Every finding on record at Otterbein Middletown

Based on observation, staff interview, and policy review, the facility failed to ensure potentially hazardous chemicals were not accessible to residents. This had the potential to affect 12 (#01, #05, #06, #07, #09, #10, #12, #27, #50, #51, #60, and #68) cognitively impaired and independently mobile residents who resided in Houses #106 and #109. The facility census was 50.Findings include: 1. Observation on 01/05/26 at 9:26 A.M. in House #109, revealed an unlocked cabinet below the sink, which contained 2 containers, one gallon each, of liquid dish machine detergent. Each container of liquid dish machine detergent contained the following warning: Danger: causes severe skin burns and serious eye damage. Harmful if swallowed and Keep out of reach of children. Continued observation revealed an additional two containers, one gallon each, of concentrated crystal dri rinse aid. Each container of the rinse aid contained the following: Warning: causes serious eye irritation and skin irritation and Keep out of reach of children.Interview at the time of the observation Dietetic Technician (DT) #383 verified the four containers of chemicals were not secured. Observation on 01/05/2026 at 9:28 A.M. of the kitchen in House #109 revealed a spray bottle labeled Xcelente multi-purpose cleaner half full of liquid located in an unlocked cabinet under the kitchen sink. The bottle labeled Xcelente included a warning on the label keep out of reach of children. Interview on 01/05/2026 at 9:29 A.M., DT #383 confirmed a bottle labeled Xcelente multi-purpose cleaner was located in an unlocked cabinet under the kitchen sink in building 109. Further interview with DT #383 revealed the bottle labeled Xcelente multi-purpose cleaner should have been located in a locked cabinet.Interview on 01/05/2026 at 10:23 A.M. with Certified Nursing Assistant (CNA) #336 revealed that approximately half of the residents in House #109 were diagnosed with dementia or other memory related issues.2. Observation on 01/06/26 at 3:44 P.M. in House #106 revealed an unlocked cabinet in the kitchen which contained one gallon of concentrated liquid dish machine detergent. The container of liquid dish machine detergent contained the following warning: Danger: causes severe skin burns and serious eye damage. Harmful if swallowed and Keep out of reach of children. Interview at the same time, CNA #386 verified the concentrated liquid dish machine detergent was not secured and should be kept in a locked cabinet. Review of a document titled Storage and Use of Poisonous Substances Policy & Procedure (cleaning supplies, pesticides, etc.) with a revised date of May 2013 revealed Detergents and sanitizers are permitted to be stored in the locked cabinet under the sink next to the dishwasher. Other items are stored in locked cabinets in the dirty utility room.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and prepared in a manner to prevent the potential spread of foodborne illness. The facility also failed to ensure kitchen equipment was maintained in a clean and sanitary manner. This had the potential to affect 31 residents (#01, #04, #05, #06, #07, #09, #10, #12, #14, #17, #20, #22, #27, #30, #33, #35, #47, #50, #51, #52, #53, #57, #60, #65, #67, #68, #75, #76, #77, #78, and #79) who resided in Houses #105, #106, and #109. The facility census was 50.Findings include: 1. Observation on 01/05/26 at 9:21 A.M. in House #109, revealed a bag of salad mix in the bottom drawer of the refrigerator, with an open date of 01/01/26, was unsealed. Upon lifting the bag of salad out of the drawer, the contents fell out of the bag onto the floor. Interview at the time of the observation, Dietetic Technician (DT) #383 verified the salad mix was opened and not sealed. Observation on 01/05/26 at 9:22 A.M. in House #109 revealed the oven was coated in a thick brown film throughout. Interview at the time of the observation, DT #383 verified the oven was coated in a thick brown film throughout and was in need of cleaning. Observation on 01/05/26 at 9:30 A.M., in House #109, revealed the air fryer was coated in a thick brown residue and did not appear to have been cleaned after multiple uses. Interview at the same time, DT #383 verified the air fryer was coated in a brown residue and in need of cleaning. 2. Observation on 01/05/26 at 9:41 A.M. in the refrigerator of House #105 revealed the following:A) a large pitcher of pineapple in juice which contained two open dates, 12/26 and 01/01, and did not specify the contents.B) a bag of carrots which was unopened, with a best by date of 12/04/25.C) a bag of carrots, opened and twisted at the top, opened on 12/21/25 and with a best by date of 12/29/25.D) a bag of brown celery, not sealed and not dated.E) a bag of unopened salad mix with a best by date of 12/25/25.F) a container of yogurt in the freezer with a best by date of 10/26/25, and silent for a date it was frozen.G) a bag of mixed fruit, dated 12/3, which was wide open and the fruit was covered in a thick layer of ice crystals. Interview at the time of the observations, DT #383 verified the pitcher of pineapple in juice was not labeled with its contents and had two open dates, the two bags of carrots were past the best by date and one was open, the bag of celery was brown, not sealed and not dated, the bag of salad mix and yogurt were past the best by dates, and the bag of fruit was not sealed and covered in ice crystals. Observation on 01/05/26 at 9:48 A.M. of the dry storage in House #105 revealed a 9 by 13 pan with a frosted cake, approximately half remaining, with no date, an open bag of powdered sugar in a ziplock bag that was not sealed, two open boxes of baking soda in ziplock bags that were not zipped, and an open bag of flour, rolled on top, torn on the sides, and contents on the shelf. Interview at the time of the observations, DT #383 verified the cake was not labeled, powdered sugar and baking soda were not sealed, and the flower was unsealed and spilling out onto the shelf. Observation on 01/05/26 at 9:56 A.M. in the kitchen of House #105, revealed the hood slats were coated in a dark grey fuzzy substance, the oven was coated in a thick brown substance, and the air fryer was coated in a thick brown residue and did not appear to have been cleaned after multiple uses. Interview at the same time, DT #383 verified the hood slats were coated in a dark grey fuzzy substance, the oven was coated in a thick brown substance, and the air fryer was coated in a brown residue and all were in need of cleaning. Review of the facility policy titled, Food Storage Policy and Procedure, dated 05/2013, revealed food should be stored, labeled, and dated to assure stock rotation and prevent food illnesses. Canned fruit should be placed in a container with the name and date refrigerated. Baking goods are marked with the month and day and placed in dry storage. 3. Observation on 01/07/26 at 7:35 A.M. in House #106 revealed Certified Nursing Assistant (CNA) #327 preparing sausage links for the breakfast meal. CNA #327 was observed reaching in the pan with her bare hands, touching the sausage. Interview on 01/07/26 at 7:37 A.M., CNA #327 denied touching the sausage links with her bare hands, and stated she was reaching in the pan trying to pick something out. CNA #327 verified she should not have reached into the pan with bare hands due to the potential contact with the food and cooking surface. Review of the facility policy titled, Food Handling and Preparation Policy and Procedure, dated 05/2013, revealed food was to be prepared using only clean, sanitized utensils.

Based on record review, observations, interviews, and policy review, the facility failed to follow appropriate infection control practices. This affected three residents (#19, #48, and #80) and had the potential to affect all nine residents (#19, #24, #26, #32, #48, #59, #66, and #74) who reside in House #102. The facility census was 50.Findings include:1. Review of the medical record for Resident #19 revealed an admission date of 12/18/25. Diagnoses included bacterial infection, bacteremia, paroxysmal atrial fibrillation, alcoholic cirrhosis of liver with ascites, type two diabetes mellitus with diabetic neuropathy, hypertension, heart failure, other low back pain, hyperlipidemia, gout, and congestive heart failure.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Resident #19 was assessed to require setup assistance for oral and personal hygiene, substantial/maximal assistance for toileting and lower body dressing, partial/moderate assistance for bathing and bed mobility, supervision for upper body dressing, and was independent for eating.Review of the active physician orders revealed an order dated 12/18/25 for enhanced barrier precautions.Observation on 01/05/26 at 10:07 A.M. revealed Resident #19 had a cart outside the room with personal protective equipment (PPE). There was no signage outside the door that indicated the type of precautions Resident #19 was on. Interview on 01/05/26 at 10:08 A.M. with Certified Nurse Aide (CNA) #323 verified there was no sign on Resident #19's door.2. Review of the medical record for Resident #48 revealed an admission date of 01/06/26. Diagnoses included acute kidney failure, type two diabetes mellitus without complications, chronic cough, and hyperlipidemia.Review of the admission MDS assessment dated [DATE] revealed the assessment had not been completed yet.Review of the active physician orders revealed an order dated 01/06/26 for enhanced barrier precautions.Observation on 01/07/26 at 8:14 A.M. revealed Occupational Therapist (OT) #500 exited Resident #48's room while wearing gloves. OT #500 removed her gloves and discarded them in a nearby trashcan and did not sanitize her hands. There was an enhanced barrier precautions sign on the door that instructed everyone to sanitize their hands after leaving the room.Interview on 01/07/26 at 8:15 A.M. with OT #500 confirmed she had not sanitized her hands after removing her gloves.3. Review of the medical record for Resident #80 revealed an admission date of 01/04/26. Diagnoses included influenza due to other identified influenza virus with other respiratory manifestations, acute respiratory failure with hypoxia, acute kidney failure, anxiety disorder, chronic kidney disease stage three b, and hyperlipidemia.Review of the admission MDS assessment dated [DATE] revealed the assessment had not been completed yet.Review of the active physician orders revealed an order dated 01/04/26 for contact isolation due to influenza.Observation on 01/05/26 at 9:31 A.M. revealed Resident #80 had a cart outside her room for PPE. There was no signage outside the door that indicated the type of precautions Resident #80 was on. Interview on 01/05/26 at 9:32 A.M. with OT #500 verified there was no sign outside the door related to the type of precautions Resident #80 was on. Review of the facility policy titled Hand Hygiene Procedure, revised 03/27/25, revealed hand hygiene should be performed after removing PPE.Review of the facility policy titled Isolation Precautions Process, revised 03/26/25, revealed signage for transmission based precautions would be posted at the entry to the resident's room to alert them of the need to consult the nurse prior to entering.

Based on medical record review, interview, and policy review, the facility failed to ensure advanced directives were correct. This impacted two (Residents #02 and #07) out of three residents reviewed for advanced directives. The facility census was 50. Findings include:1. Review of the medical record for Resident #02 revealed an admission date of 02/24/22. Diagnoses included dementia severe with psychotic disturbance, atrial fibrillation, hypertension, anemia, congestive heart failure, other asthma, vitamin deficiency, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had severely impaired cognition. Resident #02 was assessed to require supervision for eating, partial/moderate assistance for oral and personal hygiene, substantial/maximal assistance for upper body dressing, and was dependent on staff for toileting, bathing, lower body dressing, bed mobility, and transfer. Review of the active physician orders revealed an order dated 03/11/25 for Do Not Resuscitate Comfort Care (DNRCC). Review of the plan of care revised on 05/09/25 revealed Resident #02 had a code status of DNRCC. Review of the document titled DNR ORDER FORM, dated 03/11/25, revealed Resident #02 had a code status of DNRCC-Arrest checked instead of DNRCC. Interview on 01/06/26 at 1:39 P.M. with Social Worker #314 verified the physician order was for DNRCC but the signed DNR form was for DNRCC-Arrest. 2. Review of medical record of Resident #07 revealed an admission date of 04/11/2024. Diagnoses included type II diabetes mellitus with diabetic polyneuropathy, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified, and cerebral infarction, unspecified. Review of MDS assessment dated [DATE] revealed Resident #07 had severe problems with thinking and memory and demonstrated no behaviors. The resident utilized a walker, was independent with eating, upper body dressing, and personal hygiene, set up assistance for oral hygiene, supervision assistance for lower body dressing, sit-to-stand, bed to chair and toilet transfers, and ambulation, and moderate assistance for toileting, bathing, and tub transfers. Record review on 01/06/2026 at 9:50 A.M. of Resident #07's paper medical record revealed a document titled DNR Order Form dated 03/14/2024 which indicated the resident's code status was Do Not Resuscitate-Comfort Care Arrest (DNR-CCA). Record review of Resident #07's Electronic Medical Record (EMR) revealed a physician order dated 08/04/2025 which indicated Resident #07's code status was Do Not Resuscitate-Comfort Care (DNR-CC). Further EMR review revealed a care plan dated 11/27/2025 indicated a code status of DNR-CC. Interview on 01/06/2026 at 2:16 P.M. with Licensed Practical Nurse (LPN) #377 confirmed documentation in Resident #07's paper medical record documented a code status of DNR-CCA on a document titled DNR Order Form with a signature date of 03/14/2024. Continued interview with LPN#377 confirmed Resident #07's EMR documented a code status of DNR-CC. Review of a document titled Advance Directives Policy with a revised date of 03/19/2025 defined DNR Identification as The standard forms of identification approved by the facility, which record a resident's status as either a DNR Comfort Care resident or a DNR Comfort Care-Arrest resident. This document further states, The facility will also determine whether the resident's physician issued a DNR Order in another setting (e.g., hospital, home) and whether the resident would like a DNR Order issued while in the facility. The Advanced Directives Policy further states, If applicable, a DNR Order will be obtained from the resident's physician and placed in the medical record.

Based on observation, resident and staff interview the facility failed to maintain a clean environment. This affected one (#20) of one resident reviewed for a clean environment. The facility census was 50.Findings include: Review of Resident #20's medical record revealed admission to facility on 12/12/2025 with diagnoses of osteochondropathies to left ankle and foot, acute osteomyelitis of left ankle and foot, congestive heart failure, and generalized anxiety disorder, Review of the Minimum Data Set (MDS) assessment revealed Resident #20 had a moderate cognitive impairment. The resident was independent with eating, required setup cleanup assistance with oral hygiene, substantial/maximal assistance with toileting and bathing, Resident #20 utilized a wheelchair for mobility.Observation on 01/06/26 at 10:33 A.M. in Resident #20's room revealed ceiling vent was heavily coated in a dark grey fuzzy material.Interview on 01/06/26 at 2:41 P.M. with Resident #20 in Resident #20's room revealed resident was concerned about dust build up on ceiling vent, stating that vent needs to be cleaned.Interview on 01/06/26 at 2:41 P.M., Certified Nursing Assistant (CNA) #348 confirmed the ceiling vent in Resident #20's room was heavily coated in a dark grey fuzzy material and needed to be cleaned.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner. This affected three (#22, #20 and #19) of three residents reviewed for admission MDS assessments. The facility census was 50. Findings include: 1. Review of the medical record of Resident #22 revealed an admission date of 12/12/25. Diagnoses included bacterial infections of unspecified site, hypertension, and scoliosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was not completed until 12/30/25. The resident had intact cognition, was independent with eating, required substantial/maximal assistance with toileting, bathing, and was dependent for bed mobility. 2. Review of the medical record for Resident #20 revealed an admission date of 12/12/2025. Diagnoses included osteochondropathies to left ankle and foot, acute osteomyelitis of left ankle and foot, congestive heart failure, and generalized anxiety disorder. Review of the admission MDS assessment dated [DATE] revealed the assessment was not completed until 12/29/25. Resident #20 had a moderate cognitive impairment, was independent with eating, required setup cleanup assistance with oral hygiene, substantial/maximal assistance with toileting and bathing, and Resident #20 utilized a wheelchair for mobility. 3. Review of the medical record for Resident #19 revealed an admission date of 12/18/25. Diagnoses included bacterial infection, bacteremia, paroxysmal atrial fibrillation, alcoholic cirrhosis of liver with ascites, type two diabetes mellitus with diabetic neuropathy, hypertension, heart failure, other low back pain, hyperlipidemia, gout, and congestive heart failure. Review of the admission MDS assessment dated [DATE] revealed the assessment was not completed until 01/07/26. Resident #19 had intact cognition, required setup assistance for oral and personal hygiene, substantial/maximal assistance for toileting and lower body dressing, partial/moderate assistance for bathing and bed mobility, supervision for upper body dressing, and was independent for eating. Interview on 01/07/26 at 3:26 P.M., Registered Nurse (RN) #344 verified MDS assessments for Residents #22, #20, and #19 were not completed in a timely manner. RN #344 verified admission MDS assessments should be completed within 14 days of admission.

Based on record review, observation, and interviews, the facility failed to timely arrange podiatry services. This affected one (Resident #54) out of one resident reviewed for ancillary services. The facility census was 50.Findings include:Review of the medical record for Resident #54 revealed an admission date of 08/18/25. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease, wedge compression fracture of second lumbar vertebra subsequent encounter for fracture with routine healing, hypertension, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease stage three, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact. Resident #54 was assessed to require supervision for oral hygiene, toileting, upper body dressing, personal hygiene, bed mobility, and transfer, partial/moderate assistance for bathing, substantial/maximal assistance for lower body dressing, and was independent for eating.Review of the plan of care initiated on 10/17/25 revealed Resident #54 had diabetes mellitus and was at risk for complications. Interventions included refer to podiatry as needed.Observation on 01/07/26 at 8:33 A.M. of Resident #54's right foot revealed her toenails were thick and some were over half an inch long. Resident #54 reported her toenails were long and painful.Interview on 01/07/26 at 8:34 A.M. with Certified Nurse Aide (CNA) #341 verified Resident #54's toenails were thick and over half an inch long.Interview on 01/07/26 at 11:03 A.M. with Resident #54's daughter revealed she had asked facility staff multiple times to address Resident #54's toenails.

Based on medical record review and staff interview, the facility failed to ensure medical records were updated in a timely manner. This affected one (#52) of two residents reviewed for care conferences. The facility census was 50. Findings include:Review of the medical record of Resident #52 revealed an admission date of 10/04/24. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, lung cancer, hypertension, hypothyroidism, dysphagia, breast cancer, anxiety, peripheral vascular disease, and drug-induced constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with eating, required supervision with toileting and bed mobility, partial/moderate assistance with bathing, and substantial/maximal assistance with transfers. Review of the medical record revealed care conferences were held on 01/22/25, 04/15/25, 07/14/25, and 10/27/25. Further review of the medical record revealed the care conferences held on 01/22/25 and 04/15/25 were created on 06/16/25 and completed on 06/16/25, the care conference dated 07/14/25 was created on 01/05/26 and completed on 01/05/26, and the care conference dated 10/27/25 was created on 01/05/26 and completed on 01/06/26.Interview on 01/07/26 at 3:15 P.M., Social Worker (SW) #314 verified the care conferences were not documented timely. SW #314 stated she had gotten behind on documentation. Interview on 01/07/26 at 3:16 P.M., the Director of Nursing (DON) also verified the care conferences were not documented in the medical record in a timely manner.

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, observations, staff and resident interviews, manufacturer instructions and facility policy review, the facility failed to ensure a resident's wheelchair was secured in the facility's wheelchair van resulting in the wheelchair tipping over during transport. This affected one (#14) of three residents reviewed for accidents. The facility census was 53. Findings include: Review of Resident #14's chart revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with exacerbation, centrilobular emphysema, paroxysmal atrial fibrillation, , malignant neoplasm of unspecified part of right bronchus or lung, hypertension, dysphagia, malignant neoplasm of lower lobe left bronchus or lung, acquired absence of right leg above the knee, peripheral vascular disease, chronic pain and hyperlipidemia.Review of Resident 14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and the resident #14 required moderate assistant sitting to standing, and transfers.Review of Resident #14's progress note dated 09/24/25 at 3:45 P.M., revealed Resident #14 was sent to the emergency department (ED) from her appointment.Review of Resident #14's progress note dated 09/24/25 at 3:49 P.M., revealed Resident #14 required emergency services during her transport and emergency medical services (EMS) (911) was called. Resident #14 was taken to the hospital by EMS. Resident #14's daughter was called by the facility at 3:17 P.M. and a voicemail was left notifying Resident #14's daughter to call Registered Nurse (RN) #125 back.Review of Resident #14's progress note dated 09/24/25 at 5:45 P.M., revealed Resident #14 returned from the Emergency Department (ED) with orders for Tylenol which the resident already had in place Resident #14 was transferred to her chair and was eating dinner. Resident #14 was placed on neurological (neuro) checks.Review of Resident #14's hospital ED note dated 09/24/25, revealed Resident #14 presented in the ED with a head injury after the wheelchair she was seated in tipped backwards while she was riding in a wheelchair van. Resident #14 was on blood thinners and denied significant any complaints. Resident #14 had tenderness to the back of the head. A computed tomography (CT) of the head was completed with no acute intracranial processes and a CT of the cervical spine without contrast was completed with no acute displaced fracture. Resident #14 was diagnosed with a closed head injury, ordered to receive Tylenol and released. Review of CNA #140's witness statement dated 09/24/25, revealed the statement was taken over the phone by CNA #58. CNA #140 reported CNA #118 did not want to take Resident #14 to the appointment so CNA #140 told her that she would complete the last two check and changes and take Resident #14 to the appointment if CNA #118 would load Resident #14 into the van and have her ready to go. CNA #118 called CNA #140 when she was parked in front of the house and CNA #140 went outside and got into the van. CNA #118 told CNA #140 that Resident #14 was ready to go. CNA #140 greeted Resident #14, CNA #140 fastened her own seatbelt and began driving towards the appointment. As CNA #140 approached the intersection to get onto the interstate, the traffic light was red. When the light turned green, CNA #140 made a left turn to get onto the ramp and while making the left turn, CNA #140 saw Resident #14's leg lift and her wheelchair tipped backwards. CNA #140 heard and saw her hit her head on the wheelchair ramp. CNA #140 immediately pulled the van over to the right side of the road, got out, and opened the back door to check on Resident #14's condition. Resident #14 told CNA #140 she was okay, and this wasn't her fault. Resident #14 stated CNA #118 did not finish locking the wheelchair. CNA #140 told Resident #14 that she could not move her until she was assessed. CNA #140 called Licensed Practical Nurse (LPN) #129 and LPN #129 who CNA #140 to call emergency medical services (EMS) due to the head impact. While waiting, Resident #14 unbuckled her seatbelt and rolled onto her side. CNA #140 called EMS and waited for EMS to arrive. When EMS arrived, Resident #14 initially said she was fine, but they encouraged her to be evaluated. Resident #14 agreed and left with EMS for further evaluation. CNA #140 took the van back to the facility. The statement was signed by CNA #140. Review of CNA #118's witness statement dated 09/24/25, revealed the statement was taken over the phone by CNA #58. CNA #118 reported CNA #140 offered to handle the appointment, but they still had two residents that needed to be changed. CNA #140 stated she would take care of doing those check and changes if CNA #118 could go ahead and get Resident #14 loaded into the van. CNA #118 proceeded to load Resident #14 in front of the house where she resided. CNA #118 secured the back wheelchair straps and buckled Resident #14's seatbelt. CNA #118 was unable to access the front wheelchair straps from behind, so she intended to secure them from the side doors afterward. After raising the ramp, CNA #118 got into the van and drove the van to another house. CNA #118 forgot to strap down the front of the wheelchair. When CNA #118 pulled up at the other house, CNA #140 came outside, and CNA #118 informed her that Resident #14 was ready to go. At that moment CNA #118 did not remember or did not think to mention that the front straps were not secured. The statement was signed by CNA #118.Review of Resident #14's progress note dated 09/25/25 at 4:21 P.M., revealed Resident #14 was observed sitting comfortably in her recliner upon entry to the room. No acute distress was noted. Resident #14 verbalized that she was experiencing pain in her neck and shoulders and was describing it as tightness and soreness. Nursing was notified, and as needed (PRN) Tylenol was administered. The on call provider was notified of the shoulder and neck pain. Resident #14's neuro checks were noted to be within normal limits.Review of Resident #14's progress note dated 09/25/25 and authored by Nurse Practitioner (NP) #650, revealed the Director of Nursing (DON) would like to know if Resident #14 could get a PRN oxycodone for breakthrough pain. Resident #14 was recommended to receive oxycodone routine, three times a day and was prescribed Tylenol 650 milligrams (mgs) PRN. Resident #14 was involved in a fall on 09/24/25 and was having more pain related to the fall. NP #650 sent the request to the primary care provider who could order the oxycodone if appropriate. Resident #14 was ordered ibuprofen 800 mgs everyday PRN for three days for breakthrough pain.Review of Resident #14's progress note dated 09/25/25 at 6:58 P.M., revealed Resident #14 received a new order from the on call provider for PRN ibuprofen. The psychiatric provider completed an on-site assessment and reported no concerns. Resident #14's daughter was notified of the NP visit and the new orders.Review of Resident #14's progress note 09/25/25 authored by Physician Assistant (PA) #500, revealed PA #500 saw the resident due to resident being transported to an appointment on 09/24/25 when the front wheels of her wheelchair were not locked causing the wheelchair to fall backward when the van went up a hill. Resident #14 hit her head during the fall but denied loss of consciousness, emesis, or seizure-like activity. Resident #14 was evaluated in the ED and imaging of the head and neck showed no acute traumatic pathology. Resident #14 reported mild soreness and sustained abrasions to her chin, right cheek, and right neck. Resident #14 denied pain in her arms, hips, chest, or abdomen. Resident #14 had abrasions on the chin, right cheek and right neck. The note stated Resident #14 experienced a closed head injury yesterday when her wheelchair fell backward while being transported to an appointment and the resident sustained abrasions to the chin, right cheek, and right neck during the incident. Diagnoses listed on the progress note were unspecified injury of the head subsequent encounter and unspecified multiple injuries subsequent encounter.Review of Resident #14's psychiatric progress note dated 09/25/25, revealed Resident #14 was seen by psychiatric NP #600. Resident #14 denied any increase in depression or anxiety. Resident #14 had no change in sleep patterns or appetite and no signs of heightened arousal, intrusive memories, or avoidance behaviors. Resident #14 stated that she was frightened during the incident (fall in van) and felt trapped. She reported frustration about having to go to the ED and having to wait for a ride back to the facility. She stated that she would never ride in the transportation van again.Review of the facility's SRI created on 09/25/25 at 3:15 P.M., revealed Resident #14's daughter alleged neglect of the resident while in the facility's transportation van. On 9/24/25, Resident #14 was transported in the facility's transport van. The CNAs loading Resident #14 into the transport van had miscommunicated on fully securing Resident #14's wheelchair into the transport van resulting in Resident #14 tipping backward during the transport. The SRI was completed on 10/01/25 and the allegations of neglect or mistreatment were substantiated.Review of Resident #14's Interdisciplinary Team (IDT) progress note dated 09/29/25 at 1:40 P.M., revealed the IDT met to review Resident #14's fall on 09/24/25 which occurred during a scheduled transport. Resident #14 was seated in a wheelchair which had been secured with two of the four tie-downs when it tipped backwards. Resident #14 hit her head and was evaluated at the hospital. All tests were negative, and Resident #14 returned to the facility by family transportation. Resident #14 was noted with a small bump and scattered abrasions on her chin. Resident #14 stated the abrasions were from the neck brace that was placed by EMS. Resident #14's pain was treated with oral pain medications upon her return, and the physician was aware. Resident #14 remained at baseline with no concerns. The intervention was for anti-tippers to be placed on the wheelchair. Resident #14's family requested that all further transportation be completed by family or an outside transportation provider. The transportation staff were re-educated on securing wheelchairs in transport vehicles.Review of Certified Nursing Assistant (CNA) #118's bus and van transport checklist dated 11/07/24, revealed residents were to be secured with a four point lockdown system with a separate seat belt. Apply two lockdowns to the front of the wheelchair and two lockdowns to the back of the wheelchair and make sure the lockdowns are attached to the interlock system on the floor of the bus and on the wheelchair. The checklist was signed by CNA #118 on 11/07/24. Review of CNA #140's bus and van transport checklist dated 11/21/24, revealed residents were to be secured with a four point lockdown system with a separate seat belt for the resident. Apply two lockdowns to the front of the wheelchair and two lockdowns to the back of the wheelchair and make sure the lockdowns are attached to the interlock system on the floor of the bus and on the wheelchair. The checklist was signed by CNA #140 on 11/21/24. Review of CNA #140's disciplinary action notice dated 09/29/25, revealed CNA #140 was placed on a final written warning. The notice stated CNA #140 accepted responsibility for transporting a resident to a scheduled appointment. Prior to departure, CNA #140 did not verify that the resident's wheelchair was properly secured and as a result, the resident's wheelchair tipped backwards during transit posing a significant safety risk. The notice was signed by CNA #140 on 09/29/25.Review of CNA #118's disciplinary action notice dated 10/02/25, revealed CNA #118 was placed on a final written warning. The notice stated CNA #118 agreed to assist with loading and securing a resident for transport to a scheduled appointment. During the process, CNA #118 secured the back of the wheelchair and fastened the resident's seatbelt. After completing these steps, CNA #118 closed the ramp and handed off the keys to the CNA responsible for driving the resident. CNA #118 forgot to lock down the front of the wheelchair. The failure to fully secure the wheelchair resulted in the resident's wheelchair tipping backwards during transit. The notice was signed by CNA #118 on 10/02/25.Interview with LPN #129 on 10/09/25 at 7:56 A.M., revealed CNA #140 called her about an incident with the facility's van on an unknown date between 2:40 P.M. and 3:00 P.M. LPN #129 stated that CNA #140 informed her that Resident #14 fell backwards in the facility's van when CNA #140 was driving onto the highway. LPN #129 informed CNA #140 to call EMS and not to move Resident #14. LPN #129 reported she informed RN #125 about the incident and RN #125 took over the incident after she was informed. Interview with CNA #140 on 10/09/25 at 9:13 A.M., revealed she could not remember the date of the incident, but her shift was supposed to end at 3:00 P.M. on that date. CNA #140 stated that CNA #118 did not feel well and was tired. As a result, CNA #118 asked CNA #140 if she would take Resident #14 to her appointment. CNA #140 stated she told CNA #118 that she did not want to transport Resident #140, but CNA #118 continued to ask her. CNA #140 reported she felt bad for CNA #118 and agreed to transport Resident #14 to the appointment if CNA #118 would get the van, get Resident #14's paperwork together, get Resident #14 ready and would pick her up in the van while CNA #140 finished caring for the last two residents and took out the trash. CNA #140 stated that CNA #118 pulled up in the van with Resident #14, handed CNA #140 the paperwork and said that Resident #14 was ready to go. CNA #140 stated she got in the van and said hi to Resident #14 and noted that Resident #14 had her seatbelt fastened. CNA #140 stated she started to drive to the appointment and CNA #140 stopped at a red light to turn left on to Interstate 75 going southbound. CNA #140 reported the light turned green and she turned left onto the ramp to the highway. CNA #140 stated that she saw Resident #14 go backwards with her feet up in the air as she turned and was going up the ramp to the highway. CNA #140 reported she pulled over on the ramp, turned on her hazard lights and got out of the van. CNA #140 stated she opened the door of the van and saw Resident #14's wheelchair had flipped over and Resident #14's head was up against the van's wheelchair ramp. CNA #140 reported Resident #14 stated just get me up and it's okay it's not your fault. CNA #140 stated she told Resident #14 that she could not move Resident #14, but Resident #14 stated she was fine and there was nothing wrong with her. CNA #140 stated she observed that Resident #14 had the back two straps attached to her wheelchair, but the front straps were not in place when she opened the door. CNA #140 called the facility and reported the incident to LPN #129. CNA #140 was advised by LPN #129 to call EMS and CNA #129 called EMS and her supervisor, CNA #58. CNA #140 stated EMS arrived on the scene and blocked the ramp. CNA #140 reported EMS got Resident #14 out of the van and placed her in her wheelchair. CNA #140 reported Resident #14 unfastened her own seatbelt and was trying to reposition herself on the floor of the van prior to EMS arriving at the scene. CNA #140 stated that EMS took Resident #14's vitals and Resident #14 was refusing to go to the hospital because she stated she was fine. CNA #140 called LPN #129 back and told her that Resident #14 was refusing to go to the hospital and LPN #129 spoke with EMS. EMS informed Resident #14 that she needed to go to the hospital to be checked out because of her medications and Resident #14 agreed. CNA #140 stated EMS put Resident #14 on the stretcher from her wheelchair and they took her to the hospital. CNA #140 reported she transported residents a lot and had never had any incidents prior to the incident with Resident #14. CNA #140 stated she was educated on transportation after the incident.Interview with CNA #118 on 10/09/25 at 9:31 A.M., revealed CNA #140 offered to transport Resident #14 to an appointment on an unknown date around 2:30 P.M. if CNA #118 got Resident #14 in the van while CNA #140 finished caring for her last two residents. CNA #118 stated she did not go on the transport, but she got Resident #14 ready, hooked up her oxygen and wheeled her into the van. CNA #118 reported she locked the back two straps of Resident #14's wheelchair to the van and she fastened Resident #14's seatbelt. CNA #118 stated she could not reach the front two straps for Resident #14's wheelchair and she planned to enter the front of the van to strap the front two wheelchair straps. CNA #118 stated she put the ramp to the van up and it slipped her mind to anchor the front two straps of Resident #14's wheelchair. CNA #118 reported CNA #140 came out and left with Resident #14. CNA #118 stated she had been doing transportation for 2.5 years and had never had any incidents prior to the incident. CNA #118 reported that she was reeducated on transporting residents. Observation of Resident #14 on 10/09/25 at 9:07 A.M. revealed Resident #14 was lying in bed. Resident #14 appeared clean and dressed appropriately. Interview with Resident #14 at the same time revealed the resident did not know the staff names but reported one CNA placed her in the van and the other CNA drove her to an appointment a few weeks ago. Resident #14 stated the two CNAs never corresponded together and the CNA that drove never tied down her wheelchair. Resident #14 reported she put on her own seat belt, but she did not have any tie downs on her wheelchair. Resident #14 stated that her whole wheelchair went backwards when the CNA turned the corner onto the highway. Resident #14 reported she was pinned under her wheelchair, and her oxygen fell off. Resident #14 stated the CNA pulled over but would not touch her. Resident #14 reported she hit her head on the door of the van and EMS arrived and got her out of the van and took her to the hospital. Resident #14 stated she sustained a bump on the back of her head which was sore. Resident #14 also reported she had pain to her back and shoulders. Resident #14 denied any respiratory issues or issues with her oxygen during the transportation incident. Resident #14 stated the incident was very scary.Interview with the Administrator, CNA #58 and the DON on 10/09/25 at 10:32 A.M., revealed CNA #118 and CNA #140 were splitting transportation duties for Resident #14's appointment on 09/24/25. The Administrator reported CNA #118 would get Resident #14 ready and loaded into the van and CNA #140 would drive her to the appointment. The Administrator stated that CNA #118 and CNA #140 completed the switch off of the van and Resident #14 had her seatbelt fastened so CNA #140 drove off not knowing that CNA #118 only strapped in the back to straps of Resident #14's wheelchair in the van. The Administrator stated CNA #140 started driving onto the highway ramp and CNA #140 heard Resident #14 tip backwards. The Administrator reported that CNA #140 pulled over and called LPN #129. LPN #129 informed CNA #140 to call EMS and CNA #58. The Administrator stated that CNA #140 called EMS and waited for EMS to arrive. The Administrator reported CNA #140 did not move Resident #40 and Resident #14 was transported to the hospital by EMS. The DON reported she called Resident #14's daughter and the resident's daughter returned her call and was notified of the incident. The Administrator stated that Resident #14's CT scans at the hospital were negative and no injuries were noted except for tenderness to the back of her head. The DON stated Resident #14 was assessed by the physician and psychiatry on 09/25/25 with no findings and that Resident #14 was given some PRN Tylenol and ibuprofen for her shoulders after the incident as Resident #14 already was prescribed narcotic pain medication three times a day. The DON stated Resident #14 was placed on neuro checks and those were within normal limits and Resident #14 appeared to be at her baseline. The Administrator stated the facility immediately suspended CNA #118 and CNA #140 from driving to appointments. The Administrator reported that an SRI was opened on 09/25/25 because Resident #14's daughter reported that she felt that Resident #14 was neglected by the facility on that date. The Administrator stated the van was not utilized during the investigation and the facility outsourced transportation to companies. The Administrator reported CNA #118 and CNA #140 were placed on suspension and removed from the schedule when the neglect allegation was made on 09/25/25 and all CNAs were educated on transportation. The Administrator also stated that all staff completed competencies on how to secure residents in the wheelchair van. The Administrator stated the facility interviewed residents that were transported within the past 30 days and no one had any additional concerns with transportation. The Administrator stated transportation was reinstated at the facility on 10/06/25 and a transportation audit was initiated to ensure all residents were appropriately strapped in the transport van before leaving. The Administrator also stated the facility initiated the transportation checklist. CNA #58 stated she interviewed both CNA #140 and CNA #118 after the incident. CNA #58 verified CNA #118 admitted that she forgot to strap down the front of Resident #14's wheelchair prior to her appointment on 09/24/25. The Administrator stated the facility no longer used CNA #118 and CNA #140 as drivers at the facility and they were given a final written warning about the incident. The Administrator also reported that the facility discussed the incident in the Quality Assurance (QA) meeting. Review of the wheelchair vans undated manufacture instructions revealed attach the four tie- down hooks to the solid frame members or weldments near seat level. Ensure the tie downs are fixed at approximately 45 degrees. Do not attach the hooks to wheels, plastic or removable parts of the wheelchair.Review of the facility's undated guidelines and regulations for a minibus carrier, revealed there should always be a total of four anchor points with two in the front of the wheelchair and two in the back of the wheelchair.As a result of the incident, the facility took the following actions to correct the deficient practice by 10/06/25: On 09/24/25, Resident #14 was transported to the hospital for assessment.On 09/25/25, Resident #14 was assessed by PA #500 and psychiatric NP #600 with no new orders.On 09/25/25, the facility's QA committee held ad hoc meeting regarding transportation. Transportation education and demonstrations were scheduled for 09/29/25 and the transportation checklist was reviewed. The facility also developed a transportation audit.On 09/25/25, all CNAs were provided with education on securing wheelchairs in the wheelchair van by CNA #58.On 09/26/25, the Administrator completed interviews of the residents that had utilized the facility transportation with no findings.On 09/29/25, all CNAs were educated in person by Corporate Maintenance Director #700 on wheelchair transportation and all staff demonstrated their competencies on the bus and transport van checklist.On 10/06/26, transportation audits were initiated by the Administrator, CNA #58, the DON or designee on all facility transportations to ensure residents were strapped in correctly, residents had the correct durable medical equipment and to ensure staff were following the transportation checklist. The Audits will be completed for four weeks. This deficiency represents non-compliance investigated under Complaint Number 2634560 and 2629140.

Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure the resident medical record was retained and complete. This affected one resident (#56) out of three resident records reviewed. The facility census was 56 residents. Findings include: Review of the medical record for Resident #56 revealed an admitted on 04/08/22. Diagnoses included polyneuropathy, pain in the left leg, chronic atrial fibrillation, chronic kidney disease, and osteoporosis. Resident #56 was cognitively intact. Review of the plan of care dated 04/09/23 revealed Resident #56 was at risk for pain related to decreased range of motion, weakness, decreased activity of daily living, polyneuropathy, left leg pain, and osteoporosis. Interventions included providing pain management each shift, provide rest for involved joints, avoid activities, monitor for ideal body weight, evaluate, and provide adaptive equipment, use range of motion, and refer to therapy. Review of the physician orders dated 04/15/23 revealed Resident #56 was ordered oxycodone (a narcotic pain medication) five mg every four hours as needed for pain. Review of the medical record revealed there was no narcotic count sheet or pharmacy control sheet for the month of March 2023 or April 2023. Interview on 05/19/23 at 1:38 P.M., Resident #56 said he had not taken any narcotic pain medication over the last couple of months. Interview on 05/19/23 at 2:09 P.M., with the Director of Nursing (DON) who stated she did not have the paper narcotic count sheets for March 2023 and April 2023 for Resident #56. The DON stated she thought another nurse had not filed them properly and had them shredded. The DON stated the process for the narcotic sheets were to be filed in the hard chart of the resident or filed in medical records. The DON stated she could not verify what nurse had taken the narcotic sheet record for Resident #56. Review of the medical record on 05/19/23 at 2:09 P.M. with the DON who verified there was only the May 2023 narcotic count sheet for Resident #56. Review of facility policy titled Medical and Personnel Record Storage, Retention, and Destruction Policy, dated 09/23/2005, revealed the facility shall store, retain, and destroy all records in a manner that was compliant with federal, state, and local laws, regulations, and rules, and that was consistent with this policy and accepted standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00142766.

Based on medical record review, staff interview, and policy review, the facility failed ensure pain management was provided. This affected two residents (#43 and #56) out of three residents reviewed who had pain managed at the facility. The facility census was 56. Findings Include: 1. Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, type two diabetes, spondylosis, sciatica, and [NAME] syndrome (a disorder affecting the contraction of the bowel). Resident #44 was alert and oriented. Review of the plan of care dated 03/16/23 revealed Resident #44 was at risk for chronic pain related sciatica, spondylosis, and osteoarthritis. Interventions included administering analgesia per orders, identifying and treating, identify previous pain, monitor pain characteristics, notify the physician if interventions were unsuccessful, and provide the resident with reassurance that pain was time limited. Review of the physician order dated 07/16/22 revealed that Resident #44 had an order for Tylenol Extra Strength 500 milligram take two tablets by mouth every eight hours need for pain. Review of the physician order dated 07/18/22 revealed Resident #44 had an order for pain monitoring, to observe for pain. If pain was present treat trying non-pharmacological interventions such as ice packs, warm compress, repositioning, massage, distraction activity prior to medicating if appropriate and check those utilized, if other document in the progress notes every shift. Review of the physician order dated 12/24/22 revealed Resident #44 had an order for Oxycodone (a narcotic pain medication) five milligram tablet take one by mouth every six hours as needed for pain. Discontinued on 04/27/23. Review of the physician order dated 04/27/23 revealed that Resident #44 had an order for Oxycodone five milligram tablet take one by mouth every eight hours as needed for pain. Review of the Medication Administration Record (MAR) dated from 04/01/23 through 05/19/23 revealed Resident #44 had no non-pharmacological interventions prior to the administration of pain medication on 04/15/23, 04/16/23, 04/17/23, 04/18/23, 04/21/23, 04/23/23, 04/28/23, 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/15/23, and 05/19/23. Interview on 05/19/23 at 4:08 P.M., with the Director of Nursing (DON) who verified the nurse who administered pain medication to Resident #44 had not tried a non-pharmacological pain intervention before administering pain medication to Resident #44. 2. Review of the medical record for Resident #56 revealed an admitted on 04/08/22. Diagnoses included polyneuropathy, pain in the left leg, chronic atrial fibrillation, chronic kidney disease, and osteoporosis. Resident #56 was cognitively intact. Review of the plan of care dated 04/09/23 revealed that Resident #56 was at risk for pain related to decreased range of motion, weakness, decreased activity of daily living, polyneuropathy, left leg pain, and osteoporosis. Interventions included providing pain management each shift, provide rest for involved joints, avoid activities, monitor for ideal body weight, evaluate, and provide adaptive equipment, use range of motion, and refer to therapy. Review of the physician order dated 04/08/22 revealed Resident #56 had an order for pain monitoring, to observe for pain. If pain was present treat trying non-pharmacological interventions such as ice packs, warm compress, repositioning, massage, distraction activity prior to medicating if appropriate and check those utilized, if other document in the progress notes every shift. Review on an order dated 04/15/23 revealed Resident #56 had Oxycodone five mg every four hours as needed for pain. Review of the MAR dated from 04/01/23 through 05/19/23 revealed Resident #56 had no non-pharmacological interventions before pain medication was administered on 04/03/23, 04/08/23, 04/13/23, 04/14/23, 04/17/23, 04/23/23, 04/26/23, 04/28/23, and 05/06/23. Interview on 05/19/23 at 3:34 P.M., with the DON who stated the facility had a lack of documentation. The DON verified the nurse who gave narcotics to Resident #56 had not used non-pharmacological interventions before pain medication was administered. Review of the facility policy titled Pain Management, dated 12/28/21 revealed if the resident identified pain, the nurse would perform a thorough assessment of the resident's pain to differentiate the various types and degree of pain. The assessment will be documented in the medical record. The assessment process will include location of pain, intensity of pain, quality, onset, and aggravating factors. Non-pharmacological forms of interventions will be considered whenever appropriate. The resident, and resident representative when appropriate will be educated regarding this role in managing pain. This deficiency represents non-compliance investigated under Complaint Number OH00142766.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of COVID-19. This impacted one (#102) of five residents reviewed for infection control procedures and had the potential to affect all 12 residents residing in House #105 (#12, #11, #10, #09, #08, #07, #06, #05, #04, #103, #102 and #101). The facility identified one resident (#22) who was currently in isolation for positive COVID-19. The facility census was 58. Findings include: Review of the medical record of Resident #102 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #102's immunization record revealed Resident #102 refused the COVID-19 vaccination. Review of the Admission Screen and Baseline Care Plan dated 09/20/22 revealed the resident was in quarantine for possible COVID-19. Resident #102 was on droplet and contact precautions as a precaution to prevent the spread of the virus to others in the event of a positive COVID-19 test result. Interventions included for staff to wear PPE during care and follow isolation procedures and COVID-19 testing per the facility, health department, and CDC guidelines. Further review revealed Resident #102 was alert but non-verbal and dependent on two staff for bed mobility, transfers, and toileting. Interview on 09/21/22 at 8:45 A.M., the DON and Administrator stated, prior to entering the rooms of residents on quarantine or isolation for COVID-19, staff should don full PPE, including a gown, N-95 mask, and gloves. Interview on 09/21/22 at 9:15 A.M. Elder Assistant (EA) #300 stated House #105 had one resident (#102) on quarantine. EA #300 stated full PPE, including a gown, N-95 mask, and gloves, was required to enter the room. Observation on 09/21/22 at 9:17 A.M. revealed the door to Resident #102's room had two signs, one indicating the resident was on transmission-based precautions and everyone must clean hands when entering the room and leaving the room, wear a mask, eye protection, gown, and gloves, and the second sign with a red stop sign saying to see the nurse before entering. A bin was observed, outside of the room, containing hand sanitizer, N-95 masks, gowns, and gloves. An unidentified person was overheard inside the room, talking to the resident. Observation on 09/21/22 at 9:18 A.M., revealed Occupational Therapist (OT) #305 say goodbye to Resident #102 and exit the room, wearing a surgical mask and eye protection. Concurrent interview, OT #305 verified she was in Resident #102's room and was not wearing an N-95 mask nor a gown. OT #305 stated she did wear gloves while working with the resident. OT #305 stated she was in Resident #102's room doing an evaluation and forgot to don the gown and N-95 mask prior to entering the room. OT #305 further affirmed the need to don a gown and N-95 mask prior to entering Resident #102's room. Interview on 09/21/22 at approximately 11:30 A.M., the DON verified full PPE (gown, N-95 mask, gloves, and eye protection) were required to enter the room of any resident on isolation or quarantine for COVID-19, including the room of Resident #102. Review of the facility policy titled, COVID-19 Policy and Procedure, dated 02/07/22 revealed new residents who are not up-to-date with vaccines are required to quarantine in their private room with transmission-based precautions for 10 days or 7 days with a negative test within 48-hours. Precaution signage is placed on the resident door. Full transmission-based precautions PPE should be worn for the care of any resident with suspected COVID-19. Review of facility policy titled, Isolation Precautions Process, dated 08/01/22, revealed the use of PPE, including a gown and gloves, upon entering the room of a resident on contact precautions, is required. This deficiency substantiates Complaint Number OH 779 and is an example of ongoing non-compliance following the Annual survey completed on 08/15/22.

Based on observation, staff interview, and policy review, the facility failed to ensure hazardous chemicals were not accessible to residents. This had the potential to affect six (#7, #9, #19, #34, #45, and #210) cognitively impaired and independently mobile residents who reside in House #101 and House #102 out of the 24 total residents who reside in House #101 and House #102. The facility census was 56. Findings include: 1. Observation of an unlocked cabinet under the sink in the kitchen in House #101 on 08/08/22 at 11:30 A.M. revealed there was a container of sanitizing wipes, oven cleaner, floor cleaner, two liters of disinfectant, [MEDICATION(S)] base cleaner, multi-purpose cleaner, disinfectant deodorizer, potential of hydrogen (PH) acid, bathroom cleaner, and a gallon of mineral blend. Interview with State tested Nursing Aide (STNA) #141 on 08/08/22 at 11:35 A.M. confirmed the chemicals in the unlocked cabinet under the sink in House #101 should have been locked up. STNA #141 confirmed lock on the cabinet under the sink was brokedn and was unable to be locked. 2. Observation on 08/08/22 at 2:45 P.M. revealed the second sink in the kitchen in House #102 had chemicals under the sink which included a cleaner, bleach wipes, and a lemon cleaner. Interview on 08/08/22 at 2:45 P.M. with Certified Nurse Aide (CNA) #113 stated there were chemicals under the sink in House #102, and it was not locked. CNA #113 stated there were ambulatory confused residents in House #102. Observation on 08/08/22 at 2:54 P.M. revealed the door to the kitchen by the counter in House #102 was open on the left and right side, and no staff were observed for five minutes. Review of the policy titled Storage and Use of Poisonous Substances Policy and Procedure (cleaning supplies, pesticides etc.), dated 06/01/08, revealed the purpose of the policy was to provide a place where toxic materials such as cleaning supplies, pesticides etc. may be stored without the risk of contaminating food or anything that may come in contact with food. The three categories of poisonous substances are: pesticides, detergents, sanitizers, corrosives and other chemicals and flammables. Each of these categories is to be stored separately from the others They may not be stored above or next to food, food equipment, utensils linens or disposables (single-service and single-use articles). However detergents and sanitizers are permitted to be stored in the locked cabinet under the sink next to the dishwasher. Other items are to stored in locked cabinets in the dirty utility room.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the staff wore appropriate personal protective equipment when in resident rooms under quarantine precautions. This affected two (#44 and #205) residents and had the potential to affect all 12 residents (#27, #28, #31, #44, #49, #51, #54, #205, #206, #207, #208, and #210) who reside in House #102. The census was 56. Findings include: 1. Review of the medical record revealed Resident #44 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's plan of care, dated 07/19/22, revealed Resident #44 was at risk for possible Covid-19 and was on droplet and contact isolation as a precaution to prevent the spread of the virus to others in the event of a positive Covid-19 test result. Interventions included partners to wear personal protective equipment during care and follow isolation procedures, wear a mask during care, have all activities, meals, medication, and therapy in his room. Review of the medical record for Resident #44 revealed Resident #44 had not received a Covid-19 vaccination. 2. Review of the medical record for Resident #205 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #205's plan of care, dated 08/02/22, revealed Resident #205 was at risk for being in quarantine for possible Covid-19. Resident #205 was in droplet and contact isolation as a precaution to prevent the spread of the virus to others in the event of a positive Covid-19 test result. Interventions included partners to wear personal protective equipment during care and follow isolation procedures. Resident #205 will have all activities, meals, medications, and therapy in their room. Resident #205 will have oxygen saturations monitored at least daily. Review of the medical record for Resident #205 revealed she received the first dose of a Covid-19 vaccine on 02/12/21 and the second dose on 03/22/21. Resident #205 had not recieved a Covid-19 booster. Observation on 08/08/22 at 10:08 A.M. revealed Certified Nurse Aide (CNA) #113 was leaving Resident #44's room and only had a surgical mask, face shield, and blue isolation gown on when in Resident #44's room. CNA #113 then left Resident #44's room and went to the main great room to use hand sanitizer. CNA #113 then went to Resident #205's room and only wore a surgical mask, face shield, and blue isolation gown when in Resident #205's room. Interview with CNA #169 on 08/08/22 at 10:23 A.M. revealed staff was supposed to wear a face shield, or goggles. CNA #169 stated she had eyeglasses on instead of her face shield. CNA #169 stated her shift started at 7:00 A.M. and she had not worn goggles or a face shield all shift to any of the rooms in Hosue #102, even the resident rooms who were on quarantine. Observation on 08/08/22 at 10:24 A.M. of CNA #169 revealed she only had on her personal eyeglasses and was not wearing goggles or a face shield. Interview on 08/08/22 at 10:57 A.M. with STNA #132 revealed if staff enter a Covid-19 positive or Covid-19 quarantine room, they should wear an N95 respirator, isolation gown, face shield, and surgical gloves. Interview on 08/08/22 at 11:59 A.M. with the Director of Nursing (DON) revealed the PPE boxes at the room doors should have hand sanitizer to utilize after doffing PPE upon leaving Resident #44 and Resident #205's rooms, who were under quarantine. The DON stated staff was to wear N95 respirator, isolation gown, surgical gloves, a hair net, and face shield when in Covid-19 positive or quarantine rooms. The DON stated no staff should be walking to the main great room to utilize hand sanitizer after leaving a resident room who was under quarantine. The DON stated the hand sanitizer should be in the PPE box outside the room. Review of the Covid-19 Policy and Procedures, revised 02/07/22, revealed new residents or those that have been readmitted and are not up to date with vaccines, are required to quarantine in their room with transmission-based precautions on the appropriate unit for 10 days or seven days with a negative test within 48 hours or longer.

Based on observation, staff interview, and policy review, the facility failed to ensure food items had an open date and were were not expired. This had the potential to affect all 24 residents (#6, #8, #9, #11, #14, #16, #27, #28, #31, #33, #34, #38, #41, #44, #45, #49, #51, #54, #105, #205, #206, #207, #208, and #210) who resided in House #101 and House #102. The facility census was 56. Findings include: 1. Observation of the kitchen in the 101 house on [DATE] at 11:07 A.M. revealed there was cereal which was opened and was not dated, dark rye bread which was opened and had an expiration date of [DATE], hot dog buns which were opened and had an expiration date of [DATE], hamburger buns with an expiration date of [DATE], hoagie buns which were unopened and had an expiration date of [DATE], sweet and sour sauce dated [DATE], powdered sugar which was opened and was not dated, pecans which were opened and were not dated, heath bits which were opened and were not dated. In the refrigerator there were individual wrapped swiss and American cheese which was opened and was not dated, shredded sharp cheddar cheese which was opened and was not dated, swiss cheese slices which were opened and were not dated, cherries which were opened and were not dated, waffle cones which were opened and had an expiration date of [DATE], biscotti's which were opened and were not dated, crackers which were opened and were not dated, two bags of lettuce with use by dates of [DATE], 48 ounces of brewed coffee which was opened and was not dated, 52 ounces of strawberry banana cream which was opened and was not dated, 32 ounces of french vanilla coffee creamer which was opened and was not dated, 32 ounces of vanilla creamer which was opened and was not dated, 32 ounces of caramel vanilla creamer which was opened and was not dated, and 24 ounces of syrup which was opened and was not dated. Interview with the Diet Tech (DT) #143 on [DATE] at 11:11 A.M. verified all of the above items were supposed to be dated with an open date and the items that were expired should have been thrown away. Review of policy titled Food Labeling and Dating, dated [DATE], revealed the policy was to ensure all foods were easily identified so as to avoid confusion/errors during food preparation and to ensure stock was rotated properly. The policy revealed once a food item is opened it should be dated the month, day and year it was opened. 2. Observation on [DATE] at 2:42 P.M. with Certified Nurse Aide (CNA) #113 revealed the pantry refrigerator in house #102 had a bag of food from a fast food restaurant which was not labeled, an old round white foam container which had dried up baked beans which was not labeled, and an opened potato salad in a large container which was not dated or labeled. Interview on [DATE] at 2:43 P.M. with CNA #113 revealed the potato salad was just opened yesterday ([DATE]). CNA #113 stated that the bag of food from a fast food restaurant was from a resident who was discharged . Observation on [DATE] at 2:45 P.M. with CNA #113 revealed the house #102 refrigerator, which was located in the kitchen, had a large thick and chunky salsa which had open date of [DATE], a large jar of medium salsa which had an open date of [DATE], and a pitcher of tea which was not labeled or dated. Interview on [DATE] at 2:46 P.M. with CNA #113 revealed she thought the tea in the pitcher in the refrigerator was made last Thursday ([DATE]). Interview on [DATE] at 1:30 P.M. with Dietitian #333 revealed the salsa should probably be thrown out seven days after opening. Dietitian #333 stated the facility did not have a chart that was followed in order to determine the number of days food was permitted to be used prior to being thrown out.

Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure a urinalysis was completed in a timely manner. This affected one (Resident #33) out of one resident reviewed for urinary tract infections ([CONDITION(S)]). The census was 56. Findings include: Medical record review for Resident #33 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Her functional status was limited assistance for bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and bowel. Review of Resident #33's progress note dated 07/31/22 revealed Resident #33 complained of dysuria and had some mental status changes. The physician was notified and an order was received for a urinalysis. Review of Resident #33's progress notes dated 08/01/22 through 08/06/22 revealed no concerns for [CONDITION(S)] symptoms for the resident. Review of Resident #33's progress note dated 08/04/22 revealed the urinalysis lab was rescheduled. Review of the laboratory results for Resident #33 revealed the urine was collected on 08/04/22 and the results were dated 08/07/22 and Resident #33 was positive for a [CONDITION(S)]. Interview with Resident #33 on 08/08/22 at 2:39 P.M. revealed a staff member came and got the urine specimen, but because it sat in the refrigerator, someone had to get another specimen from her. She said it was sometime last week. She said the facility told her she had a [CONDITION(S)]. Interview with the Director of Nursing (DON) on 08/10/22 at 2:28 P.M. confirmed Resident #33's urine sat in the refrigerator and another urine had to be retrieved which delayed the completion of the urinanalysis. Review of the policy titled Urinary Tract Infections, Urinary Incontinence, dated 07/01/07, revealed it was the policy of the facility to provide care and services to prevent urinary tract infections in the residents.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents received oxygen according to physician orders. This affected one (Resident #35) out of two residents reviewed for oxygen. The facility identified six residents who utilized oxygen per nasal cannula. The facility census was 56. Finding include: Review of the medical record for Resident #35 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's Minimum Data Set assessment dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required extensive two-person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/09/22 at 9:31 A.M. revealed Resident #35 had oxygen on at three liters per minute, and the sterile humidifier water for Resident #35's concentrator was empty. Resident #35's oxygen tubing was dated 08/01/22. Interview on 08/09/22 at 9:32 A.M. with Resident #35 revealed there was something wrong with his oxygen last night and it was irritating his nose. Interview on 08/09/22 at 9:28 A.M. with Certified Nurse Aide (CNA) #188 revealed the sterile humidifier water was empty on Resident #35's oxygen concentrator. Interview on 08/09/22 at 9:35 A.M. with Registered Nurse (RN) #154 verified Resident #35's oxygen concentrator was set at three liters per minute.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a resident was provided incontinence care in a timely manner. This affected one (Resident #206) out of one resident reviewed for incontinence care. The facility identified 43 residents who were incontinent of bladder. The census was 56. Findings include: Review of the medical record for Resident #206 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #206's plan of care, dated 08/09/22, revealed Resident #206 was at risk for moisture associated skin damage to groin/buttocks, diabetic ulcer to left heel, pressure area to left lower back. Interventions include administer treatment as ordered apply moisture barrier to my perineal area and buttocks after incontinence episodes, apply moisture lotion to extremities, float heels while in bed or recliner, low air mattress for bed, monitor effectiveness, monitor for complaints of pain and provide interventions as needed, and turn and reposition for infection at site as evidenced by redness and [CONDITION(S)]. Observation of wound care for Resident #206 on 08/11/22 at 11:45 A.M. revealed Resident #206 had a depend on that was saturated with urine. Interview with Resident #206 at the time of the observation revealed he was trying to get staff to change him. Resident #206's bed was saturated with urine and there was a puddle when Resident #206 had to be rolled for his back treatment. Resident #206's hospital gown was saturated with urine. Interview on 08/11/22 at 12:00 P.M. with Respiratory Therapist (RT) #444 revealed no one had come yet to change Resident #206 due to the incontinent episode. RT #444 stated Resident #206 was saturated with urine and needed changed. Interview on 08/11/22 at 12:04 P.M. with Certified Nurse Aide (CNA) #181 revealed she had started working on 08/11/22 at 9:30 A.M. and had not changed Resident #206. CNA #181 stated the other aid (CNA #189) left for the day but had changed Resident #206 earlier. Observation on 08/11/22 at 12:04 P.M. of Resident #206 revealed his depends were saturated with urine and it was leaking onto his air mattress. The bed had a circumference of roughly three feet of urine under Resident #206, with several puddles of urine on his backside. Review of the Urinary Incontinence, Indwelling Catheters, and Urinary Tract Infections Policy, revised 07/20/11, revealed each resident who was incontinent of urine was identified, assessed, and provided with appropriate treatment and services to achieve and maintain as much normal urinary function as possible.

Based on medical record review, and staff and resident interview, the facility failed to ensure residents received new eyeglasses in a timely manner. This affected one (Resident #14) out of one resident reviewed for vision. The census was 56. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an eye examination conducted on 02/07/22 revealed Resident #14 requested new eyeglasses and they were ordered. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired. Interview with Resident #14 on 08/08/22 at 2:17 P.M. revealed her eyeglasses were broken and it had been quite sometime since she ordered new eyeglasses however she had not received the new eyeglasses yet. Interview with the Administrator on 08/11/22 at 10:40 A.M. revealed the eyeglasses were ordered for Resident #14, but the facility had not received them yet and they should have arrived already. She denied knowing whether or not a staff member had followed up with the eye company.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure there was an ongoing activity program to meet the needs of the residents. This affected three (#9, #11, and #14) out of four residents reviewed for activities. The census was 56. Findings include: 1. Medical record review for Resident #9 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's progress notes dated 05/11/22 through 08/11/22 revealed there was no documentation regarding activities or refusals. Review of Resident #9's Admission Minimum Data Set (MDS) assessment, dated 05/17/22, revealed it was somewhat important to have books, newspapers, and magazines, listen to music, be around animals, and do things with groups of people. It was very important to keep up with the news, get fresh air, and participate in religious activities. Review of Resident #9's task documentation for activities from 07/12/22 through 08/12/22 revealed there was nothing documented. Review of Resident #9's Quarterly MDS assessment, dated 08/02/22, revealed Resident #9 was cognitively intact. Review of the activity calendar dated 08/08/22 through 08/11/22 revealed on 08/08/22 there was a lunch in House #102, manicures in all of the houses, and chaplain service in House #101 at 1:00 P.M. On 08/09/22, there was bingo in House #106, and the beauty shop was open for all houses. On 08/10/22, there was morning donuts in House #109 and smores in all of the houses after lunch. On 08/11/22, there was a button tree craft in House #106. Observation in House #101 on 08/08/22 at 10:00 A.M., 12:00 P.M. and 2:00 P.M. revealed there wasn't any manicures being provided or a Chaplain service in House #101. Observation in House #101 on 08/09/22 at 11:00 A.M. revealed there was no bingo activity occuring in the House #101. Interview with Resident #9 on 08/08/22 at 2:49 P.M. revealed she did not know about any activities in House #101. She said she liked to play bingo, but did not know if the facility had it or not. Interview with the Activities Director (AD) #147 on 08/09/22 at 10:45 A.M. revealed she had been employed at the facility for a few days. The Activity Director was leading bingo in House #106. Interview with Resident #9 on 08/09/22 at 10:58 A.M. revealed she was not asked to go to bingo in House #106. Interview with State tested Nursing Aide (STNA) #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. 2. Medical record review for Resident #14 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's progress notes from 05/11/22 through 08/11/22 revealed there was no documentation regarding activities or refusals. Review of Resident #14's care plan, dated 06/21/22, revealed she had preferences for activities which were: arts and crafts, listening to performers, listening to easy listening music on the radio, watching animal plant on my television, attending bible study when she feels up to it, holding the house bunny, movie night, bingo, listening to performers and would like to go out of the facility for a outing activity. Review of the Annual MDS assessment, dated 06/23/22, revealed Resident #14 was moderately cognitively impaired. Further review of the MDS revealed it was very important fpr Resident #14 to have books, newspapers, and magazines, be around animals, and keep up with the news. It was somewhat important to listen to music, to do her favorite activities, go outside, and to participate in religious activities. It was not very important to do things with groups of people. Review of the spiritual activity documentation revealed from 05/03/22 through 08/12/22 there were seven visits to see Resident #14. Review of the tasks for activities from 07/12/22 through 08/12/22 revealed there was nothing documented. Review of the activity calendar dated 08/08/22 through 08/11/22 revealed on 08/08/22 there was a lunch in House #102, manicures in all of the houses, and chaplain service in House #101 at 1:00 P.M. On 08/09/22, there was bingo in House #106, and the beauty shop was open for all houses. On 08/10/22, there was morning donuts in House #109 and smores in all of the houses after lunch. On 08/11/22, there was a button tree craft in House #106. Observation in House #101 on 08/08/22 at 10:00 A.M., 12:00 P.M. and 2:00 P.M. revealed there wasn't any manicures being provided or a Chaplain service in House #101. Observation in House #101 on 08/09/22 at 11:00 A.M. revealed there was no bingo activity occuring in the House #101. Interview with Resident #14 on 08/08/22 at 2:13 P.M. revealed she did not know about any activities in the facility and denied anyone would come into visit with her one on one. Interview with STNA #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. 3. Medical record review for Resident #11 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of spiritual activity documentation revealed from 05/03/22 through 08/12/22 there were three visits to see the Resident #11. Review of Resident #11's annual MDS assessment, dated 05/25/22, revealed Resident #11 was moderately cognitively impaired. Further review of the MDS revealed it was very important for Resident #11 to be around animals, keep up with the news, do things with groups of people, do her favorite activities, and participate in religious services. It was somewhat important for Resident #11 to have books, newspaper, and magazines, listen to music, and to go outside. Review of Resident #11's care plan, dated 05/25/22, revealed the resident enjoyed many activities and programs, but needed continuous encouragement, reminders and motivation. She preferred ice cream social, music and memories, and television. Review of Resident #11's tasks for activities from 07/12/22 through 08/12/22 revealed there was nothing documented. Review of the activity calendar dated 08/08/22 through 08/11/22 revealed on 08/08/22 there was a lunch in House #102, manicures in all of the houses, and chaplain service in House #101 at 1:00 P.M. On 08/09/22, there was bingo in House #106, and the beauty shop was open for all houses. On 08/10/22, there was morning donuts in House #109 and smores in all of the houses after lunch. On 08/11/22, there was a button tree craft in House #106. Observation in House #101 on 08/08/22 at 10:00 A.M., 12:00 P.M. and 2:00 P.M. revealed there wasn't any manicures being provided or a Chaplain service in House #101. Observation in House #101 on 08/09/22 at 11:00 A.M. revealed there was no bingo activity occuring in the House #101. Interview with Resident #11 on 08/09/22 at 9:55 A.M. revealed she had not participated in any activities recently and no one comes into see her anymore. Interview with STNA #175 on 08/10/22 at 10:41 A.M. revealed she had been in House #101 for close to a year. She stated the facility had not provided activities to the residents since around March 2022 when the previous activity director resigned. She stated since COVID-19 hit, the residents have not been going to other houses for activities either. She confirmed if an activity was provided for a resident then it should be documented in the tasks in the electronic system. Interview on 08/10/22 at 2:15 P.M. during the Resident Council Meeting revealed Residents (#5, #9, and #11) were in attendance. All three residents expressed concerns regarding activities. All three residents expressed they were bored and wish they had more to do. Interview with the Administrator on 08/10/22 at 2:29 P.M. revealed they had been without an activity director since around March or April 2022. The Administrator confirmed the activity schedule was only for the houses listed on the schedule and said corporate didn't want the residents going from house to house to participate in activities. She revealed the facility hired a new activity director and the activities calendar was going to be revamped. Review of policy titled Engagement and Activity, dated 02/06/09, revealed it was the goal of the facility to create a home where persons living in the home have a choice and excellent quality of life and care coupled with providing an environment rich in meaningful engagement experiences. Given this standard, we (the facility) hold accountable to proper documentation of the engagement experience by following Documentation of Engagement and Activity process. Furthermore, it is everyone's responsibility to engage the resident in all facets of life.

Based on medical record review, staff interview and interview of medical office personnel, the facility failed to ensure a resident was appropriately supervised upon returning from an appointment resulting in an avoidable fall for Resident #3. This resulted in actual harm when Resident #3 sustained a new fracture to the left femur as a result of an avoidable fall. This affected one (#3) resident of three residents reviewed for falls. The facility identified 17 residents at high risk for falls. The facility census was 45. Findings include: Review of Resident #3's medical record revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's brief interview for mental status score (BIMS) was zero (0) out of 15, indicating severe cognitive impairment. Resident #3 was assessed as requiring extensive two person assistance with transfer. Further record review revealed that Resident #3 was admitted to the facility for physical therapy (PT) following a hospital admission. Resident #3 had surgical repair of a left femoral fracture on 01/12/17. Resident #3's fracture was the result of a fall sustained while living at an assisted living facility. Review of a Fall Risk assessment dated [DATE] revealed Resident #3's fall risk score was 24 out of a possible 39. A score of nine or higher put a resident at risk for falls. Resident #3 was identified as being at risk for falls related to one to two falls in the last 90 days; has cognitive impairments; limited vision but identifies objects; requires assistance for elimination (bathroom) use; ambulates with problems and devices; not steady, only able to stabilize with human assistance; age related factors; health conditions and medication usage. Resident #3 had a care plan in place for risk for falls dated 01/18/17. Review of progress notes for Resident #3 revealed the following information: A progress note dated 01/24/17 at 2:34 P.M. read: Elder up with assistance this shift, into wheelchair this shift. Elder continues to have confusion noted. Elder is out to appointment with orthopedic physician #100 for follow-up. A progress note dated 01/24/17 at 10:29 P.M. read: at approximately 4:30 P.M. was found on the bathroom floor by the elder assistants (EA). Upon entering room this nurse found elder sitting on bathroom floor facing the toilet seat with legs extended out in front of him. Elder's wheelchair was toward the left side of the elder in the bedroom. Elder stated he tried to get out of his wheelchair to stand up and the wheelchair wheeled backwards, elder lost his balance and fell on his bottom. Elder was a four person assist from the ground back to the wheelchair. Range of motion (ROM) was performed in the upper and lower extremities. No injuries noted. Elder was given as needed (PRN) Norco (a narcotic pain medication) for pain to the knees. Family and primary physician were both notified. A progress note dated 01/26/17 at 1:00 P.M. read: at 1:00 P.M. elder verbalized increased pain to the left lower extremity and knee area. Primary physician notified of increased pain and a request by this nurse to obtain X- Radiation (X-rays) to the extremity, waiting on response. A progress note dated 01/27/17 at 10:42 A.M. read: noted that X-rays to the left lower extremity had not been completed and this nurse called X-ray provider. X-ray provider stated technician (Tech) will be here as soon as possible. Tech arrived and attempted to complete X-rays to the left extremity per orders. Tech stated to this nurse that she was only able to get a lateral view order due to elder yelling out in pain. This nurse noted elder's surgical left hip to be rotated out and that elder was unable to straighten left knee. Primary physician notified and new orders were received to send elder to emergency room (ER) for evaluation of hip and to notify orthopedic physician #100 that elder would be going to ER for evaluation and primary physician wanted orthopedic physician #100 to see elder in hospital if possible. A progress note dated 01/27/17 at 12:37 P.M. read: this nurse received call form ER at 11:53 A.M. stating that elder will be coming back to the facility. Charge nurse stated elder has a new left hip fracture that is stable with current hardware. Elder is non- weight bearing at this time and needs follow up appointment with orthopedic physician #100. A physician order [REDACTED].#3's left knee and two view X-ray to left tibia, fibula and femur. A physician order [REDACTED].#3 to ER for left lower extremity evaluation due to increased pain and unable to obtain X-rays. The discharge instructions for Resident #3 from a local ER dated 01/27/17 were reviewed. The discharge disposition indicated there is an area to the left hip that is newly broken compared to the patient's previous X-rays; however it is being properly stabilized by the hardware that was place during the previous fracture. Patient should be completely non- weight bearing. Office visits notes for Resident #3 from orthopedic physician #100 dated 02/01/17 were reviewed. Under the heading Medical Decision Making was the note that read: Overall patient is comfortable, he did have a new fall sustaining a new fracture of his femur, at this point the construct is stabilizing. During an interview on 02/06/17 at 1:40 P.M. state tested nursing assistant (STNA) #30 stated that when a resident returns to the facility form an appointment that the nurse is supposed to be called. STNA #30 stated nurses are supposed to sign for residents, not STNA's. STNA #30 stated she would make sure the resident is safe and toileted upon return. STNA #30 stated she had worked at the facility three years. The Administrator stated in an interview on 02/06/16 at 2:05 P.M. that a STNA signed for Resident #3 upon return from an appointment on 01/24/17. The Administrator stated there was no formal training, in-service, or policy stating that a STNA could not sign for a resident. The Administrator stated that it should be common practice. During in an interviews with the Administrator, Licensed Practical Nurse (LPN) #40 and Registered Nurse (RN) #30 on 02/06/16 at 2:30 P.M. all three stated that nurses were supposed to sign for residents returning to the facility, not STNA's. The Administrator, LPN #40 and RN #30 confirmed that Resident #3 was left unattended in his room after return from an orthopedic office visit on 01/24/17 and that it was unclear how long Resident #3 was lying on the floor until found by the nurse. The Administrator, LPN #40 and RN #30 confirmed that an STNA had signed for Resident #3's return. The Administrator, LPN #40 and RN #30 confirmed that the nurse on duty 01/24/17 was not made aware by the STNA that Resident #3 had returned to the facility and the resident was not checked on for safety. The Administrator, LPN #40 and RN #30 confirmed that Resident's fall on 01/24/17 was preventable. A phone interview was conducted with a medical assistant (MA) #90 of orthopedic physician #100 on 02/06/17 at 3:27 P.M. MA #90 stated that she had spoken with orthopedic physician #100 and confirmed that a new fracture to the left femur of Resident #3 was present on X-rays obtained 01/27/17 and that this new fracture was not linked to the prior fracture that required surgical repair. This deficiency substantiates Complaint Number OH 268.