Every finding on record at MCV Health Care Facilities, Inc

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure resident dignity was maintained during medication administration. This affected one (#59) of five residents observed during medication administration. The facility census was 61.Findings include:Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had moderately impaired cognition and was dependent for toileting and bathing.Review of the care plan dated 06/03/25 for Resident #59 revealed the resident had impaired cognitive function or impaired thought processes related to dementia.Observation on 06/25/26 at 7:49 A.M. revealed Resident #59 was sitting in the common dining area with 13 other residents in the room. Resident #59 had two residents sitting at her table. Further observation revealed Registered Nurse (RN) #42 entered the room, lifted up Resident #59's shirt exposing her bare stomach, and administered an injection. Interview on 06/25/26 at 7:55 A.M. with RN #42 verified the injection for Resident #59 was given while in the common area. RN #59 stated nurses always administer medications, including injections, where ever the resident was at the time of administration.Interview on 06/25/26 at 8:45 A.M. with the Director of Nursing (DON) confirmed all administration of injections should be in a private area or resident room.Review of the undated facility policy titled, Resident Rights, revealed residents had the right to respect and dignity.

Based on review of the medical record, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure as needed psychotropic medications were not ordered for more than 14 days without adequate documented rationale. This affected one (#2) of five residents reviewed for unnecessary medications. The facility census was 61.Findings include:Review of the medical record for Resident #2 revealed an admission date of 12/23/25. Diagnoses included type II diabetes mellitus, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of ten. The resident was assessed to require setup with eating, was dependent with toileting, transfers, and dressing, and required substantial assistance with bathing.Review of the physician order dated 04/28/26 revealed Resident #2 was ordered Ativan one (1) milligram (mg) with instructions to give 1 tablet by mouth every four hours as needed for anxiety with no stop date. Further review of the order revealed no stop date was addressed in the order as of 06/24/26. There was no documented rationale for an extension of the medication beyond 14 days in the medical record.Review of the pharmacy recommendation in May 2026 revealed a recommendation that Resident #2's as needed Ativan needed a stop date, which required a discontinuation or a new order.Interview on 06/25/26 at 8:40 A.M. with the Director of Nursing (DON) verified the May 2026 pharmacy recommendation for Resident #2 was not followed and the resident's as needed Ativan order extended beyond 14 days without adequate documented rationale for continued use.Review of the undated facility policy titled, Psychotropic Medications, revealed physicians and mid-level providers would use psychotropic medications appropriately working with the interdisciplinary team (IDT) to ensure appropriate use, evaluation, and monitoring. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure care conferences were completed in a timely manner. This affected one (#2) of two residents reviewed for care conferences. The facility census was 61.Findings include:Review of the medical record for Resident #2 revealed an admission date of 12/23/25. Diagnoses included type II diabetes mellitus, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of ten. The resident was assessed to require setup with eating, was dependent with toileting, transfers, and dressing, required and substantial assistance with bathing.Review of the care conference notes since admission revealed Resident #2 had only had one care conference dated 04/07/26. Interview on 06/25/26 at 10:38 A.M. with Social Worker Assistant (SWA) #36 revealed care conferences were to be completed quarterly. SWA #36 verified Resident #2 received one care conference since admission.Review of the undated facility policy titled, Care Conference Policy, revealed the facility was to ensure interdisciplinary communication, individualized care planning, discharge planning, and resident/family involvement. Care conferences would be conducted at least quarterly every three months for long-term care residents.

Based on medical record review, staff interview, and policy review, the facility failed to ensure pressure ulcers were thoroughly assessed and interventions were initiated to prevent pressure ulcer development for at risk residents. This affected one (#3) of two residents reviewed for pressure ulcers. The census was 61. Findings include: Review of the medical record for Resident #3 revealed an admission date on 06/01/26. Diagnoses included congestive heart failure (CHF), dysthymic disorder, major depressive disorder, osteoarthritis, pathological fracture, iron deficiency, insomnia, and fracture of the shaft of the left tibia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The resident was assessed to require set up with eating, and was dependent with toileting, bathing, dressing, and transfers. Resident #3 was assessed with no pressure wounds on admission but was at risk for pressure wounds. Review of the nursing assessment/baseline care plan report dated 06/01/26 for Resident #3 revealed a skin tear on the right elbow and right antecubital, and bruising to the right hand (back), left antecubital, left elbow, left lower leg (front), right lower leg (front), and left lower leg front. Recommended interventions included the elevation of the heels, repositioning, and barrier cream.Review of an assessment used to predict pressure sore risk dated 06/01/26 revealed Resident #3 was at moderate risk.Review of the progress note dated 06/13/26 at 3:00 P.M., authored by Licensed Practical Nurse (LPN) #219, revealed Resident #3 had a discolored blister on his left heel. All parties were notified. A new order was received to apply an abdominal (ABD) pad for padding and protection to be changed three times a week and as needed until healed.Review of the treatment administration record (TAR) dated June 2026 for Resident #3 revealed no interventions were in place to float heels prior to 06/13/26. Review of the physician order dated 06/16/26 revealed Resident #3 was ordered Sage boots (padded boots) to bilateral heels when in bed two times a day.Review of the twice weekly skin assessment dated [DATE] for Resident #3 revealed a blister was identified but no measurements or description was provided.Interview on 06/24/26 at 2:56 P.M. with the Director of Nursing (DON) confirmed there was no mention of the blister to Resident #3's heel until 06/13/26 and no treatments were in place until 06/17/16, and measurements were not completed until 06/18/26. Follow up interview on 06/24/26 at 3:24 P.M. with the DON reported her expectation of staff for initial or new wounds was to measure the wounds.Interview on 06/25/26 at 12:11 P.M. with Medical Director (MD) #300 revealed her expectation for nursing staff was to measure and describe wounds, in detail, when they were first identified.Interview on 06/25/26 at 1:48 P.M. with Wound Nurse Practitioner (WNP) #305 revealed she expected staff to document and describe the wound in detail to help with monitoring the wound before she saw it with her weekly rounds.Review of the undated facility policy titled, Skin Care Policy and Procedure, revealed the purpose of the policy was to prevent and properly treat impaired skin. All residents are assessed upon admission and have daily skin assessments completed by a nurse for three days after admission. This is done by a nurse visually assessing a resident and completing the skin assessment form, a Braden scale assessment is completed, twice weekly skin assessments will be completed on the same schedule as showers.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure residents were free from potential hazards. This had the potential to affect three (#11, #33, and #37) of three residents on the Special Care Unit identified as independently mobile and cognitively impaired. The facility census was 61. Findings include:1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included altered mental status, chronic atrial fibrillation, unspecified dementia, and unspecified glaucoma. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severely impaired cognition. Review of the care plan dated 03/30/26 revealed Resident #11 had impaired cognitive function, impaired thought processes, and was alert and oriented to self only. He was pleasantly confused related to altered mental status and unspecified dementia. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, other seizures, and altered mental status.Review of the most recent MDS assessment dated [DATE] revealed Resident #33 had severe cognitive impairment, was assessed to wander, and was dependent for toileting and bathing.3. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included Parkinsonism, dementia, anxiety disorder, cognitive social or emotional deficit, and major depressive disorder.Review of the most recent MDS assessment dated [DATE] revealed Resident #37 had moderately impaired cognition, disorganized thinking, and wandering behavior. Observation on 06/23/26 at 7:10 A.M. to 7:21 A.M. in the Special Care Unit (SCU) revealed the treatment cart next to the nursing area was unlocked with the right half door of the nursing station open and no staff were in sight anywhere in the common area. Further observation revealed eight residents were in the common area and three (#11, #33, and #37) of those residents were identified by the facility to be independently mobile.Interview on 06/23/26 at 7:22 A.M. with Licensed Practical Nurse (LPN) #41 confirmed the treatment cart was unlocked and the door to the nursing area was open to the common area. Interview and observation on 06/23/26 at 8:01 A.M. with the Director of Nursing (DON) of the treatment cart in the SCU hallway in common area confirmed multiple wound supplies including topical medications were in the cart. The DON also confirmed the items such as a bottle of liquid bleach, a bottle of liquid furniture polish, a spray bottle of laundry cleaner, a bottle of liquid disinfectant cleaner, and a bottle of liquid multi-surface cleaner were under the sink in an unlocked cabinet in the SCU nursing area during the observation.Review of the undated facility policy titled, Hazardous Chemical Storage and Security Policy (Memory Care Unit), revealed all hazardous chemicals shall be stored in locked cabinets or locked housekeeping closets when not in direct use and remain inaccessible to residents at all times.

Based on observation, staff interview, resident representative interview, and facility policy review, the facility failed to ensure foods were prepared and served to residents with the correct consistency. This affected three (#04, #11, and #48) of three residents reviewed moist and minced diet consistency. The total census was 61.Findings include: 1. Medical record review for Resident #11 revealed he was admitted to the facility on [DATE]. His diagnoses included glaucoma, pulmonary embolism, hypercholesteremia, chronic kidney disease, anemia, chronic atrial fibrillation, dementia, anxiety, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment for Resident #11 revealed he was cognitively impaired. Resident #11 required set up assistance from staff with his meals and oral hygiene. Resident #11 was dependent on staff for medication administration, toilet use, lower body dressing, bathing, and putting on shoes. Resident #11 required partial assistance from staff with upper body dressing.Review of Resident #11's care plan dated 06/12/26 revealed the resident was to receive a minced and moist diet.Interview with Resident #11's Resident Representative (RR) on 06/22/26 at 10:12 A.M. revealed the family was concerned with the consistency of the moist and minced diet provided to the resident. The RR revealed Resident #11's food appeared to be watered down and had a soupy appearance.Observation of the test tray at lunch on 06/24/26 at 12:15 P.M. with Dietary Manager (DM) #195 revealed the tray contained a moist and minced chicken patty that appeared very watered down and spread across the plate in with an oatmeal type consistency. The vegetable soup was smooth and had the consistency of a pureed diet.Interview with DM #195 on 06/24/26 at 12:15 P.M. confirmed the consistency of the chicken patty was not consistent with the moist and minced diet. DM #195 confirmed the consistency of the soup was relative to a pureed diet texture.2. Medical record review for Resident #4 revealed she was admitted to the facility on [DATE]. Her diagnoses included insomnia, diabetes mellitus (DM), hypothyroidism, heart failure, essential primary hypertension, major depressive disorder, fibromyalgia, and dementia.Review of the MDS assessment, dated 06/10/26, for Resident #4 revealed she was cognitively impaired. Resident #04 was dependent on staff for eating, oral hygiene, medication administration, upper body dressing, lower body dressing, toilet use, personal hygiene, and bathing.Observation of the evening meal on 06/24/26 at 4:47 P.M. revealed Certified Nurse Aide (CNA) #13 assisted Resident #4 with her dinner. The turkey a la King was spread across the plate with a brown liquid ring. CNA #13 stirred the food prior to feeding it to Resident #4.Interview with CNA #13 on 06/24/26 at 4:47 P.M. confirmed she assisted Resident #4. CNA #13 confirmed Resident #4 required a minced and moist diet. CNA #13 revealed she continued to stir the food at a fast pace to try to thicken it up like a gravy because it appeared to runny.3. Medical record review for Resident #48 revealed she was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, dementia, anxiety disturbance, and dysphagia.Review of the MDS assessment for Resident #48, dated 04/27/26, revealed she had impaired cognition. Resident #48 required set up assistance from staff with eating and putting on shoes. She required moderate assistance from staff with oral hygiene, bathing, upper body dressing, lower body dressing, toilet use, and personal hygiene. She was dependent on staff for medication administration.Observation of Resident #48 on 06/24/26 at 4:49 P.M. revealed CNA #32 assisted Resident #48 with her meal.Interview on 06/24/26 at 4:49 P.M. with CNA #32 confirmed the turkey a la King on Resident #48's meal was very runny and spread across the plate.Review of the undated facility policy titled, Minced & Moist Procedure Guide, confirmed the goal was for food to be very soft, moist, and have some small chopped, lumpy or minced texture. In most food items, the food should stay on the fork and have minimal liquid separation. House minced and moist will consist of small chopped or minced or pulsated mechanical soft foods that may be combined with same puree food item to reach soft, lumpy, moist consistency. In most cases, little to no liquid should sperate from minced and moist foods.

Based on observation, staff interview, and policy review, the facility failed to ensure drinks were stored and served at an appropriate temperature. This affected three (#33, #41, and #44) of three residents the facility identified who ingested milk that was out of temperature range. The facility census was 61. Findings include:Observation and interview on 06/24/26 at 8:02 A.M. of the Memory Care Unit (MCU) refrigerator, with Director of Maintenance (DOM) #135, revealed the thermometer measured 48 degrees Fahrenheit (F). DOM #135 confirmed the temperature of the refrigerator and stated the food was not cold to touch.Interview and observation on 06/25/26 from 8:05 A.M to 8:30 A.M with Dietician #295 and Dietary Manager (DM) #195 revealed temperature checks of drinks from the refrigerator included milk that was in the door measured 46.7 degrees F and a gallon of milk on the middle shelf measured 51 degrees F. Dietician #295 and DM #195 confirmed all of the items that require refrigeration would be thrown out. Interview on 06/25/26 at 8:35 A.M. with Certified Nurse Aide (CNA) #32 confirmed Resident #33, Resident #41, and Resident #44 consumed milk out of the refrigerator unit that were not in acceptable temperature range.Review of the undated policy titled, Food Handling and Storage, revealed all refrigerated foods should be stored at a temperature between 32 degrees and 41 degrees.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff providing direct care to residents with enhanced barrier precautions wore appropriate personal protective equipment during the delivery of care. This affected one (#3) of five residents reviewed for infection control precautions. The facility census was 61. Findings include:Medical record review for Resident #3 revealed he was admitted to the facility on [DATE]. His diagnoses included congestive heart failure (CHF), dysthymic disorder, major depressive disorder, osteoarthritis, pathological fracture, iron deficiency, insomnia, and fracture of the shaft of the left tibia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact.Review of the orders for Resident #3 revealed an order dated 06/01/26 for urinary catheter care.Review of the orders for Resident #3 dated 06/18/26 revealed the resident was ordered treatment to a left heel wound to include application of betadine, cover with a dry dressing, and wrap with Kerlix.Review of the care plan dated 06/21/26 for Resident #3 revealed no goal or intervention for enhanced barrier precautions (EBP) and review of all current orders for June 2026 revealed no order for EBP.Observation on 06/24/26 between 11:18 A.M. and 11:33 A.M. revealed Registered Nurse (RN) #105 completed wound care to Resident #3's left heel in his room without wearing a gown. RN #105 walked out of the room to get scissors and proceeded back into Resident #3's room again with no gown and completed the dressing change. Observation of the EBP sign outside of Resident #3's door indicated for caregivers to wear gloves and a gown for high-contact resident care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care or use, and wound care. Interview on 06/24/26 at 11:40 A.M. with RN #105 stated she did not normally wear gowns during wound care, only with open wounds. RN #105 confirmed the EBP sign at Resident #3's room. RN #105 stated her supervisor told her no gown was needed for care.Interview on 06/24/26 at 2:26 P.M. with the Director of Nursing (DON) revealed Resident #3 did not have an active order for EBP or have it in the care plan. The DON stated Resident #3 was in EBP and staff should be following the policy.Review of the facility policy titled, Enhanced Barrier Precautions, dated 2024, revealed an order for EBP will be obtained for residents with any of the following including chronic wounds and indwelling medical devices.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility investigation review, staff and resident interviews, and facility policy review, the facility failed to ensure a gait belt was in place to prevent a fall. This affected one (Resident #08) of three residents reviewed for accidents. The census was 61. Review of Resident #08's chart revealed Resident #08 admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, hypertension, disorientation, unspecified osteoarthritis, muscle weakness, other abnormalities of gait and mobility, major depressive disorder, overactive bladder, other specified anxiety disorders, visual hallucinations, and allergic rhinitis.Review of Resident #08's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required moderate assistance with toileting, upper body dressing, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, and walking ten feet and required maximal assistance with showering, toilet transfers, and tub transfers. Resident #08 was dependent with lower body dressing and putting on and taking off footwear and required supervision with personal hygiene. Resident #08 had not had any falls since her admission to the facility but Resident #08 had a fall in the last month prior to admission to the facility.Review of Resident #08's fall risk assessment dated [DATE] revealed Resident #08 had fallen one to two times in the past six months. Resident #08 was unable to independently come to a standing position, exhibited loss of balance while standing, required hands on assistance to move from place to place, used an assistive device and had a decrease in muscle coordination. Resident #08 was at high risk for falls.Review of Resident #08's fall care plan dated 03/12/26 revealed Resident #08 was at risk for falls. Interventions included anticipate and meet the resident's needs, be sure the call light is within reach, encourage the resident to use the call light for assistance, provide a prompt response to all requests for assistance, encourage non skid footwear as ordered, follow facility fall protocol, provide maximum to moderate assistance with transfers and walking short distances, Resident #08 uses a walker and a wheelchair for long distances, assistance with wearing shoes when walking, review information post falls and attempt to determine the cause of falls, record possible root causes of falls, alter and remove any potential causes of falls, educate the resident, family and caregivers as to causes and orthostatic blood pressures for three days.Review of Resident #08's progress note dated 02/26/26 at 3:08 P.M. revealed a care conference was held with Resident #08, Resident #08's daughter, therapy and Social Services (SS) #90. Resident #08 needed minimal assistance to get in and out of bed and minimal to moderate assistance with standing. Resident #08 had been having pain in her left foot and therapy was working on leg strength and balance as Resident #08 leaned backwards when standing. Resident #08's discharge goal was to return to her single level condo where she resided alone. Resident #08 had used home health in the past.Review of Resident #08's progress note dated 03/05/26 at 2:38 P.M. revealed a care conference was with Resident #08, Resident #08's daughter, therapy, nursing, the dietician and SS #90. Resident #08 required contact to minimal assistance with bed mobility and minimal assistance with transfers. Resident #08 leaned back when she stood up and therapy was working on balance. Resident #08 was walking 25 feet with the walker and therapy still needed to work on stairs. Resident #08 required minimal to moderate assistance with lower body dressing and toilet transfers. Review of Resident #08's occupational therapy progress note dated 03/06/26 revealed Resident #08 performed a toilet transfer requiring contact guard assistance using grab bars while needing constant verbal cueing for good sequencing. Review of Resident #08's physical therapy progress note dated 03/06/26 revealed Resident #08 performed git training with a two wheeled walker using contact guard assistance. Resident #08 also performed a sit to stand transfer from the recliner and wheelchair with minimal assistance to contact guard assistance. Review of Resident #08's fall risk assessment dated [DATE] revealed Resident #08 had fallen one to two times in the past six months. Resident #08 was unable to independently come to a standing position, Resident #08 exhibited loss of balance while standing and Resident #08 used an assistive device and Resident #08 had a decrease in muscle coordination. Resident #08 was at moderate risk for falls.Review of Resident #08's progress note dated 03/10/26 at 1:15 P.M. revealed Licensed Practical Nurse (LPN) #107 was informed by the Certified Nursing Assistant (CNA) #242 that Resident #08 had fallen in her room. Upon arriving, LPN #107 noted Resident #08 was on her back on the floor at the foot of the bed. A pillow was placed under Resident #08's head. CNA #242 stated Resident #08 fell backwards when walking with her to the bathroom. A head to toe assessment was completed for injuries. Vital signs were taken and neurological checks were initiated. Resident #08 was noted with a red raised area to the back of the head. Neurological checks were within normal limits and the physician was notified. A new order was put in place for shoes for ambulation. Resident #08's daughter was notified and was present. Resident #08's daughter requested Resident #08 be sent to the emergency room (ER) for evaluation and treatment.Review of Resident #08's neurological assessments from 03/10/26 at 2:00 P.M. to 03/13/26 at 11:15 P.M. revealed all neurological checks were within normal limits.Review of Resident #08's progress note dated 03/10/26 at 2:05 P.M. revealed emergency medical services (EMS) was called per Resident #08 and Resident #08's daughter's request.Review of Resident #08's progress note dated 03/10/26 at 2:18 P.M. revealed Resident #08 exited the facility with EMS by stretcher.Review of Resident #08's hospital note dated 03/10/26 revealed Resident #08 presented to the ER from the skilled nursing facility by EMS for a witnessed fall. Resident #08 was being assisted to the bathroom by staff when they took their hand off of her gait belt to open the door and she fell backwards and hit her head. Resident #08 denied loss of consciousness or vomiting. Resident #08 was at her baseline for mental status. Resident #08 noted some pain in the left side of her neck that had been present for a few days. Resident #08 was given Tylenol prior to leaving the skilled nursing facility. Further review of the hospital note revealed Resident #08 was awake and was at her baseline for neurological and mental status. Resident #08 had a small contusion of the occipital scalp and some tenderness of her left paraspinal musculature of her neck. A computed tomography (CT) of the head and neck did not show any significant acute traumatic injuries. The clinical impressions for the ER visit were listed as thyroid nodule incidentally noted on imaging study, fall initial encounter and injury of the head initial encounter.Review of the head CT without contrast dated 03/10/26 revealed No acute intracranial abnormality. Resident #08 had a two centimeter (cm) nodule on the left thyroid lobe. Review of Resident #08's progress note dated 03/10/26 at 6:09 P.M. revealed Resident #08 returned from the hospital. Resident #08 had a CT of the head and cervical spine. No new orders were given. Resident #08's daughter arrived before Resident #08. Neurological checks were continued per schedule and the physician was made aware of the resident's return.Review of Resident #08's progress note dated 03/10/26 at 10:14 P.M. revealed Resident #08 was alert and oriented to person, place and situation. Resident #08 was intermittently confused and forgetfulness was noted. Resident #08 was pleasant and cooperative to care. No signs or symptoms of respiratory distress or shortness of breath were noted. Resident #08 complained of left leg pain. Routine Tylenol was given and effective. Resident #08 remained on neurological checks. Resident #08's daughter requested that her mother not be awakened for neurological checks and only wanted them to be done while awake. Resident #08 was resting quietly in bed with her call light and belongings in reach.Review of CNA #242's undated witness statement revealed CNA #242 was assisting a resident who needed to use the restroom on 03/10/26 at 1:15 P.M. The resident was using a walker and CNA #242 was walking beside her while providing guidance and support. CNA #242 had a hand on the resident at all times while assisting her. As they approached the bathroom door, CNA #242 reached for the door knob to open the door while maintaining her hand on Resident #08 for support. At that moment, the resident began to lose balance and went down to the floor. The resident fell backward and struck her head on the floor. The incident occurred quick while CNA #242 was assisting the resident with the walker and maintaining support.Review of Resident #08's undated investigative summary signed by the Director of Nursing (DON) revealed Resident #08 fell at the facility on 03/10/26 at 1:15 P.M. The nurse was informed by CNA #242 that Resident #08 had fallen in her room. Upon arrival, the nurse noted Resident #08 was on her back on the floor at the foot of the bed. A pillow was placed under the resident's head. CNA #242 stated Resident #08 fell backwards when walking with Resident #08 to the bathroom. Per the interview with CNA #242, CNA #242 stated she did not have the gait belt on the resident. CNA #242 stated she opened the door and at that time Resident #08 leaned backwards and lost her balance. CNA #242 had her hand on Resident #08 but was unable to prevent the fall from occurring. CNA #242 stated she called for the nurse and placed a pillow under her head and stayed with Resident #08. The nurse assessed Resident #08 for injury, vitals were taken and neurological checks were initiated. Resident #08 was noted with a red raised area to the back of the head. Neurological checks were within normal limits and the physician was notified. A new intervention was put in place for Resident #08 to have shoes on for ambulation. Resident #08's daughter was notified by the resident and was present at the facility. Resident #08's daughter requested for Resident #08 to be sent to the ER for evaluation due to Resident #08 having a hematoma to the back of the head. Resident #08 was sent to the hospital at 2:15 P.M. Resident #08 returned to the facility on [DATE] at 6:00 P.M. and a head CT was completed at the ER and was negative. Resident #08 also had pain to the buttocks and lower back. Xrays of the lumbar spine and bilateral hips were completed on 03/11/26 and showed arthritis but no fracture or dislocation. The immediate intervention was footwear while ambulating and CNA #242 was educated on gait belt usage by LPN #107 and RN #44 on 03/10/26. An in-service for all nursing staff to review and sign on gait belt usage was completed.Review of Resident #08's progress note dated 03/11/26 at 10:25 A.M. revealed the interdisciplinary team (IDT) discussed Resident #08's fall from 03/10/26 where Resident #08 was noted on her back on the floor at the foot of her bed. A pillow was placed under Resident #08's head and the CNA stated Resident #08 fell backwards when walking with her to the bathroom. After a root cause analysis, the intervention for the fall was proper footwear during ambulation.Review of Resident #08's progress note dated 03/11/26 at 2:00 P.M. revealed the Director of Nursing (DON) spoke with Resident #08 regarding the 03/10/26 fall and how she was feeling. Resident #08 stated that she was anxious to ambulate at that time for fear of falling. Resident #08 stated that she was anxious and had a fear of falling prior to the recent fall. Resident #08 stated that she was having pain in her lower back and buttocks, but the Tylenol was effective. Resident #08 felt like her biggest barrier at that time was her anxiety and being worrisome. Resident #08 stated that her Lexapro helped but that was something she had been dealing with for a long time. Resident #08 was working with therapy on ways to help her anxiety.Review of Resident #08's progress note dated 03/12/26 at 2:29 P.M. revealed a care conference was held with Resident #08, Resident #08's daughter, the DON, dietician, therapy and SS #90. Resident #08 was able to sit to stand with contact guard and Resident #08's longest standing tolerance was 35 seconds. Resident #08 was seen by the physician on 03/10/26 and Resident #08 had an order for Tylenol. Resident #08 had a muscle relaxer and an x-ray on 03/11/26 which were negative for fractures. The DON discussed doing bladder scans as an option and Resident #08 was seen by psychiatry on 03/11/26. Psychiatry spoke with Resident #08 about her anxiety. ST was also working with Resident #08 on techniques to help with anxiousness such as writing things down.Review of CNA #242's personnel file revealed CNA #242 was hired by the facility on 03/09/25. Further review of CNA #242's personnel file revealed CNA #242 had a first written warning disciplinary action form dated 03/10/26. The disciplinary action form stated CNA #242 assisted a resident to the restroom in her room on 03/10/26. The resident required hands on assistance with transfers and ambulation. While ambulating to the restroom, CNA #242 did not use a gait belt per facility policy. Corrective actions included CNA #242 will use a gait belt for all residents requiring hands on assistance for transfers and ambulation. The gait belt policy was reviewed and understood by CNA #242. The disciplinary action form was signed by CNA #242 and LPN Supervisor #26 on 03/13/26.Observation of Resident #08 on 03/31/26 at 11:30 A.M. revealed Resident #08 was sitting in her recliner in her room. Resident #08 appeared clean and appropriately dressed.Interview with Resident #08 on 03/31/26 at 11:30 A.M. revealed Resident #08 denied having any falls at the facility. Resident #08 denied having any falls while walking to the bathroom with staff at the facility. Resident #08 reported no concerns regarding the facility. Interview with the DON on 03/31/26 at 11:45 A.M. revealed CNA #242 was ambulating Resident #08 from the recliner in her room to the bathroom on 03/10/26 when CNA #242 went to open the door to the restroom and Resident #08 fell backwards onto the floor. The DON stated that Resident #08 hit the back of her head on the floor and CNA #242 yelled for the nurse while she remained with Resident #08. The DON also reported CNA #242 placed a pillow under Resident #08's head while waiting for the nurse. LPN #107 and RN #44 came to Resident #08's room and assessed Resident #08. The DON reported Resident #08's neurological check and vitals were within normal limits and Resident #08 was assisted into a chair. The DON reported Resident #08 had a area to the back of her head and the physician was contacted by LPN #107. The DON stated that Resident #08's physician was notified by LPN #107 and Resident #08's daughter arrived to the facility while the DON was on the telephone with the physician's office within minutes of the fall. The DON reported Resident #08's daughter was called by Resident #08 after the fall and LPN #107 had not called Resident #08's daughter because LPN #107 called Resident #08's physician prior to the daughter. The DON stated that LPN #107 told Resident #08's daughter that she would be right with her and Resident #08's daughter told the DON that she felt LPN #107 was dismissing her. The DON stated LPN 107 spoke with Resident #08's daughter and Resident #08's daughter wanted Resident #08 sent to the hospital. The DON reported Resident #08 was sent to the hospital at 2:15 P.M. and Resident #08 returned from the hospital at 6:00 P.M. The DON stated Resident #08 had a negative head CT at the hospital and no new orders. The DON reported Resident #08 had not fallen at the facility prior to the 03/10/26 fall and the facility investigated the fall and found that CNA #242 did not have a gait belt on the resident at the time of the fall. The DON verified Resident #08 required contact guard assistance and the use of a gait belt with ambulation and transfers. The DON confirmed that therapy also assessed Resident #08 prior to the fall on 03/10/26 and Resident #08 required contact guard assistance and the use of a gait belt for ambulation. The DON reported the facility also added an intervention for Resident #08 to have footwear during ambulation because Resident #08 was wearing gripper socks but no shoes at the time of the fall. The DON stated Resident #08 informed the facility that she walked better when wearing shoes. The DON stated the facility completed immediate education with CNA #242 on the gait belt policy on 03/10/26 and the facility completed education of all nurses, CNAs and therapy staff on the gait belt policy on 03/11/26. The DON also reported the facility initiated audits to ensure that staff were using gait belts when assisting residents with ambulation and transfers. The DON stated that she spoke with Resident #08's daughter on 03/11/26 and a care conference was completed on 03/12/26. Interview with the DON on 03/31/26 at 12:24 P.M. revealed the DON verified Resident #08 had a history of leaning backwards during ambulation prior to the fall on 03/10/26. Attempted to call CNA #242 on 03/31/26 at 12:30 P.M. with no response. Interview with Physical Therapist (PT) #700 on 03/31/26 at 2:11 P.M. revealed Resident #08 was assessed to use a gait belt with staff when ambulating at the time of her fall on 03/10/26. PT #700 stated Resident #08 had a history if leaning backwards while ambulating and having anxiety about falling prior to the fall on 03/10/26. Telephone interview with LPN #107 on 03/31/26 at 1:06 P.M. revealed LPN #107 was called to Resident #08's room by a CNA for a fall on 03/10/26 in the afternoon. LPN #107 stated Resident #08 was lying on her back by the foot of the bed with her feet by the bathroom with LPN #107 entered the room. LPN #107 reported Resident #08 was not wearing a gait belt and Resident #08's gelt belt was on Resident #08's dresser. LPN #107 stated Resident #08 was wearing non skid socks. LPN #107 reported Resident #08's vitals were taken and neurological check was completed and was within normal limits. LPN #107 reported Resident #08 had a red raised area in the back of her head that was approximately the size of a half dollar. LPN #107 stated that Resident #08 was assisted to her wheelchair and then was taken to the bathroom. LPN #107 reported CNA #242 told LPN #107 that CNA #242 was ambulating Resident #08 to the bathroom without her gait belt and CNA #242 took her hand off of Resident #08 to open the bathroom door and Resident #08 fell backwards onto the floor. LPN #107 stated she called the physician after assessing Resident #08 and Resident #08's daughter entered the facility while she was on the phone with the physician because Resident #08 called her daughter to inform her of the fall. LPN #107 reported she planned to call Resident #08's daughter after getting off the phone with Resident #08's physician. LPN #107 stated Resident #08's daughter was upset that LPN #107 did not call her and Resident #08's daughter wanted Resident #08 sent to the hospital. LPN #107 reported Resident #08 was sent to the hospital by EMS per her daughter's request. LPN #107 verified Resident #08 required staff to use a gait belt with transfers and ambulation at the time of the fall on 03/10/26 and the information about Resident #08's ambulation and transfer status was on the board at the nurses station for nursing staff. Interview with the DON on 03/31/26 at 4:25 P.M. verified CNA #242 received a first written warning disciplinary action on 03/13/26 for ambulating Resident #08 to the bathroom without a gait belt on 03/10/26. Review of the facility's undated accidents and supervision policy revealed residents will remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents.Review of the facility's use of gait belts policy dated October 2022 revealed the facility would use gait belts with all residents that could not independently ambulate or transfer for the purpose of safety.As a result of the incident, the facility took the following actions to correct the deficient practice by 03/21/26: On 03/10/26, Resident #08 was sent to the hospital for evaluation and treatment after the fall. Resident #08 returned to the facility on [DATE] with no new orders.On 03/10/26, Registered Nurse (RN) #44 educated CNA #242 on the proper usage of gait belts and that gait belts were to be used at all times during transfers when a resident required any hands on assistance for transfers or ambulation.On 03/11/26 the DON educated all nurses, CNAs and therapy staff on the gait belt policies and that gait belts were to be utilized by nurses, CNAs and therapy staff with hands on assistance or guidance when ambulating or transferring residents. This included transfers to and from bed, to the wheelchair, to the recliner, to the shower chair, and during ambulation when staff must have their hands touching the resident in order to steady them. Gait belts were to be in staff member's pocks or on their person as part of the uniform. The education was completed 03/21/26. On 03/16/26, the facility initiated an ongoing audit of appropriate gait belt usage give times ten observations a week for the first week, eight observations a week for the second week, six observations a week for the third week and four observations a week for the fourth week.This deficiency represents past non compliance investigated under Complaint Number 2802547.

Based on record review, staff interview, and facility policy review, the facility failed to ensure accurate documentation of pain medication administration. This affected two (Resident #2 and #3) of the three residents reviewed. The facility census was 61.Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of [DATE] with diagnoses including Parkinsonism, unspecified, anemia, dementia, psychosis, hypertension, anxiety. The resident is long term care, cognitively impaired and receiving hospice care. Review of the electronic Medical Record Report (eMAR) revealed Resident #2 was ordered Morphine Sulfate Oral Solution (opioid) 20 milligrams per milliliter (mg/ml), give 0.25 mg by mouth every eight hours for pain and Morphine Sulfate Oral Solution 20 mg/ml, give 0.25 mg by mouth every two hours as needed (PRN) for pain. Review of the eMAR under the order of Morphine Sulfate Oral Solution 20 mg/ml, give 0.25 mg by mouth every eight hours for pain revealed a dose of 0.25mg Morphine Sulfate was administered at 5:00 A.M. on [DATE]. Review of the Controlled Drug Log revealed the dose administered on [DATE] at 5:00 A.M. was documented on the PRN order of Morphine Sulfate Oral Solution 20 mg/ml, give 0.25 mg by mouth every two hours as needed for pain. Interview with DON on [DATE] at 9:01 A.M. verified the entry was made on the incorrect Controlled Drug Log page. 2. Review of the medical record for Resident #3 revealed an admission date of [DATE] with diagnoses including cerebral infarction, Alzheimer's Disease, atrial fibrillation, anxiety disorder, Type II Diabetes Mellitus, dysphagia, and unspecified convulsions. The resident received Hospice care and expired in the facility on [DATE]. Review of the medication orders for Resident #3 revealed the resident had an order for Oxycodone HCl (opioid) oral tablet 5mg, give one tablet by mouth two times a day for pain and Oxycodone HCl oral tablet 5mg, give one tablet every four hours as needed for pain. Review of the Controlled Drug Log for [DATE] revealed a PRN dose of Oxycodone 5mg was administered on [DATE] at 8:00 P.M. and on [DATE] at 1:00 A.M. Review of the [DATE] eMAR revealed missing entries for the PRN administrations of Oxycodone 5mg on [DATE] at 8:00 P.M. and [DATE] at 1:00 A.M.Review of the Controlled Drug Log for [DATE] revealed a PRN dose of Oxycodone 5mg was administered on [DATE] at 8:00 P.M. and on [DATE] at 11:00 P.M. Review of the [DATE] eMAR revealed missing entries for the PRN administrations of Oxycodone 5mg on [DATE] at 8:00 P.M. and [DATE] at 11:00 P.M.Interview with DON on [DATE] at 9:01 A.M. verified the above entries of Oxycodone 5mg PRN were made on the Controlled Drug Log under the PRN order page but were not documented on the eMAR. Record review of the Medication Administration Policy, updated [DATE], revealed the individual administering the medication must electronically sign the resident's eMAR on the appropriate box, after giving the medication. This deficiency represents non-compliance investigated under Complaint Number 2605790.

Based on medical record review, observations, staff and resident interviews and review of facility policies, the facility failed to ensure staff implemented infection control protocols when providing care to residents. This affected 10 (#52, #51, #31, #29, #41, #46, #3, #59, #13 and #2) out of 17 residents sampled for infection control. Facility census was 67. Findings included: 1. Observation on 10/31/23 from 11:55 A.M. through 12:05 P.M. with State tested Nursing Assistant (STNA) #171 revealed the staff assisted Resident #52 with the lunch meal while wearing gloves. After assisting Resident #52, STNA #171 assisted Resident #51 with the same pair of gloves. STNA #171 then got up out of her chair and went to Resident #31 and picked up her pizza and handed it to the resident by using the same glove. Then STNA #171 went to Resident #29 to give him a bite of his pizza by using the same surgical gloves and feeding him at the mouth with her hands. STNA #171 then went to Resident #41 to give her pizza in her hand with the same surgical gloves on. STNA #171 then went to the pizza box with the same surgical gloves to take a new piece of pizza to give to Resident #46, that laid pizza on his plate. STNA #171 then took off her pair of surgical gloves and hand hygiene with alcohol sanitizer. Interview on 10/31/23 at 12:05 P.M. with STNA #171 confirmed she had the same pair of gloves and did not perform hand hygiene while assisting Resident #29, #31, #41, #46, #51, and #52 with their lunch meals. 2. Review of the medical record for Resident #3 revealed admitted [DATE]. Diagnoses include traumatic subdural hemorrhage, compression fracture of second thoracic vertebra, diabetes mellitus type two, congestive heart failure and atherosclerotic heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #3 was at risk for pressure ulcers with three deep tissue injuries and moisture associated skin damage. Resident #3 had pressure reduction devices for the chair and bed. Resident #3 had pressure ulcer/injury care. Review of the plan of care dated 10/24/23 revealed Resident #3 has pressure ulcers to right buttock and coccyx, related to decreased mobility, incontinence, and malnutrition, prefers to sit in chair and will decline at times to lay down and reposition between mealtimes. Goal for pressure ulcers to be healed with no signs/symptoms of infection and no further pressure ulcers. Interventions include, but not limited to, encourage good nutrition and hydration to promote healthier skin. Encourage house supplement as ordered. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotions on dry skin as indicated. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to physician. Staff to observe enhanced barrier precaution: gown and glove use during high-contact resident care activities. Review of Resident #3's physician order dated 10/31/23 at 6:30 P.M. revealed Enhanced Barrier Precautions for (wound) every shift. Orders dated 10/19/23 at 4:15 P.M. revealed Triad Hydrophilic Wound Dress External Paste (wound dressings), apply to buttocks topically every day and night shift for wound care and apply to buttocks topically as needed for wound care. Review of the medical record for Resident #59 revealed admitted [DATE]. Diagnoses include non-pressure chronic ulcer of left lower leg, cellulitis of left lower leg, atrial fibrillation, chronic pulmonary obstructive disease, asthma, Parkinson's Disease and history of venous thrombosis and embolism. Review of the Admission MDS assessment dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was at risk for pressure injury, with skin and ulcer/injury treatments, and application of nonsurgical dressings (with or without topical medications) other than to feet. Review of the nursing assessment/baseline care plan dated 10/17/23 revealed Resident #59 had multiple skin concerns to his coccyx, right and left hand, left and right lower leg, and bilateral feet. Resident #59 was at high risk for skin breakdown and required barrier cream with goal for alterations to heal without signs or symptoms of infection. Review of Resident #59's physician orders dated 10/31/23 at 6:30 P.M. revealed Enhanced Barrier Precautions for (wound) every shift. Order dated 10/19/23 at 2:45 P.M. revealed cleanse left lower extremity with normal saline. Pat dry, cover with layer of Adaptec followed by calcium alginate. Cover with abdominal pad, wrap with Kerlix. Change Monday, Wednesday, Saturday night and as needed for saturation. Observation on 10/31/23 from 8:47 A.M. through 9:07 A.M. with the Director of Nursing (DON) verified that all residents who were on enhanced barrier precautions were to have a personal protective equipment box outside their rooms with signs and supplies. The DON confirmed Resident #3, and Resident #59 were to be in enhanced barrier precautions but neither resident had signage, and/or personal protective equipment outside their rooms. Interview on 10/31/23 at 4:14 P.M. Resident #59 stated some staff wore gowns while providing care and completing wound dressing changes and some staff did not wear the gowns. 3. Review of medical record revealed Resident #13 had an admitted [DATE]. Diagnosis included dementia, type two diabetes, and cognitive communication. Review of MDS assessment dated [DATE] revealed Resident #13 BIMS was 13 out of 15 that indicated she was cognitively intact. Resident #13 required for assistance extensive two-person physical assist for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #13 used a wheelchair for mobility. Observation on 11/02/23 from 9:45 A.M. through 10:12 A.M. with Resident #13 receiving a bed bath from Licensed Practical Nurse (LPN) #97 and LPN #550. Observation on 11/02/23 at 10:00 A.M. LPN #97 had been assisting in giving bed bath to Resident #13 and stated she would get more linens on linen cart. LPN #97 took off her surgical gloves but did not perform hand hygiene. LPN #97 left the room, then returned with clean linens. LPN #97 applied new surgical gloves to assist with the bed bath again. Observation on 11/02/23 at 10:08 A.M. with LPN #550 had performed incontinence care with her gloves on cleaning bowel movement up. LPN #550 then proceeded to wash up Resident #13, then applying lotion to Resident #13's back with the same gloves on. Interview on 11/02/23 at 10:12 A.M. with LPN #550 verified she did not change her gloves or hand hygiene, after cleaning bowel movement with Resident #13, before apply lotion to Resident #13 back. LPN #97 verified she had never hand hygiene when leaving, and returning bringing back the clean linens. 4. Review of the medical record for Resident #2 revealed he was admitted to the facility on [DATE], transferred to the hospital on 07/04/23, and readmitted on [DATE]. Diagnoses included acute respiratory failure with hypoxia, congestive heart failure, acute pulmonary edema, atrial fibrillation, type two diabetes mellitus and hyperlipidemia. Review of the quarterly MDS assessment, dated 09/14/23, revealed this resident had severe cognitive impairment Resident #2 was assessed to require extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision for eating. Review of the active physician orders revealed an order dated 10/12/23 to cleanse area of left buttock with normal saline apply alginate and mepilex during day shift on Tuesday, Thursday, and Saturday for wound care. Observation on 11/02/23 at 10:31 A.M. with Registered Nurse (RN) #120 and RN #72 who placed personal protective equipment: gown and surgical gloves on before entering Resident #2's room. Neither nurse (RN #120 or RN #72) performed hand hygiene before donning personal protective equipment (PPE) to enter Resident #2's room. Observation on 11/02/23 at 10:32 A.M. with RN #120, and RN #72 who performed a skin observation/assessment of Resident #2. Interview on 11/02/23 at 10:39 A.M. RN #120 confirmed he did not perform hand hygiene before entering Resident #2's room and stated hand hygiene should have been performed. Review of facility policy titled Enhanced Barrier Precautions dated 2023, revealed that all nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. Review of facility policy titled Hand Hygiene Policy dated June 2023, revealed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Review of the facility policy titled Infection Prevention and Control Program dated 2023 revealed that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment according to the established facility policy governing the use of personal protective equipment.

Based on medical record review, staff interview and facility policy review, the facility failed to ensure activity care plans were person centered for two residents ( #57 and #38) of two reviewed for activities. The facility census was 66. Findings include: 1. Medical record review revealed Resident #57 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Review of care plan dated 12/17/18 revealed Resident #57's was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The only intervention was the resident needed assistance with activities of daily living (ADLs) as required during the activity. Interview with Activity Director #223 on 12/18/18 at 11:10 A.M., confirmed the activities care plan for Resident #57 was not person centered. 2. Medical record review for Resident #38 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the care plan dated 06/05/17 revealed the Resident #38 was dependent on staff for activities, cognitive stimulation and social interaction related to cognitive deficits. The interventions listed were to assure the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed, compatible with individual needs and abilities; and age appropriate. Interview on 12/18/18 at 11:12 A.M., with Activities #223 confirmed care plan for Resident #38 was not person centered and not individualized. Activities #223 revealed there were no known interests documented. Review of the facility policy titled, Care Planning, undated revealed the interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to provide adequate assistance for activities of daily living (ADLs) for one resident (#40) of two reviewed for ADLs. The facility census was 66. Findings include: Medical record review for Resident #40 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #40 was rarely/never understood. She required a limited assistance for transfers. Observation on 12/18/18 at 9:55 A.M., of State tested Nursing Aide (STNA) #222 revealed the STNA attempted to get Resident #40 out of a chair, in the dining room. The STNA put his left hand underneath her right armpit and attempted to get the resident up and continued to pull her hands apart with his right hand, while still applying pressure under her armpit to raise her up out of the chair. The STNA did not use a gait belt. Interview on 12/18/18 at 10:03 A.M., with STNA #222 verified he should have placed a gait belt around the waist of the resident instead of using his hand with pressure underneath her armpit to raise the resident to a standing position. Review of the facility policy titled, Gait Belt Policy, undated, revealed it was the policy of the facility that nursing staff members utilize gait belts for residents that need hands-on assistance or guidance when ambulating.

Based medical records review, observation, and staff interview, the facility failed to obtain an order for [REDACTED].#21) of two residents reviewed for respiratory care. The facility census was 66. Findings include: Review of Resident #21's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #21 was assessed as being severely cognitively impaired in a comprehensive Minimum Data Set (MDS) assessment dated [DATE]. Further review of Resident #21's medical record revealed no active order for O2 administration. An order was discontinued on 06/23/18 for O2 at two liters per minute, per nasal cannula, as needed to keeps SATS greater than 90% due to non-use of O2. During observations made on 12/16/18 at 4:22 P.M., and 12/17/18 at 8:56 A.M., Resident #21 was observed lying in bed with O2 being administered per nasal cannula at 2 liters per minute. Review of Resident #21's [MEDICAL CONDITION] care plan revealed staff would monitor vital signs, skin color, pulse oximetry (SATS), airway functioning and degree of restlessness which may indicate [MEDICAL CONDITION]. Review of vitals recorded for Resident #21 revealed O2 SATS had not been recorded since 12/04/18. During an interview 12/17/18 at 2:57 P.M., with Licensed Practical Nurse (LPN) #100 confirmed there was no an active order for O2 administration in Resident #21's electronic medical record. The Director of Nursing (DON) confirmed in an interview on 12/18/18 at 10:20 A.M., that Resident #21 did not have an active order for O2 when it was being administered on 12/16/18 and 12/17/18. The DON confirmed in a second interview on 12/18/18 at 11:15 A.M., that Resident #21's O2 SATS were not documented since 12/04/18. The DON also confirmed one of Resident #21's [MEDICAL CONDITION] care plan interventions listed was to monitor vitals, such as pulse oximetry (SATS).

Based on observation, medical record review, staff interview, and review of the facility's medication storage policy, the facility failed to secure a resident's medications. This affected two residents (#44 and #49) of two reviewed for unsecured medications. The facility census 66. Findings include: During a tour of the 400 hallway on 12/16/18 at 4:28 P.M., medications were observed unattended on top of a medication cart. A single pink/orange oblong shaped tablet was observed in a medication cup, as well as a white powder in a plastic cup with a plastic spoon inside. A nurse was observed approximately two doors down at another medication cart. This nurse exited the hallway at 4:29 P.M., and entered a resident's room. At 4:31 P.M., a State tested Nursing Assistant (STNA) #27 approached the medication cart, noticed the tablet in the cup on top of the medication cart. The STNA picked up the cup with the tablet inside and was going to throw the medication away when the surveyor intervened and asked the STNA to get the nurse who was responsible for the medication cart. At 4:36 P.M., Licensed Practical Nurse (LPN) #34 confirmed STNA #27 had told her of the medication that was left on top of the medication cart. LPN #34 confirmed the medications were left unattended on top of the medication cart. On 12/17/18 at 7:23 A.M., LPN #34 identified the tablet left attended on top of the medication cart was Memantine [MEDICATION NAME] (dementia medication) and confirmed it belonged to Resident #44. On 12/18/18 at 6:16 P.M., LPN #34 identified the white powder left unattended on the medication cart as [MEDICATION NAME] (laxative) and confirmed it belonged to Resident #49. Review of Resident #44's medical record revealed the resident had a current order for Memantine [MEDICATION NAME]. Review of Resident #49's medical record revealed the resident had a current order for [MEDICATION NAME]. Review of the facility's undated policy titled, Storage of Medications, revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on medical record review, staff interview, resident interview, and review of peritoneal [MEDICAL TREATMENT] policy, the facility failed to accurately document [MEDICAL TREATMENT] medications used in the peritoneal [MEDICAL TREATMENT] solution. This affected one resident (#13) of one reviewed for [MEDICAL TREATMENT]. The facility census was 66. Findings include: Review of medical record review of Resident #13, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 was cognitively intact. Review of Resident #13's physician's orders [REDACTED]. Review of Resident #13's physician's orders [REDACTED]. Inject 6,000 units of [MEDICATION NAME] as an anticoagulant in to one 6,000 mL of PD solution bag nightly. Review of physician's orders [REDACTED].#13 was to receive one green 2.5 % 6,000 milliliter (mL) bag of PD solution if weight was over 200 pounds. Resident #13 was to receive one yellow 1.5 % bag of 6,000 mL bag of PD solution if weight was below 200 pounds. Review of Medication Administration Record [REDACTED]. On 12/18/18 at 3:50 P.M., during an interview with Resident #13, he verified he was only getting one 6,000 mL bag of PD solution nightly. On 12/18/18 at 4:00 P.M., interview with Licensed Practical Nurse (LPN) # 32, revealed she verified both orders for [MEDICATION NAME] (6,000 and 12,000 unites) were active and being documented as being administered from 12/11/18 through 12/17/18. On 12/18/18 at 4:45 P.M., interview with LPN #195, verified she normally worked night shift and was very familiar with Resident #13's peritoneal [MEDICAL TREATMENT] procedures. LPN #195 verified she checked the resident's weight to verify which bag of PD solution to administer. LPN #195 verified she injected 6,000 units of [MEDICATION NAME] in one bag of 6,000 mL bag of PD solution nightly. LPN #195 also verified she wasn't aware that she was signing off on the two different orders. Review of an undated facility policy titled, Peritoneal [MEDICAL TREATMENT], revealed nurses were to review all existing orders and instruction for care pertaining to the resident's [MEDICAL TREATMENT]. Nurses were also to verify, [MEDICATION NAME] solution/concentration, medications to be added, number of exchanges and infusion, swell and drain times, monitoring parameters and laboratory orders.

Based on review of self -reported incident, review of facility policy, review of facility investigation and staff interview, the facility failed to protect a resident from physical abuse by a staff member. This affected one resident (#25) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record of Resident #25 revealed an admission date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) revealed Resident #25 was severely cognitively impaired and required extensive assist of activities of daily living. Review of the Self-Reported Incident dated 01/10/2018 at 10:45 A.M. revealed State tested Nursing Assistants (STNA) #86, #88 and #90 were providing care and making preparations to get residents out of bed. STNA #95 observed Resident #25 hitting and swinging at STNAS #86, #88 and #90. STNA #95 walked into the room to assist the STNAs when Resident #25 slapped the STNA #95 in the face. STNA #95 placed his right arm around Resident #25 head and neck from behind and pushed the resident forward to stop her from swinging. The incident was witnessed by STNAs #86, #88, and #90 and immediately reported to Licensed Practical Nurse (LPN) #98 who advised the STNA to report the incident to the Assistant Director of Nursing. Review of the SRI facility investigation revealed statements from STNAs #86, #88, #90 and #95. STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. On 01/11/18, the local police department was contacted and an incident report was filed at 8:05 A.M. STNA #95 was terminated on 01/12/18. Interview on 01/22/18 at 4:03 P.M.,with the Administrator verified on 01/10/18, he was not contacted about the alleged incident until 1:25 P.M. on 01/10/18. The Administrator verified STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. Review of facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated November 2017, revealed an owner, licensed administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficiency substantiates Complaint Number OH 627.

Based on review of self -reported incident, review of facility policy, review of facility investigation and staff interview, the facility failed to implement the facility policy on providing protection of a resident from physical abuse by a staff member and immediately reporting an alleged abuse incident to the Administrator. This affected one resident (#25) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record of Resident #25 revealed an admission date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) revealed Resident #25 was severely cognitively impaired and required extensive assist of activities of daily living. Review of the Self-Reported Incident dated 01/10/2018 at 10:45 A.M. revealed State tested Nursing Assistants (STNA) #86, #88 and #90 were providing care and making preparations to get residents out of bed. STNA #95 observed Resident #25 hitting and swinging at STNAS #86, #88 and #90. STNA #95 walked into the room to assist the STNAs when Resident #25 slapped the STNA #95 in the face. STNA #95 placed his right arm around Resident #25 head and neck from behind and pushed the resident forward to stop her from swinging. The incident was witnessed by STNAs #86, #88, and #90 and immediately reported to Licensed Practical Nurse (LPN) #98 who advised the STNA to report the incident to the Assistant Director of Nursing. Review of the SRI facility investigation revealed statements from STNAs #86, #88, #90 and #95. STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. On 01/11/18, the local police department was contacted and an incident report was filed at 8:05 A.M. STNA #95 was terminated on 01/12/18. Interview on 01/22/18 at 4:03 P.M.,with the Administrator verified on 01/10/18, he was not contacted about the alleged incident until 1:25 P.M. on 01/10/18. The Administrator verified STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. Review of facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated November 2017, revealed an owner, licensed administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficiency substantiates Complaint Number OH 627.

Based on review of self -reported incident, review of facility policy, review of facility investigation and staff interview, the facility failed to immediately report an alleged incident of resident abuse by a staff member. This affected one resident (#25) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record of Resident #25 revealed an admission date of [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) revealed Resident #25 was severely cognitively impaired and required extensive assist of activities of daily living. Review of the Self-Reported Incident dated 01/10/2018 at 10:45 A.M. revealed State tested Nursing Assistants (STNA) #86, #88 and #90 were providing care and making preparations to get residents out of bed. STNA #95 observed Resident #25 hitting and swinging at STNAS #86, #88 and #90. STNA #95 walked into the room to assist the STNAs when Resident #25 slapped the STNA #95 in the face. STNA #95 placed his right arm around Resident #25 head and neck from behind and pushed the resident forward to stop her from swinging. The incident was witnessed by STNAs #86, #88, and #90 and immediately reported to Licensed Practical Nurse (LPN) #98 who advised the STNA to report the incident to the Assistant Director of Nursing. Review of the SRI facility investigation revealed statements from STNAs #86, #88, #90 and #95. STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. On 01/11/18, the local police department was contacted and an incident report was filed at 8:05 A.M. STNA #95 was terminated on 01/12/18. Interview on 01/22/18 at 4:03 P.M.,with the Administrator verified on 01/10/18, he was not contacted about the alleged incident until 1:25 P.M. on 01/10/18. The Administrator verified STNA #95 continued to work on the unit until he was dismissed from his assignment and put on administrative leave around 1:30 P.M. on 01/10/18 pending an internal investigation. Review of facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated November 2017, revealed an owner, licensed administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficiency substantiates Complaint Number OH 627.

Based on medical record review, review of self reported incidents (SRI), policy review, and staff interview, the facility failed to report in a timely manner an allegation of physical abuse. This affected one (#88) resident out of two SRI's reviewed for physical abuse during the annual survey. The census was 71. Findings include: Medical record review for Resident #88 revealed he was admitted on [DATE] and currently resides in the facility. His comprehensive assessment dated [DATE] revealed he was rarely or never understood. He was an extensive assistance for all activities of daily living. His [DIAGNOSES REDACTED]. Review of SRI revealed on 04/21/17 at 6:00 P.M. a State tested Nursing Aide (STNA) #1 reported to a nurse that she witnessed State tested Nursing Assistant (STNA) #300 with his hand on the shoulder of Resident #88 applying pressure in an attempt to redirect resident to sit down during dining. It was reported in the SRI Resident #88 was assessed and no injuries were found. Interview with Associate Director of Nursing (ADON) on 11/08/17 at 3:00 P.M. revealed STNA #300 did not leave the building until the end of his shift at 6:30 P.M. She revealed STNA #1 reported to the nurse before end of shift and the nurse reported this allegation to her the ADON after change of shift. She reported STNA #300 was monitored by the nurse and didn't leave the dining room after the allegation was reported and then punched out at 6:36 P.M. She stated she thought this was an immediate reporting and stated STNA #300 was monitored until the end of shift. She further stated she considered the incident poor customer service and discourteous manner. She stated she called STNA #300 on 04/21/17 and told him not to return to work pending investigation and stated he was terminated on 04/25/17 over the phone. Review of the facilities undated policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revealed an employee must always report any abuse or suspicion of abuse immediately to the Administrator.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on clinical record review, review of a police report, review of a preliminary coroner's report, review of manufacturer guidelines for the use of siderails, staff interviews, and observations, the facility failed to ensure the resident environment remained free of accident hazards from siderails resulting in Immediate Jeopardy for one (Resident #61) of seven sampled residents. The facility identified 22 residents using half side rails. On August 12, 2011 at 3:00 P.M., the Executive Director and Director of Nursing (DON) were notified that Immediate Jeopardy began on 05/25/11 when Licensed Social Worker (LSW) #3 conducted an assessment of the side rails on Resident #61's bed and documented Resident #61's inability to get in and out of bed safely, ability to climb over the bed rail and the use of the bed rail presented a risk to the resident. Although the assessment documented risks and resident vulnerabilities associated with use of a side rail, the facility failed to analyze the safety of the side rail for Resident #61. On 07/20/11, Resident #61 was found with her head entrapped between the mattress and inside lower edge of the right half side rail. Her face was pale and broken capillary blood vessels were visible on her left cheek. Dried blood was present on her left ear and had pooled on the side rail. The preliminary coroner ' s report dated 07/21/11 stated the cause of death was asphyxia due to neck compression. The Immediate Jeopardy was removed and the deficient practice corrected on 07/27/11 when the facility implemented the following corrective actions: ? Between 07/20/11 and 07/27/11, the facility re-assessed twenty-two (22) residents for the use of half side rails. By 07/27/11, four residents continued with the safe and appropriate use of half side rails on their beds. The other 18 residents had bed rails removed from the bed. ? On 07/22/11, the facility reviewed and revised the policy for Proper Use of Side Rails. The policy was revised to include a physical therapy evaluation of the resident ' s ability to safely and appropriately use side rails. The policy was implemented on 07/27/11. ? Between 7/20/11 and 7/24/11, the Director of Nursing in-serviced all nursing staff on all shifts on the safe and appropriate use of half side rails and the side rail assessment. ? On 09/12/11, two state tested nurse aides #20 and #21, the MDS Coordinator RN #14, the DON, LSW #3 and Quality Assurance Coordinator , LPN #15 were interviewed and confirmed they received training and verbalized knowledge of the assessment procedure and policy for safe and appropriate use of side rails. ? On 09/12/11, four residents in the facility used side rails. One resident (#12) was in a bariatric bed and the use of side rails was recommended by the bed manufacturer. The resident was alert and oriented and verbalized she used the side rails as assistive devices for bed mobility. Resident #14 and #55 used bilateral half side rails at their request. These residents could demonstrate safe use of the side rails for bed mobility and transfers. Resident #58 only used half side rail for transfers and the rail was lowered down when he was in bed. ? Through staff identification and quarterly MDS assessment reviews, the facility will evaluate the use of side rails. Information gathered will be referred to the interdisciplinary team (side rail subcommittee) and QAA. On 09/12/11, the facility provided evidence of monitoring for the proper use of the side rails on Residents #12, #14, #55, & #58. Findings include: Review of Resident #61 ' s undated Accumulative [DIAGNOSES REDACTED]. Licensed Social Worker (LSW) #3 completed a side rail assessment dated [DATE]. The assessment identified Resident #61 was not able to get in and out of bed safely, had problems with balance due to CVA with hemiparesis, believes she is able to get in/out of bed independently, possibly would climb over the side rails, and there was a risk to the resident if the side rails were used. The assessment documented the right sided bed rail was implemented on 05/25/11 and served as an enabler to promote independence. The assessment did not identify any risk factors to the resident with the use of the right side rail. Nursing notes dated 05/25/11 and documented by RN #1 stated at 3:15 P.M., Resident #61 was attempting to swing her legs over the side of the bed. The most recent annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61with severe cognitive impairments, dementia and a cognitive decline. According to the assessment, Resident #61 would become delusional/paranoid at times, believing that her family has left her or that she needs to go to them. The resident required extensive assistance of one staff person for bed mobility and extensive assistance of two staff persons for transfers. The assessment documented Resident #61 did not walk and required staff assistance to move from a seated to standing position. The assessment did not identify the use of any side rails. The medical record did not contain a plan of care to address the use of side rails. However, the nurse aide assignment sheet used by nurse aides to direct resident care indicated an upper half side rail was used on the right side of the resident ' s bed to assist her with bed mobility. According to nursing notes documented by Licensed Practical Nurse (LPN) #5 on 07/20/11 at 1:00 A.M., Resident #61 was observed in bed with her eyes closed. At 3:45 A.M., LPN #5 documented in the Nurse's Notes that STNA #7 went into Resident #61 ' s room to give care and found Resident #61 out of bed with her knees on the floor and the right side of her cheek and jaw touching the mattress. The resident ' s left cheek and jaw were touching the side rail. Bright red drainage was noted around the outer canal of the left ear and left cheek. Small red spots were present on her left cheek and her face was pale. STNA #7 called for assistance and LPNs #5 and #13 responded to her call. Both LPNs assessed Resident #61 and found her without any pulse, respirations or signs of life. LPN #5 further documented in the Nurse's Notes the Director of Nursing (DON), 911(emergency services) and Resident #61 ' s physician were immediately called and notified of the resident ' s condition. According to the 07/22/11 police report, a detective was dispatched to the facility with the call to 911 and arrived at the facility at 5:10 A.M. On 08/12/11 at 6:15 A.M. and 08/16/11 at 6:28 A.M., LPN #5 was interviewed. She stated STNA #7 was passing ice around 3:50 A.M. while she (LPN #5) was standing at the medication cart with LPN #13. She stated STNA #7 came out of Resident #61 ' s room and told her something was wrong with Resident #61 and she thought the resident was dead. When both LPN #5 and LPN #13 entered the room, they found the resident's head trapped between the side rail and the mattress of the bed. The resident ' s left cheek was against the bottom curve of the right half side rail with her right cheek against the mattress. LPN #5 stated Resident #61 ' s face was extended up and her right torso was against the mattress in a slanted position. The resident ' s right leg was extended and her knee was on the floor. The resident ' s left knee was not touching the floor. LPN #5 stated the resident's feet were against the door and she was more pale than normal but was not blue. She had no pulse, was not breathing and her eyes were half closed. According to the Police Incident Report dated 07/22/11, when the detective arrived in Resident #61's room, she had not been moved from the position STNA #7 had found her. She was still lying off the side of the bed with her head caught between the side rail and the mattress. The incident report documented the detective recommended an autopsy of Resident #61 ' s body. The Incident Report also documented Resident #61 ' s cause of death would be ruled an accident. Review of the Coroner's Report dated 07/21/11 revealed the cause of Resident #61 ' s death was asphyxia due to neck compression. The report documented the resident was found unresponsive with her head caught between the side rail and mattress. There was a large compression mark on the resident ' s left anterior lateral surface of the neck. Prominent small red spots were present on her face and pulmonary congestion was present. Review of the bed manufacturer ' s information revealed a warning of possible injury or death when using an assistive device on the bed. The warning stated it was extremely important to review the resident ' s physical and mental condition and initiate a care plan to address the potential for entrapment. Review of the revised policy for Proper Use of Side Rails dated 07/22/11 and implemented on 07/27/11 revealed physical therapy would evaluate each resident ' s ability to safely and appropriately use side rails on a quarterly basis or with a significant change of condition. Based on this evaluation, recommendations would be made for the use or removal of side rails on each resident ' s bed. On 09/12/11at 9:00 A.M., a tour of the facility revealed four residents were using side rails. Resident #12 was in a bariatric bed and use of side rails was recommended by the bed manufacturer. The resident was alert and oriented and verbalized she used the side rails as an assistive device for bed mobility. Residents #14 and #55 used bilateral half side rails at their request. These residents were alert and oriented and could demonstrate safe use of the side rails for bed mobility and transfers. Resident #58 only used one half side rail for transfers. The rail was lowered when he was in bed. On 09/12/11 at 12:00 P.M., LSW #3 stated during interview she based the 05/25/11 side rail assessment on information gathered from interviews with direct care staff and her observations of the resident. She stated direct care staff told her Resident #61 could not safely transfer alone and used the right side rail for bed mobility and transfers. She stated the assessment was reviewed by the interdisciplinary team (IDT) who felt the benefits of the use of the right side rail out-weighed the risks. However, LSW #3 stated the IDT did not recognize Resident 61 ' s inability to get in and out of bed safely and ability to climb over the side rail as a risk to the resident. These factors were not considered in the determination if the use of the side rail was a potential accident hazard for the resident. LSW #3 continued to say there were no alternative interventions trialed as direct care staff felt the use of the side rail was appropriate. On 09/13/11 at 10:30 A.M., the DON stated during interview that with the changes made to the policy and procedure for the proper use and assessment of side rails, the IDT team would not have used the side rail on the right side of Resident #61 ' s bed and other options would have been explored. This citations substantiated Complaint Number OH 872.