Grande Oaks

Observation of the camera revealed no evidence the camera had independent locomotion; however, it could rotate without direct physical manipulation. Resident #41's daughter showed the surveyor an app on her phone demonstrating the camera could be set to a fixed position.

She said that Wi-Fi in the resident's room often went out, and when it did the camera reset its' settings, and she had to turn off its mobility again.

The daughter reported she had numerous recorded incidents of staff yelling at or mistreating the resident and staff often blocking the camera by placing towels over it or standing directly in front of it that had been lost because the SD card from the camera was missing when the facility returned the device to her.

During the interview, Resident #41's daughter revealed at the 08/28/25 care conference, she attempted to demonstrate the device's fixedˆposition capability, but she stated the Administrator refused to review it.

She then shared she had sent emails to facility administrative staff explaining the camera's functionality and need to be reset after Wi-Fi outages to keep it in a fixed, which the facility failed to respond to. Resident #41's daughter revealed she stopped sending emails after a 12/02/25 care plan meeting because she stated during this meeting she was threatened with a 30-day discharge notice for sending excessive emails.

Record review revealed the facility provided no documented evidence explaining the loss of the memory card or demonstrating attempts to investigate or recover the resident's memory card from the camera.

Review of emails sent by Resident #41's daughter from [NAME] 2025 through March 2026 (including on 08/12/25, 10/02/25, 10/13/25, 11/15/25, 03/12/26, 03/17/26, and 03/25/26) to verified email addresses of facility staff revealed communication voicing concerns of persistent WiˆFi failures within the facility causing the camera to reboot and rotate automatically.

The emails noted the camera device was always set to a fixed position and never placed on motion tracking.

The emails included repeated requests for maintenance intervention of the facility Wi-Fi system to address connectivity issues which had been ongoing (per the daughter) for over a year.

Review of the facility's electronic monitoring policy revealed it required cameras to be fixedˆposition but contained no prohibition against twoˆway audio, despite the Administrator citing audio use as a reason for removal.

This discrepancy demonstrated the facility relied on unwritten or inconsistently applied expectations when removing the resident's property.

Review of the facility's concern log from March 2025 to March 2026 revealed no entries regarding camera compliance issues, despite the Administrator's assertion the matter had been discussed numerous times over the last year.

The absence of such documentation beyond care conference minutes (from the meeting held on 12/02/25 which focused on the volume of the daughter's emails rather than any verified cameraˆrelated noncompliance and contained no evidence of progressive steps or efforts to reconcile the issue) contradicts the facility's claim of ongoing issues and undermines justification for immediate removal of the resident's property.This deficiency represents noncompliance investigated under Complaint Number 2804759 and Complaint Number 2726820.

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resident's records.

resident's medical records request was honored in accordance with policy.

This failure affected one

include:

Record review showed that the daughter of Resident #41 sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563, Social Worker #574, and carbon copied (cc) the Long-Term Care Ombudsman requesting the resident's medical records.

She also asked to be sent any required forms needed to complete the requestDuring interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed these emails were sent but stated she did not recall seeing the records request.During a separate interview at the same time, Social Worker #574 reported that she began employment on 03/16/26, one day after the first email was sent.

Although she used the same social worker email address to which the request was sent, she stated she did not review emails that predated her start date.

She denied knowledge of any records request and said such requests would go through the AdministratorAn interview with the Administrator on 04/27/26 at 4:35 P.M. revealed he was not aware that Resident #41's family had made a records request, but he confirmed that an email dated 03/15/26 requesting records had been sent to facility management addresses

Review of the facility's medical records release policy dated 06/01/24 revealed that all resident record requests must be referred to the Administrator.

The policy directs the facility to review each request, verify the requesting party's access rights, request further information if needed, and notify the relevant office to ensure the request is completed.This deficiency represents noncompliance investigated under Complaint Number 2726820.

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limited to receiving treatment and supports for daily living safely.

record review and interview, the facility failed to uphold its responsibility to protect residents' rights

affected one (Resident #41) of one resident reviewed for personal property.

The facility census was 42.Findings include:

Record review of Resident #41 revealed she was admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure.

Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had mild or no cognitive impairment.

Her progress notes revealed no documentation of any missing SD card, socks, or cord, or of any broken phones or cameras.Review of an email sent to the verified email address of the Director of Nursing (DON), Assistant Director of Nursing (ADON) #563 and Ohio Department of Health (ODH) email addresses by the daughter of Resident #41 on 03/19/26 revealed the daughter reported a set of cabin socks given as a Christmas present were stolen from her room on 03/17/26.

She also said she previously reported two cameras, and a phone were broken by staff with no reimbursement.Review of an email sent to the verified email address of the ombudsman's office by the daughter of Resident #41 on 03/14/26 revealed she reported a missing camera and SD card.Review of an email from Regional Nurse #626 dated 04/21/26 revealed the facility did not have an inventory list for Resident #41's possessions.

Review of the Ohio Department of Health Certification and Licensure website revealed no alleged misappropriation events were reported by the facility within the last six months.Interview with Resident #41 on 04/19/26 at 10:08 A.M. revealed she had cameras that were missing.

She also said staff took the cord off her [NAME] music device last week and now it was unusable.

She could not say if she notified the staff but said her daughter probably did so.Interview with Ombudsman #700 on 04/20/26 at 1:16 P.M. revealed her office was notified of a missing SD card for Resident #41's camera in March 2026.

They went to the facility to follow up on the concern and staff denied knowledge of the missing SD card.Interview with the Administrator, DON, ADON #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed the Administrator removed the camera from Resident #41's room and said there was no SD card present at that time. He said staff had not been told of any missing items including a missing cord, socks, or SD card.Interview with Resident #41's daughter on 04/21/26 at 4:07 P.M. revealed she said staff removed a camera from the resident bedside and returned it to her without the SD card she purchased to store data in it.

Staff had also broken two cameras since June 2026 and broke the resident's phone by dropping it.Interview with Regional Nurse #626 on 04/29/26 at 3:30 P.M. confirmed the facility did not have any recent ?soft file' documenting response to concerns for the family of Resident #41 which may not be logged in her official medical records.

Record review of the resident concern log from March 2025 to March 2026 revealed no concerns related to Resident #41.This deficiency represents noncompliance investigated under Complaint Numbers 2726820, 2639150, 2623912, and 2606964.

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said she lost track of how many times she reported the alleged perpetrators via emails.

She said that

interview, the facility furnished a call log allegedly demonstrating they made efforts to contact the

to the daughter's phone number labeled no answer, two labeled answered, and one documented inbound call from the daughter.

There was no record of the results of these calls.Interview with the Administrator on 04/22/26 at 3:16 P.M. revealed he said Resident #41 did not know what he was talking about when he spoke with her for the SRI investigation. He said the resident's daughter never answers her phone and never calls back when he tries to reach out regarding any of her concerns.

Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.

Record review of the facility's undated electronic monitoring policy revealed the facility would not independently access recordings but would request the recordings if needed for an abuse or other investigation.

Record review of the facility's abuse policy dated 01/01/24 revealed the facility was to immediately investigate reports of abuse, neglect, or exploitation.

This investigation was to include interviewing all involved persons and to be focused on determining if abuse occurred.

All alleged violations were to be reported to the state agency within two hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312, Complaint Numbers 2726820, 2623912 and 2606964.

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Review of her progress notes revealed no evidence of documented abuse or misappropriation allegations in 2026.

She was hospitalized [DATE] for sepsis and returned to the facility 03/06/26.

Record review of emails sent by the daughter of Resident #41 to verified email addresses of facility staff and ODH revealed the following allegations regarding the care of Resident #41:- An email dated 01/24/26 said Licensed Practical Nurse (LPN) #533 gave Tramadol (opioid pain medication) doses too close together and behaved with animosity and hatred, saying ?ridiculous things' about the resident and daughter.- An email dated 02/02/26 said LPN #533 intimidated Resident #41, who was afraid to be alone with her.- An email dated 02/05/26 said LPN #533 did not give medications as ordered and falsely said the resident refused care. Resident #41 also called for incontinence care and had her light turned off with no response for several hours.- An email dated 02/09/26 said Certified Nurse Aide (CNA) #576 disrespected Resident #41's personal belongings daily and spoke to her like a three-year old.- An email dated 02/18/26 said an unclarified aide enacted verbal abuse by continually yelling at Resident #41.- An email dated 03/19/26 said a set of cabin socks were stolen from Resident #41.

Record review of the ODH Certification and Licensure website revealed the only self-reported incident (SRI) involving Resident #41 within the last six months was SRI #271831 dated 03/09/26, which involved an allegation of neglect and mistreatment by LPN #533 and CNA #576.Interview with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #563, and Regional Nurse #626 on 04/20/26 at 2:26 P.M. revealed they denied knowledge of all abuse, neglect, and misappropriation allegations in the above noted emails.

They confirmed these allegations did not have SRI investigations or documented reporting to ODH.

Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.

Record review of the facility's abuse policy dated 01/01/24 revealed all allegations of abuse, neglect, and exploitation were to be reported to the state agency within 2 hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312 and Complaint Numbers 2726820, 2623912 and 2606964.

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made efforts to contact the daughter of Resident #41 for interview during the SRI investigation.

The

these calls.Interview with the Administrator on 04/22/26 at 3:16 P.M. revealed he said Resident #41

resident's daughter never answers her phone and never calls back when he tries to reach out regarding any of her concerns.

Record review of the resident concern log for the past year revealed no documented concerns regarding Resident #41.

Record review of the facility's undated electronic monitoring policy revealed the facility would not independently access recordings but would request the recordings if needed for an abuse or other investigation.

Record review of the facility's abuse policy dated 01/01/24 revealed the facility was to immediately investigate reports of abuse, neglect, or exploitation.

This investigation was to include interviewing all involved persons and to be focused on determining if abuse occurred.

All alleged violations were to be reported to the state agency within 2 hours if the allegations involved abuse and 24 hours if they did not.This deficiency represents noncompliance investigated under Master Complaint Number 2961312 and Complaint Numbers 2726820, 2623912 and 2606964.

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for dependent residents.

This affected one (Resident #28) of three residents reviewed for activities of

revealed he was admitted to the facility 07/03/25 with diagnoses including respiratory failure, paraplegia, and anoxic brain damage.

His care plans dated 07/21/25 noted he was totally dependent on staff for ADL, and his nails should be checked daily for length and cleanliness.

His Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified he was never or rarely understood, was dependent on staff for ADL care, and his mouth could not be assessed for dental problems. He was ordered to receive oral care twice per day and had no orders indicating any treatment of thrush (an oral fungal infection commonly involving white patches on the tongue).Observation of Resident #28 on 04/21/26 at 11:10 A.M. revealed his teeth appeared brown, although the surveyor could not determine if the color was natural or due to debris in the mouth. He was not interviewable or responsive to questions.

His mouth hung open, and a white rough layer could be visualized on the tongue consistent with thrush.

His fingernails extended roughly one to two centimeters from the top of the fingers and curled downwards at their ends.Interview with Assistant Director of Nursing (ADON) #563 on 04/21/26 at 11:31 A.M. verified these findings.This deficiency represents noncompliance investigated under Master Complaint Number 2961312, and Complaint Numbers 2726820 and 2668853.

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Review of the progress notes dated 02/25/26 revealed a note at 7:28 A.M. stating Resident #18 was approached several times throughout the shift for hygiene (check and change), each time she refused.

She was educated on the importance of being clean and dry for skin integrity.

She verbalized understanding yet continued to refuse. At 12:40 A.M., Resident #18 was assessed by NP #950 for a necrotic area to the right lower extremity.

Upon communication with the physician, Resident #18 received new orders to be sent to the hospital for surgical debridement.

Review of the progress note dated 02/26/26 at 5:28 P.M. revealed Resident #18 was admitted to the hospital with diagnosis of sepsis and surgical debridement of the right lower extremity.

During an interview on 04/19/26 at 10:25 A.M., Resident #18 stated she had fallen out of bed during care.

One staff member was providing care when she was pushed out of bed, fell on the floor and injured her leg. Resident #18 said the wound was not healing, and she was now at risk of losing her leg.

During an interview on 04/20/26 at 2:26 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #563 and Regional Nurse #626 revealed Resident #18 had a fall while receiving incontinence care and as a result a hematoma formed that later turned into a leg wound. LPN #563 revealed Resident #18's leg wound was necrotic and had some redness and swelling and required debridement in the hospital.

During an interview on 04/22/26 at 10:44 A.M. with LPN #623 stated Resident #18 complained of leg pain since her fall, and the fall caused cellulitis and ongoing issues.During an interview on 04/29/26 at 12:03 P.M., LPN #563 stated Resident #18 had no skin assessments regarding her right lower extremity, no documentation regarding follow-up care and/or notification to the physician and no new orders for treatment.

The skin issue related to her right lower extremity did not present itself until 02/20/26, and after a change in condition, Resident #18 was sent to the hospital. Resident #18's hospital stay and return to the facility was related to UTI and was treated with antibiotics. Resident #18's skin issues were not the focus due to her having a history of skin concerns. LPN #563 verified after Resident #18 returned from the hospital on [DATE], a progress note indicated she had a red, swollen area with moderate drainage to her right lower extremity and the wound was not properly assessed, monitored, treated, or documented to prevent further harm.

The facility's Pressure Injury Prevention and Management Policy requires staff to follow a systematic process for all skin integrity concerns, including prompt identification, assessment, documentation, treatment, monitoring, and provider notification of any skin changes.

The policy mandates that licensed nurses complete fullˆbody skin assessments on admission, readmission, weekly, and as needed, and that any skin changes be immediately assessed, with measurements, wound characteristics, and findings documented in the medical record. It further requires the implementation of timely, evidenceˆbased interventions based on the wound's characteristics and the resident's risk factors, along with ongoing monitoring to evaluate healing and identify complications.

The policy also directs staff to notify the physician of any new wounds, lack of healing, or complications, and to modify the care plan when a wound worsens or the resident's condition changes.

These requirements apply broadly to all wounds, not only pressure injuries, and establish the facility's responsibility to ensure prompt assessment, treatment, and monitoring of any newly identified skin issue.This deficiency represents non-compliance investigated under Complaint Number 2795717.

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Review of his most recent wound assessment dated [DATE] revealed he had a Stage IV pressure sore on his buttocks.Observation and attempted interview of Resident #28 on 04/20/26 at 10:18 A.M. revealed he was not interviewable and demonstrated no evidence of understanding or awareness of the surveyor's questions. He was in bed laying on his back with a wedge cushion on a bedside table at the foot of the bed.

His head was elevated roughly 30 degrees and there were no pillows or other devices beneath either side to turn him off his back.Observations of Resident #28 on 04/20/26 at 12:54 P.M., 3:09 P.M., and 5:05 P.M. revealed he continued to be on his back with the wedge pillow on a bedside table during each observation.Interview with Assistant Director of Nursing (ADON) #563 on 04/20/26 at 5:15 P.M. confirmed Resident #28 had not been repositioned for several hours that day.This deficiency represents noncompliance investigated under Complaint Number 2726820.

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Review of the facility document titled, Fall/Skin Incident Report (04/03/26), CNA #506 revealed while

way under the resident's buttocks and tried to adjust her the best we could. It wasn't good enough because she slipped out of it.

Review of LPN #618's written statement revealed when the resident was being transferred, she slid from the mechanical lift pad onto the floor.

The facility's Fall Prevention and Management Policy (revised 10/02/22) requires that all residents be assessed for fall risks on admission, quarterly, after any fall, and as needed.

Identified risks must lead to individualized interventions, added to the care plan, monitored for effectiveness, and revised as needed.

All falls must be assessed by nursing, investigated, and reviewed by the interdisciplinary team, and appropriate fallˆprevention measures must be implemented.

Per policy, a fall includes any unintentional descent to the floor, including near misses, and the facility must ensure safe supervision and correct use of assistive devices to prevent foreseeable accidents.

This deficiency represents non-compliance investigated under Complaint Number 2795717.

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#630 stated she was not sure why Resident #18 was placed on fluid restrictions, but she assumed it

meetings.

She was monitoring Resident #18's weights weekly and was aware of her weight gain of

ongoing documented refusals. RD #630 also revealed Resident #18's January 2026 assessment was the most recent weight obtained but could not identify where the weight came from since the last weight documented was from October 2025. RD #630 stated she did not have a new weight for Resident #18, so she reused a previous documented weight. RD #630 revealed she had not assessed Resident #18 in person, therefore her documented assessments were only from information gathered from risk meetings and the medical record. EMR. RD #630 revealed she used the information from previous assessments and other areas of Resident #18 medical record to complete nutritional documentation. RD #630 acknowledged that the information documented in Resident #18 medical record did not accurately reflect Resident #18's current nutritional health status.

This deficiency represents non-compliance investigated under Complaint Numbers 2668853 and 1320283 (OH00166923).

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updated, be reviewed by dietician, and meet the needs of the resident.

ensure the correct serving size for the mechanically altered meat was served.

This affected three

census was 42.Findings include:Observation of the tray line on 04/21/26 between 12:31 P.M. and 12:49 P.M. revealed Dietary Aide (DA) #555 serving mechanically altered meals using a green-handled #12 scoop, providing only one scoop of mechanically altered meat per meal. At 12:49 P.M., staff were observed pushing the last meal cart to the final unit.

Review of the diet extension sheet showed that the mechanically altered meat (beef stroganoff) was to be served using a #6 scoop.During an interview on 04/21/26 at 12:50 P.M., DA #555 and Regional Dietary Manager (RDM) #900 confirmed that the green-handled scoop used was a #12 scoop. RDM #900 stated that, when using a #12 scoop, DA #555 should have provided two scoops to meet the required portion size. DA #555 verified she had provided only one scoop to each resident receiving mechanically altered beef

Review of the diet order listing report dated 04/19/26 confirmed that three residents (Residents #6, #22, and #33) were receiving mechanically altered diets.

Review of the facility's undated Scoop Sizes chart showed that a #12 green scoop provides 2.78 ounces, while the #6 white scoop provides 4.66 ounces

Review of the Portion Control/Spreadsheets policy (revised 08/01/24) indicated that to ensure nutritional adequacy, residents must receive the appropriate portions of food as planned on the menu.This deficiency represents non-compliance investigated under Complaint Numbers 2726820,2623912, and 1320283 (OH00166923).

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in accordance with accepted professional standards.

resident record review and staff interviews, the facility failed to ensure the accuracy and consistency

different mattress orders that were both documented as being in place for the same dates.

This affected one (Residents #17) of 22 residents sampled during the survey.

The facility census was 42.Findings include:Review of Resident #17's medical record revealed an admission date 12/19/25 with diagnoses of bilateral primary osteoarthritis of hip, morbid obesity, and type II diabetes mellitus with hyperglycemia.

Record review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was cognitively intact and was at risk for developing pressure ulcers.During an interview on 04/19/26 at 10:12 A.M., Resident #17 reported he had not had an air mattress since the end of March 2026.

However, physician orders dated 04/16/26 and the April 2026 Treatment Administration Record (TAR) showed the resident had active orders for both an air mattress and a pressureˆredistribution mattress from 04/16/26 through 04/19/26, and documentation reflected that both surfaces were in place from 04/16/26 through 04/18/26.An observation on 04/19/26 at 11:30 A.M. revealed Resident #17 was on a regular pressureˆredistributing mattress, not an air mattress. At the time of the observation, licensed Practical Nurse (LPN) #552 confirmed that only a pressureˆredistributing mattress was in use, despite the presence of two conflicting mattress orders in the record.

The air mattress order was discontinued following this observation and interview.This deficiency represents noncompliance investigated under Complaint Number 2606964.

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residents.

This affected one (Resident #41) of four residents reviewed for environmental concerns.

admitted [DATE] with diagnoses including dementia, anxiety disorder, and chronic respiratory failure.

Her Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she needed substantial assistance from staff for bed mobility.Observation of Resident #41 on 04/19/26 at 10:08 A.M. revealed her call light was hanging from the bed rail outside of her reach on the right side.

The right side had three pillows stacked preventing her from reaching the cord to pull the call light up into reach.Interview with Registered Nurse (RN) #518 on 04/19/26 at 10:38 A.M. confirmed the above observation.

Following surveyor intervention, she placed the call light within resident reach.This deficiency represents non-compliance investigated under Complaint Number 2726820.

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and the public.

and homelike environment.

This affected three (Residents #8, #29, and #36) of four residents

observation on 04/19/26 at 10:14 A.M., Resident #8's room had a large hole in the wall behind the head of the bed with multiple scrapes, scratches, and areas of missing paint.

Walls, floors, and the nightstand surrounding the resident's room contained large brown- and yellow-colored dried splatter stains of unknown origin.

The floor was visibly dirty and covered with food particles and debris.

Interview on 04/19/26 at 10:20 A.M. with Registered Nurse (RN) #518 observed and verified the condition of Resident #8's room.

• On 04/22/26 at 9:23 A.M., observation of Resident #29's room revealed the air conditioner unit's

front cover was hanging off, and the vent cover was detached and lying on the floor.

The floor had dirt marks and debris. A long curved gouge was present in the floor by the entrance door, caused by the door dragging.

The door was very difficult to close.

On 04/22/26 at 9:29 A.M., observation of Resident #36's room revealed the door was difficult to open.

The floor was dirty with stains, dirt, and debris.

The outlet supplying power to the television was missing its cover.

The vent cover was partially detached. A small dent with crumbling wall material was observed above the baseboard near the room entrance.

On 04/22/26 at 9:54 A.M., Director of Maintenance (DOM) #590 verified the door to Resident #36's room was hard to open, stating it had been removed previously to bring in a large bed. He stated the door could be repaired, but not immediately. DOM #590 also verified the missing outlet cover, the dented wall area, and the loose vent cover, stating he would address all items except the door, which would require additional time.

On 04/22/26 at 9:58 A.M., DOM #590 verified conditions in Resident #29's room, including the difficulty closing the door and the resulting damage to the floor. He confirmed the AC unit cover and vent cover were off, stating the resident's bed had struck the units.

On 04/22/26 between 10:08 A.M. and 10:20 A.M., the Housekeeping Supervisor (HSKS) #505 verified the floor conditions in Residents #29's and #36's rooms. HSKS #505 stated the facility had experienced staffing issues but was fully staffed that week and working to catch up.

Reviewed policy Safe and Homelike Environment, revised 06/01/24 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

This deficiency represents non-compliance investigated under Master Complaint Number 2961312 and Complaint Numbers 1320285 (OH001320285), and 1320283 (OH00166923).