (G) and (H)









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of rule 3701-17-59 of the Administrative

Code;

(11) If skilled care is provided to the

resident by staff members, a

determination by a physician or other

licensed healthcare professional working

within their scope of practice of:

(a) Whether the resident's personal

care needs have been affected by the

skilled nursing care needs, other

than the administration of medication or

supervision of special diets; and

(b) Whether any changes are

required in the manner personal care

services are provided. The

individual conducting the

assessment shall establish the extent, if

any, of the changes required.

(12) If skilled nursing care is provided to

the resident by staff members, the

resident's attending physician or other


within their scope of practice, shall sign

orders documenting the need for skilled

nursing care, including the specific

procedures and modalities to be used and

the amount, frequency, and duration. This

care shall be provided and reviewed

pursuant to paragraph (B) of rule

3701-17-59.1 of the Administrative Code.

(13) If the resident has been determined

to have medical, psychological, or

developmental or intellectual impairment,

the assessment must include:









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(a) A plan for addressing the

assessed needs of the resident;

(b) The need for physical environment

and design features to support the

functioning of residents with

assessed needs; and

(c) The need for increased

supervision, due to decreased safety

awareness or other assessed

condition.


by:


facility failed to ensure initial health

assessments were completed, including a



within their scope of practice, as to

whether or not the resident was capable

of self-administering medications as

required for Resident #1 and Resident

#11. This affected two residents

(Resident #1 and #11) of four residents

reviewed who had been admitted in the

past year.

Findings include:

1. Record review revealed Resident #11

was admitted to the facility on 04/01/15

with diagnoses including seizure disorder,

anemia, dementia, hypertension,

gastroesophageal reflux disease and









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fractured right shoulder.

Review of the resident's medical record

revealed no health history and physical

had been completed by the resident's

physician, no prescription medication

orders and no determination by a

physician or other licensed healthcare

professional working within their scope of

practice, as to whether or not the resident

was capable of self-administering

medications.


licensed practical nurse (LPN) #41

verified no health history and physical, no

prescription medication orders and no



within their scope of practice, as to

whether or not the resident was capable

of self-administering medications had

been completed.


was admitted to the facility on 03/05/15

with diagnoses including right leg

amputee, muscle weakness, gout, atrial

fibrillation, iron deficiency, chronic pain,

retinopathy, hypertension, diverticulosis,

hemorrhage of gastrointestinal tract,

osteoarthritis, lumbar scoliosis and

tobacco use. Review of the resident's

history and physical revealed it was

completed on 01/16/15 during a

hospitalization. During the on-site

investigation, the facility identified

Resident #1, as being the only resident

who self administered medications.









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Record review revealed no determination

by a physician or other licensed

healthcare professional working within

their scope of practice, as to whether or

not the resident was capable of

self-administering medications.



verified no determination by a physician or



to whether or not the resident was

capable of self-administering medications

had been completed.

This violation is an incidental finding to

Master Complaint Number OH00079229.

R 0313 R 0313O.A.C. 3701-17-58 (D) Resident Health

Assessments

O.A.C. 3701-17-58 (D) Subsequent to

the initial health assessment, the

residential care facility shall require each

resident's health to be assessed at least

annually unless medically indicated

sooner. The annual health assessment

shall be performed within thirty days of the

anniversary date of the resident's last

health assessment. This health

assessment shall include documentation

of at least the following:

(1) Changes in medical diagnoses, if any;

(2) Updated dietary requirements,

including any food allergies;









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(3) Height and weight;

(4) Prescription medications,

over-the-counter medications, and dietary

supplements;

(5) A functional assessment as described

in paragraph (C)(8) of this rule;

(6) If the resident has been determined to

have medical, psychological, or

developmental or intellectual impairment,

an assessment as described in paragraph

(C)(13) of this rule;

(7) Type of care or services, including the

amount, frequency, and duration of skilled

nursing care, the resident needs as

determined by a licensed health

professional in accordance with

paragraph (D) of this rule;

(8) A determination by a physician or



to whether or not the resident is capable

of self-administering medications. The

documentation also shall specify what

assistance with self-administration, as

authorized by paragraph (F) of rule

3701-17-59 of the Administrative Code, if

any, is needed or if the resident needs to

have medications administered in

accordance with paragraphs (G) and (H)

of rule 3701-17-59 of the Administrative

Code; and

(9) If skilled care is provided to the

resident by staff members, a









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within their scope of practice, of:

(a) Whether the resident's personal

care needs have been affected by the

skilled nursing care needs, other

than the administration of medication or

supervision of special diets; and

(b) Whether any changes are

required in the manner personal care

services are provided. The

individual conducting the assessment

shall establish the extent, if any, of the

changes required.


by:


facility failed to ensure annual health

assessments were completed for

Resident #2, Resident #15 and Resident

#32. This affected three residents

(Resident #2, #15 and #32) of six

residents reviewed who had resided in the

facility for over a year.

Findings include:


was admitted to the facility on 04/01/10.

Record review revealed no evidence an

annual health assessment had been

completed for the resident.



verified an annual health assessment was









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not completed as required for the

resident.










resident.










resident.



R 0314 R 0314O.A.C. 3701-17-58 (E) Resident Health

Assessments

O.A.C. 3701-17-58 (E) The residential

care facility shall require each resident's

health to be assessed if a change in

condition or functional abilities warrants a

change in services or equipment. The

assessment shall include, as applicable,

documentation of paragraphs (D)(1) to









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(D)(9) of this rule. The facility shall make

a good faith effort to obtain information

from residents about assessments

independently obtained outside the

facility.


by:


facility failed to complete a

comprehensive assessment for Resident

#31 following an acute change in

condition resulting in an extended

hospitalization. This affected one resident

(Resident #31) of ten residents whose

records were reviewed.

Findings include:

Record review revealed Resident #31 was

admitted to the facility on 06/30/14 with

diagnoses including schizoaffective

disorder, dementia, hypothyroidism,

urinary tract infection and constipation.

Record review revealed the resident had

a legal guardian appointed for person

only. Record review revealed a physician

history and physical, dated 07/07/14. The

history and physical revealed the resident

had a diagnosis of schizophrenia and

would benefit from nursing psychological

services.

A plan of care, dated 01/27/15 revealed

the resident was ambulatory with no

devices, continent and provided self care

for bathing and toileting. A comment









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included on the plan revealed the resident

required hourly checks and staff were to

document hourly. There was no

indication on the care plan as to when or

why the hourly checks were required.

Record review revealed the resident had

most recently been seen by the nurse

practitioner on 04/21/15. There was no

evidence the resident received

psychological services between 06/30/14

and 05/01/15 in the facility.

Review of a nursing progress note, dated

04/30/15 at 7:00 A.M. revealed security

reported the resident was removed from

the facility at 1:15 A.M. per police due to a

violent outburst, throwing items and

kicking walls. The note indicated the

resident threw a chair at another resident.

The resident's guardian was notified of

the behavior and gave instructions to call

the police to remove the resident from the

facility. Record review revealed the

resident remained out of the facility for

treatment until 05/26/15, at which time the

resident returned to the facility.

Review of hospital documentation, dated

05/01/15 revealed a hospital encounter,

due to aggression. The hospital records

revealed the resident was admitted due to

psychotic symptoms and aggression

towards other residents in the assisted

living. A referral was made to a mental

health agency for ongoing psychiatric

treatment as requested by the resident's

guardian. Upon readmission to the facility

on 05/26/15, the resident had a follow up









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appointment with psychological services

on 05/29/15 at 12:00 P.M.

Record review revealed upon

readmission, 05/26/15 changes had been

made to the resident's medications

including changes to psychoactive

medications. Record review revealed no

evidence the resident's follow up

appointment with psychological services

on 05/29/15. Additionally, record review

revealed no nursing progress notes

related to the resident's psychological

needs following her re-admission.

Record review revealed no evidence the

resident had been comprehensively

assessed following her re-admission to

the facility on 05/26/15. There was no

evidence the resident's psychosocial

needs, including the need for and use of

psychoactive medications were

re-assessed to ensure the resident

maintained the highest practical level of

well being.



revealed Resident #31 was admitted on

06/30/14 with recommendations for

psychological services but they had not

been initiated because of issues with the

resident's insurance and finding someone

to see her. LPN #41 verified on 04/30/15

the police were called by the facility

security officer because of behaviors the

resident was exhibiting. There was no

nurse on duty at the time. The resident

remained out of the facility until 05/26/15.









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Upon re-admission, LPN #41 verified no

comprehensive assessment was

completed to ensure the residents

psychosocial needs were assessed and a

plan was developed to ensure the

resident maintained her highest

practicable level of well-being. LPN #41

also indicated the resident did not go to

the follow up appointment on 05/29/15 as

scheduled as there had been issues with

the guardian not picking her up in time to

go and the facility did not provide

transportation on this date. LPN #41 was

unable to state whether the guardian was

aware of the appointment prior to

05/29/15.

Following the interview with LPN #41, the

request was made to review the hourly

checks completed for Resident #31.

However, no evidence was available to

determine the hourly checks had been

completed as per the nursing plan of care

initiated on 01/27/15. No explanation was

provided related to why the hourly checks

were initially required and/or why they

were not being completed.



R 0338 R 0338O.A.C. 3701-17-59 (H)(1) Personal Care

Services

O.A.C. 3701-17-59 (H)(1) Residential

care facilities that administer medication

shall comply with all of the following:

(1) No medication shall be given to any

resident unless ordered by a physician or









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individual authorized under state law to

prescribe medications. Ordered

medications shall be administered unless

the resident refuses or the resident

exhibits symptoms that contraindicate

medication administration. If a medication

is not administered, the staff member

responsible for administering the

medication shall document in the

resident's record why the medication was

not administered. Telephone orders shall

not be accepted by a person other than a

licensed nurse, another physician or a

pharmacist except that a licensed health

professional may receive, document and

date medication orders concerning his or

her specific discipline, to the extent

permitted by applicable licensing laws. If

orders are given by telephone, they shall

be recorded with the prescriber's name

and the date, and the order signed by the

person who accepted the order. All

telephone orders shall be signed by the

physician who gave the order or other

licensed health professional with

prescriptive authority working under the

supervision of or in collaboration with the

physician within fourteen days after the

order was given. The residential care

facility may accept facsimile and

electronic documentation of orders in

accordance with paragraph (B)(4) of rule

370117-59.1 of the Administrative Code;


by:










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facility failed to ensure medications were

administered as ordered to Resident #31.

This affected one resident (Resident #31)

of two residents reviewed for medication

administration.

Findings include:



diagnoses including schizoaffective

disorder, dementia, hypothyroidism,

urinary tract infection and constipation.

Record review revealed the resident was

unable to self administer medications and

medications were administered by

licensed nursing staff.

Review of a nursing progress note, dated

04/30/15 at 7:00 A.M. revealed security

reported the resident was removed from

the facility at 1:15 A.M. per police due to a

violent outburst, throwing items and

kicking walls. The note indicated the

resident threw a chair at another resident.

The resident's guardian was notified of

the behavior and gave instructions to call

the police to remove the resident from the

facility. Record review revealed the

resident remained out of the facility for

treatment until 05/26/15, at which time the

resident returned to the facility.

Record review revealed upon

readmission, 05/26/15 changes had been

made to the resident's medications

including changes to psychoactive

medications. Review of the June 2015

medication administration records









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revealed the resident was not

administered any of the medications

scheduled to be given on 06/01/15 at 9:00

A.M. or 12:00 P.M. This included ten

medications some of which were

psychoactive medications. There was no

indication of the medication administration

records or in the nursing progress notes

as to why the medications were not

administered as ordered.



verified Resident #31 was not

administered her medications at 9:00

A.M. or 12:00 P.M. on 06/01/15. The LPN

was unable to provide any explanation as

to why the medications were not

administered as ordered.



R 0391 R 0391O.A.C. 3701-17-62(B) Changes in

resident health status; incident

O.A.C. 3701-17-62(B) As used in this

paragraph, "incident" means any accident

or episode involving a resident, staff

member, or other individual in a

residential care facility which presents a

risk to the health, safety, or well-being of

a resident. In the event of an incident, the

facility shall do both of the following:

(1) Take immediate and proper steps to

see that the resident or residents involved

receive necessary intervention including,

if needed, medical attention or transfer to

an appropriate medical facility; and









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(2) Investigate the incident and document

the incident and the investigation. The

facility shall maintain an incident log

separate from the resident record which

shall be accessible to the director and

shall contain the time, place, and date of

the occurrence; a general description of

the incident; and the care provided or

action taken. The facility shall maintain a

notation about the incident in the

resident's record.


by:


facility failed to maintain an accurate and

complete incident log separate from the

resident record which included the time,

place, date of occurrence, general

description of incident and care provided

or action taken. This affected one

resident (Resident #11) of ten residents

whose records were reviewed.

Findings include:



diagnoses including seizure disorder,

anemia, dementia, hypertension,

gastroesophageal reflux disease and

fractured right shoulder.

Review of the nursing progress notes,









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dated 05/09/15 at 10:00 A.M. revealed the

resident's power of attorney (POA) was in

to see the resident. The resident stated

he fell the other day in the bathroom and

his finger hurts to bend. The note

indicated the nurse checked the first

finger on the right hand which was painful

with his first knuckle swollen and painful.

The POA indicated the resident would be

taken to the urgent care this afternoon.

Record review revealed the resident was

treated for a contusion. His hand was

wrapped upon return to the facility.

Review of the incident and accident log

revealed the above finger contusion

and/or resident report of falling were not

included on the facility incident and

accident log.



verified there were no incidents involving

Resident #11 contained on the incident

and accident log. The LPN indicated the

previous administrator/director of nursing

had directed staff to only include

witnessed falls on the incident and

accident log. Review of the incident and

accident log with LPN #41 at that time

revealed there were no incidents at all

included on the log for 2015.











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R 0394 R 0394O.A.C. 3701-17-62 (C)(3) Changes in

resident health status; incident

O.A.C. 3701-17-62 (C)(3) Each

residential care facility shall establish and

implement appropriate written policies

and procedures to control the

development and transmission of

infections and diseases which, at

minimum, shall provide for the following:

(3) Individuals providing personal care

services or skilled nursing care that may

result in exposure to body substances,

shall wear disposable vinyl or latex gloves

as a protective barrier and shall remove

and dispose of the used gloves and wash

hands before contact with another

resident. If exposed to body substances,

the individual who has been exposed shall

wash his or her hands and other exposed

skin surfaces immediately and thoroughly

with soap and water. The facility shall

provide follow-up consistent with the

guidelines issued by the U.S. centers for

disease control and prevention for the

prevention of transmission of human

immunodefiency virus and hepatitis B

virus to health-care and public-safety

workers in effect at the time. Individuals

providing personal care services or skilled

nursing care shall wash their hands

before and after providing the services or

care even if they used gloves;


by:









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interview the facility failed to ensure

disposable vinyl or latex gloves were

available for staff while providing personal

care services. This had the potential to

affect all 49 residents at the facility.

Findings include:


Resident #15 revealed the staff didn't

always wear gloves when providing care

to her and she didn't know if there were

gloves available or not.

On 06/01/15 at 2:00 P.M. interview

Resident #23 revealed staff wear gloves,

but not very often. The resident indicated

he was unsure why or when staff should

be wearing gloves.


life enhancement caregiver (LEC) #19

revealed she didn't have gloves to wear

and use everyday while working in the

facility. The employee stated the facility

was out of gloves most of the time.


Resident #48 revealed staff do not wear

gloves when changing her bed or when

cleaning. The resident stated she thought

staff should be wearing gloves, but they

tell her there are no gloves for them to

use.


Resident #13 revealed she does not see

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the hallway or other apartments.


LEC #39 revealed she had worked at the

facility for about two months on the night

shift (7:00 P.M. to 8:00 A.M.). LEC #39

stated she brings in her own gloves from

home to wear and so do the other staff

members. The LEC revealed there were

no gloves available for the staff working

during the night and there hadn't been for

the past week. LEC #39 revealed there

was no nurse in the facility during the

night (from 11:00 P.M. to 7:00 A.M.) and

gloves were never available during that

time.



revealed she had begun working in the

facility about a month prior. The LPN

revealed there was no nurse on duty from

approximately 11:00 P.M. to 7:00 A.M.

and the nursing office was locked when

no nurse was in the building. When

asked where gloves were for the

caregivers who worked overnight, the

LPN stated they were in the sitting area

next to the nurse's station. Observation

of this area revealed the box containing

gloves was empty.

An observation on 06/02/2015 at 8:30

A.M. again revealed the box where gloves

were to be kept in the sitting area next to

the nurse's station was empty. LPN #41

verified also verified this was the place for

gloves to be kept for staff to use and that

there were none available. LPN #41









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revealed the gloves were stored in the

nursing office, which was locked when the

nurse left at 11:00 P.M. each evening.

An interview with the business office

manager on 06/02/15 at 10:25 A.M.

revealed she was responsible for ordering

supplies. The BOM provided a bill from a

local medical supply company for gloves

ordered on 04/28/15 which included one

case of small, one case of medium and

one case of large gloves. A receipt from

Walgreens dated 04/20/2015 revealed

four boxes of gloves were purchased.

The BOM verified no gloves have been

purchased since 04/28/15 and no other

receipts were available to determine any

other times gloves had been purchased.

The BOM indicated if the facility ran out of

gloves, someone would run out to the

store to buy more.


Number OH00078698.

R 0551 R 0551O.A.C. 3701-17-60 (B) Dietary Services;

Supervision of Special Diet

O.A.C. 3701-17-60 (B) Each residential

care facility that agrees to provide three

daily meals for a resident shall make

available at least three nourishing,

palatable, attractive and appetizing meals

at regular hours. The meals shall provide

the dietary referenced intake of the "Food

and Nutrition Board" of the "National

Academy of Science", be based on a

standard meal planning guide from a diet

manual published by a dietitian, approved

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least a four-hour scheduled interval

available between the mid-point of the

breakfast meal and the mid-point of the

noon meal and between the mid-point of

the noon and the mid-point of the evening

meal. The hours of meal service shall

take into consideration residents'

preferences. The facility shall make

evening snacks available.


by:


interview the facility failed to ensure meals

provided were palatable and appetizing.

This had the potential to affect all 49

residents residing in the facility.

Findings include:

Review of the resident council meeting

minutes, dated 05/12/15 revealed

residents voiced they were not happy

about the food quality. Review of the

resident council minutes from the meeting

held on 02/10/15 revealed complaints

from Resident #2 about the quality and

taste of the food served by the facility. On

01/13/15 during the resident council

meeting, Resident #2 voiced concerns

about the food quality.


cook #14 revealed the meal being served

for dinner on this date was not the meal

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The cook indicated changes were posted

in the hallway for the residents to know

ahead of time. Cook #14 also verified the

facility did not maintain any record of food

substitutions for the past year.


Resident #48 revealed the food was so

bad she wouldn't feed it to animals. The

resident stated she tried to eat it but

usually just went back to her room to eat

food she had. The resident stated she

had peanut butter on toast and drank

Lactaid milk, which was not offered here.

The only milk available was 2%. Resident

#48 stated the facility did not serve

seafood or fish, green vegetables like

salad, or anything that was nutritious. The

resident stated the food was the "bottom

of the barrel". There were no snacks out

for the residents, not even a banana. The

dietary staff do not follow the menu and

the resident's don't know until we sit down

to eat what we are having.


Resident #43 revealed he hated the food

at the facility. The resident stated it was

"nasty bottom shelf that can't be altered to

taste decent". The resident stated the

menu was posted but it changed every

day and he didn't know exactly what was

on the menu or what he was having at

meal times.

On 06/01/15 at 5:10 P.M. a test tray was

completed. The meal consisted of white

rice, one piece of skinless chicken breast

in a teriyaki sauce, and broccoli. The









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broccoli was overcooked and mushy with

no taste. The chicken breast was chewy,

with a bitter after taste and tasted was of

poor quality.


dietary manager (DM) #17 revealed the

facility had changed food vendors

approximately two months prior. The DM

indicated he was aware that many of the

facility residents were unhappy with the

quality of the food and had voiced

concerns related to the food being served.

The DM indicated he had shared these

concerns with the administrator at that

time, but that there were no changes

made and nothing he could do to resolve

the residents concerns.



revealed the quality of the food served

was not good. LEC #39 indicated the

facility did not provide for evening snacks

or fruit for the residents to enjoy in the

evenings.


Resident #2 at 2:40 P.M. revealed the

food was terrible. The resident voiced

concerns that fresh fruit and vegetables

were not served. The resident also stated

the meat was tough, like rubber with no

taste. The resident was aware the facility

had a new vendor and indicated the

quality of the food was terrible. There

were no snacks put out for residents, like

fruit or cookies and nothing to drink

except coffee right now as the pop









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machine was broken again. The resident

stated the pop machine breaks down

every couple months and it's the only

"treat" I get.


cook #14 revealed the facility menus were

provided from the food vendor. The cook

stated if the facility does not have enough

of a certain food for everyone, or if the

item did not come, then the facility would

offer a substitute. Cook #14 revealed

there was not a written log or book of

substitutions.


Number OH00078698.

R 0567 R 0567O.A.C. 3701-17-60 (M) Dietary Services;

Supervision of Special Diet

O.A.C. 3701-17-60 (M) Each residential

care facility that provides meals shall plan

all menus for meals at least one week in

advance. Food shall vary in texture, color

and include seasonal foods. Residential

care facilities shall maintain records of

dated menus, including complex

therapeutic diets, as served for a period of

at least one year. The records shall be

made available to the director upon

request. The records shall indicate any

substitutions made to the menus except

that alternate items offered to individual

residents because of food intolerances or

preferences do not need to be recorded

unless the resident is on a complex

therapeutic diet. All foods substituted shall

be of similar nutritive value.









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facility failed to ensure dated menus, as

served for a period of at least one year

reflected any substitutions made to the

menu. This had the potential to affect all

49 residents residing in the facility.

Findings include:


cook #14 revealed the meal being served

for dinner on this date was not the meal

on the pre-planned menu for the date.

The cook indicated changes were posted

in the hallway for the residents to know

ahead of time. Cook #14 revealed the

facility did not maintain any record of food

substitutions for the past year.


Resident #48 revealed dietary staff do not

follow the menu and the resident's don't

know until we sit down to eat what we are

having.


Resident #43 revealed the menu was

posted but it changed every day and he

didn't know exactly what was on the menu

or what he was having at meal times.


cook #14 revealed the facility menus were

provided from the food vendor. The cook

stated if the facility does not have enough

of a certain food for everyone, or if the









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item did not come, then the facility would

offer a substitute. Cook #14 revealed

there was not a written log or book of

substitutions.


Number OH00078698.

R 0603 R 0603O.A.C. 3701-17-63 (D) Building, plumbing

& fire safety requirements

O.A.C. 3701-17-63 (D) Lavatories,

bathing facilities, and shower facilities

shall be provided with pressure balancing

thermostatic mixing devices in

accordance with the Ohio plumbing code

to prevent unanticipated changes in hot

water temperatures.


by:


facility failed to ensure lavatories, bathing

facilities and shower facilities were

provided with pressure balancing

thermostatic mixing devices in


to prevent unanticipated changes in hot

water temperatures. This had the

potential to affect all 49 residents.

Findings include:

During a visit at the facility, by the

ombudsman on 04/09/15 concerns were

identified by some of the residents that

the hot water did not stay hot long

enough.









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maintenance employee #36 revealed the

facility did not have pressure balancing

thermostatic mixing devices installed in


on all lavatories, bathing facilities and

shower facilities to prevent unanticipated

changes in hot water.


maintenance employee #36 revealed as

part of a previous plan of correction to

ensure water temperatures were

maintained as required (between 105 and

120 degrees Fahrenheit), the facility

implemented a system to check the hot

water temperatures in six different rooms

each week. Maintenance employee #36

provided the hot water temperature logs

completed since February 2015, which

was when he indicated this plan was

implemented, following a survey by the

State agency.

Review of the Water Heater Temperature

logs, provided by maintenance employee

#36 revealed water temperatures were

obtained on 02/04/15, 02/05/15, 02/06/15

and 02/09/15. On 02/09/15 the water

temperature in Elm Valley Room 27 was

95 degrees Fahrenheit.

On 02/06/15 the water temperatures on

the Elm Valley unit in Rooms 14, 18 and

23 were 100 degrees Fahrenheit. On

02/06/15 the water temperature on the

Elm Valley Room 27 was 95 degrees.









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On 02/05/15 the water temperature in

Dogwood Knolls Room 28 was 90

degrees Fahrenheit. An undated sheet

revealed the water temperature in

Crabtree Commons Room 16 was 80

degrees Fahrenheit.

Temperatures recorded in April 2015

were dated they had been obtained on

04/17/15, 04/20/15 and 04/21/15 in 12

different resident rooms. There was one

water temperature obtained for one room

in May 2015, which was noted on

05/26/15.

On 06/03/15 at 1:00 P.M. additional

interview with maintenance employee #36

verified the facility had not been checking

hot water temperatures on a routine basis

to ensure they were maintained at an

appropriate temperature as required. The

maintenance employee further explained

there were five current rooms in the

facility (on the Elm Valley and Crabtree

Commons units) that received hot water

from a 19 gallon hot water tank in the

attic. These rooms were currently

occupied by Resident #1, #18, #20 and

#24. The fifth room, located on the

Crabtree Commons unit was currently

unoccupied. The maintenance employee

revealed that if run for even a short

amount of time in these rooms, the hot

water would be gone and the water would

be cold. The employee indicated,

Resident #18 frequently voiced concerns

with the water not being hot enough

because it took her longer to get into the

tub.









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Number OH00078698.

R 0604 R 0604O.A.C. 3701-17-63 (E) Building, plumbing


O.A.C. 3701-17-63 (E) The water supply

for a residential care facility shall be taken

from a public supply, if available. Each

residential care facility using a water

source other than a public water system

shall comply with all applicable local and

state regulations regarding the

construction, development, installation,

alteration, and use of private water

systems.


by:


facility failed to ensure annual backflow

assembly testing was completed as

required to ensure the safety and

uninterrupted public water service to the

facility. This had the potential to affect all


Findings include:



revealed as of 04/15/15 the previous

administrator/director of nursing had been

been terminated. The BOM revealed

there were bills that had not been paid as

a result of the previous









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administrator/director of nursing.

A review of the unpaid bills revealed a

notice dated 04/28/15 from the local

public utilities requesting backflow

assembly testing to be completed, with an

inspection report to be filled out and

returned. The notice indicated the testing

was to be completed within 15 days - after

that date, water termination procedures

would start. Additional notices, with a due

date of 05/06/15 revealed an outstanding

balance of $14,677.56 with a turn off date

on or after 05/13/15.


a representative from the City of

Columbus Department of Public Utilities

revealed the facility had three devices at

their location that required backflow

assembly testing be done annually. The

representative revealed the testing was

due to be completed by 04/03/15. The

letter issued on 04/28/15 reflected the

facility was past due and not in

compliance with this rule. The

representative revealed it was the

responsibility of the facility to hire an

approved independent contractor to

complete the testing and submit the

required paperwork to the public utility

department. Review of the account

revealed no evidence any contact had

been made by the facility to resolve the

outstanding debt or ensure the backflow

assembly testing was completed as

required.










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Number OH00079229.

R 0614 R 0614O.A.C. 3701-17-63 (K)(1) Building,

plumbing & fire safety requirements

O.A.C. 3701-17-63 (K)(1) Each

residential care facility shall conduct the

following drills unless the state fire

marshal allows a home to vary from this

requirement and the residential care

facility has written documentation to this

effect from the state fire marshal:

(1)Twelve fire exit drills,one conducted on

each shift at least every three months to

familiarize staff members and residents

with signals, evacuation procedures and

emergency action required under varied

times and conditions. Fire exit drills shall

include the transmission of a fire alarm

signal to the appropriate fire department

or monitoring station, verification of

receipt of that signal, and simulation of

emergency fire conditions except that the

movement of infirm and bedridden

residents to safe areas or to the exterior

of the structure is not required. Drills

conducted between nine p.m. and six

a.m. may use a coded announcement

instead of an audible alarm. Residential

care facilities that have an alarm system

that is not capable of sending a fire alarm

signal if an audible alarm is not used shall

transmit a fire alarm signal and

verify receipt of that signal no more than

twelve hours after the coded

announcement. Fire drills shall meet the

following requirements.

(a) Each staff member shall









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participate in at least one fire drill

annually.

(b) One staff member with knowledge

of the disaster preparedness plan and the

fire evacuation routes shall be

designated to observe and evaluate each

drill and shall not participate in that

drill.

(c) Residents capable of

self-evacuation shall be actually

evacuated to safe areas or to the

exterior of the residential care facility in at

least two fire drills a year on each shift.

Movement of non-ambulatory

residents to safe areas or to the exterior

of the facility is not required.


by:


facility failed to ensure fire drills were

completed as required. This had the

potential to affect all 49 residents residing

in the facility.

Findings include:

Review of the facility licensure survey

history revealed an annual survey

completed on 07/24/14 resulted in a

violation related to the facility not

completing fire drills as required. This

violation was subsequently corrected

during a follow up survey completed on









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02/02/15.


the employee responsible for the facility

maintenance, Employee #36 revealed the

front office maintained copies of all the

fire drill records and fire records. On

06/02/15 at 8:20 A.M. the fire drill records

were requested from the business office

manager (BOM) since the last annual

survey. At 8:30 A.M. the BOM provided

fire drill records indicating these were all

of the records available.

Review of the fire drill records provided

revealed a fire drill record dated 05/10/15

with a start time of 6:15 A.M. and end

time of 6:18 A.M. Under the type of drill

the exercise the facility documented "fire

alarm went off" and no fire was located.

The drill record included the names of five

staff and two residents (Resident #4 and

Resident #42).

Record review revealed on 05/11/15 at

9:40 P.M. a note from the security officer

revealed the alarm system activated

about 9:40 P.M. The panel key trouble

read "CC & DK Corridor". The note

stated the security officer inspected the

CC & DK apartment; no fire. The

security officer deactivated the system

and real normal. The fire department

showed up about 8-10 minutes and

inspected and found no fire. The incident

was reported to the fire alarm monitoring

system. The note also indicated the fire

man suggested to call the alarm company

to fix the problem.









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A second record, dated 05/15/15 was

contained in the file. There was no date

or time on this record, but it reflected a

fire drill was held on this date with eight

staff in attendance and four residents

(Resident #4, Resident #5, Resident #15

and Resident #38).

Record review and interview with the

BOM and maintenance employee #11 on

06/02/15 at 2:12 P.M. verified the only

evidence of fire drills completed from

February 2015 (the date of the follow up

survey) and 06/02/15 was the above drills

dated 05/10/15 and 05/11/15. The BOM

verified the drill records were incomplete

on 05/15/15 and did not include

information as to when the drill had been

conducted. The BOM verified there was

no evidence any fire drills had been

completed in February 2015, March 2015

or April 2015.

Based on review of the fire drill records

there was no evidence all residents

capable of self-evacuation were actually

evacuated to safe areas or to the exterior

of the residential care facility in at least

two fire drills a year on each shift.



R 0622 R 0622O.A.C. 3701-17-63 (Q) Building, plumbing


O.A.C. 3701-17-63 (Q) Each residential

care facility shall provide for annual

training in fire prevention









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for regularly scheduled staff members on

all shifts to be conducted by the state fire

marshal or township, municipal or local

legally constituted fire department.

Records of this training shall be kept at

the facility.


by:


facility failed to provide annual training in

fire prevention for regularly scheduled

staff members on all shifts to be

conducted by the State fire marshal or

township, municipal or local legally

constituted fire department. This had the

potential to affect all 49 residents residing

in the facility.

Findings include:

Record review revealed on 03/27/15 at

1:00 P.M. maintenance employee #11

provided an all staff fire safety and fire

extinguisher training. The training

attendance record revealed the length of

the training was half hour and 32

employees, including maintenance

employee #11 signed the sign in sheet to

reflect their attendance.



verified the facility maintenance employee

conducted the annual fire training for the

facility. The BOM revealed the

maintenance employee had also

conducted the training in 2014. The BOM

revealed no training was completed by the









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State fire marshal or township, municipal

or local legally constituted fire department

annually as required.



R 0657 R 0657O.A.C. 3701-17-64 (D)(6) Space

Requirements

O.A.C. 3701-17-64 (D)(6) As used in

this paragraph, "bathroom" means a room

or rooms including at least one toilet, one

shower or bathtub, and one sink. Each

residential care facility shall provide at

least one toilet, one shower or bathtub,

and one sink for every eight residents

living in the residential care facility. Each

residential care facility shall meet the

following requirements regarding

bathroom facilities:

(6) Each bathtub, shower, and sink

shall have hot and cold running water. If

the residential care facility is in

control of the hot water temperature, the

hot water shall be at least one hundred

five degrees Fahrenheit and no more than

one hundred twenty degrees Fahrenheit

at the point of use. If a resident is in

control of the hot water temperature in his

or her resident unit, the residential

care facility shall ensure that the hot water

is at a safe temperature sufficient

to meet the preferences of the

resident.


by:









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facility failed to ensure water

temperatures in bathroom facilities were

maintained between 105 and 120 degrees

Fahrenheit at the point of use. This had

the potential to affect all 49 residents.

Findings include:

During a visit at the facility, by the

ombudsman on 04/09/15 concerns were

identified by some of the residents that

the hot water did not stay hot long

enough.


maintenance employee #36 revealed as

part of a previous plan of correction to

ensure water temperatures were

maintained as required (between 105 and

120 degrees Fahrenheit), the facility

implemented a system to check the hot

water temperatures in six different rooms

each week. Maintenance employee #36

provided the hot water temperature logs

completed since February 2015, which

was when he indicated this plan was

implemented, following a survey by the

State agency.

Review of the Water Heater Temperature

logs, provided by maintenance employee

#36 revealed water temperatures were

obtained on 02/04/15, 02/05/15, 02/06/15

and 02/09/15. On 02/09/15 the water

temperature in Elm Valley Room 27 was

95 degrees Fahrenheit.

On 02/06/15 the water temperatures on









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the Elm Valley unit in Rooms 14, 18 and

23 were 100 degrees Fahrenheit. On

02/06/15 the water temperature on the

Elm Valley Room 27 was 95 degrees.

On 02/05/15 the water temperature in

Dogwood Knolls Room 28 was 90

degrees Fahrenheit. An undated sheet

revealed the water temperature in

Crabtree Commons Room 16 was 80

degrees Fahrenheit.

Temperatures recorded in April 2015

were dated they had been obtained on

04/17/15, 04/20/15 and 04/21/15 in 12

different resident rooms. There was one

water temperature obtained for one room

in May 2015, which was noted on

05/26/15.

On 06/03/15 at 1:00 P.M. additional

interview with maintenance employee #36

verified the facility had not been checking

hot water temperatures on a routine basis

to ensure they were maintained at an

appropriate temperature as required. The

maintenance employee further explained

there were five current studio rooms in the

facility (on the Elm Valley and Crabtree

Commons units) that received hot water

from a 19 gallon hot water tank in the

attic. These rooms were currently

occupied by Resident #1, #18, #20 and

#24. The fifth room, located on the

Crabtree Commons unit was currently

unoccupied. The maintenance employee

revealed that if run for even a short

amount of time in these rooms, the hot

water would be gone and the water would









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be cold. The employee indicated,

Resident #18 frequently voiced concerns

with the water not being hot enough

because it took her longer to get into the

tub.

Review of the Water Heater

Temperatures log sheet revealed staff

were provided the following information

related to water temperatures. "Let the

water run long enough; the distance from

the water heater to the faucet is different

in the studio, versus the 1 bedroom,

versus the 2 bedroom, and the makes

and models are also different". The sheet

also indicated for staff to record the

hottest temperature- "acceptable range is

100 degrees to 130 degrees".


maintenance employee #36 verified the

information related to acceptable hot

water temperature range documented on

the temperature log sheet was not in

accordance with the licensure

requirement of 105 to 120 degrees

Fahrenheit.


Number OH00078698. This violation was

also issued during the annual survey

completed on 07/08/13, the annual survey

completed 07/24/14 and the post survey

revisit surveys completed on 02/02/15

and 04/02/15.

R 0660 R 0660O.A.C. 3701-17-65 (A) Building

Maintenance, Equipment, Supplies

O.A.C. 3701-17-65 (A) Each









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residential care facility shall maintain

heating, electrical, and other building

service equipment in good working and

safe condition. Each residential care

facility shall have its central heating

system checked every two years by a

heating contractor.


by:

Based on record review, staff interview

and interview with a representative from

the electric company, the facility failed to

ensure electric services would continue to

be supplied to all areas of the facility

without interruption. This had the potential

to affect 49 of 49 residents.

Findings Include:



revealed on 04/15/15 the previous

administrator/director was terminated.

Since that date, the facility owner had

assumed responsibility for the facility as

an administrator, but that she (the BOM)

was responsible for staffing, bill payment

and day to day operations. The BOM

revealed electric services were included

in the monthly room and board cost for all

residents. The BOM revealed she had

bills from local utility companies that had

not been paid since the previous

administrator/director was terminated.

Review of statements from the American

Electric Power company provided by the

BOM to review revealed statements dated









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from April 2015 and May 2015 which

included both current charges, past due

charges and disconnection notices.

Interview with the BOM on 06/01/15 at

11:35 A.M. revealed she was aware of the

past due notices and indicated the bills

had not been paid/were not current as of

this time.


an American Electric Power (AEP)

Customer Service Representative

revealed that AEP had not received

payment in full for the outstanding electric

bills for the facility. The AEP

representative further stated each

individual resident apartment had an

electric meter and then the facility had five

meters that supplied the common areas

and areas such as the kitchen/dining

room, laundry. The AEP representative

further stated she had been told, by the

current owner, the facility had been

bought by a new company on 04/15/15.

However, she stated there was no record

of this with the electric company and no

evidence any plans had been made by

the current owner to ensure payments

were made in full to prevent the

discontinuation of service.




R 0661 R 0661O.A.C. 3701-17-65 (B) Building

Maintenance, Equipment, Supplies

O.A.C. 3701-17-65 (B) Each

residential care facility shall maintain a









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clean, healthy environment by doing at

least the following:

(1) Establishing and implementing

housekeeping and maintenance

procedures to assure a clean, safe,

sanitary environment;

(2) Providing durable garbage and

refuse receptacles to accommodate

wastes. The residential care facility

shall store all garbage and other refuse in

leakproof containers with tight fitting

covers until time of disposal, and dispose

all wastes in a satisfactory manner;

(3) Eliminating any existing insects

and rodents and taking effective

measures to prevent the presence

of insects and rodents in or around any

building used for a residential care facility

or part thereof. The extermination

of insects and rodents shall be done in

such a manner as not to create a

fire or health hazard.


by:


interview the facility failed to maintain a

clean, safe and sanitary resident

environment and failed to ensure

measures were in place effectively

eliminate insects and rodents. This had

the potential to affect all 49 residents

residing in the facility.

Findings include:









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1. On 06/01/15 at 10:45 A.M. observation

revealed three ground hogs in the

courtyard between the apartments. Three

holes were observed in the ground in the

courtyard area. Two of the holes were

observed under the screened porch of

Room 12 on Crabtree Commons hallway.

During the observation, a ground hog was

observed to go into one of the holes

under the screened porch.

On 06/01/15 at 10:55 A.M. observation of

the courtyard on the other side of the

building revealed a ground hog in the

screened porch of Room 11 on Elm

Valley hallway. The ground hog was in

the porch area for approximately 10

minutes and then crawled back under the

door.

On 06/01/15 at 2:12 P.M. Resident #6

was observed sitting in the hallway area

watching the ground hogs. He stated

there were too many of the animals and

was aware the facility puts traps out but

doesn't know how many are caught. Five

ground hogs were observed in the

courtyard at that time. One of the ground

hogs was observed to go under the porch

of Room 12 on the Crabtree Commons

hallway again. Across the hallway looking

out to the other courtyard were four

ground hogs eating.


Resident #13 revealed no rodents,

animals or bugs were in her apartment at

that time. The resident further explained

the closet in her kitchen had a trap door









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to the outside crawl space and animals

can come up in it. The resident stated

she kept a fan against the door to keep

the door shut and keep animals from

getting into her apartment. The resident

stated the ground hogs get in her

screened porch and she doesn't use it

any more for fear of the ground hogs. An

observation at 4:15 P.M. of the utility

closet revealed a cut out in the floor

measuring approximately two feet by two

feet. When the surveyor stepped on the

corner it lifted, allowing the underneath

crawl space to be visible.


Resident #43 revealed staff routinely left

the front door of the facility propped open.

The resident stated the dining area was

close to the front door and he had found

"bugs" in his food. The resident stated he

didn't eat the cole slaw or applesauce on

the table at dinner time because of the

bugs in the food. Observation of the front

door area at that time revealed the door

was propped open.



revealed she had seen mice and rats in

the hallways at night. LEC #39 stated

many of the rooms on the Elm Valley unit

had been treated for bed bugs. LEC #39

stated the facility treats the rooms, but the

bed bugs come back.

Although, no current rooms were

observed with bed bugs during the time of

the complaint investigation, review of the









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pest control invoices and statements

revealed the most current pest control

visit was dated 05/11/15. During the visit,

Resident #33's room and surrounding

rooms were were treated for active bed

bugs. The pest control note also revealed

a metal catch and release trap for the

ground hogs was placed outside.

On 06/03/15 at 11:55 A.M. the front door

to the facility was again observed propped

open.



verified the facility did have pest control

services onsite in May 2015 to address

issues with bed bugs in the facility. The

BOM also verified pest control also sets

traps for the ground hogs, but was unable

to provide written evidence of how the

facility was proactively trying to eliminate

the ground hogs from the resident living

areas.

2. An initial environmental tour of the

facility began on 06/01/2015 at 9:15 A.M.

The door to the back of the facility, going

out to the dumpster area was observed to

be rusted out around the edges and at the

bottom. On the right side of the door at

the bottom was a hole approximately 5

inches in diameter.

A tornado spot sign, hanging in a picture

frame on the wall in the hallway of the

Dogwood Knolls unit by the fire

extinguisher was observed to have

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the front of the frame.

Observation of the Crabtree (CC) unit for

Rooms 20-25 revealed there was no

posted fire evacuation route. Also in the

middle of the CC hall was a small sitting

room. The carpet was observed to be

raised up in several areas and a dark

discoloration appearing to look like a

water spot was observed on the ceiling

approximately three feet long.

Observation of Resident #32's room

revealed there was a large brown water

discoloration stain on the ceiling

approximately four feet long by one foot

wide.

Observation of Resident #13's room

revealed a utility closet with a cut out

square in the floor that opened to the

outside crawl space. It measured

approximately two feet by two feet.

There was a large brown water spot/stain

on the ceiling in the main corridor to the

assisted living apartments near the store

with supplies.

On 06/03/15 at 2:40 P.M. a follow up tour

with licensed practical nurse (LPN) #21

verified the above environmental

concerns as noted above.


Number OH00078698.









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R 0803 R 0803O.A.C. 3701-17-67 (C) Records and

Reports

O.A.C. 3701-17-67 (C) Copies of all

current licenses, approvals and

inspections required by rules 370117-50

to 3701-17-68 of the Administrative Code;


by:


facility failed to ensure all fire safety

inspection reports were available for

review. This had the potential to affect all


Findings include:

Record review revealed an invoice, dated

04/13/15 reflecting an outside company

had provided fire safety inspections

including an annual fire extinguisher

inspection, annual backflow inspection,

annual hydrant flow test and inspection,

annual fire alarm inspection, wet sprinkler

system inspection, semiannual restaurant

system inspection, emergency/exit light

inspection, emergency light with 90

minute battery backup, batter, 5# ABC

recharge, wet chemical hydrotest, 2.5#

ABC recharge, six year maintenance,

replacement O-ring, one 4.6 gallon wet

chemical recharge, bulb and battery

replacement.










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the business office manager revealed the

results of this inspection was not available

to review as it had not been provided to

the facility because the facility had not

paid for the services provided.


Number OH00079229.

R 9999 R 9999Final Observations


by:

3721.122 [Effective 9/15/2014] Screening

and accomodations for sex offenders.

Before an individual is admitted as a

resident to a home, the home's

administrator shall search for the

individual's name in the internet-based

sex offender and child-victim offender

database established under division (A)

(11) of section 2950.13 of the Revised

Code. If the search results identify the

individual as a sex offender and the

individual is admitted as a resident to the

home, the administrator shall provide for

the home to do all of the following:

(A) Develop a plan of care to protect the

other residents' rights to a safe

environment and to be free from abuse;

(B) Notify all of the home's other residents

and their sponsors that a sex offender

has been admitted as a resident to the

home and include in the notice a

description of the plan of care developed

under division (A) of this section;

(C) Direct the individual in updating the

individual's address under section

2950.05 of the Revised Code and, if the









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individual is unable to do so without

assistance, provide the assistance the

individual needs to update the individual's

address under that section.

History. Added by 130th General

Assembly File No. TBD, HB 483, §101.01,

eff. 9/15/2014.


facility failed to ensure prior to admitting a

resident, the home's administrator

completed a search for the resident's

name in the internet-based sex offender

and child-victim offender database

established under division (A)(11) of

section 2950.13 of the Revised Code as

required. This affected six residents

(Resident #1, #5, #11, #13, #20 and #48)

identified by the facility to have been

admitted since 09/15/14 and had the

potential to affect all 49 residents.

Findings include:

During the onsite investigation, the facility

provided a resident roster which included

a list of current residents and their

admission date.

Review of the roster revealed Resident #1


Review of the roster revealed Resident #5


Review of the roster revealed Resident

#11 was admitted to the facility on

04/01/15.



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11/10/14.



11/20/14.



revealed the facility did not complete a

search for the resident's name in the

internet-based sex offender and

child-victim offender database established

under division (A)(11) of section 2950.13

of the Revised Code as required. The

BOM revealed she was unaware of this

requirement and verified it had not been

completed for any resident admitted to the

facility since 09/15/14.




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