Every finding on record at Country Club Center V, Inc

Based on observation, interview, and record review, the facility failed to ensure medications, the medication cart, and the treatment cart were secured properly. This had the potential to affect 10 residents (Residents #11, #15, #20, #22, #25, #27, #36, #37, #41, and #34) who were identified as cognitively impaired and independently mobile. The facility census was 46.Findings include:Observation on 04/20/26 at 10:41 A.M. revealed the medication cart and treatment cart located near the main nurses' station were unlocked and unattended.Interview on 04/20/26 at 10:42 A.M. with Licensed Practical Nurse (LPN) #115 confirmed the medication and treatment carts were unlocked and unattended.Observation on 04/21/26 at 6:12 A.M. of the medication cart in the 200 hallway revealed a bottle of Gabapentin (anticonvulsant used to treat partial seizures and neuropathic pain) 300 mg/6 mL solution sitting on top of the cart unattended. At this time, both the medication and treatment carts were locked. However, the Gabapentin remained unsecured on top of the cart through 6:19 A.M.Observation at 6:19 A.M., Registered Nurse (RN) #142 emerged from a resident's room and approached the medication cart. He unlocked the treatment cart, which remained unlocked. RN #142 prepared a resident's medication using the Gabapentin solution and entered the resident's room at 6:20 A.M. During this period, the treatment cart remained unlocked and unattended from 6:20 A.M. through 6:25 A.M.Interview on 04/21/26 at 6:25 A.M. with RN #142 confirmed the gabapentin had been left on top of the medication cart while he was assisting another resident across the hallway with a treatment. He acknowledged the medication remained unattended and that the treatment cart was left unlocked while he was in the resident's room.Interview on 04/21/26 at 9:35 A.M. with the Director of Nursing (DON) confirmed medications must be stored securely in medication carts, and that medication and treatment carts must remain locked when staff are not preparing medications and must not be left unlocked when staff are not present.Review of the facility's Medication Storage Policy dated 07/01/21 revealed that medication rooms, carts, and medication supplies are to remain locked when not attended by authorized personnel.

Based on record review and interview the facility failed to report alleged abuse concerns to the state agency timely. This affected one (Resident #8) out of one residents review for abuse. The facility census was 46. Findings include:Review of the medical record for Resident #8 revealed an admission date of 08/25/24 with diagnoses including Type II Diabetes Mellitus, need for assistance with personal care, muscle weakness, chronic pain syndrome, legal blindness and low back pain.Review of care plan dated 01/07/25 revealed Resident #8 required assistance from staff to meet activities of daily living, interventions include assist with hair, oral, transfers, toileting and bed mobility as needed. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 is cognitively intact, exhibits no physical or verbal behaviors, and requires substantial/maximal assistance with toileting.Review of a hospice note dated 04/14/26 revealed the resident reported a facility staff person was mean to me last night. She was helping me to the toilet and she was being rough. I started screaming and telling her my leg hurt, but she didn't listen and kept doing it anyway. I tried to push her away from me, and she brought her hand to my face and made contact. She didn't hit my face, but I think she wanted to. She does not like me and there is nothing I can do about it. Registered Nurse (RN) #126 was made aware of this concern by the hospice nurse and reported, There is a complaint with one of our third shift aides. She was suspended for an investigation. Staff reported no matter the outcome, this aide will not be permitted to care for the resident. We don't know what will happen next, but we are investigating.Interview on 04/21/26 at 10:32 A.M. with Resident #8 revealed that on either 04/10/26 or 04/11/26 an incident occurred with a night shift aide. Two aides were attempting to change her brief and rolled her over; the resident reported one of the aides were pushing too hard and hurting her left leg. The aide did not stop until the resident began yelling, and at one point the aides hand made its way up to the resident face. The resident stated that a male nurse entered the room and made the aide stop turning her. The aide then left the room immediately, and the resident reported she had not seen that aide or the other staff nurse since. Resident #8 reported the hospice nurse was made aware of her concerns, the resident could not provide any identifying details or names of the alleged abuser. Interview on 04/21/26 at 10:51 A.M. with Licensed Practical Nurse (LPN) #129 revealed she was unaware of Resident #8's report of abuse; however, she stated that if she had been aware, she would have immediately notified the Director of Nursing (DON) or Administrator.An attempted interview was made on 04/21/26 at 11:03 A.M. with Hospice Nurse #200.Interview on 04/21/26 at 11:22 A.M. with RN #126 revealed she had been made aware of the abuse allegation by Hospice Nurse #200. She stated that when she learned of the concern on 04/14/26, she reported it to both the Administrator and Assistant Director of Nursing (ADON) #144.Interview on 04/21/26 at 11:25 A.M. with the Administrator and DON revealed that after reviewing the hospice documentation, they confirmed neither hospice nurse #200 nor RN #126 notified them of the reported abuse concerns. The DON stated she was responsible for reviewing hospice records in a timely manner and acknowledged she had not seen the documented report of abuse.Interview on 04/21/26 at 11:37 A.M, with Resident #8 and the DON revealed an abuse interview was initiated at that time.Interview on 04/21/26 at 12:36 P.M. with LPN #130 revealed she was also unaware of Resident #8's report of abuse, and stated any such report would be relayed immediately to the DON or Administrator.Review of SRI case #273583 created 04/21/26 at 11:35 A.M. involving resident #8 revealed hospice note claiming a resident was mean to her. Review of the facility's abuse policy dated 03/01/26 revealed staff must report all incidents and allegations in a timely manner to the Administrator or designee. The policy further states that if an allegation involves abuse or serious bodily injury, it must be reported to the state no later than two hours after the allegation is made.

Based on medical record review, staff interview, and facility policy review, the facility failed to monitor weights for a resident that experienced a significant weight loss. This affected one (Resident #3) of one resident reviewed for nutrition. The census was 46.Findings Include:Resident #3 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure with hypoxia, acute respiratory failure, dependence on respirator, neuromuscular dysfunction of bladder, hypertension, Type II Diabetes, hyperlipidemia, chronic kidney disease, colostomy status, cerebral infarction, tracheostomy status, morbid obesity, anoxic brain damage, obstructive and reflux uropathy, and muscle weakness. Review of his minimum data set (MDS) assessment, dated 03/13/26, revealed he had a severe cognitive impairment.Review of Resident #3's weights, dated 03/10/26 to 03/29/26, revealed the following weights documented as being completed:03/10/26 (289.1 pounds), 03/27/26 (262 pounds), and 03/29/26 (262.7 pounds). The weights taken represented a 9.4 percent decline from 03/10/26 to 03/27/26. Review of Resident #3's physician orders, dated 03/15/26 to 04/19/26, revealed the facility was to complete weekly weights for four weeks. The order was dated as being originally created on 03/09/26, but not started until 03/15/26. Review of Resident #3's care plan, dated 03/09/26, revealed he was at risk for malnutrition. The goals for this care plan were to have no significant weight changes noted, which included five percent or more in 30 days. Interview with Director of Nursing (DON) on 04/21/26 at 11:28 A.M. confirmed she can't explain why Resident #3 did not have any weights from 03/10/26 to 03/27/26. She confirmed there should have been at least one other weight between 03/10/26 and 03/27/26, and there was a significant weight loss when the second weight was obtained. Interview with Dietitian #201 on 04/21/2026 at 12:27 P.M. confirmed when they (her and another contracted dietary staff) visited the facility on 03/18/26, they did not have any recommendations because there were no weight changes. When asked if it was her preference to have weights taken once a week for the first four weeks after a resident admission, she stated she would have the facility follow their policy and/or dietary orders when it comes to obtaining weights. Review of facility Height and Weight policy, dated 09/26/16, revealed a height and weight will be obtained from each resident upon admission to the facility and entered into EMR under the weights and vitals tab. Hospital weights will not be used. Baseline height and weight will be updated in EMR yearly prior to annual MDS. All newly admitted residents will be weighed weekly and longer if requested per dietitian, physician or per nursing recommendation. Weights will be recorded in EMR and will be made available for dietitian visits.

Based on medical record review and staff interview, the facility failed to properly address and plan for resident's diagnosis of post traumatic stress disorder (PTSD) by identifying specific triggers and addressing underlying causes. This affected one (Resident #17) of one resident reviewed for PTSD. The census was 46.Findings Include:Resident #17 was admitted to the facility on [DATE]. Her diagnoses were acute and chronic respiratory failure, congestive heart failure, muscle weakness, dependence on respirator, mild cognitive impairment, venous insufficiency, chronic obstructive pulmonary disease, peritoneal abscess, borderline personality disorder, mood disorder, hypokalemia, mild protein calorie malnutrition, morbid obesity, tracheostomy status, anxiety disorder, depression, insomnia, Type II Diabetes, and hypertension. Review of her minimum data set (MDS) assessment, dated 01/29/26, revealed she was cognitively intact. Review of Resident #17's Life Event Checklist (LEC)-5 document, dated 10/10/24, revealed the following difficult or stressful events that have occurred in her life: life threatening illness or injury and sudden accidental death. There was nothing else listed on this form to identify specifically what the events were that caused difficulty and stress in Resident #17 life. Review of Resident #17 care plan, dated 09/17/24, revealed resident had PTSD and/or experienced a traumatic event(s)in the past related to life-threatening illness or injury, or sudden accidental death. Review of her interventions revealed the following: observe for indications that resident is experiencing a triggered event, which included increased anxiety, crying, withdrawn, not eating, and anger and offer psychological services as needed. There was nothing listed within the care plan to identify what the events were that caused the traumatic experience so others were aware of what incidents/actions could cause harm to her mental health. Review of Resident #17's behaviors logs, dated 02/01/26 to 04/21/26, revealed there was only one behavior identified during that period, which was verbal behaviors directed to others. The behavior logs were not personalized to Resident #17 behaviors. Interview with Director of Nursing (DON) on 04/21/26 at 9:12 A.M. confirmed the behavior log is general and not specific to Resident #17. She confirmed they could not find any documentation to identify what the specific incidents were that caused the trauma in her life, nor a plan to help address potential triggers from the incident(s) that occurred in her past.

Based on observations, staff interview, resident interview, record review, review of facility call light audits, and policy review, the facility failed to ensure call lights were answered timely for two residents (#14 and #45) out of three residents reviewed for timely call light response time. The facility census was 44. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 09/29/24. Diagnoses included respiratory failure with hypoxia, vent dependence, dysphagia, muscle weakness and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and required substantial maximal assistance for toileting. Resident #14 was noted as always incontinent of bowel and bladder. Review of the plan of care dated 05/05/24 revealed Resident #14 was incontinent of bowel and bladder with interventions to provide privacy with incontinence care, observe skin after each episode, assist with incontinence care and assist the resident with briefs, pads, and pull ups. Observation on 08/28/25 at 11:35 A.M. revealed the call light for Resident #14 had been activated at 11:17 A.M. and had been going off for 18 minutes. At 11:41 A.M. The call light was deactivated by staff and Registered Nurse (RN) #172 informed staff over the radio that Resident #14 requested incontinence care. Interview on 08/28/25 at 11:45 A.M. with Resident #14 revealed she had put on her call light for incontinence care. She revealed she had been waiting a while and had not yet received any care. Continuous observation on 08/28/25 from 11:45 A.M. to 12:05 P.M. revealed incontinence care was not provided, but staff entered the room at 11:48 A.M. to provide Resident #14 her lunch tray. At 12:00 P.M., Assistant Director of Nursing (ADON) #119 entered the residents room and stated Oh, you have your tray. She then spoke with RN #172. They asked additional staff who the aides working were and requested the location of Certified Nursing Assistant (CNA) #153. The ADON went to find CNA #153 and they arrived at Resident #14's room. Interview on 08/28/25 at 12:05 P.M. with CNA #153 revealed she was unaware Resident #14 had requested incontinence care. She revealed she did not hear the radio or call light. She revealed she was in the kitchen assisting with passing trays. Interview on 08/28/25 at 12:06 P.M. with ADON #119 revealed she had been in the residents room previously and did not provide the care. She acknowledged Resident #14 had waited 49 minutes which she stated was too long to wait for incontinence care. She reported she did not have any expectation of how quickly call lights should be answered and stated when staff are available. Interview on 08/28/25 at 12:08 P.M. with Director of Nursing (DON) and Administrator revealed they had no rule of thumb for staff to respond to call lights. The DON revealed the facility policy was vague and agreed 49 minutes was too long for call lights to be answered for incontinence care. She also acknowledged call lights should not be turned off or deactivated until the actual care was being provided. Interview on 08/28/25 at 12:11 P.M. with RN #172 revealed all staff were responsible to answer call lights and confirmed 49 minutes was way too long to wait. 2. Review of the medical record for Resident #45 revealed an admission date of 04/01/25. Diagnoses included acute chronic respiratory failure, vent dependence, muscle weakness, malnutrition and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition and revealed the resident was dependent upon staff for eating. Observation on 08/28/25 at 11:35 A.M. revealed the call light for Resident #45 had been activated at 11:09 A.M. and had been going off for 26 minutes. At 11:41 A.M. The call light was deactivated by staff. Interview on 08/28/25 at 11:49 A.M. with Resident #45 revealed she had put on her call light to see the Respiratory Therapist. She stated it took a while for the nurse to come in and revealed she was not sure she when care was going to come. She stated she wanted the Respiratory Therapy for trach care. Continuous observation on 08/28/25 from 11:41 A.M. to 11:54 A.M. revealed respiratory therapy staff entered the room at 11:54 A.M. Interview on 08/28/25 at 12:09 P.M. with Respiratory Therapy #205 revealed he met with Resident #45 and she had requested ice chips. Interview on 08/28/25 at 12:08 P.M. with Director of Nursing and Administrator revealed they had no rule of thumb for staff to respond to call lights. The DON revealed the facility policy was vague and agreed 45 minutes was too long to wait for ice chips. Interview on 08/28/25 at 12:17 P.M. with Certified Nursing Assistant (CNA) #175 revealed the expectation was for call lights to be answered within seven minutes. Review of call lights audits from 06/02/25 to 08/19/25 revealed 14 of 36 took over 10 minutes with the longest call light taking 20 minutes. Review of facility policy titled, Call Lights dated 03/12/16, revealed staff shall strive to answer call lights and meet resident needs as promptly as possible. This deficiency represents non-compliance investigated under Complaint Number 1331479, 2564567 and 2569231.

Based on record review and staff interview, the facility failed to ensure Resident #51 was provided choice and self-determination regarding discharge planning. This affected one Resident (#51) of three reviewed for resident rights. The facility census was 44. Findings include:Review of the medical record for Resident #51 revealed an admission date of 05/14/25. Diagnoses included cerebral infarction, non-traumatic intracerebral hemorrhage, aphasia, dysphagia, and memory deficit. Review of the Power of Attorney (POA) documents dated 2017 revealed Resident #51 had named her three daughters as her healthcare POA's. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition and required dependence upon staff and maximum assistance for mobility. Review of Resident #51's physician letter dated 07/07/25 revealed the resident had cognitive impairment and required assistance with decision making. The letter also mentioned possible financial abuse. Review of progress notes dated 07/07/25 revealed Resident #51 had worked with an elder care attorney and was trying to change POA paperwork. The progress note dated 07/08/25 stated the resident requested facility representation anytime her daughter was in the facility. The progress note dated 07/09/25 revealed the facility informed the residents daughter that the resident requested a facility representative when she was present in the facility. Resident #51's daughter explained the resident was angry that they stopped the resident's sister from accessing the resident's money. Resident #51's daughter stated they were considering moving her to Tennessee to get her away from her sister and closer to her two daughters. Facility staff explained the facility would follow POA paperwork and the residents wishes. Review of the note dated 07/15/25 revealed Resident #51 stated I don't want those two here. Staff asked who she had referred to and she stated two of her daughters. The resident also stated, they did this to her, (implying causing her sisters suicide attempt). Resident #51 requested a court appointed guardian. Staff then called the resident's daughter to let her know what was said. The note dated 07/16/25 revealed Resident #51's daughter called the facility and requested a referral be sent to Capri Gardens, as she worked there. The note dated 07/25/25 revealed Resident #51 transferred to Capri Gardens and the facility was not to tell the resident's sister where the resident went. Interviews on 08/27/25 from 11:00 A.M. to 4:20 P.M. with the Director of Nursing (DON) and Social Services (SS) #150 confirmed the facility had no documented evidence that Resident #51 had a say in her discharge plan and did not have evidence Resident #51 was agreeable to her discharge plan. They acknowledged a concern related to the documentation of Resident #51 wanting a different decision maker and after each attempt, the resident's daughter(s) put barriers in place. SS #150 confirmed the timing of the letter was suspicious and reported it was odd that it included information about the financial concerns between family members and no cognitive assessment was completed. SS #150 also acknowledged odd timing of family requesting resident transfer the day after she requested a court appointed guardian. She reported no conversations with Resident #51 were documented regarding if she took part in the discharge process or if she was agreeable. This deficiency represents non-compliance investigated under Master Complaint Number 2575389.

Based on record review and interview, the facility failed to ensure staff implemented physician orders and monitored vital signs as required. This affected one resident (Resident #24) out of three records reviewed for following physician orders. The facility census was 44.Findings include:Review of the medical record for Resident #24 revealed an admission date of 10/29/24 with diagnoses including peripheral vascular disease, edema, muscle weakness, depression, paroxysmal atrial fibrillation (a fib), anxiety and essential hypertension.Review of the care plan dated 11/11/24 revealed Resident #24 had the potential for symptoms of cardiac impairment related to a fib and hypertension. Interventions included administering medication as ordered, following up with the cardiologist as ordered and observe for side effects.Review of a physician order dated 12/20/24 revealed orders for Amiodarone hydrochloride (HCl) oral tablet 200 milligrams (mg) to be given by mouth once daily for a fib.Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] showed Resident #24 was severely cognitively impaired.Review of a progress note dated 08/09/25 showed the nurse spoke with the on-call physician regarding Resident #24's amiodarone. The physician gave parameters to hold the medication if the residents heart rate was less than 60 beats per minute (bpm) and to check blood pressure and heart rate twice daily for 14 days.Review of physician orders dated 08/10/25 revealed orders for blood pressure checks twice daily for 14 days.Review of a progress note dated 08/13/25 showed a new order for Amiodarone 100 mg by mouth daily with instructions to hold if heart rate was less than 50 beats per minute and to notify cardiology if the medication was held.Review of a physician order dated 08/14/25 showed Amiodarone HCL oral tablet 100 mg to be given by mouth once daily for paroxysmal atrial fibrillation with instructions to hold if heart rate was less than 50 beats per minute.Review of the medication administration record (MAR) and treatment administration records (TAR) from 08/10/25 through 08/24/25 showed the residents blood pressure and heart rate vital signs were not monitored twice daily as ordered.Review of the blood pressure summary from 08/10/25 through 08/28/25 showed the residents blood pressure was only monitored once daily.Review of the pulse summary from 08/10/25 through 08/28/25 showed the residents heart rate was only monitored once daily.Review of the MAR from 08/01/25 through 08/31/25 showed Amiodarone HCL oral tablet 100 mg was given by mouth once daily for a fib with instructions to hold the medication if the heart rate was less than 50 bpm and to notify the cardiologist if the medication was held. On 08/20/25 the resident's heart rate was documented at 49 bpm and on 08/23/25 it was 45 bpm. The medication was documented as held on both dates.Review of progress notes dated 08/20/25 and 08/23/25 showed no documentation the cardiologist was notified of the low heart rates requiring the medication to be held per the physician orders.Interview on 08/27/25 at 2:42 P.M. with the Director of Nursing (DON) confirmed the medical record did not contain evidence the physician was notified that the Amiodarone was held on 08/20/25 and 08/23/25. The record also did not contain blood pressure and heart rate measurements as ordered from 08/10/25 through 08/24/25.Interview on 08/27/25 at 3:53 P.M. with Licensed Practical Nurse (LPN) #139 confirmed the medical record did not show the cardiologist was notified that Resident #24's Amiodarone was held on 08/20/25 and 08/23/25. LPN #139 confirmed she received the order on 08/10/25 for staff to check blood pressure twice daily for 14 days. Upon further review of the record she identified that under order type for Amiodarone she selected other orders no documentation required which resulted in the entry not appearing on the MAR or TAR. LPN #139 confirmed vital signs were not completed.

Based on record review, observations, staff interviews, review of the menu/meal spreadsheets, and review of facility policy, the facility failed to ensure residents received a nourishing meal per the facility menu and spreadsheets and failed to follow meal tickets for resident's choice. This affected two residents (#5 and #12) of three reviewed for nutrition. The facility identified two residents (#12 and #45) as receiving puree diets and seven residents (#4, #8, #9, #14, #19, #25, and #35) as receiving mechanical soft diets. The facility census was 44. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 01/13/21. Diagnoses included hemiplegia and hemiparesis, vascular dementia, senile degeneration of the brain, mood disorder, muscle weakness and heart disease. Review of the diet order dated 02/27/25 revealed orders for Resident #5 to receive a regular diet with mechanical texture. Review of Resident #5's meal ticket dated 08/26/25 revealed the resident should receive mechanical (MM5) glazed ham, green beans, rice pudding and au gratin potatoes and a wheat dinner roll. Review of the menu/spreadsheet for the meal on 08/26/25 revealed the mechanical diet included mechanical glazed ham, au gratin potatoes, brussels sprouts with bacon, a wheat dinner roll and a berry truffle, but the dessert was substituted for rice pudding. Observation on 08/26/25 at 11:19 A.M. revealed [NAME] #145 took food temperatures for all food items to be served at lunch. No green beans were observed to be made. Observation and interview on 08/26/25 at 11:47 A.M. with Certified Nursing Assistant (CNA) #165 revealed she brought Resident #5 her meal tray. The resident received brussel sprouts on her tray. The CNA confirmed green beans were not provided on the tray and she was unsure why. The CNA confirmed the ticket stated green beans and had no mention of brussel sprouts. Interview on 08/26/25 at 11:47 A.M. with Kitchen Manager (KM) #174 confirmed green beans were not made according to the menu/spreadsheet. The KM confirmed she did not know why and stated, I am not the cook. 2. Review of the medical record for Resident #12 revealed an admission date of 07/17/23. Diagnoses included Alzheimer's disease, dementia without behaviors and dysphagia. Review of the diet order dated 07/18/23 revealed orders for Resident #12 to receive a regular diet with puree texture. Review of Resident #12's meal ticket dated 08/26/25 revealed the resident should receive puree glazed ham, puree brussels sprouts, puree rice pudding, puree au gratin potatoes and puree bread. Review of the menu/spreadsheet for the meal on 08/26/25 revealed the puree diet meal included puree glazed ham, puree brussels sprouts, puree au gratin potatoes, puree bread and puree berry truffle, but the dessert was substituted for rice pudding. Observation on 08/26/25 at 11:19 A.M. revealed [NAME] #145 took food temperatures for all food items to be served at lunch. The only puree items observed were pureed ham and pureed brussel sprouts with bacon. No pureed au gratin potatoes, pureed rice pudding or pureed bread was made. Observation on 08/26/25 at 12:00 P.M. with Resident #12 revealed she only received pureed meat and pureed brussel sprouts. Resident #12 did not receive any puree au gratin potatoes, pureed rice pudding or pureed bread.Observation and interview on 08/26/25 at 12:02 P.M. with Kitchen Manager #174 confirmed Resident #12 only received pureed meat and pureed brussel sprouts and the resident did not receive any puree au gratin potatoes, pureed rice pudding or pureed bread. The KM stated she was waiting on the blender to dry before making the puree au gratin potatoes. The KM reported she was unsure why the items were not provided at time of service. After surveyor intervention, KM began making puree au gratin potatoes.Interview on 08/28/25 at 8:40 A.M. with Diet Tech #200 revealed residents should be served all items marked on the meal ticket. Review of facility policy titled, Menu and Preferences dated 12/17/24, revealed a menu shall be provided for resident meals and shall meet resident's nutritional needs. Menus shall be served as written unless changed for preference or unavailability.

Based on observation, staff interview, review of the facility menu and spreadsheet, and review of facility policy, the facility failed to ensure food was in a form to meet individual needs of the residents. This affected one resident (#12) of three reviewed for nutrition. The facility identified two residents (#12 and #45) who received a puree diet. The facility census was 44. Findings include: Review of the medical record for Resident #12 revealed an admission date of 07/17/23. Diagnoses included Alzheimer's disease, dementia without behaviors and dysphagia.Review of the diet order dated 07/18/23 revealed an order for Resident #12 to receive a regular diet with puree texture.Review of the meal spreadsheet dated 08/26/25 revealed the regular texture meal was to receive brussels sprouts with bacon and the puree meal was to receive puree glazed ham, puree brussels sprouts, and puree au gratin potatoes. There was no mention that bacon was to be included within the puree vegetable on the nutrition spread sheet. Observation on 08/26/25 at 11:15 A.M. revealed [NAME] #145 scooped several servings of brussels sprouts into a metal container. The contents of the container were dumped into the blender without scraping the sides. Brussels sprout leaves and pieces of bacon were left in the metal container. After the food was blended, it was scooped back into the metal container with the full brussels sprout leaves and chunks of bacon bits. The large unpureed pieces were visible in the container. Interview on 08/26/25 at 11:47 A.M. with Kitchen Manager (KM) #174 confirmed the brussels sprouts had chunks of full leaves and bacon on the container. The Kitchen Manager informed [NAME] #145 who started to remake them. Observation and interview on 08/26/25 at 12:11 P.M. with the Kitchen Manager (KM) #174 confirmed puree food should be a smooth consistency without any chunks. A plate of puree food was made and observed with brussels sprouts with bacon and a serving of ham that was chunky in consistency. The KM confirmed the ham was a chunky consistency (similar to ham salad) and bacon bits could visibly be picked out of the brussels sprouts. She confirmed both were not the proper consistency. The KM had also just made puree au gratin potatoes and was scooping the mixture into a metal container. Several chunks were observed on the sides of the blender and were scooped out to be served. The KM confirmed it was not a smooth consistency and placed the mixture back in the blender to continue mixing after surveyor intervention. Interview on 08/28/25 at 8:40 A.M. with Diet Tech #200 revealed puree food should be a smooth consistency without chunks and should hold a shape. She reported the bacon could not be pureed as it would not break down in the blender and would remain chunky. Review of facility policy titled, Puree Food Production Procedure dated 12/11/14, revealed puree food shall be processed until they were a pudding like consistency.

Based on observation, record review, and interview, the facility failed to ensure proper infection control policies and procedures were maintained during resident personal care. This affected one (Resident #31) out of three residents reviewed for incontinence care. The facility census was 44.Findings include:Review of the medical record for Resident #31 revealed an admission date of 08/16/21 with diagnoses including constipation, neuromuscular dysfunction of the bladder, retention of urine, chronic pain syndrome, chronic obstructive pulmonary disease and age-related osteoporosis.Review of the care plan dated 10/27/24 revealed Resident #31 was frequently to totally incontinent of bowel and bladder related to impaired mobility, with diagnoses of neurogenic bladder and urinary retention. Interventions included to administer medication, apply barrier cream, assist the resident with pads/briefs/pull-ups, assist with toileting as needed and requested and provide privacy during incontinence care.Review of the Minimum Data Set (MDS) 3.0 assessment completed on 07/10/25 revealed Resident #31 was cognitively intact, had no impairment of upper and lower extremities, was dependent on staff for toileting needs, and required substantial to maximal assistance with rolling left and right in bed. Additionally, the resident was frequently incontinent of bowel and bladder.Review of the bowel and bladder evaluation dated 08/19/25 revealed the resident was incontinent of stool daily, was immobile or required two-person assistance with toileting, was forgetful but followed commands, was sometimes aware of the need to toilet and had functional type incontinence.Observation of incontinence care on 08/26/25 from 11:31 A.M. to 11:53 A.M. involving Resident #31 and Certified Nurse Assistant (CNA) #144 revealed that hand hygiene was performed prior to entering the room. Upon approach, the aide introduced herself, donned gloves, and removed the resident's blanket, revealing a soiled brief with noticeable urine and bowel movement odor. The aide began wiping the resident's front area multiple times, each wipe visibly soiled, discarding used wipes into the bedside trash can. After removing the soiled gloves, she reached into her pocket for a walkie-talkie, bringing it to her mouth to request additional supplies. When the supplies arrived, she received them from another staff member, placed them on the bed, and donned a new pair of gloves from her pocket without performing hand hygiene. She placed a clean pad and depends under the resident and continued cleaning, noting the need for additional wipes to reach the feces between the resident's crevices. Bowel movement was again visible on the aide's gloves while assisting the resident in repositioning from side to side. After completing care to the resident's backside, the aide moved back to the front peri-area without changing gloves or performing hand hygiene, and cleaned visible bowel movement from the front area. Once care was completed, all soiled wipes and gloves were discarded, the clean brief was secured, and the resident was covered with personal blankets. The aide then washed her hands with soap and water in the restroom. Hand sanitizer was visibly available in the resident's room during the observation and at the exit.Interview on 08/26/25 at 11:55 A.M. with CNA #144 confirmed hand hygiene should have been performed after doffing soiled gloves and before donning new ones, which was not completed during Resident #31's incontinence care.Interview on 08/27/25 at 2:42 P.M. with the Director of Nursing (DON) confirmed hand hygiene should be conducted after taking off soiled gloves and/or prior to putting on clean gloves.Review of the undated incontinence care policy revealed residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections.Review of the undated hand hygiene policy revealed employees shall wash their hands after handling potentially contaminated objects and after removing gloves.This deficiency represents non-compliance investigated under Complaint Number 2564567 and Complaint Number 2569231.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of self-reported incident, interviews, review of facility policies, and employee handbook, the facility failed to ensure Resident #50 was free from verbal abuse on social media. This affected one (Resident #50) out of three residents reviewed for abuse. Facility census was 49. Findings include: Review of the medical record revealed Resident #50 was admitted on [DATE] and discharged on [DATE] with diagnoses of paraplegia, chronic respiratory failure, dysphagia, tracheostomy, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. The MDS revealed no behaviors. Resident #50 felt down/depressed/hopeless, had trouble falling/staying asleep or sleeping too much, feeling tired or having little energy, and feeling bad about herself/a failure/let family down. Resident #50 had no impairment to upper extremities. Review of Self-Reported Incident (SRI) revealed on [DATE] at 4:00 P.M. the Director of Nursing (DON) notified the Licensed Nursing Home Administrator (LNHA) of inappropriate messages posted by an employee on Facebook. The messages reflected what was believed to be terrible things to say about any individual and their family and were aggressive and racist by nature. The facility assumed that the employee was speaking about a resident. The employee was suspended immediately. No names were named in any of the posts. LNHA spoke with the resident to assure psychosocial support was available if needed. Resident verbalized she did see the post but was unbothered. Review of the typed statement by the Assistant Director of Nursing (ADON) dated [DATE] revealed the ADON spoke with Resident #50 about the Facebook posts made by Certified Nursing Assistant (CNA) #75. The ADON assured Resident #50 the matter would be properly handled by management staff. The ADON offered emotional support to Resident #50. Resident #50 was accepting and appreciative of ADON offering emotional support and assuring Resident #50's safety. The incident was immediately reported to the Director of Nursing (DON). Review of the Facebook posts revealed, CPS (child protective services) will be getting them kids soon as you go to jail for killing your other kids, That's why I hate (expletive) like you maybe you should've died with all your kids the world would be a better place, Don't be mad the CC wont fire me, and You and your kids deserved everything that happened to ya'll. Review of the typed statement by the LNHA dated [DATE] revealed Resident #50 had seen the posts on Facebook and was aware CNA #75 had been suspended. Resident #50 verbalized that she felt comfortable with the action being taken. The LNHA asked Resident #50 if she felt safe and Resident #50 stated she did. Resident #50 refused any psychosocial support. Review of employee file for CNA #75 revealed a hire date of [DATE]. CNA signed an acknowledgement of employee handbook, abuse policy, and cell phone and social media policy on [DATE]. Interview on [DATE] at 10:38 A.M. with Resident #50 verified she was friends with CNA #75 on Facebook and saw the negative posts made about her. Resident #50 and her friends were upset about what was posted. Resident #50 stated the previous day she had exchanged words with CNA #75 and CNA #75 was cursing at Resident #50. Activity Director #65 was working on the floor as a CNA and could not help with the crafts. Resident #50 told CNA #75 to go to work so Activity Director #65 could help with crafts. Resident #50 stated she was surprised that CNA #75 posted negative comments on Facebook because they had been friends. Resident #50 stated she felt CNA #75 verbally abused her and disrespected Resident #50 by the comments that were made and referring to the death of Resident #50's child. Interview on [DATE] at 11:39 A.M. CNA #75 stated she did not post on Facebook and her Facebook profile was cloned. CNA #75 stated Resident #50 told CNA #75 to go relieve Activities Director #65. CNA #75 stated Resident #50 got really smart about it and told CNA #75 what to do. Another CNA told CNA #75 she did not have to do what Resident #50 said. Resident #50 continued to tell CNA #75 what to do. CNA #75 verified she told Resident #50 to take her butt down the hallway. CNA #75 verified she was irritated with Resident #50 telling her what to do and Resident #50 was texting the DON and Activity Director #65 about the situation. CNA #75 stated Resident #50 was under the influence of drugs and alcohol and did not have children buckled in when the wreck occurred that killed Resident #50's daughter and Resident #50's sister. The van rolled seven times and Resident #50 was injured and on a ventilator and now paralyzed because of the accident. CNA #75 stated she became friends with Resident #50 on Facebook to help raise money for Resident #50. CNA #75 stated she was not asked to write a statement about the Facebook posts before being suspended or terminated. Resident #50 posted on Facebook that she would sue the facility if they did not terminate CNA #75. CNA #75 stated the facility terminated her so Resident #50 would not sue. During the interview CNA #75 was unable to provide any evidence her Facebook was cloned or that the posting on her Facebook page was about someone else other than Resident #50. Interview on [DATE] at 12:31 P.M. with Activities Director #65 revealed she was working on the floor and CNA #75 was supposed to replace her so Activities Director #65 could return to the activity room to help residents with a craft. CNA #75 pointed her finger at Resident #50 and said the DON told CNA #75 what to do. CNA #75 then stated she was tired of Resident #50 telling her how to do her job. Activities Director #65 stated CNA #75 needed to discuss her concerns in private and not in front of other residents. CNA #75 walked away at that time. Interview on [DATE] at 1:26 P.M. LNHA revealed she did not feel abuse had occurred due to a resident and facility was not originally named. LNHA verified that since the original posts were made, the posts had been shared on many forums and the facility has received multiple phone calls from people in the community. Review of the Abuse policy revised [DATE] revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse and mental abuse including abuse facilitated or enabled through the use of technology to demean or humiliate a resident. Review of the Cell Phones and Social Media policy revised [DATE] revealed the policy was intended to assist employees who partake in social media activities to do so effectively and responsibly and to ensure that a resident's right to privacy is maintained and residents remain free from abuse. The policy revealed while engaging in any form of social networking, employees were prohibited from sharing confidential resident information. Employees could not share any information about residents regardless of whether the employee thought the subject of such information was unidentifiable. No employee may friend or accept a friend request on social media from a resident. Review of the employee handbook revealed prohibited conduct included making false, malicious, vicious, or misleading statements about any employee, the company, or its services. This included any disparaging comments posted on social media sites. Prohibited conduct also included knowingly and negligently providing incorrect or misleading information. Threatening, intimidating or coercing any person was also prohibited. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of [DATE]: [DATE] at 4:00 P.M. LNHA became aware of an inappropriate racially insensitive post on social media by CNA #75. [DATE] at 4:30 P.M. LNHA and DON suspended CNA #75 pending investigation regarding prohibited conduct. [DATE] LNHA was sent additional social media posts further incriminating CNA #75. [DATE] CNA #75 was terminated for several offenses of prohibited conduct outlined in the handbook. [DATE] LNHA initiated SRI. [DATE] Random audit of residents completed, no knowledge of any social media posts or abuse. [DATE]-[DATE]: Education with was completed. Facility continues to monitor weekly for reports of inappropriate social media postings or any knowledge of abuse or harm. This deficiency represents non-compliance investigated under Complaint Number OH00162004.

Based on resident record review, resident interview, staff interviews, and review of facility policy, the facility failed to notify Resident #23's representative of incidents and falls. This affected one (Resident #23) of three residents reviewed for notifications. The facility census was 48 residents. Findings include: Review of medical record for Resident #23 revealed she was admitted on [DATE] with diagnoses of acute pulmonary insufficiency, chronic obstructive pulmonary disease, cutaneous abscess of abdominal wall, peritoneal abscess, borderline personality disorder, and anxiety disorder. Review of Resident #23's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicative of intact cognition. On 04/13/24, Resident #23 sustained a fall and complained of left sided pain and a bruise was noted. There was no evidence in the medical record the resident's representative was notified. On 05/08/24, Resident #23 was sent to the emergency department. There was no evidence in the medical record the resident's representative was notified. On 06/22/24, Resident #23 sustained a fall. There was no evidence in the medical record the resident's representative was notified. On 08/19/24, Resident #23 sustained a fall and complained of pain in her ribs. There was no evidence in the medical record the resident's representative was notified. On 09/25/24, Resident #23 sustained a fall. There was no evidence in the medical record the resident's representative was notified. Interview with Resident #23 on 01/15/25 at 4:10 P.M. and on 01/16/25 at 11:23 A.M. confirmed Resident #23 desired her representative be contacted in case of falls, incidents, changes in condition, and new medication, and treatment orders. Interview with Registered Nurse #156 on 01/15/25 at 4:15 P.M. and Licensed Practical Nurse #105 on 01/16/25 at 9:25 A.M. revealed in case of a fall or change in condition, a full nursing assessment should be made, and then the provider and resident representative should be notified of the incident. Interview with the Director of Nursing on 01/15/25 at 2:46 P.M. confirmed that if there is a change in condition or fall, the nurse should do a full assessment and then call the provider and the resident representative. Interview confirmed the resident's representative was not notified of the falls on 04/13/24, 06/22/24, 08/19/24, and 09/25/24, and not notified of the transfer to the Emergency Department on 05/08/24. Review of a facility policy named, Falls Policy and Procedures revised 01/27/20 revealed in the case of a resident fall, the physician and the responsible party will be notified. This deficiency represents non-compliance investigated under Complaint Number OH00161507.

Based on medical record review, review of the facility policy, and staff interview, the facility failed to investigate an injury of unknown origin when a resident sustained a right hip fracture at the facility. This affected one (Resident #44) of three residents reviewed for injury of unknown origin. The facility census was 43. Findings include: Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included presence of an artificial hip joint, dementia, repeated falls, osteoarthritis, and osteoporosis. Review of the hospital discharge note dated 04/07/23 revealed the resident's injury was a combination of a fall and her osteoporosis. Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/23, revealed Resident #44 had significantly impaired cognition. Resident #44 required extensive assistance of two people with bed mobility and transfers, and was not walking. Review of Resident #44's medical record from 04/07/23 to 04/30/23 revealed there was no reported falls or accidents involving Resident #44. Review of the nursing progress notes for Resident #44 revealed the following entries: On 04/30/23 at 1:31 P.M., staff reported Resident #44 was transferred to the bathroom by family and then they approached the State tested Nursing Assistant (STNA) and in loud voice they asked her did you drop my mother because she can't bear weight and was having trouble ambulating? The STNA informed them that she did not drop their mother and that there had been no reported falls. On 04/30/23 at 2:02 P.M., earlier that shift, daughter-in-law approached the nurse's station expressing concern stating resident's right leg was swollen. The nurse entered the room to find Resident #44 in a recliner chair. Both legs were edematous, right leg does appear tight compared to left and it was shiny in appearance, slightly [NAME] than left leg. Right leg was slightly warmer than left. Resident #44 does say that this leg was stiff and heavy harder to move. A new physician order was obtained for venous Doppler, an a one time order 20 milligrams of Lasix (diuretic). After lunch, the family called the nurse to the room, stating they want Resident #44's hip x-rayed as well. The daughter-in-law stated she was a nurse and felt that the hip was out of place. An order for an x-ray of the right hip was obtained. On 04/30/23 at 3:37 P.M., (Late Entry) it was reported by staff, that once the family arrived this date around 10:00 A.M., the family were the only ones that transferred Resident #44 in and out of her chairs. The family even continued to transfer her even after reporting to the nurse that she couldn't walk and couldn't bear weight. They did not turn on the call light for assistance. On 04/30/23 at 7:44 P.M., the nurse received verbal report that the Doppler study was negative for a deep vein thrombosis (DVT). The radiology staff person was unable to perform two view exam, however did verbally confirm Resident #44 had a hip dislocation. An order was received to send Resident #44 to the emergency report (ER) for an evaluation and treatment. On 04/30/23 at 7:45 P.M., Emergency 911 services were called and Resident #44 transferred to the hospital at 8:00 P.M. The hospital reported she was admitted with a right hip fracture. Interview on 05/17/23 at 10:45 A.M. with Licensed Practical Nurse (LPN) #450 revealed on 04/30/23 when LPN #450 started her shift, the night shift nurse reported Resident #44 had not slept sleep well, wanted to sit with feet dangling because that was comfortable for her. That morning, everything seemed fine. While LPN #450 was charting, a woman unknown to LPN #450 approached the nurse's station stating Resident #44 has swelling in her right leg. When LPN #44 observed, both legs were swollen, right leg was tighter than left, called on-call physician stated to get a Doppler study. The woman didn't complain about Resident #44 not being able to walk or range of motion. The nurse noted that morning, the right foot had decreased flexion. The physician ordered a dose of Lasix (diuretic). Resident #44 had some cognitive impairment and would not use her call light and did not follow restrictions for weight bearing and tried to get up on her own several times. Resident #44 usually accepted help but she was very impatient and very impulsive. LPN #44 responded quickly to yelling because the resident does not use call light and won't wait. Resident #44 said her right leg felt heavy but did not complain of pain. Resident #44 made some faces with palpation. No bruising noted and no complaints of discomfort other than when she was flexing that ankle. Interview on 05/17/23 at 11:30 A.M. with State tested Nursing Assistant (STNA) #420 revealed Resident #44 had been improving with therapy. On Saturday 04/29/23, Resident #44 had self-transferred at dinner so staff were trying to keep her wheelchair out of reach so she would ask for assistance to transfer. On Sunday 04/30/23, Resident #44 seemed to complain of more hip discomfort and leg became more swollen as day went on. The nurse asked the family if they wanted Resident #44 sent to the hospital but since it was Sunday the family wanted to wait on the x-rays before sending her to the hospital. Resident #44 said it hurt more to transfer but was unable to say why. Resident #44 could be sassy but never refused care. Interview on 05/23/23 at 9:19 A.M. with Assistant Director of Nursing (ADON) #500 verified the facility did not complete an investigation of an injury of unknown origin when Resident #44 sustained a right hip fracture at the facility. Review of the facility policy titled Accident/Incident Reporting, last revision date 08/13/14, revealed accidents or incidents are occurrences that need further investigation, outlines guidelines for reporting, and how to thoroughly investigate. This deficiency represents non-compliance investigated under Complaint Number OH00142570.

Based on record review and facility staff interview the facility failed to have eight hours of Registered Nurse (RN) coverage daily. This had the potential to affect all 50 residents who live in the facility. Findings Include: Review of the daily staffing punch detail for 12/31/22 revealed there were four Licensed Practical Nurses who worked 12/31/22 and eight State tested Nursing Assistants who worked on 12/31/22. There were no Registered Nursing hours accounted for on 12/31/22. During an interview with the Director of Nursing (DON) on 01/04/23 at 2:44 P.M. it was confirmed there was no Registered Nurse (RN) who worked in the facility on 12/31/22. The DON stated there was a holiday schedule mishap and no RN was scheduled on 12/31/22 but two RN's were scheduled to work the next day 01/01/23.

Based on record review and facility staff interview, the facility failed to provide restorative nursing services to three (#10, #20 and #40) of three reviewed for restorative services. The facility census was 50. Findings Include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact. Resident #10 had no delusions, hallucinations or behaviors coded. The resident required extensive assist with transfers, bed mobility, toileting, dressing and personal hygiene, the resident required supervision with eating. The resident has an indwelling catheter and is frequently incontinent of bowel. Resident #10 had a care plan indicating the resident has potential for decreased range of motion (ROM) related to decreased strength in upper extremities and limitation in range of motion. The goal was to maintain current level of function and interventions listed were the restorative programs for the resident dated 11/01/22. Review of Resident #10's medical record revealed the resident had restorative nursing programs initiated on 11/01/22. The programs were initiated as follows: Passive range of motion to lower extremities, while sitting in a wheelchair with the brakes locked, State tested Nursing Assistant (STNA) sits in front of wheelchair and slowly straightens residents knees to a comfortable stretch. Hold for 15 to 30 seconds and release, do three repetitions. STNA to place foot between residents feet and slowly open knees hold for 15 to 30 seconds and release, do three repetitions. Perform program five to seven days a week for a minimum of 15 minutes. Range of motion to upper extremities: provide ROM to bilateral upper extremities in all planes, perform the program five to seven days a week for a minimum of 15 minutes. Review of the restorative program documentation for the last 30 days revealed the resident received both programs on the following days: 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/17/22, 12/18/22, 12/22/22, 12/27/22, 12/28/22, 12/29/22, 12/30/22, and 01/03/23. The resident received 12 days of restorative treatment for both programs, and not the 20-28 days of treatment as stated in the program. Interview with Clinical Regional Nurse (CRN) #200 on 01/03/22 at 3:00 P.M. confirmed the Resident #10 did not receive the restorative programs as they were documented to be delivered. 2. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to disorder of autonomic nervous system, diabetes type two, and major depression. Review of the most recent MDS dated [DATE] quarterly assessment revealed resident has minimal hearing difficulty without a hearing aide, had visual impairment but no corrective lenses, the resident is cognitively intact. The resident had no behaviors, required extensive assist with bathing, bed mobility, dressing, personal hygiene, and toileting. The resident requires supervision for eating. The resident was independent with locomotion on and off the unit with set up help. The resident is always incontinent of bowel and bladder. Resident has restorative program as follows: Restorative program range of motion upper extremities, should -flexion (arms over head) and back down x 10 repetitions, two times. Elbow- flexion and extensions time 10 repetitions two times, wrist flexion and extension side to side for 10 repetitions, two times, fingers flexion and extension for 10 repetitions times two, five to seven days a week for a minimum of 15 minutes dated 06/15/22. Restorative program range of motion active range of motion to bilateral lower extremities while sitting in wheelchair. March 30 times, toe tap heal tap 30 times kick 30 times for a minimum of 15 minutes five to seven times a week may do group exercises as tolerated, dated 06/15/22 Review of restorative documentation for the last 30 days revealed the resident received upper extremity ROM on 12/12/22, 12/13/22, 12/14/22, 12/15/22, 12/19/22, 12/22/22, 12/28/22, 12/29/22, 12/30/22 and 01/03/22. The resident received 10 days of the restorative program when the program should have been delivered 20-28 days. Review of Lower extremity ROM restorative program for the last 30 days revealed the program was completed on 12/14/22, 12/15/22, 12/19/22, 12/22/22, 12/29/22, 12/30/22 and 01/03/23. The resident received 7 days of the restorative program when the program should have been delivered 20-28 days. 3. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to difficulty walking, type two diabetes, and anxiety disorder. Review of the most recent Minimum Data Set, dated dated dated [DATE] quarterly assessment revealed the resident had minimal difficulty hearing with no hearing aid, was visually impaired and used a corrective lens. The resident had mild cognitive impairment, the resident had no behaviors, required extensive assist with bed mobility, limited assist with transfers, dressing, toileting, and personal hygiene, independent with eating and locomotion off the unit. The resident is frequently incontinent of bowel and bladder and had no restorative minutes coded. Resident had restorative nursing program for ambulation stating the resident would ambulate 50 feet two times a day, five to seven day a week for a minimum of 15 minutes and with uses a walker, dated 03/27/21. Resident had restorative nursing program for passive range of motion to lower extremities while sitting in a wheelchair with the braked locked. STNA sits in front of wheel chair and slowly straightens residents knees to a comfortable stretch, hold for 15-30 seconds and release for three repetitions, STNA to place foot between resident feet and slowly open knees hold for 15 to 30 seconds and release for three repetitions, five to seven days a week for a minimum of 15 minutes. Resident may use onmicycle for 15 minutes dated 03/27/21. Review of restorative documentation for the last 30 days revealed the resident received her restorative ambulation program on the following days: 12/12/22, 12/13/22, 12/15/22, 12/19/22, 12/20/22, 12/27/22, 12/29/22 and 01/03/22. The resident received 8 days of the restorative ambulation program when the program should have been delivered 20-28 days. Review of Restorative documentation for the last 30 days revealed the resident received her passive ROM restorative program on the following days: 12/12/22, 12/13/22, 12/19/22, 12/22/22, 12/28/22, 12/29/22 and 12/30/22. The resident received 7 days of the restorative program when the program should have been delivered 20-28 days. Interview with STNA #120 on 01/03/23 at 10:06 A.M. revealed the STNA is not able to complete all restorative programs for residents who have restorative programs at the facility. The STNA stated she will touch bases with each resident on restorative and she will complete the minimum part of the program and ask the resident to complete the parts of the program they can perform independently. The STNA also verified she is pulled to the floor as floor staff on days when she is scheduled to provide restorative services to residents. Interview with the Administrator 01/04/22 at 11:40 A.M. verified the restorative programs for Resident #20 and #40 were not provided as ordered. The Administrator stated the facility has been under critical staffing due to Sars CoV 2 (COVID-19) outbreak and were doing the best they could with COVID in the building. The Administrator stated when the facility is under critical staffing if you are an STNA you are on the floor providing direct patient care. This deficiency represents non-compliance investigated under Complaint Number OH00138308.

Based on record review, resident interview and facility staff interview, the facility failed to ensure one (#10) of three residents with power chairs had access to the power chair which allows the resident to be independently mobile. The facility census was 50. Findings Include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact, felt down, depressed or hopeless seven to 11 days, had trouble sleeping seven to 11 days, was feeling tired or having little energy seven to 11 days, had poor appetite, or overeating two to six days and felt bad about herself, that she was a failure or had let yourself or family down two to six days of the review. Resident #10 had no delusions, hallucinations or behaviors coded. The resident required extensive assist with transfers, bed mobility, toileting, dressing and personal hygiene, the resident required supervision with eating. The resident has an indwelling catheter and is frequently incontinent of bowel. Review of progress notes revealed the note on 09/29/22 at 1:50 P.M. the resident arrived at the facility via transport stretcher with a bag of belongings. The resident was placed in isolation due to a bedbug infestation. No family or other persons were present at the time of admission. Progress note dated 09/30/22 at 8:29 A.M. revealed the resident personal items from the hospital were in a bag that smelled like it was soaked in rubbing alcohol. The bag is described to have liquid pooled at the bottom of the bag and the bag contained a phone charger, phone case, power chair charger, fan, small purse, and a rosary. The note indicated the phone charger, phone case and rosary were washed with soap and water and returned to the resident per her request. Review of the history and physical dated 10/03/22 per the physician revealed the resident was seen at a community hospital from 09/18/22 through 09/29/22 for worsening depression with suicidal ideation. The resident was found to not have active suicidal ideation's but acute on chronic depression, failure to thrive and a difficult social situation. Hospital course included psychiatry consult, Sertraline (antidepressant) therapy was increased, and the resident had physical and occupational therapy. The resident was medically stabilized and transferred to the skilled nursing facility for ongoing care and therapy. The resident stated she had extensive aide services and was able to live independently using a Hoyer lift to transfer her to her motorized wheelchair. However, her services had not been unreliable and she feels she may need alternative arrangements. The resident noted she had not walked in three years. The assessment and plan revealed adult failure to thrive syndrome as the resident is unable to care for herself at home and home health was not going into the home due to a bedbug infestation. Chronic depression exacerbation secondary to living conditions with the antidepressant being increased in the hospital. Progress note dated 10/11/22 at 8:36 A.M. revealed the residents reported the manual wheelchair and the recliner are uncomfortable to her and the facility obtained a Broda chair for the resident as Resident #10 has not been able to obtain her power chair. Progress note dated 10/11/22 at 4:16 P.M. revealed Resident #10 was making multiple calls to individuals outside the facility demanding they bring her power wheel chair to the facility. The note indicated the nurse spoke to the power chair company and the company confirmed they went to Resident #10's home to work on the power chair prior to the resident being hospitalized . The company reported they saw bedbugs in the power chair and they were unable to work on the chair and left Resident #10's home. The power chair company expressed they did not know how the power chair was transported to the hospital where it currently is located. The company expressed they had parts for the power chair but they will not work on the chair until it had been treated by a certified person to kill the bedbugs. The company stated they require a certificate of decontamination to work on the chair. The power chair is noted to be at the hospital and to not have been treated. The power chair company indicated they had spoken to the hospital and explained the chair had to be treated by a certified professional and the hospital had not gotten back with them. The company stated they would call the facility if they were notified of any activity concerning the power chair. Progress note dated 10/11/22 at 4:30 P.M. revealed Resident #10 was informed the power chair needed certified treatment before it can be transported to the facility. The resident was informed she may have her clothes brought to the facility as they can be laundered with high heat to kill bedbugs, but the other belongings were requested to not be brought to the facility due to the items potentially causing an infestation of the facility. Progress note dated 10/12/22 at 11:17 A.M. revealed Resident #10 had canceled her upcoming appointment to the podiatry and to the urologist as the resident did not have her power chair to go to the appointments. The facility offered to transport the resident with a manual wheelchair or a Broda chair and the resident declined. Progress note dated 10/12/22 at 12:27 P.M. revealed Resident #10 stated the Broda chair has allowed her to be up without pain, the note indicated Resident #10 was pursuing a replacement power chair but will use the Broda chair until she has a power chair available. Resident #10 stated she will not come out of her room stating she wants to be independent and will not have people push her around. Review of resident care plan indicated the resident has inappropriate behaviors of refusing care, refusing medication, refusing appointment, and refusing to get up in the chair, the resident refuses to get up or go anywhere until she receives her own personal power chair dated 12/14/22. Interventions included psychology/psychologist consult dated 12/14/22. There were no interventions related to the obtaining the residents personal power chair for her use. Interview on 01/03/22 at 9:20 A.M. with the Administrator revealed the ambulette transport companies in the area of the facility are not transporting residents to appointments any longer due to staffing. The Administrator revealed the facility has a transport vehicle that they can use to assist residents getting to and from appointments, however the resident has to be in a wheelchair, Broda chair or ambulatory to be transported by the facility so the resident can be securely transported in their bus. If a resident uses a motorized wheelchair for mobility, they are transported using either a wheelchair or Broda chair. Interview with Resident #10 on 01/03/22 at 11:05 A.M. revealed the resident had no concerns with her belonging, stated she knew when she left her apartment that she was leaving all of her belongings due to the bug infestation. The resident stated her mother has brought in her clothing and the facility took it and laundered it so there were no bugs. The resident stated her power chair was taken from her at the hospital. Resident #10 stated after a week in the hospital, the power chair was returned to her hospital room and the hospital staff stated the chair had been treated. The resident stated after the chair was placed in her room she saw bed bugs on the chair and alerted the hospital staff. The resident stated she was moved to an isolation room and the hospital removed her chair and she did not know where they placed it. The resident stated her chair did not come to the nursing facility as it must be professionally cleaned and the hospital will not allow an outside company to come on their property and clean the chair. The resident stated she does not want bed bugs and does not want the chair if it has bugs in it but stated she has funds in the bank to have the chair cleaned but the facility wont allow it on the property unless it has a certification stating it is bug free and the hospital will not allow an outside company access to their property to treat the chair. The resident verified she has a chair at the nursing facility she can get up in but she often chooses to not get in the chair as she does not know when staff will have the time to put her back in bed. The resident stated the last time she was up was on 12/25/22. Interview with the Director of Nursing (DON) on 01/03/22 at 3:28 P.M. revealed when Resident #10 admitted from the hospital the transport company refused to bring the chair in their transport vehicle due to the bedbug infestation. The DON stated Resident #10 and the hospital were communicating on the power chair and how to get the chair to the resident. The DON stated the resident was informed the facility required a certificate from the exterminator that the chair was bug free. The DON stated on admission the hospital had included a report that stated they sprayed the chair base, but not a follow up report that the chair was bug free. The DON revealed she had spoken to a the company which supplied Resident #10 with the power chair and had been informed the company will not touch the chair until it has been verified it was free of bedbugs. The DON stated the company had parts for the power chair and had gone to the Resident home to install the parts and had seen bedbugs climbing out of the power chair wheels and motor and they left the home without completing the part change out. The DON stated the company had conflicting reports on the status of the chair as one person stated the chair was not working while another one stated the power chair works just fine as it is without the parts being replaced. The DON stated no one at the facility has worked with the hospital to get Resident #10's power chair cleaned. The DON stated the resident had been on the phone with the hospital but she was no sure what the process would be to get the power chair cleaned and who is responsible to ensure it is returned to the resident. The DON stated the hospital told the facility on admission the power chair had been sitting outside in the cold so there should not be any bedbugs alive on the chair. The DON stated the resident items the hospital sent at the time of admission were in a bag with what smelled like rubbing alcohol and the liquid was immersing all the belongings. The DON stated the items were the power cord to the power chair, phone charging cord, wallet, and a Bible. The DON stated the items in her wallet were removed, cleaned and returned to the resident, and the facility bought the resident a replacement Bible. The DON stated she is fairly sure the power cord is ruined as it was immersed in a liquid solution that smelled like rubbing alcohol. The DON stated this is why the facility needs a certificate that the chair is bug free as the hospitals process for cleaning Resident #10's personal items was not concurrent with the standard process of treating for bedbugs. The DON verified the power chair is Resident #10's personal property and confirmed it is what the resident uses to be independently mobile. The DON reiterated the chair had to have a certificate of being bug free to enter the facility and the hospital has not provided the facility with the certificate. Interview with the DON on 01/03/22 at 4:02 P.M. revealed the facility did receive information from the hospital regarding the resident room at the hospital and the power chair being treated by an exterminator in the hospital. The DON stated the report revealed the room base boards and the power chair were treatment with the total treatment time of six minutes. The DON stated the exterminator's report did not guarantee the chair was bug free. The DON stated after she received the exterminator report from the hospital the Administrator and the facilities corporate office had an email exchange were the Administrator explained the issues with the power chair and corporate stated it is a risk to take the chair to the facility. The Administrator replied she is not willing to take the risk in her email dated 11/21/22. The DON stated after email exchange she did communicate with the hospital and she was told the hospital would treat the chair and provide the facility with the required documentation, however she has not heard from the hospital and verified it had been over a month since that interaction with the hospital had occurred an no communication had occurred. Interview with clinical regional nurse (CRN) #200 on 01/03/22 at 4:20 P.M. confirmed the resident had a power chair at the hospital and the report from the hospitals does not indicate the chair was treated fully in the motorized compartment to ensure no bugs were present, and the facility could not take it or they would be negligent by bringing an a piece of equipment that would introduce bedbugs into the facility. The CRN stated he understands it is how the resident is independently mobile, but as the chair is not here, he did not know how to facilitate it being cleaned to get it to be safe to come to the facility. CRN #200 verified the last facility documentation regarding the resident power chair was from the hospital on 11/11/22 and stated the chair was in a room that was sprayed for bedbugs, but the report did not detail if the chair was free of bed bugs and if the motorized compartment was spayed to ensure no bugs were present. The CRN stated he does not know how the facility would facilitate the chair being cleaned to the point of no bugs when it is not on their property. He also verified the facility had no documentation in over a month of what steps they are attempting to get the chair returned to the resident. Interview with the DON 01/03/22 at 5:00 P.M. revealed she spoke to the company who services the power chair and it was confirmed the documentation provided by the outside hospital did not meet their criteria enabling them to work on the chair as the paperwork did not have a reinspection report indicating the chair was free of bugs. The DON verified she had received an email from the hospital on this date and it confirmed Resident #10's power chair is still at the hospital. The DON stated she informed the hospital again that the facility needed a reinspection report certifying the power chair was free of bugs and the facility would be happy to take the chair into the facility for the resident's use. The DON stated the hospital stated they would have to get back to her, and she has not heard back. This deficiency represents non-compliance investigated under Complaint Number OH00138308 and OH00137497.

Based on record review, resident and facility staff interview, the facility failed to ensure one ( #10) of three residents reviewed for attending out side provider appointments was timely seen by neurologist. The facility census was 50. Findings Include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact, felt down, depressed or hopeless seven to 11 days, had trouble sleeping seven to 11 days, was feeling tired or having little energy seven to 11 days, had poor appetite, or overeating two to six days and felt bad about herself, that she was a failure or had let yourself or family down two to six days of the review. Resident #10 had no delusions, hallucinations or behaviors coded. The resident required extensive assist with transfers, bed mobility, toileting, dressing and personal hygiene, the resident required supervision with eating. The resident has an indwelling catheter and is frequently incontinent of bowel. Resident #10's record revealed the resident had a neurology appointment on 11/18/22. Review of resident care plan indicated the resident has inappropriate behaviors of refusing care, refusing medication, refusing appointment, and refusing to get up in the chair, the resident refuses to get up or go anywhere until she receives her own personal power chair dated 12/14/22. Interview on 01/03/22 at 9:20 A.M. with the Administrator it was revealed the ambulette transport companies in the area of the facility are not transporting residents to appointments any longer due to staffing. The Administrator revealed the facility has a transport vehicle that they can use to assist residents getting to and from appointments, however they resident has to be in a wheelchair, Broda chair or ambulatory to be transported by the facility so the resident can be securely transported in their bus. If a resident uses a motorized wheelchair for mobility, they are transported using either a wheelchair or Broda chair. Interview with Resident #10 on 01/03/22 at 11:05 A.M. revealed she had a neurology appointment scheduled in November 2022 when she was admitted to the facility. The Resident stated it took a year to get the appointment set up, the resident revealed the November appointment was canceled and rescheduled for 12/09/22. The resident stated she did not go to the 12/09/22 appointment as she asked to night shift staff to get her ready and they stated they did not have her as having an appointment, Resident #10 stated she had told the facility about the appointment. Interview with State tested Nursing Assistant (STNA) # 160 who provides transportation for residents at the facility on 01/03/22 at 4:55 P.M. revealed Resident #10 had refused to go to her neurology appointment as she did not have her power chair to be transported to the appointments in. The Resident rescheduled her neurology appointment but did not provide the facility with the information regarding the date and time of the appointment. STNA #160 stated she was made aware of the appointment on the date it was scheduled at 4:30 A.M. and the appointment was scheduled at 7:30 A.M. STNA #160 revealed she had prior transports set on that day and could not provide transport to Resident #10. STNA #160 revealed the neurology appointment was rescheduled for February 2023. STNA #160 verified after the resident's neurology appointment was canceled due to conflict with transportation she had a conversation with Resident #10 to ensure the resident notified her if she had set an appointment so the transportation could be worked out and provided for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00138308.

Based on record review, resident and facility staff interview, the facility failed to timely provide one (#10) vision services of three residents reviewed. The facility census was 50. Findings Include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact. Resident #10 had no delusions, hallucinations or behaviors coded. The resident required extensive assist with transfers, bed mobility, toileting, dressing and personal hygiene, the resident required supervision with eating. Review of Resident #10's consent to have ancillary services which included dentist, podiatry, optometry, and audiology revealed the consent was signed by the resident on 09/30/22 indicating the resident wanted to have these services. Review of the ancillary eye doctor list revealed the eye doctor visited the facility on 10/05/22 and Resident #10 was not on the list to be seen. Interview with Resident #10 on 01/03/22 at 11:05 A.M. revealed the resident eye glasses were broken on 12/25/22 and the resident had tape on the nose bridge of the glasses holding the glasses together. The resident stated she had just gotten some super glue and she was going to attempt to glue them together. The resident verified the facility had set her up to be seen by the optometrist in January 2023. Interview with the social service designee (SSD) #250 on 01/04/23 at 7:50 A.M. the SSD stated if a resident has broken glasses and they are on case load for the eye doctor at the facility they send the doctor a note about the broken glasses and if they are not on the case load of the eye doctor at the facility a community eye provider is consulted and an appointment made regarding the broken device. When asked what was happening with Resident #10's glasses the SSD stated she did not know her glasses were broken. Interview with the DON on 01/04/22 at 8:25 A.M. it was confirmed Resident #10 had signed the consent to be seen by the optometrist on 09/30/22 and the optometrist was in the facility on 10/05/22 and Resident #10 was not seen or added to the optometry list to be seen on that day. This deficiency represents non-compliance investigated under Complaint Number OH00138308.

Based on record review, resident and staff interview the facility failed to timely provide psychological services for one (#10) of one reviewed for psychological services. The facility census was 50. Findings Include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact, felt down, depressed or hopeless seven to 11 days, had trouble sleeping seven to 11 days, was feeling tired or having little energy seven to 11 days, had poor appetite, or overeating two to six days and felt bad about herself, that she was a failure or had let yourself or family down two to six days of the review. Resident #10 had no delusions, hallucinations or behaviors coded. The resident required extensive assist with transfers, bed mobility, toileting, dressing and personal hygiene, the resident required supervision with eating. The resident has an indwelling catheter and is frequently incontinent of bowel. Review of Resident #10's hospital Psychiatry consultation dated 09/18/22 revealed the resident was evaluated due to acute and chronic depression with suicidal ideation's with no plan but constant thoughts. History of Resident #10's present illness was documented as having multiple sclerosis, depressive disorder neurogenic bladder, bilateral lower extremity paraplegia, chronic pain and secondary to social factors such as poor living environment, home health aide issues and financial problems. Resident reports that at home she had been dealing with bed bugs and cockroaches. Due to her limited mobility, she has not been able to adequately exterminate the bugs. Due to the infestation her regular home health aide was unable to provide care. The resident reported about one and a half weeks of difficulty sleeping, decreased interest, irritability and hopelessness due to her inability to remove the bedbugs and have her aides care. The resident revealed she recently had to euthanize her cat of [AGE] years due to inability to re-home the animal due to the bug infestation. The resident denies suicidal ideation's but confirms a passive death wish secondary to her housing instability. The resident revealed she was a devout Catholic and suicide is not compatible with her belief system, however she revealed she has passive death wishes when her disease or social burden increase. The consult revealed the resident was positive for problems with depression and bilateral lower limb spasticity and housing instability. Recommendations from the consult include additional treatment planning steps to reduce suicide risk including outpatient treatment and psychotherapy/counseling. Progress note dated 09/30/22 at 3:55 P.M. revealed Resident #10 was tearful and expressed anxiety and fear over bugs infesting her home. The resident received new order for Buspar (antianxiety) 5 milligram one tablet three times daily. Review of the medication administration record revealed the medication change was completed as ordered. Review of the history and physical dated 10/03/22 per the physician revealed the resident was seen at a community hospital from 09/18/22 through 09/29/22 for worsening depression with suicidal ideation. The resident was found to not have active suicidal ideation's but acute on chronic depression, failure to thrive and a difficult social situation. Hospital course included psychiatry consult, Sertraline (antidepressant) therapy was increased, and the resident had physical and occupational therapy. The resident was medically stabilized and transferred to the skilled nursing facility for ongoing care and therapy. The resident stated she had extensive aide services and was able to live independently using a Hoyer lift to transfer her to her motorized wheelchair. However, her services had not been unreliable and she feels she may need alternative arrangements. The resident noted she had not walked in three years. The assessment and plan revealed adult failure to thrive syndrome as the resident is unable to care for herself at home and home health was not going into the home due to a bedbug infestation. Chronic depression exacerbation secondary to living conditions with the antidepressant being increased in the hospital. Resident is noted to be tearful on examination. Review of resident care plan indicated the resident has inappropriate behaviors of refusing care, refusing medication, refusing appointment and refusing to get up in the chair, the resident refuses to get up or go anywhere until she receives her own personal power chair dated 12/14/22. Interventions included psychology psychologist consult dated 12/14/22. Progress note dated 10/20/22 at 11:07 A.M. revealed Resident #10 was referred to in house counseling services. Review of Resident #10's medical record revealed the record was silent to the resident being provided psychotherapy or counseling services at the facility. Interview with Resident #10 on 01/04/22 at 7:45 A.M. revealed the resident denied being offered counseling services and indicated she would not refuse the services. Interview with the Director of Nursing (DON) on 01/04/22 at 8:30 A.M. it was confirmed the psychiatrist consult from the hospital dated 09/18/22 recommended out patient psychotherapy/counseling for Resident #10. The DON stated she did not know if the services were provided, she would have to talk to Social Service Designee (SSD) #250. Interview with SSD on 01/04/22 at 8:20 A.M. it was confirmed the resident did have a referral to the counseling provider at the facility on 10/11/22. The SSD stated maybe when Resident #10 was assessed there was no need for services, or the resident refused services. SSD #250 stated she would need to pull their notes to see what they documented. Interview 01/04/22 at 9:23 A.M. with SSD #250 revealed the counseling service did not have Resident #10 on their case load and had not provided a consult or services to Resident #10. SSD #250 stated a verbal referral was made to the counseling service however no provider came to assess the resident. The SSD stated she is making the referral now. This deficiency represents non-compliance investigated under Complaint Number OH00138308.

Based on observation and resident and staff interview, the facility failed to maintain a home like environment for residents. This affected one (#5) out of three residents reviewed for physical environment. Facility census was 45. Findings include: Observation of Resident #5's bathroom door on 08/02/22 at 9:05 A.M. with the resident present revealed the inside of the door had the paint peeled off the door in an approximately four foot tall by two and a half feet wide section in the middle of the door. There were paint chips noted on the bathroom floor. Resident #5 stated someone must have done that before and Resident #5 had no other information to provide on the paint not being on the door. During an interview and observation of the facility with the Administrator on 08/02/22 at 11:40 A.M. confirmed the paint on Resident #5's bathroom door was peeling off in a large section and the door should not look the way is did. This deficiency substantiates complaint number OH 521.

Based on medical record review, staff interviews, and review of a facility policy, the facility failed to adequately assess a resident after a fall and ensure fall interventions were implemented. This resulted in actual harm when Resident #3 experienced a fall resulting in a cervical spine (C2) fracture. This affected one (#3) of three residents reviewed for accidents. The facility identified 29 residents at risk for falls. The facility census is 36. Findings include: Review of Resident #3's medical record revealed a recent admission date of [DATE] and original admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) assessments dated 08/11/13 and 07/31/13 revealed her Brief Interview Mental Status (BIMS) score was 05 which indicated cognitive impairment. Review of Resident #3's Fall Risk assessment dated [DATE] revealed her fall risk score was 12 and a 10 or above was identified as high risk. Review of Resident #3's Social Service Progress Notes dated 07/31/13, revealed documentation resident is alert, but confused. Review of Resident #3's undated Cognition Care Plan revealed resident is cognitively impaired due to [DIAGNOSES REDACTED]. Review of Resident #3's Fall Care Plan dated 08/11/13 revealed interventions to keep call light within reach, remind resident to call for assistance, clutter free environment, proper footwear as indicated, use of proper assistive devices, redirect as needed, rest periods as needed, escort to activities of choice, observe for safety, therapy as ordered, and alarm as needed for safety. No fall care plan was found in Resident #3's medical record prior to the date of 08/11/13. Review of Resident #3's Nurse's Notes dated 07/31/13 at 6:45 A.M., revealed resident was found sitting on floor next to bed and had stated she slid out of side of bed with no injuries noted. Further review of Nurse's Notes revealed no documentation regarding if alarm was sounding or if Resident #3 was wearing non-skid footwear. Review of Resident #3's Incident/Accident Report dated 07/31/13 at 6:45 A.M., revealed resident was found sitting on floor and had stated slid off of side of bed. Further review of Incident/Accident Report revealed no documentation regarding if alarm was sounding or if Resident #3 was wearing non-skid footwear. Further review of Incident/Accident Report revealed interventions put in place to prevent reoccurrence was to orient resident multiple times per shift and when confusion is noted. Review of Resident #3 ' s Nurse's Notes dated 07/31/13 at 9:20 P.M., revealed alarm sounding and found resident laying on right side holding head and screaming. Further review of Nurse's Notes revealed her catheter had been pulled out, her left foot was bleeding, and she was yelling and holding her neck. Further review of Nurse's Notes revealed documentation of no complaints of pain and there was no documentation regarding neurological assessment or vital signs found. No documentation regarding if proper non-skid footwear was in place. Review of Resident #3 ' s Nurse's Notes dated 07/31/13 at 9:50 P.M., revealed Resident #3 left in ambulance for the emergency room . Review of Resident #3's Incident/Accident Report dated 07/31/13 at 9:20 P.M., revealed alarm sounding and found resident yelling on the floor holding head and yelling. Further review of Incident/Accident Report revealed no documentation of neurological assessment, vital signs, or if proper non-skid footwear was in place. Review of Resident #3's hospital Computed Tomography (CT) scan of cervical spine dated 08/01/13 revealed an cervical spine (C2) impression of development of an acute type two odontoid fracture with minimal displacement. Review of Resident #3's Nurse's Notes dated 08/21/13 at 3:15 A.M., revealed alarm sounding and found resident laying on floor on right side with head at foot of bed parallel to bed and stated she got out of bed and fell . Further review of Nurse's Notes revealed no documentation of neurological assessment or vital signs were found, and no documentation regarding if proper non-skid footwear was in place. Review of Resident #3's Incident/Accident Report dated 08/21/13 at 3:15 A.M., revealed documentation of no apparent injury noted. Further review of Incident/Accident Report revealed no documentation of neurological assessment or vital signs. Further review of Incident/Accident Report revealed interventions put in place to prevent reoccurrence was to encourage resident to use call light to ask for assistance when wanting to get out of bed. Interview with MDS Nurse #7 on 08/28/13 at 1:20 P.M., stated Resident #3 had only been in the facility one day because she fell twice, fractured her neck, and was admitted to the hospital so therefore didn't have a MDS care plan for falls at the time of the falls. MDS Nurse #7 further stated the nurses are to complete short term plans of care when things are needed for residents such as falls, but verified Resident #3 did not have a short term care plan in place even after the first fall on 07/31/13. Interview with DON on 08/28/13 at 1:37 P.M., stated Resident #3 had an order for [REDACTED]. DON verified there was no documentation regarding if the alarm was in place for the fall on 07/31/13 at 6:45 A.M. and the interventions to prevent reoccurrence were to orient resident multiple times per shift and when confusion is noted. DON verified when Resident #3 fell on [DATE] at 9:20 P.M., there was no documentation of vital signs or neurological assessments found in the medical record before going to the hospital and Resident #3 had fractured her neck. DON further verified when Resident #3 fell on [DATE] at 3:15 A.M., there was no documentation of vital signs, neurological assessment, or if resident was wearing non-skid footwear. DON further verified the only new intervention put in place for prevention for reoccurrence was to encourage resident to use call light to ask for assistance when wanting out of bed. Review of an undated facility policy entitled "Policy and Procedure for Falls" revealed procedure for post fall, immediately check neurological status, movement, and vitals. Further review of policy revealed to complete a short term care plan for immediate evaluation, and implementation of appropriate prevention of further falls and list all treatments, if applicable, resulting from falls.