Every finding on record at Courtyard at Seasons

Based on observation, staff interview and review of the facility policy, the facility failed to safely serve food in a manner to avoid possible contamination and food borne illnesses. This had the potential to affect all of the residents residing in the facility who received food from the facility kitchen. The facility identified one (Resident #36) who received no nutrition by mouth. The facility census was 42 residents.Findings include:Observation on 09/03/25 at 12:05 P.M of trays being assembled revealed Dietary Aide (DA) #10 donned gloves, grabbed a tray off the cart, reviewed the tray ticket, and picked up a sandwich off the steam table. DA #10 placed food on the plate using serving utensils and removed and replaced the lid to the heated serving compartment with gloved hands. DA #10 then picked up the next tray, reviewed the ticket, picked up a chicken breast with gloved hands and placed it on a plate. Interview on 09/03/25 at 12:10 P.M. with DA #10 at 12:10 P.M. confirmed he had donned gloves and residents' food (sandwich and chicken breast) directly with his gloved hands after touching multiple surfaces and items in the environment. Observation on 09/03/25 at 12:17 P.M. revealed DA #10 picked up a tray, reviewed a tray ticket, and used tongs to put a sandwich on the counter to cut it in half. DA #10 picked up a knife and held the sandwich with his gloved hand to cut it in half. DA #10 then picked up each half of the sandwich with tongs and placed it on the plate. DA #10 then removed his gloves, washed his hands and applied new gloves. DA #10 pulled the next tray, reviewed the ticket, and put a piece of chicken breast on the counter using tongs. DA #10 then cut the chicken breast using his gloved hand to hold the chicken breast as he sliced it. Interview on 09/03/25 at 12:20 P.M. with DA #10 confirmed he touched the sandwich and the chicken breast directly with his gloved hands while slicing the items. DA #10 confirmed he touched other surfaces in the kitchen before and after touching the residents' food. Interview on 09/03/25 at 12:28 P.M. with Food Service Manager (FSM) #157 confirmed gloves should be changed and proper hand hygiene performed prior to touching any food items during tray line. Review of the facility policy titled Hand Hygiene versus Alcohol Based Hand Rub dated 06/15/16 revealed staff should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to residents after contact with contaminated surfaces even if gloves are worn and after removing gloves. Wearing gloves did not relace hand hygiene).

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) during direct care for residents with orders for enhanced barrier precautions (EBP). This affected one (Resident #50) of three residents reviewed for EBP. The facility also failed to take preventative measures to minimize the risk of legionella per the facility's water management plan. This had the potential to affect all of the residents residing in the facility. The facility census was 42 residents.Findings include: 1.Review of the medical record for Resident #50 revealed an admission date of 08/26/25 with diagnoses including but perforation of intestine, colostomy status, and hypertension.Review of the physician's orders for Resident #50 revealed an order dated 08/26/25 for the resident to be on enhanced barrier precautions related to presence of an ostomy. Observation on 09/03/25 at 8:21 A.M. of colostomy care for Resident #50 per Licensed Practical Nurse (LPN) #30 and Certified Nursing Assistant (CNA) #110 revealed the staff donned gloves prior to care but did not don gowns.Interview on 09/03/25 at 8:30 A.M with LPN #30 confirmed Resident #50 had an order for EBP due to the colostomy. LPN #50 confirmed staff should don a gown and gloves prior to providing direct care to a resident on EBP. LPN #30 confirmed staff had not donned gowns prior to colostomy care for Resident #50.Interview on 09/03/25 at 8:34 A.M with CNA #110 confirmed the aide had not donned a gown prior to assisting with colostomy care for Resident #50.Review of the facility policy titled Enhanced Barrier Precautions-Skilled dated 04/09/24 revealed staff members should wear a gown and gloves when participating in high contact resident care including touching indwelling medical devices for residents with physician's orders for EBP.2. Review of the facility water management program dated 12/29/17 revealed the facility should conduct regular water testing including visual inspections, checking levels, and checking temperatures to minimize the risk of legionella.Interview on 09/03/25 at 4:00 P.M with Maintenance Assistant (MA) #48 and the Administrator confirmed the facility had no recent concerns with legionella, but the facility had no evidence of recent water testing including checking water temperatures.Review of the facility policy titled Health and Wellness Legionella Disease dated 04/22/25 revealed the facility should use preventative maintenance to quickly identify a potential risk of legionella.

Based on observation, staff interview, and review of the facility policy, the facility failed to provide a comfortable homelike atmosphere for residents dining in the skilled nursing dining room. This affected six (Residents #3, #12, #15, #21, #27, #38) and had the potential to affect all of the residents residing in the facility with the exception of one facility-identified resident (#36) who did not receive nutrition by mouth. The facility census was 42 residents. Findings include:Observation on 09/02/25 at 4:53 P.M. of dinner in the skilled nursing dining room revealed staff served residents on trays directly from the serving cart. The staff did not remove the plates from the meal trays. Interview on 09/02/25 at 4:55 P.M. with Certified Nursing Assistant (CNA) #104 confirmed resident meals were served on trays and staff did not remove the plates of food, utensils, and beverages from the tray. Observation on 09/03/25 at 12:34 P.M. of lunch in the skilled dining room revealed staff served residents on trays directly from the serving cart. The staff did not remove the plates from the meal trays. Interview on 09/03/25 at 12:35 P.M. with Food Service Manager (FSM) #157 confirmed resident meals were served on trays and staff did not remove the plates of food, utensils, and beverages from the tray. Interview on 09/03/25 at 12:47 P.M. with FSM #157 confirmed the facility policy indicated resident food should be taken off the tray and placed on the table in front of each resident to be served in a homelike style. Review of the facility policy titled Meal Service - Hospitality and Customer Service Standard revealed table settings should include tablecloths or place mats, center pieces, presetting of glassware, china plates and tableware without the tray.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident code status was correctly noted in the medical record This affected three (Residents #9, #28, and #31) of 16 residents reviewed for advance directives. The facility census was 42 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of 12/08/24 with diagnoses including atherosclerotic heart disease, hypertension, major depressive disorder, anxiety disorder, and cardiomyopathy. Review of the paper chart for Resident #28 revealed a signed Do Not Resuscitate (DNR) form dated 12/18/24 indicating the resident's code status was DNR Comfort Care. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 06/17/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the active physician orders for Resident #28 in the electronic health record revealed an order dated 08/18/25 for the resident to be a full code status. Interview on 09/03/25 at 10:45 A.M. with Licensed Practical Nurse (LPN) #38 confirmed Resident #28 had a current order for a code status of full code and had a signed DNR form in his paper chart. 2. Review of the medical record for Resident #31 revealed an admission date of 10/24/24 with diagnoses including unspecified dementia, type two diabetes mellitus, and hypertension. Review of the paper chart for Resident #31 revealed there was a sticker on the outside of the chart which indicated the resident's code status was DNRCC-A. The chart included a DNRCC form signed by the physician dated 09/01/24. Review of the MDS assessment for Resident #31 dated 05/21/25 revealed the resident required staff assistance with ADLs. Interview on 09/03/25 at 10:15 A.M. with Certified Nursing Assistant (CNA) #90 confirmed she would check the resident's chart if she needed to determine the resident's code status. Interview on 09/03/25 at 10:23 A.M with the DON confirmed the nurse labeled resident charts on admission to reflect the resident's code status. The DON verified Resident #31's chart had a sticker indicating the resident's code status was DNRCC-A, but the resident's correct code status was DNRCC. Review of the facility policy titled Advance Directives dated 04/22/25 revealed upon admission staff would verify resident advanced directives and ensure a signed copy of advanced directive was be kept in resident's chart.

Based on medical record review, observation and staff interview, facility failed to ensure staff provided the appropriate level of supervision during mealtime. This affected one (Resident #38) of six facility-identified residents who required supervision with meals. The facility census was 45. Findings include: Review of the medical record for Resident #38 revealed an admission date of 08/28/24 with diagnoses including cerebral atherosclerosis, dysphagia, and depression. Review of the physician's orders for Resident #38 revealed an order dated 11/01/24 for a regular diet, pureed texture and nectar fluids consistency.Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 06/05/25 revealed the resident had severe cognitive impairment and required supervision from staff with eating.Review of care plan for Resident #38 dated 06/09/25 revealed the resident was at severe nutritional and hydration risk. The goal of the care plan was for resident to be able to safely and effectively chew and swallow a pureed diet with nectar thick liquidsReview of the physician's orders for Resident #38 dated 06/17/25 revealed the resident's diet was liberalized to include mechanical soft foods for pleasure.Review of the physician's orders for Resident #38 dated an order dated 06/24/25 for staff to provide the resident with assistance with feeding at breakfast daily.Observation on 09/02/25 at 5:03 P.M. revealed Resident #38 was sitting in the dining room at a table by herself facing the wall and exhibited episodes of coughing while eating which grew worse as the meal continued. The Surveyor asked Certified Nursing Assistant (CNA) #104 to check on the resident. CNA #104 sat down and faced the Resident #38 and encouraged the resident to slow down in eating. CNA #104 then assisted Resident #38 to take smaller bites at a slower pace. Interview on 09/02/25 at 5:28 P.M. with CNA #104 confirmed Resident #38 had been sitting where staff could not easily see her and the resident had been coughing while eating. CNA #104 confirmed when she provided supervision to Resident #38 at the Surveyor's request. CNA #104 confirmed staff need to intervene immediately to assist any resident who is coughing while eating. Interview on 09/03/25 at 10:20 A.M. with the Director of Nursing (DON) confirmed Resident #38 had an order for staff to assist the resident with eating for breakfast as resident had greatest difficulty eating on her own soon after waking up. The DON confirmed Resident #38 needed supervision at all meals and the expectation was for aides to be stationed in the dining room during all meals and to monitor all residents eating in the dining room.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin was dated upon opening. This affected one (Resident #31) of six residents who had orders for insulin. The facility failed to ensure expired medications were discarded. This affected one (Resident #54) of 42 residents reviewed for medication storage. The facility census was 42 residents.Findings include:1. Review of the medical record for Resident #31 revealed an admission date of 11/11/24 with diagnoses including dementia, type two diabetes, and hyperlipidemia. Observation on 09/03/25 at 3:54 P.M of medication storage with Registered Nurse (RN) #76 revealed the Lantus insulin pen for Resident #31 had not been dated upon opening. Interview on 09/03/25 at 3:55 P.M. with RN #76 confirmed Resident #31's Lantus insulin pen had not been dated upon opening. 2. Review of the medical record for Resident #54, revealed an admission date of 08/26/25 with diagnoses including myoneural disorder, rhabdomyolysis, and type two diabetes.Review of the active physician's orders for Resident #54 revealed an order for oyster shell calcium 500 milligrams (mg) twice dailyObservation on 09/03/25 at 4:01 P.M. of the medication cart with RN #76 revealed the oyster shell calcium for Resident #54 had an expiration date of July 2025.Interview on 09/03/25 at 4:02 P.M. with RN #76 confirmed the oyster shell calcium for Resident #54 was expired and should have been discarded.Review of facility policy titled Medication Storage Standard dated on 12/12/24 revealed the facility will follow state regulations regarding medication storage.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received dental services. This affected one (Resident #43) of three residents reviewed for dental services. The facility census was 42 residents. Findings include: Review of the medical record for Resident #43 revealed an admission date of 09/15/23 with diagnoses which included hereditary idiopathic neuropathy, peripheral venous insufficiency, arthritis, and depressionReview of the admission packet for Resident #43 dated 07/19/23 revealed the resident signed the admission packet which noted the facility would arrange for physician visits as authorized under the agreement for ancillary services prescribed by a physician. Review of the physician's orders for Resident #43 revealed an order dated 08/22/23 for resident to receive ancillary services as needed including dental services.Review of the Minimum Data Set (MDS) for Resident #43 dated 05/20/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.)Interview on 09/03/25 at 3:37 P.M. with Resident #43 confirmed she had never been offered the opportunity to see a dentist since her admission to the facility. Resident #43 confirmed she had no emergent need for a dentist but felt she needed to have her teeth cleaned and evaluated. Interview on 09/03/25 at 5:11 P.M. with the Administrator confirmed Resident #43 had not been seen by a dentist since her admission to the facility.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered appropriate pneumococcal immunizations. This affected one (Resident #42) of eight residents reviewed for immunizations. The facility census was 42 residents.Findings include: Review of the medical record for Resident #42 revealed an admission date of 11/09/22 with diagnoses including chronic atrial fibrillation, gastrointestinal hemorrhage, and hyperlipidemia.Review of the immunization record for Resident #42 revealed the resident received Pneumovax 23 (PPSV23) on 11/10/22.Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 08/15/25 revealed the resident was cognitively intact and the resident's pneumococcal immunizations were completed.Interview on 09/04/25 at 12:20 P.M with the Director of Nursing (DON) confirmed the facility did not offer Pneumococcal Conjugate Vaccine (PCV)15, PCV20, or PCV21 vaccines to Resident #42 due to accidentally marking his pneumococcal immunizations as complete.Review of the facility policy titled Offering Pneumococcal Vaccine dated 03/06/25 revealed upon admission residents will be assessed for eligibility to receive the pneumococcal vaccines (PCV15, PCV23, and PPSV20) and will be offered within 5 days of admission.

Based on medical record review, staff interview, review of facility investigation, and review of facility Self-Reported Incident, the facility failed to conduct a thorough investigation regarding staff to resident retaliation. This affected one (Resident #25) of three residents reviewed for abuse. The facility census was 35. Findings include: Medical record review for Resident #25 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment revealed Resident #25 was cognitively intact and required extensive assistance with Activities of Daily Living (ADLs). The resident had no behaviors noted. Further review of the medical record, including progress notes from August through October of 2022 revealed no documented incidents of abuse/retaliation and/or conversations had with Resident #25 related to incidents of staff retaliation. Interview on 10/13/22 at 12:15 P.M. with Resident #25 revealed State tested Nurse Aide (STNA) #500 was rough while providing care. Resident #25 asked STNA #500 not to push on his left hip because she was making it hurt. Resident #25 realized STNA #500 was on the phone via Bluetooth during the encounter. Resident #25 reported this incident to STNA #65. Later, STNA #500 came back into Resident #25's room and confronted him about him telling on her for being on the phone. STNA #500 reported she was on the phone due to family business. Resident #25 told STNA #500 she was lying because he overheard her talking about a party. Resident #25 reported he expressed his concerns to unknown nurses. Resident #25 verified he was never interviewed by administrative staff about the incident and no statement was obtained. Interview on 10/13/22 at 2:03 P.M. with STNA #65 revealed Resident #25 reported STNA #500 was not attentive while providing care in August 2022. STNA #65 reported she informed the nurse and spoke with STNA #500 about not taking personal phone calls while working. Resident #500 reported the phone call was a family emergency. STNA #65 also explained to STNA #500 Resident #25 had pain and she needed to be gentle when providing care to him. STNA #65 denied being interviewed by administrative staff regarding the incident Resident #25 reported. STNA #65 verified Resident #25 reported the incident to many staff members. Attempted interview on 10/14/22 at 2:30 P.M. and 3:42 P.M. with STNA #500 were unsuccessful. Review of the SRI dated 08/16/22 revealed Resident #25 alleged STNA #500 retaliated against him for reporting her to management for having a personal conversation on her cell phone while providing care. Resident #25 told the Administrator STNA #500 was rude and having a personal conversation via Bluetooth while providing care. Resident #25 reported to the nurse, who spoke with STNA #500. STNA #500 came back to Resident #25's room, pointed her finger at hm and told him, How dare you report me. I was having a personal conversation about a death in the family. All resident who received care from STNA #500 were interviewed. Review of the facility's investigation documents revealed six residents were interviewed about feeling safe in the facility on 08/19/22. There was no evidence staff witness statements were obtained or staff interviews were conducted. Additional review revealed no evidence staff were educated on the facility's abuse policies and procedures or about retaliation. Review of untitled document dated 08/17/22 written by the Assistant Director of Nursing (ADON) revealed on 08/16/22 at 6:53 P.M. the Administrator requested the ADON to contact STNA #500 in regard to Resident #25's complaint and inform STNA #500 she would be suspended pending an investigation. The ADON called STNA #500 on 08/16/22 at 7:35 P.M. to discuss the incident with Resident #25. STNA #500 reported it was a misunderstanding. STNA #500 went to answer Resident #25's call light while she was on the phone discussing funeral arrangements with a family member. When she was entering the room, she was hanging up and telling her family she could call them back later. STNA #500 reported once she heard about Resident #25 reporting her for being on the phone, she went back to his room to explain and apologize. STNA #500 denied there was an argument and denied approaching Resident #25 in an aggressive manner. STNA #500 was notified she would be suspended pending an investigation. Interview on 10/13/22 at 3:10 P.M. with the Administrator revealed he was an interim administrator, and the previous Administrator #600 was terminated on 10/05/22. Administrator #600 was the Administrator who completed the SRI dated 08/16/22. The Administrator was unaware of any staff interviews being conducted or staff witness statements obtained related to the incident from the SRI dated 08/16/22. Review of facility policy titled, Abuse Investigation Skilled, dated 07/12/22 revealed the individual conducting the investigation will interview staff members on all shifts who have had contact with the resident during the period of the alleged incident and witness reports will be made in writing. This deficiency is an example of continued noncompliance from the survey dated 07/12/22.

Based on observation of tray line and a test tray, resident, family, and staff interview, review of the resident council meeting minutes, review of the facility's policy, and record review, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 40 residents who received food from the kitchen. The facility identified one resident (#37) who did not receive food from the kitchen. The facility census was 41. Findings include; Interview on 07/05/22 at 10:28 A.M. with Resident #141 stated the facility's food was often served cold and this issue was ongoing. Interview on 07/05/22 at 11:15 A.M. with Resident #142 stated the food was served cold. Resident #142 stated this was really the only concern or complaint regarding the facility's food. Interview with Resident #4's spouse on 07/05/22 at 12:29 P.M. stated there were times the hot food was served cold. Observation on 07/06/22 at 11:34 A.M. revealed Dietary Cook (DC) #500 placed a food thermometer in a pan of mixed vegetables without sanitizing the thermometer and obtaining a temperature of 199 degree Fahrenheit (F). DC #500 wiped the food thermometer with a dry dish towel and placed it in a large pan of black bean salad and obtain a temperature of 196 degrees F. DC #500 was observed wiping the food thermometer with a dry dishtowel and placing in the meat of a quesadilla and obtaining a holding temperature of 122.5 degrees F. DM #362 was observed to provide DC #500 a alcohol wipe and encouraged him to clean the food thermometer with the alcohol wipes. DM #362 explain to DC #500 the holding temperature for the beef quesadilla was too low and to put in the oven to bring to a temperature of 165 degrees F. Observation of the tray line on 07/06/22 at 12:12 A.M. revealed the tray line was located in the temporary kitchen area due to remodeling. DM #362 stated the facility does not have enough lids to cover the food dishes to ensure the foods stays hot. Observed the tray line run out of lids to cover the food and placed the food in a four-compartment styrofoam container. DM #362 stated the reason they do not have enough lids was because her supplier has them on back order. DM #362 stated she has checked with three suppliers, however, has not asked the current supplier she was using. Observation of meal trays delivered to the floor on 07/06/22 at 12:38 P.M. revealed the last tray was delivered to a resident at 12:38 P.M A test tray was completed at this time and revealed the lunch was served in a styrofoam container and the black beans were served at room temperature. The quesadilla was beef in a flour tortilla wrap with nothing else on it. There was no cheese or garnish like sour cream and/or salsa. The tortilla was cold and chewy. An interview on 07/06/22 at 3:24 P.M. with the Registered Dietitian (RD) #361 revealed the RD was unable to determine why the facility would serve a plain quesadilla that consisted of beef wrapped in a shell without cheese or garnish. The RD stated the quesadillia should have contained cheese. The RD stated she was unaware the facility did not have enough lids to ensure the foods served remained hot on the unit. Review of the resident's diets revealed Resident #37's diet was nothing by mouth. Review of the facility's Resident Council Meeting Notes dated 05/17/22 revealed Resident #12 had an issue of cold food on her tray. The Resident Council Meeting Notes dated 06/21/22 revealed Resident #12 had the same issue that her food on her tray was often cold and it was an ongoing issue. Review of the facility's policy titled Food Preparation-Food Temperatures Policy, dated 09/05/19, revealed foods should be served at proper temperature to insure food safety and palatability.

Based on observation, record review, review of the facility's policy, and staff interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 40 residents who received food from the kitchen. The facility identified one resident (#37) who did not receive food from the kitchen. The facility census was 41. Findings include: Observation and interview during the initial tour of the facility's kitchen on 07/05/22 at 8:12 A.M. revealed Dietary Manager (DM) #362 was standing in the kitchen area without a hair net covering her hair. The dining room manger (DRM) #322 was standing at the counter with no hair net covering her hair. DM #362 confirmed the findings. DM #362 provided a tour of the kitchen and confirmed an employee lunch was located inside the facility's refrigerator. A pound cake was observed on a shelf in the refrigerator with no label or date. DM #362 confirmed a large bag of open frozen cookies with no label or date. DM #362 opened the free standing ice cream cooler and revealed four three gallon tubs of ice cream with no lids. DM #362 confirmed the ice cream should be covered and labeled with a date. Observation on 07/06/22 at 11:34 A.M. revealed Dietary Cook (DC) #500 placed a food thermometer in a pan of mixed vegetables without sanitizing the thermometer. DC #500 then wiped the food thermometer with a dry dish towel and placed the thermometer in a large pan of black bean salad. DC #500 was observed wiping the food thermometer with a dry dishtowel and placing in the meat of a quesadilla. DM #362 then gave DC #500 a alcohol wipe and encouraged him to clean the food thermometer utilizing the alcohol wipe. Interview on 07/06/22 at 11:34 A.M. with DC #500 confirmed he did not sanitize the food thermometer while obtaining the food temperatures. Review of the resident's diets revealed Resident #37's diet was nothing by mouth. Review of the facility's policy titled Food Preparation Policy, dated 08/20/18, revealed food items should be stored following good sanitary practices and local codes and manufactories specifications. Review of the facility's policy titled General Cleaning and Sanitizing, dated 03/18/21, revealed food contact surfaces must be cleaned and sanitized after every use. Review of the facility's policy titled Personal Hygiene Policy-Personal Hygiene, dated 08/20/18, revealed for staff to wear a clean hat or other hair restraint in all kitchen production/food service areas. Hair must be appropriately restrained per state regulations.

Based on record review, review of Resident Council meeting minutes, review of the facility's policy, and resident and staff interviews, the facility failed to respond to grievances identified at the Resident Council meetings. This affected two (Residents #8 and #12) of three residents interviewed regarding Resident Council meetings. The facility census was 41. Findings include: Record review for Resident #8 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/22/22, revealed Resident #8 had mild cognitive impairment. Record review for Resident #12 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 05/01/22 revealed Resident #12 was cognitively intact. Interviews during Resident Council meeting on 07/07/22 at 10:40 A.M. revealed Resident #8 stated the facility staff does not follow up on concerns brought to the attention of the Resident Council. Resident #12 stated she has the same concern. Resident #12 stated she has brought issues and concerns to the Resident Council meetings, and the facility never followed up on her issues and concerns. Resident #8 stated she feels the concerns were not addressed and not followed up on. Both residents provided examples of bringing their concerns of agency staff and their lack of customer service and approach. Resident #8 and #12 stated they have not received follow up regarding agency staff. Review of the Resident Council meeting minutes, dated January 2022 through March 2022, revealed the facility failed to have a Resident Council meeting for the months of March 2022 and April 2022 and no issues were identified for February 2022. However, during the months of January 2022, May 2022, and June 2022, the Resident Council met and brought forward concerns or grievances for the facility to address. There was no indication the concerns or grievances were followed up by the facility. Interview with the Activity Director (AD) #359 on 07/07/22 at 11:03 A.M. revealed she provides the resident council notes with the grievances and concerns to the Administrator. AD #359 could not confirm if the grievances were followed up on because they were given to the Administrator. Interview on 07/07/22 at 2:32 P.M. with the Administrator confirmed the facility failed to have Resident Council Meetings for the month of March 2022 and April 2022. The Administrator confirmed the facility did not address or provide follow up regarding any of the concerns or grievances brought forth from Resident Council for the months reviewed January 2022 through June 2022. Review of the facility's policy titled Resident Council/Association, dated 09/09/21, revealed the facility representative will be responsible for researching state regulatory guidelines to meet their specific regulations for their community setting and population.

Based on staff interview, medical record review, review of the facility's Self-Reported Incidents and investigations, and policy review, the facility failed to complete thorough investigations of allegations of resident abuse. This affected two (Resident #16 and #97) of three residents reviewed for abuse. The facility census was 41. Findings include: 1. Review of the medical record for Resident #97 revealed an admitted [DATE] with a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had intact cognition. Resident #97 required one-person extensive assistance with transfers, dressing, toileting, and bathing. Review of Resident #97's medical record revealed no documentation of an incident occurring on 02/25/22. Review of the self-reported incident (SRI) control number 9 revealed Resident #97 reported an allegation of neglect on 02/25/22. Resident #97 reported Licensed Practical Nurse (LPN) #343 came into her room to provide care. At that time, LPN #343 asked Resident #97 to turn down her television and was unable to transfer Resident #97. The Director of Nursing (DON) interviewed Resident #97. Resident #97 reported LPN #343 told her loudly to turn down the television, and night shift was unable to transfer her at that time. The DON spoke to LPN #343. LPN #343 stated Resident #97's family requested staff to encourage her to turn off her television at night for rest. LPN #343 explained to Resident #97 the importance of sleep. LPN #343 reported Resident #97 was hard of hearing and raised her voice to speak over oxygen concentrator and the television. LPN #343 revealed Resident #97 requested to get in her recliner at 4:00 A.M., and LPN #343 explained she was doing medication pass and would not be able to assist her at that time. Resident #97 requested to get up to use the restroom. LPN #343 explained Resident #97 was incontinent and felt she was being manipulative to get out of bed. LPN #343 educated Resident #97, and Resident #97 agreed to wait until day shift to get out of bed. Social services will meet with Resident #97 to determine when she would like to get out of bed in the mornings and update her care plan. Staff will be educated on how to accommodate resident's needs. Review of the facility's investigation revealed it did not include staff and resident statements. The investigation did not include any skin assessments of Resident #97 to assess if Resident #97 had any skin impairments related to lack of assistance with toileting when Resident #97 requested to utilize the restroom. The investigation did not include any assessments or interviews of nearby residents. Interview on 07/07/22 at 2:56 P.M. with the DON verified the facility's information regarding SRI 9 was very limited and reported previous Administrator completed this abuse investigation. The DON reported the facility interviewed residents on the same hall where the incident occurred but unable to obtain the documentation. The DON verified there was no skin assessment completed for Resident #97 after the allegation of neglect. 2. Review of Resident#16's medical record revealed Resident #16 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/07/22, revealed Resident #16 had severely impaired cognition. Resident #16 required extensive assistance with bed mobility and transfers. Resident #16 was totally dependent on staff for dressing, eating, toilet use, and personal hygiene. Review of Resident #16's progress notes dated 02/23/22 revealed a hospice nurse reported to the nurse bruising and swelling identified on Resident #16's left foot third digit. The note stated Resident #16 did not voice any complaints of pain. Review of the facility's Self-Reported Incidents (SRI) control number 1 revealed there was an allegation of injury of unknown origin reported to the State Survey Agency. Resident #16 had a bruise of unknown origin identified on 02/23/22. The bruise was located on the third digit toe on Resident #16's left foot. The facility could not provide an investigation related to this SRI. Interview on 07/07/22 at 3:11 P.M. with the Director of Nursing (DON) confirmed the facility did not have an investigation on SRI 1. The DON confirmed the facility reported the bruise of unknown origin to the State Survey Agency as a reportable abuse; however, did not complete an investigation of the cause. The DON stated Resident #16 was known to be combative with care, so the nursing staff assumed this was the cause of the injured toe. Review of the facility's policy titled Abuse Investigation, dated 02/21/12, revealed the facility will identify and investigate all suspicions of abuse. The facility will complete a thorough investigation following an allegation of abuse. The investigation will consists of notifying the physician, family, interviewing staff, and interviewing residents among other steps.

Based on staff interview, review of the facility's policy, and record review, the facility failed to provide written notification of the resident's transfer to the hospital to the residents and/or their representatives. This affected two (Residents #27 and #32) of four residents reviewed for transfers. The facility census was 41. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE] with surgical aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without relief. The physician ordered Resident #32 be sent to the emergency room for further evaluation. There was no evidence Resident #32 received a written notice of transfer. Interview on 07/07/22 at 9:02 A.M. with the Director of Nursing (DON) verified the facility was not providing a written reason for transfer to the resident and/or resident's representative. The DON stated they had a change in personnel and the written reason for transfer was not being completed. 2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #27 was cognitively intact. Review of the progress notes revealed Resident #27 was discharged to the hospital on 09/09/21. Resident #27 returned from the hospital on 09/15/21. There was no evidence the facility provided written notification of transfer to the hospital to Resident #27. Interview on 07/07/22 at 12:55 P.M. with the Director of Nursing (DON) verified the facility did provide written notification of the resident's transfer to the hospital to Resident #27. Review of the facility's policy titled Transfer, Discharge Notice, dated 03/07/18, revealed all transfer/discharge notices must be sent to the resident, resident representative(s), the Long-Term Care Ombudsman program, and any state specific agency, as required.

Based on staff interview, review of facility's policy, and record review, the facility failed to provide bed hold notices to the residents and their representatives when the residents transferred to the hospital. This affected two (Residents #27 and #32) of four residents reviewed for bed hold notices. The facility census was 41. Findings included: 1. Review of the medical record for Resident #32 revealed an admitted [DATE] with surgical aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without relief. The physician ordered Resident #32 be sent to the emergency room for further evaluation. There was no evidence Resident #32 received a bed hold notice when sent to the hospital Interview on 07/07/22 at 9:02 A.M. with the Director of Nursing (DON) verified the facility did not provide Resident #32 and/or resident's representative of a bed hold notice when Resident #32 went to the hospital on 05/25/22. The DON stated they had a change in personnel and the bed hold notices were not being completed. 2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #27 was cognitively intact. Review of the progress notes revealed Resident #27 was discharged to the hospital on 09/09/21. Resident #27 returned from the hospital on 09/15/21. There was no evidence the facility provided a bed hold notice to Resident #27. Interview on 07/07/22 at 12:55 P.M. with the Director of Nursing (DON) verified the facility did not provide Resident #27 and/or resident's representative a bed hold notice when Resident #27 went to the hospital on 09/15/21. The DON stated they had a change in personnel and the bed hold notices were not being completed. Review of the facility's policy titled Transfer, Discharge Notice, dated 03/07/18, revealed the facility will provide notice of their Bed-Hold policy to the resident and representative at the time of admission and again with emergency transfer from the facility.

Based on medical record review, review of the facility's policy, and staff interviews, the facility failed to hold quarterly care conferences with residents. This affected one (Residents #10) of 16 residents reviewed for care conferences. The facility census was 41. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of the care conferences from 06/21/21 to 07/07/22 revealed Resident #10 had care conferences on 06/21/21, 09/20/21, and 12/08/21. There was no additional care conference documentation available after 12/08/21. Interview on 07/07/22 at 9:41 A.M. with Social Services Director (SSD) #300 verified all care conference documentation was in the electronic medical records. SSD #300 verified Resident #10's last care conference was 12/08/21. Review of the facility's policy titled, Care Plan Process-Skilled, dated 07/07/22, revealed to ensure the timeliness of each resident's person-centered, baseline and comprehensive care plan, and to ensure that these care plans are reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care.

Based on staff interview, review of the facility's policy, and record review, the facility failed to ensure residents were weighed as ordered, residents were re-weighed as needed and timely documentation of addressing the resident's weight changes. This affected one (Resident #10) of five residents reviewed for nutrition. The facility identified four residents with unplanned significant weight gain or loss. The facility census was 41. Findings include: Review of the medical records for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 04/22/22, revealed Resident #10 was cognitively intact and required supervision and setup help only for eating. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's weights revealed the following weights: 166.6 pounds (lbs.) on 01/07/22; 174.0 lbs on 01/08/22, 158.0 lbs. on 04/26/22; and 116.0 lbs on 05/01/22. On 05/01/22, it was a 26.5% significant weight loss. There was no re-weight listed for May 2022 and no June 2022 weight listed in the medical record. Further review of the medical record revealed there was no documentation addressing a re-weight was needed for May 2022 and no documentation related to why there was no weight for June 2022. Interview on 07/06/22 at 3:07 P.M. with Registered Dietitian (RD) #361 stated on 05/01/22 at 116.0 lbs. weight was in error. RD #361 stated she would ask for for re-weights by providing the Director of Nursing (DON) with a report. RD #361 verified that there was no dietary note from her related to the weight on 05/01/22 and verified that there were no monthly weight for June 2022. RD #361 stated the facility's policy was for residents to be weighed monthly by the 10th of the month. Interview on 07/06/22 at 4:48 P.M. with the Director of Nursing (DON) stated the nurses on the floor should be checking and getting residents re-weighed at that time of unusual weights, then notify the physician if there was a significant change. Aides would not be aware of previous weights, only nurses. The DON verified there was no documentation to support nursing contacted the physician. Review of the facility's policy titled Weights Policy, dated 03/03/21, revealed all residents will be weighed monthly by the 10th of the month with weights recorded on the Vital Sign Flow Sheet or the electronic health record (EHR) and in the Weight Log Form. If a discrepancy in weight is noted, the resident will be re-weighed.

Based on staff interview, review of the facility's policy and risk assessment, and review of the employee files, the facility failed to ensure the facility newly hired staff received the second step of the [MEDICATION(S)] skin test (TST). This had the potential to affect all 41 residents residing in the facility. The facility census was 41. Findings include: Review of the employee file for State tested Nursing Assistant (STNA) #326, revealed a hire date of 06/07/22. Further review of the employee file revealed a form titled Initial TB testing for Residents and Health Care Workers, dated 01/28/21, revealed the first TB step was completed on 05/27/22 and results were read on 05/30/22. However, the second step was blank and not completed. Review of the employee file for STNA #316 revealed a hire date of 05/12/22. Review of the form titled Initial TB testing for Residents and Health Care Workers, dated 01/28/22, revealed the first TB step testing was completed on 04/27/22 and results read on 04/29/22. However, the second step was blank and not completed. Review of the employee file for STNA #350 revealed a hire date of 05/31/22. Review of the form titled Initial TB testing for Residents and Health Care Workers, dated 01/28/22, revealed the first TB step testing was completed on 05/06/22 and results were read on 05/09/22. However, the second step was blank and not completed. Interview on 07/07/22 at 2:32 P.M. with the Director of Nursing (DON) revealed the facility failed to complete the second TB testing for new hires STNA #326, #316 and #350. Review of the facility's TB risk assessment titled [CONDITION(S)] (TB) risk assessment worksheet, dated 2022, revealed the facility will assess employees for TB upon hire and PRN (as needed). Review of the facility's policy titled Community-Employee [CONDITION(S)] Testing Policy, dated 02/10/22, revealed it is the standard for the company that all employees receive a two-step intra-cutaneous (Mantoux) test.

Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs) and review of facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency, The Ohio Department of Health (ODH) when a resident was discovered with a bruise from knee to ankle and no explanation of the bruise. This affected one (Resident #40) of three residents reviewed for injuries. Facility census was 37. Findings include: Review of the medical record for the Resident #40, revealed an original admitted [DATE], was discharged with return anticipated (DRA) on 11/02/21, readmitted on [DATE] and DRA on 12/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact, had no behaviors, did not reject care, did not wander, was one-person physical assist and required extensive assistance with activities of daily livings (ADLs), required supervision for eating, and was always incontinent to bowel and bladder. Review of the weekly skin assessments from 10/03/21 through 10/19/21 revealed no documented weekly skin assessments being completed. Review of daily skilled nursing notes dated 10/04/21 through 10/21/21 revealed no documented evidence of bruise on right leg, any documented injuries noted to right leg or bruise being reported to administration, physician and/or resident's representative. Review of therapy notes dated 10/13/21 for Resident #40 indicated resident had bruise on right lower extremity but no specific injury was listed. Review of facility generated SRIs dated 10/19/21 revealed no documented evidence of an SRI being created for injuries of unknown source. Review of nurse's progress notes for Resident #40 dated 10/19/21 revealed resident had a bruise from right knee descending to ankle and right ankle had two plus pitting [CONDITION(S)]. Notes indicated resident had a fractured right hip and due to pain, resident refused to allow ankle to be elevated on pillow. Nurses progress notes revealed no documented evidence residents bruise on right leg was reported to administration, physician and/or residents representative. During review of daily skilled nurses notes for Resident #40 dated 10/19/21 revealed no documented evidence of bruise being noted or reported. Interview with Director of Nursing (DON) on 12/21/21 at 11:55 A.M. indicated she was not aware of the bruising documented on 10/19/21. DON stated she was made aware when surveyor questioned the documentation. Interview with LPN #21 on 12/21/21 at 12:00 P.M. indicated she created the nurses progress note on 10/19/21 but could not remember much about it. LPN #21 stated the bruise extended from her knee to her ankle. LPN #21 stated resident was not able to get out bed by herself and refused to move side to side due to her hip being very painful so there was no way she could have fallen or injured it by herself. LPN #21 stated resident was incontinent of bowel and bladder and refused to get up and refused to move. LPN #21 stated she did not notify the Assistant Director of Nursing (ADON), DON, the physician and/or resident's representative when she discovered the bruise. LPN #21 stated she did not document the bruise on her daily skilled nurses notes. Subsequent interview with DON on 12/21/21 at 12:14 P.M. revealed there was no investigation started and no SRI was created when resident #40 was discovered with a bruise from knee to ankle on 10/19/21. DON stated LPN #21 should have immediately reported the bruise to her, physician, and resident's family. Review of 04/12/19 facility policy titled Injuries of Unknown Origin revealed the facility would have a policy in place to ensure complete investigation of any injury of unknown origin. This investigation should assist in determining if the injury can be explained as to its occurrence of if the potential for abuse evidence is, and if abuse is suspected then the abuse protocol was to be followed. Policy indicated all injuries including bruises skin tears, cuts and or lacerations should be reported to the ADON and/or DON. The licensed nurse would be responsible for completing entirely the report to include all known facts relevant to the injury that occurred, and the licensed nurse would be further responsible for notifying the ADON, DON resident's physician and responsible family member related to the injury. Policy also indicated the ADON, and DON would initiate an investigation. Policy indicated for injury to be determine as Injury of Unknown source the source of the injury was not observed by any person and resident could not explain the injury and the injury was suspicious. This was an incidental finding discovered during the course of complaint Number OH 764 investigation and is an example of continued noncompliance from the survey dated 11/26/21.

Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs) and review of facility policy, the facility failed to investigate an injury of unknown origin when a resident was discovered with a bruise from knee to ankle and no explanation of bruise being documented. This affected one (Resident #40) of the three residents reviewed for injuries. Facility census was 37. Findings included: Review of the medical record for the Resident #40, revealed an original admitted [DATE], was discharged with return anticipated (DRA) on 11/02/21, readmitted on [DATE] and DRA on 12/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact, had no behaviors, did not reject care, did not wander, was one-person physical assist and required extensive assistance with activities of daily livings (ADLs), required supervision for eating, and was always incontinent to bowel and bladder. Review of therapy notes dated 10/13/21 for Resident #40 indicated resident had bruise on right lower extremity but no specific injury was listed. Review of nurse's progress notes for Resident #40 dated 10/19/21 revealed resident had a bruise from right knee descending to ankle and right ankle had two plus pitting [CONDITION(S)]. Notes indicated resident had a fractured right hip and due to pain, resident refused to allow ankle to be elevated on pillow. Nurses progress notes revealed no documented evidence residents bruise on right leg was investigated. Review of facility generated SRIs dated 10/19/21 revealed no documented evidence of an SRI being created for injuries of unknown source for Resident #40. Interview with Director of Nursing (DON) on 12/21/21 at 11:55 A.M. indicated she was not aware of the bruising documented on 10/19/21. DON stated she was made aware when surveyor questioned the documentation. Interview with Licensed Practical nurse (LPN) #21 on 12/21/21 at 12:00 P.M. indicated she created the nurses progress note on 10/19/21 but could not remember much about it. LPN #21 stated the bruise extended from her knee to her ankle. LPN #21 stated resident was not able to get out bed by herself and refused to move side to side due to her hip being very painful so there was no way she could have fallen or injured it by herself. LPN #21 stated resident was incontinent of bowel and bladder and refused to get up and refused to move. LPN #21 stated she did not notify the Assistant Director of Nursing (ADON), DON, the physician and/or resident's representative when she discovered the bruise. LPN #21 stated she did not document the bruise on her daily skilled nurses notes and stated she was never interviewed about the bruise. Subsequent interview with DON on 12/21/21 at 12:14 P.M. revealed there was no investigation completed when Resident #40 was discovered with a bruise on right leg from knee to ankle on 10/19/21. Review of 04/12/19 facility policy titled Injuries of Unknown Origin revealed the facility would have a policy in place to ensure complete investigation of any injury of unknown origin. This investigation should assist in determining if the injury can be explained as to its occurrence of if the potential for abuse evidence is, and if abuse is suspected then the abuse protocol was to be followed. Policy indicated all injuries including bruises skin tears, cuts and or lacerations should be reported to the ADON and/or DON. The licensed nurse would be responsible for completing entirely the report to include all known facts relevant to the injury that occurred, and the licensed nurse would be further responsible for notifying the ADON, DON resident's physician and responsible family member related to the injury. Policy also indicated the ADON, and DON would initiate an investigation. Policy indicated for injury to be determine as Injury of Unknown source the source of the injury was not observed by any person and resident could not explain the injury and the injury was suspicious. This was an incidental finding discovered during the course of complaint Number OH 764 investigation and is an example of continued noncompliance from the survey dated 11/26/21.

Based on record review and staff interview, the facility failed to ensure residents received adequate supervision during transfers to prevent injuries. This affected one (#15) of three sampled residents who experienced actual harm with a head injury after a fall during a staff assisted transfer. Findings include: Review of Resident #15's assessment dated [DATE] and accumulative [DIAGNOSES REDACTED]. Review of her fall risk assessment dated [DATE] revealed she was identified as at high risk for falls due to having intermittent confusion, occasional incontinence, balance problems, requiring assistance devices, medication usage, and predisposing diseases. Review of the most current assessment dated [DATE] revealed the resident was assessed as requiring limited assistance of one person for transfers, walking, and locomotion. Review of the 02/14/13 assessment for balance revealed the resident was not steady and was only able to stabilize with staff assistance when moving from the seated to standing position, when walking, for turning around; and for moving from bed to the wheel chair. Review of the facility policy for use of a gait belt revealed the facility had a policy requiring gait belts for all transfers that require staff assistance and when assisting residents to ambulate. Review of Resident #15's medical record revealed she had an ongoing care plan for falls with an initiation date of 03/12/13. According to the care plan the resident was identified as at risk for falls due to impaired safety awareness requiring staff assistance and a history of falls. The interventions included assist resident with one staff for all ambulation to bathroom and us of roller walker. The resident's plan of care for Activities of daily living (ADL) stated the resident required supervision to extensive assistance for all ADL's. The residents care cardex stated she required assistance of one with the use of a gait belt for all transfers. Review of nursing documentation in Resident #15's medical record signed by LPN #14 on 03/14/13 revealed the resident fell while being transferred from the bed to the wheelchair on 03/14/13 at 5:45 A.M. According to the documentation the resident was being assisted by State tested Nursing Assistant (STNA) #28 at the time of the fall and the resident bent at the waist and then her head hit the floor. Review of nursing notes revealed the resident was transported to the hospital at 7:15 A.M. and was returned to the facility by 12:15 P.M. Review of a witness statement dated 03/19/13 written by LPN #14, the LPN whom assessed the resident the morning of the fall, revealed that STNA #28 called for her from Resident #15's doorway on 03/14/13 at 5:45 A.M. She documented that when she entered the resident's room the resident was sitting up on the side of the bed. According to the documentation STNA #28 stated while transferring the resident to her wheelchair the resident fell and hit her head on the floor. According to the statement the nurse ask the resident if she knew why she fall and she stated no and stated it happened so quick. Review of nursing notes dated 03/18/13 revealed the resident had bruising of the forehead and bilateral eyes as a result of this fall. Review of documentation dated 03/14/13 from the hospital emergency department revealed the resident had a final [DIAGNOSES REDACTED]. Review of the CT scan of the cervical spine dated 03/14/13, completed during the emergency room visit on 03/14/13, revealed the final results were suspected old fracture right aspect arch of 1; age indeterminate type II fracture of base of the dens; and severe degenerative changes C3-C7. Review of physician's orders revealed the resident was sent back to the facility from the hospital with an order for [REDACTED]. On 03/15/13 a telephone order was obtained for a C-Collar and for routine and as needed percocet. Review the pain observation and management flow sheets and medication administration records for February and March revealed the resident had increased complaints of pain and increased use of as needed pain medication after she experience the fall. On 04/06/13 at 6:35 A.M. STNA #28 was interviewed. During interview she stated that on 03/14/13 at 5:45 A.M. she was assisting Resident #15 to transfer from the bed to the wheelchair. She stated she was not using a gait because the facility had never issued her one. She stated after getting the resident to the standing position facing the wheel chair the resident lost her balance and fell back on the bed in the sitting position and then fell from the bed to the floor. She stated she hit the floor head first. In her signed written statement she documented that she was only able to grab the resident's waist because it happen so quick. She stated that after the fall she called for the nurse whom was at the end of the hall passing medication and then assisted the resident from the floor to the side of the bed before the nurse arrived to the room just seconds after being called. During interview STNA #28 stated she had been providing care to this resident on the night shift for the past year and had never used a gait belt for this resident nor any other residents because she had never been given one. Review of a facility employee performance correction notice dated 03/22/13 revealed on 03/14/13 STNA #28 was counseled for performing an improper transfer resulting in injury to Resident #15. According to the performance correction notice STNA #28 attempted to transfer the resident from the bed to the wheelchair without using a gait belt and the resident fell to the floor causing injury to her face. This certification deficiency substantiates Complaint Control Number OH 714.