Every finding on record at Altercare Somerset Inc.

Based on interview and closed record review, the facility failed to ensure a resident received showers or bed baths at least twice weekly. This affected one resident (#70) of six residents sampled for showering. The facility census was 68.Findings include:Review of Resident #70's closed medical record revealed an admission date of 04/21/26, a discharge date of 05/16/26 and diagnoses including age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with routine healing, paroxysmal atrial fibrillation, cerebral infarction, congestive heart failure, anemia, asthma, hypothyroidism, and pulmonary hypertension.Review of Resident #70's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Former Resident #70 used a wheelchair for mobility and required partial/moderate assistance with toileting hygiene, showering/bathing, and bed mobility and substantial/maximal assistance for transfers. Review of Resident #70's facility shower sheets revealed the resident received a shower on 04/28/26, 05/06/26 and on 05/12/26. Resident #70 was offered and refused a shower on 05/07/26. Further review of the facility shower sheets revealed no documentation Resident #70 received a shower/bed bath on 04/22/26, 04/23/26, 04/24/26, 04/25/26, 04/26/26, 04/27/26, 04/29/26, 04/30/26, 05/01/26, 05/02/26, 05/03/26, 05/04/26, 05/08/26, 05/09/26, 05/10/26, or 05/11/26. Review of Resident #70's occupational therapy notes dated 04/25/26 written by Certified Occupational Therapy Assistant (COTA) #200 revealed that with full set up the resident was able to complete oral care/denture care, wash her hands and face and upper body with supervision.Review of Resident #70's occupational therapy notes dated 05/05/26 written by COTA #201 revealed Resident #70 was able to complete activity of daily living tasks with supervision to maximum assist.During an interview on 05/19/26 at 1:08 P.M. the Director of Nursing (DON) stated the Certified Nursing Assistants (CNAs) are to offer showers to the residents on their scheduled shower days and then a bed bath if the resident does not want a shower to allow the residents to pick their preferred bathing method. Residents are care planned for two showers a week but are scheduled for and offered three.During an interview on 05/19/26 at 1:50 P.M. the Administrator verified there was no other documentation of showers/bed baths being completed on 04/22/26, 04/23/26, 04/24/26, 04/25/26, 04/26/26, 04/27/26, 04/29/26, 04/30/26, 05/01/26, 05/02/26, 05/03/26, 05/04/26, 05/08/26, 05/09/26, 05/10/26, or 05/11/26.This deficiency represents non-compliance investigated under Complaint Number 3007427.

Based on observation, medical record review, interview and facility policy review, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. This affected three residents (#9, #44 and #54) of 25 sampled residents. The facility census was 69. Findings Include:1. Review of the medical record for Resident #44 revealed an initial admission date of 08/20/23 with the latest readmission of 05/21/24 diagnoses included the protein calorie malnutrition, urinary tract infection (UTI), depression, mood disorder, hypothyroidism, anemia, metabolic encephalopathy, solitary pulmonary nodule, chronic pain, atrial fibrillation, anorexia, osteoarthritis, dementia, macular degeneration and cerebral atherosclerosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Observation of Resident #44 on 02/23/26 at 10:58 A.M., revealed Resident #44's custom wheelchair was extremely dirty with food debris in the crevasses of the wheelchair and visible dirt all over the wheelchair. Interview with Licensed Practical Nurse (LPN) # 161 on 02/26/26 at 11:23 A.M., verified the resident's wheelchair was extremely dirty with food debris in the crevasses of the wheelchair and visible dirt all over the wheelchair. 2. Review of the medical record for Resident #54 revealed an initial admission date of 09/15/22, diagnoses included but were not limited to chronic kidney disease, intellectual disabilities, dysphagia, depression, anxiety disorder, obesity, hypothyroidism, osteoporosis, scoliosis, mixed incontinence, hypertension, migraine, insomnia and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Observation on 02/23/26 at 1:11 P.M., revealed the resident's wheelchair with custom padded armrests was extremely dirty with visible dirt and dried food on custom padded armrests. Interview with LPN #161 on 02/26/26 at 11:23 A.M., verified the resident's wheelchair was extremely dirty with visible dirt and dried food on custom padded armrests. 3. Review of medical record for Resident #9 revealed an admission date of 12/13/23 and a readmission date of 11/17/25, diagnoses included Parkinson's disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview Mental Status (BIMS) score of 15 indicating no impaired cognition and she was receiving oxygen therapy. Review of the physician's orders dated 11/26/25 revealed oxygen two to four liters via nasal cannula to maintain saturations above 90 percent (%) every shift. Observation on 02/25/2026 at 10:11 A.M. of Resident #9's oxygen concentrator revealed a dried brown substance covering the front of the concentrator. Interview and observation on 02/25/26 at 10:31 A.M. with Registered Nurse (RN) #209 verified the dried brown substance covering the front of the oxygen concentrator. Interview with Environmental Service Coordinator #133 on 02/25/26 at 10:35 A.M. revealed the expectation for cleaning medical equipment is at least twice weekly or as needed. Review of facility policy titled Housekeeping Care and Cleaning of Equipment dated 07/01/25, revealed equipment will be cleaned and maintained in a sanitary condition to prevent the spread of infectious disease.

Based on medical record review, interview, and review of facility policy review, the facility failed to ensure the baseline care plan was timely reviewed and provided to one ((Resident #74) of 24 residents reviewed. The census was 69.Findings include:Review of Resident #74's medical record revealed the resident was admitted on [DATE] with diagnoses including hypertensive emergency, repeated falls, dementia, and major depressive disorder.Review of the admission Nursing assessment dated [DATE] revealed an unsigned Baseline Care Plan dated 01/28/26. There was no evidence that the resident was provided with the baseline care plan or that it had been reviewed with her or the resident representative.Review of the initial Resident Care Conference dated 02/03/26 revealed no evidence the resident or resident representative was provided with a copy of the baseline care plan.Review of the care conference progress notes authored by Social Services Coordinator #178 dated 02/03/26 revealed current medications, all orders, care plan, and progress with therapy was discussed at the care conference.Interview on 02/24/26 at 2:50 P.M. with Regional Nurse #225 verified Resident #74 had not been provided with a copy or explained the baseline care plan during the required time frame.Review of facility policy title Care Planning-Comprehensive, dated 05/01/25 revealed A baseline care plan is completed upon admission (within 48 hours) based on data.

Based on observation, medical record review, interviews and facility policy review, the facility failed to ensure residents who were dependent on staff were provided routine bathing. This affected two residents (#10 and #36) of six residents reviewed for activities of daily living (ADL). The facility census was 69. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 08/14/24 with the latest readmission date of 07/15/25. Diagnoses included but were not limited to spinal stenosis lumbar region, dementia, chronic obstructive pulmonary disease, palliative care, chronic respiratory failure, chronic pain, hyperlipidemia, hypertension, myasthenia gravis, diabetes mellitus, depression, anxiety, migraine, atrial fibrillation, congestive heart failure, cardiomyopathy, arthritis, candidiasis and anemia. Review of the resident's significant change MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors, including rejection of care. Review of the plan of care dated 02/04/26 revealed the resident was receiving hospice benefits while residing in the facility due to end stage congestive heart failure (CHF). Interventions included give shower/bath, personal care, and nail care. Review of the resident's shower documentation for December 2025 revealed the resident had 14 opportunities for a scheduled shower. Further review revealed the facility had no documented evidence the resident received a shower and/or bed bath on 12/03/25, 12/08/25 and 12/31/25. Review of the resident's shower documentation for January 2026 revealed the resident had 13 opportunities for a scheduled shower. Further review revealed the facility had no documented evidence the resident received a shower and/or bed bath on 01/05/26, 01/07/26, 01/12/26, 01/16/26, 01/21/26 and 01/26/26. Review of the resident's shower documentation for February 2026 revealed the resident had 11 opportunities for a scheduled shower. Further review revealed the facility had no documented evidence the resident received a shower and/or bed bath on 02/02/26, 02/04/26, 02/11/26, 02/16/26 and 02/20/26. Review of the facility's shower schedule revealed the resident was to receive a shower or bed bath every Monday, Wednesday and Friday. On 02/23/26 at 10:12 A.M., observation and interview with Resident #10 revealed she had not had a bath in two weeks or had her hair combed in two weeks. Observation of the resident revealed the resident's hair had large areas of matted hair on the back of her head. Further observation revealed the resident's fingernails were long, jagged and had a brown substance under the nail. On 02/24/26 at 11:35 AM interview with Licensed Practical Nurse (LPN) #161 verified the resident had not received her scheduled showers or bed baths. On 02/26/26 at 9:44 A.M., an interview with Hospice Aide (HA) #201 revealed she provided a bed bath on 02/24/26 and washed the resident's hair. The HA revealed she worked most of the time removing the matted areas from her hair. The HA verified the resident's nails were long, jagged and had a brown substance under the nail. On 02/26/26 at 9:50 A.M., an interview with Certified Nursing Assistant (CNA) #113 revealed nail care was to be provided with showers and as needed. The CNA verified the resident's nails were long, jagged and had a brown substance under the nail. 2. Review of the medical record for Resident #36 revealed an initial admission date of 08/31/23 with the latest readmission of 10/10/23. Diagnoses included but were not limited to cerebrovascular accident with left sided hemiplegia, dysphagia, chronic congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, hypertension, hyperlipidemia, schizophrenia, Alzheimer's disease, bipolar disorder, anxiety disorder, depression, insomnia, gastro esophageal reflux disease (GERD), anemia, constipation and atrial fibrillation. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior displayed no behaviors, including rejection of care. Review of the resident's shower documentation for December 2025 revealed the resident had 13 opportunities for showers. Further review revealed the facility had no documented evidence the resident received a scheduled shower on 12/02/25, 12/06/25, 12/11/25 and 12/27/25. Review of the resident's shower documentation for January 2026 revealed the resident had 14 opportunities for showers. Further review revealed the facility had no documented evidence the resident received a scheduled shower on 01/03/26, 01/06/26, 01/15/26, 01/17/26, 01/22/26, 01/27/26 and 01/31/26. Review of the resident's shower documentation for February 2026 revealed the resident had 10 opportunities for showers. Further review revealed the facility had no documented evidence the resident received a scheduled shower on 02/07/26, 02/14/26 and 02/21/26. On 02/23/26 at 3:56 P.M., an interview with Resident #36 revealed she had not been provided a shower and/or bed bath in more than a week. Observation of the resident during the time of the interview revealed the resident's hair was unkempt and greasy. On 02/25/26 at 11:52 A.M., an interview with LPN #161 verified the resident had not received her scheduled shower and/or bed bath. Review of the facility policy titled, Shower-Tub Bath, last revised 05/01/25 revealed the facility would assist residents with bathing per their plan of care. Review of the facility policy titled, Nail Care Finger/Toe, last revised 05/01/25 revealed it was the policy of the facility to clean, trim and maintain nail care to enhance the resident's state of well-being.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure fall prevention interventions were implemented as indicated. This affected one resident (#47) of three residents reviewed for falls. The facility census was 69.Findings include:Review of the medical record for Resident #47 revealed an admission date of 12/08/18 with diagnoses including cerebral infarction, difficulty in walking, vascular dementia, muscle weakness, lack of coordination, other abnormalities of gait and mobility, and unsteadiness on feet.Review of the physicians orders revealed an order dated 03/10/25 to encourage resident to wear gripper socks when non-skid footwear not in place for safety three times a day and an order dated 01/18/26 or gripper sock on while out of bed.Review of the falls care plan last reviewed/revised 02/09/26 revealed Resident #47 was at risk for falls/injury related to incontinent of bowel/urine and impaired gait. Interventions included gripper socks applied for safety dated 07/08/25, encourage resident to wear gripper socks while in bed dated 01/24/21, and encourage resident to wear gripper socks when not wearing shoes dated 12/17/20.Observations on 02/23/26 at 3:29 P.M. revealed Resident #47 was observed without gripper socks on. 02/24/26 at 11:00 A.M., and 02/25/26 at 8:00 A.M. revealed Resident #47 was observed without gripper socks on. Observation and interview on 02/24/26 at 11:00 A.M. revealed Resident #47 was observed without gripper socks on and was attempting to stand up from the bed. Resident stated she is having a hard time due to the floor being slippery.Observation on 02/25/26 at 8:00 A.M. revealed Resident #47 was observed without gripper socks on.Interview with Registered Nurse (RN) #209 on 02/25/2026 at 2:14 P.M. it was verified Resident #47's gripper socks were not in place.Review of facility policy titled Fall Prevention, dated 05/01/25 revealed staff will ensure that safety interventions are in place for each resident to reduce the risk of falls.

Based on medical record review, and staff interview, this facility failed to ensure a resident who required an indwelling foley catheter for bladder elimination was monitored for appropriate daily urine output as well as documenting urine output each shift. This affected one (Resident #46) of the three residents reviewed for bladder elimination. The facility census was 69.Findings include:Review of the medical record for Resident #46 revealed an admission date of 08/04/2023. Diagnoses included sepsis due to a urinary tract infection, acidosis, metabolic encephalopathy, and retention of urine. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #46 required an indwelling catheter for urine elimination. Review of the plan of care dated 07/29/2025 revealed Resident #46 had alteration in elimination related to obstructive uropathy and the need for a foley catheter. Interventions included to record intake and output as ordered by the physician. Review of the plan of care dated 07/31/2024 revealed Resident #46 had a potential for fluid imbalance and complications related to diagnosis including a history of urinary tract infection and acute kidney failure. Interventions included to observe for a fluid imbalance. Review of Resident #46's current physician orders revealed an order for staff to record urinary output three times a day. Review of Resident #46's urine output from 11/25/2025 through 02/24/2026 revealed urine output was not being documented three times a day and there were multiple days where it was documented only one time with some urine output for those days ranging between 100 to 200 milliliters for the entire day. Interview on 02/26/2026 at 1:30 P.M. with the Director of Nursing confirmed Resident #46 had a physician order for their urine output to be monitored and documented three times a day and this was not being completed per order.

Based on record review, observation, and interview, the facility failed to ensure meal intakes were monitored and documented for three (Resident #44, #46, and #74), and the facility failed to ensure an order supplement was documented for one, (Resident #44). This affected three of six reviewed for nutrition and hydration. The facility census was 69. Findings include: 1.Review of the medical record for Resident #46 revealed an admission date of 08/04/2023. Diagnosis included sepsis due to a urinary tract infection, dysphagia oropharyngeal phase, and type two diabetes. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #46 was noted to be 68 inches tall and weight 199 pounds. Resident #46 required supervision for eating. Review of the plan of care dated 07/31/24 revealed Resident #46 was at risk for dehydration or fluid maintenance, potential for fluid imbalance and complications related to dysphagia, type two diabetes, and history of urinary tract infections. Interventions include to offer fluids at meals daily, observe for fluid imbalance, provide fluids at bedside between meals, monitor meal intakes. dietary to review meal intakes, and fluid needs. Review of Resident #46's current physician orders revealed a low concentrated sweet diet with thin consistency fluids and double portions at meals. There was also an order to encourage Resident #46 to drink eight ounce of water every shift. Review of Resident #46's meal intake including fluids from 11/25/2025 through 02/24/2026 revealed multiple days where only one to two meals were documented which included fluids for each meal. Some days reflected a fluid intake as low as 320 milliliters (ML). Interview on 02/26/2026 at 1:30 P.M. with the Director of Nursing confirmed Resident #46's meal intakes were supposed to be monitored and documented with each meal and confirmed there were not being properly monitored. Review of the facility policy titled Hydration, dated 05/01/2025 revealed: The goal for total fluid hydration offered per day should exceed 2300 ml, unless determined by the dietitian or medical provider that this volume of fluid is contraindicated due to the resident's medical condition. 2. Review of the medical record for Resident #74 revealed an initial admission date of 01/28/26 with diagnoses including muscle weakness, unspecified dementia, dysphagia, constipation, and major depressive disorder. Review of the plan of care last reviewed/revised 02/03/26 revealed the resident was at risk for altered nutrition regards to hypertensive emergency and past history of hypothyroidism, hyperlipidemia, hypertension and GERD (Gastro-esophageal reflux disease without esophagitis). Interventions included offer menu alternatives as needed, honor food preferences as available and reasonable, provide diet per physician order and supplements per physician order. Review of the resident's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the resident's meal percentage for January 2026 revealed no documented meal percentage intakes for 01/30/26 for breakfast and lunch. Review of the resident's meal percentages for February 2026 revealed no documented meal percentage intakes for 02/01/26 and 02/23/26 for breakfast, lunch and dinner; 02/03/26, 02/05/26, 02/06/26, 02/13/26, and 02/20/26 for breakfast and lunch; 02/04/26, 02/10/26, 02/14/26, 02/17/26, 02/19/26 for dinner. Review of nutrition progress note dated 02/03/26 at 10:03A.M. authored by Dietician #210 revealed intakes are good since admission, mostly 76-100% per medication administration record (MAR). No nutritional recommendations noted. Review of nutrition progress note dated 02/12/26 at 10:43 A.M. authored by Dietician #210 revealed family is requesting Boost supplement daily for additional nutritional support. Intakes are good, mostly 50-100%. Review of progress note dated 02/18/26 at 6:21 P.M. authored by Licensed Practical Nurse (LPN) #141 revealed resident with poor appetite and not eating meals. Interview on 02/25/26 at 11:00 A.M. with the Director of Nursing (DON), revealed aides are expected to do charting daily and the nurses are expected to check aides charting before the end of their shift. The DON verified the lack of documentation for meal intakes. Interview on 02/26/26 at 9:07 A.M. with Dietician #210 revealed the staff are entering supplements and meals most of the time. If she had any concerns, she sends an email to the DON and Assistant Director of Nursing (ADON) regarding missing meal percentages. She stated she needed the documentation of intakes in the residents record to do her job. 3. Review of the medical record for Resident #44 revealed an initial admission date of 08/20/23 with the latest readmission of 05/21/24 with the protein calorie malnutrition, Urinary Tract Infection (UTI), depression, mood disorder, hypothyroidism, anemia, metabolic encephalopathy, solitary pulmonary nodule, chronic pain, atrial fibrillation, anorexia, osteoarthritis, dementia, macular degeneration and cerebral atherosclerosis. Review of the plan of care dated 05/19/24 revealed the resident was at risk for altered nutrition with a recent history of significant weight loss. Interventions included offer menu alternatives as needed, honor food preferences as available and reasonable, provide diet per physician order and supplements per physician order. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident rejected care. The resident's weight was coded at 101 pounds, had no known weight loss and received a therapeutic diet. Review of the resident's meal percentage for December 2025 revealed no documented meal percentage intakes for 12/01/25, 12/03/25,12/04/25,12/05/25,12/06/25,12/07/25,12/09/25,12/10/25 12/15/25, 12/16/25,12/20/25, and 12/23/25 for breakfast and lunch, 12/13/25, 12/14/25,12/18/25,12/19/25,12/26/25, 12/29/25, 12/30/25 and 12/31/25 for dinner. Review of the resident's meal percentages for January 2025 revealed no documented meal percentage intakes for 01/01/25 for lunch and dinner, 01/02/25, 01/03/25, 01/04/25, 01/05/26, 01/06/26, 01/18/26, 01/21/26, 01/26/26, 01/27/26, 01/28/26 and 01/29/26 for breakfast and lunch, 01/07/26, 01/11/26, 01/12/26, 01/13/26, 01/14/26, 01/23/26, 01/24/26, 01/25/26 and 01/30/26 for dinner and 01/31/26 for lunch. Review of the resident's meal percentage for February 2026 revealed no documented meal percentage intakes for 02/01/26, 02/02/26 for dinner, 02/03/26, 02/04/26, 02/09/26, 02/10/26, 02/13/26 for breakfast and lunch, 02/06/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/21/26, 02/22/26, 02/23/26, 02/24/26 and 02/25/26 for dinner. On 2/26/26 at 8:34 A.M., an interview with the Director of Nursing (DON) verified the lack of documentation for meal intakes and each meal should be documented on the resident's electronic medical record.

Based on observation, record review, facility staff interview, and facility policy review, the facility failed to follow physician 's order for oxygen administration. This affected one resident (#9) of one resident reviewed for respiratory care. The facility census was 69.Findings include: Review of medical record for Resident #9 revealed an admission date of 12/13/23 and a readmission date of 11/17/25 with diagnoses including Parkinsons disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview Mental Status (BIMS) score of 15 indicating no impaired cognition and she was receiving oxygen therapy. Review of the physician's orders dated 11/26/25 revealed oxygen two to four liters via nasal cannula to maintain saturations above 90 percent (%) every shift. Observation on 02/25/2026 at 10:11 A.M. of Resident #9 revealed the nasal cannula was in place and the oxygen concentrator was turned off. Interview and observation on 02/25/26 at 10:31 A.M. with RN #209 verified Resident #9's nasal cannula was in place but she was not receiving any oxygen due to the oxygen concentrator was not turned on. RN #209 further verified the physician's order for oxygen is continuous. Review of facility policy titled Oxygen Administration dated 05/01/25, revealed it is the facility's policy to provide oxygen services to residents using professional standards of care.

Based on medical record review and staff interview the facility failed to follow up with psychiatric recommendations in a timely manner. This affected one resident (#8) of two residents reviewed for mood and behavior. The facility census was 69.Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/02/26 with diagnoses including schizophrenia, depression and muscle weakness. Review of the medical record revealed hospital clinical discharge instructions dated 01/02/26 with instructions to follow up with psychiatry in one week. Review of the hospital discharge documentation revealed Oxcarbazepine (an anticonvulsant medication sometimes used as a mood stabilizer) being down titrated to 30 milligrams (mg) and started on Lamotrigine (an anticonvulsant medication sometimes used as a mood stabilizer) 25 mg twice daily with slow up titration in outpatient setting. Review of Resident #8 ' s physicians orders revealed an order for Doxepin (antidepressant) 75 mg at bedtime, Invega Sustenna (antipsychotic) 156 mg/milliliters (ml) intramuscular injection every three weeks, Lamotrigine 25 mg twice daily, and Olanzapine (antipsychotic) 100mg twice daily. Interview on 02/25/26 at 2:00 P.M. with the Director of Nursing (DON) revealed the psychiatric nurse practitioner (NP) # 300 visited Resident #8 in house on 01/30/26 but it takes about a month to obtain the progress notes. If the NP had new orders, they are given to the DON or if the visit is on the weekend the orders are given to the floor nurses. DON stated the facility will obtain the NP # 300 progress note. Interview on 02/26/2026 8:15 A.M. with the DON provided the psychiatric progress note dated 01/30/26 and it revealed new recommendations to obtain Genesight testing if resident and family agreeable, obtain records from previous outpatient psychiatric provider to confirm diagnosis, previous medication trials, etc. The DON verified these recommendations were not completed.

Based on observation, record review, staff and family interview, the facility failed to honor a resident's stated beverage preference. This affected one, (Resident #22) of two residents reviewed for choices. The facility census was 69. Findings include:Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and chronic kidney disease. Review of the the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively impaired, and required supervision and assistance with eating and drinking. Resident #22 relied on staff to ensure adequate hydration was maintained.Review of the facility document titled Resident Centered Care Food Preferences revealed juice was identified as the resident's preferred beverage at meals. There was no documentation indicating the resident preferred water over juice. During an interview on 02/23/26 at 10:45 A.M., Resident #22's daughter and Power of Attorney (POA) revealed the resident does not want water to drink and prefers juice. The POA stated staff continued to provide water despite the resident's stated preference and expressed concern the preference was not consistently honored.On 02/23/26 at 10:30 A.M., Resident #22 was observed seated in his room. A clear plastic cup containing water was on the bedside table within reach. No juice or other beverages were observed.On 02/24/26 at 9:15 A.M., Resident #22 was observed during the breakfast meal period. The meal tray was present in the room, and no additional beverage was noted on the tray. A hospital mug containing water was observed at bedside. No juice or other preferred beverage was present.On 02/25/26 at 1:30 P.M., Resident #22 was observed during the lunch meal period. The meal tray was present, and no additional beverage was noted on the tray. The resident had only a cup of water available. No juice or other preferred beverage was observed.During an interview on 02/23/26 at 9:15 A.M., Licensed Practical Nurse (LPN) #161 stated she was not aware Resident #22 preferred juice and did not want water. LPN #161 stated staff typically provided fluids available on the unit and was unaware of a documented preference indicating juice should be offered instead of water.During an interview on 02/23/26 at 1:40 P.M., Certified Nursing Assistant (CNA) #131 stated she was not aware Resident #22 preferred juice and did not want water. CNA #131 stated she provided fluids available during meal service and throughout the shift and had not been informed of a specific instruction to offer juice instead of water.During an interview on 02/24/26 at 10:05 A.M., CNA #139 revealed she was not aware Resident #22 preferred juice and did not want water and reported staff provide fluids available on the unit unless otherwise directed.Review of the facility policy regarding resident-centered care and food preferences revealed fluids are to be provided based on resident preferences.

Based on record review, observation, interview, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for one, (Resident #22) of 24 residents reviewed. The facility census was 69.Findings include:Findings include:Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and chronic kidney disease.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively impaired reflected cognitive impairment and needed for supervision and assistance with eating and drinking. The MDS revealed Resident #22 required staff assistance to ensure adequate hydration.During an interview on 02/23/26 at 10:45 A.M., Resident #22's daughter and Power of Attorney (POA) stated the resident does not want water to drink and prefers juice. The POA stated staff continued to provide water despite the resident's stated preference.Review of the facility document titled Resident Centered Care Food Preferences revealed juice was identified as the resident ' s preferred beverage at meals. There was no documentation indicating the resident preferred water over juice.Review of the comprehensive care plan revealed the resident required assistance with activities of daily living and to monitor intake. The care plan did not include a person-centered intervention identifying the resident's preference for juice instead of water, nor did it include measurable objectives or direction to staff to provide fluids consistent with the resident's stated preference.On 02/23/26 at 10:30 A.M., Resident #22 was observed in his room with a clear plastic cup containing water on the bedside table within reach. No juice or alternative fluids were present.On 02/24/26 at 9:15 A.M., Resident #22 was observed in his room with a cup of water present. No other beverages were observed.On 02/25/26 at 1:30 P.M., Resident #22 was observed in his room with a cup of water present. The resident was not observed being offered juice.During an interview on 02/23/26 at 9:15 A.M., Licensed Practical Nurse (LPN) #161 stated she was not aware Resident #22 preferred juice and did not want water.During an interview on 02/23/26 at 1:40 P.M., Certified Nursing Assistant (CNA) #131 stated she was not aware Resident #22 had a documented preference for juice over water.During an interview on 02/24/26 at 10:05 A.M., CNA #139 stated she had not been informed of a specific instruction to offer juice instead of water to Resident #22.Review of the facility's care plan policy revealed residents' comprehensive care plans are to include identified food and beverage preferences to ensure person-centered care and implementation by staff.

Based on record review and interview, the facility failed to ensure a resident, who required assistance with personal care, received assistance with activities of daily living (ADLs). This affected one resident (#11) of six residents reviewed for ADL assistance. The facility census was 71. Findings include: Closed record review revealed Resident #11 was admitted to the facility on [DATE]. Review of the resident's Face Sheet revealed the resident had admitting diagnoses including displaced midcervical fracture of left femur, closed fracture with routine healing, respiratory failure, chronic obstructive pulmonary disease, and hypertension. Resident #11 discharged from the facility on 03/31/25 to home. Review of ADL documentation including bed mobility, transfers, eating, toileting, bathing, bowel and bladder incontinence care from 03/29/25 through 03/31/25 revealed no evidence Resident #11 received any assistance with her ADLs on 03/30/25 and 03/31/25. Interview on 04/09/25 at 8:51 A.M. with Resident #11's family revealed while visiting Resident #11, her clothes had not been changed, she had not received assistance with eating and was left laying flat to eat so she had food all over her clothes and face. Interview on 04/10/25 at 2:10 P.M. with the Administrator confirmed there was no documented evidence Resident #11 received assistance with her ADLs on 03/30/25 or 03/31/25. The surveyor requested a facility policy for ADL care to residents but a policy was not received at the time of the survey. This deficiency represents non-compliance investigated under Complaint Number OH00164242.

Based on record review, observation, and interview, the facility failed to protect residents' confidential information. This affected three residents (#66, #88, and #99) of seven residents reviewed for HIPAA. The facility census was 71. Findings include: Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including type II diabetes, muscle weakness, and respiratory failure. Record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, muscle weakness, and altered mental status. Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses muscle weakness, syncope and collapse, and congestive heart failure. Interview on 04/09/25 at 8:51 A.M. with a resident's family member revealed they had a concern regarding the resident's HIPAA protected information laying on the nurses station visible to visitors with no staff present. Observation on 04/10/25 at 8:15 A.M. revealed while the surveyor was standing at the nurses station counter, the desk was visible. On the desk, Resident #66's code status form was visible (full code status), Resident #88's code status form was visible (DNRCCA), and the computer screen was unlocked and open to Resident #99's orders, including an order for skin prep to bilateral heels and two medication orders. There was no staff at the nurses station at the time of the observation. Interview on 04/10/25 at 8:19 A.M. with Certified Nursing Assistant (CNA) #310 confirmed information regarding Residents #66, #88 and #99 were visible at the nurse's station. The surveyor requested a policy regarding HIPAA protected information and the facility did not provide one. This deficiency represents non-compliance investigated under Complaint Number OH00164242.

Based on record review, review of the facility's shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance needed to receive showers as scheduled. This affected three (Resident #3, #9, and #30) of three residents reviewed for activities of daily living (ADL). Findings include: 1. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a dislocation of his right hip prosthesis, unsteadiness on feet, repeated falls, diabetes mellitus with diabetic neuropathy, muscle weakness, malignant neoplasm of the prostate, congestive heart failure, and hypertension. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he known to reject care during the seven days of the assessment period. He required substantial assistance with showers/baths and transfers. Review of Resident #3's care plan revealed he had a care plan in place for ADL functional status which required therapy services related to a decline in his prior level of function of ADL's/mobility. It was due to an impaired ability to perform ADL's and difficulty walking and the goal was for his ADL function to improve. The interventions included allowing him as much independence with ADL's as possible while still maintaining his safety, provide encouragement as needed to participate with ADL's daily and to offer praise for his efforts, provide assistance as needed with ADL's and to refer to the resident's profile for ADL assistance needed. Review of the Unit 2 shower schedule revealed Resident #3 was to receive a shower/bath every Tuesday, Thursday, and Saturday on the day shift. Review of Resident #3's shower documentation from 11/26/24 to 12/21/24 revealed the resident had no documented evidence of receiving showers/baths on his scheduled shower days on six of the 12 opportunities he was to receive one. There was no evidence he received a shower or bath on 11/30/24, 12/05/24, 12/07/24, 12/10/24, 12/19/24 or 12/21/24. He was further indicated to have only received a partial bed bath on 11/28/24, which was a scheduled shower day. 2. Review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. He remained in the facility until he was discharged home on 12/20/24. His diagnoses included orthopedic aftercare, infection of a surgical site, fracture of the upper end of his femur, difficulty walking, muscle weakness, adult onset diabetes mellitus, depression, acute and chronic respiratory failure, and abnormalities of gait and mobility. Review of Resident #9's admission MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors or reject care during the seven days of the assessment period. He did not have any functional limitation in range of motion (ROM). He was dependent on staff for showers/bathing and required partial/moderate assistance for transfers. Review of Resident #9's care plan revealed he had a care plan in place for an impaired ability to perform or participate in daily ADL care related to a history of multiple fractures, muscle weakness, and abnormal posture. His goal was to participate with ADL's as much as possible and to have a neat appearance daily. The interventions included providing him assistance with ADL care as needed. Review of the Unit 2 shower schedule revealed Resident #9 was scheduled to receive a shower/bath every Tuesday, Thursday, and Saturday on the day shift. Review of Resident #9's shower documentation from 11/27/24 to 12/20/24 revealed the resident had no documented evidence of receiving showers or baths on 11/28/24, 11/30/24, 12/03/24, 12/05/24, 12/07/24, 12/10/24, 12/12/24, 12/14/24, 12/17/24, or 12/19/24, on his scheduled shower days. There was no evidence of the resident receiving a shower 10 out of 10 opportunities when a shower was scheduled. He was documented to have received showers on 12/04/24, 12/09/24, 12/13/24, and 12/18/24, which were non-scheduled shower days. There were six times out of the 10 showers that he should have received, in which no shower had been offered or provided. 3. Review of Resident #30's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hypertension, muscle weakness, abnormal posture, age-related osteoporosis, chronic pain syndrome, arthritis, and cataracts Review of Resident #30's admission MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors or reject care during the three days of the assessment period. She was not known to have any functional limitation in her range of motion. She required partial/moderate assistance for showers/baths and transfers. Review of Resident #30's active care plan revealed she had a care plan in place for an impaired ability to perform or participate in daily ADL's related to muscle weakness and chronic pain syndrome. The goal was for the resident to participate with ADL's as much as possible and to remain clean and dry, comfortable, and neat in appearance daily. The interventions included providing assistance with all ADL care as needed. Review of the Unit 1 shower schedule revealed Resident #30 was scheduled to receive showers every Tuesday, Thursday, and Saturday on the day shift. Review of Resident #30's shower documentation from 12/02/24 until 12/23/24 revealed the resident was not documented as having received any showers/baths on 12/03/24, 12/07/24, 12/14/24, 12/17/24, or 12/19/24, which were all scheduled shower days. A bed bath was documented as having been provided on 12/12/24. Three showers were documented as having been given, out of the nine opportunities the resident was scheduled to receive one. On 12/23/24 at 11:01 A.M., an interview with Resident #30 revealed she did not get showers that often when she was scheduled to receive one. She confirmed the documentation of her showers seemed accurate in regards to her not receiving a shower five of the days she was scheduled to receive one. She denied that she had asked for a bed bath on 12/12/24, when it was documented as having been provided to her on a scheduled shower day. She denied that the staff typically asked if she wanted a shower, but reported the staff just come in and do what they want to do. It was her preference to receive showers and she stated she may only get one of the three showers that were scheduled for her each week. On 12/23/24 at 11:09 A.M., an interview with the facility's Director of Nursing (DON) confirmed the three residents (#3, #9, and #30) reviewed for showers were missing documented evidence of receiving a shower on their scheduled shower days and that the documentation that she had already provided was the only documentation they had. She stated the facility was in the process of hiring a new shower aide, with the current one moving back into working on the floor. The DON reported the shower aide was very busy and also helped out on the floor and that was why they could not get the scheduled showers completed when they had a shower aide. She stated they hoped by replacing their current shower aide with a new one, it would allow them to get the showers completed as scheduled. On 12/23/24 at 12:15 P.M., an interview with the facility's Administrator revealed the completion of resident's showers had been an ongoing issue. She reported the facility continued to work to get the issue resolved and it was a work in progress. Review of the facility's undated policy on Shower/Tub Baths revealed it was the facility's policy to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. It stated the following information should be recorded on the resident's ADL record and/or in the resident's medical record: the date and the time the shower/tub bath was performed; the name and the title of the individual(s) who assisted the resident with the shower/tub bath; all assessment data obtained during the shower/tub bath; how the resident tolerated the shower/tub bath; if the resident refused the shower/tub bath, the reason(s) why and the intervention taken; and the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00160691.

Based on observation, resident interview, and staff interview, the facility failed to ensure residents had the right to a safe, clean, and sanitary environment. This affected 42 of 67 residents (25 residents were identified to not use the facility's two shower rooms (Residents #3, #4, #6, #17, #21, #22, #36, #37, #38, #39, #42, #44, #47, #48, #50, #52, #53, #54, #55, #59, #63, #64, #65, and #66). The facility's census was 67. Findings include: On 10/28/24 at 10:25 A.M., an observation of the facility's main shower room on Unit 1 revealed the commode in the shower room was missing a toilet seat. There was a black colored substance on the vinyl floor, near the left side of the shower stall where the vinyl flooring met the tiled shower stall's floor. The black substance was not a stain and transferred to a paper towel when using it to wipe over the black substance. There was also dirt and grime build-up in the grout lines of the tiled shower stall floor and in the lower half of the tiled walls that enclosed the shower stall. The dirt and grime on the tiled floor covered about half of the surface area of the floor. The cleaner areas had gray colored grout lines, while the dirtier areas had dark gray to black grout lines. The vinyl flooring in front of the shower stall was peeling back mid-way and to the right end of the shower stall. The floor's underlayment was exposed where the vinyl flooring was peeling back. A metal transition strip was noted to go across the shower stall separating the tiled floor of the shower stall with the vinyl flooring that covered the resident of the shower room's floor. On 10/28/24 at 10:31 A.M., an observation of the facility's main shower room on Unit 2 revealed the grout lines between the tiled floor in the shower stall also had dirt and grime build-up. The grout lines were dark gray to black in color instead of the gray color it should have been. Dirt and grime build-up was also noted in the grout lines between some of the wall tiles that surrounded the shower stall. There was torn vinyl flooring noted to the left of the shower stall. The torn areas in the vinyl floor had a sealant that had been applied over the cracks in the vinyl, but the sealant was coming loose. The shower room also had a strong mildew odor that was present and noticeable when entering the shower room. On 10/28/24 at 3:15 P.M., a follow up observation was made of the environmental concerns noted earlier in the facility's two shower rooms. The Director of Nursing (DON) accompanied the surveyor and verified the findings. Unit 1's shower room was noted to have standing water in the area where the vinyl flooring was peeling back in from of the shower stall. The water was puddled right over top of the area where the vinyl flooring was peeling back away from the transition strip in front of the shower stall where the vinyl flooring and the tiled floor met. Other findings previously mentioned were still present in the Unit 1 shower room. The shower stall in Unit 2's shower room was noted to have a brown substance that looked like feces on the floor. No residents or other staff were in there at the time the observation was made. The DON stated the shower stall should be cleaned/ disinfected between each resident use. She acknowledged Unit 2's shower room had a strong mildew odor in it that was noticeable when entering the shower room. The other concerns noted in Unit 2's shower room remained. The DON reported she would have to have the shower rooms clean and would see about getting the toilet seat to the commode in Unit 1 fixed. On 10/28/24 at 3:30 P.M., an interview with Resident #14 revealed she had concerns about mold in the facility's shower rooms and it was like that on both sides. She claimed that was mold that was on the wall and on the floor. She mentioned the area of the vinyl flooring that was coming up and exposing the underlayment beneath it. She stated that could not be good for the water to be getting under the vinyl flooring. She alleged it had been like that for the past year or year and a half. They (facility) have said that they were going to fix it, but had to wait on something. She was not sure what they were waiting on and did not feel it should have taken that long to be fixed. She also confirmed the toilet seat on the commode in Unit 1's shower room had been off for about a month or a month and a half. This deficiency represents non-compliance investigated under Complaint Number OH00158499.

Based on record review and staff interview, the facility failed to ensure a resident's medical record was complete and accurate to reflect activities of daily living (ADL) care that was provided to the resident while in the facility. This affected one resident (#69) of four residents reviewed for accuracy of medical records. Findings include: Review of Resident #69's closed electronic medical record (EMR) revealed she was admitted to the facility on [DATE] for a respite stay. She remained in the facility until 08/24/24, when the resident's family opted to take her home, prior to the end of her five day respite stay. Her diagnoses included Alzheimer's disease, dementia without behavioral disturbances, unspecified protein calorie malnutrition, hypertensive heart disease with heart failure, pressure ulcer to an unspecified site and at an unspecified stage, contractures of muscles of multiple sites, and a personal history of malignant neoplasm of the breast. Review of Resident #69's care plans revealed she had care plans in place to address her being at risk for skin breakdown, having existing wounds, and receiving hospice care. The interventions included the need to assist the resident with bed mobility, observing the resident for any incontinence episodes and provide incontinence care as needed, hospice aide to provide a shower/ bath and assist with personal hygiene care 1-3 x's weekly, shower or bathe per resident schedule and tolerance, and provide oral care. Review of Resident #69's Point of Care History report from 08/22/24 to 08/24/24 revealed the facility staff did not document the provision of any ADL care to the resident on 08/22/24 and 08/23/24 (first two days of her three day stay). There was no documentation of any ADL care being provided until 08/24/24 at 5:47 A.M. when the resident was finally documented as having received ADL assistance to include bed mobility, transfers, eating, toilet use, bathing assistance, and toileting. On 10/24/24 at 2:05 P.M., an interview with the DON confirmed the facility's Point of Care History did not document any ADL care that had been provided to Resident #69 for the first two days of her three day stay. She reported the resident was assisted with those things, but they were not documented. She was not able to explain why the staff did not document ADL care when they occurred. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00159030.

Based on review of a facility self-reporting incident (SRI), it's related investigation, staff interview, and policy review, the facility failed to ensure resident's personal money was not misappropriated by facility staff. This affected one resident (#36) of one residents reviewed for misappropriation and one of two SRI's reviewed. Findings include: Review of SRI with tracking #251595 dated 09/06/24 revealed an allegation of misappropriation was alleged involving Resident #36 and facility staff member. The initial source of the allegation was a facility staff member. Resident #36 was indicated to have been able to provide meaningful information when interviewed. The narrative summary of the incident revealed the date and time of the occurrence was on 09/20/24 at 11:30 A.M. and in the resident's room. Resident #36 reported he had lent a staff member (Housekeeper #77) $20.00 and it had not been paid back yet. Staff notified the administrator immediately of that allegation. An interview was conducted with Resident #36 who reported Housekeeper #77 had asked to borrow $10.00 from him approximately two months ago. He stated he did not have $10.00, but he had a $20.00, so he lent her $20.00. He denied reporting it to anyone before then. He did not have any concerns and he wanted to help Housekeeper #77, as they were friendly and got along well. Resident #36 reported no further concerns. An interview with Housekeeper #77 was conducted and she admitted she borrowed the $20.00 and had not paid it back yet. She denied she had asked any other residents to borrow money or accepted money from any other residents. She was placed on administrative leave pending the investigation. The Administrator interviewed other staff and residents with no relative concerns reported. The facility unsubstantiated the allegation indicating the evidence indicated misappropriation did not occur. As a result of the investigation, the facility could not conclude that misappropriation, or the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent, occurred. Resident #36 was reimbursed in the amount of $20.00. The facility indicated they followed the abuse reporting policy. Review of the facility's related investigation for SRI #251595 revealed the facility's administrator obtained a statement from Resident #36 on 09/06/24. She documented the interview on an Event Statement form that was identified as a Quality Assessment and Assurance (QAA) form. She documented Resident #36 stated approximately two months ago, Housekeeper #77 had asked him to borrow $10.00. He stated he only had a $20.00, so he lent her $20.00. He indicated they got along well and he was happy to help her. He had not reported it to anyone until then. Resident #36 indicated he was not concerned, he was just wondering when he could get his $20.00 back. It was explained to the resident that the facility would reimburse him and provided education to the resident to report any concern immediately. He indicated he did not report it because he was not concerned but voiced understanding that staff were not permitted to ask residents for money or to borrow money. Further review of the facility's related investigation revealed the facility's administrator documented her interview she conducted with Housekeeper #77 on 09/06/24. The facility's Director of Nursing (DON) was indicated to be present at the time of the interview, as well as the facility's housekeeping supervisor. When asked about the allegation of her borrowing money from a resident and not paying it back, Housekeeper #77 became tearful and stated yes I did that and I know better, I haven't paid him back yet but I can. She stated she felt she and the resident had a good relationship and she asked to borrow $10.00 dollars, but the resident only had a $20.00, so he lent her the $20.00 approximately two months ago. She denied she had asked to borrow money or had accepted money from any other residents. She then stated I promise I have never done that before or since then, I know I shouldn't have and I know this isn't allowed. It was communicated to the housekeeper that she would be placed on administrative leave pending the investigation, and the housekeeper voiced understanding. Review of a written statement obtained from Housekeeper #77 on 09/11/24 confirmed she asked Resident #36 to borrow $10.00 and he gave her $20.00. A month went by and she did not pay it back. Resident #36 asked another employee if she (Housekeeper #77) still worked there and that she had borrowed money from him and had not paid him back yet. Housekeeper #77 stated another employee reported it to her supervisor. Review of Housekeeper #77's employee personnel file revealed she received disciplinary action on 09/11/24. The disciplinary action indicated it was her first offense. The date of the violation was on 09/06/24 and the employer statement indicated the employee violated Section 11 of the Employee Handbook under prohibited conduct specifically #16, and #36. Number 16 was accepting money, gifts, gratuities etc. from the residents, the resident's families, or visitors. Number 36 pertained to unprofessional behavior or conduct. On 10/28/24 at 4:51 P.M., an interview with the DON revealed they had the state investigator from the abuse, neglect, and misappropriation department in a couple weeks ago and they reviewed the allegation of misappropriation and the facility's investigation. They also talked with Housekeeper #77 while there. She stated there was nothing that came out of that from what she knew. The facility's administrator was out of the facility during the complaint investigation. The DON was asked why the facility unsubstantiated the allegation, when the employee confirmed she asked to borrow money from Resident #36. She stated the resident consented to loan her the money. She acknowledged staff members were not permitted to ask the resident's for monetary assistance, after staff had made the resident believe that staff were in a financial crisis. Staff were in a position that may be perceived as one of power over a resident. As such, staff may be able to manipulate or unduly influence decisions by the resident. Staff must not accept or ask a resident to borrow money through request for a loan or solicitation. A resident's apparent consent was not valid if it it was obtained through coercion or fear, whether it was expressed by the resident or suspected by staff. Review of the facility's policy on Abuse, Mistreatment, Neglect, Injuries of Unknown Origin, and Misappropriation of Resident Property. Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. An investigation of the allegation or suspicion would be conducted. After investigation, the facility should reach a conclusion analyzing all the evidence and making a determination whether the allegation or suspicion was substantiated. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00159030.

Based on record review, review of shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance they needed for bathing/ showers. This affected three residents (#8, #14, and #20) of four residents reviewed for showers. Findings include: 1. Review of Resident #8's closed medical record revealed the resident was admitted to the facility on [DATE]. He remained in the facility until he was discharged to an inpatient rehabilitation unit on 10/24/24. His diagnoses included orthopedic aftercare, infection of a surgical site, fracture of the upper end of the right femur, difficulty walking, muscle weakness, and pressure ulcers on his bilateral heels. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. he was not known to have displayed any behaviors nor was he known to reject care. He was dependent on staff for bathing/ showers. Review of Resident #8's active care plans revealed the resident had a care plan in place for an impaired ability to perform or participate in daily activities of daily living (ADL) care related to fracture of left upper & right upper femurs, fracture of left & right pubis, fracture of sacrum, bilateral fracture of acetabulum, bilateral fracture of ilium, laceration of spleen, bilateral contusion of kidneys, bilateral flank hematomas, abnormal posture, muscle weakness, and other symbolic dysfunctions. The care plan was initiated on 03/12/24. The goal was for the resident to participate with ADL's as much as possible and he would remain clean and dry, comfortable, and neat in appearance daily. Interventions included providing nail care and shampoo hair with showers per weekly schedule; groom hair daily and encourage resident to participate as able; provide/assist with am and pm care; encourage resident to participate with hygiene as tolerated; assist with and/or shave facial hairs every day prn or per resident preference; provide assistance with all ADL care and mobility as needed/ anticipate resident needs as able. Review of the shower schedule for Unit 2 revealed Resident #8 was scheduled to receive a shower or bath every Tuesday, Thursday, or Saturday. His shower was to be provided on day shift (7A to 3P). Review of Resident #8's shower documentation from 09/26/24 through 10/24/24 revealed there was no documented evidence of the resident being given a shower or bath on his scheduled shower days on 09/28/24, 10/05/24, 10/12/24, 10/15/24, and 10/19/24 (five of the 12 days he was scheduled). There was no evidence of the resident refusing his bath or a shower those days on the shower sheets or in the nurses' progress notes. On 10/29/24 at 10:06 A.M., email correspondence with the facility's Director of Nursing (DON) confirmed she did not have any documented evidence to support Resident #8 being given a bath or a shower on his scheduled shower days on 09/28/24, 10/05/24, 10/12/24, 10/15/24, or 10/19/24. She reported the shower sheets were where the staff documented the bath or shower when it had been given. 2. Review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included polyosteoarthritis, muscle weakness, difficulty walking, unsteadiness on feet, chronic pain syndrome, morbid obesity, and pain in right shoulder. Review of Resident #14's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors or reject care. Review of Resident #14's active care plans revealed the resident had a care plan in place for an impaired ability to perform or participate in daily ADL care related to polyosteoarthritis and weakness. The care plan was initiated on on 03/12/24. The goal was for the resident to participate with ADL's as much as possible and she would remain clean and dry, comfortable, and neat in appearance daily. The interventions included providing nail care and shampoo hair with showers per weekly schedule; groom hair daily and encourage the resident to participate as able; provide/assist with am and pm care; encourage the resident to participate with hygiene as tolerated; assist with and/or shave facial hairs every day and prn or per resident preference; observe/report any decline in ADL's, mobility or cognition; Provide assistance with all ADL care and mobility as needed; anticipate resident needs as able; and encourage resident to participate with care as tolerated. Review of the shower schedule for Unit 1 revealed Resident #14 was scheduled to receive a shower or bath every Tuesday, Thursday, or Saturday. The shower or bath was to be completed on day shift. Review of Resident #14's shower documentation on paper shower sheets for the past 30 days (09/26/24 through 10/26/24) revealed there was no documented evidence of the resident receiving a bath or a shower on 09/28/24, 10/03/24, 10/05/24, 10/12/24, or 10/17/24 (five of the 14 showers that were scheduled during that time). There was no indication that the baths or showers were offered and refused. On 10/28/24 at 3:30 P.M., an interview with Resident #14 revealed she was supposed to get showers every Tuesday, Thursday, and Saturday. She reported it was more common than not for her to only receive two showers a week, instead of the three she was scheduled for and preferred. She indicated this past week, she did not get a shower on Thursday or Saturday. She stated the shower she was supposed to get Saturday was not done until Sunday. They only had two aides on the floor those days and it made it hard for them to get the showers done. She denied she refused any showers when offered. On 10/29/24 at 10:06 A.M., email correspondence with the facility's DON confirmed she did not have any documented evidence to support Resident #14 being given a bath or a shower on her scheduled shower days on 09/28/24, 10/03/24, 10/05/24, 10/12/24, or 10/17/24. She denied the missed showers/ baths on the resident's scheduled shower day was related to staffing in any way. She indicated baths and showers were only documented on the paper shower sheets and she did not have anything else to prove they had been offered and/ or refused. 3. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included difficulty walking, abnormalities of gait and mobility, muscle weakness, bipolar disease, Parkinson's disease, and morbid obesity. Review of Resident #20's quarterly MDS dated [DATE] revealed the resident did not have any communication issues and he was cognitively intact. No behaviors were known, but the resident was indicated to have rejected care during that seven day assessment period. Review of Resident #20's active care plans revealed the resident had a care plan in place for an impaired ability to perform or participate in daily ADL Care related to a T5-T6 vertebrae fracture and rib fractures. The goal was for the resident to participate with ADL's as much as possible and will remain clean and dry, comfortable, and neat in appearance daily. The interventions included to observe/report any decline in ADL's, mobility or cognition; provide assistance with all ADL care and mobility as needed; anticipate resident needs as able; encourage resident to participate with care as tolerated. Review of the shower schedule for Unit 2 revealed Resident #20 was scheduled to receive a bath or a shower every Monday, Wednesday, and Friday. The bathing activity was to take place on the day shift. Review of Resident #20's documented showers revealed he was documented as having received a shower or bath on all scheduled days except 10/18/24 (1 of 14 opportunities). There was no documented evidence of the resident refusing that bath or shower when scheduled. On 10/29/24 at 10:06 A.M., email correspondence with the facility's DON confirmed she did not have any documented evidence to support Resident #20 being given a bath or a shower on his scheduled shower days on 10/18/24. She was not able to provide evidence of a bath or shower having been offered and refused for 10/18/24. This deficiency represents non-compliance investigated under Complaint Number OH00158499 and Complaint Number OH00158311.

Based on record review and staff interview, the facility failed to ensure a resident's nutritional status was adequately monitored by recording meal percentages and fluid intake amounts that were consumed during her stay in the facility. This affected one resident (#69) of three residents reviewed for nutrition. Findings include: Review of Resident #69's closed electronic medical record (EMR) revealed she was admitted to the facility on [DATE] for a respite stay. She remained in the facility until 08/24/24, when the resident's family opted to take her home, prior to the end of her five day respite stay. Her diagnoses included Alzheimer's disease, dementia without behavioral disturbances, unspecified protein calorie malnutrition, hypertensive heart disease with heart failure, pressure ulcer to an unspecified site and at an unspecified stage, contractures of muscles of multiple sites, and a personal history of malignant neoplasm of the breast. Review of Resident #69's physician's orders revealed the resident had an order in place for her breakfast, lunch, and dinner intakes, as well as the resident's fluid intakes. The order had been in place since 08/22/24. Review of Resident #69's meal and fluid intakes revealed there had not been a single meal or a single fluid ounce of liquids that had been documented as having been consumed by the resident during her stay in the facility between 08/22/24 and 08/24/24. The report was ran by the facility's Director of Nursing (DON) and provided for review on 10/24/24 at 1:56 P.M. On 10/24/24 at 2:05 P.M., an interview with the DON confirmed the report she provided for Resident #69's meal and fluid intakes did not have any documentation on it at all. She reported the staff should have been entering the resident's meal and fluid intakes into the computer, after they occurred. She denied they had anywhere else where the resident's meal percentage consumption and her fluid amounts she drank would have been recorded. She acknowledged without the documentation, she could not show evidence of the resident receiving three meals a day or given fluids throughout the day. She further acknowledged they could not show adequate monitoring of the resident's nutritional status as it was not able to be determined how much the resident was eating or drinking to maintain her proper nutritional and hydration status. She could not explain why there was no documentation for the resident during her three day stay in the facility. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00159030.

Based on medical record review, interview, and review of facility policy, the facility failed to develop and implement a comprehensive, effective and individualized nutritional program to ensure nutritional recommendations were implemented timely, weights and assessments were completed timely, care plans were updated appropriately, and significant/severe weight changes were addressed for Resident #264. Actual harm occurred when Resident #264 who was cognitively impaired and weighed 104 pounds on 05/19/24 experienced a gradual weight loss until 06/24/24 when she experienced a severe 8.5% (9 pounds) weight loss. The nutritional recommendations for Resident #264 that were made on 05/19/24 were not put in place until they were recommended again on 06/09/24. A nutritional assessment was not completed again following the 06/09/24 recommendation, and as of 07/18/24 Resident #264 weighed 93.8 pounds which was severe 6.7% (6.8 pound) weight loss from 06/20/24. This affected one resident (#264) of two residents reviewed for nutrition. The facility census was 62. Findings include: Review of the medical record for Resident #264 revealed an admitted [DATE] with diagnoses including unspecified fracture of left femur, metabolic encephalopathy, muscle weakness, anorexia, dorsalgia, anemia, protein-calorie malnutrition, depression, osteoarthritis, and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #264's census revealed she was admitted on [DATE] with hospice services. The resident was discharged on [DATE] with return expected and returned on 05/13/24 without hospice. Resident #264 was discharged again on 05/19/24 with return expected and she returned on 05/21/24. Review of Resident #264's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The assessment revealed the resident was 59 inches tall and weighed 104 pounds. Resident #264 was on a regular diet. Review of Resident #264's weights revealed there were no documented weights from 05/08/24 to 05/18/24. On 05/19/24 Resident #264 weighed 104 pounds. Review of Resident #264's nutrition assessment revealed the dietician completed one assessment for the resident which was dated 05/19/24. The assessment revealed the resident was on a regular diet and had varied intake. The dietitian recommended a house supplement twice a day for additional nutritional support. The goal was for the resident to be hydrated and nourished as her condition allowed. Review of an email dated 05/19/24 (provided 07/18/24 at 11:27 A.M.) revealed Dietitian #199 informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #124 that she recommended starting Resident #264 on house supplement twice a day. Review of the physician's orders for Resident #264 from 05/19/24 to 06/05/24 revealed no orders for house supplement. Review of the physician's orders for Resident #264 revealed an order dated 05/21/24 for a regular diet. Additionally, there was a new order for weekly weights from 05/21/24 to 06/18/24. Review of Resident #264's weights revealed on 05/22/24 she weighed 140.2 pounds and on 05/24/24 she weighed 104.2 pounds. Review of Resident #264's progress note dated 05/24/24 revealed her weight had been obtained and the weight of 140.2 pounds was incorrect her weight was 104.2 pounds. Review of Resident #264's weights revealed on 05/28/24 she weighed 93 pounds. Review of the medical record revealed no evidence a reweigh was obtained at this time. Review of Resident #264's progress note dated 06/05/24 revealed Dietitian #199 reviewed weights and a weekly weight update was requested. The resident's most recent weight was showing a weight change since admission. The resident had variable oral intakes. Dietitian #199 recommended beginning four ounces of the house supplement twice a day for additional nutritional support. Review of the email dated 06/05/24 (provided on 07/18/24 at 11:31 A.M.) revealed Dietitian #199 informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #124 that she needed a weekly weight on Resident #264 because of a weight change since admission. She also recommended beginning her on four ounces of house supplement twice a day. Dietitian #199 indicated this had been recommended previously and had been missed. Review of Resident #264's physician order dated 06/06/24 revealed an order for house supplement four ounces twice a day. Review of Resident #264's Medication Administration Record (MAR) from 06/06/24 to 07/14/24 revealed the house supplement did not have any indication of how much of the supplement the resident accepted. Resident #264 had refused the supplement on 07/01/24 and 07/03/24. Review of Resident #264's weights revealed on 06/07/24 she weighed 102.8 pounds, on 06/09/24 she weighed 101.2 pounds, on 06/20/24 she weighed 100.6 pounds, on 06/24/24 she weighed 95 pounds, and on 07/01/24 she weighed 95.4 pounds. Her 07/01/24 weight was a severe 7.2% weight loss thirty days. Review of Resident #264's plan of care dated 06/10/24 revealed the resident was at risk for altered nutrition related to a hip fracture with surgical wound and diagnoses. She was receiving hospice care and was to receive no routine weights for comfort. The plan of care revealed Resident #264 might not meet her estimated needs related to likely decline in condition or intakes. She was receiving a regular diet with variable intakes. House supplement was recommended twice a day, and the resident was receiving the medication Mirtazapine which might act as an appetite stimulant. Interventions included offering menu alternatives as needed, honoring food preferences, and not completing routine weights related to comfort measures, and providing the diet and supplements as ordered. Review of Resident #264's progress note dated 07/15/24 revealed a new order was received to continue weekly weights. Review of Resident #264's weights revealed a weight on 07/17/24 of 92.2 pounds and a weight on 07/18/24 of 93.8 pounds which was a severe 6.7% (6.8 pound) weight loss over thirty days. Review of Resident #264's medical record revealed Dietician #199 documented a nutritional assessment for Resident #264 on 05/19/24 and a progress note for the resident on 06/05/24 and no other documentation from the dietician was present in the medical record. Interview on 07/17/24 at 3:01 P.M. and 3:20 P.M. with Dietitian #199 revealed she worked six to twelve hours a week remotely for the facility. She reported she monitored significant weight changes weekly on Saturday by running a significant weight change report. Dietitian #199 indicated that when a resident had significant weight loss, she put them on weekly weights and monitored the weight weekly until the weight loss was corrected. She reported she was not always sure what was going on with residents and would ask staff for updates. Dietitian #199 revealed weights were supposed to be obtained within a week of admission. Dietitian #199 indicated she was unsure when Resident #264 was removed from hospice Dietitian #199 indicated Resident #264 was supposed to be getting weekly weights and had never been removed from the list. Dietitian #199 indicated she was not aware why the supplement as recommended on 05/19/24 had not been implemented. Dietitian #199 also indicated that supplement documentation should include percentages as she uses it in nutrition assessments. The last time Resident #264 was assessed was 06/05/24. Interview on 07/18/24 at 8:35 A.M. with the Director of Nursing (DON) confirmed the supplement did not get put in place for Resident #264 on 05/19/24 because she went out to the hospital that day. It did not get started when she returned on 05/21/24 but was implemented after the dietitian recommended it again on 06/05/24. Interview on 07/19/24 at 9:50 A.M. with the Administrator confirmed Resident #264's nutrition plan of care was incorrect as she stopped receiving hospice care on 05/13/24.

Based on medical record review, staff interview and review of facility's policy and procedure on falls, the facility failed to ensure adequate supervision or proper assistance with activities of daily living for two residents who were at a fall risk or had a history of [REDACTED].#57). Resident #57 sustained actual harm when left unsupervised while ambulating, fell and sustained a brain bleed requiring hospitalization . Resident #22 sustained actual harm when a transfer was completed by only one state tested nurse aide (STNA) and the resident required two assists. Resident #22 fell and sustained a shoulder laceration that required emergency treatment. This affected two of three residents reviewed for falls. The facility census was 54 residents. Findings include: 1. Closed medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/25/16, revealed the resident required supervision with one person physical assistance for mobility on and off the unit and in her room. Review of the resident's fall care area assessment, dated 11/29/16, revealed Resident #57 was at risk for falls related to a history of falls, weakness, recent urinary tract infection, right shoulder pain, dizziness, dementia, ataxia, osteoarthritis, hypertension, left [DIAGNOSES REDACTED], and rhabdomylosis. The resident was noted to be unsteady on her feet, and she used a walker for ambulation with staff assistance. Preventative measures were noted to be in place and she was receiving physical, occupational, and speech therapy. Review of Resident #57's activities of daily living (ADL) plan of care, dated 11/18/16 and revised on 12/05/16, revealed the resident had an ADL self-care performance deficit related to repeated falls. The interventions included to provide limited assist with one person for mobility and supervision with one person physical assistance for locomotion. Review of the physical therapy evaluation and plan of treatment form, dated 11/20/16, revealed Resident #57 had recently fallen at home outside and stayed on the ground until the resident's daughter found her after nine hours of the resident lying on the ground in 20 degree weather. Afterward, the resident was treated for [REDACTED]. The resident was noted to have a history of multiple falls with injuries, decreased cognition, and poor safety awareness. The resident lacked insight into safety awareness and the current situation, and was at a moderate risk for falls. Basic mobility for walking required supervision with touching assistance. The goal for the resident was to increase ability to safely ambulate unlimited distances within the community using a rollator walker with supervision. At the time of discharge from physical therapy services on 11/30/16, the resident was a stand by assist for ambulation. Review of Resident #57's progress notes revealed on 11/29/16, the resident's daughter attended the care conference meeting and the daughter had concerns regarding the resident falling and walking too fast. There was no mention regarding how the staff addressed the daughter's concern. Further review of the resident's progress notes revealed on 11/30/16 at 12:10 P.M., the resident was observed ambulating down the hall toward her room with her rollator walker. The resident entered her room, and then Licensed Practical Nurse (LPN) #2 heard a noise followed by another noise. Upon observation, the resident was lying prone on the floor next to the wall and her bathroom door. Her right leg was extended but under her left leg. Her right arm was tucked under her body. Her glasses were broken and under the right side of her face with the left lens pulled upward away from her face and over the forehead and ear area. Her blood pressure was 203 over 122 initially. She had loss of consciousness (approximately seven minutes) and the resident slowly regained consciousness. Blood was pooled under the right side of her face with her nose dripping, and pressure was applied. The resident had blood in her hair and appearance of a gash to side of head. Pressure was applied to stop the bleeding. On 11/30/16 at 12:15 P.M., the emergency number 9-1-1 was notified of need to transport. The resident's daughter was in the room and made aware. At 12:17 P.M. the physician was notified. The investigation of the fall began immediately. The resident's brother and daughter were in the room at the time of the fall. During the event, the brother was standing next to the resident. He stated that he was, coming out of the bathroom when she fell . The resident was lying with her body parallel with the bathroom door/wall. Her feet were lying next to the doorway where the door was opened. Her rollator walker was at the top portion of her body and twisted (not standing upright). The resident's daughter was in the recliner at the time and stated that she did not see the actual fall but confirmed that the brother was in the bathroom at the time. On 11/30/16 at 3:16 P.M., it was noted the resident was being flown to another hospital with [DIAGNOSES REDACTED]. Review of the facility's fall investigation revealed on 12/02/16 LPN #2 provided the following statement: The nurse told the resident, your food will be coming, so let's go back to your room. The nurse walked the resident to the area right before the room, and then walked ahead of resident. The nurse was standing by Room 406 and turned around to make sure the resident was going to the right room (408). The resident was walking past the room and was instructed to go back to where the room was. The resident looked around, and went into Room 408. The resident walked into the room and the nurse heard a loud banging noise. The nurse ran into room and saw the resident lying on the floor. Interview with Physical Therapist Assistant (PTA) #11 and Rehabilitation Director (RD) #12 on 03/06/17 at 10:28 A.M. confirmed the resident should have been supervised with ambulation. PTA #11 explained Resident #57 was unsteady, non-compliant with using her rollator walker, and unsafe. PTA #11 stated the resident was at moderate risk for falls. RD #12 stated she was present in the care conference meeting and confirmed the daughter expressed concern regarding how fast the resident walked. RD #12 was unable to state what they did to address the daughters concern. Further interview with the PTA #11 on 03/06/17 at 1:12 P.M. said the resident definitely required supervision with mobility due to the resident's low safety awareness. The PTA stated he told nursing that the resident required supervision, but was unable to recall any names of staff he told that to. Interview with LPN #2 on 03/06/17 at 11:20 A.M. revealed she was assisting passing the lunch trays with the state tested nursing aides (STNA) on the floor. LPN #2 stated she noticed the resident was sitting at the end of the hallway. LPN #2 stated she asked Resident #57 if she was hungry and would like to go to her room to eat lunch. LPN #2 stated the resident agreed and began walking to her room. LPN #2 stated Resident #57 was really confused when she was sitting in the chair and noted the resident had got her hair done earlier in the day. The LPN stated she was independent for mobility on the unit and confirmed she did not supervise or assist Resident #57 into her room. LPN #2 confirmed she did not witness the resident falling. Interview with the Director of Nursing (DON) on 03/06/17 at 11:45 A.M. revealed Resident #57 was independent with mobility The DON confirmed the resident's plan of care, MDS 3.0 assessment and care area assessment stated the resident required assistance with mobility. Further interview with the DON on 03/06/17 at 2:12 P.M. defined supervision required that staff actually have eyes on that resident. Interview with Corporate Nurse #5 and the Administrator on 03/06/17 at 2:04 P.M. revealed the fall was witnessed by Resident #57's daughter. Review of the progress note indicated the daughter said she did not observe the resident fall, the Corporate Nurse confirmed the fall was an unwitnessed fall. The Corporate Nurse said she considers every resident supervised if they reside in the facility. The Corporate Nurse confirmed she was not aware the resident required any assistance with mobility. 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's activities of daily living (ADL) plan of care dated 02/05/17 revealed the resident required extensive assistance with two-person physical assistance with transfers. Review of the resident's admission MDS 3.0 assessment dated [DATE] revealed the resident required extensive assistance with two-person's physical assistance with transfers. Review of the resident's fall plan of care dated 02/02/17 and revised on 02/05/17 revealed the resident was at risk for falls related to right food deep vein thrombosis, edema, [DIAGNOSES REDACTED], development disability, peripheral vascular disease and urinary incontinence. Review of Resident #22's progress notes dated 02/26/17 at 10:55 A.M. revealed one STNA was transferring the resident from her wheelchair to her bed for the night and the resident slid/fell to the floor on 02/25/17 at 9:30 P.M. On assessment, the resident was observed to have a 1.75 centimeter (cm.) in length, by 1.75 cm. wide and 0.25 cm. in depth raised area to the posterior superior skull, and an approximately eight inch in length by 1 millimeter (mm.) wide by 0.2 mm depth laceration to the left shoulder ranging from the superior shoulder angled in an approximate 45 degree angle ending left of the posterior medial line. The resident was noted to be on an anticoagulant and was sent to the emergency room to follow the facility's policy. The resident returned to the facility from the ER with no new diagnosis. Review of a progress note dated 02/28/17 at 11:14 A.M. indicated Resident #22 had fallen during morning as staff were trying to get the resident up into her wheelchair for breakfast. As staff was transferring per her usual, the resident's legs gave out and she began to fall toward the wheelchair and the resident missed the wheelchair. Interview with the DON on 03/06/17 at 2:45 P.M. confirmed the ADL plan of care and admission MDS 3.0 assessment stated the resident was a two-person assist with transfers and the resident's fall progress note stated it was only one staff transferring the resident. The DON confirmed she did not know the resident was a two-person assist with transfers. Further interview with the DON on 03/07/17 at 8:31 A.M. confirmed the facility's fall investigation did not match the nurse's fall progress note. The DON confirmed the resident only fell on ce and confirmed the resident fell in the evening from her wheelchair to her bed and not in the morning from her bed to her wheelchair. Review of the facility's policy and procedure on falls revised 11/16 revealed it would be the facility's stand to complete an initial assessment, on-going monitoring/evaluation of the resident's condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. Guidelines included to if a resident sustained [REDACTED]. This deficiency substantiates Complaint Number OH 766.