Every finding on record at Maple Knoll Village

Based on record review, resident and staff interview, and facility policy review, the facility failed to safely and properly position a resident during incontinence care. Actual harm occurred on 04/08/26 when Certified Nurse Assistant (CNA) #525 rolled Resident #10 in bed away from her and the resident fell onto the floor sustaining a closed fracture of left femur and a laceration of upper forehead which required sutures. This affected one (Resident #10) of one resident reviewed for falls. The facility census was 68 residents. Findings include: Review of the medical record for Resident #10 revealed admission date of 05/22/23 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type two, and morbid obesity. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 01/14/26 revealed the resident was cognitively intact, was dependent on staff assistance with toileting and hygiene, required substantial/maximal assistance for rolling left and right from lying position on back, and was dependent for transfer to and from bed to chair. Review of the fall risk evaluation for Resident #10 dated 01/14/26 revealed the resident was at high risk for falls. Review of the health status note for Resident #10 dated 01/27/26 written by MDS Registered Nurse (RN) #350 revealed the resident frequently required two staff members for hygiene and mobility. Review of the progress note for Resident #10 dated 04/08/26 at 6:18 P.M. written by Licensed Practical Nurse (LPN) #435 revealed CNA #525 reported Resident #10 had rolled out of bed while staff were providing care. Resident #10 was found lying flat on his stomach between the wall and the bed with a bleeding laceration above his eye. Resident #10 was sent to the hospital via 911 for further evaluation and treatment. Review of a written statement regarding Resident #10's fall dated 04/08/26 by LPN Supervisor #400 revealed the after the aide reported rolling the resident away from her and out of bed the nurse educated CNA #525 that she should be rolling residents towards her and not away from her when assisting residents in bed. Review of the hospital summary report for Resident #10 dated 04/14/26 revealed the resident was admitted to hospital on [DATE] following the fall out of bed and was treated for left distal femur fracture and head laceration which required sutures. During an interview on 5/04/26 at 1:28 P.M., Resident #10 stated an aide rolled him out of bed on 04/08/26 when she was providing incontinent care. Resident #10 stated he was rolled over the right side of the bed and the caregiver was on the opposite side of the bed when she rolled him. Resident #10 stated that because of the fall he broke his left leg and received stitches to a laceration on his forehead. During an interview on 05/05/26 at 9:50 A.M., CNA #525 verified on 04/08/26 when she was providing incontinence care to Resident #10, she rolled the resident away from her, and the resident continued to roll over and fell off the bed landing on the floor. During an interview on 5/05/26 at 10:42 A.M., the Director of Nursing (DON) stated the best practice for rolling a resident while providing care to residents in bed was to roll a resident towards the caregiver to lower the chance for falls. During an interview on 05/05/26 at 11:55 A.M., LPN Supervisor #400 stated the best practice was to roll a resident towards the caregiver for bed mobility if there was only one care giver present. During an interview on 05/07/26 at 10:06 A.M., MDS RN #350 verified she made the health status note dated 01/27/26 documenting Resident #10 frequently required two staff for hygiene and mobility. MDS RN #350 confirmed she interviewed staff that provided care to Resident #10, and they stated Resident #14 often required the assistance of two staff. Review of the undated facility policy titled Fall Program Policy/Procedure revealed the facility's goal was to minimize resident risk for falling and sustaining injury without compromising functional mobility.

Based on observation, staff interview, and review of the facility policy, the facility failed to store and prepare food in a sanitary manner to prevent contamination and spoilage. This had the potential to affect all residents except for one (#68) that did not consume food from the kitchen due to a diet of nothing by mouth. The facility census was 68 residents. Findings include: 1.Observation on 05/04/26 at 9:43 A.M. with Executive Chef (EC) #6051 revealed the walk- freezer in the main kitchen located in the basement revealed it contained the following items: a box of strawberry pastries opened and exposed to air, two bags of undated dinner rolls, a box of pork chops opened and exposed to air. Interview on 05/04/26 at 9:43 A.M. with EC #605 confirmed the undated and open-to-air items in the walk-in freezer.2. Observation on 05/05/26 at 11:44 A.M. of the main kitchen with Dietary General Manager (DGM) #610 revealed in the revealed there was food debris and several gnats flying above the floor drain on the ground in front of the industrial sized cooking appliances as staff were cooking. Interview on 05/05/26 at 11:44 A.M. with DGM #610 confirmed the food debris and gnats to the grate in the main kitchen. 3. Observation on 05/06/26 from 10:09 A.M. with EC #605 revealed the walk-in freezer in the main kitchen contained a box of cheese manicotti that was not properly sealed and a box of cookie dough opened and exposed to air. Interview on 05/06/26 at 10:09 A.M. with EC #605 confirmed the opened and exposed to air items in the walk-in freezer. Review of the facility policy titled Food and Supply Storage revised January 2026 revealed the procedure was to cover, label and date unused portions and open packages.Review of the facility policy titled Pest Control revised January 2025 revealed the food and nutrition services department should be free of all rodents and insects.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received adequate grooming and nail care. This affected two (Residents #44 and #70) of two residents reviewed for activities of daily living (ADLs). The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 04/01/22 with diagnoses including dementia, traumatic subdural hematoma and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 03/16/26 revealed the resident had severe cognitive impairment and was required maximal assistance with grooming and hygiene. Review of the care for Resident #44 dated 10/31/22 revealed Resident #44 had a self-care performance deficit. Interventions included staff were to assist with and perform ADLs as needed. Observation on 05/04/26 at 11:49 A.M. revealed Resident #44 had facial hair to the chin approximately one inch in length. Observation on 05/05/26 at 8:24 A.M. with the Director of Nursing (DON) revealed Resident #44 had facial hair to the chin approximately one inch in length. Interview on 05/05/26 at 8:35 A.M. with the DON confirmed staff should have shaved Resident #44's facial hair. 2. Review of the medical record for Resident #70 revealed an admission date of 10/22/25 with diagnoses including atrial fibrillation, malignant neoplasm of skin and protein-calorie malnutrition. Review of the MDS assessment for Resident #70 dated 04/24/26 revealed the resident had moderate cognitive impairment and required maximal staff assistance with personal hygiene. Review of the care plan for Resident #70 dated 10/22/25 revealed the resident had an ADL self-care performance deficit. Interventions included staff were to check nail length and trim and clean on bath day and as necessary. Observation 05/04/26 at 10:41 A.M. revealed Resident #70's fingernails were long and had an unidentified brown substance under the nails. Interview on 05/04/26 at 10:42 A.M. with Resident #70 confirmed she would like to have her fingernails cut and cleaned. Observation on 05/05/26 at 8:25 A.M. with the DON revealed Resident #70's fingernails were long and had an unidentified brown substance under the nails. Interview on 05/05/26 at 8:26 A.M. with the DON confirmed staff should have cut and cleaned Resident #70's fingernails. Review of the facility policy titled Activities of Daily Living undated revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected two (Residents #2 and #25) of 17 residents with medications stored in the Three North medication cart. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/14/25 with diagnoses including diabetes mellitus type two and chronic kidney disease. Review of the physician's orders for Resident #2 revealed an order dated 06/08/25 for Lantus insulin 10 units at bedtime. Review of the Medication Administration Record (MAR) for Resident #2 dated April 2026 revealed the resident received Lantus insulin daily from 04/23/26 through 04/30/26. Review of the MAR for Resident #2 dated May 2026 MAR revealed the resident received Lantus insulin daily from 05/01/26 through 05/04/26. Observation of the Three-North medication cart on 05/05/26 at 2:00 P.M. with Licensed Practical Nurse (LPN) #435 revealed Resident #2's Lantus insulin vial was dated on 03/26/26. Interview on 05/05/26 at 2:00 P.M. with LPN #435 verified Resident #2's Lantus insulin vial should have been discarded on 04/23/26, 28 days from the date it was removed from the refrigerator and placed on the medication cart. 2. Review of the medical record for Resident #25 revealed an admission date of 04/21/26 with diagnoses including diabetes mellitus type two and congestive heart failure. Review of the physician's orders for Resident #25 revealed an order dated 04/28/25 for Lantus insulin 20 units at bedtime. Review of the MAR for Resident #25 dated April 2026 revealed the resident received Lantus insulin 04/28/26, 04/29/26 and 04/30/26. Review of the MAR for Resident #25 dated May 2026 MAR revealed the resident #25 received Lantus insulin from 05/01/26 through 05/04/26. Observation of the Three-North medication cart on 05/05/26 at 2:00 P.M. with LPN #435 revealed Resident #25's Lantus insulin injector-pen was not dated when placed on the medication cart. Interview on 05/05/26 at 2:00 P.M. with LPN #435 verified Resident #25's Lantus insulin injector-pen should have been dated when removed from the refrigerator and placed on the medication cart. Interview on 05/07/26 at 10:12 A.M. with the Director of Nursing verified Lantus insulin had a 28-day expiration date after opening and/or storage at room temperature, i.e. being placed on the medication cart. Review of the facility's contracted pharmacy services Product Expiration Dates document revised January 2022 revealed Lantus insulin vials and pen-injectors had a 28-day expiration date after opening and/or storage at room temperature, i.e. being placed on the medication cart. Review of the policy titled Storage of Medications undated revealed that drug containers that had missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the dispensing pharmacy or destroyed.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff provided timely incontinence care. This affected two (Residents #15 and #16) of three residents reviewed for call light response. The facility census was 66 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 02/16/24 with diagnoses including cerebral infarction, diabetes, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 08/06/25 revealed the resident had no cognitive impairments and required substantial assistance to total dependence on staff for activities of daily living (ADLs). Review of the medical record for Resident #16 revealed an admission date of 01/06/23 with diagnoses including dementia, depression, and Barrett's esophagus. Review of the MDS assessment for Resident #16 dated 09/05/25 revealed the resident had no cognitive impairment and was dependent of staff for ADLs. Observation on 09/22/25 from 3:05 P.M. until 3:25 P.M. revealed Residents #15 and #16's call lights were sounding. Staff did not respond to the call lights. Interview on 09/22/25 at 3:25 P.M. with Resident #15 confirmed he had activated his call light because he needed assistance with being changed. Interview on 09/22/25 at 3:26 P.M with Resident #16 confirmed she had activated her call light because she needed to be changed as she was soiled and had diarrhea. Observation on 09/22/25 at 3:34 P.M. revealed Certified Nursing Assistant (CNA) #25 entered Resident #15's room and turned off his call light without providing care. Interview on 09/22/25 at 3:36 P.M. with CNA #25 confirmed she had been off the unit on a lunch break and had just returned. CNA #25 confirmed she was unaware no one had been available to answer the call lights from 3:05 P.M. to 3:25 P.M. Review of the facility policy titled Supporting Activities of Daily Living undated revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number 2580344 and and Complaint Number 135097 (OH00161949) and Complaint Number 1395096 (OH00161797) and Complaint Number 1395095 (OH00160987.)

Based on medical record review, staff interview, and review of the facility policy, the facility staff failed to safely and properly position a resident in bed during incontinence care in order to prevent falls. This affected one (Resident #10) of three residents reviewed for falls. The facility census was 66 residents.Findings include:Review of the medical record for Resident #10 revealed an admission date of 03/07/10 with diagnoses including dementia, depression, and cerebrovascular disease. Review of the care plan for Resident #10 dated 10/31/22 revealed the resident had a self-care deficit secondary to multiple diagnoses including Alzheimer's disease with severe cognitive impairment and aphasia. Resident #10 was dependent on staff for all areas of care. Review of the care plan for Resident #10 dated 11/16/22 revealed the resident was incontinent of bowel and bladder and staff were to check and change the resident regularly.Review of the incident note for Resident #10 dated 07/30/25 at 5:50 A.M. revealed Resident #10 fell out of bed while Certified Nursing Assistant (CNA)#35 was providing incontinence care. CNA had reached for a clean brief, and the resident fell out of bed. No injuries were noted at the time of the fall, and the resident was to have two caregivers present during incontinence care in the future. Review of the progress note for Resident #10 dated 07/30/25 at 12:26 P.M. revealed the resident had developed bruises to the left arm since the fall and the physician gave an order for x-rays which were negative. Review of a written statement regarding Resident #10's fall on 07/30/25 per CNA #35 dated 07/30/25 revealed when the aide was changing Resident #10, the resident rolled out of the bed and onto the floor. Review of a written statement regarding Resident #10's fall on 07/30/25 per Licensed Practical Nurse (LPN) #51 dated 07/30/25 revealed CNA #35 notified her that Resident #10 had fallen out of bed during peri-care. The nurse observed Resident #10 lying on the floor on her back to the left side of the bed. CNA #35 stated she laid Resident #10 on her side and while the aide was reaching for the clean brief at the end of the bed the resident rolled out of the bed and onto the floor. There were no injuries noted at the time of the fall. Review of the incident note for Resident #10 dated 07/31/25 at 12:25 P.M. revealed the Interdisciplinary Team (IDT) met to review the resident's fall on 07/30/25. CNA #35 had rolled Resident #10 onto her right side in the bed to provide incontinent care. CNA #35 stated she was grabbing for the incontinence brief at the end of the bed and trying to open it when Resident #10 rolled out of bed on to the floor on 07/30/25 at 5:50 A.M. Resident #10 had x-rays completed to left arm, bilateral hips, pelvis, and spine with no fractures. Resident #10 did sustain bruises to her left elbow and forearm. A new intervention to prevent further falls was for the facility to have two staff people assist with incontinence care.Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 08/18/25 revealed the resident had severe cognitive impairment and was dependent on staff for completing activities of daily living (ADLs.)Interview on 09/22/25 at 4:07 P.M. with CNA #25 confirmed when providing care, you should never roll a resident away from you because they could roll off the bed.Interview on 09/23/25 at 3:20 P.M. with CNA #35 confirmed while she was providing incontinence care to Resident #10 the bed was raised and she rolled the resident on her right side, which was away from the aide, and then the resident rolled out of bed.Review of an online clinical resource titled Turning Patients Over in Bed: Medline Plus Medical Encyclopedia undated at: https://medlineplus.gov/ency/patientinstructions/000426.htm#:~:text=Standing%20with%20one%20foot%20ahead,the%20person's%20hip%20toward%20you revealed the following steps should be followed when turning a resident in bed: explain to the resident what you are planning to do so they know what to expect, encourage the person to help if possible, stand on the opposite side of the bed the resident will be turning towards, move the patient towards you, step around to the other side of the bed, ask the resident to look towards you (this will be the direction in which the person is turning.)This deficiency represents noncompliance investigated under Master Complaint Number 2587988 and Complaint Number 1395095 (OH00160987.)

Based on record review, review of self-reported incidents (SRI's), review of the staffing schedule, review of time card punches, staff interviews and review of facility policy, the facility failed to implemented their policy to remove a staff from the duty following an abuse allegation and while an investigation was being completed. This affected one (#42) of 22 residents reviewed for abuse. Facility census was 75. Findings include: Review of the medical record for Resident #42 revealed admitted [DATE]. Diagnoses include, but not limited to, cerebral infarction, hemiplegia and hemiparesis, left non-dominant side, dysphasia, pain in left knee, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The Resident required clean-up assistance for eating and substantial/maximal assistance toileting hygiene. Review of the plan of care dated 11/22/23 revealed Resident #42 had a self-care deficit secondary to cerebral vascular accident (CVA) with left sided hemiplegia, decreased activity tolerance, compromised strength, and pain. Goals include maintain current ability to feed self meals every day after staff sets up trays as needed and will continue to participate with Activities of Daily Living (ADL) by washing upper body after set up. Interventions include allow resident ample time to absorb cues and complete tasks. Assist resident with meal consumption as needed. Assist with opening packages/containers as needed. Set up and supervise ADL's, assist and perform as needed. The resident is at risk for decline in bed mobility related to CVA and left sided weakness with goal for resident to assist with bed mobility with no more that extensive assistance of staff member. Interventions include observe for tolerance of bed mobility program; offer praise on efforts and participation as needed. State tested Nurse Aide (STNA) to offer verbal and physical cues to resident to participate with bed mobility to fullest extent possible. Interview on 12/20/23 4:35 P.M. Resident #42 stated she had the remote out, asked the STNA #248 where to put the remote because the STNA had moved the bedside table. Resident #42 stated STNA #248 took the remote and threw it against the wall. She hit the resident's hand. Resident #50, roommate, told the STNA to leave the room. Another aide finished the shift. Resident #42 stated she thought the supervisor came back to talk to us on that same night. Review of SRI and investigation revealed Licensed Practical Nurse (LPN) #207 was aware of the incident on 11/25/23 and the Administrator was notified on 11/27/23. Review of time card punches for STNA #248 revealed she punched in on 11/24/23 at 7:06 A.M. and punched out on 11/25/23 at 7:56 A.M. Review of the written statement dated 11/25/23 revealed Resident #42 stated STNA #248 had slapped her hand and thrown her remote. She reported LPN #207 and the supervisor came into the room. The STNA came into the room and said she did not hit Resident #42. Interview on 12/21/23 at 12:09 P.M. the Director of Nursing (DON) stated the STNA #248 had been moved to another unit, Resident #42 had been removed from the STNA's assignment, but the STNA completed her scheduled shift following Resident #42's allegation. The DON verified the STNA should have been sent home immediately. Interview on 12/21/23 at 12:12 P.M. the Administrator stated he was notified of the incident on Monday 11/27/23 at 4:30 P.M. and he notified the scheduler to remove STNA #248 off the schedule. The scheduler left a message and a texted with STNA #248 to not come in. Review of the schedule dated 11/27/23 revealed STNA #248 had been crossed off the schedule. Review of the timecard for STNA #248 revealed she clocked in on 11/27/23 at 7:03 P.M. and clocked out at 7:53 A.M. The Administrator stated there had been multiple call offs that night, the night shift team were not aware of the circumstances, and not sure why STNA #248 had been crossed off the schedule, but they let her work on a different unit and Resident #42 was not on her assignment. The Administrator stated STNA #248 tried to come in and work again on 11/28/23 but night shift management had been informed of the circumstances and STNA #248 had been sent home. Time clock punches verified his statement. Review of facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy/Procedure, undated, revealed the employees must always report any abuse or suspicion of abuse immediately to the Administrator. The Administrator will involve key leadership personnel as necessary to assist with reporting, investigation, and follow up. The facility shall report to the State Agency and local law enforcement agency any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility. The facility shall report immediately, but not more than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury; or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. While the investigation is being conducted, accused individuals employed by the facility will be removed from the schedule and denied access to the resident until investigation is complete and further decision is made regarding continued employment/access to resident.

Based on record review, observation, staff interviews, and policy review, the facility failed to ensure a residents air mattress was plugged in and properly functioning to potentially prevent pressure ulcer development. This affected one resident (#55) out of two residents reviewed for skin breakdown. Facility census was 75. Findings include: Record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including fracture of the lower end of right radius, fracture of lower end of right femur, moderate protein-calorie malnutrition, chronic obstructive pulmonary disease, peripheral vascular disease and hypertension. Review of Resident #55's care plan initiated on 08/04/23 revealed Resident #55 is at risk skin breakdown related to decreased mobility, pain, antidepressant use, oxygen tubing, admitted with surgical wound right hip, skin tear and excoriation on buttocks. Interventions noted the resident required assist with turning and repositioning every shift, encouragement to turn side to side, body audits weekly, pressure reduction mattress to bed, and tropical treatment per physician orders. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had no pressure ulcers. Review of quarterly Braden Scale for Predicting Pressure Ulcers dated 11/08/23 revealed Resident #55 was at moderate risk for developing pressure ulcers due to decreased mobility. Observation on 12/18/23 at 10:42 A.M. revealed Resident #55's air mattress was not on. The lights on the electric box for the air mattress were not lit up. Observation on 12/19/23 at 8:37 A.M. revealed Resident #55's air mattress was not on. The lights on the electric box for the air mattress were not lit up. Observation on 12/20/23 at 8:42 A.M. revealed Resident #55's air mattress was not on. The lights on the electric box for the air mattress were not lit up. Interview on 12/20/23 at 8:42 A.M. with LPN #308 confirmed the air mattress for Resident #55 was unplugged. LPN #308 confirmed the air mattress should be plugged in and turned on. LPN #308 also revealed the lights on the air mattress should be lit up. Observation on 12/20/23 at 10:22 A.M. revealed Resident #55's air mattress was not on and the lights on the electric box for the air mattress were not lit up. Interview on 12/20/23 at 10:22 A.M. with LPN #308 confirmed Resident #55's air mattress was not plugged in and the lights on the electrical box were not on. Interview further revealed the plug to air mattress box was damaged and that maintenance needed called. LPN #308 confirmed Resident #55's air mattress was an intervention to prevent pressure ulcer development. Review of facility policy Pressure Ulcer/Injuries, undated, revealed the facility will review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Policy also revealed that the facility will implement interventions for prevention, select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors.

Based on medical record review, staff interviews and review of facility policy, the facility failed to ensure a residents hemodialysis access site was monitored and documented per the facility policy. This affected one (#61) out of one residents reviewed for dialysis services. The census was 75. Findings include: Review of the medical record for Resident #61 revealed admitted [DATE]. Diagnoses include, but not limited to, cerebral infarction, end stage renal disease (ESRD), dependence on renal dialysis, atrial fibrillation (A Fib), and bilateral osteoarthritis (OA) of knee, Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition. The resident required special treatment of dialysis. Review of the Plan of Care dated 11/06/23 revealed Resident #61 has End Stage Disease related to: diabetes mellitus (DM) with goal the resident will have immediate intervention should any signs or symptoms (s/sx) of complications from dialysis occur through the review date. The resident will have no s/sx of complications from dialysis such as: nausea/vomiting (N/V); disorientation; pruritis; delusions; decreased blood pressure (BP) any day through through the review date. Check arm shunt for bruit and thrill- notify physician (MD) and Dialysis Center immediately if neither present Keep dressing to dialysis access site clean and dry. Call MD immediately for development of fever, chills, excessive bleeding at shunt site; swelling at left arm shunt site; pain at access site not relieved with pain medication. Observe the resident for s/s of dialysis intolerance as listed in goal. Review of physician orders dated 09/02/23 revealed Dialysis: Days of the week: Monday, Wednesday, and Friday. Send bagged lunch or breakfast. Review of the Medical Administration Record (MAR) and Treatment Administration Record (TAR) for December 2023 revealed orders and documentation dated 09/02/23 for Dialysis: No blood pressure (BP) and/or no blood draws left arm. There were no orders or documentation specific to monitoring the hemodialysis (HD) access site. Interview on 12/20/23 at 2:44 P.M. Licensed Practical Nurse (LPN) #229 stated they watched Resident #61's dialysis site to make sure there were not any problems. LPN #229 confirmed monitoring did not pop up on the electronic charting record, for documentation. LPN #229 thought Resident #61 had orders for no BP or intravenous sticks and monitor site. LPN #229 stated his access site was in the left arm. The Assistant Director of Nursing (ADON) #09 verified on 12/21/23 at 11:50 A.M. that there was no monitoring of Resident #61's hemodialysis site per the facility policy. Review of facility policy titled Dialysis Policy/Procedures, dated 11/28/18, revealed the licensed nurse will provide monitoring and documentation of the status of the resident's HD access site to observe for bleeding and other complications.

Based on record review, observation, staff interviews, and policy review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while in a residents room who was positive for Coronavirus Disease 2019 (COVID-19) This affected one (#46) of one residents reviewed for transmission based precautions for COVID-19. The facility census was 75. Findings include: Record review revealed Resident #46 admitted to the facility on [DATE] with diagnoses including dementia, anxiety, vitamin deficiency, hypertension and COVID-19. Review of Resident #46 physician orders revealed an order dated 12/13/23 for Isolation: COVID-19, gloves, gown, eyewear and N-95 required for entry into room. All services to be provided for in room. every shift for COVID isolation for 11 Days. Pt to remain in room by himself with no roommate. Observation on 12/18/23 at 12:14 P.M. revealed STNA #289 in Resident #46's room providing care at bedside without an N-95 mask on. STNA #289 was noted with a gown, gloves, glasses and a surgical mask on. N-95 masks were located at the entry to Resident #46's room in the personal protective supply area. Interview on 12/18/23 at 12:14 P.M. with STNA #289 revealed she did not see them, when asked if she should have an N-95 mask on. Interview on 12/18/23 at 12:18 P,M. with the Assistant Director of Nursing confirmed an N-95 must be worn in all COVID-19 positive rooms. Review of facilities COVID-19 Novel Corona Virus Policy/Procedure dated 03/02/20 revealed it is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for the COVID-19 and to adhere to Standard, Contact and Airborne Precautions, including the use of eye protection. For a resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place. Limit only essential personnel to enter the room with appropriate personal protective equipment (PPE) and respiratory protection. PPE includes: Gloves, Gown, Respiratory Protection N-95 filtering face piece respirator prior to entry and removal after exiting. Perform hand hygiene after discarding.

Based on record review, staff interviews, review of facility policy, review of self-reported incidents (SRIs) and review of facility investigation, the facility failed to report an allegation of abuse to the state agency. This affected one resident (#30) out of three residents reviewed for abuse. The facility census was 83. Findings included: Review of the medical record for Resident #30 revealed an admission of 03/09/21. Diagnoses included dementia, type 2 diabetes mellitus, benign prostatic hypertrophy, gastroesophageal reflux disease, repeated falls, chronic obstructive pulmonary disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 04/06/23, revealed the resident was cognitively impaired. The resident had a brief interview for mental status (BIMS) score of 07. Review of the plan of care for Resident #30 dated 11/15/22, revealed the resident could be verbally inappropriate towards staff. Interventions included administering medications as ordered, discussing/exploring feeling of anger/anxiety with resident, and maintaining consistent caregivers as schedule would permit. Review of the witness statement written by LPN #107 regarding the incident with Resident #30 and his family revealed that on 04/11/23 at 3:30 P.M., the family of the resident requested that staff put Resident #30 in his wheelchair so they could take the resident outside. Licensed Practical Nurse (LPN) #107 stated that she was unable to locate State tested Nursing Assistant (STNA) #183. At 3:45 P.M., STNA #183 arrived on the floor. The family of Resident #30 approached LPN #107 at 3:50 P.M. stating there was a problem. The family member alleged that STNA #183 was being rude to them and cussing at them. LPN #107 walked down the hallway with the family member to the Resident #30's room. STNA #183 was noted in the hallway spinning around in a rolling chair talking on her personal phone. LPN #107 asked STNA #183 to help her place the resident in his wheelchair. STNA #183 stated that she does not have time for this expletive. His expletive has been rude to me. The family of Resident #30 tried to apologize to STNA #183 stating that he is like this with everyone. STNA #183 responded by saying expletive this, I am not on this expletive. At this time, LPN #107 stated that she escorted STNA #183 off the floor asking her to leave and not return to the floor. Review of the facility investigation dated 04/13/23, regarding the incident that occurred with Resident #30's family on 04/11/23, revealed the facility stepped in when they recognized a bad situation. STNA #183 was asked to leave the floor immediately. Administrative Registered Nurse (RN) #100 provided statements and documentation that LPN #107 was interviewed and STNA #183 was interviewed. STNA #183 had left the facility after the incident and did not care for any residents after being asked to leave the floor. STNA #183 was notified of her termination. No residents were interviewed that were cared for by STNA #183 on 04/11/23. The cameras were not accessed to review the details and specifics of the incident. Interview on 04/19/23 at 11:55 A.M. with Licensed Practical Nurse (LPN) #107, revealed there was an incident between a State tested Nursing Assistant (STNA) (identified as STNA#183) and the family member of Resident #30 that occurred in the last couple of weeks. LPN #107 was on shift when she heard STNA #183 using profanity towards a resident's family near the resident. LPN #107 immediately intervened between STNA #183 and the family members. LPN #107 escorted STNA #183 off the floor and checked on Resident #30 and his family and the incident was reported to the Director of Nursing (DON). Interview on 04/19/23 at 1:45 P.M. with Administrative RN #100 confirmed that the facility did not report this incident of alleged abuse to the state agency. Review of facility's SRI's for 04/11/22, revealed no documented evidence the facility created an SRI for the alleged staff-to-resident abuse. Further review of the SRI's revealed the facility created a verbal abuse allegation on 04/20/23 dated 04/12/23 at 2:11 P.M. The SRI was unsubstantiated. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 10/21/22, revealed the facility failed to implement their policy. Mental abuse is defined as including, but not limited to, humiliation, harassment, threats of punishment, or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner; There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment; cannot relate what has occurred; or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Finally, Notification/submission to the State Agency will be made by the Director of Nursing/designee within 24 hours of incident being identified. Follow up with the State Agency will be completed within five working days of the initial report. This deficiency represents non-compliance investigated under Complaint Number OH00140219.

Based on record review, staff interviews, review of facility's investigation, and review of facility policy, the facility failed to thoroughly investigate an alleged incident of staff-to-resident abuse. This affected one resident (#30) out of three residents reviewed for potential abuse. The facility census was 83. Findings included: Review of the medical record for Resident #30 revealed an admission of 03/09/21. Diagnoses included dementia, type 2 diabetes mellitus, benign prostatic hypertrophy, gastroesophageal reflux disease, repeated falls, chronic obstructive pulmonary disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 dated 04/06/23, revealed the resident was cognitively impaired. The resident had a brief interview for mental status (BIMS) score of 07. Review of the plan of care for Resident #30 dated 11/15/22 revealed the resident can be verbally inappropriate towards staff. Interventions included administering medications as ordered, discussing/exploring feeling of anger/anxiety with resident, and maintaining consistent caregivers as schedule would permit. Review of the witness statement written by Licensed Practical Nurse (LPN) #107 regarding the incident with Resident #30's family revealed that on 04/11/23 at 3:30 P.M., the family of the resident requested that staff put Resident #30 in his wheelchair so they could take the resident outside. LPN #107 stated that she was unable to locate State tested Nursing Assistant (STNA) #183. At 3:45 P.M., STNA #183 arrived on the floor. The family of Resident #30 approached LPN #107 at 3:50 P.M. stating there was a problem. The family member alleged that STNA #183 was being rude to them and cussing at them. LPN #107 walked down the hallway with the family member to the Resident #30's room. STNA #183 was noted in the hallway spinning around in a rolling chair talking on her personal phone. LPN #107 asked STNA #183 to help her place the resident in his wheelchair. STNA #183 stated that she does not have time for this expletive. His expletive has been rude to me. The family of Resident #30 tried to apologize to STNA #183 stating that he is like this with everyone. STNA #183 responded by saying expletive this, I am not on this expletive. At this time, LPN #107 stated that she escorted STNA #183 off the floor asking her to leave and not return to the floor. Review of the facility's investigation dated 04/13/23, regarding the incident that occurred with Resident #30's family on 04/11/23, revealed the facility stepped in when they recognized a bad situation. STNA #183 was asked to leave the floor immediately. Administrative Registered Nurse (RN) #100 provided statements and documentation that LPN #107 was interviewed and STNA #183 was interviewed. STNA #183 had left the facility after the incident and did not care for any residents after being asked to leave the floor. STNA #183 was notified of her termination. No residents were interviewed that were cared for by STNA #183 on 04/11/23. The cameras were not accessed to review the details and specifics of the incident. Interview on 04/19/23 at 11:55 A.M. with LPN #107, revealed there was an incident between STNA #183 and the family member of Resident #30 that occurred in the last couple of weeks. LPN #107 was on shift when she heard STNA #183 using profanity towards a resident's family near the resident. LPN #107 immediately intervened between STNA #183 and the family members. LPN #107 escorted STNA #183 off the floor and checked on Resident #30 and his family and the incident was reported to the Director of Nursing (DON). Interview on 04/19/23 at 1:45 P.M. with Administrative RN #100 verified the facilities investigation showed no proof STNA #183 was cursing at Resident #30; however, RN #100 agreed that the resident could hear his family getting yelled at by STNA #183 because they were right outside the room in the hallway. She agreed that she would feel some type of distress if someone was yelling at her family member. RN #100 confirmed that she did not interview those cognitively intact residents on the unit cared for by STNA #183 to confirm that no mistreatment had taken place. Additionally, the facility had cameras throughout the hallways and RN #100 confirmed those cameras were not reviewed as a part of the investigation. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 10/21/22, revealed the facility failed to implement their policy. Mental abuse is defined as including, but not limited to, humiliation, harassment, threats of punishment, or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner; There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment; cannot relate what has occurred; or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Additionally, It is the policy of facility that reports of abuse are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened if anything. The Administrator or designee will investigate the incident with the assistance of appropriate personnel. Staff are expected to cooperate during the investigation to assure the resident is fully protected. The investigation will include who was involved, resident statements (staff should attempt to interview non-verbal residents or cognitively impaired residents. If unable to be interviewed or if the resident declines to be interviewed then staff will observe the resident, assess resident behaviors, affect, and response interactions and document findings), resident's roommate statements, involved staff and witness statements of events, observations of resident and staff behaviors during the investigation, and environmental considerations. This deficiency represents non-compliance investigated under Complaint Number OH00140219.

Based on medical record review, mechanical lift manufacturer's recommendation review, facility policy review, facility investigation, witness statement review, and staff interview, the facility failed to provide two staff members when utilizing a mechanical lift for a resident transfer This resulted in actual harm when Resident #19 sustained a fall from the bed which resulted in a left distal midshaft [MEDICAL CONDITION] that required surgical intervention. This affected one (#19) of one residents reviewed for accidents. The facility census was 122. Findings include: Review of the medical record for Resident #19 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and with transfers. Review of care plan for falls initiated on 12/18/18 revealed the resident had the potential for harm/injury related to falls secondary to weakness, dementia with poor long- and short-term memory, impaired mobility, impaired cognition, prescribed antidepressant and antipsychotic, poor judgment and safety awareness. Interventions included the resident required the assistance of two staff with activities of daily living (ADLs). Review of the physical therapy discharge summary for Resident #19 dated 01/17/19 revealed resident received physical therapy services from 12/19/18 through 01/17/19. Further review of discharge summary revealed resident required maximum assistance of two staff with transfers, and staff should use the Sara lift (mechanical lift) when transferring resident. Review of physician orders [REDACTED]. Review of physician progress notes [REDACTED]. Further review of the note revealed the resident was a fall risk and required two-person assistance for transfers. Review of the nurse progress note for Resident #19 dated 02/14/19 revealed the resident was sent to the hospital via 911 due a fall which occurred on 02/14/19 at 6:15 [NAME]M., and the resident had complained of leg pain immediately following the fall. Review of the facility fall investigation for Resident #19 dated 02/14/19 revealed the nurse found resident lying on the floor complaining of severe hip pain. Further review of the investigation revealed the State tested Nursing Assistant (STNA) #177 reported the resident became combative with care and while attempting to secure the Sara lift pad around the resident, the resident began to slide out of bed, and STNA #177 lowered the resident to the floor. Review of the witness statement from STNA #177 dated 02/14/19 revealed the aide was by herself while attempting to transfer Resident #19 out of bed using the Sara lift. Further review of statement revealed Resident #19 became combative as the aide was positioning the lift pad around the resident and the resident began to slide out of bed. STNA #177 stated she then lowered Resident #19 to the floor. Review of hospital records for Resident #19 dated 02/14/19 thru 02/16/19 revealed the resident was admitted on [DATE] due to a fall that occurred at the facility. Further review of the record revealed the resident sustained [REDACTED]. Interview on 01/16/20 at 11:30 [NAME]M. with the Director of Nursing (DON) confirmed STNA #177 had attempted to transfer Resident #19 using the Sara mechanical lift without the assistance of two staff on 02/14/19. The DON verified the resident sustained [REDACTED]. Review of the Sara Lift manufacturer's recommendations dated 04/20/16, revealed the Sara lift should be used in accordance with a full clinical assessment of the resident and his/her condition. Review of facility policy titled Lifting Machine, Using a Mechanical dated 09/23/19, revealed the resident center care may indicated the resident has been assessed to need two staff persons to use the sit-to- stand lift as per the resident's plan of care.

Based on observation, staff interviews, review of the planned menus, and review of facility policy, the facility failed to prepared ground meat in accordance with the planned menu in order to meet the individual needs of residents with chewing/swallowing difficulties. This had the potential to affect 18 (#114, #69, #89, #15, #1, #86, #9, #60, #73, #68, #44, #43, #96, #19, #109, #50, #17 and #85) of 18 residents with a physician's orders [REDACTED]. The facility census was 122. Findings include: Observations of the meal preparation and service was observed in the central kitchen, and in the third floor serving, kitchen on beginning at 10:57 [NAME]M. on 01/15/20. The planned menu for the lunchtime meal included a choice of soup, barbequed (BBQ) pulled pork, cole slaw or cantelope, and pudding or ice cream. Review of the production sheet for special diets, and the steam table set up sheet for the serving kitchens, revealed that pulled BBQ pork was to be of a ground consistency for residents on soft/mechanically soft diets. Observations on 01/15/20 at 11:42 [NAME]M., the hot food arrived in the third floor serving kitchen in an enclosed hot cart from the central kitchen. At that time Dietary Staff (DS) #143 began setting up the steam table in the serving kitchen and the temperature of the food was taken at 11:50 [NAME]M. There was no ground BBQ pork evident on the steam table for service. The pulled BBQ pork for regular diets included small chunks and strands of pork which would potentially not have been suitable for residents with chewing and/or swallowing difficulties. Observations at 12:04 P.M., revealed DS #143 began plating food for service in the third floor unit dining room and room trays. DS #142 was asked at that time if ground BBQ pork was to have been prepared for service. DS #142 and DS #143 affirmed there was no ground BBQ pork on the steam table, or in the hot cart delivered by the kitchen. DS #148 who was also assisting commented that the facility dietitian, Registered Dietitian (RD) #114 may have okayed the use of the pulled pork for the ground diets. Interview on 01/15/20 at 12:40 P.M. with DS #143 was asked if he was provided any additional information about the ground pork. He reported there was supposed to have been some prepared and sent up to the floor for the lunch time meal. He stated the central kitchen did prepare and send up ground consistency pork to the serving kitchen for service to residents on soft/mechanically soft diets after being questioned by the surveyor. Observation on 01/15/20 of Residents #73 and #68, both with orders for soft diets, were observed eating in the third floor dining room. The BBQ pork they were eating had been ground, and was obviously a different texture than the BBQ pork that was served to residents on regular diets in the same dining room. Interview on 01/15/20 at 3:11 P.M., with DS #142 regarding why no ground BBQ pork was prepared, until it was brought to the attention of dietary staff by the surveyor. DS #142 reported that DS #131, a sous chef, was responsible for preparing the ground pork for the lunchtime meal that day, that he missed the line specifying that 20 servings of ground pork were to be prepared. He affirmed that no ground pork had been prepared in advance, but that BBQ pork was ground on discovery that none had been prepared and was served to residents on soft diets. Interview with Registered Dietitian (RD) #114 on 01/15/20 at 3:19 P.M., verified the BBQ pork served to regular diets during the lunchtime meal would have not been acceptable for residents with orders for a soft/mechanically soft diet. Review of the undated policy for diets revealed that residents are offered diets as ordered by the physician, and listed the diets. The diet described as soft/mechanically soft/dental soft specified that meat was to be ground to facilitate chewing.

Based on observations, record reviews and staff interviews, the facility failed to ensure each resident was treated in a manner that promoted their individuality and dignity during dining. This affected two(#7 and #79) residents, who were dependent on the physical assistance of one staff to eat, of 36 residents located on the third floor of the facility. The facility census was 122. Findings include: Review of the medical record of Resident #7 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly minimum data set (MDS) assessment revealed the resident was identified by the facility as having short and long term memory problems, severely impaired cognitive skills, and being totally dependent on one staff person for eating/drinking. Resident #7 had contractures of both hands. The resident was located on the third floor secured unit. Review of the medical record of Resident #79 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly MDS assessment revealed the resident was identified by the facility as having short and long term memory problems, severely impaired cognitive skills, and being totally dependent on staff for eating/drinking. Resident #79 had contractures of both hands. The resident was located on the third floor secured unit. Observation on 01/14/20 at 8:33 [NAME]M. of the residents on the third floor, secured unit, were observed having breakfast in the third floor unit dining room. There were four State tested Nurse Aides (STNAs) and the Director of Nursing (DON) in the dining room at that time feeding residents who needed assistance to eat. All the residents had been served their breakfast at the time the observation started. There were two residents (#7 and #79) who were seated at tables with their breakfast trays in front of them and their food covered. There were nursing staff feeding other residents at the same tables as residents #7 and #79, sitting directly across from them. At 8:37 [NAME]M., STNA #80 who had completed feeding another resident across the table from Resident #79, uncovered the food on the tray and began to feed Resident #79. At 8:44 [NAME]M., one addition STNA #29 entered the dining room and uncovered Resident #7's food and began feeding her, 11 minutes after the observation began. Interview with the Director of Nursing (DON) on 01/15/20 at 5:30 P.M. regarding the observations made during the breakfast meal in the third floor dining room. The DON verified Residents #7 and #79 were served their food and not fed, while others around them were eating independently or being assisted as needed. She shared that she observed what as going on, and verbalized that STNA #29 was not readily available to assist with feeding as he was helping another resident who needed extensive assistance in the bathroom. The DON stated the expectations was that residents were to be fed at the time they were served. She stated that is how the meal period was arranged may need to be reviewed for example implementing two seating, or review utilization of staff during meals. The DON reported the problems was not related to lack of staff. Interview with STNA #80 on 0/1/16/20 at 10:27 [NAME]M., regarding observations made during the breakfast meal in the third floor unit dining room on 01/15/20. STNA #80 stated that sometimes there were sufficient staff present to feed all the dependent residents when service, and sometimes not. STNA #80 shared that some STNAs may be assisting other residents with showers or other care needs, and then come to the dining room after the residents had already been served.

Based on medical record review, observation, resident and staff interview, the facility failed to maintain a homelike environment. This affected one (#113) of 24 residents reviewed for environment. The census was 122. Findings include: Review of the medical record for Resident #113 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for Resident #113 dated 10/03/19 revealed resident was cognitively intact and required extensive assistance of two staff with transfers. Review of the care plan for Resident #113 dated 04/10/19 revealed resident had the potential for falls related to amputation. Interventions included transfer resident using a Hoyer lift. Observation of Resident #113's room on 01/13/20 at 9:30 [NAME]M. and 10:22 [NAME]M., revealed the Hoyer lift for the fourth floor was being stored in the resident's room. Resident #113 was in her wheelchair. Interview on 01/13/20 at 10:22 [NAME]M. with Resident #113 verified the Hoyer lift for the fourth floor had been stored in her room since approximately 8:00 [NAME]M. on 01/13/20. Resident #113 further stated she did not like the lift being stored in her room. Interview on 01/13/19 at 10:30 [NAME]M. with Registered Nurse (RN) #66 confirmed the Hoyer lift was in resident's room and it was not in use. RN #66 further stated the Hoyer lift for the fourth floor should not be stored in a resident room.

Based on observations, medical record review, facility policy review, resident and staff interviews, the facility failed to ensure tubing for oxygen and respiratory treatments was dated when opened and changed regularly. This affected two (#113 and #316) of two residents reviewed for respiratory care. The census was 122. Findings include. 1. Review of the medical record for Resident #113 revealed an admission date of [DATE], with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) Assessment for Resident #113 dated 10/03/19 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living. Review of (MONTH) 2020 physician orders [REDACTED]. Observation of Resident #113 on 01/13/20 at 10:38 [NAME]M., revealed the oxygen tubing was not dated. Interview on 01/13/20 at 10:38 [NAME]M. with Resident #113 confirmed she was unsure when her oxygen tubing had last been changed. Interview on 01/13/20 at 10:45 [NAME]M., with Registered Nurse (RN) #66 verified Resident #113's oxygen tubing was not dated, and she was unsure when it had been changed. RN #66 stated the oxygen tubing should be dated when opened and should be changed at least weekly. 2. Review of the medical record for Resident #316 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Observation on 01/16/20 at 8:17 [NAME]M., of Resident #316 revealed the tubing to resident's hand-held nebulizer treatment was dated 01/05/20. Interview on 01/16/20 at 8:17 [NAME]M., with Licensed Practical Nurse (LPN) #36 verified the tubing to Resident #316's hand nebulizer treatment was dated 01/05/20. LPN #36 further stated the tubing to the nebulizer treatments should be dated when opened and should be changed at least weekly. Review of facility policy titled Oxygen Connecting Tubing Cleaning/Change Procedure dated 09/13/16 revealed oxygen tubing should be changed weekly.

Based on observations, medical record review, facility policy review, pharmacy online resource review and staff interviews, the facility failed to ensure expired medications were discarded and medications had an open date and expiration date. This had affected three (#79, #3 and #42) of 122 residents who received medications in the facility. The census was 122. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the medical record for Resident #79 revealed an order dated 12/19/19 for [MEDICATION NAME] liquid every eight hours routinely. Observation of medication storage room on third floor on 01/15/20 at 8:07 [NAME]M. with Registered Nurse (RN) #66 revealed bottle of liquid [MEDICATION NAME] with an expiration date of 12/2019. Interview on 01/15/20 at 8:09 [NAME]M. with Registered Nurse (RN) #66 confirmed the medication storage room on the third floor contained a bottle of liquid [MEDICATION NAME] with an expiration date of 12/2019. RN #66 confirmed the medication was expired and should have been discarded. 2. Review of the medical record for Resident # 3 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of record for Resident #3 revealed an order dated 02/21/19 for one-half of a Vita-Day multi-vitamin tablet daily. Observation of the 300 Hall cart on 01/15/20 at 11:30 [NAME]M., with Licensed Practical Nurse (LPN) #58 revealed the cart contained a bottle of Vita-Day multi-vitamin for Resident #3 which did not have a manufacturer's expiration date. The bottle had been dated as opened on 10/24/19. Interview on 01/15/20 at 11:35 [NAME]M., with Licensed Practical Nurse (LPN) #58 confirmed the bottle of multivitamins for Resident #58 did not have a manufacturer's expiration date, and she could not confirm if it was expired or not. LPN #58 further stated expired medications should be discarded and not administered to residents. 3. Review of the medical record for Resident #42 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Observation of the 400 Hall cart on 01/15/20 at 7:42 [NAME]M. with LPN #83 revealed the cart contained an undated opened bottle of Refresh [MEDICATION NAME] eye drops and undated opened tube of Refresh PM for Resident #42. Interview on 01/15/20 at 7:50 [NAME]M., with LPN #83 confirmed Refresh [MEDICATION NAME] and Refresh PM for Resident #42 were undated and opened. LPN #83 further stated ophthalmic preparations should be dated upon opening and discarded within 30 days. Review of the undated facility policy titled Drug Storage revealed expired medication should be removed from storage promptly and destroyed. Review of The International Pharmacopeia, Seventh Edition, dated (YEAR), (http://apps.who.int/phint/2017/index.html#d/b.6.2.1.3) revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened.

Based on the medical record review and staff interviews, the facility failed to ensure a resident medical records contained documentation of resident incident resulting in injury. This affected one (#92) of 24 resident's medical records reviewed. The census was 122. Findings include: Review of medical record for Resident #92 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #92 dated 12/17/19 revealed resident was cognitively impaired and required extensive assist of one staff with activities of daily living (ADLs). Review of the nurse progress note for Resident #92 dated 12/14/19 at 4:18 P.M. documented by Licensed Practical Nurse (LPN) #38 revealed an order to apply pressure dressing to skin tear to resident's left arm, cleanse with normal saline, approximate skin, apply steri strips, monitor steri strips every shift until healed. Review of the medical record for Resident #92 revealed it was silent regarding an account of how resident sustained [REDACTED]. Interview on 01/15/20 at 3:29 P.M. with LPN #38 confirmed the night shift nurse, LPN #8, reported Resident #92 had a sustained a skin tear to her left forearm during the night shift on 12/14/19. LPN #38 further confirmed she obtained a physician order [REDACTED]. Interview on 01/15/20 at 4:33 P.M. with LPN #8 confirmed the aide reported Resident #92 sustained a skin tear during care, and he applied a dressing to resident's arm. LPN #8 further confirmed he notified LPN #38 of Resident #92's skin tear at the change of shift report on 12/14/19, but he did not document the incident in the resident's medical record. Interview on 01/16/20 at 1:12 P.M. with the Director of Nursing (DON) confirmed Resident #92's medical record contained no documentation regarding an account of how resident sustained [REDACTED]. The DON further confirmed incidents involving resident injury should be documented in the medical record.

Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs), review of witness statements, review of personnel records, and review of facility policy, the facility failed to ensure a resident was free from staff to resident physical abuse. This affected one (#6) of four residents sampled. The census was 129. Findings include: Review of record for Resident #6 revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) for Resident #6 dated 05/13/19 revealed resident was cognitively intact, required extensive assistance of one staff with bed mobility, transfers, and toilet use, and was coded as having verbal behavioral symptoms. Review of care plan for Resident #6 dated 06/14/19 revealed the resident exhibited behaviors which included wandering, restlessness, getting up without assistance and delusions related to her children. Interventions included the following: offer one on one in a quiet area, allow resident to vent/express feelings, provided consistent routine. Review of nurse progress note for Resident #6 dated 06/06/19 timed at 1:56 A.M. revealed the resident reported (former) State tested Nursing Assistant #60 got mad at her and shook her. Further review of note revealed the following actions were taken: Director of Nursing (DON) interviewed alleged perpetrator immediately and sent her home pending investigation, initial report was filed with Ohio Department of Health (ODH), body audit was completed of resident with no bruises/ abrasions or signs of injury noted, physician was notified with no new orders given, local police were notified and took report from resident. Review of SRI initiated on 06/06/19 timed at 12:41 A.M. revealed facility investigated an allegation of physical abuse on the part of former STNA #50 towards Resident #6. Initial allegation per Resident #6 revealed Resident #6 alleged STNA #60 got mad at her and told her she didn't need to go to the bathroom and that STNA #50 got angry with her and shook her. Further review of the SRI revealed the summary of the incident included the following actions were taken related to the allegation: local police were notified of resident allegation and came to facility on 06/6/19 at 1:12 A.M. to interview the resident, resident was re-interviewed on 06/06/19 at 1:10 P.M. with her husband present and at that time stated that STNA #50 did not shake her but that she had pushed her down onto the bed when she was trying to go to the bathroom and would not let her wash her hands after toilet use and also that Sitter #60 witnessed the alleged events, interviewed Sitter #60 which confirmed Resident #6's allegations, obtained written statements from involved parties, suspended STNA #50 pending investigation on 06/06/19 and terminated STNA #50 on 06/10/19. Further review of the SRI revealed investigation was completed on 06/11/19 , that the facility substantiated that physical abuse had occurred per former STNA #50 towards Resident #6, and the police were contacted again to inform them that an eyewitness had substantiated the resident abuse. Review of written statement per alleged perpetrator, former STNA #50 dated 06/06/19 revealed STNA acknowledged that she took the resident to the bathroom on 06/05/19 and made her lay back down. Review of witness statement per Sitter #60 revealed STNA #50 wasn't happy because resident kept getting up from her bed and appeared upset because the resident's bed alarm kept going off. Further review of the statement revealed Sitter #60 witnessed STNA #50 come into Resident #6's room on 06/05/19 at about 10:40 P.M. and put the resident back to bed in a way that was very inappropriate, that the STNA pushed the resident causing the resident to actually fall on the bed. Further review of the statement revealed sitter alleged that when STNA toileted Resident #6 resident asked if she could wash her hands but STNA #50 refused to do so. Interview with the Director of Nursing (DON) on 07/22/19 at 3:30 P.M. confirmed that facility's investigation had substantiated physical abuse per former STNA #50 towards Resident #6 on 06/05/19 at approximately 10:40 P.M. when STNA pushed the resident down onto the bed and also refused to allow/assist resident with hand hygiene following toileting on 06/05/19. DON further confirmed that Resident #6 and resident's representative declined to press criminal charges against former STNA #50. Review of former STNA #50's personnel file revealed a termination notice dated 06/10/19 which revealed former STNA #50 was terminated by phone due to initial report that the employee shook a resident and refused to let resident wash her hands after toileting and that a private duty sitter witnessed the employee push resident to bed and refuse to allow resident to wash her hands. Review of facility policy titled Abuse, Neglect, and Misappropriation of Resident Property dated 09/22/18 revealed the facility will ensure that each resident is free from abuse. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interviews, review of facility video surveillance, and review of the facility drug storage policy, the facility failed to ensure medications were secured and supervised on the dementia unit. This resulted in Immediate Jeopardy and the likelihood for serious potential harm for two cognitively impaired independently mobile residents (#144 and #153) when Licensed Practical Nurse (LPN) #202 left the medication cart on the dementia unit unlocked with the second drawer from the bottom pulled out all the way and Residents #144 and #153 were observed wandering past the unsecured medication cart, unsupervised. This affected two (#144 and #153) of eight residents reviewed for accident hazards. The facility identified a total of 21 residents who were cognitively impaired and independently mobile on the dementia unit. The facility also failed to accurately assess, obtain physician orders and ensure a proper fitting mattress was in use with side rails for three (#22, #45 and #111) of eight residents reviewed for accident hazards that had the potential for harm that was not Immediate Jeopardy. On 09/14/17 at 2:11 P.M., the Administrator, Director of Nursing (DON), and Risk Management/Staff Development Registered Nurse (RM/SD-RN) #401 were notified Immediate Jeopardy began on 09/14/17 at 6:03 A.M. when LPN #202 left the medication cart on the dementia unit unlocked and unsupervised, with the second to the bottom medication drawer pulled open all the way leaving medications clearly visible and accessible to any passerby. The medication drawer contained Divalproex Sodium (anticonvulsant medication with serious toxicity, including death, may occur after acute ingestion), Quetiapine (antipsychotic medication, overdose symptoms may include severe drowsiness and loss of consciousness), Gabapentin (anticonvulsant medication, overdose symptoms may include vision changes, severe drowsiness, slurred speech, weakness), Furosemide (diuretic, overdose symptoms may include fainting, severe weakness, severe decreased amount of urine), and Ferrous Sulfate (iron product, overdose symptoms may include stomach pain, nausea, vomiting, diarrhea). Observation on 09/14/17 at 6:04 A.M. revealed Resident #153 was unsupervised and independently propelled himself in his wheelchair past the unsecured medication cart and Resident #144 independently ambulated past the unsecured medication cart. The Immediate Jeopardy was removed and corrected on 09/15/17 at 12:41 P.M. when the facility took the following corrective actions: · The medication cart on the dementia unit was locked and secured by LPN #202 on 09/14/17 at 6:08 A.M. · On 09/14/17, RM/SD-RN #401 verified with Scheduling Manager (SM) #27 that LPN #202 was not scheduled to work on night shift and LPN #202 was removed from the schedule. · The DON and Human Resource Director (HRD) #405 terminated LPN #202 on 09/14/17 from employment. · The Medical Director was notified of the issue with the unsecured medication cart on the locked dementia unit on 09/14/17 at 3:00 P.M. and he reviewed and accepted the abatement plan. · Observation of medication carts on 09/14/17 after 6:08 A.M. and on 09/15/17 revealed all carts were secured or properly supervised. · Education on medication and treatment cart safety, which included roles and responsibilities of staff, was initiated and completed on 09/14/17 with all LPN's both on duty and upon reporting to duty. Education was completed by the DON, RM/SD-RN #401, and Registered Nurse Unit Managers (RNUM) #8, #20 and #135. Staff unable to participate in the education were removed from the schedule until education could be completed. · Education on medication and treatment cart safety was initiated with State tested Nursing Assistants (STNA's), Housekeepers, Laundry Staff, Maintenance Staff, and Ancillary Nursing Team members on 09/14/17 and completed on 09/15/17 by RM/SD-RN #401 and Director of Environmental Services (DES) #213. · New employee orientation presentation was updated on 09/14/17 by RM/SD-RN #401 to include medication and treatment cart safety and roles and responsibilities of staff in relation to medication and treatment cart safety. · Medication and Treatment Cart audits were initiated by the DON, RM/SD-RN #401, RNUM's #8, #20, and #135 and Registered Nurses (RN's) #103, #104, #145 and #214 every two hours on 09/14/17 at 7:00 A.M. for 48 hours, then every shift for four weeks. Completed audit tools will be forwarded to the DON to initiate further follow-up as indicated and present findings to the Quality Assurance Performance Improvement (QAPI) committee on 09/29/17 for review. Frequency of audits after initial auditing would be determined based upon findings and recommendations of the QAPI committee. · The DON notified the Ohio Board of Nursing via the complaint form regarding the deficient practice of LPN #202 on 09/15/17. · RN and LPN orientation and annual skills checklists were updated by RM/SD-RN #401 on 09/14/17 to include medication and treatment cart safety. · Pharmacy is scheduled to conduct monthly medication pass audits on each shift with emphasis on medication and treatment cart safety beginning September 2017 for three months with audit results reported to the DON to initiate further follow-up as indicated and present findings to QAPI committee. Frequency of audits after initial auditing to be determined by QAPI committee. · On 09/15/17 between 1:10 P.M. and 1:30 P.M., interviews were conducted with eight staff regarding training on medication storage in regards to unsecured medication carts. LPN's #139, #140, #218 and State tested Nursing Assistant (STNA's) #9, #45, #143, #146, and #217 revealed they were in-serviced about medication and treatment carts and were knowledgeable about their responsibilities in regards to safety of medication and treatment carts. Findings include: 1. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED].#144 had severely impaired cognitive skills for daily decision making, was independent with walking on the unit, extensive assistance was required with eating and toileting, and Resident #144 was totally dependent with personal hygiene. Resident #144 was assessed as having behaviors that included pacing, rummaging and wandering, which occurred daily. Review of care plans dated 06/23/17 revealed Resident #144 had Alzheimer's disease, wasn't oriented, mumbled to self with nonsensical speech, required supervision from staff, would frequently bend over and remove socks, shoes, and clothes, wandered with exit seeking behaviors, entered offices and other resident's rooms, picked up invisible things from the floor and wiped floor with hands, pushed furniture, wheelchairs, and sat on the floor. Review of the memory support secure unit assessment dated [DATE] revealed Resident #144 had a [DIAGNOSES REDACTED]. Resident #144 was assessed as appropriate for the secure dementia unit. Medical record review revealed Resident #153 was admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED].#153 was rarely/never understood and had modified independence with daily decision making. Resident #153 was independent with locomotion on the unit and utilized a wheelchair for mobility. Supervision was required with eating, extensive assistance with toileting, and Resident #153 was totally dependent with personal hygiene. Resident #153 was assessed with [REDACTED]. Verbal behavioral symptoms directed towards others were identified as screaming and cursing and behavioral symptoms not directed towards others such as hitting or scratching self, pacing, rummaging, and disrobing in public, which occurred one to three days. Review of care plans dated 03/02/17 revealed Resident #153 was hard of hearing and his hearing aids were found chewed up in his mouth. Behaviors were impulsive with decreased safety awareness, wanders in wheelchair, cognitive deficits, limited insight, and combative with care. Review of the memory support secure unit assessment dated [DATE] revealed Resident #153 had dementia and could ambulate or self-propel in wheelchair. Resident #153 was assessed as appropriate for the secured unit due to dementia, behaviors and risk of elopement. Observation on 09/14/17 at 6:04 A.M., upon entrance to the secure dementia unit, revealed the Winding Way medication cart was unlocked with the second to bottom drawer pulled out all the way allowing visibility and accessibility to medications in the drawer. No staff members were visible within eyesight of the medication cart. Resident #153 independently propelled himself with his hands and feet past the unsecured medication cart towards a common area located at the end of the hall. Resident #144 independently ambulated past the cart and wandered throughout the hall. LPN #202 returned to the cart at 6:06 A.M. Interview on 09/14/17 at 6:06 A.M. with LPN #202 revealed she had stepped away from the medication cart for a few minutes to answer the telephone and all drawers to the cart had been closed. LPN #202 pointed at Resident #144 and indicated the resident must have touched and opened the drawer to the medication cart. Observation of the opened drawer contents with LPN #202 revealed two boxes of Divalproex sodium 125 milligrams (mg) with a total of 95 capsules, one box of 30 Furosemide 20 mg, one box of 21 Quetiapine 25 mg, one box of 90 Gabapentin 300 mg, and one box of 60 Ferrous Sulfate 325 mg. Also, contained within other unsecured drawers included two pairs of scissors, tuberculin and insulin syringes, and lancets. Review of the facility video surveillance on 09/14/17 at 3:04 P.M. with the DON revealed LPN #202 walked away from the medication cart with the second to bottom drawer pulled all the way out at 6:03 A.M. At 6:04 A.M., STNA's #128 and #146 were observed walking past the unsecured medication cart, with the second to bottom drawer all the way out, and exited the hall. During a telephone interview on 09/15/17 at 9:35 A.M. with LPN #202, she stated she was unaware she had left the medication cart unsecured with the drawer all the way out when she went to the other side of the unit to assist another nurse obtain information off the computer. LPN #202 stated she was not honest when she initially indicated she had stepped away from the medication cart to answer the phone. LPN #202 reported there wasn't any way she could have seen the unsecured medication cart from where she was as the halls were parallel to one another, separated by common areas and walls. A telephone interview on 09/15/17 at 1:31 P.M. with STNA #146 revealed she did not recognize the medication cart was unsecured when she walked past it on 09/14/17. Review of the facility Drug Storage policy (undated) revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 2. Review of Resident #111's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the side rail assessment dated [DATE] indicated the resident required side rails to assist with bed mobility with staff assistance and the side rails did not pose a risk for entrapment. Review of the MDS dated [DATE] indicated the resident was cognitively intact and required limited assistance with bed mobility. During observation on 09/11/17 at 3:05 P.M., Resident #111 was observed in his bed with two bilateral half side rails up at the head of the bed. The mattress was noted to be smaller than the bed frame and there was a gap between the mattress and the bed frame that was approximately five inches between the mattress and the bed. The gap was noted between the upper left side rail and the metal bed frame that measured five inches wide and ten inches long. On 09/11/17 at 5:21 P.M., Resident #111 was interviewed and stated the side rail was adjustable. The resident stated the side rail had been out like that since he received the bed and the people who set up the bed told him it was adjustable. On 09/11/17 at 5:22 P.M., LPN #06 adjusted the side rail to the correct size for the mattress. LPN #06 stated she had never noticed the gap before and therefore did not know it was adjustable. LPN #06 verified the gap in the bed frame was five inches wide and ten inches long. LPN #06 stated due to the potential for an accident she would contact the company that owned the bed and have them come and look at the bed. 3. Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with activities of daily living. Further review of the medical record revealed the resident had no assessment for the use of side rails. Review of the physician orders for 09/2017 revealed no physician orders for the use of side rails. On 09/11/17 at 5:05 P.M., Resident #45 was observed in her bed with bilateral half side rails up. Gaps were noted on each side of the bed between the upper side rails and the headboard. The gaps were noted to be approximately ten inches wide. On 09/11/17 at 8:09 P.M. the gaps between the upper side rails and the headboard were measured by Maintenance Staff (MS) #410 and he verified the gap on the right side was 9.5 inches wide and the left side was 9.875 inches wide. During an interview on 09/12/17 at 8:00 A.M., the Administrator verified the resident had no assessment for side rails. During an interview on 09/12/17 at 8:45 A.M., LPN #06 verified Resident #45 had no physician orders for side rails. 4. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 06/30/17 revealed no documentation related to the use of side rails. Review of the physician order sheet dated 09/01/17 documented may use half upper side rails for bed mobility and transfer. Review of the MDS assessment dated [DATE] revealed Resident #22 had severe cognitive impairment, was always incontinent of bladder and bowel and was totally dependent on two staff for bed mobility and transfer. Review of the side rail assessment dated [DATE] revealed the resident will use her top two half side rails to assist with bed mobility. This assessment was unchanged from the previous assessment completed on 06/29/17. During an observation on 09/11/17 at 7:45 P.M. of Resident #22's bed revealed an area of increased space noted between the headboard and the end of the side rail. During an observation on 09/13/17 at 1:20 P.M., Resident #22 was up in the Geri chair and both hands were contracted at this time. She was being assisted with her lunch meal by her son. During an interview on 09/13/17 at 1:26 P.M., STNA #45 said she did not know why the resident had side rails as the resident never assisted with turning. During an interview on 09/13/17 at 1:36 P.M., STNA #09 stated the residents side rails were up so she would not fall. She further indicated the resident had not assisted with mobility and turning for a long time. During an interview on 09/13/17 at 1:58 P.M., LPN #110 confirmed Resident #22 could not assist in rolling from side to side when she was in bed. During an interview on 09/13/17 at 2:02 P.M., LPN #63 stated she worked on the dementia unit for years and they would use the side rails to assist in changing the resident. She further indicated she thought Resident #22's side rails were implemented after a fall. She stated the resident could not position herself in bed. During an interview on 09/13/17 at 4:25 P.M., MDS nurse #168 stated she thought staff were using side rails for Resident #22 to aide in peri care, but the side rails might have been implemented for safety to keep the resident from rolling out of bed. She confirmed the resident was assessed in 06/2017 and the side rails were to aide in mobility. After the reassessment on 09/12/17 the side rails were discontinued as the resident did not assist with turning. She did confirm the side rails had been discontinued after another reassessment. Review of facility policy entitled Side Rail Use with a revised date of 08/03/17 revealed the facility would ensure the safe use of side rails as resident mobility aids and would prohibit the use of side rails in restraints unless necessary to treat a resident's medical symptoms.

Based on observation, record review, review of gait belt policy and interview, the facility failed to provide a gait belt to ensure safety for one Resident (#143) with a history of falls. This resulted in harm for Resident #143 when she suffered a fracture from an avoidable fall and had an increase in pain. This involved one of three sampled resident of 23 residents identified with falls. Findings include: Review of the medical record for Resident #143 revealed [DIAGNOSES REDACTED]. Her most recent comprehensive assessment dated [DATE] assessed the resident without cognitive deficits, with extensive assist of one staff for transfers, walking in the room and corridor, and toileting. The resident utilized both a wheelchair and a rolling walker. She had a history of [REDACTED]. Other interventions included to remind resident to use her walker as well as to use a gait belt for all transfers and ambulation, resident to use a shower chair with a back and no wheels for showering. She was documented as leaning to the right when ambulating, standing and/or seated. Observation of the resident on 01/24/13 at 10:00 A.M. revealed the resident was groomed and dressed appropriately. She was seated in a wheelchair next to her bed with the call light in reach. She had a sensor alarm attached to the wheelchair. The resident was asked how she felt, and she replied she had hip and shoulder pain but the pain pills helped. She stated when she fell and broke her hip, the state tested nursing assistant (STNA) was in front of her trying to move the chair. She further indicated that the STNA should have been behind her. She said the STNA was not wearing a gait belt. Review of the Medication Administration Record (MAR) revealed the resident taking Percocet 1 to 2 tablets a total of 35 times as needed for documented moderate to severe pain from 11/12/12 to 11/30/12. Review of the December and January MAR show consistent use daily of Percocet for hip pain/shoulder pain. A Fall Nurse's notes and acute plan of care dated 11/17/12 at 11:15 A.M. revealed the resident was observed lying on the left side in the room in front of her chest of drawers with her walker on top of her. The resident stated she hit the left side of her head and complained of left hip pain. She was noted with a 1 centimeter (cm) hematoma to the left elbow and bruising to the left hand. The resident said she had lost her balance. She was assessed for injuries with complaints of left hip pain, range of motion within normal limits to left extremity and no inward/outward rotation. The physician was called and an immediate (STAT) X-ray to the left hip was ordered at 11:30 A.M. Additional orders included a physical therapy evaluation and hipsters to be worn at all times. The medication administration record (MAR) shows the resident was treated at 11:30 A.M., and 3:30 P.M. with Norco 1 tablet for severe pain to the left hip. Neurological checks were started at 11:15 A.M. and done hourly till 3:15 P.M. The X-ray was done at 1:15 P.M., electronically signed and dated by the physician at 3:07 P.M. and faxed to the facility. The results were positive for an acute angulated fracture through the femoral neck with slight impaction. There was mild generalized osteopenia. Review of the fall investigation revealed a statement from STNA #10 dated 11/07/12. She said the was walking the resident back to her recliner, situating her recliner and moving it away from the wall. The resident had her walker in front of her, holding on to it, and her wheelchair was behind her. She (STNA) was standing to the residents right. The resident lost her balance, falling to her left side in between the end of the bed and the dresser. The written statement from LPN #7 on 11/07/12 said she was called to the room by STNA #10. The resident was lying on her left side in front of the chest with her walker on top of her. Resident stated she hit her head on the floor and complained of left hip pain. The resident stated she lost her balance. The STNA was with the resident at the time of the fall but was unable to hold her. Range of Motion (ROM) was within normal limits, the resident was alert and oriented and neurological checks were within normal limits. Interview with the unit manager # 6 on 01/24/13 at 3:00 P.M. revealed a housekeeper was also in the room trying to move the recliner at the time of the fall. She revealed the STNA was supposed to be using a gait belt on the resident during the ambulation and did not use one. The facility policy for use of gait belts includes: Gait belts are used as a way to transfer, walk, and lift residents who are not able to support themselves. If a resident is unstable or unable to move without help, the gait belt must be used. Use of gait belt when walking: staff holds onto the gait belt as the resident walks. It the resident loses his balance, the staff uses the gait belt to steady the resident as much as possible. An interview with housekeeping staff #3 on 01/24/13 at 3:15 P.M. revealed she was present in the room at the time of the fall. She said she was trying to move the residents recliner away from the wall. She said the STNA was walking the resident from the bathroom with her walker. She said the aide tried to move her wheelchair out of the way but stayed with the resident. She said she fell quickly and the nurse came into check on her. Interview with LPN # 7 on 01/28/13 at 11:30 A.M. revealed the resident was walking from the bathroom with the STNA. She said when she came in the resident was on the floor with her head towards the door, lying between the bed and the chest of drawers. She did not recall where her wheelchair was, but her walker was on top of her. She verified the resident did not have a gait belt on. At 12:20 P.M. STNA #10 was interviewed. She said the resident had her walker in front of her, and she was behind her leaving the bathroom. She said her wheelchair was against the wall by the chest of drawers and the TV. She went in front of the resident to help the housekeeper move the chair. The STNA said, she thought the resident thought she was suppose to sit down in the wheelchair. The resident lost her balance and fell to the left. The STNA verified she did not have a gait belt on the resident, and was suppose to have one. She said the resident leans to the right when ambulating, sitting or standing. This substantiates Complaint #OH 770.