Every finding on record at Manor of Grande Village

Based on observations, interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 73 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 73. Findings include: Observation during a tour of the kitchen on 06/30/24 from 8:10 A.M. to 8:30 A.M. with [NAME] #566 revealed Dietary Aide (DA) #601 had a full beard with no beard net on while in the kitchen. DA #601 stated on 06/30/24 at 8:10 A.M. that he should have been wearing a beard net. Observation of the walk-in refrigerator revealed salad mix not labeled or dated, meatballs in a pan with a ripped foil cover, and a half of an undated cucumber. The door to the dining room and plate warmer had food splatter and food residue on it. The identified findings were verified at the time of observations with [NAME] #566. A revisit to the kitchen for tray line observation on 07/01/24 revealed that one food cart was dirty with food splatter on the door and inside. This was verified by Regional Dietary Manager #600 at 11:40 A.M. Further observation on 07/01/24 at 11:45 A.M. revealed the ceiling had grease and mold on it near the fan. This was verified by Regional Dietary Manager #600 during observation. Review of the undated facility policy titled, Sanitation and Food Handling, revealed that sanitary conditions will be maintained, and personnel will observe cleanliness and exercise food handling techniques.

Based on observation, interview, taste test and pureed/mechanical soft guidelines review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect four residents (#1, #22, #46, and #58) who were prescribed pureed diets of 73 residents who consumed meals from the facility's kitchen. The facility census was 73. Findings include: Observation and interview on 07/01/24 at 10:45 A.M. revealed [NAME] #566 pureed hamburgers, and they were the proper consistency. [NAME] #566 then pureed the French fries and portioned a sample into a monkey dish for the taste test. The French fries were contained lumps and were not a smooth consistency. Regional Dietary Manager #600 verified on 07/01/24 at 11:00 A.M. and stated [NAME] #566 should puree the French fries more. The French fries were pureed correctly prior to service. The facility identified four residents (#1, #22, #46, and #58) who were prescribed pureed diets. Review of the facility's pureed/mechanical soft guidelines revealed pureed foods should be pureed until smooth.

Based on record review, observation, and interview the facility failed to ensure call lights were within reach of Residents #37 and #176. This affected two residents (#37 and #176) of 73 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including multiple sclerosis, heart failure, dementia, depressive disorder, acute kidney failure, Parkinson's, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition and required moderate assistance of staff for eating, bed mobility, transfers, and hygiene. Review of the care plan dated 04/26/24 revealed Resident #37 had a history of falls related to Parkinson's, weakness, and dementia. Intervention included keeping the call light within reach. Observation on 06/30/24 at 9:45 A.M. of Resident #37 revealed she was lying in bed, and her call light was lying on the floor next to her bed. Interview at this time with Certified Nursing Assistant (CNA) #508 verified the call light was out of reach and stated the resident was able to use her call light. CNA #508 stated Resident #37 was not on her assignment. 2. Review of the medical record for Resident #176 revealed an admitted [DATE] with diagnoses including Parkinson's, schizoaffective, epilepsy, dementia, obesity, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #176 had intact cognition and impairment to one side. The resident required set up with eating and was dependent for transfers and bed mobility. The resident was dependent on staff for toileting and showers. Review of the care plan dated 06/20/24 revealed Resident #176 was at risk for falls related to weakness and seizures. Intervention included using call light for assistance. Observation on 06/25/24 at 11:49 A.M. of Resident #176 revealed she was lying in bed, and her call light was lying on the nightstand next to her bed on top of several stuffed animals. The call light was out of her reach. Interview with Resident #176 stated CNA #508 and State tested Nurse Aide (STNA) #586 changed her earlier today. The call light was placed on the nightstand by staff during care. Staff forgot to put it back within reach prior to leaving. Interview on 06/25/24 at 12:06 A.M. with STNA #586 verified Resident #176's call light was out of reach and sitting on her nightstand. STNA #586 stated Resident #176 and was not on her assignment.

Based on record review and interview, the facility failed to ensure Resident #29's code status was accurately reflected in both the hard medical chart and the electronic medical record. This affected one resident (#29) of 73 residents reviewed for advanced directives. The facility census was 73. Findings include: A review of Resident #29's hard medical chart revealed he was admitted to the facility on [DATE] with diagnoses of heart failure, end stage renal disease, and hypothyroidism. A document with the words, Full Code, was located on the face sheet in the electronic chart. A full code status means all emergency life saving measures will be provided in the event of respiratory arrest or cardiac arrest. Review of Resident #29's medical record dated 01/03/24 located in the hard chart revealed a code status of Do Not Resuscitate-Comfort Care Arrest (DNR-CCA). A DNR-CCA means a person would receive all emergency and medical care up until the time he or she experiences a cardiac or respiratory arrest, then all lifesaving measures would be stopped. Interview on 06/30/24 at 2:21 P.M. with Licensed Practical Nurse (LPN) #546 verified that the electronic chart showed Resident #29 as a Full Code, and the hard chart showed Resident #29 had a DNR-CCA.

Based on observation and interview, the facility failed to ensure Insulin KwikPens and insulin vials were dated when opened. This affected three residents (#3, #7, and #226) of twelve residents who were identified by the facility as receiving insulin. The facility census was 73. Findings include: Observation on 06/30/24 at 11:19 A.M. of a medication cart revealed two KwikPens not dated when opened, for Residents #3 and #7, and one used insulin vial not dated when opened for Resident #226. Interview at the time of the observation, Registered Nurse (RN) #530 stated all insulin pens should be dated when initially opened during the observation. Review of the facilities policies and procedures revealed no policy for insulin storage. This was verified by the Director of Nursing on 07/01/24 at 3:35 P.M.

Based on record reviews, review of three self-reported incidents (SRIs) and interviews the facility failed to ensure Resident #52 was free from physical abuse by Resident #54. This affected one resident (Resident #52) of five residents reviewed for abuse. The census was 76. Findings include: Review of SRI #244843 started on 03/05/24 and timed at 6:36 P.M. and completed on 03/11/24 and timed at 3:33 P.M. revealed Resident #54 struck Resident #52 several times on the left eye and left side of face. Staff separated immediately, assessed, completed skin checks and vitals. Immediate interventions put in place were one-on-one supervision, then every 15-minute checks for two days, deep-breathing and distraction. Review of progress noted dated 03/05/24 revealed Resident #54 had a new order for Ativan as needed for 14 days. Physician assistant and psychiatry consultations were ordered. Review of progress note on 03/08/24 revealed a care conference was held with the responsible party where the abuse policy was reviewed and alternate placement was discussed but no decision was made at that time. Review of SRI #245441 started on 03/20/24 and timed at 12:08 P.M. and completed on 03/25/24 and timed at 2:01 P.M. revealed Resident #54 struck Resident #52 on his left side. Staff separated the residents. Resident #54 was being aggressive and refused vitals. Resident #54 was sent to the emergency room at 12:44 A.M. and returned at 5:16 A.M. with no new orders. The facility was attempting to find alternate placement. The resident had one-on-one supervision until she was sent to psychiatric hospital on 03/21/24 at 7:36 P.M. Progress notes revealed Resident #54 returned to the facility on [DATE]. Review of progress note on 04/18/24 revealed social service spoke with responsible party about alternative placement. Review of SRI # 247879 started on 05/23/24 and timed at 9:13 P.M. and completed on 05/30/24 and timed at 4:38 P.M. revealed Resident #54 was witnessed holding Resident #52 against the wall then they began to strike one another across the face. They were separated and assessed. Resident #54 was placed on one-on-one observations. The intervention was Resident #54 was sent to the emergency room however she returned the same day with no new orders. Prior interventions for Resident #54 included hospitalization and medication review and every 15-minute checks for two days after incidents. a. Record review of Resident #54 revealed an admitted [DATE] with diagnoses including Wernicke's encephalopathy, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, unspecified disorder of adult personality and behavior, major depressive disorder and depression. Review of Resident #54's care plan dated 11/27/23 revealed a goal for monitoring her behaviors. Interventions included medicating as prescribed and monitoring effectiveness, praising positive behaviors and removing from public area when behavior was unacceptable. The care plan was not revised since initiated or after each incident Resident #54 displayed aggressive, abusive behavior. Review of Resident #54's progress note dated 05/23/24 at 8:15 P.M. revealed a state tested nursing assistant (STNA) saw Resident #54 with her hands around the neck of Resident #52. The note stated they began to strike one another back and forth on the face. The residents were separated and assessed. A skin check was performed, vitals were stable, one-on-one supervision was initiated, and all parties were notified. b. Record review of Resident #52 revealed an initial admitted [DATE] and re-admitted [DATE] with diagnoses including cerebral infarction, dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and Alzheimer's Disease. Review of Resident #52's progress note dated 05/23/24 at 8:10 P.M. revealed a STNA saw Resident #52 being held against the wall by another resident with a hand around his neck. The residents began to strike each other back and forth on the face. The residents were separated and assessed. A skin assessment was completed. Resident #52 had an abrasion to the left side of his neck and right side of his face. He denied pain. It stated he would be sent to the hospital when transportation was available. Interviews on 06/03/24 from 3:20 P.M. to 5:00 P.M. with STNA #201 revealed Resident #54 was upset about missing money and it escalated. She believed Resident #54 knew what she was doing at the time though she did not recall later. Licensed Practical Nurse (LPN) #203 revealed she had seen her be accusatory before. She stated the resident was forgetful. STNA #209 revealed what Resident #52's nickname was which was how Resident #54 identified him as when questioned. STNA #201, STNA #202 and STNA #209 did not mention specific interventions attempted when asked. Review of the record revealed no evidence of non-pharmacological interventions attempted. Interview and observation on 06/03/24 at 5:14 P.M. revealed Resident #54 was sitting in the dining room outside of the nursing station window talking to LPN #203. Resident denied being aware of any incidents with other residents and looked surprised but said if someone said it happened, it must have. She said the only person she could think of having an issue with was Resident #52, calling him by his nickname, unbeknownst to the surveyor at the time. Interview and observation on 06/03/24 at 5:18 P.M. revealed Resident #52 was sitting in the common area on the couch beside a female resident watching TV. When we caught each other's eyes, he smiled but did not initially respond to his nickname when called. When asked how he was he said good. He did not answer further questions. Interview on 06/04/24 at 10:59 A.M. with Social Service Designee (SSD) #211 revealed she was attempting to find alternative placement for Resident #54 since March because of behaviors. She stated the responsible party was not initially receptive. She verified there were three SRIs involving allegations of abuse with Resident #54 as the aggressor against Resident #52. Interview on 06/04/24 at 11:45 A.M. with LPN #210 revealed there were three SRIs involving allegations of abuse between Resident #52 and Resident #54. Resident #54 had some medication changes since March. She verified the care plan did not reflect any revisions to Resident #54's interventions, especially non-pharmacological ones. She reviewed the progress notes with the surveyor revealing Resident #54 was sent to the hospitalER on [DATE] but returned the same day with no new orders. There were no additional medication changes until 05/29/24. She stated the STNAs may be the ones doing interventions but there was no evidence of what interventions were attempted. LPN #210 stated the resident did not normally have behaviors. LPN #210 stated Resident #52 and #54 seek each other out and hang out together. She stated Resident #54 does not flinch or try to hide from her. Interview on 06/04/24 at 2:00 P.M. with the Administrator revealed the facility has been actively seeking alternate placement for Resident #54 and an Emergency discharge notice was given. He stated the Ombudsman was aware. He stated the past interventions have been medication changes and hospitalization s. He verified the care plan did not have any revisions to the interventions for Resident #54's behaviors. He stated Resident #52 and Resident #54 have the right to interact with one another and the facility could not stop them from doing so. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2022 revealed the facility prevention and identification was to include the assessment, care planning and monitoring of residents with history of aggressive behaviors. The interdisciplinary team was to determine proper interventions for resident to resident cases. This deficiency represents non-compliance investigated under Complaint Number OH00154414.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of safety data sheets, review of job descriptions, and review of facility policy, the facility failed to ensure corrosive toilet cleaning products were securely stored on the memory care unit. This affected one resident (Resident #50) of three residents reviewed for accident hazards and had the potential to affect the 11 other residents (#1, #18, #19, #38, #40, #44, #46, #47, #54, #68, and #70) the facility identified as being independently ambulatory, cognitively impaired, and resided on the memory care unit. The facility census was 73. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included cerebral infarction (stroke), dementia, Alzheimer's disease, and unspecified disorientation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was severely impaired cognitively, rejected care and wandered daily, and could walk ten feet in a room, corridor, or similar space independently. Review of the care plan dated 08/11/23 revealed Resident #50 had a potential for injury related to wandering, Alzheimer's, dementia, and confusion with a goal Resident #50 would wander in safe locations and would have safety maintained. Interventions included observe for wandering, know the resident's whereabouts, determine pattern to wandering, provide one on one visits as needed, and complete safety checks as needed. Review of Resident #50's progress note, authored by License Practical Nurse (LPN) #328 and dated 11/05/23 at 10:47 A.M., revealed the author was alerted by an unidentified resident who stated no don't drink that referring to Resident #50 who was immediately observed by LPN #328 with a bottle of cleaning solution sitting next to the Resident #50 on the floor. LPN #328 asked the resident if he had drank the cleaning solution and Resident #50 responded in an expletive and stated why won't you let me die but did not indicate if he had drank it or not. LPN #328 called the physician assistant who ordered Resident #50 to be sent out to the hospital for an evaluation. Review of the hospital records for Resident #50 dated 11/05/23 revealed the physician noted it was unclear if the resident ingested a caustic substance, he was hemodynamically stable, not ill appearing or sweating, no abnormality noted to his mucus membranes or throat upon exam. The staff from the facility had reported to the hospital staff Resident #50 had a history of suicidal ideation so the resident was admitted for monitoring and a psychiatric evaluation. Further review of progress notes for Resident #50 revealed he was admitted back to the facility on [DATE]. Review of Safety Data Sheet, dated 04/15/15, identified Cling Bowl Cleaner (toilet cleaner) as having a hazardous identification of corrosive, serious eye damage, and skin corrosion. Review of the job description for the position of housekeeping aide which was signed by Housekeeping #323 on 02/17/23, revealed essential job duties included making sure all safety measures were used when housekeeping duties were being performed, which included securing chemicals. Interview on 11/08/23 at 8:11 A.M. with Housekeeping #323 revealed as she was getting the cleaning products out of the locked cabinet in the housekeeping cart on 11/05/23, she placed them temporarily on the ledge of the housekeeping cart where the mop bucket was stored until she had gotten all the products she needed. Housekeeping #323 stated when she grabbed all the cleaning products from the ledge of the housekeeping cart, she must have forgotten the toilet bowl cleaner, which was left sitting on the ledge where the mop bucket was stored. Housekeeping #323 confirmed she had left the toilet bowl cleaner unsecured on the dementia unit on 11/05/23 and chemicals needed to be secure and locked when not in use. Interview on 11/08/23 at 10:30 A.M. with State tested Nursing Assistant (STNA) #363 revealed on 11/05/23, Resident #50 was found sitting in a chair with a bottle of toilet bowl cleaner sitting on the floor next to him but had not seen him drink it. Interview on 11/08/23 at 10:39 A.M. with LPN #328 revealed on 11/05/23 she had seen a bottle of cleaner next to Resident #50 but had not seen him drink it. Interview on 11/13/23 at 8:26 A.M. with STNA #342 revealed on 11/05/23 she saw a bottle of toilet bowl cleaner sitting on the floor next to Resident #50 but had not seen him drink it. Review of facility policy Dementia Care Policy, revised March 2022, revealed the facility would provide the necessary care and services to any resident who displayed or was diagnosed with dementia which would be person-centered and would reflect the resident's goals while maximizing the resident's dignity, autonomy, privacy, socializations, independence, choice, and safety. The deficient practice was corrected on 11/06/23 when the facility implemented the following corrective actions: On 11/05/23 all residents on the memory care unit were assessed by staff as free from exposure to accident hazards. On 11/05/23, the entire building was swept by the Housekeeping Director (HD) #324 for any unsecured chemicals, with none found. On 11/05/23, the entire housekeeping department, which consisted of seven employees, was educated on securing chemicals by the Director of Nursing (DON). On 11/05/23, both housekeeping carts were inspected by the HD #324 to ensure locking mechanisms and all parts were in working order, with no concerns found. On 11/06/23, all 67 facility staff were educated by the DON or designee on safety and securing of chemicals. Starting on 11/06/23, the Administrator of designee began randomly auditing two housekeepers each business day for safety and security of chemicals for two weeks and randomly thereafter. Starting on 11/06/23, HD #324 or designee began auditing chemicals on the housekeeping cart at the beginning and the end of the shift, each business day for two weeks and randomly thereafter. The results of the audits would be reviewed by the Quality Assurance Committee. There were no further incidents of non-compliance related to residents being exposed to accident hazards through the date of this survey completed on 11/13/23. This deficiency represents non-compliance investigated under Complaint Number OH00148127.

Based on observations, facility policy review and staff interviews, the facility failed to ensure two of four medication carts were maintained locked when not in use. This had the potential to affect all residents on the 200 and 400 hallways (Residents #25 through #47 and Residents #67 through #80). The facility census was 79. Findings include: 1. Observation upon entering the 400 hallway on 06/16/23 at 6:27 A.M. revealed an unlocked medication cart with an insulin pen sitting on top of the cart. No staff were close to or around the unsecured medication cart. Interview with Licensed Practical Nurse (LPN) #140 on 06/16/23 at 6:31 A.M. revealed LPN #140 was inside a resident room, with the door closed. LPN #140 confirmed she left the medication cart unlocked with an insulin pen sitting on top of the cart. 2. Observation of the 200 hallway on 06/16/23 at 9:31 A.M. revealed an unlocked medication cart across from room [ROOM NUMBER]. LPN #170 was located by the facility Administrator at 9:35 A.M. and returned to the medication cart and confirmed the cart was unlocked. LPN #170 identified she worked for a staffing agency. Review of the facility medication storage policy dated August 2021 identified medication card and other supplies are to be stored in a lock medication cart.

Based on record review, interview, and review of the facility policy the facility failed to notify the resident representatives of a room change for two Residents (#37 and #61). This affected two Residents (#37 and #61) of three residents reviewed for notification of room change. The facility census was 78. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included end stage renal disease, diabetes, depression, and sleep apnea. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition. Review of the medical record revealed Resident #37 was moved to a semiprivate room on 12/07/22 and to a private room on 12/11/22. Review of the nurses' notes dated 12/07/22 through 12/11/22 revealed no documented evidence Resident #37 or her representative were notified of the need to change rooms. 2. Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included lymphoma, hypertension, arthritis, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 had intact cognition. Review of the medical record revealed Resident #61 was moved to a semiprivate room on 12/07/22. Review of the nurses' notes dated 12/07/22 through 12/11/22 revealed no evidence Resident #61 or her representative were notified of the need to change rooms. Interview on 12/20/22 at 8:20 A.M. with Resident #37 revealed no knowledge of a room change. Interview on 12/20/22 at 11:45 A.M. with Social Service Designee (SSD) #203 revealed she documented room changes in the electronic medical record, to include contact with the residents' representative. Interview on 12/20/22 at 12:36 P.M. with Resident #61 revealed her sister/representative was not notified prior to either move. Interview on 12/20/22 at 12:46 P.M. with SSD #203 revealed she notified both Residents #37 and #61's representatives of the room changes but did not document the contact. Interview on 12/20/22 at 12:49 P.M. with Resident #61's sister/representative confirmed she was not notified of the room changes. Review of the facility policy titled Notification of Change in Resident Condition, dated January 2022, revealed the facility would notify the resident's representative in the event of a room change. This deficiency represents non-compliance investigated under Master Complaint Number OH00138328.

Based on record review, interview, policy review, and review of facility Self-Reported Incidents (SRI)'s the facility failed follow their policy for abuse when they did not thoroughly investigate one incident of neglect and one incident of verbal abuse. This affected two Residents (#13 and #31) of seven residents reviewed for abuse. The facility census was 78. Findings include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included depression, diabetes, insomnia, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had moderately impaired cognition. She required extensive assistance of one staff for most activities of daily living (ADL). Review of the facility SRI dated 05/04/22 revealed Resident #31 reported State tested Nurse Aide (STNA) #212 was allegedly emotionally abusive. The investigation revealed witness statements were obtained from staff, and STNA #212 was provided an in-service on abuse. Upon review of the investigative file, there was no documented evidence of staff interviews or an in-service for STNA #212. 2. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included diabetes, Alzheimer's, anxiety, and hypertension. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #13 had a memory problem and required extensive assistance of two staff for most ADL. Review of the facility SRI dated 08/25/22 revealed Resident #13's family had various concerns regarding her care. The investigation revealed staff were educated on neglect but revealed no documented evidence other residents or families were interviewed about their care. Interview on 12/20/22 at 3:55 P.M. with the Administrator confirmed there were no statements from staff and no in-service for the SRI involving Resident #31, and there were no documented evidence of interviews or assessments of other residents for the SRI involving Resident #13. He confirmed the investigations could have been more thorough. Review of the facility policy for abuse, revised October 2022, revealed staff would be trained as needed on abuse and neglect and witness statements would be obtained.

Based on record review, interview, policy review, and review of the facility Self-Reported Incidents (SRI)'s the facility failed to thoroughly investigate one incident of neglect and one incident of verbal abuse. This affected two (Residents #13 and #31) of seven residents reviewed for abuse. The facility census was 78. Findings include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included depression, diabetes, insomnia, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had moderately impaired cognition. She required extensive assistance of one staff for most activities of daily living (ADL). Review of the facility SRI dated 05/04/22 revealed Resident #31 reported State tested Nurse Aide (STNA) #212 was allegedly emotionally abusive. The investigation revealed witness statements were obtained from staff, and STNA #212 was provided an in-service on abuse. Upon review of the investigative file, there was no documented evidence of staff interviews or an in-service for STNA #212. 2. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included diabetes, Alzheimer's, anxiety, and hypertension. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #13 had a memory problem and required extensive assistance of two staff for most ADL. Review of the facility SRI dated 08/25/22 revealed Resident #13's family had various concerns regarding her care. The investigation revealed staff were educated on neglect but revealed no documented evidence other residents or families were interviewed about their care. Interview on 12/20/22 at 3:55 P.M. with the Administrator confirmed there were no statements from staff and no in-service for the SRI involving Resident #31, and there were no documented evidence of interviews or assessments of other residents for the SRI involving Resident #13. He confirmed the investigations could have been more thorough. Review of the facility policy for abuse, revised October 2022, revealed staff would be trained as needed on abuse and neglect and witness statements would be obtained.

Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 76 residents currently residing in the facility. Findings include: Review of the staffing schedules from 04/14/22 through 04/17/22 revealed no registered nurses (RNs) were working in the facility on 04/17/22. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/21/22 at 6:46 P.M. with Human Resources #511 verified there were no RNs working in the facility on 04/17/22.

Based on observation, interview and review of facility policy the facility failed to date and store opened medications properly and failed to dispose of expired medications. This had the potential to affect all 76 residents residing in the facility. Findings include: Observation on 04/20/22 at 9:32 A.M. on the secured nursing unit revealed one five milliliter (ml) bottle of Sanofi brand influenza vaccine opened and undated in the refrigerator and one [MEDICATION(S)] (TB) purified protein derivative 0.1 ml bottle opened and undated. Interview with Licensed Practical Nurse (LPN) #659 at the time of the observation verified the influenza and TB vaccine bottles did not have an opened date. LPN #659 indicated the refrigerator was shared between the secured nursing unit and another nursing unit. Observation on 04/20/22 at 9:55 A.M. of the medication cart for the secured nursing unit revealed two one calcitonin nasal spray opened and undated, one [MEDICATION(S)] for Resident #7 opened and undated, [MEDICATION(S)] inhalation aerosol for Resident #3 opened and undated and a bottle of Nymic topical powder for Resident #36 opened and undated. The locked controlled medication box contained two cards of lorazapam 0.25 milligram (mg) for Resident #71, one card contained 30 pills and expired 11/18/21 and the other contained five pills and expired 01/07/22. Interview at the time of the observation with LPN #659 confirmed the expired medication, LPN #659 indicated the expired medication should have been sent back to the pharmacy since the residents were no longer residing on that hall. Two bottles of [MEDICATION(S)] 250 mg per 5 ml, one for Resident #71 and one for Resident #49 were opened and undated in the drawer of the medication cart. Observation on 04/20/22 at 10:31 A.M. of the refrigerator for Nursing Unit #1. The refrigerator had four vials of [MEDICATION(S)] 30 ml for Resident #2. Interview at the time of the observation with LPN #590 revealed Resident #2 was no longer at the facility. One bottle of [MEDICATION(S)] insulin [MEDICATION(S)] injection 10 units per ml for Resident #55 was opened and undated, one [MEDICATION(S)] Kwik pen for Resident #1 was opened and undated. Observation on 04/20/22 at 11:55 A.M. of the medicine cart for Nursing Unit #1 revealed omeprazole 20 mg had an expiration date which had been rubbed off and was not visible. One bottle of insulin [MEDICATION(S)] was opened and undated as well as a [MEDICATION(S)] pen for Resident #50 which was opened and undated. Interview on 04/20/22 with the Director of Nursing confirmed all opened medications should have an open date and expired medications should be discarded.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate use of personal protective equipment (PPE) for one resident (Resident #278) on Transmission Based Precautions (TBP), failed to [MEDICATION(S)] reusable non-critical care equipment was disinfected after each resident use, and failed to ensure linens for residents on TBP were processed appropriately in the laundry area. This had the potential to affect all residents residing in the facility. The facility census was 76. Findings include: 1. Review of Resident #278's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #278 was on transmission based precautions due to being an unvaccinated new admission. Observation on 04/20/22 at 7:34 A.M. revealed a plastic cart with personal protective equipment (PPE) outside of Resident #278's room, a door covering with PPE, and a sign on the door for Transmission Based Precautions (TBP). Observation of Registered Nurse (RN) #535 revealed she walked out of Resident #278's room and was not wearing an N95 respirator, an isolation gown, gloves, or a face shield. RN #535 was wearing a surgical mask and confirmed she was not wearing PPE as indicated for TBP. RN #535 stated Resident #278 needed something and she went in the room without donning appropriate PPE. Observation on 04/20/22 at 7:39 A.M. of RN #535 revealed she did not change her surgical mask after walking out of Resident #278's room. Further observation revaled RN #535 prepared for the next resident and walked into Resident #44's room carrying a blood pressure cuff, thermometer, and a pulse oximeter. RN #535 took Resident #44's blood pressure, temperature and measured her oxygen saturation with the pulse oximeter, walked out of the room, placed them on top the medication cart and did not disinfect the the blood pressure cuff, thermometer, or pulse oximeter before using them on the next resident. RN #535 changed her sugical mask after exiting Resident #44's room and stated she forgot to change it after leaving Resident #278's room. Observation on 04/20/22 at 8:00 A.M. of RN #535 revealed she picked up the blood pressure cuff used for Resident #44, did not disinfect it, walked into Resident #275's room and took his blood pressure. RN #535 did not disinfect the blood pressure cuff after taking Resident #275's blood pressure and placed the cuff on the medication cart. Observation on 04/20/22 at 8:23 A.M. of RN #535 revealed she did not disinfect the blood pressure cuff, thermometer, and pulse oximeter, picked them up off the medication cart, carried them into Resident #276's room and took his blood pressure, temperature, and measured his oxygen saturation levels with the pulse oximeter. RN #535 did not disinfect the blood pressure cuff, thermometer, and pulse oximeter before placing them on the medication cart. RN #535 confirmed she did not disinfect the blood pressure cuff, thermometer, and pulse oximeter after using on Resident's #44, #275 and #276. Observation on 04/20/22 at 8:55 A.M. of Licensed Practical Nurse (LPN) #591 revealed she picked up a blood pressure cuff and pulse oximeter off the medication cart, walked into Resident #125's room, took her blood pressure and measured her oxygen saturation with the pulse oximeter, walked to the medication cart, did not disinfect the blood pressure cuff and pulse oximeter before or after placing them on the medication cart. LPN #591 began preparing for the next resident and confirmed she did not disinfect the blood pressure cuff or pulse oximeter after using for Resident #125. Review of the CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 02/02/22, included empiric use of Transmission-Based Precautions (quarantine) was recommended for residents who were newly admitted to the facility and for residents who have had close contact with someone with [CONDITION(S)] CoV-2 infection if they were not up to date with all recommended COVID-19 vaccine doses. 2. Interview on 04/21/22 at 1:04 P.M. with Housekeeping Director #517 revealed laundry received from an isolation room entered the laundry room in a yellow bag and should be washed on level three of the washing machine. Interview on 04/21/22 at 2:12 P.M. with Housekeeping Aide #506 revealed she did not separate isolation laundry from other soiled laundry. Yellow bagged laundry was emptied into the regular laundry and all was placed in the washing machine at the same time, on cycle one. Housekeeping Aide #506 indicated she did not use bleach with any of the laundry and did not wear gloves, eye protection or any other personal protective equipment (PPE) when doing laundry. Review of the facility policy for laundry, undated, revealed all laundry staff were to wear appropriate (PPE) at all times. Review of the facility policy on yellow bagged linen, undated, revealed staff would be in-serviced on washing contaminated linen and using the correct wash cycle.

Based on staff interview and record review, the facility failed to ensure a resident received notice of discharge in a timely manner. This affected one resident ( Resident #20) of one resident reviewed for discharge from facility. The facility also failed to ensure written notice of hospital transfers including the reason for the transfer were given to the resident or their representative and were provided to the long term care (LTC) Ombudsman in a timely manner. This affected three residents (#30, #33, and #50) of three residents reviewed for hospitalization . The facility census was 76. Findings include: 1. Review of the medical record for Resident #20 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the accounting notes dated 03/17/22 revealed Resident #20 was provided with a 30-day discharge letter on 03/17/22. Review of the undated 30-day discharge notice, revealed Resident #20 would be discharged on [DATE] due to the resident being cut by insurance. Review of the discharge records for Resident #20, revealed the resident was discharged on [DATE]. Interview on 04/20/22 at 12:31 P.M. with Business Office Manager (BOM) #518 verified the 30-day discharge notice was undated. BOM #518 said the discharge notice was given to Resident #20 on 03/17/22, which was not 30 days prior to the resident's discharge. 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30 was transferred to the hospital on 01/21/22 and 02/23/22. Review of the annual Minimum Data Set (MDS) assessment, dated 03/30/22, revealed Resident #30 had moderately impaired cognition, required the extensive assistance of two people for bed mobility, transfers, and toileting, and extensive assistance of one was needed for locomotion, dressing and personal hygiene. Review of the Transfer/Discharge form dated 01/21/22 revealed Resident #30's daughter/ power of attorney (POA) was notified by phone, a written notice was not provided. Review of the Transfer/Discharge form from 02/23/22 revealed the Resident #30's daughter/ POA was notified by phone, a written notice was not provided. 3. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 02/03/22 revealed an X-ray ordered by the physician's assistant revealed a [CONDITION(S)] and an order to send Resident #33 to the hospital. Review of a progress note dated 02/06/22 revealed Resident #33 was sent to the hospital because she was unable to bear weight on the right side of her body and appeared to be in pain when she moved. Resident #33 was admitted to the hospital for a right [CONDITION(S)]. Review of the transfer and discharge notices from the facility for the month of February 2022 revealed there was no reason provided to Resident #33 for the transfer on 02/03/22 and there was no evidence of a transfer and discharge notice being provided to Resident #33 on 02/06/22. 4. Review of the medical record for Resident #50 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the list of hospital transfers and discharges dated December 2021 through April 2022 revealed Resident #50 transferred to the hospital on 12/02/21, 12/22/21, and 03/01/22. Review of the Transfer/Discharge Notice forms dated 12/02/21, 12/22/21, and 03/01/22 revealed the form was reviewed with Resident #50's Power of Attorney (POA) via phone and did not list the reason for the hospital transfers. Interview on 04/21/22 at 8:22 A.M. with Admissions Staff (AS) #541 revealed she emailed the LTC Ombudsman the hospital transfers and discharges for December 2021, January 2022, and February 2022 on 04/20/22. AS #541 stated she usually emailed the list in the first couple days of the following month and could not find evidence that those months were sent prior to 04/20/22. AS #541 verified the hospital transfer notices did not provide the reason for the transfer and that she did not provide written notices to the residents' or their representatives. AS #541 stated she usually asked them if they wanted a copy and believed they had all declined. Reviewed the facility policy titled Transfer Discharge Notice Protocol, dated October 2018, revealed it was the policy of the facility for staff to complete the Transfer/Discharge Notice at the time of discharge or transfer. The notice should be signed by the resident (if able) at the time of discharge or transfer. If the discharge or transfer was emergent in nature, staff were to follow up with the family via phone and review the Transfer Discharge Notice. The tracker was to include the following information: Date of Discharge, Resident's Name, Discharge Destination, Date Written Notification Provided to Resident and or Resident Representative, Date of Re-admission, and, if applicable, Location of Alternate Discharge Location. At the beginning of each month, last month's tracker was to be submitted to the Ombudsman's office and the local state department of health, if so directed.

Based on interview, record review and review of the facility policy, the facility failed to ensure advance directives (level of medical interventions a resident wishes to have performed in the event they experience an absence of a heartbeat or breathing) were located in the medical record. This affected two (Residents #32 and #66) of two residents reviewed for advanced directives. The facility census was 76. Findings include: 1. Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders dated 12/24/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This meant the resident was to receive standard medical care until her heart stopped beating or she stopped breathing. Review of the physical chart for Resident #32 revealed no evidence of the State of Ohio DNR form. Interview on 04/20/22 at 8:57 A.M. with Licensed Practical Nurse (LPN) #520 confirmed the DNR form was not in the chart and should have been. Interview on 04/20/22 at 1:49 P.M. with the Director of Nursing (DON) revealed the DNR form should be kept in the resident's physical chart. Review of the facility's policy for advanced directives revised January 2022 revealed a copy of the advanced directive should be placed in the resident's chart in the event the directive should need to be implemented. 2. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders revealed Resident #66 had an order dated 03/17/22 for Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Review of the electronic and paper medical charts for Resident #66 revealed there was no DNR paperwork present for Resident #66. Review of Resident #66's care plan dated 03/31/22 revealed there was no care plan in place regarding the resident's advanced directive. Interview on 04/20/22 at 4:14 P.M. with the Regional Administrator confirmed there was no Ohio Comfort Care Do Not Resuscitate order form or paperwork contained in the resident's medical record prior to 04/20/22.

Based on interview and record review, the facility failed to report suspicion of abuse to the State agency within the required time frame. This affected two residents (#5, and #15) of four residents reviewed regarding submitted Self-Reported Incidents (SRIs). Facility census was 76. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #5's cognition was not assessed and the resident was independent with bed mobility, required limited assistance of one staff for transfers, and supervision of one staff for ambulation. Review of the progress note dated 03/30/22 at 5:33 P.M. revealed a state tested nurse aide (STNA) notified the nurse Resident #5 attempted an inappropriate sexual act with another resident (Resident #15). Both residents were placed on 15 minute checks for 24 hours. The Unit Manager and Administrator were notified to notify physician and family. Review of the medical record for Resident #15 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #15 had severely impaired cognition and required supervision of one staff for bed mobility, and supervision with set up help for transfers, and ambulation. Review of the progress note dated 03/30/22 at 5:33 P.M. revealed the STNA notified the nurse Resident #15 attempted an inappropriate sexual act with another resident (Resident #5). Both residents were placed on 15 minute checks for 24 hours. The Unit manager and Administrator were notified to notify physician and family. Review of Self Reported Incident (SRI) number 4 dated 03/31/22 timed 2:54 P.M. revealed an allegation or suspicion of sexual abuse with a date of discovery as 03/30/22 at 9:35 A.M. involving Residents #5 and #15. Interview on 04/21/22 at 9:27 A.M. with the Director of Nursing (DON) revealed they were made aware of the incident involving Residents #5 and #15 the morning of 03/30/22 as staff were coming into work. The DON stated the Administrator handled the SRI. Interview on 04/21/22 at 6:35 P.M. with the Administrator revealed the incident involving Resident #5 and #15 was reported the following day because he wavered because the incident involved residents with dementia. The Administrator stated he wanted to talk with the residents' families and was looking for guidance regarding abuse reporting. The Administrator stated looking back he should had reported the incident the day it occurred.

Based on review of a facility Self-Reported Incident (SRI) and investigation, and staff interview, the facility failed to thoroughly investigate an allegation of sexual abuse for two residents (Residents #5 and #15). This affected two residents (Resident's #5 and #15) out of four residents reviewed for abuse. The facility census was 76. Findings include: Review of the SRI dated 03/31/22 for alleged sexual abuse involving Residents #5 and #15 revealed Resident #5 and Resident #15 were witnessed by a State tested Nurse Aide (STNA) attempting to engage in a sexual act. The witness statements in the investigative file included typed phone interviews completed by the Administrator. The witness statements were from Housekeeping Aide (HA) #580, STNA #586 and Agency Nurse #588. All three statements confirmed it looked like Residents #5 and #15 were attempting to engage in a sexual act. The statements were not signed and did not contain details regarding what was actually witnessed. Agency Nurse #588's typed statement indicated both residents were placed on 15 minute checks, skin checks were completed for both Resident #5 and #15 with no concerns, and family, physician and management were notified. Interview on 04/20/22 at 1:49 P.M. with the Director of Nursing (DON) revealed she became aware of an incident between Resident #5 and Resident #15 when she came to work 03/30/22. She was told both residents attempted to pull their pants down. The DON did not have any more specific details about the encounter. The DON indicated the Administrator was notified and began an investigation on 03/30/22. Interview on 04/21/22 at 9:00 A.M. with HA #580 revealed he walked past Resident #15's room and witnessed Resident #15 with his hands down Resident #5's pants. Resident #15 was sitting in a wheelchair and Resident #5 was standing in front of him with her pants pulled down to her upper thighs. HA #580 told STNA #586 what he witnessed. Interview on 04/21/22 at 9:53 A.M. with STNA #586 revealed she was in the nurses' station when HA #580 told her two residents (Resident #5 and Resident #15) were in a room kissing. She went to the room and asked both residents to come to the common area. She then asked another unidentified STNA to keep an eye on Resident #5 and #15 while she cared for another resident in a different area. When STNA #586 returned to the common area Residents #5 and #15 were no longer in the common area and had gone to Resident #5's room. Resident #5 had her pants down and she bent down to kiss Resident #15 who was sitting in a wheelchair. STNA #586 reported the situation to Agency Nurse #588. Review of the facility policy for abuse revised July 2021 revealed the Administrator would interview the resident, obtain a statement and review the resident's record. In the case of resident to resident abuse, the Administrator would refer to the interdisciplinary team to determine appropriate follow up interventions.

Based on record review and staff interview, the facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #279) out of one resident reviewed for [CONDITION(S)] services. The facility identified two current residents who received [CONDITION(S)] services. The facility census was 76. Findings include: Review of the medical record for Resident #279 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #279 was receiving [CONDITION(S)] services prior to admission. Further medical record review revealed documentation of Resident #279 receiving [CONDITION(S)] on 04/08/22, 04/11/22, 04/13/22, 04/15/22, 04/18/22, and 04/20/22. Review of Resident #279's admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for the resident to receive [CONDITION(S)] services prior to 04/13/22. Interview on 04/21/22 at 1:17 P.M. with the Director of Nursing verified Resident #279's medical record did not contain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review, and review of facility policy the facility failed to ensure care planned interventions were implemented to prevent one resident (Resident #7) from obtaining the code and entering a secured area on the nursing unit she resided on. This affected one resident (Resident #7) out of three residents reviewed for supervision. The facility census was 76. Findings include: Review of Resident #7's medical record revealed an admitted [DATE] and diagnoses including dementia, type two diabetes mellitus, and [CONDITION(S)]. Review of Resident #7's care plan dated, 02/11/21 revealed Resident #7 had the potential for injury and was an identified wanderer related to Alzheimer's disease, dementia, confusion, and desire to go home. The goal indicated Resident #7 would wander in safe locations and would have safety maintained. Interventions included to know Resident #7's whereabouts, attempt to divert, determine pattern to wandering, report episodes, exit door alarms on and safety checks as needed. Review of Resident #7's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #7 was rarely or never understood. Resident #7 was independent for bed mobility, transfers, and toilet use. Resident #7 was always continent of urine and bowel, was steady at all times while walking, and required supervision for locomotion. Observation on 04/18/22 at 8:22 P.M. revealed Resident #7 sitting in the common area near the nurses station. Ongoing observation revealed Resident #7 standing up, walking to a door with the word SPA on it across from the nurses station, entering a code, opening the door, walking through the door and closing the door. Licensed Practical Nurse (LPN) #583 and State tested Nursing Assistant (STNA) #584 were sitting in the nurses station talking to each other and did not observe Resident #7 using a code to open the door to the Spa room and enter. Resident #7 was in the Spa room five minutes then came out of the room and stated there were no paper towels in the bathroom to dry her hands. There were no staff members present in the SPA room. Interview on 04/18/22 at 8:26 P.M. with Business Office Manager (BOM) #518 confirmed Resident #7 was in the Spa room by herself, used a code to get in and was going to the bathroom. Interview on 04/18/22 at 8:41 P.M. with STNA #584 revealed this was her first time working in the facility, she didn't know the residents, but the residents were not supposed to know the code to the SPA room. Interview on 04/18/22 at 10:08 P.M. with the Director of Nursing (DON) revealed the residents should not know the code to the SPA room and she would get the code changed immediately. Interview on 04/18/22 at 10:10 P.M. of LPN #583 revealed BOM #518 informed her Resident #7 knew the code to the SPA room and was in the room unsupervised. LPN #583 stated she did not know Resident #7 entered the SPA room and the residents should be supervised when they were in the SPA room. Observation on 04/19/22 at 3:13 P.M. of the SPA bathroom revealed there was a large tub in the center of the room, a room with a toilet, and a door which opened to a common area outside of the secured unit. The door opening to the common area outside the secured unit required a code to open. Review of the facility policy titled Dementia Care Policy, revised 03/2022, revealed it was the policy of the facility to provide competent care to any resident who displayed or was diagnosed with dementia. Appropriate treatment and services would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review and interview the facility failed to provide preventative skin interventions to prevent Resident #215, who required staff assistance for turning and repositioning from developing pressure ulcers. This resulted in harm to Resident #215 when the resident developed an unstageable pressure ulcer to the sacrum while residing in the facility. The resident also developed a Stage II pressure ulcer to the right heel while residing in the facility. This affected one resident (Resident #215) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #215's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. A plan of care initiated on 05/28/14 revealed Resident #215 was at risk for developing pressure ulcers. Interventions listed on the care plan included to turn and reposition Resident #215 per protocol and float Resident #215's heels while in bed. The most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #215 required extensive assistance of two staff for bed mobility and transfers. The skilled nursing assessment dated [DATE] revealed Resident #215 required extensive assistance of one person for bed mobility and was alert and oriented to person, place and time. Review of a wound tracking note, dated 06/10/14 revealed Resident #215 developed a pressure ulcer to the sacrum. The ulcer was assessed to measure 1.1 centimeters (cm) in length by 0.5 cm width with 0.2 cm depth. The ulcer was assessed to have slough tissue present and assessed to be an unstageable pressure ulcer at the time of development. A wound tracking note dated 06/11/14 revealed Resident #215 developed a pressure ulcer to the right heel. The ulcer was assessed to measure three cm in length by three cm in width with no depth noted. The pressure ulcer was assessed to be a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. The wound may also present as an intact or open/ruptured blister) pressure ulcer. Record review revealed the pressure ulcer was identified by the facility on 06/10/14 and described as a fluid filled blister. Resident #215 was observed on 06/16/14 at 3:10 P.M. and 4:40 P.M. lying in bed with his heels directly on the bed surface. On 06/17/14 at 12:30 P.M., 06/18/14 at 1:24 P.M., 3:40 P.M. and 4:30 P.M. and on 06/19/14 at 7:45 A.M., 9:01 A.M. and 10:00 A.M. Resident #215 was observed lying in bed, flat on his back with his heels directly on the mattress. On 06/18/14 at 1:24 P.M. interview with unit manager #302 revealed Resident #215 was to be turned every two hours and his heels were to be floated off the mattress. The unit manager verified the resident's heels were not being floated at that time. Unit Manager #302 verified the pillow, used to float the resident's heels was on the chair in the resident's room and had not been placed under the residents heels when staff assisted the resident to bed. On 06/19/14 at 9:10 A.M. interview with the director of nursing (DON) revealed the facility protocol for turning residents was for residents to be turned every two hours. The DON indicated nursing staff could implement the turning protocol without a physician order. On 06/19/14 at 10:00 A.M. interview with Resident #215 revealed the staff do not assist him to turn every two hours in bed. The resident stated he turns himself in bed at night sometimes. Review of the State tested Nursing Assistant Kardex dated 06/19/14 failed to include information for staff that Resident #215 needed to be turned every two hours as indicated on the resident's current plan of care.