Every finding on record at Concord Care and Rehabilitation Center

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were treated with dignity/respect when staff failed to ensure residents names were not visible on their clothing. This affected one (Resident #31) of three residents reviewed for dignity. The facility census was 46. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] and diagnoses of rhabdomyolysis, heart disease, pneumonia, urinary tract infection, hypoglycemia, presence of cerebrospinal fluid drainage device, muscle weakness, altered mental status, depression, anxiety, anorexia. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of three, indicating Resident #31 was severely cognitively impaired. Resident #31 required substantial/maximal assistance with upper and lower body dressing as well as putting on/taking off footwear. Observation on 09/03/24 at 12:38 P.M. revealed Resident #31 sitting in their wheelchair in the facility common area by the nurses station wearing yellow non-slip socks that were both visibly marked with Resident #31's first name. Staff interview on 09/03/24 at 12:39 P.M. with Licensed Practical Nurse (LPN) #210 verified the above findings. Review of the facility policy titled, Dignity, with a revision date of 02/21, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents were safely smoking. This affected one (Resident #41) of one resident reviewed for smoking. The facility census was 46. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses of cardiomyopathy, hypoxemia, ascites, chronic passive congestion of liver, nicotine dependence, congestive heart failure, type two diabetes mellitus, hypertension, fatty liver, insomnia, hypotension, and dyspnea. Review of the most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #31 was cognitively intact. Observation on 09/03/24 at 10:09 A.M. of Resident #41 while they were smoking revealed Resident #41 extinguished their cigarette on the ground and then placed the butt between the cushion of their wheelchair and the wheelchair. Interview on 09/03/24 at 10:10 A.M. with Resident #41 revealed they extinguish their cigarettes on the ground and place the butt between the cushion of their wheelchair and the wheelchair until they are ready to return inside of the facility. When Resident #41 is ready to go inside, Resident #41 places the used cigarette butts into approved receptacles. Interview on 09/03/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #220 verified the above findings. Review on 09/05/24 at 11:18 A.M. of an undated facility policy titled, Smoking, revealed residents are to extinguish all cigarettes in a designated container.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to provide residents with appropriate supervision while smoking and failed to maintain smoking materials in a safe manner. This affected six (#11, #17, #23, #24, #26, and #37) of 16 residents reviewed for smoking. The census was 41. Findings include: Observation on 05/29/24 at 9:11 A.M. revealed Resident #11 was standing outside in the smoking area by herself smoking unsupervised. Observation on 05/29/24 at 9:22 A.M. revealed Resident #37 had a pack of cigarettes laying on his bed. Resident #37 was resting with his eyes closed while sitting in his custom electric wheelchair beside his bed. Interview with State tested Nurse Aide (STNA) #130 on 05/29/24 at 9:22 A.M. verified Resident #11 was outside smoking unsupervised and Resident #37 had a pack of cigarettes laying on his bed. Interview with Licensed Practical Nurse (LPN) #125 on 05/29/24 at 9:25 A.M. revealed activities staff was supposed to lock cigarettes and lighters up and dispense them to residents at smoke breaks. Observation on 05/29/24 at 11:00 A.M. outside in the smoking area revealed Resident #26, Resident #23, and Resident #37 were smoking unsupervised. Interview with Resident #23 during the observation stated Activity Aid (AA) #154 let the residents out to smoke and left the area. Interview on 05/29/24 at 11:09 with Resident #37 stated he always kept his cigarettes on him and the residents are usually not supervised while smoking. Continued observation at 11:16 A.M. revealed no staff members were in the smoking area or near the door to the smoking area. No residents were wearing smoking aprons. Resident #24 came out to the smoking area, reached into his hoodie pocket, pulled out his cigarettes and lighter, and began smoking. Interview with Resident #24 during the observation stated he rolled his own cigarettes and kept them in his possession. Observation on 05/29/24 at 11:30 A.M. revealed AA #154 and STNA #138 came out to the smoking area at 11:30 A.M. and asked if anyone wanted to go in and have lunch since a code was needed to get in and out of the smoking area. Interview with the AA #154 on 05/29/24 at 11:32 A.M. verified he left the residents who were smoking unsupervised on 05/29/24 at 11:00 A.M. to go and get a key. Observation on 05/30/24 at 9:00 A.M. revealed Resident #11, Resident #17, Resident #23, and Resident #37 were outside smoking with no supervision and Resident #37 was not wearing a smoking apron. Interview with the Quality Assurance Manager (QAM) on 05/30/24 at 9:08 A.M. verified no resident prior to 9:08 A.M. outside smoking was supervised. The QAM also verified Resident #37 did not have on a smoking apron while smoking. Review of the most current smoking assessments for Resident #11, Resident #17, Resident #23, Resident #24, Resident #26, and Resident #37 revealed each resident was to be supervised when smoking at the posted smoking times only. Resident #37's smoking assessment dated [DATE] revealed the resident could smoking while supervised and wearing a smoking apron. Review of Resident #37's current care plan revealed the resident was a current smoker who required supervision and a smoking apron to be worn every time to provide safety from burning his clothing and/or himself. Review of the undated smoking policy revealed all smoking articles (cigarettes, e-cigarettes, cigars, lighters, and lighter fluid) will be stored in a designated locked area and are supervised by the nursing staff. No resident may have any smoking articles in their room or on their person. All smokers will be supervised at all times by a designated staff member. Staff member will pass out the cigarettes and will light each cigarette. This deficiency represents non-compliance investigated under Complaint Number OH00153750.

Based on observation, medical record review, staff interview, and policy review, the facility failed to administer medications as ordered by the physician. A total of two medication errors were identified out of 30 opportunities for a medication error rate of 6.67 percent (%). This affected one (#33) of four residents observed for medication administration. The census was 41. Findings include: Review of Resident #33's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes mellitus type II, hypertension, and seizures. Review of Resident #33's current physician orders revealed the resident was to received a multivitamin with minerals to give one tablet by mouth once daily for supplement and the combined blood pressure medication valsartan-hydrochlorothiazide 160 milligrams (mg) - 25 mg tablet by mouth once daily with instructions to hold if the resident's systolic blood pressure was less than 110 millimeters of mercury (mmHg). Observation of medication administration for Resident #33 on 05/29/24 at 5:20 A.M. revealed Licensed Practical Nurse (LPN) #146 administered the resident a multivitamin tablet and administered the valsartan-hydrochlorothiazide 160 mg -25 mg after obtaining a blood pressure reading of 97/64 mmHg. The resident took the medications without incident. Interview on 05/29/24 at 6:18 A.M. with LPN #146 confirmed the nurse administered Resident #33 a multivitamin and valsartan-hydrochlorothiazide tablets, and confirmed the blood pressure medication should have been held due to the resident's low systolic blood pressure. Interview on 05/29/24 at 7:30 A.M. with the Director of Nursing (DON) revealed a multivitamin with minerals should have been administered to Resident #33 not a multivitamin. Review of the facility policy titled, Administering Medications, dated 12/12, revealed medications must be administered in accordance with the orders. This deficiency represents non-compliance under Master Complaint Number OH00154387, Complaint Number OH00154201, and Complaint Number OH00153750.

Based on observation, staff interview interview, and review of facility policies, the facility failed to ensure proper hand hygiene was maintained during medication administration. This affected two (#32 and #39) of four residents observed during medication administration. The census was 41. Findings include: Observation on 05/29/24 at 5:20 A.M. of medication administration to Resident #39 revealed Licensed Practical Nurse (LPN) #146 popped out a tablet of the pain medication gabapentin 600 milligrams (mg) into his bare hand then put the tablet in the medication cup without sanitizing his hands. Observation on 05/29/24 at 5:35 A.M. of medication administration to Resident #32 revealed LPN #146 put a supplemental vitamin C 500 mg tablet directly into his bare hand from the bottle and put it in the medication cup without sanitizing his hands. Interview with LPN #146 on 05/29/24 at 6:00 A.M. confirmed he did not wash his hands from the beginning of medication administration at 5:20 A.M. through confirmation at 6:00 A.M. LPN #146 confirmed he put medications for Resident #32 and Resident #39 into his bare hand and into a medication cup without properly sanitizing his hands. Review of the facility policy infection control policy, dated 03/18, revealed the facility and staff will identify infection transmission risks and will implement relevant precautions. Review of the facility policy titled, Medication Administration, dated 12/12, revealed staff shall follow established facility infection control procedures including handwashing.

Based on medical record review, resident and staff interview, review of a facility self-reported incident (SRI), review of witness statements, review of a local law enforcement report, review of bank records, review of Quality Assurance Performance Improvement (QAPI) notes, review of a signed acknowledgement, and review of the facility policy, the facility failed to ensure a resident was free from misappropriation of money. This affected one (#02) of three residents reviewed for misappropriation. The facility census was 46. Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, depression, anxiety, legal blindness, chronic pain, muscle weakness, lack of coordination, and tremors. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/14/23, revealed Resident #02 had a moderate cognitive impairment. Review of the nursing progress note dated 12/08/23 and timed 5:59 P.M. revealed Resident #02 stated he was missing money from his account. The resident's bank card was stopped and the police were notified. Review of a subsequent nursing progress note dated 12/08/23 and timed 6:35 P.M. revealed the resident's bank card was stopped and a new card was locked in the Director of Nursing's (DON) office. Review of the social service notes dated 12/08/23 and timed 7:31 P.M. revealed Resident #02 stated he was missing money. A police report was filed. The resident was upset but doing okay. Review of the nursing progress note dated 12/11/23 and timed 1:08 P.M. revealed Resident #02 requested to have his bank card. The bank card was given to the resident and the resident was instructed to keep the card in a safe place and not give it to anyone. The resident verbalized understanding. Review of the SRI dated 12/08/23 and timed 5:55 P.M., revealed on 12/08/23 at 3:00 P.M., Resident #02 was taken to the bank by Social Service Designee (SSD) #200 and Activities Director #201. The resident wanted to go to the bank to get statements, as his debit card was declined when he tried to use it. The statements were given to the resident while at the bank, and several withdrawals were made which the resident did not make. Upon returning to the facility, the Administrator and Director of Nursing (DON) were notified and the police were contacted. The resident's statement indicated Activities Assistant #105 made several unauthorized cash transfers and online store purchases from the resident's account. Activities Assistant #105 was contacted by the Administrator and DON for a written statement and was removed from the schedule pending investigation. The resident's card was stopped with a new one initiated. A bank new card was locked in the DON's office until the resident wanted it back. The police took a statement from Resident #02. The facility substantiated the allegation of misappropriation. Review of the written statement provided by SSD #200, revealed the staff member accompanied Resident #02 to the bank on 12/08/23 due to the resident being legally blind. The resident requested the bank teller cancel his previous debit card due to losing it. The resident also requested to withdraw money from his account and asked how much he had. The bank teller informed the resident there was $226.00 in his account. The resident stated he had not made any purchases during the month, other than at the vending machine a couple of times. The bank teller then showed SSD #200 the transaction history after obtaining permission from the resident to do so. SSD #200 noticed several cash transfers using an application called Cash App, as well as several purchases from an online retailer. SSD #200 asked the resident if he used Cash App or made purchases from the online retailer, and the resident responded he had not. The bank teller was able to pull up an individual Cash App transaction, which showed the first and middle name of Activities Assistant #105. A second name (Unknown Person #192) was also found on a transaction. SSD #200 notified the Administrator while at the bank that Resident #02's bank account was almost depleted and SSD #200 believed it was an due to an employee. Upon returning to the facility, SSD #200 took the resident and transaction history to the Administrator's office with the DON present as well. The Administrator and DON verified the name on the statement matched the employee. The police were called and a report was made. Review of the local law enforcement report, dated 12/08/23 and timed 4:55 P.M., revealed the police were called regarding a theft at the facility. The responding officer spoke with the Administrator and SSD #200. The staff members advised they were made aware of a possible theft. The staff members advised an activities assistant would assist residents in trips to stores and would have access to credit/debit cards in situations where residents could not typically shop alone. The staff advised they were made aware of possible bank fraud. The Administrator provided the officer with a bank statement which showed numerous transactions to a Cash App account. The statement also showed purchases from an online retailer, a women's clothing retailer, and partial Cash App transactions to another account. The officer then spoke with Resident #02, who advised he did not use Cash App in any way as he was legally blind and did not shop at the online retailer. Resident #02 reported all of the shopping he did was in person or with assistance by the activities aides. Resident #02 advised he did not authorize any transfers to either of the two Cash App accounts. The officer went over the statement and the resident advised which transactions could have been his. The resident advised he wished to pursue the matter criminally if possible, and was provided with a victim's rights form. The officer located at least nine transactions for the online retailer on the statement. The total value of the reported fraudulent transactions was $3,329.72, which was cumulative for both the online retailer and Cash App accounts. Review of the local law enforcement supplement, dated 12/12/23, revealed the officer received an emailed copy of requested bank statements. The officer reported the statements provided an accurate number of transactions and total of money misused from Resident #02's bank account via his debit card information. There appeared to be no fraudulent transactions in the month of September 2023. The total transactions made by Activities Assistant #105, beginning on 10/16/23 and ending on 12/08/23, included 59 withdrawals for a total of $2,771.00 and two deposits for a total of $155.41. The total transactions made by Unknown Person #192 included two withdrawals (one on 10/17/23 and one on 12/07/23) for a total of $70.75. The total transactions for purchases made from the online retailer included five purchases for a total of $283.99 and five deposits for a total of $96.35. The total for all fraudulent transactions made from Resident #02's account was $3,131.74. Review of the written statement provided by the DON, revealed Activities Assistant #105 called the facility on 12/11/23 at approximately 2:00 P.M. and reported Resident #02 had given her his bank card to transfer money into her account because the resident was appreciative of all she had done. Activities Assistant #105 reported she transferred $50.00 into her account using Resident #02's debit card. Activities Assistant #105 stated her Cash App account, used for cash transfers, had been hacked in the past. Activities Assistant #105 stated she got a new Cash App account in August 2023 and thought she had deleted Resident #02's information. Activities Assistant #105 stated she would pay any money back. Activities Assistant #105 was informed she was taken off the schedule pending investigation. Review of the undated written statement provided by Activities Assistant #105 revealed Activities Assistant #105 and Resident #02 went on an outing, possibly in October 2023. At that time, they went to the store to shop for winter clothing items. Afterwards, Resident #02 wanted to stop for food and cigarettes, so they did. While they were out, Resident #02 offered to give Activities Assistant #02 $50.00 for being kind. Resident #02 did not have cash so he told Activities Assistant #105 they could use an automated teller machine (ATM). Activities Assistant #105 reported there were not any ATMs around and suggested using Cash App. Resident #02 agreed and Activities Assistant #105 performed the transaction. Activities Assistant #105 then disconnected the card and gave the physical card back to Resident #02. Activities Assistant #105 reported her phone glitched at times and her Cash App account had been hacked in the past. Activities Assistant #105 reported she thought all of the transactions she had been making were with her own funds and had not been paying attention to any other cards linked to her account. Review of the QAPI notes dated 12/11/23, revealed a meeting was held due to a concern of misappropriation of resident funds. The facility identified the system to keep residents safe from misappropriation had failed. During interview on 12/27/23 at 9:28 A.M., Resident #02 confirmed he had money come up missing and found out a staff member had taken his bank card and was using it. During interview on 12/27/23 at 12:50 P.M., the Administrator confirmed the staff member had misappropriated funds using Resident #02's bank card. The Administrator reported Unknown Person #192 was Activities Assistant #105's [AGE] year-old daughter. During a phone interview on 12/27/23 at 2:16 P.M., Activities Assistant #105 reported Resident #02 had allowed her to take $50.00 from his bank account via Cash App a couple of months ago. Activities Assistant #105 reported thinking the resident's bank card from been removed from Cash App and did not realize she had been continuing to make charges from the resident's account. Review of the signed acknowledgment, dated 06/23/23, revealed Activities Assistant #105 signed acknowledging receiving and agreed to abide by the policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure. Review of the undated facility policy titled, Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed residents had the right to be free from abuse, neglect, misappropriation of their property, and exploitation. This deficiency represents non-compliance investigated under Complaint Number OH00149286.

Based on medical record review, staff interview, review of the shower schedule, and review of shower sheets, the facility failed to ensure residents received assistance with showers as required. This affected one (#4) of four residents reviewed for Activities of Daily Living (ADLs). The facility census was 45. Findings include: Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included traumatic brain injury, hemiplegia, difficulty in walking, cocaine abuse, and nicotine dependence. Review of the admission Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had impaired cognition. The resident required physical assistance from one staff member for part of bathing. Review of Resident #4's plan of care, dated 03/15/23, revealed the resident was resistive to care. Interventions included allowing the resident to make decisions about treatment and encouraging as much participation in care as possible. Review of the shower schedule revealed Resident #4 was to receive assistance bathing on Wednesday and Saturday nights. Review of Resident #4's bathing documentation for 03/01/23 through 04/12/23 revealed the resident did not receive scheduled showers on 03/04/23, 03/08/23, 03/25/23, and 04/08/23. No refusals were documented for these dates. Interview on 04/13/23 at 6:56 A.M., with Licensed Practical Nurse (LPN) #200 revealed when a resident refused a shower the nurse on duty would attempt to encourage them. LPN #200 stated if the resident still refused then the refusal would be documented by the State tested Nurse Aide (STNA) and signed by the nurse. Interview on 04/13/23 at 2:50 P.M., with the Director of Nursing verified there was no evidence Resident #4 was offered, received, or refused assistance bathing on these dates. This deficiency represents non-compliance investigated under Complaint Number OH00141852.

Based on medical record reviews, review of the facility policy, and staff interview, the facility failed to complete a wound assessment and treatment upon admission for Resident #16's pressure ulcer and failed to complete routine weekly wound measurements for Resident #48's pressure ulcer. This affected two (#16 and #48) of four residents reviewed for wounds. The facility census was 47. Findings include: 1. Review of Resident #16's medical record revealed an admission to the facility occurred on 02/02/23. Diagnoses including; cancer with metastasis to the colon, liver, lung and prostate; diabetes mellitus and chronic left foot wound. Review of the home health notes dated 02/02/03 revealed Resident #16 was being assisted with wound care for a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle) to the left heel. Resident #16 was receiving home health at home prior to admission to the facility on [DATE]. Review of Resident #16's admission assessment dated [DATE] and 02/03/23 revealed there was no evidence of any wound evaluation and or measurement of any wound on the left heel. The skin sections of the assessments were blank. Review of the admission physician orders dated 02/02/23 and treatment administration records (TAR) dated 02/02/23 through 02/07/23 revealed there were no treatments completed to Resident #16's chronic wound to the left heel. Review of the progress notes for Resident #16 from 02/02/23 through 02/08/23 revealed there was no mention of a wound and or treatment to Resident #16's left heel wound. Interview with the Assistant Director of Nursing (ADON) #806 on 03/15/23 at 12:35 P.M. confirmed there was no evidence Resident #16's left heel wound was assessed and measured upon admission on 02/02/23. ADON #806 confirmed there was no documented treatment completed for the wound until 02/07/23, when the wound was assessed, measured and a treatment was started. Review of the facilities prevention of pressure ulcer policy revealed the resident's skin should be assessed within eight hours of admission to the facility. 2. Review of Resident #48's medical record revealed an admission to the facility occurred on 07/25/22. Resident #48 was discharged to home on 01/12/23. Diagnoses included paraplegia, chronic pressure ulcer, and stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle) to the coccyx. Review of the facilities wound assessments and measurements revealed they were completed on 08/04/22, 09/28/22, 11/20/22 and 12/20/22. There was no evidence the wound assessments were completed on a weekly and/or routine basis. There was no evidence the wound deteriorated during his stay. Interview with Assistant Director of Nursing (ADON) #806 on 03/15/23 at 12:35 P.M. revealed she started to be the wound care nurse in the facility in November 2022. ADON #806 confirmed Resident #48 declined to see the wound team in the facility and would go out to a wound center outside the facility. ADON #806 confirmed she could not locate weekly skin wound measurements for Resident #48. ADON #806 confirmed the facility should be completing weekly wound assessments and measurements to ensure treatments were effective. Review of the facilities pressure ulcer policy dated 2013 revealed if pressure ulcers are not treated when discovered, the have the potential to became larger, painful and infected. Staff were to routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs ad symptoms of irritation or breakdown. Under assessment, the skin will be assessed fro the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. This deficiency represents non-compliance investigated under Complaint Numbers OH00138533 and OH00138085.

Based on observations, record reviews, and staff interviews, the facility failed to provide nutritional weight loss interventions to the resident. This affected one (Resident #30) of three residents reviewed for nutrition. The facility census was 47. Findings include: Review of Resident #30's medical record revealed an admission to the facility occurred on 02/18/22. Diagnoses included diabetes mellitus, chronic obstructive pulmonary disease, and dysphagia. On 02/13/23, Resident #30 was placed on hospice services for end of life care. Review of Resident #30's physician orders revealed two whole milks with meals dated 12/22/22; four ounces of prune juice with meals dated 01/05/23; and Boost pudding (high calorie nutritional supplement) and sugar free shake (high calorie nutritional supplement) with three times a day with meal on 12/22/22. Review of the nutritional assessment dated [DATE] revealed Resident #30's weight was listed at 99 pounds with recent weight loss noted. Resident #30's weight was noted on 02/17/23 at 107 pounds. Resident #30 should have two whole milks and prune juice with all meals. The assessment revealed Resident #30 should receive Ready Care 2.0 (high calorie nutritional supplement and was not a physician order), 120 cubic centimeters (cc) and Boost pudding with all meals. Review of Resident #30's meal tickets revealed no evidence the whole milk and or nutritional supplements were listed on the meal ticket. Observation of the breakfast meal on 03/15/23 starting at 7:41 A.M. revealed Cook #802 was observed plating food but not using any resident meals ticket. Cook #802 revealed the tickets were all located in a pile off to the side of where she was plating food. Cook #802 revealed she knows all the residents and was not using the meal tickets. Observation of Resident #30's meal in the dinning room on 03/15/23 at 7:44 A.M. revealed Resident #30 had been served no whole milk and no nutritional supplements. State tested Nursing Assistant (STNA) #870 was observed sitting with and assisting Resident #30 with the meal. STNA #870 confirmed confirmed Resident #30's physician orders revealed she should have received two cartons of whole milk, a sugar free shake, and Boost pudding and did not receive these. Interview with Cook #802 on 03/15/23 at 7:54 A.M. confirmed she did not use Resident #30's meal ticket to plate her food this morning. Cook #802 confirmed nutritional supplements were provided from the kitchen to the staff in the dining room. Cook #82 confirmed the staff should know who should get them. Cook #802 confirmed none of the residents in the dining room currently have their meal tickets in the dining room for staff to be aware of the diet orders, preference and or allergies. Cook #82 confirmed STNA #870 was feeding Resident #30 this morning was new from an agency and would not know what Resident #30 should receive. Interview with Dietary Manager (DM) #18 on 03/15/23 at 8:43 A.M. confirmed she was not aware Cook #802 was not using meal tickets when preparing meals for residents this morning. DM #18 confirmed when matching Resident #30's physician orders to her meal ticket that do not match. DM #18 confirmed there was a lack of communication and verification new orders were current on residents meal tickets. Observation of the lunch meal in the dinning room on 03/15/23 at 11:47 A.M. with DM #18 revealed the stack of meal tickets and was passing them out to the resident's tables in the dining room. Cook #802 was again observed plating food without using the individual meal tickets at the time of plating. Resident #30 was observed to receive her meal on 03/15/23 at 11:59 A.M. Resident #30 received a large styrofoam cup of orange drink. Resident #30 had no whole milk and no nutritional supplements (sugar free shake or Boost pudding). Review of Resident #30's meal ticket confirmed it did not match Resident #30's current physician orders and nutritional interventions for weight loss. Observation and interview with Registered Nurse (RN) #815 on 03/15/23 at 12:04 P.M. confirmed Resident #30's physician orders for meals and supplements does not match her meal ticket. RN #815 confirmed Resident #30 was not provided two cartons of whole milk, Boost pudding, or sugar free shake that was listed on her physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00141049.

Based on observations, medical record reviews, review of dietary meal tickets, and staff interviews, the facility failed to ensure residents received meal trays to accommodate their food allergies, intolerance and food preferences. This affected three (#30, #34, and #37) of four residents reviewed for dietary meals. The facility census was 47. Findings include: 1. Review of Resident #30's medical record revealed an admission to the facility occurred on 02/18/22. Diagnoses included diabetes mellitus, chronic obstructive pulmonary disease, and dysphagia. Review of Resident #30's physician orders dated 01/05/23 revealed an order for four ounces of prune juice with meals. Review of Resident #30's meal tickets dated 03/15/23 revealed no evidence the prune juice was listed on the meal ticket. The top part of the meal ticket stated peanut . with no evidence what this meant. Resident #30's food preference was hard boiled eggs for breakfast. Observation of the breakfast meal on 03/15/23 starting at 7:41 A.M. revealed Cook #802 was observed plating food but not using any resident meals ticket. Cook #802 revealed the tickets were all located in a pile off to the side of where she was plating food. Cook #802 revealed she knows all the residents and was not using the meal tickets. Observation of Resident #30's meal in the dinning room on 03/15/23 at 7:44 A.M. revealed Resident #30 had been served scrambled eggs and had no prune juice. State tested Nursing Assistant (STNA) #870 was observed sitting with and assisting Resident #30 with the meal. STNA #870 confirmed confirmed Resident #30's physician orders revealed she should have received four ounces of prune juice and hard boiled eggs. Interview with Cook #802 on 03/15/23 at 7:54 A.M. confirmed she did not use Resident #30's meal ticket to plate her food this morning. Cook #802 confirmed she was not sure what the peanut . means on Resident #30's meal ticket and stated she though it meant Resident #30 does not like peanuts. Cook #802 confirmed none of the residents in the dining room currently have their meal tickets in the dining room for staff to be aware of the diet orders and or food allergies. Cook #82 confirmed STNA #870 was feeding Resident #30 this morning was new from an agency and would not know what Resident #30 should receive. Interview with Dietary Manager (DM) #18 on 03/15/23 at 8:43 A.M. confirmed she was not aware Cook #802 was not using meal tickets when preparing meals for residents this morning. DM #18 confirmed when matching Resident #30's physician orders to her meal ticket that do not match. DM #30 revealed Resident #30's meal ticket that revealed peanut . means she should get a peanut butter and jelly sandwich if she does not eat. DM #18 confirmed there was a lack of communication and verification new orders were current on resident's meal tickets. Observation of the lunch meal in the dinning room on 03/15/23 at 11:47 A.M. with DM #18 revealed the stack of meal tickets and was passing them out to the resident's tables in the dining room. Cook #802 was again observed plating food without using the individual meal tickets at the time of plating. Resident #30 was observed to receive her meal on 03/15/23 at 11:59 A.M. Resident #30 received a large styrofoam cup of orange drink. Resident #30 had no prune juice. Review of Resident #30's meal ticket confirmed it did not match Resident #30's current physician orders. Observation and interview with Registered Nurse (RN) #815 on 03/15/23 at 12:04 P.M. confirmed Resident #30's physician orders for meals did not match her meal ticket. RN #815 confirmed Resident #30 was not provided four ounces of prune juice that was listed on her physician orders. 2. Review of Resident #34's medical record revealed admission to the facility occurred on 04/20/16 with medical diagnosis including; diabetes, stroke and dysphagia. The records revealed Resident #34 has lactose intolerance and allergy to strawberries. Review of Resident #34's dietary meal tickets for 03/16/23 revealed under special instructions on the breakfast ticket, revealed it lacked information regarding Resident #34 was allergic to strawberries. The tickets for lunch and dinner did state Resident #34 had an allergy to strawberries. 3. Review of Resident #37's medical record revealed admission to the facility 02/10/23 with diagnoses including stroke and traumatic brain injury. The records revealed on 03/15/23, Resident #37 told the facility he could not tolerate white milk. Review of Resident #37's dietary meal tickets dated 03/16/23 revealed no evidence Resident #37 could not tolerate white milk. Interview with Dietary Manager (DM) #810 on 03/15/23 at 8:43 A.M. revealed she has a computerized system that prints tickets for each of the meals. The kitchen staff should be using those tickets to plate residents preferences and ensure food allergies were revealed. DM #810 confirmed she was not notified of Resident #37's white milk intolerance that was revealed yesterday and therefore it was not placed on his meal ticket. DM #810 confirmed Resident #34's allergy to strawberries was never placed on her breakfast meal ticket however it was on the lunch and dinner tickets. DM #18 confirmed there was a lack of communication and verification new orders were current on resident's meal tickets. This deficiency represents non-compliance investigated under Complaint Number OH00141049

Based on observations and staff interview, the facility failed to have a director of food and nutrition services to provide oversight for the sanitation of the kitchen and the serving of physician ordered diets. This affected all 40 residents who reside in the facility. Findings include: Observations from 04/18/22 through 04/21/22 revealed no dietary staff member who was identified as in charge of kitchen. Observations and interviews between 04/19/22 and 04/21/22 revealed the facility failed to store food appropriately; failed to prepare food appropriately; failed to maintain a clean, sanitary kitchen; failed to serve food that was palatable, failed to provide adaptive equipment for meals, and failed to serve meals according to physician orders. Interview on 04/21/22 at approximately 3:00 P.M. with the Administrator revealed the facility has had no Dietary Manager since 02/08/22. Interview with the Registered Dietician (RD) on 04/21/22 at 3:22 P.M. revealed she was aware there was an issue with the kitchen staff not following diet orders and she thought the Administrator was going to send the new cook for training to learn how to run the kitchen.

Based on staff interview and review of facility documents, the facility failed to have an effective quality assurance program to address repeated concerns identified during three consecutive annual surveys. This affected all residents in the facility. The facility census was 40. Findings include: Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) report dated 02/18/22 revealed the facility received a deficiency for food procurement, food storage, food preparation during the annual surveys completed on 04/19/18 and 05/30/19. Interviews and observations between 04/19/22 and 04/21/22 revealed the facility failed to store food appropriately, failed to prepare food appropriately, and failed to maintain a clean, sanitary kitchen. Interview on 04/21/22 at 2:14 P.M. with the Administrator revealed the facility could provide no documentation the Quality and Performance Improvement (QAPI) committee met in 2021 or 2022. Interview on 04/21/22 at approximately 3:00 P.M. with the Administrator revealed the facility had no Dietary Manager since 02/08/22.

Based on staff interview and review of facility documents, the facility failed to ensure a quality assessment and assurance committee met at least quarterly. This affected all residents in the facility. The facility census was 40. Findings include: Review of the facility documents revealed no Quality and Performance Improvement (QAPI) committee sign-in sheets or minutes were available for 2021 and 2022. Interview on 04/21/22 at 2:14 P.M. with the Administrator revealed the facility could provide no documentation the Quality and Performance Improvement (QAPI) committee met in 2021 or 2022.

Based on observation, staff interview, review of dishwasher sanitation logs, and review of the facility policies, the facility failed to store food in a safe manner, failed to maintain a clean and sanitary kitchen area, and failed to prepare and serve food in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 40. Findings include: 1. Observations during tour of the facility kitchen on [DATE] between 6:35 P.M. and 7:15 P.M. revealed the refrigerator had chopped cabbage and diced carrots dated [DATE], unsealed and undated shredded cheddar cheese, unsealed and undated mozzarella cheese, an undated bowl of potato salad, and approximately 20 single-serving green salads uncovered and undated. The freezer had undated and unsealed meatballs, vegetable egg rolls, chicken patties, and biscuits. The dry storage area had opened, undated raisins. The wire rack of the toaster upon which bread was placed before starting the conveyor belt was coated with debris. Crumbs and debris were on the counter around the toaster, there was a dried substance on the steam table, and floating items in the deep fryer. Interview with the Cook #404 on [DATE] at approximately 7:10 P.M. confirmed confirmed the items in the refrigerator should have been dated and sealed, and the cabbage and carrots should have been discarded. Cook #404 also confirmed the dirty toaster, debris on the counter, and dried gravy on the steam table. Cook #404 stated the staff had completed the cleaning for the day and was planning to leave the kitchen when the tour of the kitchen began. Review of the log to monitor the chemical dishwasher temperatures and chlorine concentration on [DATE] at 4:26 P.M. revealed it was dated [DATE] and was blank. Concurrent interview with Dietary Aide #411 confirmed the log was blank. Dietary Aide #411 and Dietary Aide #407 stated they did not know how to test the chlorine concentration of the dishwasher. Observation on [DATE] at 4:40 P.M. revealed a half-gallon of 2% milk dated [DATE] in the snack refrigerator at the nurses' station. Concurrent interview with State tested Nurse Aide (STNA) #426 confirmed the expired milk was in the snack refrigerator. Interview on [DATE] at 5:05 P.M. with the Administrator revealed no dishwasher logs were available for February, March, and [DATE], and confirmed the dish machine logs were not completed in [DATE]. Interview on [DATE] at 1:33 P.M. with the Cook #404 revealed the facility does not use a cleaning schedule. 2. Observation on [DATE] at 11:20 A.M. revealed Cook #404 preparing for the lunch meal service. Cook #404 was observed taking the temperature of the pork tenderloin. He used a dry paper towel to wipe the thermometer and placed the un-sanitized thermometer into the broccoli. Cook #404 wiped the thermometer with the same dry paper towel and placed it in the roasted potatoes. Observation on [DATE] at 11:50 A.M. revealed Cook #404 took the temperature of the pureed pork loin, wiped the thermometer with a dry white paper towel, and placed the thermometer in the pureed broccoli. Interview on [DATE] at 11:53 A.M. with Cook #404 verified there were disinfectant wipes available for cleaning the thermometer between food items but he had not used them. Review of the facility policy titled Preventing Foodborne Illness - Food Handling, revised [DATE], revealed all employees who handle, prepare or serve food will be trained in the practices of safe food handling. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents Review of the undated facility policy titled Food Preparation and Service revealed leftovers will be labeled and dated. Leftovers will not be held longer than 48 hours. Food will be served at acceptable temperatures. 3. Observation on [DATE] at 11:53 A.M. of the kitchen found Cook #404 preparing dinner plates with pork, broccoli, potatoes, and gravy for dining room service with gloved hands. Cook #404 left the kitchen carrying two prepared plates into the dining room, returning at through the closed kitchen door without changing her gloves. At 12:03 P.M. Cook #404 returned to the steam table and began to prep six additional plates for service. At 12:04 P.M. Cook #404 carried two plates to the dining room and returned to the kitchen at 12:06 P.M. holding the door open with his gloved right hand as he spoke with Resident #16. At 12:08 A.M. Cook #404, without changing his gloves, cut two pieces of pork using a knife and fork on a cutting board. Cook #404, used his gloved hands to pick each piece of pork up, placing the pork back into the steam pan on the steam table. Interview with Cook #404 on [DATE] at 1:21 P.M. verified he did not change gloves or wash hands upon returning the kitchen to prepare more plates for service after serving meals in the dining room. Cook #404 verified he touched the door handle and the door to the kitchen when entering and then touched the pork.

Based on resident interview, observation of a meal test tray, and staff interview, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability for 13 (#4, #5, #6, #11, #12, #21, #24, #26, #27 and #33) residents with food complaints. The census was 40. Findings include: Interviews were completed with Resident #4, #5, #6, #11, #12, #21, #24, #26, #27 and Resident #33 at various times on 04/18/22 regarding meals services. All 13 residents had concerns regarding meals being cold, The residents identified this has been an on-going concern for quite a while. Observation on 04/19/22 at 12:37 P.M. revealed the requested test tray was placed on top of the food delivery cart and exited the kitchen. All resident meals were placed inside the delivery cart. Residents trays were delivered by staff on 04/19/22 between 12:39 P.M. and approximately 12:53 P.M. The test tray was removed from cart on 04/19/22 at 12:55 P.M. Test tray temperatures on 04/19/22 at approximately 12:57 P.M. revealed the diced potatoes were 90 degrees Fahrenheit, some pieces were charred and the potatoes were unpalatably cool. Interview on 04/19/22 at approximately 12:58 P.M. with Business Office Manager (BOM) #402 confirmed the temperature reading of the food from the thermometer and confirmed some pieces of the diced potatoes were charred. BOM #402 declined to taste the food.

Based on medical record review, resident interview, and staff interviews, the facility failed complete care conferences and provide the opportunity to participate in care planning meetings to make decisions about care for one (#5) out of 15 residents sampled. The facility census was 40. Findings include: Review of Resident #5's medical record revealed admission to the facility occurred on 02/07/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 01/10/22, revealed Resident #5 was cognitively intact. The medical record revealed the most recent care plan meeting for Resident #5 occurred on 10/29/21. No additional care plan meetings have occurred since 10/29/21. Interview on 04/18/22 at 7:47 P.M., Resident #5 revealed she has no had a care conference in a long time and she would like to discuss therapy options with the facility. Interview on 04/21/22 at 7:43 A.M., the Assistant Director of Nursing (ADON) confirmed there was no evidence the facility has conducted a care plan meeting for Resident #5 since 10/29/21. The ADON confirmed these should be conducted every three months. Interview on 04/21/22 at 9:02 A.M., Licensed Practical Nurse (LPN) #470 confirmed the facility does not currently have a social worker, which is whom should be scheduling care conference meetings for the residents.

Based on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed within 14 days of admission for one (#238) our of 15 residents sampled. The facility census was 40. Findings include: Review of Resident #238's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted on Hospice care due to [CONDITION(S)]. As of 04/21/22 Resident #238 did not have a completed MDS assessment. Interview with Licensed Practical Nurse #430 on 04/21/22 at 9:02 A.M. verified the facility failed to complete a MDS assessment for Resident #238.

Based on medical record review and staff interviews, the facility failed to inform in advance of the risks and benefits of a new treatment order and the option to choose an alternative order of treatment for one (#40) resident out of 15 residents sampled. The facility census was 40. Findings include: Review of Resident #40's medical record identified admission to the facility occurred on 01/25/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 discharged on [DATE]. Review of the admission assessment dated [DATE] revealed Resident #40 was alert and oriented and and independent with decisions. Resident #40 was independent with eating. Review of progress notes on 01/26/22 revealed Resident #40 was upset over his diet order and stated he was not going to be able to tolerate thickened liquids. Review of progress notes on 01/27/22 revealed Resident #40 requested and was denied ice for a dry throat. The notes revealed the dietician assessed Resident #40 on 01/26/22 and clarified the diet order of mechanical soft, nectar thick liquids. Resident #40 was documented in the progress notes as stating Bullshit, ice is the only thing that helps my dry throat. Review of progress notes dated 01/28/22 revealed Resident #40 requested regular water. The notes revealed the resident was informed until therapy changed the diet order they had to go by physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of speech therapy (ST) notes dated 01/28/22 revealed Resident #40 had a swallowing evaluation and a modified [MEDICATION(S)] swallow at the hospital which showed oropharyngeal phase dysphagia. The ST wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on 04/21/22 at 10:19 A.M. confirmed there was no evidence the facility provided Resident #40 the risk and benefits of the diet order and or allowed Resident #40 to choose his treatment.

Based on observation, staff interviews and review of facility policy, the facility failed to provide dining assistance during with meals in a dignified manner when staff stood up while feeding residents. This affected one (Resident #27) of two residents reviewed for dining assistance. The facility census was 40. Findings include: Review of Resident #27's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the resident had low cognitive function. The resident required supervision and set up assistance with eating. Observation on 04/20/22 at 8:09 A.M. revealed State tested Nurse Aide (STNA) #419 standing next to Resident #27 while feeding her bites of oatmeal. Interview at that time with STNA #419 confirmed she was standing over Resident #27 while feeding her. Review of the facility policy titled Assistance With Meals, revised July 2017, revealed residents who cannot feed themselves will be fed with attention to dignity for example: Not standing over residents while assisting them with meals. Interview on 04/21/22 at 11:18 A.M. with the Director of Nursing revealed staff should be seated while providing dining assistance.

Based on medical record reviews, resident interviews, staff interviews, observations, and review of the facility policy, the facility failed to ensure resident food preferences were served during meals. This affected two (#12 and #25) of three residents reviewed for choices. The facility census was 40. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 02/23/22, revealed Resident #12 had intact cognition. Review of the care plan initiated 02/10/22 for Resident #12 revealed he had a potential nutritional problem related to type 2 diabetes mellitus and [CONDITION(S)] requiring hemodialysis. Interventions added on 04/06/22 included double portions at all meals. Review of a progress note dated 04/06/22 revealed Resident #12 requested double portions at all meals. Review of the physician orders for Resident #12 revealed an order dated 04/07/22 for double portions with meals. Observation on 04/20/22 at 12:54 P.M. revealed Resident #12 did not have double portions on his meal tray. Interview at the time of the observation with State tested Nurse Aide (STNA) #419 confirmed Resident #12 received single portions. Review of the meal ticket for Resident #12 revealed no request for double portions. Observation on 04/21/22 at 8:40 A.M. revealed Resident #12 did not have double portions on his meal tray. Interview at the time of the observation with STNA #465 revealed Resident #12 received single portions of menu items on his breakfast tray. Interview on 04/21/22 at 10:06 A.M., Assistant Director of Nursing (ADON) #414 confirmed Resident #12 had a diet order for double portions. Further interview and observation of the meal ticket for Resident #12 confirmed his meal ticket did not include double portions. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 03/22/22, revealed Resident #25 had intact cognition. Observation on 04/19/22 at 9:07 A.M. revealed Resident #25 had biscuits and gravy on her breakfast tray. Interview at that time with Resident #25 revealed she did not like biscuits and gravy, and had received biscuits and gravy on her breakfast tray. Further observation revealed the meal ticket identified Resident #25 disliked biscuits and gravy on her tray. Interview on 04/19/22 at 9:32 A.M. with STNA #437 confirmed Resident #25 received biscuits and gravy on her breakfast tray. STNA #437 confirmed the meal ticket stated the resident had a dislike of biscuits and gravy. Review of the facility policy titled Resident Food Preferences, revised July 2017, revealed resident food preferences would be identified and included in the care plan.

Based on observation, record review, staff interview and policy review, the facility failed to ensure fall interventions were implemented as ordered for one resident identified at risk for falls. This affected one (#28) of two residents reviewed for falls with major injury of a total of 18 residents identified by the facility with falls. This resulted in actual harm for Resident #28 who fell and sustained a fractured left hip, and had a change of status as the resident required a Hoyer (mechanical) lift transfer as a result of the fracture. The facility census was 45. Findings include: Review of Resident #28's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems with severely impaired cognition. The assessment noted behaviors of inattention and altered level of consciousness. The resident's fall history was unable to be assessed upon admission, however, the assessment indicated the resident had no related fractures related to falls in the past six months prior to admission. Resident #28 required total dependence of staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. He was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on or off the toilet and for surface to surface transfers. The resident required the use of a wheelchair for mobility. Review of Resident #28's Fall Risk Evaluation forms revealed the resident was assessed to be at high risk for falls upon admission and all subsequent fall assessments completed on 10/04/17, 10/08/17, 11/09/17, 11/15/17, 11/24/17, 01/21/18 and 03/07/18. Review of Resident #28's care plan for at risk for falls, initiated on 10/09/17, included interventions to anticipate and meet the resident's needs, ensure the resident' call light was within reach and encourage the resident to use it for assistance as needed, chair alarm when out of bed and provide diversional activities as needed. The resident also had a care plan initiated on 10/09/17 to address getting up out of the chair by leaning forward until he drops on the floor and trying to get up and walk at times. Interventions included to engage in activities, notify therapy of falls, offer to toilet as needed and place in common area to supervise when restless. The resident also had an additional care plan initiated on 10/09/17 for being at risk for falls due to dementia and not knowing safety issues. Interventions included a chair alarm, a recliner chair and the assist of two staff with transfers and bed mobility. Review of nurses' notes revealed Resident #28 experienced a fall on 11/15/17 at 11:00 A.M. and was sent to the hospital for evaluation. The note indicated the resident sustained [REDACTED]. The area was cleansed with normal saline and left open to dry after triple antibiotic ointment was applied. The nurses' note also revealed a new physician order [REDACTED].#28's wheelchair for safety due to impulsive tendency of attempting to ambulate without assistance. The resident returned from the hospital at 4:00 P.M. on 11/15/17 with no new orders. Review of physician orders [REDACTED].#28's non-releasing seatbelt every two hours due to resident being unable to release. Review of a nurse's note dated 01/21/18 at 10:45 A.M. revealed the nurse was called to Resident #28's room by the aide. When the nurse entered the room, the resident was lying on the floor by his roommate's bed. There were a few drops of blood noticed on the floor from a small abrasion to his forehead that measured 2.0 centimeters (cm) in length by 0.3 cm in width by less than 0.2 cm in depth. The nurse cleansed the area with normal saline then applied triple antibiotic ointment and a Band-Aid. The resident also sustained a laceration to the back of his head that measured 1.5 cm in length by less than 0.2 cm in width by less than 0.2 cm in depth. The director of nursing (DON) and the on-call physician was notified of Resident #28's fall with no new orders received. The nurse documented the resident was in his wheelchair before the fall and that the seatbelt was not secured. The aide was educated regarding use of the seatbelt. The nurse also documented range of motion was done on all extremities and the resident was able to move all extremities. The same nurse's note then indicated the on-call physician was called back because Resident #28 was observed guarding his left leg. An order was received to obtain an x-ray of the resident's left hip and pelvis. The resident was lifted off of the floor by two staff members and put back into his chair. Review of the radiology reports from 01/21/18 indicated Resident #28 sustained an acute non-displaced [MEDICAL CONDITION] femoral neck. There was no underlying pathological lesion seen. Follow-up x-rays of the left hip were obtained on 01/30/18, 02/20/18 and on 03/14/18 which all indicated there was no change from the original fracture identified on 01/21/18. The left [MEDICAL CONDITION] continued to have no significant displacement or dislocation. Review of Resident #28's primary care physician's progress note dated 01/30/18 indicated the left [MEDICAL CONDITION] was being treated conservatively by the orthopedic surgeon who would continue to follow. Observations of Resident #28 on 04/17/18 at 9:30 A.M., revealed him sitting in a reclining wheelchair with his seatbelt in place at the nurses' station watching the activity in the hallway. The resident smiled and waived at the surveyor when approached. The resident appeared to be comfortable and displayed no signs of pain. On 04/18/18 at 10:15 A.M., Resident #28 was observed sitting in his wheelchair with his seatbelt on and fastened in the activity room with the Activity Director. He was observed holding on to a piece of fabric and listening to the music that was playing. Interview with the DON on 04/19/18 at 2:10 P.M. regarding Resident #28's fall that resulted in a left [MEDICAL CONDITION] revealed State tested Nurse Aide (STNA) #200 was being trained by another STNA the morning of the incident, 01/21/18. She stated Resident #28 was on contact precautions for a stool infection so when he self propelled himself out into the hallway, STNA #200 pushed him back into his room and then left to assist another resident in the same hall. STNA #200 then heard a loud noise and ran back into Resident #28's room and found him lying on the floor. The DON indicated Resident #28 had a physician order [REDACTED].#28's seatbelt was not fastened when he fell from his chair and sustained a left [MEDICAL CONDITION]. She also indicated there were no plans for surgical intervention as he was not a candidate for surgery and because the fracture continued to be non-displaced. The DON stated Resident #28 continued to be dependent on staff but now required the use of a Hoyer (mechanical) lift for transfers due to his non-weight bearing status. Further interview with the DON revealed STNA #200 was educated immediately at the time of the incident but never returned to work so the DON was unable to issue a discipline. The DON provided a sign-in sheet for an all staff in-service that was held on 01/19/18, prior to Resident #28's fall with fracture, which addressed the use of self-release seatbelts. She was unable to provide additional corrective action for the 01/21/18 incident involving Resident #28. Review of the facility's policy entitled Falls and Fall Risk, Managing revised (MONTH) 2007, revealed under the heading Prioritizing Approaches to Managing Falls and Fall Risk that in conjunction with the attending physician, staff will identify and implement interventions to try to minimize serious consequences of falling.