Every finding on record at Ayden Healthcare of Belle Springs.

Based on review of the self-reported incident (SRI) investigation, review of the employee time sheets, staff interviews, and review of facility policy, the facility failed to ensure further potential abuse was prevented by removing an employee suspected of sexual abuse pending the outcome of the abuse investigation. The affected one resident (#57) of three reviewed for abuse. The facility census was 80. Findings include:Review of the medical record for Resident #57 revealed an admission date of 10/13/25. Diagnoses included respiratory failure, dysphagia, chronic obstructive pulmonary disease, muscle weakness and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and required substantial maximum assistance for toileting. The assessment stated the resident was continent of urine but always incontinent of bowel. Review of SRI #270483 dated 02/03/26 at 10:42 A.M. revealed Resident #57 reported CNA #64 touched his genitals during a morning check and change. He reported it happened in the past (unknown date) and reported he had not yet reported it but contacted the police to ask questions. The police informed him they were not familiar with facility policy, and he would need to check on the facility policy. Resident #57 reported the room was dark and CNA #64 did not turn on the light or state his intent to the resident before touching his genitals. Resident #57 also mentioned he had heard that a CNA had taken pictures of his genitals and shared them with someone outside the facility. The investigation found CNA #64 had last cared for Resident #57 on night shift on 01/08/26. The investigation did not mention if the staff member accused (CNA #64) was suspended or was off work during the course of the investigation or mention how the resident's safety was maintained during the course of the investigation. The investigation found that the incident was unsubstantiated. The intention of touching the incontinence wear was to complete a check and change and with the patient's own admission he stated that there was no groping, pulling or handling of his penis or genitals. Review of the timecard revealed Certified Nursing Aide (CNA) #64 worked on 02/03/26 from 6:55 A.M. to 6:58 P.M. The timecard made no indication he was suspended pending the outcome of the investigation. Interview on 05/21/26 at 1:00 P.M. with the Administrator #73 and Director of Nursing (DON) #93 confirmed they were informed of Resident #57's concern by staff who heard he had contacted the police. They reported they spoke with Resident #57 and he reported concerns related to CNA #64 coming in his room in the dark and without speaking with him, touched his genitals. He denied any groping behavior or motions occurred and relayed that it had occurred in the past but did not know a specific date. The Administrator and DON revealed CNA #64 was working in the facility at this time and he was brought to the administrator's office and interviewed and allowed to return to his assignment on a different hall where Resident #57 lived. They acknowledged the facility abuse policy stated if a staff member was accused, they shall be immediately removed from the facility. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/2026, revealed the facility shall investigate alleged violations of abuse and neglect in accordance with its policy and ensure all residents are free from retaliation. If a staff member was accused or suspected, the facility shall immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The investigation shall include interviews with the resident, the accused individual and any witnesses. If no direct witnesses were identified interviews may be expanded to other employees or residents on that unit. The investigation should include documentation of all evidence, and a conclusion shall be reached by analyzing all evidence. This deficiency represents non-compliance investigated under Complaint Number 2983817.

Based on observation, resident interview, and staff interview, the facility failed to provide a home-like environment in regards to facility's shower rooms being in good repair. This affected two residents (#1 and #4) with the potential to affect all residents residing in the facility. The current census is 87. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 include infective bursitis right elbow, diabetes type two, neuromuscular dysfunction of bladder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was an extensive assist with Activities of Daily Living (ADLs). Review of Resident #1's care plans dated 05/2024 revealed a focus for ADL assistance. Interventions include mechanical lift for transfers, and staff assist with bathing. Interview on 06/23/25 at 12:55 P.M. with Resident #1 revealed the resident stated his main complaint with his care involved use of the shower room on the hall. Resident #1 stated every time he is being transported back to his room after his shower the shower chair wheels get stuck in the holes in the floor of the bathrooms causing the aides to have to push and pull his chair. Resident #1 stated it is uncomfortable and not homelike, and it upsets him the condition of the flooring in the bathrooms in the facility. Resident #1 stated he knows all the bathrooms in the facility are missing tiles in the floors as other residents have complained about the flooring. 2. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 include hypertension, heart failure, and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required staff assist with ADLs including bathing. Review of Resident #4's care plans dated 05/2025 revealed a focus for ADL self-care deficit. Interventions include mechanical lift for transfers, staff to assist with ADLs, and sponge bath if residents declines a shower. Interview on 06/23/25 at 3:34 P.M. with Resident #4 revealed the resident stated she is getting her showers in the main bathroom on the 300-hall per the schedule. Resident #4 stated she did not like the fact there was a hole in floor tiles and stated the aides do have to be more careful with her in the shower chair as the chair sometimes gets stuck in the hole in the floor. Resident #4 stated it was not home-like in the shower room. Observation on 06/23/25 at 1:00 P.M. of the 400-hall central shower room revealed there was one stall with a shower and a shower chair in the bathroom. Observed on the floor around the drain were several missing tiles and a depressed area of the floor. Interview on 06/23/25 at 1:02 P.M. with Certified Nurse Aide (CNA) #192 and CNA #202 verified there were missing tiles and a hole in the floor in the shower area of the bathroom. CNA #192 verified the tiles had been missing and the hole was in the floor for over a year since the aide began working at the facility. Both CNA #192 and CNA #202 verified all residents on the 400-hall are showered in the central bathroom and many residents complained about the hole in the floor due to the chair's wheels catching the hole. Both aides denied any residents falling out of the chair in the shower room. Observation 06/23/25 at 1:05 P.M. of the 300-hall central shower room revealed in the shower stall there were several missing tiles from the floor near the drain area. Interview on 06/23/25 at 1:05 P.M. with CNA #161 verified there were missing tiles in the shower stall, and it caused the shower chair's wheels to jerk. CNA #161 verified all residents on the 300-hall showered in the central shower room. Observation 06/23/25 at 1:10 P.M. of the 200-hall central shower room revealed in the shower stall there were several missing tiles from the floor near the drain area. Interview on 06/23/25 at 1:10 P.M. with CNA #101 verified there were missing tiles in the shower stall, and it caused the shower chair's wheels to jerk. CNA #101 verified all residents on the 200-hall showered in the central shower room. Interview on 06/23/25 at 1:55 P.M. with the Administrator verified in each of the central shower rooms on each of the 4 halls there were missing tiles and holes in the floor. The Administrator verified all residents use the central shower rooms for their showers and bathing. This deficiency represents non-compliance investigated udner Complaint Number OH00165407.

Based on observations, review of cleaning schedules, staff interviews, and policy reviews, the facility failed to ensure food products were dated when opened, kitchen sanitation was being maintained, and the proper sanitizer test strips were used with the dish machine. This had the potential to affect all 77 residents who received food from the kitchen. The facility census was 77. Findings include: 1. Observation on 03/10/25 at 8:00 A.M., of the kitchen revealed one bag of breadsticks open and undated in the walk-in freezer, one bag of shredded lettuce open and undated, one container of what appears to be crushed pineapple not labeled or dated, one bag of pepperoni open not dated, and two stacks of sliced cheese wrapped in saran wrap not dated observed in the walk-in refrigerator. Interview on 03/10/25 8:15 A.M., with Dietary Supervisor (DS) #122 verified the open bag of breadsticks in the walk-in freezer was not dated. Also verified the undated and labeled items in the walk-in refrigerator. Observation on 03/12/25 at 11:53 A.M., in the walk in cooler revealed three bottles of holiday nog dated 02/03/25. A large bag of orange shredded cheese was dated 03/02. Interview on 03/12/25 at 11:59 A.M., with DS #122 confirmed the expiration date was 02/03/25 and the bottles of holiday nog should be thrown out. DS #122 revealed they keep food seven to ten days after opening and she learned that from her food safety class. Review of the policy titled, General HACCP Guidelines for Food Safety, dated 2021, revealed the dietary staff will label and date foods. Review of the policy titled, General Food Preparation and Handling, dated 2021, stated Use leftovers within 7 days per Food Code or discard. Check state regulations for more detail. 2. Observation on 03/12/25 at 11:39 A.M., revealed the kitchen utensil drawer had random debris inside the drawer with the kitchen utensils were sitting on. Review of the kitchen cleaning schedule revealed the prep area is cleaned and sanitized twice a day. Interview on 03/12/25 at 11:40 A.M., with DS #122 confirmed the drawer is dirty and it needed cleaned. Review of the policy titled, General Sanitation of Kitchen, dated 2021 stated Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. 3. Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed the dish machine is a low temperature chemical machine. DS #122 revealed it uses chlorine sanitizer and they ensure it reaches the proper chemical concentration by using test strips. Observation on 03/12/25 at 11:48 A.M., with DS #122 revealed the facility is using quaternary ammonia (quat) test strips. DS #122 tested the dish machine with the quat test strips and confirmed there was no color change. Interview on 03/12/25 at 11:48 A.M., with DS #122 revealed she was not aware the test strips she was using were quat. DS #122 revealed their chemical company are changing everything out. DS #112 confirmed they were using quat test strips to check the chlorine sanitizer dish machine. Interview on 03/12/25 at 11:51 A.M., with DS #112 revealed she was asking if another kind of test strips were the correct test strips. Observation on 03/12/25 at 11:51 A.M., with DS #112 revealed the next test strips she brought were quat test strips as well. Interview on 03/12/25 at 12:36 P.M., with DS #112 revealed the dishwasher sanitizer is tested on ce every two weeks. DS #112 also revealed she is using quat test strips but probably shouldn't be using them. Interview on 03/13/25 at 1:32 P.M., with the Administrator revealed the facility currently does not have the correct test strips for the dishwasher machine. Review on 03/13/25 at 1:50 P.M., of the test strip log brought in by the Administrator revealed there are only two test strips on the sheet dated 07/05/24, 07/12/24, 07/22/24 and 08/30/24. Interview on 03/13/25 at 1:50 P.M., with the Administrator revealed those are the only two strips they have on their log. Interview on 03/13/25 at 2:49 P.M., with DS #122 confirmed there are only two strips on their test strip log and the test strips are quat test strips. Review of the policy titled, Cleaning Dishes/Dish Machine, dated 2021 ,stated The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy also stated . Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. Review of the Sanitation of Dishes/Dish Machine policy dated 2021, revealed the low temperature dishwasher has wash temperature of 120 F and a sanitation of 50 PPM hypochlorite. 4. Observation on 03/12/25 at 11:01 A.M., revealed Dietary Aide (DA) #113 was in the kitchen at a long stainless steel table rolling silverware. DA #113 was not wearing a hairnet. Interview on 03/12/25 at 11:03 A.M., with Dietary Aide #113 revealed he only wears a hairnet if he is in a food area. Observation on 03/12/25 at 11:04 A.M, revealed DS #122 told Dietary Aide #113 that if he is wrapping silverware he has to wear a hairnet. Dietary Aide #113 put on a hairnet. Interview on 03/12/25 at 12:36 P.M., with DS #122 revealed the hairnet policy is everyone has to wear one. If you come into the kitchen you put a hairnet on. Review of the policy titled, Employee Sanitary Practices, dated 2021, stated All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Note: This does not apply to employees who have a totally shaved or bald head; nor does it apply to employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food, clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on review of medical records, staff interview, observation, and review of policies, the facility failed to ensure staff follow enhance barrier precautions (EBP). This affected one (#31) of four residents reviewed for transmission based precautions. The facility failed to ensure clean laundry was not exposed to dirty surfaces and items. This had the potential to affect all residents of the facility. The facility also failed to prepare medications in a sanitary manner. This affected one (#22) of six residents reviewed for medication administration. The facility census was 77. Findings include: 1. Review of Resident #31's medical record revealed an admitted [DATE]. Diagnoses listed included cerebral infarction, hypertensive heart disease, aphasia, dysphagia, hyperlipidemia, hemiplegia, and hemiparesis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had severe cognitive impairment and an indwelling urinary catheter. Review of a care plan revealed Resident #31 was on EBP due to having an urinary catheter. Staff will use gown and gloves when providing high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use/maintenance, and chronic wound care. Observation on 03/12/25 at 9:18 A.M., of Resident #31's suprapubic urinary catheter flushing revealed Licensed Practical Nurse (LPN) #204 was not wearing a gown. LPN #204 downed gloves, entered Resident #31's room, pulled back Resident #31's bed covering and flushed Resident #31's suprapubic catheter. LPN #204 held the catheter tubing in her gloved hands, separated the tubing , and then flushed the catheter. Interview on 03/12/25 at 9:24 A.M., with LPN #240 confirmed Resident #31 was in EBP and she should have worn a gown while flushing his suprapubic catheter. Review of the policy titled,Enhance Barrier Precautions (EBP), dated 04/01/24 revealed EBP are indicated for residents with an indwelling medical device. Devices listed include central line, peripheral inserted central catheter (PICC line), midline, urinary catheter, suprapubic catheters, central vascular lines, hemodialysis catheters, feeding tubes, tracheostomy, nephrostomy, chest tube, drain tubes, and ventilator if if the resident is not know to be infected or colonized with an multi-drug resistant organism (MDRO). 36648 2. Observation on 03/12/25 at 12:22 P.M., of House Keeping Aide #137 pushing a cart in the hallway, with clean resident clothing hanging on hangers and folded in the bin not covered. Interview, at the time of the observation, with House Keeping Aide #137, verified the clean clothing was not covered. Interview and observation on 03/13/25 at 10:16 A.M. to 10: 35 A.M., with the Assistant Director of Laundry and Environmental Services #131 confirmed there are two designated laundry areas, one is a clean laundry room, and one is the dirty room. No clean laundry should be around any dirty laundry . Observation of the clean room area revealed several shelves of clean laundry neatly folded and hanging on racks not covered. One shelf along the wall revealed the folded laundry and a designated area for employee personal belongings. There were two coffee cups with lids sitting on the shelves of clean laundry items. The door in the clean laundry room leading to the washers/dryers revealed two coats belonging to staff hanging on the back of the doors. Observation of the clean area housing the two dryers revealed a large trash bin with no lid containing discarded dirty disposable laundry bags verified by the Assistant Director of Laundry and Environmental Services #131. Review of the policy titled,Laundry and Bedding, Soiled Policy, October 2018 revealed clean linen are protected from dust and soiling during transport and storage to ensure cleanliness. Clean linens are stored separately, away from soiled linens, at all times. 45751 3. Observation on 03/10/25 at 8:50 A.M., of Licensed Practical Nurse (LPN) #153 revealed the nurse was preparing medications for Resident #22. LPN #153 was observed popping a pill out of the package from the narcotic drawer into her bare hands and placing the pill onto the top of the medication cart. Observation of the top of the medication cart revealed 5 loose pills on top of the cart and a medication cup with six pills. LPN #153 was observed picking up the 5 loose pills and putting them into a medication cup with her bare hands. Interview on 03/10/25 at 8:51 A.M., with LPN #153 verified she picked up the pills with her bare hands from the top of the medication cart and placed them in the medication cup. LPN #153 stated she normally pops the medications from the narcotic drawer into her hand and would place them on the medication cart prior to putting them into a medication cup. LPN #153 stated she should not do that and should place the medications in a medication cup without touching them. Review of policy titled, Administering Medications, revised April 2019, revealed staff follows established facility infection control procedures including handwashing, antiseptic technique, gloves, isolation precautions for the administration of medications as applicable.

Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen microwave in a safe operating condition. This deficient practice had the potential to affect all 77 residents who received meals from the kitchen. The facility census was 77. Findings include: Observation on 03/12/25 at 11:41 A.M., revealed the interior ceiling of the microwave had a large black/rusty color in the middle. Interview on 03/12/25 at 11:42 A.M., with Dietary Supervisor #122 revealed the microwave is used to warm up food such as waffles and pancakes. Dietary Supervisor #122 confirmed there is rust in the microwave. Review of the policy titled, Equipment Safety,dated 2021, stated Safety precautions will be followed when using electrical equipment. The policy also stated All equipment should be cleaned properly, following the instructions in the equipment manual. Review of the policy titled, Resident Environmental Quality, dated August 2023, stated The facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The policy also stated All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.

Based on observation, staff interview, review of medication package insert, review of manufacturer recommendations, and policy review, the facility failed to ensure medications and solutions were dated when opened and stored under recommended conditions. This had the potential to affect all new admissions and residents who have their blood sugars checked using the glucometer. The facility identified 10 (#5, #6, #7, #19, #21, #29, #36, #55, #60, and #73) residents who had their blood sugars checked using the glucometer. The facility census was 77. Findings include: Observation on 03/10/25 at 8:30 A.M., of the medication cart on 200 hallway revealed one bottle of Aplisol injection (tuberculin solution) 5/0.1 milliliter (ml) not refrigerated or dated when opened. Also observed a box of assure prism control solution 4 milliliters (ml) times two vials (control solution for glucometer) open and not dated. Interview on 03/10/25 at 8:31 A.M., with Licensed Practical Nurse (LPN) #147 revealed the nurse verified the Aplisol was not refrigerated or dated. LPN #147 verified the Aplisol should be refrigerated. LPN #147 verified the glucometer control solution was opened and not dated. LPN #147 stated the night shift runs the controls on all the glucometer's and the control solution is usually in the med room. Review of the undated manufacturer recommendation for the glucometer control solution revealed do not use beyond three months (90 days) after opening the vial. Record the discard date (three months from the day the vial was opened) on the vial label. Review of the medication package insert for APLISOL(R) (Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution]), dated November 2013, revealed failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results. Storage: DO NOT FREEZE This product should be stored at 2 -8 C (36 -46 F) and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the undated policy titled, Medication Storage, revealed medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Ohio Department of Health regulations. Medications requiring refrigeration will be stored in a refrigerator that is maintained between two to eight degrees Celsius (36-46 degrees Fahrenheit).

Based on observations, staff interview, and policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. The deficient practice had the potential to affect 10 (#6, #15, #32, #34, #41, #51, #53, #54, #63, and #184) of 10 residents on a prescribed pureed diet. The facility census was 77. Findings include: Interview on 03/12/25 at 10:34 A.M., with [NAME] #109 revealed the menu for lunch was pot roast, mashed potatoes, and Normandy vegetables. [NAME] #109 revealed she would be doing the purees. [NAME] #109 stated she is looking for a baby food consistency with her purees. [NAME] #109 stated a resident doesn't have to chew a puree. [NAME] #109 stated a puree food is completed when there are no chunks and no pieces of food. [NAME] #109 revealed she does not taste the purees. [NAME] #109 confirmed they have ten residents who required a puree lunch. Observation on 03/12/25 at 10:38 A.M., revealed [NAME] #109 started making the pot roast puree. On 03/12/25 at 10:41 A.M., [NAME] #109 stated the pot roast puree was done and ready to serve. Observation of the puree pot roast revealed it looked chunky. Observation on 03/12/25 at 10:43 A.M., revealed the puree pot roast looked chunky and not smooth. The puree pot roast was tasted and it was found to be very chunky and had to be chewed. Interview on 03/12/25 at 10:44 A.M., with Dietary Supervisor (DS) #122 and [NAME] #109 confirmed the puree was chunky. Observation on 03/12/25 at 10:52 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:54 A.M., [NAME] #109 revealed the puree was done. The puree was tasted and was found to still have chunks of meat in it. Interview on 03/12/25 at 10:54 A.M., with DS #122 confirmed the puree was still chunky. Observation on 03/12/25 at 10:54 A.M., revealed [NAME] #109 started to puree the pot roast again. On 03/12/25 at 10:56 A.M., [NAME] #109 revealed the puree was finished. The puree was tasted and it was now smooth. Review of the policy titled, Level One Puree Diet, dated 12/06/20 stated Individuals with severe chewing and/or swallowing problems may be prescribed a puree diet. All foods will be pureed to a moist mashed potato or smooth pudding like consistency that eliminates the need for chewing. Pureed foods are generally cohesive. Food is pureed in a food processor to achieve a consistent smooth and easy to swallow product.

Based on observations, medical record review, family interview, staff interview and policy review, the facility failed to ensure a resident's room was maintain in good repair. This affected for one (#22) of two residents reviewed for physical environment. The facility census was 77. Findings include: Review of medical record for Resident #22 revealed an admitted [DATE]. The resident was admitted with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and epilepsy. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had severe cognitive impairment. Resident #22 required setup or clean up assistance for eating. Supervision or touching assistance was required for oral hygiene. Substantial/maximal assistance was required for toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Resident #22 is dependent for putting on/taking off footwear. Review of the care plan revealed Resident #22's dignity and autonomy will be maintained at the highest level with interventions including keeping the environment quiet and calm and keeping lighting low and familiar objects near. Observation on 03/12/25 at 4:29 P.M., revealed when entering Resident #22's room, the wall is damaged, the wall next to window is damaged with a large hole next to it, and the restroom wall is damaged. Interview on 03/12/25 at 4:31 P.M. with Certified Nurse Aide (CNA) #178 confirmed the walls are damaged. CNA #178 revealed the walls have been that way since she started working here one year ago. Observation and interview on 03/12/25 at 5:42 P.M., with the Director of Nursing (DON) confirmed the walls are damaged. The DON stated the large, damaged spot on the wall by the window is from the footboard of the bed that used to be in this room. The DON thinks the bed was moved months ago. Interview on 03/13/25 at 8:30 A.M., with the DON stated Resident #22's bed was moved on 02/27/25. Interview on 03/13/25 at 9:18 A.M., with Resident #22's daughter confirmed the walls are damaged. Resident #22's daughter stated Resident #22 would have wanted the walls fixed. Resident #22's daughter stated maintenance was notified but he said he had other projects to do first. Observation on 03/13/25 at 10:25 A.M., with Maintenance Supervisor #163 confirmed the damage on the entrance wall measured 37 inches long by 5 inches wide, the hole in the wall by the window is 20 inches long by 10 inches wide, and the damaged wall in the bathroom is 37 inches long by 15 inches wide. Review of the maintenance request log for the last 6 months revealed Resident #22's room is not listed on the log. Review of the policy titled, Resident Environmental Quality, dated August 2023 stated, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observations, record review, and staff interview, the facility failed to ensure care planned fall interventions were implemented. This affected one (#4) of three residents reviewed for falls. The facility census was 77. Findings include: Review of medical record for Resident #4 revealed an admitted [DATE], with diagnoses including morbid obesity with alveolar hypoventilation, type two diabetes, chronic kidney disease stage four, atrial fibrillation, sleep apnea, bipolar disorder, unsteadiness on feet, major depressive disorder, and anxiety. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Resident #4 required supervision or touching assistance for oral hygiene, toileting, and bathing. Partial/moderate assistance for upper and lower body dressing and personal hygiene. Supervision or touching assistance for bed mobility and transfers. Review of care plan dated 02/17/25 revealed Resident #4 was at risk for accidental falls. Interventions included educate resident on wearing appropriate footwear, educate resident on sitting down when dressing, education on use of call light for assistance, encourage resident to utilize regular chairs while in the activity room instead of walker seat, encourage to wear proper fitting shoes in good repair, non-skid footwear at all times as tolerated, perimeter mattress, Reacher at bedside/recliner, remind to lock wheeled walker before attempting to sit on it, resident to use shower bench instead of shower chair during showers, keep bed in lowest position, provide rest periods, and low bed. Observation on 03/13/25 at 10:54 A.M., of Resident #4's room revealed the resident was sitting in the recliner with proper fitting shoes. The wheeled walker was located across the room in front of the bookshelf. No Reacher was in view on the bedside table, bed, dresser, or walker. No perimeter mattress was on the bed. Interview on 03/13/25 at 10:57 A.M., with Licensed Practical Nurse (LPN) #143 verified Resident #4 had a regular mattress with no perimeters. LPN #143 stated the resident does not sleep in the bed. LPN #143 stated the resident sleeps in her recliner. LPN #143 verified the resident's Reacher was not visible. LPN #143 asked Resident #4 where her Reacher was, and the resident shrugged her shoulders. Resident #4's roommate stated check under the mattress. LPN #143 checked under the mattress and located the Reacher.

Based on observation, medical record review, staff interview, and policy review, the facility failed to implement the policy on ensure oxygen tubing was changed weekly. This affected one (#36) of three residents reviewed for respiratory care. The facility census was 77. Findings include: Review of medical record for Resident #36 revealed an admitted [DATE], with diagnoses including chronic atrial fibrillation, ischemic cardiomyopathy, type 2 diabetes, anxiety, vascular dementia, repeated falls, insomnia, pressure ulcer of left heel stage 4, acquired absence of right leg above knee, obstructive and reflux uropathy, fall on same level, acute respiratory failure with hypoxia. Review of Annual Minimum Data Set assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. Resident #36 received oxygen therapy. Review of current physician orders for Resident #36 revealed oxygen via nasal cannula at a rate of 2 liters as needed for saturations below 90%. Review of care plan dated 02/19/25 for Resident #36 revealed the resident at risk for cardiopulmonary disease/exacerbation related to atrial fibrillation, coronary artery disease, hypertension, and oxygen use. Interventions included monitor oxygen saturation, oxygen as ordered, and change tubing weekly. Observation on 03/10/25 at 9:23 A.M., of oxygen concentrator revealed the oxygen tubing was dated 02/16/25. Observation on 03/10/25 at 3:02 P.M., of oxygen concentrator revealed the oxygen tubing remained dated 02/16/25. Interview on 03/10/25 at 3:15 P.M. with Certified Nursing Assistant (CNA) #190 verified the oxygen tubing was dated 02/16/25 for Resident #36. Interview on 03/11/25 at 10:50 A.M., with Director of Nursing (DON) revealed oxygen tubing is to be changed weekly. DON stated the changing of the tubing should be on a physician order. Review of policy titled, Oxygen Administration, revised April 2023, revealed care and cleaning of equipment shall be in accordance with facility policies for each such equipment. Oxygen tubing and mask/cannula will be changed weekly and as needed if it becomes soiled or contaminated. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

Based on employee file review, staff interview, and policy review, the facility failed to implement the policy to ensure employees were checked against the Ohio Nurse Aide Registry. This affected five (Certified Nursing Assistant (CNA) #178, CNA #175, Licensed Practical Nurse (LPN) #162, Registered Nurse (RN) #171, and Activities Assistant (AA) #101 of six employee files reviewed. This had the potential to affect all residents who reside in the facility. The facility census was 77. Findings include: Review of employee file for CNA #178 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #178 was originally hired as a hospitality aide on 10/03/23. CNA #178 attended the CNA classes and passed the CNA testing on 04/20/24 which is when the employee was checked against the nurse aide registry. Review of employee file for CNA #175 revealed no evidence of the employee being checked against the Nurse Aide Registry. CNA #175 was hired on 12/22/24 as a CNA. CNA #175 attended the CNA classes on 11/26/24 and completed the course on 12/20/24. Review of employee file for LPN #162 with hire date of 02/14/25 revealed no evidence of the employee being checked against the Nurse Aide Registry. Review of employee file for RN #171 with hire date of 03/14/22 revealed no evidence of the employee being checked against the Nurse Aide Registry. Review of employee file for AA #101 with hire date of 07/15/24 revealed no evidence of the employee being checked against the Nurse Aide Registry. Interview on 03/13/25 at 2:45 P.M., with Human Resources Director (HRD #140) revealed the HRD did not run all employees against the Ohio Nurse Aide Registry. HRD #140 stated they run the employees against the abuse registry. HRD #140 verified the above employees were not ran against the nurse aide registry at the time of employment. The affected staff was checked during the survey for the nurse aide registry and no violations were found. Review of policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated on October 2024, revealed the facility will do the following prior to hiring a new employee: check the Ohio Nurse Aide Registry (and attempt to check other state registries if the individual is known to have worked in another state) for all potential new employees (licensed and unlicensed) and new volunteers to determine if there is a finding of abuse, neglect, or misappropriation of property against the individual prior to the use of that individual.

Based on medical record review, staff and resident interviews, policy review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to conduct Coronavirus Disease 2019 (COVID-19) testing as per facility policy and CDC guidelines. This affected one (#54) resident out of the five residents reviewed for infection control. The facility census was 78. Findings include: 1. Review of the medical record for Resident #54 revealed an admitted [DATE] with medical diagnoses of Parkinson's disease, hypertensive heart disease, and chronic kidney disease Stage III. Review of the medical record for Resident #54 revealed an admission minimum data set (MDS) assessment, dated 08/19/23, which indicated Resident #54 had moderate cognitive impairment and required extensive staff assistance for bed mobility, transfers, dressing and toileting. Further review of the medical record revealed documentation to support Resident #54 was up to date on COVID-19 vaccinations. Review of the medical record for Resident #54 revealed Resident #54 shared a room with Resident #168, who his/her spouse. The medical record did not contain documentation to support Resident #54 had COVID-19 testing completed since admission to the facility. Interview on 10/04/23 at 11:10 A.M. with Resident #54 confirmed Resident #168 was his/her spouse and the two residents shared a room. Resident #54 confirmed Resident #168 was transferred to the hospital where he/she tested positive for COVID-19. Resident #54 also confirmed he/she had not been tested for COVID-19 since admission to the facility. Resident #54 confirmed he/she had close contact with Resident #168. 2. Review of the medical record for Resident #168 revealed an admitted [DATE] with medical diagnoses of pneumonia, congestive heart failure, hypertensive heart disease, and atrial fibrillation. Further review of the medical record revealed Resident #168 discharged to the hospital on 09/29/23 and that Resident #168 shared a room with his/her spouse (Resident #54). Review of the medical record for Resident #168 revealed an admission MDS, dated [DATE], which indicated Resident #168 was cognitively intact and required extensive staff assistance with bed mobility, toileting, dressing and was dependent for transfers. Review of the medical record for Resident #168 revealed a nurses note, dated 09/29/23 at 7:09 A.M., which stated resident complained of shortness of breath and oxygen saturation was 68% on high flow oxygen. The note stated the physician was notified and Resident #168 was sent to the hospital. Further review revealed a nurse's note, dated 09/29/23 at 10:58 A.M. which stated Resident #168's son came to the facility and informed the nurse Resident #168 was transferred to a different hospital and he/she had tested positive for COVID-19. Interview on 10/04/23 at 2:15 P.M. with Director of Nursing (DON) stated the facility follows CDC guidelines for staff and resident testing for COVID-19. DON confirmed Resident #54 and Resident #168 were in the same room at the time Resident #168 was discharged to the hospital on 09/29/23. DON also confirmed Resident #168 tested positive for COVID-19 at the hospital. DON confirmed Resident #54 had not been tested for COVID-19 since admission to the facility. DON confirmed Resident #54 had close contact with Resident #168. Review of facility policy titled COVID-19, revised May 2023, stated staff and resident testing would be conducted following nationally accepted standards, such as CDC guidelines. Review of the CDC website revealed the CDC guidelines stated asymptomatic patients with close contact with someone with SARS-CoV-2 (also known as COVID-19) infection should have a series of three viral tests for COVID infection. Close contact is being within six feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. The testing is recommended immediately (but no earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This would typically be on day one (where day of exposure is zero), day three, and day five. This deficiency represents non-compliance investigated under Complaint Number OH00146953.

Based on record review and interview, the facility failed to ensure the Administrator's license was active. This has the potential to affect all residents residing in the facility. Current census is 83. Findings include: Review of the Administrator's employee file revealed the Administrator was placed in the position of Administrator on 08/03/21. The employee file revealed a letter from the Bureau of Executives of Long-Term Services and Supports, (BELTSS) dated 07/02/21 informing the Administrator her current license would be inactive as of 07/02/22 if renewal, including 20 hours of education, and renewal payment of the licensure fee was not completed prior to 07/01/22. Review of the BELTSS website, https://beltss.age.ohio.gov/license, revealed the Administrator's license was inactive as of 07/01/22. Review of a printed email from the Director of Nursing (DON) revealed the Administrator had paid the license renewal fee. The screen shot did list the Administrator's renewal status for 06/30/22 as late-missed deadline and there was no Licensed Nursing Home Administrator (LNHA) Continuing Education (CE) marked as satisfied. There was no date on the document identifying when it was sent or received. Review of the Board of Executives of Long-Term Services and Supports website titled Continuing Educations Requirement revealed the license will marked as inactive if more than 10 CE's are completed online, but as long as you have more than 20 CE's completed submit the information with the renewal payment and the license will be renewed. During interview on 05/04/23 at 8:31 A.M., BELTSS board member #1 stated as of 07/01/22 the Administrator's license was considered inactive due to the requirements of the renewal not being completed. The board member stated the BELTSS website was updated daily and at the time of the survey the Administrator's license was not active. During interview on 05/04/23 at 2:20 P.M. with the Administrator via conference call, revealed the Administrator stated she contacted BELTSS office in 2021, and was informed due to the pandemic she would not have to complete the 20 hours of education and her license was to remain inactive, however it would not affect her working at the facility. The Administrator stated she no longer possessed the email notification from BELTSS stating she did not have to complete the education in person due to the pandemic and still retain her license. The Administrator stated she did, however, have evidence she paid the re-instatement fee for her license. This deficiency represents non-compliance investigated under Complaint Number OH00142478.

Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff interviews, the facility failed to report an alleged incident of resident-to-resident abuse to the state agency. This affected one (#1) of four residents reviewed for potential abuse. The current census is 81. Findings include: Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses including encephalopathy, seizures, heart disease, vascular dementia, and falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, a fall risk, and was a two-person assist for Activities of Daily (ADL). Review of Resident #1's care plans dated 12/05/22 revealed a focus for fall relating to inability to walk and weakness. Interventions include frequent checks, allow for rest periods, and monitor for changes. Review of Resident #1's neurological checks dating from 02/16/23 to 02/18/23 revealed all systems the resident allowed the nurse to assess were documented as within normal limits. Multiple entries were documented as resident refused. Review of Resident #1's progress notes revealed on 02/16/23 at 4:15 P.M., the nurse was notified Resident #1 had fallen in her wheelchair when another resident pushed her over. Bruising noted to the hand and a bump on the temporal area on left side of head. Neurological checks were within normal limits, per the note the Power of Attorney (POA), management, and physician were notified. Interview on 03/20/23 at 11:35 A.M., revealed Licensed Practical Nurse (LPN) #100 was caring for Resident #1 on 02/16/23. LPN #100 stated she was called into the dining room to assess Resident #1 after she was on the floor from being tipped over in her wheelchair by another resident. LPN #100 stated she assessed the resident, started neurological checks which were normal. Notification to the POA and the physician of the resident was made and was given orders to monitor for any changes. LPN #100 stated she reported the incident to the DON. LPN #100 stated she did not see the incident but was told by the activity aide another resident pushed Resident #1 over in her wheelchair. LPN #100 stated she did not see any clear signs of injuries at the time of the incident. Interview on 03/20/23 at 2:15 P.M., with Resident #1's POA revealed the facility did inform the POA of the incident which occurred on 02/16/23. Per the POA, the nurse stated Resident #1 was pushed over in her wheelchair by another resident during activities. Interview on 03/20/23 at 3:15 P.M., with the Administrator revealed the facility did not investigate the incident on 02/16/23 with Resident #1 and Resident #2 as a fall or as a possible resident to resident abuse. The Administrator stated she could not determine if the incident between the residents was abuse or accidental. The Administrator stated she was unsure if Resident #2 was acting aggressive when he pushed over Resident #1's wheelchair. Per the Administrator a resident-to-resident interaction would need to be investigated to determine if abuse occurred. The Administrator verified the facility did not initiate a Self-Reported Incident (SRI) for the incident or report to the state agency. Interview on 03/21/23 at 12:50 P.M., with Activity Aide (AA) #311 revealed the aide was in the activity room with Resident #1 and Resident #2 on 02/16/23. AA #311 stated she was assisting another resident when she heard the commotion. AA#311 stated she had her back to the residents and turned around when she heard the crash. Resident #1 was lying on the floor. AA #311 stated she immediately separated the residents, called for a nurse, and stayed with Resident #1 until the nurse came. AA #311 stated she reported the incident to the management as per policy. Review of the Enhanced Information Dissemination & Collection (EIDC) system used to report Self-Reported Incident (SRI) reporting revealed there was no incident reported on 02/16/23 for the event occurring between Resident #1 and Resident #2. Review of the undated policy titled, Resident-to Resident Abuse, revealed the facility will report all incidents, findings, and corrective measures to appropriate agencies, including State Agency. This deficiency represent non-compliance in regards to the allegations reported in complaints OH00140578 and OH00140615.

Based on record review, review of policy, review of the Self-Reported Incident system, Power of Attorney (POA) and staff interviews, the facility failed to thoroughly investigate an alleged incident of resident-to-resident abuse. This affected one (#1) of four residents reviewed for potential abuse. The current census is 81. Findings include: Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses including encephalopathy, seizures, heart disease, vascular dementia, and falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, a fall risk, and was a two-person assist for Activities of Daily (ADL). Review of Resident #1's care plans dated 12/05/22 revealed a focus for fall relating to inability to walk and weakness. Interventions include frequent checks, allow for rest periods, and monitor for changes. Review of Resident #1's neurological checks dating from 02/16/23 to 02/18/23 revealed all systems the resident allowed the nurse to assess were documented as within normal limits. Multiple entries were documented as resident refused. Review of Resident #1's progress notes revealed on 02/16/23 at 4:15 P.M., the nurse was notified Resident #1 had fallen in her wheelchair when another resident pushed her over. Bruising noted to the hand and a bump on the temporal area on left side of head. Neurological checks were within normal limits, per the note the Power of Attorney (POA), management, and physician were notified. Interview on 03/20/23 at 11:35 A.M., revealed Licensed Practical Nurse (LPN) #100 was caring for Resident #1 on 02/16/23. LPN #100 stated she was called into the dining room to assess Resident #1 after she was on the floor from being tipped over in her wheelchair by another resident. LPN #100 stated she assessed the resident, started neurological checks which were normal. Notification to the POA and the physician of the resident was made and was given orders to monitor for any changes. LPN #100 stated she reported the incident to the DON. LPN #100 stated she did not see the incident but was told by the activity aide another resident pushed Resident #1 over in her wheelchair. LPN #100 stated she did not see any clear signs of injuries at the time of the incident. Interview on 03/20/23 at 2:15 P.M., with Resident #1's POA revealed the facility did inform the POA of the incident which occurred on 02/16/23. Per the POA, the nurse stated Resident #1 was pushed over in her wheelchair by another resident during activities. Interview on 03/20/23 at 3:15 P.M., with the Administrator revealed the facility did not investigate the incident on 02/16/23 with Resident #1 and Resident #2 as a fall or as a possible resident to resident abuse. The Administrator stated she could not determine if the incident between the residents was abuse or accidental. The Administrator stated she was unsure if Resident #2 was acting aggressive when he pushed over Resident #1's wheelchair. Per the Administrator a resident-to-resident interaction would need to be investigated to determine if abuse occurred. The Administrator verified the facility did not initiate a Self-Reported Incident (SRI) for the incident or report the incident to the state agency. Interview on 03/21/23 at 12:50 P.M., with Activity Aide (AA) #311 revealed the aide was in the activity room with Resident #1 and Resident #2 on 02/16/23. AA #311 stated she was assisting another resident when she heard the commotion. AA#311 stated she had her back to the residents and turned around when she heard the crash. Resident #1 was lying on the floor. AA #311 stated she immediately separated the residents, called for a nurse, and stayed with Resident #1 until the nurse came. AA #311 stated she reported the incident to the management as per policy. Review of the Enhanced Information Dissemination & Collection (EIDC) system used to report Self-Reported Incident (SRI) reporting revealed there was no incident reported on 02/16/23 for the event occurring between Resident #1 and Resident #2. Review of the undated policy titled, Resident-to Resident Abuse, revealed the facility will evaluate the circumstance/events leading up to the incident. This deficiency represent non-compliance in regards to the allegations reported in complaints OH00140578 and OH00140615.

Based on interviews, record review and policy review the facility failed to issue a bed hold letter to one resident ( #79) out of two residents reviewed for hospitalization . The census was 83. Review of medical record for Resident #79 revealed admitted [DATE] with limited cognitive deficits. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/22/22 Resident #79 was having outpatient testing for an upcoming surgery. At 5:15 P.M. Resident #79 representative notified the facility Resident #79 was being admitted directly into the hospital due to passing out during a magnetic resonance imaging (MRI) test earlier in the day. Review of the billing information in Resident #79 medical record revealed a stop date for services due to discharge was on 09/22/22. Review of Resident #79 nurses progress notes revealed no indication a bed hold notification was discussed or mailed to the resident or his representative. Interview on 11/03/22 at 10:05 A.M. interview with Business Office Manager #408 confirmed Resident #79 or his representative did not receive a bed hold notification letter in person or by mail after being discharged from the facility. Review of the Discharge Summary and Plan Policy(no date) revealed no information about a bed hold policy.

Based on interviews , record reviews, and policy and procedure review, the facility failed to update one resident's elopement assessment quarterly. This had the potential to affect one Resident ( #09) out of one resident reviewed for elopement. The facility census was 83. Findings include: Review of medical record for Resident #09 revealed resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] revealed resident had moderately impaired cognition. Resident #09 had inattention and disorganized thinking that fluctuated. Resident #09 required extensive assist of one staff member for Activities of Daily Living (ADL's). Review of Care Plan dated 08/01/22 revealed Resident #09 was at risk for elopement/wandering related to dementia, impaired cognition, and [CONDITION(S)]. Interventions included but not limited to administer medications as ordered, monitor and report changes in behavior, monitor side effects of medications, provide one on one visits as needed, provide diversional activities of interest as needed, redirection as needed, wander guard to be worn at all times check placement and function, and monitor skin under wander guard. Review of Elopement Risk Assessments dated 10/27/21, 02/27/22, 06/27/22, and 10/27/22 revealed assessments were completed every four months. Interview on 11/03/22 at 11:58 A.M. with Director of Nursing (DON) verified elopement risk assessments were completed every four months. DON verified that it was not completed quarterly. DON verified assessment should be done every three months for quarterly. Review of policy titled Wandering and Elopements not dated revealed residents are assessed upon admission, quarterly, and with change of status.

Based on interviews and record reviews the facility failed to update a Residents Comprehensive Care Plan . This had the potential to affect one Resident (#42) out of four residents reviewed for care plan's. The facility census was 83. Findings include: Review of medical record for Resident #42 revealed admitted [DATE] with moderate cognitive deficits. The resident was admitted with Type 2 diabetes mellitus , [CONDITION(S)], [CONDITION(S)], depression, anxiety, and [CONDITION(S)]. Review of the dentist progress notes on 02/11/22 revealed patient received her dentures for the first time. She has no history of dentures in the past. Patient was having a hard time by herself seating the dentures on her gums for a complete seal. Patient would benefit from denture adhesive until she can completely seat them on her own. Review of Resident #42 Minimum Data Set (10/17/22) did not indicate the resident was edentulous. Review of Resident #42 Plan of Care last updated 10/17/22 revealed no indication resident had dentures. On 11/01/22 at 9:25 A.M. observation and interview with Resident #42 revealed her to be tooth less and not wearing dentures. She requested to have her dentures. On 11/03/22 at 9:50 A.M., the Director of Nursing confirmed Resident #42's plan of care was updated on 11/03/22 to include denture care and wear after surveyor intervention. On 11/03/22 at 11:30 A.M., Resident #42 was observed eating lunch without her dentures. When asked where her dentures were , she stated I need my bottom teeth. On 11/03/22 at 11:57 A.M., interview with State tested Nursing Assistant (STNA) # 403 revealed she was aware Resident #42 has dentures. She confirmed Resident #42 was not wearing her dentures.

Based on medical record review, interview, and review of facility policy, the facility failed to provide documentation to support Foley catheter care was provided and Foley catheter outputs were monitored for Resident #30. This affected one (Resident #30) of one resident reviewed for urinary tract infection. The facility census was 83. Findings include: Review of the medical record for Resident #30 revealed admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had impaired cognition. The resident required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. The resident had in indwelling Foley catheter. Review of the Care Plan dated 08/10/22 revealed the resident had urosepsis infection with goal infection will resolve without complications. Interventions include administer antibiotics as ordered, assess for pain per facility policy and medication as ordered, assess for signs of infection and report to physician: redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of sections, cough, congestion, abnormal lung sound, diarrhea, vomiting, monitor for signs of urinary tract infection ([CONDITION(S)]): foul smelling urine, cloudy urine, sediment, decreased output, and vital signs as ordered. Resident is at risk for alteration in elimination. Resident will be free of complications related to appliance use. Interventions included change Foley catheter as ordered and as needed, empty Foley catheter bag every shift and as needed, Foley catheter to straight drain, keep Foley bag below level of bladder, and intake and output, record results. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for August 2022 revealed documentation for Foley catheter care routinely and as needed, every shift for Foley catheter care, was silent from 08/09/22 to 08/22/22. Documentation post catheter care order dated 08/22/22 was silent on 08/25/22 for day and night. Documentation for Foley catheter output every shift, every day and night shift for monitoring, was silent on 08/17/22 day and night shift, 08/18/22, 08/19/22, 08/21/22, 08/22/22, and 08/23/22 day shift, 08/24/22 and 08/25/22 day and night shift. The Foley catheter was discontinued on 08/26/22. Interview on 11/03/22 at 12:58 P.M. the Director of Nursing (DON) stated the resident was admitted with a Foley catheter related to severe [CONDITION(S)]. She stated he had a compromised immune system because of [CONDITION(S)] treatments. She stated he had a cystoscopy last week related to chronic [CONDITION(S)] and was followed by urology. Interview on 11/03/22 at 1:30 P.M. the DON verified no documentation for Foley care and outputs. She stated State tested Nurse Aid (STNA) may have documented in Point of Care (POC) and she would check nursing notes for additional documentation. She verified Foley care would be routine practice for any resident with an indwelling Foley catheter. At 3:00 P.M., the DON stated she was unable to locate additional documentation for Foley catheter care or catheter output. Interview on 11/03/22 at 3:03 P.M. Resident #30 stated staff were emptying his Foley bag twice a day, but he could not be sure they provided catheter care every shift. The facility had no current residents with indwelling Foley catheters. Review of facility policy titled Catheter Care, Urinary, revised date September 2014, revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain an accurate record of the resident's daily output, per facility policy and procedures. Empty collection bag at least every eight hours. Changing the indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. The following information should be recorded in the resident's medical record: the date and time the catheter care was given. The name of the individual(s) giving catheter care. All assessment data obtained when giving catheter care. Character of urine such as color, clarity, and odor. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and intervention taken.

Based on record review, interview, and policy review, the facility failed to ensure medications were stopped per prescription which led to resident receiving [MEDICATION(S)] for an extended period of time. This affected one (Resident #28) of five residents reviewed for unnecessary medications. Facility census was 83. Findings include: Review of medical record for Resident #28 revealed resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed resident had moderately impaired cognition. Resident #28 required extensive assist of two for bed mobility, transfers, and toileting. Review of Care Plan dated 09/26/22 for Resident #28 revealed resident exhibits non compliance related to refusal of preventative care, [CONDITION(S)], wearing foam boots while in bed, medications, wound care, mask, blood sugar testing, incontinence care, and breakfast. Interventions include document educational attempts made with resident and family related to non compliance, educate resident, family or responsible party on negative outcomes related to non compliance, and notify physician of non compliance. Review of discharge orders from hospital dated 03/15/22 for Resident #28 revealed prescription for [MEDICATION(S)] (steroid) 20 milligrams (mg) give 40 mg orally daily with breakfast. Dispense 10 tablets. Review of Medical Practitioner Note for Resident #28 dated 03/20/22 revealed date of service 03/18/22 stated for chronic obstructive pulmonary disease ([CONDITION(S)]) complete [MEDICATION(S)] and [MEDICATION(S)]. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of General Progress note dated 06/04/22 at 5:07 P.M. for Resident #28 revealed new order received from Nurse Practitioner to start titrating [MEDICATION(S)]. New order consisted of [MEDICATION(S)] 30 mg for one week then [MEDICATION(S)] 10 mg for one week then discontinue. Review of MAR for June 2022 for Resident #28 revealed [MEDICATION(S)] 30 mg given 06/05/22 through 06/11/22. [MEDICATION(S)] 10 mg given 06/12/22 through 06/18/22 then discontinued. Review of Medical Practitioner Note dated 06/06/22 for Resident #28 revealed tapering [MEDICATION(S)], [CONDITION(S)] controlled. Resident #28 followed wound clinic. Resident #28's legs remained bright red, non-tender, no drainage, and mild swelling compared to baseline. Consider drug reaction to [MEDICATION(S)] (antibiotic) or prolonged use of [MEDICATION(S)]. Interview on 11/03/22 at 9:38 A.M. with Director of Nursing (DON) verified [MEDICATION(S)] 40 mg was taken daily from 03/16/22 through 06/04/22 when NP titrated the dose for Resident #28. DON verified discharge order stated 10 tablets. Review of policy titled Administering Medication revised April 2019 revealed medications are administered in accordance with prescribed orders, including any required time frame. This deficiency substantiates complaint number OH 112.

Based on medical record review, staff interviews, observation, review of a facility policy, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure monitoring of a pressure ulcer was completed to ensure appropriate care and treatment was provided to prevent deterioration of a pressure ulcer. This resulted in actual harm when Resident #39's pressure ulcer was not monitored on a weekly basis and resulted in the pressure ulcer to the coccyx developing to an unstageable deep tissue injury. Consequently, Resident #39's pressure ulcer to the coccyx required wound physician intervention including debridement of the area to remove necrotic tissue and the wound was assessed as a stage IV post debridement. This affected one (#39) of one resident reviewed for pressure ulcers. The facility identified two residents currently residing in the facility with pressure ulcers. The facility census was 60. Findings include: Review of Resident #39's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She had physical behaviors to others one to three days. She experienced no rejection of care. She required extensive assistance with two plus staff for bed mobility, dressing, and hygiene. She was assessed as not having a pressure ulcer, but was at risk for a pressure ulcer. The resident had a pressure reducing device for her chair and bed. Review of the resident's care plan revealed a care plan initiated on 05/07/19 for potential impairment to skin integrity related to cerbrovascular accident, impaired mobility, and incontinence of bowel and bladder. The goal was for the resident to maintain intact skin. Interventions included assist to turn and reposition frequently and as needed, preventative dressing as ordered, pressure reducing cushion to chair, pressure reducing mattress, weekly skin audit, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of physician's orders [REDACTED]. Review of the resident's weekly pressure skin grids revealed she originally had a stage two pressure ulcer to her coccyx on 07/08/19 measuring 1.0 centimeters (cm) x 0.4 cm x 0.1 cm depth. The wound bed was described as pink with reddened surrounding skin. The physician was notified on 07/08/19. Review of the resident's nursing notes dated 07/08/19 revealed a new pressure ulcer was noted to the coccyx, stage two open area 1.0 cm x 0.4 cm x less than 0.1 cm. No drainage was noted and no signs of infection. The wound bed was pink with surrounding skin reddened. New treatment order was obtained. Review of physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. House barrier cream apply topically to affected areas after each incontinent episode. Review of the weekly pressure skin grid dated 07/09/19 revealed an area to the coccyx with original date of wound documented as 07/09/19. There were no measurements. The wound was described as having a pink wound bed with reddened surrounding skin. The physician was notified on 07/09/19. Review of the weekly pressure skin grids revealed no further grids were completed until 07/23/19. The description was a coccyx pressure wound originated on 07/09/19. The wound bed was pink with reddened surrounding skin, no drainage, no tunneling, and unchanged. No measurements were documented. Review of the weekly pressure skin grids revealed no further grids were completed until 08/07/19. The original date of the coccyx pressure area was 08/07/19 and the wound was described as pink wound bed with reddened surrounding skin. No drainage and no tunneling were noted and the wound was improved. No measurements were documented. Review of the resident's Braden scale (a tool to assess a resident's risk of developing a pressure ulcer) dated 09/05/19 revealed she was at moderate risk for a pressure ulcer. Review of the weekly pressure skin grids revealed no further grids were completed until 09/10/19. The original date of the pressure ulcer to the coccyx was 09/10/19. The wound was described as slight pink wound bed. Measurements were 0.5 cm x 0.5 cm x 0 cm. The stage was marked not applicable, and the wound was documented as healed. Review of the resident's weekly skin assessments revealed an assessment was completed on 09/21/19 and indicated the resident had no pressure ulcers. Review of the weekly pressure skin grids revealed on 09/24/19 the resident had a coccyx pressure ulcer that was healed and slightly pink. Review of the resident's shower sheets revealed one completed on 09/24/19 with no open areas. One was also completed on 09/27/19 with the sacrum area circled and open area written in. No further shower sheets after 09/27/19 were provided. Review of the resident's weekly skin assessments revealed an assessment was completed on 09/28/19 and indicated the resident had no pressure ulcers. Review of the resident's nursing notes revealed no nursing notes regarding the resident's coccyx pressure ulcer after 07/08/19 until 10/15/19. On 10/15/19, Licensed Practical Nurse (LPN) #224 documented the resident was seen by the wound physician for an unstageable deep tissue injury to the sacrum. Pressure reducing mattress noted on resident's bed, along with pressure reducing pad in wheelchair. The unstageable deep tissue injury was noted to be 3.5 cm x 3.5 cm with light serous drainage noted, with 70% viable tissue and 30% skin. New wound order obtained. The resident was recommended to be off-loaded as tolerated, obtain consent for debridement of wound, and add multivitamin. Review of the resident's (MONTH) Treatment Administration Record (TAR) revealed weekly skin audits were not signed off as completed on 10/05/19 or 10/12/19. Updated skin grids weekly were not signed off on 10/01/19 or 10/08/19. Nurses continued to sign off on the treatment to cleanse the wound to coccyx with normal saline, apply skin prep to surrounding areas and cover with adhesive foam every three days, and as needed, until 10/13/19. The last nurse to sign off the order as completed was LPN #242 on 10/13/19. Review of the weekly pressure skin grids revealed on 10/15/19 the resident had an unstageable deep tissue injury to the coccyx with an original date of 10/15/19. Measurements were 3.5 cm x 3.5 cm, no depth was noted. Wound was noted to be dark purple in color with light serous drainage. Review of Wound Physician #267's note dated 10/15/19 revealed the resident had an unstageable deep tissue injury sacrum wound with light serous exudate. She had no pain. The wound measured 3.5 cm x 3.5 cm x not measurable. The etiology was pressure. The physician ordered Leptospermum honey apply once daily, cover with foam with border, skin prep to peri-wound daily. Off-load wound, reposition per facility protocol, and obtain consent for debridement. Follow up in seven days. Review of the weekly pressure skin grids revealed on 10/22/19, the wound was described as an unstageable pressure ulcer with measurements of 3.5 cm x 3.5 cm. The wound was described as a deep tissue injury with light serous drainage and dark purple in color. Wound status was marked as declined with the physician aware. Review of physician order [REDACTED]. Review of Wound Physician #267's note dated 10/22/19 revealed the resident continued with an unstageable deep tissue injury to the sacrum measuring 3.5 cm x 5.5 cm x 0.1 cm with light serous exudate. The wound was noted to contain 20% slough, 50% other viable tissues (subcutaneous fat, dermis, muscle), and 30% skin. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. Surface area was documented as 19.25 square cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed to a depth of 0.2 cm and healthy bleeding tissue was observed. MDS post debridement stage of pressure ulcer was stage four. A new treatment was ordered for zinc ointment covered with foam with border, and apply skin prep to peri-wound area once daily. Off load wound, reposition per facility protocol, low air loss mattress. Follow up in seven days. On 10/22/19 at 7:28 P.M., LPN #224 documented Resident #39 was seen by the wound physician during rounds to follow up on wound to sacrum. She was noted to have a fair appetite. The resident's unstageable deep tissue injury wound was noted to deteriorate. Measurements were 3.5 cm x 5.5 cm x 0.1 cm. The physician completed surgical excisional debridement to remove necrotic tissue and establish margins of viable tissue. Procedure surgically excised tissue including slough, bio-film, and non-viable tissue. Hemostasis was achieved and a clean dressing was placed. Wound noted to have light serous drainage and was 20% slough, 50% viable tissue, 30% skin. Physician also noted the resident had moisture associated [MEDICAL CONDITION]. New orders were obtained. Recommendation from the physician was for the resident to be on a low loss air mattress. Observation of Resident #39's wound care on 10/23/19 at 2:30 P.M. revealed the resident was lying in bed on a pressure relieving mattress (not low air loss). An open area to the resident's sacrum measured 2.0 cm x 2.5 cm with tunneling of unknown depth noted. Surrounding skin was red and macerated. Interview with LPN #224 and the Director of Nursing (DON) on 10/23/19 at 5:55 P.M. revealed Wound Physician #267 came to the facility on [DATE] around 9:30 [NAME]M. until 11:30 [NAME]M. LPN #224 stated she did not get time to put the orders in until approximately 7:45 P.M. and this was after Maintenance Director #258 had left for the day. She stated she told Maintenance Director #258 about the resident's order for a low air loss mattress the morning of 10/23/19 verbally. LPN #224 and the DON verified the resident did not have a low air loss mattress at this time. The facility had low air loss mattresses in house. The DON stated the resident had a pressure relieving mattress for management of pressure ulcers up to stage two. Interview with Maintenance Director #258 on 10/24/19 at 8:27 [NAME]M. revealed he was not informed the resident needed a low air loss mattress until the evening of 10/23/19, after he had already left the building. He stated he received a text message. Telephone interview with LPN #242 on 10/24/19 at 10:10 [NAME]M. revealed she changed the resident's dressing on 10/13/19. She stated the resident's coccyx wound was healed. She stated there was no open area and the skin was blanchable. When asked what open area she cleansed per the order, she stated the resident had a bowel movement and she cleaned her up. She stated she did not question why the order was to cleanse wound to coccyx. She verified she did not document an assessment of the wound or attempt to clarify the order. Interview with Wound Physician #267 via telephone on 10/24/19 at 11:37 [NAME]M. revealed he did not want to speculate as to how the resident's pressure ulcer deteriorated. He stated it was possible the wound had not completely healed as documented on 09/24/19. He stated he saw the wound on 10/15/19 and it appeared as an unstageable deep tissue injury with light drainage. He stated when he debrided the wound on 10/22/19, he saw muscle fibers, so he staged it as a stage four pressure ulcer. Further interview with the DON on 10/24/19 at 3:20 P.M. revealed she asked the wound physician to look at the resident's wound on 10/15/19 as she thought they were still padding and protecting the resident's intact sacrum as a preventative measure. She did not realize the resident's order was for an open area to the coccyx. She stated she wanted the wound physician to observe the wound to see if the foam dressing was still appropriate. She verified the wound physician found an unstageable deep tissue injury on the resident's sacrum on 10/15/19 that was debrided on 10/22/19 and classified as a stage four pressure ulcer. She verified the facility did not document weekly on the resident's coccyx pressure ulcer in the skin grids or nursing notes. She stated they did not have any additional assessments. She verified the nurses were signing off for an open wound dressing, which would indicate a need for a weekly assessment. She verified the sacrum wound was first identified on 07/08/19 as a stage two pressure ulcer, with no further documentation until 07/23/19 with no assessment or measurement of the wound. She verified there was no further documentation until 08/07/19 with no measurement of the wound, then 09/10/19 with measurements of 0.5 x 0.5 x 0 depth slightly pink wound bed, improved, healed. She verified there was no further documentation on the resident's coccyx wound except the nurses continued to sign off every three days on a dressing to an open area on the coccyx until 10/13/19. Review of the NPUAP website revealed an unstageable deep tissue injury was defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Continued review of the NPUAP website revealed, a stage four pressure ulcer was defined as a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Review of a facility policy titled Skin Assessment & Documentation Policy & Procedure dated 12/01/18 revealed a weekly skin assessment must be completed by the nurse and documentation of completion of the assessment is required by initialing the TAR. Document any findings in the nurse's notes or on the weekly skin assessment form. Once a new pressure area is identified, take the following steps: (including) Measure each area once a week and as needed for any changes in the wound. Record the measurements and description on the skin grid pressure form for the appropriate wound. Any changes in skin condition should be reported to the nurse and physician for follow-up.

Based on review of closed and current medical records, review of a squad report, review of a facility self-reported incident (SRI), review of a facility investigation, interviews with staff, the physician and squad personnel, and review of the Cardiopulmonary Resuscitation (CPR) policy, the facility failed to initiate CPR or contact Emergency Medical Services (EMS) timely for one resident (#30) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #30 did not receive CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#30) of two residents reviewed for emergent change in condition and death. The facility identified 19 residents residing in the facility designated with Full Code status. Additionally, two (#17 and #48) of four current residents reviewed were placed at risk for more than minimal harm that is not Immediate Jeopardy for failure of the facility to ensure the residents code status was updated in the electronic medical record, Point Click Care (PCC), to match the code status in the paper medical record. The facility census was 53 residents. On [DATE] at 12:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 7:10 P.M. when Registered Nurse (RN) #308 was informed by State tested Nursing Assistant (STNA) #217 that Resident #30 was unresponsive, and RN #308 subsequently checked on another resident. RN #308 reported Resident #30 was fine. STNA #217 directed RN #308 to Resident #30's room and RN #308 confirmed Resident #30 was without vital signs. RN #308 called Licensed Practical Nurse (LPN) #309 to Resident #30's room and she also confirmed the resident was without vital signs; however, neither RN #308 nor LPN #309 began CPR. The STNA's were instructed to begin Resident #30's post mortem care. RN #308 and LPN #309 returned to the nurses' station and began making phone calls to the family and physician. While at the nurses' station, LPN #309 discovered Resident #30 was a Full Code. RN #308 obtained the crash cart and both nurses returned to Resident #30's room and began CPR. RN #308 could not locate a CPR mask in the crash cart and had to retrieve a CPR mask from her personal bag. LPN #223 contacted the squad and upon the squad's arrival CPR was not being provided to Resident #30. Resident #30 expired at the facility. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: · On [DATE] at 7:42 P.M. EMS took over the care of Resident #30. · On [DATE], the DON and Unit Managers, conducted an initial audit of all current residents, to validate the physician code status orders matched in the resident's medical record and on the resident's Kardex. The audit was completed on [DATE] at 11:03 A.M. · On [DATE] at 8:30 A.M., the Human Resource Director started an audit of all the nurse's personnel files to ensure active license and CPR certification. The audit was completed on [DATE] at 5:24 P.M. · On [DATE], the facility identified RN #308 will not return to the facility. · On [DATE] at 8:00 A.M. the DON and/or designee began all staff in-services regarding Emergency Management Guidelines which includes the process defining the roles and responsibilities of nursing staff involved in the care of a resident in an emergent situation, which includes physician notification of a change in condition. This was completed on [DATE] at 5:00 P.M. · On [DATE], the facility staff completed an audit of the crash cart to ensure all items needed to perform CPR were present on the cart. · On [DATE] the facility implemented procedures to ensure the deficient practice does not reoccur. New employees will receive in-service education on the Emergency Management Guidelines which includes the process defining the roles and responsibilities of nursing staff involved in the care of residents in an emergent situation. Staff Development Nurse and/or DON will provide the education. · On [DATE] at 9:30 A.M. a Quality Assessment and Assurance (QAA) Committee held a meeting with the Medical Director in attendance via teleconference. The QAA Committee reviewed and approved the facilities plan to correct the identified concern. A follow up QAA Committee meeting was held on [DATE]. · On [DATE] the DON and/or Administrator will monitor resident's code status through the morning interdisciplinary team (IDT) meeting daily for 14 days, then Monday through Friday ongoing. Areas of deficiency will be submitted to the QAA Committee and corrected immediately. · On [DATE] at 9:00 A.M., record review by the survey team revealed two (#17 and #48) out of four residents reviewed for their code status revealed a discrepancy with their identified code status on the medical record. The Unit Managers began conducted a validation audit of physician's orders for code status and all corrections were made and completed on [DATE] at 12:52 P.M. · On [DATE], one (#58) additional medical record was reviewed for emergent change in condition and death and no concerns were identified. Additionally, the facility identified 19 residents (#21, #49, #15, #37, #20, #51, #50, #55, #17, #36, #57, #46, #40, #7, #3, #18, #38, #11 and #32) with a Full Code status. Review of the 19 medical records revealed the code status on the physician orders accurately matched the code status listed on the residents' paper chart. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of Resident #30's medical record revealed a physician's order indicated the resident was a Full Code. Review of Resident #30's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident was not receiving Hospice services. Review of Resident #30's Plan of Care revealed his advanced directive was a Full Code initiated on [DATE]. Review of the physician orders dated [DATE] revealed Code Status: Full Code. The order was signed by the physician on [DATE]. Review of the nurse progress note dated [DATE] at 10:15 P.M. revealed at 7:10 P.M. the nurse (RN #308) was notified by a STNA #217 that resident was unresponsive and not breathing. At this time this nurse ran to the resident's room to confirm. Vital signs were assessed but unable to register. No pulse was noted. Resident #30 was not breathing and had a pale/blue complexion and a protruding tongue. Resident #30 was cool to touch. At this time RN #308 asked LPN #309 to come and verify Resident #30's death. At 7:19 P.M. LPN #309 completed a second check of Resident #30's vital signs and together RN #308 and LPN #309 confirmed death. Post mortem care was started by the STNA's. At 7:22 P.M. the physician was called to notified him of Resident #30's death and the nurse left a message to call facility. Resident #30's Power of Attorney (POA) was notified of his death. The DON was called, and the nurse left a message to call facility. It was noted that Resident #30 was a full code. The nurses obtained the crash cart to take it to Resident #30's room. The CPR mask was not in the crash cart. At this time, RN #308 ran to her personal bag and used her unused personal CPR mask as LPN #309 began chest compressions. At 7:50 P.M. EMS was called by LPN #223. LPN #223 also received a verbal order from the physician to release the body to funeral home. During this time RN #308 and LPN #309 continued with CPR until arrival of EMS at which time they also confirmed Resident #30's death. Review of the EMS Report dated [DATE] revealed the EMS was contacted on [DATE] at 7:37 P.M. for a [MEDICAL CONDITION]/death. Immediate response was requested. The squad arrived at the facility at 7:42 P.M. for an unresponsive male. Upon arrival EMS was met by nursing staff. They stated he was a Full Code and CPR was being performed. Upon contact with Resident #30, CPR was not being performed that EMS witnessed. No valid DNR was available at the time of arrival. EMS was advised that Resident #30 had been down for 30 minutes. The facility staff had started following their deceased resident protocol. The on-call physician was contacted and notified of the death. The physician called back and advised the facility staff Resident #30 was a Full Code. The facility staff stated that they started CPR 20 minutes after Resident #30 was found down. Approximately ten minutes of CPR was performed by the facility staff prior to EMS arrival. Four-lead was obtained, and asystole was noted at 7:51 P.M. EMS noticed Resident #30 was on six liters of oxygen via non-rebreather mask. Medical control was contacted at 7:50 P.M. the physician there advised EMS to cease any resuscitation efforts. Efforts were ceased at 7:53 P.M. The EMS report described Resident #30's condition as dead on arrival (DOA). Disposition of the report revealed Resident #30 was dead at the scene, no resuscitation attempted, and the resident was not transported. EMS personnel who responded included two paramedics and one Emergency Medical Technician (EMT). A facility SRI with an initial submission date of [DATE] at 1:28 P.M. and a final closed date of [DATE] at 5:09 P.M. regarding suspicion of neglect or mistreatment was reviewed. The SRI revealed the incident involved an agency nurse (RN #308) as the perpetrator and Resident #30 as the involved resident. The investigation revealed RN #308 found Resident #30 unresponsive and without vital signs on [DATE] at 7:10 P.M. RN #308 did not initiate CPR until at least 7:22 P.M., a minimum of 12 minutes later. The facility unsubstantiated the SRI. Further review of the facility SRI investigation revealed the following witness statements: LPN #223's statement dated [DATE] revealed she was Resident #30's nurse on [DATE] from 3:00 P.M. until 7:00 P.M. Per LPN #223 she was in Resident #30's room on [DATE] at approximately 4:50 P.M. to check his blood sugar and to give his medications. Resident #30 was sitting up in wheelchair getting ready to eat supper. At the time the code started, LPN #223 was on the 100 hall doing treatments. Per LPN #223's statement she went to call squad and the physician. STNA #276 statement dated [DATE] revealed STNA #217 asked her to check on Resident #30 because he was fidgeting a lot. When STNA #217 left the floor for break, STNA #276 went to check on Resident #30 and he was leaning forward in his wheelchair. STNA #276 asked him if he could sit up but was not able to, so STNA #276 picked up the items on the floor for him, STNA #276 came back to check on Resident #30 again not long after. STNA #276 saw he had had a bowel movement through his brief and smelled like bowel movement. STNA #276 went to get STNA #217 to ask her if she could help change him. When STNA #217 and STNA #76 returned to Resident #30's room they saw that his face was blue and that his tongue was out. STNA #217 went to get the nurse while STNA #276 stayed in the room with him. STNA #217 returned with RN #308 and the vital machine to get the vitals. RN #308 checked the pulse and said that he didn't have a pulse. Two nurses were in the room at that time. STNA #289 came to help move Resident #30 from his wheelchair to the bed, via Hoyer lift and all three STNA's helped get him in the bed. Once he was in bed the STNA's provided post mortem care. While doing post mortem care RN #308 and LPN #309 came back into the room because they discovered that he was a Full Code and started CPR. The DON's statement dated [DATE] at 8:00 A.M. documented that she missed three calls from the facility on [DATE]. She placed a return call on [DATE] at 8:02 P.M. and spoke with RN #308 who was the primary nurse for Resident #30. RN #308 reported to the DON that Resident #30 had been found unresponsive and that CPR was started, and EMS was present and confirmed his death. DON asked RN #308 to get statements from all those involved and assigned to him as to when he was last seen healthy, what care was provided to him, and the timeline of how things took place. Per the DON's statement RN #308 acknowledged the request and hung up the phone. On [DATE], DON arrived at the facility at 7:55 A.M. and began going through the statements. Upon reading the statement from RN #308 she realized that what she was told on the phone and what was typed in the statement were different. The DON immediately started an investigation, notified abuse coordinator, and started education regarding the facilities emergency management system and BLS CPR process. STNA #217's statement dated [DATE] at 9:46 A.M. included on [DATE] at approximately 6:40 P.M., before leaving for break she told STNA #276 to keep an eye on Resident #30 because he was fidgeting. Upon return to the unit at approximately 7:10 P.M., STNA #276 asked her to help change Resident #30. They went into his room and he was slumped over, he was not breathing, his face was purple, and his tongue was protruding, and his eyes were open. STNA #217 attempted to rouse him and he was unresponsive. STNA #276 stayed with Resident #30 and STNA #217 went to get RN #308. STNA #217 told RN #308 to go to Resident #30's room because he was unresponsive, and she thought he may be dead. Per the statement, RN #308 ran away and STNA #217 grabbed the vital machine. STNA #217 met RN #308 again in the hallway and RN #308 said she had talked to him in the hallway and he said he was ok. RN #308 had checked on the wrong resident. STNA #217 then took RN #308 to Resident #30 and they checked his vital signs. STNA #217 took his blood pressure and RN #308 did his pulse. LPN #309 came into the room during the vitals and she also took his pulse. LPN #309 stated he was gone and then they both left the room. STNA #217 then called out to the nurse and asked if they could put him back to bed and start post mortem care, and she said yes. STNA #289 showed up shortly thereafter and helped us transfer Resident #30 to the bed and began post mortem care. We were about half way done when both nurses came back into the room and started CPR. The STNA's left the room at that time. LPN #309's statement dated [DATE] at 4:41 P.M. revealed at 7:15 P.M. on [DATE] RN #308 asked her if she could come look at something with her. LPN #309 told her yes but she needed to finish giving someone their medications and would come. RN #308 walked away, LPN #309 locked the medication cart and gave the medication, then walked over to the 300-hall. At 7:19 P.M. LPN #309 walked into Resident #30's room. RN #308 told LPN #309 the STNA informed her that Resident #30 was deceased . RN #308 stated she had looked at him and checked him out. She said he was non-responsive, his lips were blue, and he had no pulse. LPN #309 said ok, stooped down to see his face, did a quick assessment which revealed he did not have a pulse and his pupils were fixed. LPN #309 confirmed to RN #308 that yes Resident #30 was deceased . RN #308 asked LPN #309 what needed to be done next because this was her first death. LPN #309 explained to her what she needed to do by contacting the physician for release of the body, call the DON, call the family, and post-mortem care needs to be started. LPN #309 offered to call the family and RN #308 was going to call the physician and the DON. LPN #309 and RN #308 walked to the nurse station together. LPN #309 grabbed Resident #30's medical chart and scanned his face sheet for his POA information. LPN #309 found the number and called the number on the face sheet and it was not a good number. She then put the chart aside and reached into her pocket for her log in information and logged into PCC to find out if the number for the POA had been different from what was on the face sheet. LPN #309 logged in and found the contact information. She called the numbers listed and left a message. LPN #309 then called the second person listed. They also did not answer so LPN #309 called a third person and that individual answered the call. While LPN #309 was on the phone, the first daughter she called was on another line, returning her call. Both family members were informed of Resident #30 passing away. RN #308 said she called the DON and the physician and left a message for both. After that RN #308 and LPN #309 left the nurses station and went to the room. LPN #309 told RN #308 that the funeral information might be in the chart, she said ok and we both walked back to the nurse station. LPN #309 picked up Resident #30's medical chart and opened it to check the funeral home information and saw that Resident #30 was a Full Code. LPN #309 said wait he's a Full Code. According to the statement RN #308 said she didn't know that. Per the statement, RN #308 said oh so do we do CPR and LPN #309 said yeah. RN #308 opened up the supply closet and they grabbed the crash cart and went to Resident #30's room. At this point the aides were in his room. The nurses told the STNA's they had to do CPR because Resident #30 was a Full Code. LPN #309 opened the crash cart and couldn't find a face shield. RN #308 started chest compressions. LPN #309 left to ask LPN #223 if this facility would still do compressions after all this time that he had already passed. LPN #223 said she thought that's a good idea. LPN #309 went back to Resident #30's room and asked RN #308 if she found a face shield. She stated no but she had a face shield in her bag and she went and grabbed it. RN #308 brought back the face shield and LPN #309 was doing compressions until EMS walked into the room. Interview with Administrator on [DATE] at 12:02 P.M. verified the facility conducted an investigation into Resident #30's death which revealed the resident was found unresponsive on [DATE] at 7:10 P.M. by STNA #217 who immediately informed RN #308. The Administrator also verified the facility investigation showed RN #308 did not immediately initiate CPR. RN #308 initially confirmed death with LPN #309. The STNA's then began post mortem care while RN #308 and LPN #309 began making phone calls and then discovered Resident #30 was a Full Code. CPR was not initiated until sometime after 7:22 P.M. Interview on [DATE] at 3:43 P.M. with STNA #217 verified she was working second shift on the day of Resident #30's death. STNA #217 verified she was caring for Resident #30 and got him up into his wheelchair for supper on [DATE]. STNA #217 stated she went to her meal break around 6:40 P.M. When she returned from meal at about 7:10 P.M. STNA #276 told her Resident #30 needed changed. Upon entering Resident #30's room the resident was slumped over in his wheelchair. STNA #217 stated they tried to arouse him and he was unresponsive. STNA #217 stated STNA #276 stayed with Resident #30 while she immediately informed RN #308 and STNA #217 also went to get the vitals cart. When STNA #217 returned to Resident #30's room, STNA #217 noted RN #308 checked on the wrong resident while STNA #217 was getting the vitals sign equipment. RN #308 stated the resident was fine. STNA #217 redirected RN #308 to Resident #30's room. STNA #217 and RN #308 went into the room together and checked his vital signs. STNA #217 connected the blood pressure cuff while RN #308 checked his pulse. STNA #217 verified RN #308 did not start CPR. After LPN #309 arrived at the room, RN #308 and LPN #309 pronounced Resident #30 death. STNA #217 stated the two nurses (RN #308 and LPN #309) then exited the room and STNA #217, STNA #276 and STNA #289 moved Resident #30 from his wheelchair to his bed per the mechanical (Hoyer) lift which took about five minutes and began post mortem care. STNA #217 stated they were about half way done with post mortem care when RN #308 and LPN #309 returned to the room and told the STNA's to leave because Resident #30 was a Full Code. The nurses entered Resident #30's room and closed the door, leaving it open only a crack. STNA #217 stated she could hear them initiate CPR at that time. Additionally, STNA #217 verified she checked on Resident #30 just before she left for her meal break at 6:40 P.M. Resident #30 was alive when she left for lunch and he was the first person she attended to upon her return to the unit after lunch. She noted he needed a lot of attention because he was frequently slumping over in his wheelchair and he needed help repositioning. STNA #217 stated RN #308 did not know Resident #30's code status. Interview with DON on [DATE] at 4:32 P.M. verified she was not present in the facility on [DATE] at 7:10 P.M. when Resident #30 was found unresponsive. She verified she had three missed calls from the facility and returned the calls on [DATE] at 8:01 P.M. The DON stated on [DATE] at 8:02 P.M. she spoke with RN #308 who informed her of the unexpected death of Resident #30. The DON verified in the morning, upon discovering the circumstances surrounding Resident #30's death, SRI was submitted, and an investigation was initiated. The DON verified an SRI was prompted based on the nurses did not follow Basic Life Saving (BLS) procedures and the nurses did not follow policy and procedure in regard to the CPR policy. The DON stated the facility investigation revealed RN #308 did not check Resident #30's chart for his code status. She did not initiated CPR when he was found unresponsive at 7:10 P.M. The DON stated only STNA #217 provided any emergency care by notifying the Nurse. The DON verified CPR was not initiated until at least 7:22 P.M. based on RN #308's statement. The DON also verified RN #308 asked LPN #309 to come and check on something but did not inform her that Resident #30 was deceased . RN #308 did not present the situation to LPN #309 as an emergency and verified the facility policy was to initiate CPR as soon as the need is identified, and the resident's code status should have been identified as soon as possible. Interview with STNA #289 on [DATE] at 4:53 P.M. verified she was present [DATE] when Resident #30 passed away. STNA #289 stated on [DATE] at around 7:30 P.M. she saw RN #308 running down the hall out of Resident #30's room, which prompted STNA #289 to check on him so she went into his room. STNA #289 verified Resident #30 was in his wheelchair, appeared blue and appeared to be deceased . When RN #308 returned with LPN #309 both went into Resident #30's room and STNA #289 exited the room at that time. STNA #289 witnessed the nurses come back out of his room and went to the nurse's station and were making calls. STNA #289 stated someone asked the nurses if they should begin post mortem care. STNA #289 stated one of the nurses verified they should begin Resident #30's post mortem care. Together, STNA #217, STNA #276 and STNA #289 transferred Resident #30 from his wheelchair to his bed via the Hoyer lift. After assisting with the transfer, STNA #289 left Resident #30's room. She went to the nurse station to see if there was anything else she could do. It was at this time when STNA #289 stated she heard LPN #309 ask RN #308 what was Resident #30's code status. STNA #289 verified she heard RN #308 deny knowledge of Resident #30's code status. STNA #289 stated the nurses then pulled out his chart and saw his code status was Full Code. STNA #289 stated that's when they (RN #308 and LPN #309) asked where the crash cart was and STNA #289 told them. STNA #289 verified RN #308 and LPN #309 then took the crash cart into Resident #30's room, closed the door, with only a crack of the door open and verified they initiated CPR. STNA #289 then went to the front of the building and left the EMS staff into the facility when they arrived. STNA #289 stated she directed EMS to Resident #30's room. STNA #289 stated she heard EMS staff exclaim something about why was there nothing being done? STNA #289 stated the EMT was yelling at the nurse but was unsure of the details of the exchange. Interview with RN #308 was attempted on [DATE] at 5:23 P.M. and [DATE] at 9:02 A.M.; however, she did not answer. Interview with LPN #309 on [DATE] at 5:27 P.M. revealed she was working on the opposite hall on [DATE], the night Resident #30 passed away. LPN #309 verified RN #308 came to her hall and asked her to come look at something on [DATE] at 7:15 P.M. LPN #309 verified RN #308 did not tell her Resident #30 was unresponsive and without vital signs. LPN #309 stated since she was unaware of the emergent situation she completed the medication administration she was doing before going to Resident #30's room. She arrived at Resident #30's room at 7:19 P.M. Upon arrival to Resident #30's room, RN #308 reported to her that he was unresponsive, and he was blue. LPN #309 assessed him and verified he was deceased and they did not initiate CPR. RN #308 requested help from LPN #309 telling her it was her first experience with a death. LPN #309 verified she went with RN #308 to the nurse station and began to gather information to call the DON, the family, the physician and told the STNA's to start post mortem care. It was at this time LPN #309 was checking Resident #30's chart to get the funeral home information that LPN #309 saw he was a Full Code. LPN #309 said to RN #308 Wait! He's a Full Code? RN #308 stated I didn't know that. That was when they returned to Resident #30's room and began CPR. LPN #309 verified she was not aware that RN #308 had not checked Resident #30's code status. LPN #309 verified it was sometime after 7:22 PM. and after being at the nurse station an additional 10 to 12 minutes before CPR was started. Interview was attempted by phone with STNA #276 on [DATE] at 5:58 P.M. and on [DATE] at 9:00 A.M.; however, the STNA did not answer. Interview with LPN #223 on [DATE] at 6:00 P.M. she stated she was in another resident room performing a treatment on [DATE] when Resident #30 passed away. LPN #223 stated when she came out of the other resident room, she saw RN #308 and LPN #309 were in Resident #30's room, they had the crash cart and they were doing CPR on Resident #30. LPN #223 stated she called 911 and stayed on the phone with them until they arrived at the facility. LPN #223 could not state any definitive times regarding Resident #30's death. Interview with Physician #310 on [DATE] at 9:18 A.M. stated he received two phone calls from the facility on [DATE] sometime prior to 8:00 P.M. but could not state an exact time. He stated he was informed Resident #30 was not breathing and the squad was called. Physician #310 verified he was also informed the squad stopped the code and that he was asked to release the body to the funeral home. Physician #310 could not provide definitive information regarding time frames the information was given to him. Physician #310 denied knowledge that Resident #30 was a Full Code or that CPR was not initiated. Interview by phone with the EMS Receptionist #311 on [DATE] at 10:25 A.M. revealed information from the EMS report for Resident #30 was provided. She verified EMS was called on [DATE] at 7:39 P.M. for a [MEDICAL CONDITION]/death for an unresponsive male. The squad left the station on [DATE] at 7:40 P.M. and arrived at the facility on [DATE] at 7:42 P.M. EMS staff were met at the door by nursing staff and informed Resident #30 was Full Code and CPR was being performed. However, upon arrival to Resident #30's room CPR was not being performed. Additionally, there was no valid DNR available when they arrived. Facility staff informed the paramedics Resident #30 had been down for 30 minutes. The facility nursing staff informed Paramedics they had started CPR 20 minutes after Resident #30 was found unresponsive with no pulse. Paramedics ran an Electrocardiogram (EKG) and Resident #30 was asystole (no heartbeat). Paramedics reported the lack of a heartbeat to the hospital emergency room physician who advised them to cease resuscitation. EMS Receptionist #311 stated the paramedics involved with the events were not currently working and she could not provide their personal phone numbers. Review of the facility policy titled CPR: Adult revised ,[DATE] revealed the purpose was to attempt to restore cardio-pulmonary circulation to a patient without a pulse or respirations. The American Heart Association has established guidelines for initiating CPR when [MEDICAL CONDITION] occurs. CPR is initiated unless one of the three following conditions is present: 1. A valid DNR order is in place. 2. Initiating CPR could cause injury or peril to the rescuer or 3. In the presence of obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition). In all other instances CPR is to be administered. Upon discovering an unresponsive patient with no breathing or no normal breathing, call for help. Palpate for a pulse. If no pulse is felt within ten seconds, place the patient on a flat, rigid surface. Initiate compressions. CPR procedure was described in the policy. CPR shall continue until the rescuer is relieved, or spontaneous breathing returns, a heartbeat returns or when emergency medical personnel arrive and assume control of the situation. 2. Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. Review of the residents activity of daily living self care deficit care plan, revised [DATE] identified the resident as being a Full Code. Review of Resident #17's medical record revealed the resident had a 'green' sheet in the front of her chart that identified the resident as being a Full Code. Review of the signed physician order dated [DATE] revealed the resident was a Full Code. Review of the (MONTH) (YEAR) physician orders revealed the residents advance directives were a do not resuscitate (DNR) with limited additional interventions. These orders were signed by the physician on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 7:29 A.M. confirmed Resident #17's code status in the front of her chart indicates she is a Full Code, however, her monthly physician orders including the last monthly physician orders signed (MONTH) (YEAR) identified the resident as being a DNR with limited additional interventions. 3. Review of Resident #48's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] identified the resident as having severe cognitive impairment as indicated by a BIMS score of three. Review of the residents activity of daily living self care deficit care plan, revised [DATE], identified the resident as being a do not resuscitate comfort care (DNR-CC). Review of Resident #48's medical record revealed the resident had a 'red' paper in his chart identifying the resident as being a DNR-CC. The DNR form was signed on [DATE]. Review of the (MONTH) (YEAR) physician orders revealed the residents advance directives were a do not resuscitate comfort care arrest (D (TRUNCATED)

Based on medical record review, fall investigation review, resident interviews, family interview, staff interviews, and observation, the facility failed to ensure fall prevention and mobility interventions were utilized. This resulted in actual physical and emotional harm to one resident (#11) who sustained a fall with a fractured foot when staff failed to transfer the resident using a stand up lift. This also affected one resident (#52) who sustained a fall with a laceration when her bed was not placed in the low position. Two residents were reviewed for falls with injuries. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 06/01/17, revealed the resident had intact cognition and did not refuse care. She required extensive assistance of two staff members for bed mobility, transfers, toilet use, and personal hygiene. She has functional limitations in range of motion on both sides, did not ambulate, and used a wheelchair. Review of the Care Area Assessment (CAA) summary, dated 06/01/17, documented the resident was admitted from home. She experienced vomiting and diarrhea at home, had increased weakness, and her caregiver was having more difficulty with transfers and caring for her at home. She has [DIAGNOSES REDACTED], weakness, and impaired balance. She no longer walked and used a wheelchair for mobility. Care was provided in the home by a family member. She needed assistance with bed mobility, transfers, toileting, bathing, and a wheelchair for locomotion. Used a standing lift for transfers. She was receiving physical therapy and occupational therapy services to improve on activity of daily living deficits. She was planning to return home with her spouse and home health services when her therapy goals were met. Review of the plan of care dated 05/25/17, reveled the resident has activity of daily living self care deficits as evidenced by weakness and pain related to [DIAGNOSES REDACTED]. The goal was not to develop any complications related to decreased mobility. The interventions include using a standing lift for transfers. Review of the nursing progress note dated 06/04/17 at 10:00 A.M. revealed the nurse was called to the shower room on the 400 Hallway. Resident #11 was on the floor complaining of left ankle pain. The nurse was told the resident fell when the State tested Nurse Aide (STNA) did not use the standing lift during a transfer. Two staff members assisted the resident into the wheelchair with the use of a mechanical lift. A mobile x-ray of the left ankle was obtained and the results were negative for a fracture. Review of the fall investigation revealed a witness statement written by STNA #202 on 06/04/17, documented she lowered Resident #11 to the floor in the shower room. She did not use the standing lift for the transfer to the shower chair. Review of the orthopedic consult note date 06/15/17 revealed additional x-rays of Resident #11's left foot were taken. The note documented there were three fractures to the foot. The consult documented the resident was to wear a fracture boot and could bear weight to the left foot as tolerated. Interview on 06/20/17 at 4:45 P.M., Resident #11 stated on 06/04/17 STNA #202 came into her room to help her from the bed to the bedside commode. STNA #202 did not use a gait belt or a standing lift for the transfer. When the resident told her she should have used a lift STNA #202 stated she did alright without it. After using the commode STNA #202 transferred her back to bed and did not use the lift. At about 10:00 A.M. STNA #202 came back into the room and transferred her from the bed to the wheelchair with a standing lift because the resident insisted STNA #202 use it. STNA #202 took her to the shower room and attempted to transfer her from the wheelchair to the shower chair without the use of a gait belt or a standing lift. The resident stated she told STNA #202 she needed to use the lift to transfer and STNA #202 told her she did fine without it when she transferred to the commode earlier so she could try it without the lift now. Resident #11 stated during the transfer her knees buckled and STNA#202 tried to catch her by grabbing her hands, which did not break her fall. She stated she fell hard onto the floor breaking her foot. She stated she started to cry due to the pain and STNA #202 stated don't cry let's just get you up and go on with the shower like this never happened. The resident stated she could not get up and continued to cry. STNA #202 called the nurse who came in and and asked STNA #202 why she did not use the lift to transfer the resident. STNA # 202 stated she knew she was suppose to use the lift but she did not. The resident stated her foot was very painful and it really hurts when she tries to stand on it. Interview on 06/20/17 at 5:40 P.M., the Administrator stated STNA #202 was educated on the use of lifts on 06/20/17 and was not scheduled to work with Resident #11. The Administrator verified STNA #202 had been educated on the use of lifts on 05/15/17 and was aware Resident # 11 was to use a lift, but chose not to use the lift causing the resident harm. Interview on 06/21/17 at 1:20 P.M., Resident #11 stated she was very depressed that she has to stay longer due to a broken foot and cries often since the incident. She stated she was admitted for strengthening following an illness of vomiting and diarrhea and was told she could return home after about a weeks stay when she was able to stand and pivot. Due to her foot being fractured her stay will four to six weeks. If it does not heal in six weeks she may have to have surgery. She stated she was fearful STNA #202 may retaliate against her when she came back to work. 2. Review of the medical record for Resident #133 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the social service note, dated 06/14/17, documented the resident was alert but had confusion. She was planned a short term stay at the facility for rehabilitation. Prior to admission she lived at home, with a family member and planned to return home with family providing continued care. Review of the nursing progress notes dated 06/18/17 documented Resident #133 rolled out of her bed onto the floor. An STNA alerted staff to the resident's fall. Resident #133 was observed lying on her right side. A laceration was observed on her forehead and a skin tear to her right elbow. Pressure was applied to her forehead. Vitals signs and neurological checks were done. The physician was contacted and ordered for the resident to be transferred to the emergency room (ER) to be evaluated. Review of the nursing progress note dated 06/19/17 at 4:41 P.M. documented the interdisciplinary team reviewed the resident's fall. The team decided the root cause of the fall was the resident becoming restless when waking up. All fall interventions were reviewed and the team felt the interventions were appropriate at this time and will periodically review and implement changes as needed. Review of the fall investigation revealed a witness statement dated 06/19/17, written by STNA #204, which documented when she entered Resident #133 room on 06/18/17 at approximately 8:00 A.M. the resident was on the floor and the bed was low but not all the way down. Interview on 06/19/17 at 1:43 P.M., Resident #90, who resided in the room across the hall from Resident #133, stated over the weekend Resident #133 had her call light on for a long time and then started yelling. She fell out of bed and had a cut on her forehead . He saw her lying on the floor with her head bleeding and went to the nurses station to tell the nurse she fell . He stated the bed was not in the low position when he saw her on the floor. Interview on 06/19/17 at 2:00 P.M., Resident #133's family member asked the surveyor and STNA #204 to come into the resident's room. The family member stated he wanted the surveyor to see the residents face. The resident was observed to have a black right eye and bruising down the right side of her face with a laceration above her right eye. Her family member stated she rolled out of bed and the family was told the bed was not in the lowest position when the incident occurred. He stated he asked them to put side rails up or place the bed against the wall to prevent her from falling out of bed again . He stated he was told they could not put these interventions in place because it was a restriction. It was verified by observation at this time the bed was in the low position with no other fall interventions in place. Review of an untitled facility form, printed on 06/19/17, documented for safety Resident #133's bed was to be in low position, body pillows when in bed, and reinforce need to call for assistance . Interview on 06/22/17 at 9:30 A.M., Licensed Practical Nurse (LPN) MDS Coordinator #207 stated the untitled form was the plan of care used by the STNAs to know how care for residents. She verified the low bed position was initiated 06/14/17, the body pillows were initiated on 06/19/17, and reinforce the use of call light was initiated on 06/19/17. Interview on 06/20/17 at 4:45 P.M., Licensed Practical Nurse (LPN) #211 stated she was at the nurses station when Resident #90 came down the 300 Hall and stated the lady at the end of the hall, Resident #133, was on the floor and she was bleeding from her head. She stated she ran to Resident #133's room and found her on the floor with a cut above her right eye. She stated the call light was activated when she entered the room. The bed was approximately knee height when she entered the room, which was not the lowest position.