Rae Ann Suburban

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents were free from misappropriation of property. This affected eight residents (#21, #77, #86, #88. #89, #90, #91 and #92) of 10 residents reviewed for abuse. The facility census was 81.

Inspectors wroteBased on observation, interviews and facility policy the facility failed to ensure a sanitary and clean kitchen. This had the potential to affect all 81 residents. The facility census was 81.

Inspectors wroteBased on observation, interviews and facility policy the facility failed to ensure a clean and homelike environment. This had the potential to affect all 81 residents. The facility census was 81.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a medication rate less than five percent. This affected two (Resident #9 and Resident #56) out of four residents observed during medication administration. The facility census was 81.

Inspectors wroteBased on observation, interview and facility policy the facility failed to ensure garbage was disposed of properly. This had the potential to affect all 81 residents in the facility. The facility census was 81.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all 77 residents receiving food from the kitchen. The facility identified two (#40 and #80) resident who received no food from the kitchen. The facility census was 79.

Inspectors wroteBased on review of the facility's arbitration agreement and staff interview, the facility failed to ensure its arbitration agreement did not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials and any other relevant advocacy agencies (id est (i.e.) State Survey Agency, Office of the State Long Term Care Ombudsman) regarding the arbitration process and/or outcome of the arbitration settlement. This had the potential to affect all 79 residents residing in the facility. The facility census was 79. Findings Include: [...]

Inspectors wroteBased on observation, medical record review, staff interview, review of infection control tracking logs and COVID-19 tracking logs, review of the Centers for Disease Control and Prevention documents, and review of facility policies, the facility failed to adequately track infections within the facility and failed to ensure infection control measures were maintained related to obtaining blood glucose levels and proper hand hygiene after resident contact and glove use. This had the potential to affect all 79 residents residing in the facility. The census was 79.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure its dryers were free from excessive lint build up. This had the potential to affect all 79 residents. The facility census was 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the preadmission screen and resident review (PASRR) status was coded correctly on the Minimum Data Set (MDS) assessment. This affected four (#9, #18, #34, and #58) of 23 residents identified by the facility with a level two mental illness currently residing at the facility. The facility census was 79. Findings Include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, opioid dependence, and delusional disorder. Review of the PASRR level two assessment dated [DATE] revealed Resident #9 had a level two mental illness. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and medical record review, the facility failed to ensure preferences were followed regarding application of compression bandages. This affected one (#41) of one resident reviewed for preferences. The facility census was 79.

Inspectors wroteBased on medical record review, resident and resident representative interview, staff interviews, and facility policy review, the facility failed to ensure requests for medical records were honored in a timely manner. This affected one (#78) of one residents reviewed for medical record requests. The facility census was 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) documents contained all required information. This affected three (#12, #75, and #139) of three residents reviewed for beneficiary notices. The facility census was 79. Findings Include: 1. Review of Resident #12's NOMNC form for services ending 02/26/25, and signed 02/21/25, revealed the notice contained no specific information about what services would be discontinued. 2. Review of Resident #75's NOMNC form for services ending 02/17/25, and acknowledge by the resident's family via telephone on 02/13/25, revealed the notice contained no specific information about what services would be discontinued. The area on the form that discussed which services would be discontinued was blank. 3. [...]

Inspectors wroteBased on medical record review, resident and staff interview, and Ombudsman interview, the facility failed to facilitate an orderly discharge when necessary medical supplies were not provided timely to a resident upon discharge. This affected one (#136) of four residents reviewed for discharges. The facility census was 79.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided with appropriate incontinence and perineal care. This affected one (#4) of two residents reviewed for bowel and bladder. The facility census was 79.

Inspectors wroteBased on review of personnel records and staff interview, the facility failed to ensure its certified nurse aides (CNAs) received 12 hours of in-service training per year as required. This had the potential to affect all 79 residents. The facility census was 79. Findings Include: 1. Review of the personnel record for CNA #713 revealed a hire date of 05/01/24. Review of in-service records from 05/01/24 through 05/01/25 revealed CNA #713 received 4.5 hours of in-service training all of which took place in the year 2025. 2. Review of the personnel record for CNA #740 revealed a hire date of 04/08/24. Review of in-service records from 04/08/24 through 04/08/25 revealed CNA #740 received 4.5 hours of in-service training all of which took place in the year 2025. Interview with the Administrator on 06/09/25 at 2:00 P.M. verified the lack of required in-services hours for CNA #713 and CNA #470. [...]

Inspectors wroteBased on medical record review, observation, interview, and facility policy review, the facility failed to ensure the complete physician-ordered treatment was applied to Resident #20's sacral pressure ulcer. This affected one (Resident # 20) of three residents reviewed for wound care. The facility census was 87.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 90.

Inspectors wroteBased on observation and staff interview the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 90.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #65's concern was addressed promptly. This affected one resident (#65) of three residents reviewed for grievances. The facility census was 87. Findings Include: Review of the medical record for Resident #65 revealed an admittance date of 06/29/20. Diagnoses included dementia, depressive disorder, bipolar, psychosis, schizoaffective disorder, alcohol abuse. Review of the concern log form dated 03/11/24 through 10/30/24 revealed no identified concerns for Resident #65. Review of the email correspondences dated 10/10/24 at 10:49 A.M. through 10/29/24 at 10:59 A.M. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physician orders to obtain a urinalysis with culture and sensitivity testing as ordered. This affected one (#2) of three residents reviewed for a change in condition. The census was 87.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review and policy review, the facility failed to ensure Resident #28's allegation of misappropriation was reported within 24 hours to the State agency as required. This finding affected one resident (#28) of two residents reviewed for misappropriation.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #73's legionella testing was completed as ordered. This finding affected one resident (#73) of five resident records reviewed for infection control.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure narcotic medications were removed from circulation when discontinued and accounted appropriately, resulting in one unaccounted oxycodone pill for Resident #94. This affected one resident (#94) of three residents reviewed for controlled medication administration. The facility census was 93. Findings Include: Record review of Resident #94 revealed the resident was admitted on [DATE] and discharged on 02/09/24. Diagnoses included atrial fibrillation, Crohn's disease, and anxiety disorder. The most recent order for oxycodone (a narcotic pain medication) was discontinued on 12/25/23. Review of the medication administration record revealed no evidence the medication was given after this date. [...]

Inspectors wroteBased on observation, closed medical record review, hospital record review, review of a police report, review of staff witness statements, review of the facility elopement policy and procedure and interviews, the facility failed to provide adequate supervision to prevent Resident #84, who had a diagnosis of dementia with behavioral disturbances and lacked sufficient decision-making ability to make an informed decision to leave the facility, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 11/12/23 at approximately 4:30 P.M. when Resident #84 who had been agitated, verbally abusive and combative since the lunch meal packed her bags, placed them on a wheelchair and walked through an unidentified secured door pushing the wheelchair to the outside without staff knowledge. [...]

Inspectors wroteBased on observation, interview, record review, review of facility policy, review of Centers for Disease Control and Prevention guidance, and review of the facility COVID-19 Line List, the facility failed to maintain and implement an effective infection prevention and control program to prevent the development and transmission of COVID-19, including measures to ensure the COVID-19 Line List was completed accurately, proper Personal Protective Equipment (PPE) was worn by staff when entering COVID-19 positive rooms, accurate COVID-19 isolation orders were in place for all COVID-19 positive residents, and responsible parties were notified when their roommates tested positive for COVID-19. This had the potential to affect all 83 residents residing in the facility. The census was 83.

Inspectors wroteBased on record review and interviews the facility failed to report an allegation of misappropriation for Resident #86. This affected one resident (#86) of three residents reviewed for reporting of abuse or misappropriation. The census was 83.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received wound care for a vascular sore according to the physician order for wound care. This affected one resident (Resident #43) of three residents reviewed for wound care. The facility census was 83.

Inspectors wroteBased on interviews, record reviews and observation the facility failed to ensure Resident #73 wore a smoking apron while smoking. This affected one resident (#73) of three residents reviewed for smoking. The facility census was 83.

Inspectors wrote3. Review of Resident #25's medical record revealed an admission date of 04/06/19 and a readmission date of 04/18/2020. Diagnoses included dysphagia (difficulty swallowing), pulmonary embolism, cardiac arrest, COPD, and COVID-19. Review of Resident #25's physician orders revealed an order dated 07/04/22 for Ipratropium-Albuterol nebulization solution 0.5-2.5 (3) mg/three ml inhale three ml orally every six hours as needed for shortness of breath (SOB). Observation on 08/02/22 at 11:12 A.M. with the DON and CAN #304 verified Resident #25's nebulizer was open to air sitting on his bedside table and it was not dated. Interview with the DON during the observation revealed nebulizers were to be covered and dated. 4. Review of Resident #50's medical record revealed an admission date of 09/30/21 and diagnoses including COPD, stroke, peripheral vascular disease, and hypertension. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review the facility failed to ensure a baseline care plan was completed for newly admitted residents. This affected three (Resident's #231, #233, and #234) of three residents reviewed for baseline care plans. The facility census was 69.

Inspectors wroteBased on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to screen all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This affected all 80 residents in the facility.

Inspectors wroteBased on observation and interview the facility failed to prepare the dessert to the proper consistency for the residents receiving a pureed diet. This affected seven (Resident #48, Resident #173, Resident #7, Resident #13, Resident #29, Resident #60, Resident #16) of seven residents served a pureed diet. The facility census was 80.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with the physician's order and consistent with the resident plan of care. This affected one resident (#5) of two residents reviewed for respiratory care. The facility identified 12 residents requiring respiratory care in the facility.