Every finding on record at Anna Maria of Aurora

Based on record review, interview, policy review, the facility failed to ensure medications were administered as ordered for Resident #195. This affected one (Resident #195) of three residents reviewed for quality of care. The facility census was 88.Findings include: Review of the closed medical record revealed Resident #195 was admitted on [DATE] with diagnoses including atrial fibrillation, coronary artery disease, type II diabetes mellitus, urinary retention requiring an indwelling urinary catheter, and protein-calorie malnutrition.Record review of the resident's care plan revealed care plans initiated on 06/30/25 addressed Resident #195's activities of daily living, nutrition, urinary catheter, fall prevention, cardiovascular status, and chronic medical conditions. The care plan included interventions to monitor changes in condition, notify the physician of changes in condition, administer medications as ordered, obtain laboratory studies as ordered, and provide Physical Therapy, Occupational Therapy, and Speech Therapy as indicated. The care plan was reviewed and revised on 12/10/25 following the resident's hospitalization to address the resident's decline in functional status, increased dependence on staff with activities of daily living, hospice services, and changing care needs.Record review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #195 was cognitively intact, exhibited no behavioral symptoms, was independent or required supervision with activities of daily living and mobility, had an indwelling urinary catheter, and was frequently incontinent of bowel.Record review revealed Resident #195 was hospitalized on [DATE] with sepsis, pneumonia, urinary tract infection, and abnormal laboratory findings and returned to the facility on [DATE]. Nursing documentation following readmission reflected a significant decline requiring a mechanical lift for transfers, increased assistance with feeding, decreased trunk control, inability to straighten the bilateral lower extremities because of stiffness, and therapy services were ordered.Record review of Social Services documentation dated 12/16/25 revealed the Resident #195's daughter requested hospice services because of the resident's continued decline and elected to discontinue therapy services. Hospice documentation revealed the resident was admitted to hospice effective 12/17/25.Record review of physician orders revealed an order dated 12/17/25 at 9:30 P.M. for Lorazepam (Ativan) 0.5 milligrams (mg) (antianxiety) by mouth every four hours as needed. Record review further revealed a physician order dated 12/18/25 at 8:00 P.M. for Ativan 0.5 mg by mouth every two hours. Physician orders further revealed Morphine Sulfate concentrate (opioid pain medication) was increased to every two hours for management of the resident's end-of-life symptoms.Record review of nursing documentation dated 12/17/25 at 5:56 P.M. revealed the resident was anxious, pulling at clothing, and reaching outward. Documentation reflected the family requested Ativan and the Certified Nurse Practitioner (CNP) was notified.Record review of nursing documentation dated 12/18/25 at 10:44 A.M. revealed Resident #195's respirations of 53 breaths per minute. Morphine was administered without effective relief. Hospice contacted the CNP, and the Morphine dosage was increased.Record review of nursing documentation dated 12/18/25 at 6:43 P.M. revealed Resident #195's respirations remained elevated at 56 breaths per minute. Hospice contacted the on-call provider, who issued new medication orders, including Morphine every two hours and Lorazepam (Ativan) every two hours. Documentation reflected the resident's family remaining at the bedside.Review of the December 2025 Medication Administration Record (MAR) revealed Lorazepam (Ativan) was documented as administered at 6:00 A.M. on 12/18/25. The next documented administration occurred at 4:00 A.M. on 12/19/25 despite physician orders directing administration every two hours.During an interview on 06/16/26 at 4:00 P.M., the Director of Nursing (DON) revealed the facility exhausted its emergency starter supply of Ativan and the pharmacy advised the medication had already been packaged for routine delivery.During an interview on 06/17/26 at 9:48 A.M., Clinical Director of Gardens of the Western Reserve Hospice #644 revealed hospice ordered Ativan for management of the resident's end-of-life symptoms and confirmed the resident experienced increasing respiratory distress requiring continued symptom management.During an interview on 06/17/26 at 10:00 A.M., Pharmacy Operations Manager #645 revealed the medication had been dispensed on 12/17/25 for delivery on 12/18/25. The facility contacted the pharmacy at 7:10 P.M., hospice contacted the pharmacy at 8:08 P.M., and at 8:14 P.M. the agency nurse reported not having access to the medication storage unit. The medication remained available within the medication storage unit and could have been obtained if temporary access had been authorized.During an interview on 06/17/26 at 11:20 A.M., the DON and Licensed Practical Nurse (LPN) Nurse Manager #578 revealed agency nurses could be granted temporary access to the medication storage unit after normal pharmacy hours when needed.Review of the facility's Medication Administration Policy revealed medications were to be administered as ordered by the physician. The policy further directed nursing staff to review physician orders for accuracy, transfer medication orders to the MAR, assign medication administration times, administer medications as ordered, document medication administration, monitor residents for adverse drug reactions, and notify the physician of adverse reactions.Review of the Medication Storage Unit Access (STATSAFE) Policy revealed agency nurses were not routinely granted access to the medication storage unit. If an agency nurse required a controlled substance and two facility-employed licensed nurses were unavailable, the DON or designee could authorize temporary access. If temporary access could not be authorized and the medication could not be obtained through routine procedures, the pharmacy was to be contacted for a medication drop shipment.This deficient practice represents non-compliance investigated under Complaint Number 2716326.

Based on record review, staff interview, and review of facility policies, the facility failed to administer physician ordered medications as prescribed for one resident (Resident #194) of three reviewed for medication administration. The facility did not ensure that admission medications ordered for the evening of 12/18/25 were administered as required, resulting in a delay in treatment for Resident #194. This affected one (Resident #194) of three residents reviewed for medication administration. The facility census was 88.Findings include: Review of Resident #194's closed medical record revealed the resident was admitted to the facility on [DATE] from an Acute Care Hospital Rehabilitation following spinal reconstruction surgery. Pertinent diagnoses included post-laminectomy syndrome, rheumatoid arthritis, urinary retention, urinary tract infection, hypothyroidism, hypertension, asthma, depression, and chronic pain requiring ongoing medication management.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #194 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and able to communicate healthcare needs. The MDS further documented the resident experienced frequent pain that did not interfere with sleep or participation in activities.Review of the comprehensive care plan initiated 12/19/25 revealed interventions directing staff to administer medications as ordered, routinely assess pain, monitor the effectiveness of pain interventions, notify the physician of changes in condition, and document the resident's response to interventions.Review of physician orders dated 12/18/25 revealed admission medication orders were received and verified by the attending physician at approximately 5:21 P.M. Orders included, but were not limited to, cephalexin (Keflex) (antibiotic), budesonide/formoterol (Symbicort) (inhaler for asthma and chronic obstructive pulmonary disease), sulfasalazine (anti-inflammatory), pregabalin (Lyrica) (anticonvulsant and neuropathic pain agent), methocarbamol (muscle relaxant), levothyroxine (hormone replacement), oxycodone (opioid pain medication) as needed (PRN), and additional prescribed medications. These medications were ordered for administration beginning the evening of the resident's admission.Review of the December 2025 Medication Administration Record (MAR) revealed physician-ordered medications, including Keflex, Symbicort, sulfasalazine, Lyrica, methocarbamol, levothyroxine, and PRN oxycodone, scheduled for administration on the evening of 12/18/25, were not documented as administered following physician verification of the admission orders. Documentation reflected these medications were first administered on 12/19/25. The MAR further documented the resident's pain assessment was zero on a pain scale of zero to ten, ten being the worst, upon admission and subsequently increased to six and later nine prior to the first documented administration of the ordered medications on 12/19/25.Review of nursing progress notes revealed no nursing documentation addressing the failure to administer the ordered medications, attempts to obtain the medications, physician notification, or resident follow-up during the overnight period following admission. Nursing documentation did not resume until approximately 11:00 A.M. on 12/19/25.During an interview on 06/17/26 at 1:45 P.M., the Director of Nursing (DON) stated the admission paperwork had not been completed until the following day, there were no nursing progress notes documented until approximately 11:00 A.M. on 12/19/25, and Resident #194 did not receive the nighttime medications ordered on 12/18/25. The DON further stated she was unable to explain how the agency nurse documented the resident's pain as zero on admission and nine the following morning and confirmed the resident's ordered nighttime medications had not been administered.Review of the facility's Medication Administration Policy revealed it is the facility's policy to administer medications as ordered by the physician. The policy further directed staff to review admission medications against discharge orders, review medications with the physician, transfer medications to the MAR as verified by the physician, assign a time for medication administration, monitor residents for adverse reactions following medication administration, and notify the physician when indicated.Review of the facility's Pain Evaluation and Management Policy and Procedure revealed pain evaluations are to be completed upon admission, an individualized pain management care plan is to be initiated for residents with identified pain, charge nurses are to monitor pain every shift and complete supporting documentation in the electronic health record, and nursing staff are responsible for notifying the physician if pain is not controlled.This deficiency represents non-compliance investigated under Complaint Number 2700370.

Based on observation, review of the kitchen cleaning logs, interviews and facility policy review, the facility failed to ensure the kitchen was maintained in a clean sanitary manner. The facility also failed to ensure the unit refrigerators for resident use were maintained as required. This had the potential to affect all 87 residents who received meals from the facility kitchen. The facility indicated there were no residents who received nothing by mouth. The facility census was 87.Findings include:1. Initial kitchen tour on 12/15/25 at 8:45 A.M. with Dietary Manager (DM) #700 revealed the following concerns:A. In the walk-in refrigerator there was:-a metal container of leftover egg salad with a use by date of 12/10/25-a metal container of leftover cranberry sauce with a use by date of 11/10/25-a metal container of leftover pumpkin puree with a use by date of 11/24/25-a Ziploc bag of leftover sliced turkey lunchmeat with a use by date of 12/12/25B. No thermometer was found in the walk-in freezerC. Scoops were located inside both the flour and sugar rolling bin carts sitting submerged in both the flour and sugar products.Observation on 12/15/25 at 9:00 A.M. with DM #700 revealed the six-burner gas stove was heavily soiled in and around the burner grates as well as the area around the griddle. The front of the stove was soiled with dried spills on the front and side of the stove. The area below the stove and surrounding the perimeter of the stove were heavily soiled and black in color. Observation on 12/15/25 at 9:02 A.M. with DM #700 revealed the convection oven was heavily soiled inside on the bottom below the racks.Observation on 12/15/25 at 9:05 A.M. with DM #700 of the two utensil drawers along the wall across from the oven revealed crumbs in the bottom of the drawers and the bottom of the right drawer had a dried white spill of unknown origin.Observation on 12/15/25 at 9:08 A.M. with DM #700 revealed hanging on the wall leading into the dish machine area was the three-compartment-sink sanitizer log for November and December 2025. The November log revealed 11/01/25 through 11/10/25 were completed and no additional dates for November were recorded. December 2025 log revealed only 12/06/25 and 12/07/25 were completed.Observation on 12/15/25 at 9:10 A.M. with DM #700 of the dish machine temperature log for December 2025 hanging on the wall leading into the dish machine area revealed it was supposed to be completed after each meal prior to starting the dish machine. Breakfast was not completed on 12/01/25 and 12/14/25. Lunch was not completed on 12/01/25. Dinner was not completed 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/06/25, 12/07/25 and 12/14/25.Interview on 12/15/25 at 9:14 A.M. with DM #700 confirmed all of the above areas of concern. Dietary Manager #70 stated staff were not supposed to keep leftovers and were not supposed to leave scoops in the flour or sugar bins. Staff were supposed to complete daily cleaning tasks. DM #700 confirmed there was no posted cleaning task schedule or place for staff to sign off as they completed their cleaning tasks. DM #700 stated staff were trained when they were oriented and knew what tasks they were to complete daily. DM #700 stated she does spot checks to ensure staff are completing their scheduled cleaning tasks. DM #700 confirmed the dish machine temperature logs and the three compartment sink sanitizer logs were not completed as required. DM #700 also confirmed the ovens had not recently been cleaned and were supposed to be cleaned every two weeks but was unable to state when they were last cleaned.2. Observation on 12/16/25 at 9:20 A.M. with Administrator in Training (AIT) #422 of the unit refrigerators revealed the following concerns:-the South unit refrigerator shelves were sticky, and two plastic bags were found tied but had no date or name on the bags. Inside the bags revealed an open, undated eight-ounce container of French onion dip, an open, undated unlabeled eight-ounce container of chive and onion dip, an open, unlabeled partially eaten five and quarter ounce container of turtle cheesecake with a best if used by date of 12/12/25, and an opened 11-ounce container of pre-prepared beef pot roast with a use by date of 12/12/25. -the memory care unit had an unlabeled plastic container of leftover soup with a use by date of 12/15/25.Interview on 12/16/25 at 9:33 A.M. with AIT #422 confirmed the above findings in the unit refrigerators and also confirmed the sign on the front of each refrigerator stated it would be cleaned weekly on Fridays not every three days as the facility policy stated.Review of the undated Dietary Services policy titled Sanitation Policy revealed the purpose is to maintain a clean, safe, and sanitary environment in all dietary and food service areas to prevent contamination and illness. All dietary staff, contractors, and volunteers shall follow sanitation procedures in accordance with federal, state and local regulations. All food contact surfaces must be cleaned, rinsed, sanitized and air-dried. Surfaces must be sanitized before use and after meal service. Floors must be swept and mopped daily. Storage areas must remain clean and organized. The policy was vague and did not provide specific instructions and frequency for all types of cleaning. Review of the undated facility cleaning checklist titled Main Kitchen Closing Checklist- Cooks revealed both ovens are to be cleaned top to bottom. Utensil drawer cleaned and organized (no crumbs).Review of the undated facility cleaning checklist titled Main Kitchen End of Shift Checklist-Server 2 revealed sanitizer log to be completed.Review of the undated facility cleaning checklist titled Main Kitchen End of Shift Checklist- Server 3 revealed dish machine temperate log to be completed. Review of the untitled, undated facility sign on the front of the unit refrigerators revealed For Residents: name and date must be on food. All Food and liquids must be dated once opened. If there is no date on the food, it will be tossed out. The refrigerator will be cleaned every Friday.Review of the undated facility policy titled Food Safety Information revealed if families or friends bring in treats and favorite foods and if the items need to store or re-heated, please store the food in closed microwave-safe containers labeled with your loved one's name, contents and the date. Staff will show you where items may be kept. Food may be held for three days before it is discarded due to food safety concerns.

Based on observation, staff interview and facility policy review, the facility failed to ensure the dumpster/refuse area was maintained in a clean and sanitary condition. This had the potential to affect all residents residing in the facility. The facility census was 87.Findings include:Observation during the initial kitchen tour completed on 12/15/25 at 9:16 A.M. with Dietary Manager (DM) #700 revealed the dumpster lid was open, the dumpster was overflowing, and there were four bags of garbage on the ground surrounding the dumpster. Interview at the time of the observation with DM #700 confirmed the dumpster was supposed to emptied daily, was not covered, and garbage bags should not have been lying on the ground.Review of the undated facility policy called; Sanitation Policy under the section waste disposal and pest control stated trash must be removed frequently but did not specify any specifics as to the frequency trash was to be taken out or how often the dumpster would be emptied.

Based on observation, interview, and facility policy review, the facility failed to maintain clean medication storage in the North and South medication carts. This affected 50 residents (Residents #01, #04, #05, #07, #09, #11, #13, #17, #18, #20, #22, #23, #27, #29, #32, #35, #37, #38, #40, #42, #43, #45, #46, #47, #48, #49, #51, #52, #53, #54, #59, #63, #64, #68, #69, #70, #74, #76, #78, #79, #80, #81, #82, #83, #85, #86, #87, #88, #99, #100) out of 50 residents on the North and South medication carts, and had the potential to affect all 87 residents residing in the facility.Findings include:Observation on 12/16/25 at 7:55 A.M. of the North medication cart with Licensed Practical Nurse (LPN) #720 revealed 18 unidentified pills on the bottom of the first and second drawers collectively, and powdered pill residue along the bottom and corners of the first and second medication cart drawers. Interview on 12/16/25 at 8:02 A.M. with LPN #720 for the North medication cart verified the number of loose medications, and the pill residue in the first and second medication cart drawers.Observation on 12/16/25 at 8:42 A.M. of the South medication cart with LPN #501 revealed two unidentified pills on the bottom of the second drawer. Interview on 12/16/25 at 8:42 A.M. with LPN #501 for the South medication cart, verified the two unidentified loose pills in the second drawer.Review of the undated facility document titled, Medication Storage in the Facility revealed medication storage areas are to be kept clean, well lit, and free of clutter.

Based on record review, observations, resident interview, staff interview, and facility policy review, the facility failed to ensure assistive hearing devices were in place to maintain hearing abilities. This affected one resident (#20) of one resident reviewed for assistive devices. The facility census was 87.Findings include: Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis, and chronic kidney disease.Review of the physician orders dated 06/01/25 revealed an order to place Resident #20's bilateral hearing aids in ears and lock hearing aids in medication cart as needed per request.Review of the care plan dated 09/16/25 revealed Resident #20 had potential for impaired communication and/or disorientation related to hard of hearing and wearing bilateral hearing aids. Interventions included assistance with the use of hearing aids as needed and place bilateral hearing aids in ears every morning and removed every night and lock in medication cart.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented with some cognition impairment. Review of the MDS assessment revealed Resident #20 required assistance from staff for activities of daily living (ADL).Review of the progress note dated 12/03/25 at 12:48 P.M. revealed Resident #20's new hearing aids with the new ear molds arrived to the facility.Observation and interview on 12/15/25 at 10:59 A.M. revealed Resident #20 seated in her wheelchair with family visiting. Resident #20 was observed yelling when asked questions and had trouble understanding family and state surveyor. Resident #20 stated speak louder, I can't hear what you're saying. Family revealed that Resident #20 had trouble hearing and had new hearing aids that were to be placed in her ears daily. Family revealed the facility staff were aware of Resident #20 hearing aids and the request to have them in daily. Family revealed the facility staff did not put them in Resident #20's ears as requested. Observation revealed Resident #20 did not have hearing aids in her ears at the time of the interview.Interview on 12/17/25 at 11:41 A.M. with Licensed Practical Nurse (LPN) #501 revealed Resident #20 was hard of hearing and wore hearing aids that were kept in the medication cart. LPN #501 revealed Resident #20 received a new set of hearing aids recently, approximately three weeks ago. LPN #501 revealed Resident #20's hearing aids were removed due to Resident #20 always brushing her hair behind her ears, which in return caused the hearing aids to fall out. LPN #501 revealed Resident #20's family requested staff to have the hearing aids placed in her ears. LPN #501 revealed she did not ask Resident #20 if she wanted her hearing aids placed in her ear.Observation and interview on 12/17/25 at 12:08 P.M., approximately 34 minutes later, Resident #20 was observed in her room seated in her wheelchair attempting to put a hearing aid into her left ear. Resident #20 stated no one helps me put them in. I'm trying to put them in. Resident #20 was observed continuously trying to place hearing aids in her ears with shaky hands. Resident #20 appeared upset and stated, I can't hear anyone talk.Interview and observation on 12/17/25 at 12:09 A.M. with LPN #501 revealed she was unaware that Resident #20 was upset and attempting to put her hearing aids in her ears. LPN #501 stated I'll get the batteries and head down. LPN #501 confirmed and verified the above findings at the time of the interview and observations.Review of the undated facility document titled Resident Vision and Hearing Screening revealed the facility had a policy in place to identify, treat and monitor residents who have potential for hearing needs as indicated by assessments and/or resident and family. Review of the policy revealed the facility would ensure implementation of care plan interventions and monitoring. Review of the document revealed the facility did not implement the policy.

Based on record review, observation, interview and facility policy review, the facility failed to ensure the proper delivery of oxygen and accurately document its administration according to the physician orders and the resident's comprehensive care plans. This affected two residents (Resident #01 and Resident #17) out of four residents reviewed for oxygen/respiratory therapy. This had the potential to affect 15 additional residents (Residents #06, #07, #08, #22, #25, #37, #43, #49, #52, #53, #56, #62, #69, #80, and #82) with orders for oxygen. The facility census was 87.Findings include:1. Resident #01 was admitted on [DATE] with diagnoses of chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath (SOB), and anemia. Review of the comprehensive care plan dated 08/29/25 for altered respiratory status related to a diagnosis of COPD, and SOB when lying flat at times. Intervention dated 10/02/25 included oxygen at two liters per minute via nasal cannula (a flexible plastic tube with two prongs that fit into the nostrils to deliver oxygen) for SOB and comfort as ordered. Additionally, the care plan documented an oxygen weaning program was initiated on 12/02/25 and failed. The care plan revealed there was no intervention for oxygen tubing changes. Review of December 2025 physician orders revealed a physician order dated 10/01/25 at 7:00 A.M. for Resident #01 to have oxygen at two liters per nasal cannula for SOB and comfort every shift. Resident #01 also had a physician order dated 10/07/25 at 11:00 P.M., for his oxygen tubing to be changed every Tuesday, every week on the night shift. Review of the December 2025 Medication Administration Record (MAR) revealed the oxygen at two liters per nasal cannula was signed off as administered each shift from 12/01/25 (day shift) through 12/15/25 (night shift). The evening shift of 12/06/25 was left blank on the MAR. Review of the December 2025 Treatment Administration Record (TAR) revealed the oxygen tubing was initialed as completed by Licensed Practical Nurse (LPN) #901 on 12/02/25 and 12/09/25. Review of the telephone order in the medical record revealed an order dated 12/02/25 at 9:30 A.M. for oxygen at two liters per nasal cannula for comfort and SOB. Review of the MAR for Resident #01 dated 12/02/25 at 12:00 P.M. revealed an order to check the pulse oximetry (a non-invasive device clipped on finger to check the percentage of oxygen in the blood) every four hours for 24 hours. Review of the December MAR pulse oximetry readings ranged from 95 percent to 99 percent during this time. Review of the MAR for Resident #01 dated 12/02/25 at 3:00 P.M. revealed an order to wean the oxygen as tolerated, with a goal for oxygen saturation to be maintained greater than 90 percent, document every shift regarding respiratory status, and include pulse oximetry for three days, every shift. Review of the nursing note dated 12/03/25 at 6:17 A.M. revealed the resident remained off oxygen the entire night shift, with a pulse oximetry of 97 percent on room air. Review of the nursing note dated 12/04/25 at 5:32 P.M. revealed Resident #01 remained on room air with a pulse oximetry of 97 percent. Review of the progress note dated 12/04/25 completed by Nurse Practitioner (NP) #424 revealed Resident #01's oxygen saturation had been stable on room air. Review of the quarterly Minimum Data Set (MDS) 3.0, dated 12/04/25 Section O: Special Treatments, Procedures, and Programs revealed no documentation of oxygen therapy delivered. Review of the nursing note dated 12/06/25 at 10:30 A.M. revealed an oxygen saturation of 96 percent on room air. Observation on 12/15/25 at 2:58 P.M. revealed Resident #01 in his room seated in his wheelchair. The oxygen concentrator was next to the bed and not in use. The tubing on the concentrator was dated 11/26/25. Interview on 12/15/25 at 3:10 P.M. with the Director of Nursing (DON) verified the oxygen tubing in Resident #01's room was dated 11/26/25, and the TAR for oxygen tubing change was signed off on 12/02/25 and 12/09/25 by LPN #901 as being changed. The DON verified this documentation was not accurate in Resident #01's medical record. The DON also verified he was not wearing his oxygen. Observation on 12/16/25 at 12:45 P.M. revealed the oxygen tank in Resident #01's room was shut off, and in the room at the bedside. Observation at 12:48 P.M. revealed Resident #01 seated in the dining room eating lunch with his wife present. Resident #01 was not wearing oxygen per nasal cannula as ordered. Interview on 12/16/25 at 12:49 P.M. with Resident #01's wife revealed Resident #01 had not worn his oxygen for quite some time. The family member stated the resident was off the oxygen because the facility tested him and he did not need it. Interview on 12/16/25 at 12:55 P.M. with LPN #720 revealed Resident #01's current oxygen order was for two liters continuous per nasal cannula for SOB and comfort every shift, and he was not wearing his oxygen. Interview on 12/16/25 at 1:00 P.M. with the DON verified the current oxygen order dated 10/01/25 and 12/02/25 was for Resident #01 to have oxygen at two liters per nasal cannula continuous for SOB and comfort every shift. The DON verified the physician order dated 12/02/25 to check his pulse oximetry every four hours for 24 hours with attempt to wean off his oxygen was completed and his pulse oximetry readings were above 95 percent but confirmed that his oxygen order was not changed to an as needed basis. The DON confirmed his continuous oxygen order was signed off as administered on the MAR from 12/01/25 to 12/15/25, and he was not wearing it as documented in the nursing notes and observations. Interview on 12/16/25 at 2:05 P.M. with the DON verified the care plan documented an oxygen weaning program was initiated on 12/02/25 and that Resident #01 had failed the program, but she verified this was not accurate as his pulse oximetry readings were 95 percent or above. She also verified that the MDS documentation that the oxygen was not delivered during the assessment period was not accurate. 2. Review of medical record for Resident #17 revealed an admission date of 06/17/24 and her diagnoses included Alzheimer's disease, anemia, and dysphagia (difficulty swallowing). She did not have any respiratory diagnosis listed. Review of care plan dated 09/20/24 revealed Resident #17 had altered respiratory status related to complaints of SOB with exertion at times. Interventions included oxygen at two liters as needed per nursing judgement for comfort, and change oxygen tubing as ordered. Review of quarterly MDS assessment dated [DATE] revealed Resident #17 was cognitively impaired and used oxygen. Review of December 2025 physician order revealed Resident #17 had an order dated 05/02/25 for oxygen at two liters per nasal cannula as needed per nursing judgement for comfort. She had an order dated 06/12/25 to have her oxygen tubing changed every Tuesday on night shift. Review of December 2025 TAR revealed the oxygen tubing was initialed as replaced by LPN #901 on 12/02/25 and 12/09/25. Observation and interview on 12/15/25 at 10:14 A.M. revealed Resident #17 were sitting in her recliner, and she had an oxygen concentrator sitting next to her bed not in use. The nasal cannula connected to the concentrator had a piece of tape on the tubing dated 11/26/26. Interview with Resident #17 revealed she was unable to indicate when she wore her oxygen and/or when the last time she did due to cognitive impairment. Interview on 12/15/25 at 3:08 P.M. with the DON verified the oxygen tubing in Resident #17's room was dated 11/26/25. She verified Resident #17 had an order to change the tubing weekly, and the TAR was initialed as the tubing was changed on 12/02/25 and 12/09/25 by LPN #901. The DON verified this documentation was not accurate in Resident #17's medical record as the tubing in her room was dated 11/26/25, indicating the last time it was changed. Review of the facility policy labeled, Oxygen Administration, dated March 2004, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. The policy revealed the nurse was to verify the physician's order, review the care plan and assemble the equipment. There was no documentation in the policy regarding changing oxygen tubing.

Based on record review, interview, observation, and review of the facility policy, the facility failed to ensure medical records contained accurate documentation. This affected three (Residents #1, #17, and #45) out of 22 residents for accuracy of medical records. The facility census was 87.Findings include:1. Review of the medical record for Resident #45 revealed an admission date of 06/01/23 with diagnoses including paranoid schizophrenia, anxiety disorder and wounds to his left medial ankle and heel. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition and had one vascular wound. Review of the November 2025 and December 2025 Physician Orders revealed Resident #45 had the following orders: an order dated 09/20/25 to irrigate his left medial ankle with normal saline and apply anacept gel (a clear antimicrobial gel that kills bacteria and assists with debridement) to the wound. The order to his left medial ankle was discontinued and changed on 12/05/25 to Dakins (a diluted bleach solution for cleaning a wound and killed bacteria) one forth strength solution apply moistened gauze to left medial ankle and dermaseptin (a skin protectant ointment that created a barrier to prevent irritation) to peri wound (skin surrounding the wound) and cover with foam adhesive dressing every evening. In addition, Resident #45 had an order dated 11/13/25 to irrigate his left heel with normal saline, apply betadine (an antiseptic solution), abdominal (ABD) pad and wrap with Kerlix gauze every evening shift. Review of the November 2025 Treatment Administration Record (TAR) revealed an order dated 09/20/25 to irrigate his left medial ankle with normal saline and apply anacept gel to wound. The nurse was then to apply dermaseptin to the macerated outer skin of the wound, and cover with foam adhesive every evening shift. The TAR was blank on 11/07/25 and 11/22/25 indicating the treatment was not done. Resident #45 also had an order dated 11/13/25 to irrigate his left heel with normal saline, apply betadine, ABD pad and wrap with Kerlix gauze every evening shift. The TAR was blank on 11/22/25 indicating the treatment was not done. Review of the care plan last revised 11/19/25 revealed Resident #45 was at risk for further skin breakdown and/ or pressure injury related to impaired mobility, and weakness. He had a vascular wound (an ulcer due to poor circulation) to his left ankle and a deep tissue injury (a pressure ulcer caused by damage to soft tissue beneath intact skin) to his left heel. Interventions included encourage Prevalon boots (heel protector) while in bed, pressure relieving mattress to bed, and treatments as ordered. Review of the December 2025 TAR revealed Resident #45 had an order dated 09/20/25 to irrigate his left medial ankle with normal saline and apply anacept gel to wound. The nurse was then to apply dermaseptin to the macerated outer skin of the wound, and cover with foam adhesive every evening shift. The TAR was blank 12/01/25, 12/02/25, and 12/03/25 indicating the treatment was not done. The order to his left medial ankle was discontinued and changed on 12/05/25 to Dakins one forth strength solution apply moistened gauze to left medial ankle and dermaseptin to peri wound outer skin and cover with foam adhesive dressing every evening. The TAR was blank on 12/06/25. Resident #45 also had an order dated 11/13/25 to irrigate his left heel with normal saline, apply betadine, ABD pad and wrap with Kerlix gauze every evening shift. The TAR was blank 12/01/25, 12/02/25, 12/03/25, and 12/06/25 indicating the treatment was not done. Interview on 12/15/25 at 10:53 A.M. and 12/17/25 at 11:44 A.M. with Resident #45 revealed he felt his treatments were completed as ordered. Interview on 12/17/25 at 11:40 A.M. with MDS/ Licensed Practical Nurse (LPN) #513 verified on Resident #45's November 2025 and December 2025 TARs that the treatments were blank for the following dates: 11/07/25, 11/22/25, 12/01/25, 12/02/25,12/03/25 and 12/06/25 indicating the treatments were not completed. She revealed she felt the treatment was completed, but that the nurse did not document accurately the completion of the treatments. Review of the witness statement dated 12/18/25 and completed by LPN #712 revealed on 12/02/25 she had changed Resident #45's foot treatments to assist the other nurse but forgot to sign off the treatment. Review of the witness statement dated 12/19/25 and completed by LPN #621 revealed on 12/01/25 she performed Resident #45's treatments but did not chart. 2. Resident #01 was admitted on [DATE] with diagnoses of chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and anemia. Review of Resident #01's care plan for altered respiratory status initiated on 08/29/25 revealed no intervention for oxygen tubing changes. Review of the physician orders dated 10/01/25 at 7:00 A.M. revealed an order for oxygen at two liters per nasal cannula for shortness of breath and comfort, every shift for comfort and shortness of breath. Physician orders dated 10/07/25 at 11:00 P.M., revealed an order for the oxygen tubing change every Tuesday, every week on the night shift. Review of the TAR for December 2025 revealed the oxygen tubing was initialed as replaced by LPN #901 on 12/02/25 and 12/09/25. Observation on 12/15/25 at 2:58 P.M. revealed Resident #01 in his room seated in his wheelchair. The oxygen concentrator was next to the bed and not in use. The tubing on the concentrator was dated 11/26/25. Interview on 12/15/25 at 3:10 P.M. with the Director of Nursing (DON) verified the oxygen tubing in Resident #01's room was dated 11/26/25, and the TAR for oxygen tubing change was signed off on 12/02/25 and 12/09/25 by LPN #901. The DON verified this documentation was not accurate in Resident #01's medical record. 3. Review of the medical record for Resident #17 revealed an admission date of 06/17/24 with diagnoses including Alzheimer's disease, anemia, and dysphagia (difficulty swallowing). She did not have any respiratory diagnoses listed. Review of the care plan dated 09/20/24 revealed Resident #17 had altered respiratory status related to complaints of shortness of breath with exertion at times. Interventions included oxygen at two liters as needed per nursing judgement for comfort, and change oxygen tubing as ordered. Review of the quarterly MDS assessment dated [DATE] revealed Resident #17 was cognitively impaired and used oxygen. Review of the December 2025 physician order revealed Resident #17 had an order dated 05/02/25 for oxygen at two liters per nasal cannula as needed per nursing judgement for comfort. She had an order dated 06/12/25 to have her oxygen tubing changed every Tuesday on night shift. Review of the December 2025 TAR revealed the oxygen tubing was initialed as replaced by LPN #901 on 12/02/25 and 12/09/25. Observation and interview on 12/15/25 at 10:14 A.M. revealed Resident #17 was sitting in her recliner, and she had an oxygen concentrator next to her bed not in use. The nasal cannula connected to the concentrator had a piece of tape on the tubing dated 11/26/26. Interview with Resident #17 revealed she was unable to indicate when she wore her oxygen and/or when the last time she did due to cognitive impairment. Interview on 12/15/25 at 3:08 P.M. with the DON verified the oxygen tubing in Resident #17's room was dated 11/26/25. She verified Resident #17 had an order to change the tubing weekly, and the TAR was initialized as the tubing was changed on 12/02/25 and 12/09/25 by LPN #901. The DON verified this documentation was not accurate in Resident #17's medical record as the tubing in her room was dated 11/26/25, indicating the last time it was changed. Review of the facility policy labeled, Oxygen Administration, dated March 2004, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. The policy revealed the nurse was to verify the physician's order, review the care plan and assemble the equipment. There was no documentation in the policy regarding changing oxygen tubing. Review of the facility policy labeled, Clean Dressing Change, dated 02/26/20, revealed the nurse was to check the physician order for the current treatment order. There was no documentation in the policy regarding ensuring the treatment was documented in the TAR as completed. Review of the facility policy labeled, Charting, dated March 2025, revealed the DON or designee would review all skilled and long-term charting to ensure continuity of care, nursing care was appropriate, timely and complete.

Based on record review, observation, interview, review of Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure droplet infection control precautions (infection control measures to stop germs spreading by respiratory droplets from coughing, sneezing and/or talking that travel short distances about three to six feet) were followed for Resident #82. This affected one (Resident #82) of one resident with a physician order for droplet precautions. The facility census was 87.Findings include:Review of the medical record for Resident #82 revealed an admission date of 11/22/25 with diagnoses including chronic respiratory failure and hypoxia, COVID-19, chronic congestive heart failure, and obstructive sleep apnea. Review of the nursing note dated 12/11/25 at 10:42 A.M. and completed by Registered Nurse (RN)/ Minimum Data Set (MDS) #812 revealed Resident #82 tested positive for COVID-19 and was on droplet precautions. Review of the physician order dated 12/11/25 revealed Resident #82 had a physician order for droplet precaution isolation due to COVID-19 and may discontinue (12/21/25) after ten days with improvement of sign and symptoms. Review of the care plan dated 12/11/25 revealed Resident #82 was at risk for complications related to diagnosis of COVID-19 and was on droplet precautions. Interventions included droplet precautions for all services in her room due to COVID-19 and monitor for signs of respiratory distress. Observation on 12/16/25 at 11:42 A.M. revealed the x-ray technician (XRT) #423 left the room of Resident #82 with a face shield and surgical face mask. Interview on 12/16/25 at 11:42 A.M. with XRT #423 revealed that she was wearing a gown, gloves, face shield and surgical mask (a mask that covers the mouth and nose and acts as a barrier to transmission of infectious agents) while delivering x-ray services. Further, XRT #423 revealed she did not know the rules regarding what type of mask and did not ask staff prior to entering the room. She verified she had worn only a surgical mask in the room while within six feet of Resident #82 as she took her x-ray. Observation of the isolation cart third (bottom) drawer revealed a supply of N95 masks. XRT #423 verified the availability of N95 (a disposable filtering facepiece respirator that was designed to protect the wearer from airborne particles) masks.Observation on 12/16/25 at 11:42 A.M. revealed signage on the room door for Resident #82 indicated special droplet/contact precautions (Washington State Hospital Association and Washington State Department of Health, last revised 03/09/20). Detailed precautions included to (a) Clean hands when entering and leaving room, wear face mask, eye protection (face shield or goggles), and gown and glove at door. (b)When doing aerosolizing procedures fit tested N95 with eye protection or higher required. (c) Keep door closed. (d) Use patient dedicated or disposable equipment. (e) Clean and disinfect shared equipment. (The signage did not indicate to wear an N95 mask at all times when in the room for all services).Interview on 12/16/25 at 12:00 P.M. with the Director of Nursing (DON) confirmed that Resident #82 was on droplet precautions for COVID-19 and required an N95 mask for any staff and/ or vendor that entered the room. Interview on 12/18/25 at 9:00 A.M. RN/ Infection Control Designee #411 verified the signage on Resident #82's door indicated special droplet/contact precautions that included clean hands when entering and leaving room, wear face mask, wear eye protection (face shield or goggles), and gown and glove at door. The signage also indicated during aerosolizing procedures to wear an N95. She revealed the signage should have indicated wearing an N95 during all services not just aerosols. She verified that all staff/ vendors were to wear an N95 mask when in a room with a resident positive for COVID-19 including XRT #423 should have worn one. Review of x-ray service agreement with the facility dated 06/01/10 does not include infection control practices or following facility infection control policies.Review of the facility document titled, Isolation, Initiating Transmission-Based Precautions, last revised 11/04/24, revealed droplet precautions included COVID-19 in the list of examples requiring droplet precautions within the policy. The policy revealed in addition to standard precautions, put on a mask (and eye protection if recommended) when entering the room or cubicle. The policy does not include type of mask to be used. Review of the facility policy labeled, Infection Control Policy, dated 01/23/24, revealed the facilities infection control policies and practices apply equally to all personnel, consultants, residents, visitors, volunteers and all general public alike. Review of CDC guidelines labeled, Infection Control Guidance: SARS-CoV-2 (COVID-19) revealed staff that enter the room of a patient with suspected or confirmed COVID-19 should adhere to standard precautions and use an approved N95 mask, gown, gloves and eye protection.

Based on closed record review, interview and review of facility policy, the facility failed to provide adequate assistance/supervision and develop and implement a comprehensive, individualized and effective fall prevention program for Resident #91 to prevent falls with injury and failed to ensure the resident was adequately and timely assessed post fall. Actual harm occurred beginning on 09/27/24 when Resident #91, who was at high risk for falls, had a history of multiple falls and was cognitively impaired with poor safety awareness, sustained a witnessed fall resulting in injury in the rehab gym when Physical Therapy Assistant (PTA) #432 walked away from Resident #91 during treatment to get equipment and the resident fell while being left unattended. On 09/30/24 (three days after the fall), Resident #91's wife alerted staff to bruising to the resident's rib area. An x-ray was ordered revealing multiple rib fractures. On 10/05/24 Resident #91 sustained a fall when he stood up from his wheelchair while being left unattended by staff and fell to the ground fracturing his right wrist requiring treatment in the hospital emergency room to obtain a cast to his right wrist. This affected one resident (#91) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the closed medical record for Resident #91 revealed the resident was admitted to the facility on [DATE] with diagnoses including fracture of femur with routine healing, sleep behavior disorder, fracture of radius, disorder of bone density and structure, restlessness, multiple fractures of the ribs left side, orthopedic aftercare, pulmonary hypertension, dementia, repeated falls, atrial fibrillation, age related macular degeneration and Parkinson's disease. The resident was discharged to another facility on 10/24/24. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident # 91 was admitted to the facility on [DATE] from a general hospital. Resident #91 was usually able to make self-understood and usually able to understand others and had impaired vision. Resident #91 had long term memory problems and short-term memory problems and moderately impaired decision-making skills. The assessment revealed the resident required moderate assistance to roll left and right in bed, was dependent on staff to sit on the side of the bed, lie back in bed, transfer from the bed to the chair and transfer on and off the toilet. Resident #91 did not attempt to walk ten feet. Resident #91 was continent of bladder. The assessment also noted Resident #10 had a fall history prior to admission. Review of the Fall Risk Evaluation dated 09/10/24 revealed Resident #10 was a high risk for falls. Review of the plan of care initiated of 09/11/24 revealed Resident #91 had a self-care deficit on admission from a recent hospitalization for a fall with left femur neck fracture for which he had a surgical nailing performed. Due to cognitive deficits, the resident often forgot to use the walker and had frequent falls. The care plan revealed the resident required increased assistance with care related to impaired mobility, pain and severe cognition deficits, combative and resistant with care. Resident #91 also had a plan of care for being at high fall risk related to impaired mobility, pain, severe cognition deficits, increased potential for lethargy, increased agitation, combative and resistant with care, poor safety awareness, psychoactive and opioid medication use, repeated falls at home, behaviors and Parkinson's disease. Fall interventions included administer pain medication as needed, anticipate and meet residents needs, keep call light in reach and encourage use, bed in low position, call daughter or wife when having unsafe behaviors, fall risk evaluation upon admission, quarterly and as needed, monitor changes in balance and safety awareness, monitor for lethargy, pressure alarm to bed, provide assistance as needed with activity of daily living (ADL), physical therapy and occupational therapy evaluation and treatment to increase independence with transfer and mobility, and short string personal alarm to wheelchair. Review of a nursing progress note dated 09/22/24 at 5:59 P.M. authored by Registered Nurse (RN) #392 revealed staff heard resident's alarm go off from the end of the hallway. Resident attempted to stand from the recliner in the lounge area and sank to the floor. Review of the facility document titled Resident Incident Report, dated 09/22/24 and authored by RN #392, revealed Resident #91 had a witnessed fall in the TV lounge at 4:30 P.M. The resident was last toileted at 2:30 P.M. and was sitting in a recliner watching a Brown's game on TV. The resident stated he got up to go to the office and fell . The witness was Registered Nurse (RN) #392. The incident description indicated the resident stood from the recliner, his legs went out and he sat on the floor on his bottom. An alarm was ringing but the RN could not get to the resident in time. An assessment of the resident was completed with no complaints of pain or abnormal vital signs. Additional comments on the document included the resident had a large group of family in to visit who had just left and he fell . The Certified Nurse Practitioner (CNP) was notified with no new orders. The immediate intervention was a short-string personal alarm to chair. Review of the witness statement dated 09/22/24 and authored by Licensed Practical Nurse (LPN) #309 revealed LPN #309 was in another room assisting staff with a transfer when an alarm started to sound. Another nurse, who also was helping assist, looked out of the room and saw Resident #91 standing up. Both nurses headed toward Resident #91 who was found sitting on his bottom saying help. No staff were present with Resident #91 prior to this fall. Review of physician's orders dated 09/23/24 revealed an order for a short string personal alarm, check placement and function every shift to alert staff of transfers. Review of the facility document titled Steel Valley portable x-ray, dated 09/25/24, revealed a left shoulder x-ray was completed and results indicated no acute fractures noted. Review of the Physical Therapist Summary of Skill progress note dated 09/26/24 written by Physical Therapist (PT) #433 revealed Resident #91 needed skilled interventions and training in safe sit to stand and stand to sit mobility. Minimal assist/contact guard assist was needed for sit to stand and stand pivot with front wheeled walker and a Nustep (a piece of specialized equipment which is a recumbent cross-trainer used for low-impact exercise) for 23 minutes to work on strength per therapy goals. Review of the facility document titled Physical Therapy Treatment Encounter Note, dated 09/27/24, revealed transfer training was being provided to increase functional task performance to and from the wheelchair with use of a front wheeled walker and verbal cues for hand placement with contact guard assist to minimal assist to promote prior level of function with decreased fall risk. An additional comment revealed near the end of the therapy session Resident #91 stood from his wheelchair and lost his balance falling onto his right side. The physical therapy assistant (PTA) was across the room and not close enough to help although (the employee) did call out (to the resident) to sit. However, Resident #91 did not (follow the verbal command) due to cognitive deficits. The note included nursing was notified and the resident was assessed with no injuries. Review of the facility document titled Resident Incident Report, dated 09/27/24, revealed Resident #91 had a witnessed fall in the rehab gym at 10:00 A.M. The resident had a personal alarm in place at the time of the fall. The resident was witnessed by PTA #432 to stand up from his wheelchair, leaning to his right side and fell on to his right side and shoulder. The resident had no complaints of pain, no abrasions or contusions. He was at baseline mentation; no abnormal vitals and the physician and family were notified. Interventions included two persons assist and direct attendance during therapy. Review of the witness statement dated 09/27/24 and authored by PTA #432, revealed immediately prior to the fall Resident #91 was sitting in his wheelchair in the therapy gym with his personal alarm in place. PTA #432 who was working with the resident walked across the room away from the resident to get the Nustep set up and after turning to walk back saw Resident #91 stand up from his wheelchair without holding on to anything, lost his balance then fell on to the floor onto his right upper and lower extremities. The resident had on non-skid socks and no injury was noted. Review of a nursing note dated 09/27/24 at 10:03 A.M. written by LPN #320 revealed nursing was notified by therapy that Resident #91 stood up on his own in the gym and fell to the right side. The fall was witnessed by two therapists. Review of a facility Incident Report dated 09/30/24 revealed bruises were found by Resident #91's spouse. Bruises were evaluated to left rib cage and scattered bruises to hand. Resident complained of pain to left shoulder. Treatment included an x-ray of the ribs. Interventions included discussing with wife a one-on-one sitter for Resident #91. Review of medical record nursing note dated 09/30/24 revealed Resident #91 was seen by the CNP who ordered left rib x-ray status post fall. Purple bruising and mild pain noted to area. Review of facility document titled Steel Valley portable x-ray dated 09/30/24 revealed Resident #91 had his left ribs x-rayed and the results were an acute displaced left posterior 7th, 8th and possible 9th rib fracture. Review of the CNP note dated 10/01/24 revealed Resident #91 had closed fractures of multiple ribs on the left side with improving ecchymosis (bruising). Pain was being controlled with routine Tylenol and narcotic pain medication as needed. A lidocaine patch was added for pain. The resident was seen sitting in his chair without complaint of pain. The note included staff to ensure fall precaution. Review of the facility document titled Resident Incident Report, dated 10/05/24 revealed Resident #91 had a witnessed fall in the dining area at 3:44 P.M. The resident had a personal alarm in place and stated he was looking for his office. The incident description indicated Resident #91 was trying to get up several times throughout the shift. The Certified Nursing Assistant (CNA) placed him in his wheelchair and pushed him to the table. Resident #91 kept trying to stand up and kept unlocking his wheelchair. Next thing he fell on to the floor. After the fall his right hand was bruised, and right wrist was swollen, and he had complained of pain with touch/range of motion. The physician and family were notified. The immediate intervention was to move the resident to a more supervised location. Review of medical record nursing note dated 10/05/24 at 3:39 P.M. revealed Resident #91 fell . Resident #91 stood up from his wheelchair. Resident #91 stated he was in pain. An x-ray was order to the right hand and right wrist. Review of facility document titled Steel Valley portable x-ray dated 10/05/24 revealed Resident #91 had an x-ray of right wrist that revealed an acute distal radial fracture and osteopenia. Review of medical record nursing note dated 10/06/24 at 12:24 A.M. revealed Resident #91 x-ray result of right wrist was reported to the CNP and a new order was obtained to send Resident #91 to the emergency room for evaluation. Review of medical record nursing note dated 10/06/24 at 4:32 A.M. revealed Resident #91 came back to the facility from the hospital with a soft fiberglass cast on his right wrist which was to be on for one week. The note included the resident would need a hard cast and clinic shoulder immobilizer. A follow up appointment was needed with orthopedics. A cat scan of the head was done with no new orders. Review of the CNP note dated 10/07/24 revealed Resident #91 had a closed fracture of the distal end of the right radius with routine healing and unspecified fracture morphology after falling over the weekend with right wrist pain. Pain was controlled with routine Tylenol, narcotic pain medication as needed and lidocaine patch. The note included the facility was to ensure fall precaution. Review of the witness statement dated 10/07/24 authored by CNA #348 revealed Resident #91 was attempting to get out of his recliner (on 10/05/24) so CNA #348 moved him to his wheelchair and pushed him to the dining room table with a snack. He appeared confused and slightly aggressive, and he was dry. The chair alarm was present, and he had on non-skid socks. CNA #348 documented the fall was unwitnessed by her, as she observed him on the floor. Review of the investigation worksheet, dated 10/07/24, revealed Resident #91 had a witnessed fall on 10/05/24. Resident #91 said he was looking for the office. Contributing factors were non-compliance, being resistive to care and confusion. The investigation summary revealed the resident's personal alarm was sounding, he stood up from his chair took one step and fell . Staff had requested he sit down when he stood. Interventions ordered in response to this fall included a medication review, review by the interdisciplinary team, and a private duty sitter. Interview on 12/04/24 at 6:33 A.M. with Nurse Unit Manager (NUM)# 346 verified Resident #91 fell in the dining room, the TV lounge and in the therapy room during his admission with resultant fractures to his ribs and right wrist. NUM #346 stated Resident #91 was non-compliant and combative and he was known to get up at any time. NUM #346 revealed awareness of Resident #91 having falls at home prior to admission. Interview on 12/04/24 at 11:25 A.M. with PTA # 432 with Administrator #431 present revealed Resident #91 needed a gait belt for walking. PTA #432 stated Resident #91's baseline was maximum (staff) assist moving from wheelchair to standing position and the resident was not able to walk. Therapy provided daily treatments and Resident #91 needed contact guard minimum assistance to stand from sitting. During the interview, PTA #432 revealed (on 09/27/24) Resident #91 was sitting in his wheelchair by the four-step fixture located near the entrance door in the therapy gym. PTA #432 stated Resident #91 remained seated in the wheelchair while she walked 20 feet to retrieve the NuStep equipment. PTA #432 verified Resident #91 stood up while she was away from the resident, Resident #91 lost his balance, but PTA #432 stated she was not close enough to keep Resident #91 from falling. PTA #432 verified a hand must be on Resident #91 with contact assistance. Interview on 12/04/24 at 3:35 P.M. with Resident #91's wife revealed during the resident's stay she would stay overnight to monitor Resident #91 from falling. The day of Resident #91's last fall in the facility on 10/05/24 resulted in the resident sustaining a broken wrist. She stated on this date, she had informed the nurse she was leaving Resident #91 for an hour, and he fell after she left. She stated she requested the x-ray of Resident #91's hand after the fall on 10/05/24. She stated in addition, she had found the bruising on Resident #91 on 09/30/24 (from the fall that occurred on 09/27/24) and requested the x-rays to be taken. The x-rays on 09/30/24 revealed the resident had broken ribs. During the interview Resident #91's wife showed the surveyor pictures she had taken on 09/30/24 of a large bruise over the resident's rib area and multiple scattered bruises to Resident #91's right hand after he fell on [DATE]. Interview on 12/06/24 at 2:17 P.M. with CNA #348 revealed on 10/05/24 Resident #91 was agitated, so she placed the resident at a table in his wheelchair to eat a snack. CNA #348 stated she believed Resident #91 would be safe alone and stepped away without notifying another nurse. CNA #348 stated Resident #91 then stood to up on his own and fell . CNA #348 verified Resident #91 required monitoring at all times to prevent falls. Interview on 12/06/24 at 3:21 P.M. with RN #392 revealed she worked the night of 09/22/24 and witnessed Resident #91 fall. RN #392 stated the night Resident #91 fell , the rehab unit had a new admission that required three people to transfer the resident to bed. RN #392 was assisting with the new admission transfer with other staff when she heard Resident #91's alarm sound. RN #392 stated she was at the other end of the hall and could not run to Resident #91 fast enough to prevent his fall. Interview on 12/09/24 at 11:10 A.M. with the Director of Nursing (DON) revealed she did not have clinical oversight of the fall investigations because NUM #346 was in-charge of the fall investigations, so the DON was only involved in the post-fall interdisciplinary meeting. She stated she did not observe bruising to Resident #91's body. The DON stated on 09/22/24 Resident #91 had been sitting in a recliner then sat down from his recliner onto the floor. The DON verified he did fall onto his right side on 09/27/24 in the therapy gym. The DON stated Resident #91's falls were caused by Resident #91's agitation and staff had to repeat often for him to stay seated. The DON stated nursing staff were aware Resident #91's wife also had to repeatedly tell the resident to remain seated, but the resident could not understand to remain seated because of his dementia. When the resident fell on [DATE] the DON revealed nursing staff knew Resident #91's wife was not in the facility to watch him as he had been placed at a table to have a snack. Review of facility policy titled Falls Policy and Procedure, undated, revealed residents were assessed for fall risk factors and the facility strived to reduce the risk of falls and injuries by implementing the Falls Policy and Procedure. Residents are assessed for fall risk factors. The interdisciplinary team worked with the resident and family to identify and implement appropriate interventions to prevent falls or injuries. This deficiency represents non-compliance investigated under Complaint Number OH00159706.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interviews, resident interview, review of the facility self-reported incident (SRI), review of the facility investigation, and facility policy and procedure review, the facility failed to ensure misappropriation did not occur for Resident #50. This affected one resident (#50) of four residents reviewed for misappropriation. The facility census was 92. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included major depressive disorder, chronic congestive heart failure, and age-related osteoporosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition, required partial/moderate assistance from staff for transfers, and used a walker for ambulation. Review of the self-reported incident (SRI) tracking number 248730 dated 06/17/24 revealed Resident #50's wallet was found by a housekeeper in the staff restroom on the rehab unit the morning of 06/17/24. The wallet was returned, and the resident reported that a debit card was missing from the wallet. Resident #50 along with the Director of Nursing (DON), called the resident's bank to identify any questionable transactions. The resident identified two transactions, a withdrawal at 6:05 P.M. on 06/16/24 from an ATM at a gas station down the street and another ATM withdrawal at a nearby ATM at 11:18 PM on 06/16/27. The resident then closed the account while on the phone with the bank. Review of the facility's investigation revealed an undated handwritten statement from Housekeeper (HSK) #601 revealed on 06/17/24 she was cleaning the bathroom by the nurse's station in the rehab unit. While bending down to restock the shelf, she noticed it was very dusty. When she took her rag to wipe, her nail caught on something. When she looked to see what it was, she found a wallet. She then took said wallet to the front desk and was not sure who it belonged to. Further review of the facility's investigation revealed a typed statement by the DON dated 06/17/24 revealed a nurse approached her at approximately 8:00 A.M. to let her know that a resident's wallet was found in the staff bathroom on the rehab unit. The DON spoke with Resident #50, who stated that her debit card was missing and that she believed the wallet was last in her purse yesterday, the morning of 06/16/24. In the typed statement, Resident #50 stated the pin code to her debit card was written on a piece of paper in her purse. Resident #50 gave the DON permission to call the bank where they noted transactions on 06/16/24 at 6:05 P.M. for $403.50 at a non-bank ATM. There was also a cash transaction at a bank ATM on 06/16/24 at 11:18 P.M. for $117.00. Resident #50 did not make the transactions as she was in the facility and presumed the fraudulent transactions were from the theft of her debit card. The DON assisted the resident with cancelling her debit card and reporting that her credit card was stolen. The statement also indicated the resident and daughter stated the purse was last seen either on 06/11/24 or 06/13/24. The investigation included a typed timeline based on the review of camera footage throughout the facility showing State tested Nurse Aide (STNA) #507 entered Resident #50's room from 5:33 P.M. to 5:34 P.M. STNA #507 went to the restroom on the rehab unit from 5:46 P.M. to 5:48 P.M. STNA #507 then went into Resident #50's room at 5:48 P.M. to 5:51 P.M. STNA #507 left the facility at 5:57 P.M. STNA #507 pulled out of the parking lot at 5:59 P.M. STNA #507 returned to parking lot at 6:19 P.M. STNA #507 returned to the facility at 6:24 P.M. STNA #507 left facility at 10:56 P.M. to the parking lot. STNA #507 left the parking lot at 11:13 P.M. turning right out of the parking lot. Review of Resident #507's punch detail revealed he last worked on 06/16/24 from 3:23 P.M. to 10:55 P.M. Review of the typed statement for STNA #507 dated 06/18/24 at 12:25 P.M. via phone revealed he worked on 06/16/24 from 3:00 P.M. to 11:00 P.M. on the rehab unit (Resident #50's unit). STNA #507 denied being aware Resident #50 having a purse/wallet in her room or of it going missing. Interview on 07/12/24 at 9:14 A.M. with the Administrator revealed STNA #507 was permanently suspended until final evidence was subpoenaed from the ATM videos. The Administrator stated the police were involved and there was currently an ongoing investigation. The Administrator stated they can't say STNA #507 did it, and he never admitted anything. The Administrator stated they substantiated their investigation because Resident #50's wallet was taken. The Administrator stated they suspect STNA #507 but had no hard evidence. The Administrator stated on the facility's camera footage they were able to see STNA #507 leaving around the time of the withdrawals. Interview on 07/12/24 at 10:17 A.M. with Resident #50 revealed she hated that it happened. Resident #50 stated she had a small wallet that contained her identification card, medical cards, $20 bill, check book, and bank card. Resident #50 stated her purse was in bag wrapped tight, in the drawer, close to her bed. Resident #50 stated she wasn't aware it was missing until one morning a nurse came in with her wallet and stated someone put in the lost and found. Resident #50 stated someone took money from her, but she had talked to a detective who came out. Resident #50 stated as far as she knows they were looking into everything but don't know if they came up with anything. Resident #50 stated she had to cancel the card right away. Resident #50 stated she did not know who could have done it but didn't believe it was someone working at the facility because she felt the staff were excellent. Resident #50 stated she wasn't always in her room and at times she was in therapy or outside with her sister. Resident #50 stated it was kind of scary, and her daughter was upset about the incident. Resident #50 stated she got everything back except her bankcard. Review of the facility policy Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment Policy, revised 01/28/17, revealed the facility will not tolerate, abuse, neglect, exploitation, or mistreatment of its residents, or misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, exploitation, mistreatment, the misappropriation of resident property and injury of unknown source and report the results of any such investigation as required by law. The deficient practice was corrected on 07/09/24 when the facility implemented the following corrective actions: All staff were educated on Abuse/Neglect/Misappropriation on 06/17/24. Care conference forms with residents and their representatives list under question number three: security measure or intervention to reduce risk of loss currently in place now include a statement for family to monitor, advise to alert staff immediately if personal belongings are missing. Care conferences are conducted within seven days of admission to the rehab unit and weekly throughout facility. Resident/Family Handbook on page 13 revised to include loss/missing items: the facility encourages residents to not keep valuables, jewelry and/or significant amounts of money (cash, credit cards, etc.) on their person or in their room. However, if the resident finds that something is missing (property, money, etc.) please let the nurse, nurse manager, or administrator know immediately. Residents and family can also voice their concerns by calling the facility confidential concern/grievance line. (The number was listed). Weekly Resident Property Monitoring of four resident interviews weekly dated 06/21/24, 06/26/24, 06/28/24, 07/05/24, and 07/12/24 with no negative findings completed by Assistant Director of Nursing (ADON) #467 and Nurse Unit Manager (UM) #441. Weekly camera monitoring of staff on various shift once weekly dated 06/25/24 of third shift on 06/18/24, 07/01/24 of second shift on 06/30/24, and 07/09/25 of first and second shifts on 07/06/24 with no negative findings completed by Human Resources (HR) #602. Audits and monitors to continue for six weeks. Review in QAA/QAPI committee in the upcoming meeting next week. This deficiency represents non-compliance investigated under Master Complaint Number OH00155122.

Based on observation, interview, and facility policy review the facility failed to securely store medications. This had the potential to affect the four independently ambulatory residents (#59, #53, #24, and #48) in non-secured units. The facility census was 90. Findings include: On entry into the facility on [DATE] at 8:00 A.M., the surveyor observed a large, full paper bag on a table in the unmonitored breezeway inside the unlocked main entrance. The bag was stapled shut and labeled 'return to pharmacy.' Observation on 08/21/23 at 8:30 A.M. alongside the interim Director of Nursing revealed the bag contained 43 medication cards and one medication bottle. All of these items contained at least one remaining pill. Interview with the Interim Director of Nursing on 08/21/23 at 8:39 A.M. confirmed the above observations. She confirmed there was no electronic monitoring of the entryway and that medications should be in locked storage when not in use. Review of the facility medication storage policy, dated 04/01/2013, revealed medications were to be stored securely in locked or monitored areas, and only pharmacy staff and those authorized to administer medications were to have access to them.

Based on observation, interview, and facility policy review the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except one resident (#51), who received nothing by mouth. The facility census was 90. Findings include: Observations on 08/21/23 from 9:22 A.M. through 9:41 A.M., with Dietary Manager (DM) #540 revealed underneath a prep table in area where the juice machine was located was a bulk container of sugar with a scoop stored inside. There was also sticky food splatter observed on the clear lid and the white portion under the lid of the container. Next to the sugar container was bulk flour container that had a cup stored inside of it. The clear lid also had sticky food splatter. Observed in the next room over was a rack that the juice containers were stored, underneath the rack the floor was dirty, sticky, and also with a moderate amount of black specks in the sticky spillage. Observation of the steam table revealed streaks of grease that were solidified drippings down the front of it under the white ledge/table portion, the side facing the stove. Observed underneath the steam table was a shelf where several pans were stored was various food debris. Observed various food debris and splatter along the side of the plate warmer which was located next to the steam table. Across from the steam table was the stove, observed streaks of dried grease with food stains on the front of it. Observation of the steamer next to the stove on the bottom shelf were several stacked pans with various food debris and crumbs on the shelf. Across from the steamer and next to the plate warmer was a prep table, the bottom shelf had several long sheet pans and cutting boards stored there with various food debris and crumbs on this shelf. Observation of the dish machine revealed a moderate amount of lime buildup. Interview on 08/21/23 between 9:22 A.M. through 9:41 A.M., with DM #540 verified all the above findings. Review of the facility policy titled Food Receiving and Storage, revised 2014, revealed Food Services, or other designated staff, will maintain clean food storage areas at all times.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon discharge from the facility. This affected one resident (#337) of one resident reviewed for conveyance of funds. The facility census was 90. Findings include: Review of the closed medical record for Resident #337 revealed an admitted [DATE] and date of death of [DATE]. Review of the letter from Collections Enforcement Section of the Attorney General's office dated 01/06/23 revealed resident funds for Resident #337 were not dispersed within 30 days of death. Review of the business records for Resident #337 revealed a check for $610.24 was dispersed to the treasurer of the state dated 01/06/23 to close Resident #337's account. Interview on 08/24/23 at 11:45 A.M. with Accounting #592 revealed he was unsure why the funds for Resident #337 were not dispersed within 30 days following her death.

Based on record review, interview and observation, the facility failed to ensure proper cleaning of a pressure ulcer was done for Resident #46 and Resident #[AGE]. This affected two residents (Resident #46, and Resident #[AGE]) out of three residents reviewed for pressure ulcers. The facility census was 95. Findings Include: 1. Resident #[AGE] was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. According to her Minimum Data Assessment ((MDS) dated [DATE] Resident #[AGE] had severe cognitive impairment. Functionally she needed extensive assistance of one person for dressing and personal hygiene. She needed extensive assistance of two people for transfers and toilet use. At this time she was listed as having no pressure ulcer on the skin assessment part of the MDS but was at risk for the development of pressure ulcers. Review of the pressure ulcer record assessment revealed Resident #[AGE] had a stage three pressure ulcer to her coccyx that measured 1.2 centimeters 0.7 centimeters and 0.2 in depth. Observation of the dressing change for the resident's wound on 02/25/20 at 1:30 P.M. on 02/25/20 revealed Licensed Practical Nurse (LPN) #205, during the dressing change, proceeded to change her gloves after removing the old dressing and applied new gloves to clean the wound. After applying the wound cleaner spray she proceeded to wipe the wound in the center and then wiped around the exterior of the wound. She then wiped from the exterior of the wound sideways onto the wound. During the cleaning of the wound, it was noted she cleaned the wound in a sideways manner, back and forth; each time bringing dirt from the outside area of the wound onto the wound. Interview with LPN #205 during interview on 02/25/20 at 1:40 P.M. verified the above findings. 2. Resident #46 was admitted to this facility on 08/09/17. The admitting [DIAGNOSES REDACTED]. This resident is on hospice. Review of this resident's Minimum Data Set assessment dated [DATE] revealed this resident had severe cognitive impairment. Functionally she needed extensive assistance of two people for all activities of daily living. According to the skin assessment of this MDS the resident had a facility acquired stage IV pressure ulcer. Observation of the dressing changed for this resident at 1:40 P.M. on 02/25/20 revealed LPN #206 proceeded to wash her hands and put on clean gloves. She removed the old dressing and proceeded to clean with wound with wound cleanser and wipes. During the cleaning of the wound, it was noted she cleaned the wound in a sideways manner, back and forth; each time bringing dirt from the outside area of the wound onto the wound. Interview with LPN#206 on 02/25/20 at 2:00 P.M. verified that she did not clean the wound in a circular motion from the least contaminated area to the most contaminated. She verified she did not use clean gauze with each wipe and did not turn over the gauze to a clean area when cleaning the wound. The deficiency substantiates complaint OH 112.

Based on interview and record review the facility failed to provide Resident #42 with activities that met his preferences and psychosocial needs. This affected one resident (Resident #42) out of 27 residents interviewed regarding activities. Findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact and independent in daily decision making, and it was very important to Resident #42 to do activities with groups of people, to participate in favorite activities, and to go outside to get fresh air when the weather permitted. Review of the activity assessment dated [DATE] indicated Resident #42's current activity pursuits/interests included shopping and outdoors. It was additionally noted he enjoyed visiting his wife, Bingo, football pool and shopping at the local department store. Review of the activity plan of care revised on 10/14/19 indicated he would benefit from a variety of programs to help maintain his current functional abilities. The interventions included documenting attendance/refusals, encouraging him to attend, praising attendance and providing him a monthly calendar. Although the plan was revised, it lacked inclusion of Resident #42's preferences or interventions to meet his activity needs. Interview of Resident #42 on 12/09/19 at 1:35 P.M. revealed Resident #42 was very disappointed and disheartened that the facility had decided not to continue dine in (lunch brought to the facility from area restaurants monthly) each month from (MONTH) until March. The facility had also chosen to discontinue outings to an area department store from (MONTH) until March. Resident #42 was told the food gets too cold when it was brought in for lunch, and there was not enough staff for the outings. Interview of Assistant Activities Director (AAD) #502 on 12/11/19 at 8:14 [NAME]M. revealed the dine in was only from (MONTH) through (MONTH) because a staff member fell in the snow and was injured. AAD #502 confirmed that the residents would like to have dine in all year, and Resident #42 had also requested that it continue all year. Interview of Activities Director #501 on 12/11/19 at 8:34 [NAME]M. revealed field trips were from (MONTH) through (MONTH) for safety reasons, and dine in was (MONTH) through October. AD #501 stated that the program was new and having area restaurants deliver food during the winter months was something she had not thought of but would consider. AD #501 stated that field trips required a lot of effort to plan and additional staff members needed to be scheduled so that there were six staff for ten residents on the bus.

Based on observation, interview, and record review, the facility failed to ensure room trays were served at appetizing temperatures. This affected three of three residents (Residents #46, #76, and #35) who complained of food temperatures and ate meals in their rooms on the North Unit. Findings include: Interviews on the North unit on 12/09/19 from 9:56 [NAME]M. through 2:57 P.M. with Residents #46, #76, and #35 revealed concerns related to receiving hot foods served at cold temperatures. Observation of tray line on the North unit on 12/10/19 at 11:45 [NAME]M. with Foodservice Worker (FW) #200 revealed the following food temperatures: corn-167 degrees Fahrenheit (F), spinach 177 degrees F, mechanical chicken 187 degrees F, chicken 165 degrees F, cream of chicken 168 degrees F, salmon 177 degrees F. FW #200 stated room trays were served room by room after the dining room was served. A test tray was completed on 12/10/19 at 12:38 P.M. after last room tray was served with FW #200. The chicken was 136 degrees F and tasted hot, palatable, and was easy to chew. The spinach was 114 degrees F and was cool to taste but palatable. The corn was 119 degrees F and was cool to taste but palatable. Interview at this time with FW #200 verified the corn and spinach tasted cool. Interview on 12/10/19 at 12:54 P.M. with FW #200 revealed that there was typically three to four residents who ate in their room on the North unit. Review of the undated facility policy titled Policy and Procedure Conducting Test Trays, revealed test trays would be completed at least once monthly at breakfast, lunch, or dinner meal service. Additional test trays would be completed as needed based on patient complaints about cold food. The purpose was to assure meal trays were delivered to residents in a timely manner, assuring food was at the proper temperature and quality when it was served to the patient.

Based on record review and staff interview the facility failed to ensure personal funds were disbursed timely following the death of a resident. This affected two residents (Resident #190 and #191) of five residents reviewed for personal funds. Findings included: 1. Closed record review revealed Resident #191 was admitted to the facility 02/03/15 and signed consent for the facility to manage the resident's personal funds. The record revealed Resident #191 passed away in the facility on 11/16/16. Review of facility provided funds account information for Resident #191 revealed the resident's funds were returned to the State of Ohio on 02/21/17, more than 90 after the death of the resident. 2. Closed record review revealed Resident #190 was admitted to the facility on [DATE] and signed consent for the facility to manage the resident's personal funds. The record revealed Resident #190 passed away in the facility on 02/02/17. Review of facility provided funds account information revealed the resident's funds were returned to the State of Ohio on 08/11/17, more than six months after the death of the resident. An interview was conducted on 08/17/17 at 11:30 A.M. with facility Controller #90 and the resident funds accounts were reviewed. During the interview Controller #90 stated the facility was unaware of the requirement to complete a final accounting of the resident's funds within 30 days of the resident's death.

Based on observation and staff interview, the facility failed to maintain clean and repaired resident equipment. This affected five (Residents #5, #66, #45, #40, #38) of 18 residents residing on the dementia unit. Findings Include: Observation on 05/10/16 at 1:30 P.M. of Resident #5's floor mats revealed there were tears in the mat. This was confirmed by State tested Nurse Aide (STNA) #40 on 05/10/16 at 1:30 P.M. Observation of the dining room on the dementia unit on 05/13/16 at 8:15 A.M. revealed the wooden table rocked back and forth when touched and the surface of the table had areas where the finish had been worn off. At that time, the Director of Nursing (DON) confirmed the table rocked back and forth and that the finish was coming off the table. Observation of Resident #66's wheelchair on 05/13/16 at 10:48 A.M. revealed the wheelchair's wheels were dirty and the arm rests of the chair were cracked. At that time, Licensed Practical Nurse (LPN) #30 confirmed the wheels were dirty and the arm rests were cracked. Observation on 05/13/16 at 10:49 A.M. of the recliner in the common area of the dementia unit revealed red marks on the brown seat cushion. LPN #30 said Resident #45 liked to sit in the chair and confirmed the red marks on the cushion on 05/13/16 at 10:49 A.M. Observation on 05/13/16 at 10:51 A.M. of Resident #40's wheelchair revealed numerous dried white dried spots on the wheels of the chair. An interview with Licensed Practical Nurse (LPN) #30 on 05/13/16 at 10:51 A.M. verified the wheelchair had white spots on it. Observation of Resident #38's wheelchair arms on 05/13/16 at 10:57 A.M. revealed the sheepskin covers wrapped around the arms were secured with tape and the color of the sheepskin was a dingy brown, the chair alarm on the chair was missing the cover over the battery, and the wheels of the chair were dirty. This was confirmed by LPN #30 at the time.

Based on observation and interview, the facility failed to ensure residents had access to light switches in their rooms. This affected two (Residents #85 and #160) of 21 sampled residents. Findings include: Interviews with Resident #85 on 05/10/16 at 1:02 P.M. and with Resident #160 on 05/10/16 at 12:47 P.M. revealed both residents complained they were not able to operate their overbed lights when in bed because they were unable to reach the light switches. The light switches were on the wall at an accessible height, but their beds were positioned so that the light switches were inaccessible. Observation of Resident #85's bed on 05/10/16 at 1:15 P.M. indicated his bed was placed so the switches were extended beyond the foot of the bed. During his interview he stated he absolutely would like to be able to operate his overbed light. Observation of Resident #160's bed with the head of the bed raised on 05/10/16 at 12:47 P.M. and on 05/12/16 at 8:16 A.M. indicated the bed was perpendicular to the wall and she was unable to reach backwards to access the switch, particularly when the head of bed was raised. During her interview she stated, I can't reach the switch when I'm in bed. The above observations and lack of light switch access were verified with the Director of Nursing on 05/12/16 at 10:13 A.M.