Every finding on record at Chardon Center

Based on record review, interview and facility policy review, the facility failed to ensure Residents #67, #189 and #196 were provided with showers as scheduled. This finding affected three residents (#67, #189 and #196) of five residents reviewed for showers. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #189 was admitted on [DATE] with diagnoses including encounter for orthopedic aftercare following a surgical amputation, diabetes, and generalized weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #189 exhibited moderate cognitive impairment and was dependent on staff for showers/bathing. Review of the activities of daily living (ADL) care plans revealed an intervention dated 03/25/25 for shower/bathing, and Resident #189 was totally dependent on staff. Review of the shower schedules revealed Resident #189 was scheduled for showers Sunday and Thursday during the nightshift. Review of the Documentation Survey Report form dated 03/21/25 to 04/14/25 revealed Resident #189 received a shower/bath on 03/27/25, 03/30/25, 04/07/25 and 04/13/25. Interview on 04/14/25 at 10:37 A.M. with Resident #189 revealed he had only received two bed baths and one shower since admission. Interview on 04/15/25 at 12:12 P.M. with the Director of Nursing (DON) confirmed Resident #189 should have had at least six showers/baths since 03/21/25 and was only provided four showers/bathes since admission. 2. Review of the medical record revealed Resident #196 was admitted on [DATE] with diagnoses including myelodysplastic syndrome and unspecified cirrhosis of the liver. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #196 had intact cognition and was dependent on staff for showers/bathing. Review of the ADL care plans revealed an intervention dated 03/25/25 for shower/bathing, and Resident #196 was totally dependent on staff. Review of the shower schedules revealed Resident #196 was scheduled for showers Tuesday and Saturday on nightshift. Interview on 04/14/25 at 10:40 A.M. with Resident #196 revealed she had not received a shower/bath since admission. Review of the Documentation Survey Report form from 03/21/25 to 04/14/25 revealed Resident #196 refused a shower/bath on 04/05/25 and received a shower/bath on 04/09/25. Interview on 04/15/25 at 12:12 P.M. with the DON confirmed Resident #196 should have had at least six showers/baths since 03/21/25, and the resident refused one shower/bath and received only one shower/bath. 51521 3. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including muscle weakness, unspecified lack of coordination, and abnormal posture. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition, required substantial/maximal assistance for shower/bathing, was dependent for mobility and transfers with the assistance of two or more staff for showers and all transfers by Hoyer (mechanical) lift. Review of the shower scheduled revealed Resident #67 was to receive showers every Sunday and Thursday. Review of the plan of care dated 02/14/25, revealed Resident #67 required assistance for ADL self-care. Interventions included bed mobility, transfer with Hoyer lift, bathing, toileting and hygiene required the assistance of two staff. Review of the Documentation Survey Report Form dated 03/01/25 through 03/31/25 revealed Resident #67 received showers on 03/13/25, 03/27/25, and 03/30/25. Interview on 04/16/25 at 9:38 A.M. with Resident #67 revealed that she would like to have her showers as scheduled and would like more showers than her scheduled two days. Resident #67 revealed issues with staff having time to Hoyer her to be showered. Interview with Executive Director on 04/17/25 at 8:42 A.M. verified the skin assessment/shower sheets revealed that Resident # 67 only received three showers in March on 03/13/25, 03/27/25, and 03/30/25. Review of the undated Routine Resident Care policy revealed routine resident care was defined as care that was not necessarily medically or clinically based but necessary for quality of life promoting dignity and independence as appropriate including routine care by a nursing assistant. The routine care by a nursing assistant includes but not limited to bathing, dressing, eating, hydration and toileting.

Based on record review, observations, interviews and review of the facility policy, the facility failed to ensure oxygen tubing was changed and dated and oxygen was set to the ordered liter flow per minute. This affected five residents (#1, #5, #8, #61, and #65) out of eight residents reviewed for oxygen. The facility census was 85. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included epilepsy, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure and atrial fibrillation. Review of Resident #1's Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. He required setup or clean up assistance with eating and dressing. He was independent with bed mobility, and required supervision or touching assistance with showers, toileting, and personal hygiene. Review of the Care Plan dated 04/09/25 revealed Resident #1 had COPD and chronic respiratory failure. Goals and interventions included Resident #1 would have a reduction in complications related to COPD, staff were to administer medications per order, observe for side effects and effectiveness, and report any abnormal findings to the physician. Staff were to monitor vital signs, observe for signs and symptoms of COPD, increased shortness of breath, coughing with or without mucus, wheezing, tightness in the chest, and anxiety. Oxygen therapy as ordered, and changing tubing per facility policy. Review of Resident #1's Physician orders dated April 2025 revealed an order for oxygen at three liters per minute (lpm) via nasal cannula (NC) continuous every shift. Change oxygen tubing and humidifier every seven days and as needed on Wednesday on night shift. Observation on 04/14/25 at 10:08 A.M. of Resident #1's oxygen revealed it was set at four lpm. Interview on 04/14/25 at 10:10 A.M. with Licensed Practical Nurse (LPN) #585 revealed they verified Resident #1 was to be on three lpm of oxygen, and the resident was on four lpm of oxygen. 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included systolic congestive heart failure, venous insufficiency, chronic atrial fibrillation, and COPD. Review of Resident #5's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. He required setup or clean up assistance with eating, supervision or touching assistance with bed mobility, partial to moderate assistance for oral hygiene, showers, dressing, and personal hygiene. He required substantial to maximal assistance for toileting. Review of Resident #5's care plan dated 02/24/25 revealed the resident had COPD with potential for shortness of breath while lying flat. Interventions and goals included staff administering medications per medical providers order, observing for side effects and effectiveness, reporting abnormal findings to the medical provider, resident and resident representative. Provide oxygen therapy as ordered, change tubing per facility policy and provide bilevel positive airway pressure (BiPAP)/continuous positive airway pressure (CPAP) as ordered. Review of Resident #5's physician orders dated April 2025, revealed the resident was to wear a BiPAP with settings of 16/10 with an oxygen bleed of two lpm at bedtime. Observation made on 04/14/25 at 10:18 A.M. revealed the oxygen tubing from the oxygen concentrator to the BiPAP machine was last changed and dated 04/03/25. Interview on 04/14/25 at 10:20 A.M. with LPN #585 revealed she verified the oxygen tubing had not been changed since 04/03/25, and the tubing was to be changed weekly. 3. Review of Resident #8's medical record revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia, COPD, and congestive heart failure (CHF). Review of Resident #8's Medicare 5-day admission MDS assessment dated [DATE] revealed the resident had intact cognition. She required setup to clean up assistance with eating, partial to moderate assistance for oral hygiene, and bed mobility. She required substantial to maximal assistance for showers, dressing, and personal hygiene. Review of Resident #8's care plan dated 02/09/25 revealed the resident had oxygen therapy related to diagnosis of COPD and CHF. Interventions and goals included the resident would not have signs or symptoms of poor oxygen absorption, staff would encourage or assist with ambulation as indicated, staff to give medications as ordered by the physician, monitor and document side effects and effectiveness, staff to monitor for signs and symptoms of respiratory distress and report to the physician as needed. Resident #8 to have oxygen at four lpm via nasal cannula. Review of Resident #8's physician orders dated April 2025 revealed the resident was prescribed oxygen at four lpm via nasal cannula continuously every shift. Change oxygen tubing and humidification every seven days and as needed, every night shift on Wednesday and as needed. Observation on 04/14/25 at 9:38 A.M. of Resident #8's oxygen tubing revealed it was undated as to when it was changed last. The humidification bottle was undated and empty, and the oxygen concentrator was set to 4.5 lpm. Interview on 04/14/25 at 9:40 A.M. with Resident #8 revealed staff had not changed the oxygen tubing in over a week. Resident #8 stated her oxygen was to be at four lpm. Interview on 04/14/25 at 9:41 A.M. with LPN #585 verified Resident #8's oxygen tubing was not dated, the humidification bottle was empty and undated, and the concentrator was set to 4.5 lpm and not 4 lpm per the resident's physician's orders. 4. Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included COPD, nonspecific abnormal findings of lung field, personal history of other malignant neoplasm of bronchus and lung. Review of Resident #61's quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. She required setup or clean up assistance for eating and oral hygiene. She required substantial to maximal assistance for bed mobility and was dependent on staff for toileting hygiene, showers, dressing and personal hygiene. Review of Resident #61's care plan dated 04/02/25 revealed the resident had COPD with potential for shortness of breath while lying flat. Interventions and goals included staff administering medications per physician orders, oxygen therapy as ordered, and changing tubing per facility policy. Review of Resident #61's physician orders dated April 2025 revealed oxygen at two lpm via nasal cannula, change oxygen tubing and humidifier every seven days and as needed every night shift on Wednesday. Observation on 04/14/25 at 10:12 A.M. of Resident #61's oxygen tubing revealed it was undated, and oxygen was set at three lpm. Interview on 04/14/25 at 10:13 A.M. with LPN #585 verified Resident #61's oxygen tubing was undated, and the oxygen was set at three lpm and not at two lpm per the physician orders. 5. Review of the medical record for Resident #65 revealed an admitted [DATE]. Diagnoses included CHF, emphysema, atrial fibrillation, hypertension, and heart failure. Review of Resident #65's annual MDS assessment dated [DATE] revealed she had intact cognition. She required setup or clean up assistance for eating and oral hygiene and substantial to maximal assistance for showers, dressing, and personal hygiene. She was independent with bed mobility. Review of Resident #65's care plan dated 02/24/25 revealed she had COPD with potential of shortness of breath while lying flat, staff were to apply oxygen therapy as ordered and change tubing per facility policy. Review of Resident #65's physician's orders dated April 2025 revealed the resident was prescribed oxygen at two lpm via nasal cannula continuous every shift, change oxygen tubing and humidifier every seven days on Wednesday and as needed. Observation on 04/14/25 at 9:58 A.M. of Resident #65's oxygen revealed the oxygen tubing had not been changed since 04/03/25 and was set at 3.5 lpm. Interview on 04/14/25 at 10:00 A.M. with Resident #65 revealed her oxygen was to be at three lpm, and the oxygen tubing had not been changed in a couple of weeks. Interview on 04/14/25 at 10:04 A.M. with LPN #585 verified Resident #65's oxygen tubing had not been changed since 04/03/25 and they confirmed the oxygen was set at 3.5 lpm and not three lpm. Review of the undated facility policy titled Supplemental Oxygen using Nasal Cannula revealed oxygen is to be administered per physician orders, and oxygen tubing is to be labeled and dated when opened and changed every seven days.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff knocked on Resident #21's room door and/or asked permission to enter the resident's room prior to entering. This affected one resident (#21) of one resident reviewed for privacy. The facility census was 85. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including epilepsy, respiratory failure, chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, depression, and personal history of cerebral infarction without residual deficits. Observation on 04/16/25 at 8:27 A.M. revealed Certified Nurse Aide (CNA) #500 walked into Resident #21's without knocking on the door or asking permission to enter the room. Interview with Resident #21 on 04/15/25 at 9:03 A.M. revealed staff does not respect his privacy. They just walk into the room without knocking or asking permission. Interview with CNA # 500 on 04/16/25 at 8:43 A.M. verified CNA #500 did not knock or ask permission before entering Resident #21's room. Review of the undated policy titled Resident Rights revealed residents' private space and property shall be respected at all times, and staff will knock before entering resident room and wait for an answer and/or request permission before entering residents' rooms.

Based on observation, interview, and review of facility policy, the facility failed to ensure staff were not re-using N95 masks during a COVID-19 outbreak. This had the potential to affect all 74 residents residing in the facility. Findings include: Observation on 02/01/23 at 9:04 A.M. of Licensed Practical Nurse (LPN) #107 revealed she donned a gown, N95 mask with surgical mask overtop, gloves, and face shield to enter Residents #38 and #51's room. Signs on the door indicated droplet isolation precautions should be followed. Upon exiting the room, LPN #107 doffed her gown, gloves, and surgical mask in the room and performed hand hygiene. She did not change her N95 mask. Interview on 02/01/23 at 9:10 A.M. with LPN #107 verified she did not change her N95 mask. She stated she wore the same N95 mask all day and just discarded the surgical mask that she put on overtop to go in COVID-19 isolation rooms. She also indicated the only training she received was to follow the precautions on the doors of isolation rooms. Observation on 02/01/23 at 9:51 A.M. of State tested Nurse Aide (STNA) #108 revealed she donned a gown, gloves, face shield, and N95 mask with multiple surgical masks over top to enter Residents #18 and #58's room. Signs on the door indicated droplet isolation precautions should be followed. Upon exiting the room, STNA #108 discarded the top surgical mask, gown, and gloves. She did not discard or change her N95 mask. Interview on 02/01/23 at 9:53 A.M. with STNA #108 verified she only discarded the top surgical mask and continued wearing the same N95 mask. She stated she wore the same N95 mask all day long. She stated the education she received was to follow the instructions on the doors of isolation rooms. Observation on 02/01/23 at 10:17 A.M. of LPN #109 revealed she donned a gown, gloves, face shield, and retrieved a N95 mask from on top of the medication cart to enter Residents #66 and #69's room. Signs on the door indicated isolation precautions for aerosol treatments only. Upon exiting the room, LPN #109 discarded her gown and gloves and performed hand hygiene. She removed her N95 mask and placed it on top of the medication cart. Interview on 02/01/23 at 10:17 A.M. with LPN #109 verified she placed the N95 mask on top of the medication cart and she wore the same N95 mask all day long. She stated she would put the N95 mask on over top of a surgical mask and when she was done with it, she would place the N95 mask on the medication cart to use later. Interview on 02/01/23 at 11:32 A.M. with Regional Registered Nurse (RN) #106 confirmed N95 masks should be changed when exiting isolation rooms and that staff should have received education on proper personal protection equipment (PPE) use. Review of facility policy titled Criteria for COVID-19 Requirements, dated 09/23/22, revealed full personal protective equipment (PPE) including a gown, N95 mask, eye protection, and gloves was required for COVID-19 isolation rooms, PPE would be discarded before exiting the room, and a new surgical mask or N95 mask would be applied when exiting the room. This deficiency represents non-compliance investigated under Master Complaint Number OH00139867 and Complaint Number OH00139828.

Based on record review, observations and interviews the facility failed to provide a dignified existence for all residents. This affected one (Resident #36) of 10 residents observed for activities and staff interaction. The census was 66. Findings Include: Review of medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included unspecified dementia, history of falls, and anxiety disorder. Resident #36 was receiving hospice services. Review of the plan of care dated 08/17/21 revealed Resident #36 was at risk for falls due to balance problems, history of falls and weakness. Review of the plan of care dated 12/09/22 revealed Resident #36 had a self-care deficit and required assistance by staff for activities of daily living (ADL). Review of the 01/16/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #36 revealed she had severe cognitive impairment. Observation on 01/18/23 from 10:03 A.M. to 12:00 P.M. revealed Resident #36 dressed in street clothes seated in a Broda (geriatric) chair in front of the nurse's desk. Staff walking by Resident #36 did not engage with her in any manner; the staff did not extend a greeting or make any acknowledgement of her presence at any time during the observation. Observations on 01/18/23 from 1:55 P.M. to 3:52 P.M. revealed Resident #36 dressed in street clothes seated in a Broda chair in front of the nurse's desk. Staff were observed walking past Resident #36 with no interaction. Observation on 01/18/23 at 3:53 P.M. revealed staff taking Resident #36 to her room to complete incontinence care. Observation on 01/18/23 at 4:11 P.M. revealed Resident #36 was back out in front of the nurse's desk. Observation and interviews on 01/18/23 at 4:12 P.M. with State tested Nurse Assistant (STNA) #40, Licensed Practical Nurse (LPN) #41 and Registered Nurse (RN) #89 revealed they were seated behind the nurse's desk. All staff were asked if Resident #36 attended any activities during the day. RN #89 was the only staff to reply stating Resident #36 attended activities in the evenings when family visited. Staff were unable to provide an explanation as to why Resident #36 was seated by herself throughout the day with no interaction by staff as they walked past and with no opportunities to interact with other residents. This deficiency represents non-compliance investigated under Complaint Number OH00138971.

Based on observation, record review, and interview the facility failed to ensure care plan interventions were implemented for fall prevention. This affected two residents (Resident's #3 and #40) out of five residents reviewed for falls. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, opioid abuse, altered mental status, and lack of coordination. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. Functionally, she required extensive assistance of one staff for bed mobility, transfers, dressing, and personal hygiene. Resident #3 required extensive assistance of two staff for toileting. Review of the plan of care dated 05/20/21 with a revision date of 06/02/21 revealed Resident #3 was at risk for falls due to the disease process, safety awareness, history of falls, impaired ambulation, and impaired mobility. Interventions included but were not limited to bed in low position while occupied and floor mats on each side of the bed. Observation on 05/24/22 at 10:15 A.M. of Resident #3 revealed fall interventions were not in place. Resident #3 was lying in bed with a tray table over the bed, floor mats were on both sides of the bed and the bed was in normal position, not low. This was verified at the time of the observation by Personal Care Assistant (PCA) #102. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, unspecified dementia with behavioral disturbance, and major depressive disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #40 was rarely understood. Functionally, she required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. Resident #40 required extensive assistance with one staff for personal hygiene. Review of the plan of care dated 09/06/16 with a revision date of 01/05/18 revealed Resident #40 was at risk for falls due to gait and balance problems and unaware of safety needs. Interventions included but were not limited to bed in low position while occupied and floor mats on each side of the bed. Observation on 05/24/22 at 9:54 A.M. of Resident #40 revealed fall interventions were not in place. Resident #40 was lying in bed with a tray table over the bed, floor mats were on both sides of the bed, and the bed was in normal position, not low. This was verified at the time of the observation by Licensed Practical Nurse (LPN) #103. This deficiency substantiates Complaint Number OH 771.

Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to ensure personal protective equipment (PPE) was donned and doffed correctly during care of Resident #62, who was on droplet precautions and failed to ensure hand hygiene was consistently implemented to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 73 residents of the facility. Findings include: Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #62's medical record revealed the Minimum Data Set (MDS) 3.0 assessment was in progress. Review of the physician's orders for May 2022 revealed COVID-19 Testing on the day of admission and on day seven. Review of the rapid (Binax) COVID-19 test completed on 05/23/22 revealed Resident #62 was negative for COVID-19. Review of Resident #62's baseline care plan dated 05/23/22 revealed the resident did not receive the COVID-19 vaccine and was on droplet precautions. Observation and interview on 05/24/22 at 9:40 A.M. revealed Housekeeping Supervisor #106 was seen cleaning Resident #62's room without a gown and gloves. He was wearing a surgical mask and a face shield. After surveyor intervention, Housekeeping Supervisor #106 stated he was only dry mopping the floor, and he forgot to put on PPE. Housekeeping Supervisor #106 then put on the proper PPE and went back into the room. Resident #62's room had signage outside the room and PPE was available hanging on the door. During an interview on 05/24/22 at 9:44 A.M. with Registered Nurse (RN) #105, Housekeeping Supervisor #106 was observed exiting Resident #62's room wearing his gown. He doffed the gown as he was walking up the hallway. Housekeeping Supervisor #106 wadded up the gown and discarded it in the trash can near the nurses' station and did not perform hand hygiene after discarding his gown. RN #105 verified the observation. Interview on 05/24/22 at 1:20 P.M. with District Manager #109 of the housekeeping company revealed Housekeeping Supervisor #106 was hired recently and was trained in infection control. District Manager #109 stated that training for donning and doffing PPE was completed for Housekeeping Super #106 on 03/26/22. Review of the facility policy with a revised date of 03/02/22 titled, Criteria for COVID-19 Requirement and Resident Placement, revealed full PPE is required when entering a resident room which includes: N95 mask, eye protection, gown, gloves. Full PPE should be located at or near the entrance to resident room, PPE is discarded before exiting the room. The eye protection may be discarded and new one applied or may be cleaned after each patient encounter. Surgical mask is applied when exiting the room and perform hand hygiene per protocol before/after care and donning/doffing PPE. Review of the CDC guidelines dated 02/02/22 titled, Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes revealed that a new admission who are not up to date with all recommended COVID-19 vaccinations should be quarantined and healthcare personnel to include environmental services should wear full PPE (gowns, gloves, eye protection and N95 or higher-level respirator).

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #11 received proper assistance to maintain personal hygiene. This affected one resident (Resident #11) out of three residents reviewed for personal hygiene. Findings include: Review of Resident #11's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment, dated 10/07/21, revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, toilet use and personal hygiene. Resident #11 was always incontinent of bowel and had an indwelling catheter for urine. Review of Resident #11's medical record from 11/28/21 through 01/11/22 did not reveal documentation Resident #11 refused to be shaved, have his fingernails trimmed and cleaned, or refused to have his teeth brushed. Review of Resident #11's care plan, revised 01/12/22, revealed the resident had potential for oral and dental health problems. He had his own teeth. Resident #11 would be free of infection, pain or bleeding in the oral cavity by, through the review date. Resident #11 would comply with mouth care at least daily through the review date. Interventions included to monitor and document and report to the physician signs and symptoms of oral and dental problems needing attention, and to provide mouth care as per activity of daily living (ADL) personal hygiene. Resident #11 had a deterioration in ADL. Interventions included resident required two staff participation for bathing, and in the morning, after meals, and at bedtime oral care routine included to brush teeth, rinse dentures, clean gums with toothette, rinse mouth with wash. Interventions included Resident #11 required extensive assistance of one staff participation with personal hygiene and oral care. Resident #11 was resistive to care related to dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to allow resident to make decisions about treatment regime, to provide sense of control, and if possible negotiate a time for ADLs so that the resident participated in the decision making process. Return at the agreed upon time. Observation on 01/12/22 at 8:58 A.M. of Resident #11 revealed resident was laying in bed and had a long, scraggly gray beard and mustache. Neither the beard or mustache had a neat, groomed appearance. Resident #11's fingernails were yellow, approximately one quarter to one half inch in length and had brown material underneath them. Resident #11 stated he would like to have his beard and mustache shaved off, he had told the staff he wanted them shaved, but the staff did not seem anxious to do it. Resident #11 stated he would like his fingernails trimmed and cleaned. Interview on 01/12/22 at 9:19 A.M. with Family Member (FM) #280 revealed Resident #11 was neglected and not receiving proper care by the facility staff. FM #280 stated Resident #11 was confused at times but did not want his beard and mustache long and scraggly. FM #280 stated she visited Resident #11 on 12/17/21 and observed his beard was long and scraggly, his fingernails were dirty, brown, had gunk underneath them, and his toothbrush was covered with dirt and crusty material. FM #280 stated she threw the toothbrush away and his toothpaste was hard as a rock and obviously had not been used in a long time. FM #280 stated she returned on 01/04/22 for a visit and brought a new toothbrush with her, Resident #11's beard was still long and scraggly, his fingernails were still long and dirty, and the same hard tube of toothpaste was in his bedside table with no toothbrush noted. FM #280 stated Resident #11 did not brush his teeth from 12/17/21 through /1/04/22 because there was not a toothbrush in his bedside table or in the bathroom and the toothpaste was still the same rock hard tube as before. FM #280 stated she gave Resident #11 the new toothbrush, got Resident #11 a new tube of toothpaste, and Resident #11 was able to brush his teeth. FM #280 stated Resident #11 was so happy to be able to brush his teeth. FM #280 stated she spoke with the Administrator about the lack of care and the Administrator told her she was trying to make things better. Interview on 01/12/22 at 11:00 A.M. with Resident #11 revealed staff did not brush his teeth. Observation of a toothbrush and tube of toothpaste in Resident #11's bedside table did not have the appearance either had been used. The toothbrush was dry, and did not have any material on the bristles and the toothpaste tube was full and did not look like any had been squeezed out of the tube. Interview on 01/12/22 at 11:05 A.M. with State tested Nursing Assistant (STNA) #213 revealed she did not know Resident #11 wanted his beard and mustache shaved, did not know he wanted his fingernails cleaned or he wanted his teeth brushed. STNA #213 confirmed she did not ask Resident #11 if he wanted any of those things done. STNA #213 stated in the past she asked Resident #11 if he wanted these things done and he said no. STNA #213 stated she did not think she was allowed to trim Resident #11's beard because she would need scissors and did not think she was allowed to trim Resident #11's fingernails. STNA #213 stated she would ask the nurse if he was a diabetic and would trim and clean his nails if she was allowed to. STNA #213 stated if Resident #11 was a diabetic she would file his nails and clean under his fingernails to get the brownish material out of them. Observation on 01/12/22 at 11:05 A.M. of Resident #11 revealed he told STNA #213 he wanted his beard and mustache shaved, his fingernails cleaned and trimmed and he would like to brush his teeth. Interview on 01/12/22 at 12:11 P.M. with Assistant Director of Nursing/Unit Manager (ADON/UM) #269 revealed Resident #11 could be resistant to care. ADON/UM #269 stated if residents refused care she would follow up to find a time the residents agreed to for their care. ADON/UM #269 stated if a resident refused care the STNA's would document it in the aide charting in the medical record. ADON/UM #269 stated each resident had an ambassador who was responsible to talk to the resident and make sure their needs were met. Observation on 01/12/22 at 1:48 P.M. of Resident #11 revealed he had been shaved and his beard and mustache were gone. Resident #11's fingernails were clean, and trimmed, and he stated he brushed his teeth. Resident #11 had a big smile on his face, stated it felt so good to have his beard and mustache shaved, his fingernails trimmed and to brush his teeth. Resident #11 stated he was in much better shape now than when the surveyor first met him. Interview on 01/13/22 at 1:15 P.M. with Administrator revealed if a resident refused care attempts were made to give the care later the same day or the next day. Interview on 01/13/22 at 1:32 P.M. with ADON/UM #269 revealed she replaced Resident #11's toothbrush and toothpaste on 01/12/22, but did not remember what time she replaced it. Interview on 01/13/22 at 2:12 P.M. with Minimum Data Set (MDS) Nurse #274 revealed she was Resident #11's Resident Ambassador. MDS Nurse #274 stated she tried to make daily rounds and not less than three times a week for the residents she was assigned to and would talk to the residents about concerns, needs. MDS Nurse #274 stated Resident #11 did not like to get out of bed for showers but would agree to a bed bath, and did not typically refuse a bed bath. Interview on 01/13/22 at 3:34 P.M. with FM #280 revealed she absolutely, positively, mentioned Resident #11's fingernails were long, brown, with gunk under the nails and he needed his teeth brushed and it was not getting done. FM #280 stated she did not mention Resident #11's beard and mustache needed shaved because she had been trying to get the facility to do it for the last seven months and she felt like she was wasting her breath to mention it again. FM #280 stated she was so upset when she spoke to the Administrator she was crying. FM #280 stated she visited the facility on 01/13/22 (today) and the toothbrush in Resident #11's nightstand was the same toothbrush she bought and brought to the facility a week ago. FM #280 stated there was a sign on Resident #11's bulletin board stating to please cut his fingernails as needed, and the sign had been there for seven months. Observation on 01/13/22 at 3:40 P.M. of a sign posted on Resident #11's bulletin board in his room and the sign included to to please trim my fingernails as needed. Review of the facility policy titled Routine Resident Care, revised, 04/06/16, included it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. Provided routine daily care by a certified nursing assistant with specialized training in rehabilitation and restorative care under the supervision of a licensed nurse including encouraging maximum function for each resident, implementing and maintaining program for skin care, observing and documenting all aspects of care. This deficiency substantiates Complaint Number OH 530.

Based on interview, observation, and record review, the facility failed to ensure call lights were answered in a timely fashion to meet the needs of residents. This affected three residents observed for call light response (Resident's #6, #18, and #22) and had the potential to affect any of the 73 residents residing at the facility at the time of the survey. Findings include: 1. Observation on 12/20/21 at 11:27 A.M. revealed Resident #6's call light was on (the surveyor could not identify when it initially was turned on). At 11:54 A.M. Maintenance Assistant #301 entered the room and spoke pleasantly with the resident and said he would get the help she needed. The call light was still on when he left. Interview with Resident #6 on 12/20/21 at 12:00 P.M. (with the call light still on) revealed she was calling for pain medications and said call light times were often long due to short-staffing. She was in tears and was grimacing apparently in pain, and said she had been calling for help for an hour. Interview with Licensed Practical Nurse (LPN) #302 on 12/20/21 at 12:11 P.M. revealed he was aware Resident #6 was ringing for pain medications, and he said she had been medicated for pain only a few hours ago. He would see if she had any other medication available. Record review of Resident #6 revealed she was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed she did receive oxycodone (an opioid pain medication) for pain on 12/20/21 at 10:41 A.M., but she also had and order for acetaminophen 1000 milligrams (mg), an anti-[CONDITION(S)] pain medication, available as-needed up to every eight hours for pain. This review (done late in the afternoon on 12/20/21) revealed she had not received the acetaminophen dose yet that day and was given it on 12/20/21 at 12:26 P.M. 2. Observation on 12/20/21 at 4:40 P.M. revealed Resident #22's call light was on (the surveyor could not identify when it initially went on). Continuous observation until 4:59 P.M. revealed no staff entered the room, and an aide was noted to walk past it. Interview with Resident #22 on 12/20/21 at 4:59 P.M. revealed he was calling for assistance getting to the bed from his chair. Continued observation of Resident #22's room revealed the call light was answered on 12/20/21 at 5:10 P.M. Record review of Resident #22 revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 required extensive two-staff physical assistance for transfers. 3. Observation on 12/21/21 at 9:13 A.M. revealed Resident #18's call light was on (the surveyor could not identify when it initially turned on). Ongoing observation until 10:13 A.M. revealed no staff entered the room. Two nurses were noted seated at the nursing station at 9:33 A.M. and 9:55 A.M. who appeared to be working on computer charting. Interview with Resident #18 on 12/21/21 at 9:49 A.M. revealed she said she had her call light on since 9:00 A.M. for assistance using the bedpan and no staff had come. The surveyor intervened on 12/21/21 at 10:13 A.M. and informed Registered Nurse (RN) #303 that Resident #18 had been observed to wait an hour for assistance toileting. Following surveyor intervention, RN #303 entered the room and addressed Resident #18's needs. Record review of Resident #18 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS 3.0 assessment dated [DATE] revealed Resident #18 required total two-staff physical assistance for toileting. The surveyor reviewed the above findings with the Administrator and Director of Nursing (DON) on 12/21/21 at 10:44 A.M. This deficiency substantiates Complaint Number OH 929.

Based on observation, record review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of three unstageable pressure ulcers for Resident #55. Actual Harm occurred on 12/05/19 when Resident #55, who was bedfast and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown tissue) and/or eschar (tan brown or black tissue) in the wound bed) pressure ulcers to the right heel, left heel and coccyx. This affected one Resident (#55) of two residents reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers. Findings include: Record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On 08/13/19 a physician order [REDACTED].M. snack and bedtime (HS) snack. Review of Resident #55's care plan initiated 07/02/19 revealed Resident #55 had a potential for actual impairment to skin integrity due to fragile skin, [MEDICAL CONDITION] to her lower extremities, a deficit in self care performance related to dementia, incontinent of urine and stool and was at nutritional risk for weight loss and dehydration. The interventions included apply barrier cream to buttocks and peri area after each incontinent episode, encourage good nutrition and hydration in order to promote healthier skin, provide and serve snacks and supplements as ordered, pressure relieving devices to bed and wheelchair, turn and reposition every two hours and elevate legs in bed. Record review revealed Resident #55 was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE]. Review of the 11/04/19 Admission Evaluation completed by Licensed Practical Nurse (LPN) #352 upon the resident's return from the hospital revealed Resident #55 could not walk, did not stand or sit in a chair, used a mechanical lift for transfers and was dependent on staff to roll in the bed from back to sides and sides to back. The Braden Observation Tool dated 11/04/19 and authored by LPN #352 revealed Resident #55's skin was very moist, she was confined to bed, had potential problems with friction and shearing of the skin and very limited mobility being unable to independently make significant changes in body position. The tool scored the resident at moderate risk for skin breakdown with interventions listed as encourage turn and reposition, float heels, elevate legs above heart while in bed and place a blanket between resident and mechanical lift. Review of the physician orders, dated 11/04/19 revealed the resident was ordered to be non weight bearing (NWB), pressure reduction mattress to the bed, encourage and assist resident to float heels in bed, encourage and assist her to turn and reposition every two hours and a consistent carbohydrate, no added salt diet. The Med Plus NSA nutritional supplement was not reordered by the physician upon readmission. Review of a progress note dated 11/05/19 and authored by Certified Registered Nurse Practitioner (CRNP) #900 revealed Resident #55 had been recently in the hospital for [MEDICAL CONDITION], had a decrease in weight following the hospital stay of 12.4 pounds (weight noted at 160 pounds) and trace [MEDICAL CONDITION] to the bilateral extremities. Review of the facility document titled MD Progress Note, dated 11/08/19, authored by Primary Care Physician (PCP) #901 revealed Resident #55 had an elevated blood sodium level at 149, her weight was stable at 174 pounds and she may have been dehydrated. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #55 had cognitive impairment, did not reject care, was at risk for pressure ulcers requiring pressure reducing devices to her bed and chair, was always incontinent of bowel and bladder and required total assistance by two staff for transfers and extensive assistance of two staff for bed mobility, dressing, toileting and hygiene. A physician order [REDACTED]. Review of a progress note dated 11/13/19 and authored by CRNP #900 revealed Resident #55 had not been eating well, would not sit up in bed more than 30 degrees, had trace [MEDICAL CONDITION] and needed fluids encouraged due to high blood sodium levels being monitored by the CRNP. Review of the Braden Observation Tool dated 11/17/19 indicated Resident #55 was chair fast, had very limited mobility, adequate nutrition and was low risk for skin impairment. Review of the MD Progress Note dated 11/22/19 and authored by PCP #901 revealed Resident #55 had decreased by mouth intake of meals and was at risk for weight loss and dehydration so a diet downgrade would be considered because she refused to sit upright for meals. Review of the documented titled Skid Grid Non Pressure, dated 11/24/19, revealed the resident had developed on 11/17/19 an abrasion to her left front thigh from improper briefing. The abrasion was described as no skin loss, red in color, no exudate and size of 10.0 centimeters (CM) length by 10.0 cm width and 0.0 depth. Review of the Weekly Skin Check document dated 11/26/19 revealed new areas since the last skin check. A progress note dated 11/27/19 authored by Registered Dietitian (RD) #373 revealed the resident's weight was up three percent (%) and nursing staff reported her by mouth intakes were increased. RD #373 added the RN was made aware of the weight gain and current interventions would continue along with monitoring. There was no assessment of actual percentage of meal intakes or implementation of any supplements or meal fortifiers (foods used to provided a concentrated source of calories and protein) for nutritional support during this review by RD #373. Review of the Weekly Skin Check documented dated 12/03/19 indicated there were no new skin areas. Review of the facility documents titled Skin Monitoring Comprehensive CNA Shower Review, from 11/07/19 to 12/05/19 revealed the resident was provided bed baths due to shower refusals during that time frame, there were no skin impairment areas identified to the heels or coccyx and the sheets were signed and dated by the charge nurses. Review of a progress note dated 12/06/19 at 7:54 P.M. revealed while Resident #55 was being moved with the mechanical lift from the bed to the shower chair it was identified the resident had discoloration to her bilateral heels, an area to the right lateral foot, an abrasion to left third toe and discoloration to coccyx. The note continued to describe the right heel had a deep tissue injury measuring four centimeters (cm) in length by five cm, the left heel had deep tissue injury measuring 2.5 cm in length by 5.8 width, the coccyx had an unstageable ulceration measuring 1.2 cm by 1.5 cm and third toe had an abrasion. The physician and daughter were made aware of the ulcers and treatments were ordered at that time. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired right heel pressure ulcer identified on 12/05/19 measuring 4.0 cm length by 5.0 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, red color with granulation tissue present, no drainage or pain. The treatment order was paint with [MEDICATION NAME] (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19, and authored by LPN #370 revealed an in-house acquired left heel pressure ulcer identified on 12/05/19 measuring 2.5 cm length by 4.8 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, eschar (tan, brown or black color) with necrotic (dead) tissue present, no drainage or pain. The treatment order was paint with [MEDICATION NAME] (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired coccyx pressure ulcer identified on 12/05/19 measuring 1.2 cm length by 1.5 cm width with an undetermined (UTD) depth and unstageable. The ulcer was assessed to have distinct edges, with yellow slough (dead skin tissue that may have yellow or white appearance) present, bloody drainage and no odor. The treatment order was for [MEDICATION NAME] and a foam dressing daily. On 12/16/19 at 1:31 P.M. RN #375 and LPN #335 were observed completing wound care for Resident #55. Proper infection control procedures were followed and the resident denied pain before starting the dressing changes. Upon positioning the resident to expose the coccyx there was no dressing in place and a small area of dry pink and dark color skin was noted on the coccyx. A dressing dated 12/15/19 was removed from the right heel. The right heel was observed to have a large purple and black colored area which was covered with eschar. A dressing dated 12/15/19 was removed from the left heel. The left heel appeared calloused with purple dotted areas of deep injury. The resident retracted her left foot during cleansing and complained of extreme tenderness to the left heel. All ordered treatments were implemented and dated 12/16/19. On 12/17/19 at 11:01 [NAME]M. observation and interview with Resident #55 revealed she appeared pale and tired, as she closed her eyes a few times during the conversation. The resident was able to have reciprocal conversation remaining oriented to the situation. She was laying on her back on a pressure reducing mattress, head elevated to approximately 30 degrees and her heels were wrapped in white bandages and elevated on a bolster. Resident #55 had been watching television while waiting for her lunch. She was alert with some confusion, as she said she did not remember why she had bandages on her feet. She indicated she preferred to stay in bed only occasionally getting up to a chair and did not have a good appetite. On 12/17/19 at 4:54 P.M. during an interview with Certified Dietary Manager (CDM) #372, CDM #372 revealed prior to her going to the hospital on [DATE] the resident had been receiving fortified foods that consisted of fortified cereal, fortified potato and fortified pudding but it was not restarted when she returned from the hospital on [DATE]. CDM #372 said it was up to the registered dietitian to implement the fortified foods. She added the resident did receive snacks twice a day as before she went to the hospital. On 12/18/19 from 9:56 [NAME]M. to 10:27 [NAME]M. interview with RD #373 verified she had not completed a comprehensive nutritional assessment on the resident when she returned to the facility on [DATE] but instead did a progress note on 11/27/19 addressing the three percent weight gain with no new recommendations. RD #373 identified Resident #55 as a nutritional risk prior to her hospitalization on [DATE], had put her on fortified foods three times a day and Med Plus NSA supplement four ounces twice a day with snacks twice a day. RD #373 verified the Med Plus NSA and fortified foods were not restarted for the resident upon return to the facility on [DATE]. RD #373 shared she implemented a Promod (protein) supplement on 12/06/19 after the multiple in-house acquired pressure ulcers were reported to her at the weekly meeting but as of 12/18/19 she had still not done a comprehensive nutritional assessment of the resident with the last one being 09/25/19 when her quarterly review was due. On 12/18/19 at 1:11 P.M. interview with LPN #314 who reviewed the Skin Monitoring Comprehensive CNA Shower Review documents from 12/01/19 and 12/05/19 verified the documents indicated there were no skin impairment areas notated on them. LPN #314 added she would assume the resident's skin was intact during that time period based on the documents reviewed. On 12/18/19 at 4:02 P.M. interview with the Director of Nursing (DON) and RN #375 both verified Resident #55 developed pressure related wounds to her bilateral heels and coccyx in the facility. The DON revealed she believed the wounds were caused because Resident #55 had [MEDICAL CONDITION] in her legs and was wearing Prafo boots in bed which caused the pressure on her heels. She had no comment regarding how the ulcer on the resident's coccyx developed or how it first identified as an unstageable pressure ulcer. On 12/18/19 at 4:41 P.M. during an interview with RN #375, the RN indicated she believed the coccyx pressure ulcer developed from prolonged pressure as a result of the resident having the head of her bed elevated, [MEDICAL CONDITION] in her heels and keeping her legs elevated put pressure on the coccyx.

Based on record review, observation and interviews, the facility did not ensure foods were served at palatable temperatures. This had the potential to affect all residents in the facility except for one Resident (#35) who did receive food by mouth. The facility census was 77. Findings included: Resident interviews were conducted on 12/15/19 from 9:06 [NAME]M. to 12:45 P.M. with Residents #25, #27, #39, #45 and #52. The residents consistently reported that hot foods were not hot and it could be at any meal the food was not hot. Resident #52 said she expected to get cold eggs when they were ordered. Resident #45 shared he did not eat a full meal a lot of times due to the hot foods being too cool, and he had lost weight. Resident #39 said the longer the trays sit in the hall waiting to get passed the colder the food was to him. Record review was conducted of the Food Committee Meeting Minutes dated 06/2019 which indicated foods were served at the proper temperature based on the floor staffing. On 09/19/19 the minutes reflected foods were served at the proper temperatures most of the time, but the meal carts took too long to pass. On 11/14/19 a comment was noted regarding eggs being cold in the morning. Observation was conducted on 12/18/19 at 10:59 [NAME]M. of the lunch trayline food temperatures in the kitchen with Certified Dietary Manager (CDM) #372. CDM #372 used a calibrated, digital touch point thermometer to obtain the following food temperatures: balsamic pork - 209.5 degrees Fahrenheit (F), roasted potato - 176 degrees F, zucchini - 169.5 degrees F and scalloped apples - 31.3 degrees F. Tray line service began at 11:11 [NAME]M. with CDM #372 serving. She placed the foods onto a plate that had been warmed in a stainless steel plate warming unit. The plates were then placed onto a plastic thermal base and covered with a plastic thermal dome cover. The thermal bases and dome covers were noted to be aged to the point the plastic was starting to separate forming a scale like appearance to the domes and bases. The cart going to the 100 unit for room trays was loaded with 12 trays and the last tray, a test tray, at 11:19 [NAME]M. At 11:22 [NAME]M. the cart left the kitchen and arrived on the 100 unit at 11:23 [NAME]M. District Dietary Manager (DDM) #371 followed the cart to the unit with the surveyor. Using a calibrated, digital touch point thermometer DDM #371 began taking test tray temperatures at 11:32 [NAME]M. when the last tray, the test tray, was passed by the unit staff. The test tray temperatures were as followed: milk - 37 degrees F, scalloped apples 40.7 degrees F, balsamic pork 104.3 degrees F, roasted potato 113.5 degrees F and zucchini 113.9 degrees F. The food flavor and texture were good, however, the food temperature palpability of the pork, potato and zucchini felt barely warm in the mouth. These temperatures were verified with DDM #371 at the time of the observation.

Based on observation, record review, interview and policy review, the facility failed to provide written notification of room changes to Resident #29 prior to conducting the room changes. This affected one Resident (#29) of one resident reviewed for room changes and had the potential to affect all 77 residents residing in the facility. Findings include: Review of the medical record for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent, provide consistent caregivers, use task segmentation, and encourage activity programs consistent with his interests. Observation on 12/16/19 at 9:01 [NAME]M. revealed resident was not in his room, the room was absent of personal belongings, and the bed was without linen. Review of progress notes dated 12/15/19 at 1:51 P.M. indicated resident was notified of a room change and family was also notified. Further review of progress notes revealed on 06/10/19 at 1:44 P.M. indicated a message was left for family to inform of a room change, and on 06/11/19 at 12:05 P.M. a room change was made. Review of profile sheet revealed Resident #29 was listed as his own representative and family as emergency contact. Additional review of the entire medical record revealed no signed written notices for room changes indicated on 12/15/19 and 06/10/19. Interview on 12/17/19 at 4:36 P.M. with Social Worker #376 confirmed Resident #29 had two room changes on 12/15/19 and 06/11/19. She verified there was no written notice and indicated she only verbally talked with Resident #29 for both room changes and called the family. Interview on 12/18/19 at 4:13 P.M. with Social Worker #376 verified she completed the room change form on the electronic medical record when a room change was made but did not provide it to the residents or have residents sign it. Review of facility policy, Resident Room Change Policy, dated 05/30/19, revealed Social Service was to complete Notification of Room Change and New Roommate Notification forms in the medical record. Review of this form revealed a Resident's Signature area.

Based on record review, interview and policy review, the facility failed to ensure Resident #10 and Resident #29 were free from physical abuse. This affected two residents (Residents #10 and #29) of three residents (Residents #10, #29 and #131) reviewed for abuse and neglect. The facility census was 77. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Record review revealed Resident #131 was admitted to the facility on [DATE] with dementia with behavioral disturbance, persistent mood (affective) disorder, and major [MEDICAL CONDITION]. Review of the most recent annual MDS 3.0 assessment, dated 07/30/19 revealed Resident #131 was cognitively impaired. Review of the care plan dated 05/03/18 revealed target behaviors of delusions, inappropriate language, aggressiveness, and disruptive to others. The care plan also reflected a history of resident to resident altercation in the dining room initiated on 01/18/17 and resolved on 10/16/17. Resident #131 was discharged from the facility on 09/07/19. Review of the facility self reported incident (SRI) tracking number 2 dated 06/04/19 revealed Resident #131 punched Resident #10 in the back while passing behind her in the dining room. Resident #131 was removed from the dining room and staff were directed to keep both residents separated. Local law enforcement was not contacted. Resident #131's medications were reviewed by the Consultant Pharmacist on 06/06/19. Resident #10's skin was assessed and identified no bruising or swelling but complaints of pain and tenderness below the left shoulder blade. She received counseling services on 06/10/19. Staff were inserviced on Abuse, Neglect, and Re-directing Residents on 06/05/19. Interview on 12/18/19 at 7:29 [NAME]M. with the Director of Nursing verified the findings of the above SRI. Reviewed the facility Abuse, Neglect and Misappropriation policy, dated 09/02/16, revealed with resident to resident altercation, the facility would separate the residents, conduct appropriate assessments on each resident, may place the aggressive resident in a quiet area to reduce stimulation, notify the physician, update the care plan, make appropriate referrals, and complete a thorough investigation following the initial report. 2. Record review revealed Resident #29 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident had no cognitive impairment and required staff supervision and set-up assistance with with activities of daily living (ADL). Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Review of SRI tracking number 7 dated 11/30/19 revealed upon investigation Resident #29 and #10 had a witnessed verbal argument which resulted in Resident #10 striking Resident #29 on the face. Both residents were immediately separated. Resident #10 was placed on safety checks for supervision through 12/01/19. Upon assessment, Resident #29 had no injury. Local law enforcement was contacted, and no police report was filed. Interview on 12/18/19 at 7:29 [NAME]M. with the Director of Nursing verified the findings of the above SRI. Reviewed facility Abuse, Neglect and Misappropriation policy, dated 09/02/16, revealed with resident to resident altercation, the facility would separate the residents, conduct appropriate assessments on each resident, may place the aggressive resident in a quiet area to reduce stimulation, notify the physician, update the care plan, make appropriate referrals, and complete a thorough investigation following the initial report.

Based on record review, interview and policy review, the facility failed to implement the policy and procedure for reporting alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Review of the medical record for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent, provide consistent caregivers, use task segmentation, and encourage activity programs consistent with his interests. Review of the progress note dated 07/08/19 at 6:02 P.M. indicated resident had a bruise to the left thigh measuring six by eleven. The unit of measurement was not noted. Review of the progress note dated 08/06/19 at 4:05 [NAME]M. indicated resident had returned from a leave of absence and a skin check revealed the right side of the cheek and jaw was slightly swollen, the right arm, abdomen, left foot and lower back had scratches. Review of the progress note dated 10/24/19 at 12:33 P.M. indicated resident had returned from a leave of absence and the staff observed a bruise to the left upper back measuring 26 centimeters (cm) by 5 cm, and a bruise to the left upper extremity measuring 7 cm by 3 cm. Interview on 12/17/19 at 4:36 P.M. with Social Worker (SW) #376 verified Resident #29 had taken multiple leave of absences to visit home, and the injuries on 07/08/19, 08/06/19 and 10/24/19 were each after one of those visits. She confirmed the facility's interdisciplinary team had concerns about the injuries, discussed those concerns, and decided Resident #29 would start counseling services. SW #376 also verified there were concerns of abuse, but Resident #29 was minimizing it and so the concerns were shared with the counselor. SW #376 confirmed she had not discussed it with anyone else or reported it to anyone else. Interview on 12/18/19 at 10:50 [NAME]M. with SW #376 verified the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #335 were included in the interdisciplinary meeting to discuss Resident #29 after the last injury on 10/24/19. SW #376 confirmed she expressed concerns about abuse. Interview on 12/18/19 at 10:50 [NAME]M. with the DON and LPN #335 verified there was an interdisciplinary meeting held after Resident #29's injury was discovered on 10/24/19 to discuss concerns, and verified abuse was discussed at the meeting. The DON verified there was a different administrator for the facility at the time who was aware. Interview on 12/18/19 at 10:50 [NAME]M. with the Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to report it and investigate. Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported.

Based on record review, interview and policy review, the facility failed to report alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Review of the medical record for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent, provide consistent caregivers, use task segmentation, and encourage activity programs consistent with his interests. Review of the progress note dated 07/08/19 at 6:02 P.M. indicated resident had a bruise to the left thigh measuring six by eleven. The unit of measurement was not noted. Review of the progress note dated 08/06/19 at 4:05 [NAME]M. indicated resident had returned from a leave of absence and a skin check revealed the right side of the cheek and jaw was slightly swollen, the right arm, abdomen, left foot and lower back had scratches. Review of the progress note dated 10/24/19 at 12:33 P.M. indicated resident had returned from a leave of absence and the staff observed a bruise to the left upper back measuring 26 centimeters (cm) by 5 cm, and a bruise to the left upper extremity measuring 7 cm by 3 cm. Interview on 12/17/19 at 4:36 P.M. with Social Worker (SW) #376 verified Resident #29 had taken multiple leave of absences to visit home, and the injuries on 07/08/19, 08/06/19 and 10/24/19 were each after one of those visits. She confirmed the facility's interdisciplinary team had concerns about the injuries, discussed those concerns, and decided Resident #29 would start counseling services. SW #376 also verified there were concerns of abuse, but Resident #29 was minimizing it and so the concerns were shared with the counselor. SW #376 confirmed she had not discussed it with anyone else or reported it to anyone else. Interview on 12/18/19 at 10:50 [NAME]M. with SW #376 verified the Director of Nursing (DON) and Licensed Practical Nurse #335 were included in the interdisciplinary meeting to discuss Resident #29 after the last injury on 10/24/19. SW #376 confirmed she expressed concerns about abuse. Interview on 12/18/19 at 10:50 [NAME]M. with the DON and LPN #335 verified there was an interdisciplinary meeting held after Resident #29's injury was discovered on 10/24/19 to discuss concerns, and verified abuse was discussed at the meeting. The DON verified there was a different administrator for the facility at the time who was aware. Interview on 12/18/19 at 10:50 [NAME]M. with Administrator confirmed it was the facility's policy with any allegation or suspicion of abuse to report it and investigate. Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported; in the event an allegation is made, the facility will take measures to protect residents from harm during an investigation; and accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law.

Based on record review, interview and policy review, the facility failed to thoroughly investigate a physical abuse incident involving Resident #10 and Resident #29. This affected two Residents (#10 and #29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Record review revealed Resident #29 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive impairment and required staff supervision and set-up assistance with with activities of daily living (ADL). Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Review of the facility self-reported incident (SRI) tracking number 7 dated 11/30/19 revealed upon investigation Resident #29 and #10 had a witnessed verbal argument which resulted in Resident #10 striking Resident #29 on the face. Both residents were immediately separated. Resident #10 was placed on safety checks for supervision through 12/01/19. Upon assessment, Resident #29 had no injury. Local law enforcement was contacted, and no police report was filed. Interview on 12/15/19 at 10:36 [NAME]M. with Resident #29 revealed he was living in the room next to Resident #10 and did not remember how long ago the incident took place. He stated Resident #10 said bad things about him, his family, and his wife to be so he got mad and called her names in return, then she punched him in the jaw. Resident #29 indicated Resident #10 picks on him by sitting in places where he likes to go and sticks her middle finger up at him. He confirmed the police talked with him about the incident and encouraged him to not press charges so he did not. Interview on 12/15/19 at 11:06 [NAME]M. with Resident #10 revealed there were issues between her and Resident #29 building prior to the incident on 11/30/19. She indicated Resident #29 was living in the room next to hers and walked around her, watched her, and taunted her by calling her names. She stated on the day of the incident he walked over to her, leaned down into her face, and called her a (expletive), so she hit him in the mouth. She expressed Resident #29 was intimidating since she was in a wheelchair and he was not. Resident #10 indicated she told the police that Resident #29 harassed her, and the police talked Resident #29 out of pressing charges. Resident #10 further explained right after the incident Resident #29 sang a song in her face to get rid of evil he has to cut me like a goat, then he cracked his knuckles and had his fists clenched around her which caused her to feel scared and worried. Interview on 12/17/19 at 5:32 P.M. with Administrator confirmed no additional residents or staff assigned to the area where Resident #10 and #29 reside and the incident took place were interviewed. He also confirmed Resident #10 was not interviewed in detail about the effects of the incident and no follow-up interviews with Resident #10 and Resident #29 were conducted. Interview on 12/18/19 at 7:29 [NAME]M. with Director of Nursing verified no additional residents or staff assigned to the area where Resident #10 and #29 reside and the incident took place were interviewed. She also confirmed Resident #10 was not interviewed in detail about the effects of the incident and no follow-up interviews with Resident #10 and Resident #29 were conducted. Interview on 12/18/19 at 9:56 [NAME]M. with State tested Nursing Assistant (STNA) #330 verified Resident #29 sang a song to Resident #10 that ended with off with her head, then looked at Resident #10, grinned and laughed, so she told Resident #10 to stay by the nurses station and reported it to the nurse on duty. STNA #330 stated Resident #29 likes to instigate and start things with other residents. Review of the progress notes dated 12/4/2019 at 4:51 P.M. confirmed Resident #29 was observed ambulating in hallway, pacing back and fourth around the nursing station with his headphones around his neck, singing explicit alleged song lyrics taunting Resident #10 while staring at her and verbalizing vulgar language and violence. Interview on 12/18/19 at 10:00 [NAME]M. with Registered Nurse (RN) #315 verified Resident #29 usually kept to herself, and Resident #10 did not know personal space or boundaries and gets very close to people. Review of the facility policy on Abuse, Neglect and Misappropriation, dated 09/02/16, revealed following the initial report of the alleged violation the facility will complete a thorough investigation.

Based on record review, interview and policy review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR) recommendations were incorporated into Resident #53's plan of care. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the PASRR determination from the Ohio Department of Mental Health dated 05/03/19 revealed Resident #53 was approved for a sixty day nursing facility stay to expire on 07/02/19, and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the PASRR determination from the State Department of Mental Health revealed Resident #53 had a history of [REDACTED]. Review of the care plan dated 07/15/19 revealed no evidence of the PASRR recommendations included into the care plan. Interview on 12/18/19 at 12:29 P.M. with Registered Nurse #345 verified Resident #53's care plan did not reflect the PASRR determination recommendations including discharge planning for return to the community. Review of facility policy entitled, Plan of Care Overview, dated 05/30/19, revealed care plan documents are resident specific/resident focused and reflect resident/representative opportunities for participation and preferences.

Based on record review and interview, the facility failed to ensure a valid Pre-Admission Screen and Resident Review (PASRR) was in place for Resident #53. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the PASRR determination from the Ohio Department of Mental Health dated [DATE] revealed Resident #53 was approved for a sixty day nursing facility stay to expire on [DATE], and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency prior to admission on [DATE]. Interview on [DATE] at 4:36 P.M. with Social Worker #376 verified a new PASRR was not requested for Resident #53 when it expired on [DATE], and no valid PASRR was currently in place for Resident #53's continued stay at the facility.

Based on interview and record review, the facility failed to ensure Resident #52 had a current discharge plan of care and failed to have documented evidence of care plan meetings. This affected one (Resident #52) of two (Residents #52 and #79) reviewed for discharge. The facility census was 77. Findings include: Review of the medical record for Resident #52 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the care plans for Resident #52 revealed there was no discharge plan in place. Review of the medical record for Resident #52 revealed no documented evidence of care plan meetings. Review of the nursing progress note on 09/19/19 at 11:18 [NAME]M. the interdisciplinary team (IDT) revealed Resident #52's original admission was 10/18/18, the resident was discharged home. Resident #52 was readmitted from home on 02/02/19. The resident's family had not managed the resident at home, and Resident #52 was Long-Term Care (LTC) with a guardian. Review of the Baseline Care Plan signed 02/04/19 revealed the original discharge plan was for the resident to discharge home. Interview on 12/15/19 at 11:07 [NAME]M. with Resident #52 revealed the resident wanted to know when she would be able to go back home to live with her children. Interview on 12/17/19 at 6:08 P.M. Licensed Social Worker (LSW) #376 stated Resident #52's children were not able to take care of her. The resident had a guardian appointed on 06/11/19. Interview on 12/18/19 at 3:05 P.M. LSW #376 verified there was no current discharge plan in the medical record, and there had been no documented care plan meetings.

Based on observation, interview and record review, the facility failed to ensure Resident #52 was wearing a wander/elopement alarm per physician's order. This affected one (Resident #52) of two (Residents #52 and #8) reviewed for wandering/elopement. The facility census was 77. Findings include: Review of the medical record for Resident #52 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. A wander/elopement alarm was used daily. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the Wandering Observation Tool dated 10/15/19 revealed the resident was at risk for elopement. Review of the plan of care dated 07/15/19 revealed the resident was at risk for elopement/wandering behavior related to an attempt to exit out the front door. Interventions included to apply a code alert bracelet, check function every shift, check placement every shift, assess for hunger, thirst, ambulation or toileting needs when found attempting to exit and provide diversionary activities. Review of the physician's orders for 12/2019 identified orders for a code alert bracelet (a bracelet that alerts staff if a resident attempts to exit the facility). Observation and interview on 12/17/19 at 1:41 P.M. revealed Resident #52 was not wearing a code alert bracelet. The Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #375 checked the resident for wander guard/code alert bracelet placement and verified it was not on the resident. Interview on 12/17/19 at 3:32 P.M. with RN #375 revealed Resident #52's wander guard/code alert bracelet was just found in the laundry.

Based on medical record review, interview and review of facility fall investigation and policy for falls, the facility failed to ensure physician ordered and care planned interventions were followed to prevent a fall for one (Resident #43) of three residents reviewed for falls. Actual harm occurred when Resident #43 was left standing without appropriate assistance during care and sustained a fall with subsequent fracture to her lower left leg and ankle bones. The facility census was 93. Findings include: Review of the medical record for the Resident #43 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care initiated 11/08/18 revealed Resident #43 was at risk for falls due to gait and balance problems. Interventions included education of resident, family members and care givers about safety reminders; ensure resident was wearing appropriate footwear when ambulating. The plan of care also included Activities of Daily living (ADL) self care performance deficit related to her disease process. Interventions included to have the resident use a walker when ambulating in the facility with constant contact provided by staff while ambulating; two staff assistance for bed mobility to reposition and turn in bed and for transfers, and bilateral grab bars to the bed to enhance mobility and transfers. Review of the admission Minimum Data Set (MDS) assessment, dated 11/13/18, revealed Resident #43 had intact cognition, required extensive physical assistance of two persons for bed mobility and transfers, supervision with one person physical assistance with ambulation, and had no falls. Review of the fall risk assessment dated [DATE] revealed Resident #43 was alert and oriented; required a wheelchair or ambulation assistance for mobility, was non-ambulatory; required minimum assistance with a gait belt and may use a walker for transfers. Review of physician orders [REDACTED].#43 identified orders for the resident to ambulate in the facility with a walker and contact assistance and for contact assistance with transfers every shift. Review of the nurses notes dated 01/03/19 at 6:30 A.M. revealed, on 01/03/19 around 6:00 A.M. during care provided by a State tested Nurse Aid (STNA), Resident #43 was standing at the bedside holding a bed rail and dropped to her knees and laid back on the floor. The resident denied hitting her head, and pain or injury other than abrasions to her left knee and left lower leg. Resident #43 was wearing non-skid socks at the time. Resident #43 was assessed by nurses and returned to her bed. A late entry nurses note dated 01/04/19 at 3:30 P.M. revealed per family request Resident #43 was sent out to the local emergency department for evaluation for a skin problem. A nurses note dated 01/05/19 at 12:04 A.M., revealed the facility received a call from the hospital informing them the resident was admitted with a left leg fracture. Review of hospital/ emergency department history and physical dated 01/05/19 for Resident #43 revealed, on 01/04/18, Resident #43 arrived at the emergency room complaining of pain to her left ankle after a fall at the nursing home. The resident said, she fell at the nursing home while attempting to ambulate, and had gradually increasing pain for which she came to the hospital. Review of X-ray results taken at the hospital of Resident #43's left ankle revealed an isolated left lateral malleolus fracture and a nondisplaced proximal fibula fracture (fractures of the lower left leg and ankle bones). Review of the facility fall investigation dated 01/05/19 revealed, on 11/07/18 Resident #43 was admitted to the facility and received physical and occupational therapy. Resident #43 was alert and oriented and able to make decisions for herself. She was admitted to the facility after a hospital stay subsequent to falls at home. On 01/03/19, Resident #43 and an episode of incontinence and requested to have her bed linens changed by an STNA. The STNA offered to transfer the resident to a wheelchair or toilet while she changed the bed linens, but Resident #43 stated she wanted to stand at her bedside. Resident #43 got up and stood at the bedside holding the side rail. Resident #43's legs became weak, she fell to the ground, and knocked over the tray table at her bedside. Nurses arrived, provide assistance to the resident and assessed her for injury and pain which the resident denied other than abrasions to her left knee and shin. The nurses completed full range of motion assessments of Resident #43 without complaints of pain. Resident #43 was later taken by ambulance to a previously scheduled doctor's appointment. The facility was unable to determine when the left ankle fracture occurred. The resident did not return to the facility from the hospital. Interview on 01/17/19 at 7:30 A.M., with STNA #505 revealed around 6:00 A.M. on 01/03/19 she responded to Resident #43's call light. The resident had an episode of incontinence and wanted her bed linens changed. STNA #505 stated she offered to help Resident #43 to transfer to a wheelchair or to the bathroom to clean up while she changed her bed linens, but Resident #43 declined and stated she wanted to stand while the linens were changed. STNA #505 stated she assisted Resident #43 to stand and hold onto the side rail of the bed while she changed the bed linens. STNA #505 stated she allowed the resident to stand independently and without staff support, though she was holding onto the side rail of the bed. STNA #505 stated, when she turned to change the bed linens, Resident #43 fell to the floor, straight down when her knees gave out and laid back onto the floor. She stated LPN #110 then entered the room and assisted her with the care of Resident #43 and they put her back to bed with the use of a Hoyer lift at the request of the resident. STNA #505 stated, other than abrasions to Resident #43's left knee and left shin, the resident denied having any injuries or pain. Interview on 01/17/19 at 7:40 A.M. interview with LPN #110 revealed on 01/03/19 around 6:00 A.M. she was working as an aid at the facility and was looking for STNA #505 when she found the aid in Resident #43's room. She stated STNA #505 was changing the bed linens and Resident #43 was standing, holding onto the side rail of the bed by herself. LPN #110 stated STNA #505 was on the other side of Resident #43's bed at the time and no one was supporting the resident. She stated she looked at Resident #43 and she appeared stable, then she turned to exit the room and heard a noise and turned to see Resident #43 laying on the floor. Resident #43's head was near the foot of the bed, her feet were under the bed and her over bed table was knocked over. LPN #110 stated she went back into the room to assess the resident. STNA #505 went to get LPN #111 who was the charge nurse. LPN #110 stated she assessed Resident #43 and performed full range of motion of her upper and lower extremities and Resident #43 denied any pain, discomfort or injury other than abrasions to her left knee and shin (anterior left lower leg). LPN #111 arrived and performed her own assessment and range of motion checks with no other pain or injury noted. LPN #110 stated they returned Resident #43 to her bed using the Hoyer lift at the request of the resident. On 01/17/19 at 1:03 P.M. interview with the DON confirmed Resident #43 was assessed to be at risk for a fall and care planned interventions and physcian orders included to provide contact physical assistance for transfers and ambulation. The DON verified, on 01/03/19 around 6:00 A.M., her staff did not provide contact assistance to the resident during care, resulting in a fall. The DON stated one of her staff members should have had at least one hand physically holding Resident #43 while she was standing and holding onto the side rail of her bed so they could support her and prevent the resident from falling. The DON verified the resident went to the hospital the following day and they received a call from the hospital informing them the resident was admitted with a [MEDICAL CONDITION] leg. Review of facility policy titled fall risk observation dated 10/17/13 revealed the policy indicated to promote resident centered care by providing fall risk observations on admission, quarterly and following any fall that occurs and to institute appropriate precautions that are individualized to the resident needs. Review of facility policy fall prevention program guidelines dated 06/24/14 revealed residents needed to be assessed for falls, and measures were to be taken to prevent resident falls. This deficiency substantiates Master Complaint Number OH 100 and Complaint Number OH 952.