Every finding on record at Robert a Barnes Center

Based on medical record review, staff interview, and review of facility transfer notices, the facility failed to ensure appropriate transfer/discharge notifications were made to the state Ombudsman office. This affected three residents (#16, #22 and #23) of three resident records reviewed for discharge. The census was 18. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria, and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #16's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #16's discharge. 2. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, bacterial pneumonia, anxiety, dementia, stage three chronic kidney disease, and atrial fibrillation. Review of Resident #22's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required supervision or touching assistance for eating, oral hygiene and personal hygiene and substantial/maximal assistance for toileting and shower/bathing. Review of Resident #22's physicians orders revealed an order on 03/18/25 to discharge the resident to the Assisted Living. Review of the progress notes dated 03/18/25 at 11:16 A.M. revealed Resident #22 was discharged from the facility at 10:00 A.M. via a family car accompanied by his daughter. Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #22's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #22's discharge. 3. Review of Resident #23's medical record revealed they were admitted to the facility on [DATE]. Diagnoses included fracture of the pelvis/sacrum, high blood pressure, diabetes, and osteoporosis. Review of Resident #23's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact. She was independent with eating, required set up or clean up assistance with oral hygiene, and required substantial/maximal assistance with toileting, shower/bathing, and dressing. It also noted she was occasionally incontinent of bladder and frequently incontinent of bowel. Review of the progress notes dated 04/16/25 at 6:20 A.M. revealed Resident #23 had two to three bowel movements today that were watery, mixed with some small 'round' hard stool, and it still felt like she had to 'go'. The resident declined being taken to the toilet to try to go. Fluids were encouraged in moderation. Abdominal bowel sounds were noted in the upper two quadrants, but nothing was heard in the lower right quadrant and very little was heard in the lower left quadrant. It stated she felt firm in the lower quadrant and it was painful when palpated. The on-call physician was notified and ordered a STAT kidneys, ureters and bladder (KUB) diagnostic test or to send the resident for an evaluation if the resident was having increased pain. The resident stated she wanted to go to the hospital. She was admitted to the hospital with a urinary tract infection (UTI). Review of facility documentation, transfer notices, and the residents medical record revealed there was no documented evidence that the Office of the State Long Term Care (LTC) Ombudsman was aware/notified of Resident #23's transfer/discharge. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing verified the Ombudsman was not notified of Resident #23's discharge.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed as required. This affected one resident (#16) of 17 residents records reviewed for MDS assessments. The census was 18. Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. It also noted he was occasionally incontinent of urine and always continent of bowel. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Further review of the medical record for Resident #16 revealed there was no discharge MDS assessment completed. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing confirmed a discharge MDS assessment was not completed for Resident #16.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed as required. This affected one resident (#16) of 17 residents records reviewed for MDS assessments. The census was 18. Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hydrocephalus, Alzheimer's disease with early onset, depression, dysarthria and anarthria. Review of Resident #16's admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired. He required supervision or touching assistance for eating and partial/moderate assistance for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. It also noted he was occasionally incontinent of urine and always continent of bowel. Review of Resident #16's physicians orders revealed an order to discharge the resident home with Physical Therapy, Occupational Therapy, Speech Therapy, a home health aide and nursing services with current medications on 01/13/25. Review of the progress notes revealed on 01/13/25 at 1:10 P.M., Resident #16 was discharged from the facility via a family car accompanied by his sister. Further review of the medical record for Resident #16 revealed there was no discharge MDS assessment completed. Interview on 06/18/25 at 11:09 A.M. with the Director of Nursing confirmed a discharge MDS assessment was not completed for Resident #16.

Based on record review, observation, resident interview, staff interview, and review of facility menu spreadsheets, the facility failed to provide a varied menu for a resident on a pureed diet. This affected one resident (Resident #7) and had the potential to affect two residents (#1 and #7) receiving a pureed diet. The facility census was 18. Findings include: Review of Resident #7's medical record revealed that she was admitted on [DATE] with diagnoses that included dysphagia and gastrostomy status. Review of Resident #7's Minimum Data Set (MDS) significant change assessment dated [DATE] revealed that she had intact cognitive status. Review of Resident #7's physician orders dated 06/10/25 revealed that she was on a regular diet of pureed consistency and thin liquids. Review of the pureed menu spreadsheets from 04/06/25 through 05/18/25 (42 days), approved by Registered Dietitian #110, revealed that green beans were served 20 times and mashed potatoes were served 34 times. Interview with Resident #7 on 06/16/25 at 9:59 A.M. and on 06/18/25 at 9:23 A.M. revealed that she felt that there was no variety in the pureed diets. She stated that she received mashed potatoes and/or green beans every day. Observation on 06/16/25 at 11:48 A.M. revealed that Resident #7 was served mashed potatoes at her lunch meal. Resident #7 was overheard saying to Certified Nursing Aide (CNA) #75 that she wished that she could have been served the pureed version of the starch that the regular textured diet residents were served at that meal, which was sweet potato fries. CNA #75 did not offer to serve her an alternative food item. Interview with CNA #76 on 06/17/25 at 10:21 A.M. revealed that the same items were usually served for lunch and dinner for pureed meals, with little variety offered. She stated that there was usually always mashed potatoes on the plate. Interview with CNA #75 on 06/17/25 at 10:27 A.M. revealed that residents who were served pureed textures seemed to receive the same meals repeatedly, with little variety. She stated that she had brought it to the dietary department's attention on repeated occasions in the past, but that nothing changed. Interview with Registered Dietitian #110 on 06/18/25 at 11:19 A.M. revealed that upon review of the pureed diet menu spreadsheets, green beans were served too frequently. She also confirmed that there were other alternatives for mashed potatoes, as a starch, that could have been used for pureed options.

Based on observation, staff interview, and review of facility policy, the facility failed to prepare pureed diets at the proper consistency. This had the potential to affect two residents (Resident #1 and #7) that the facility identified as receiving a pureed diet consistency. The facility census was 18. Findings include: Interview with Sous Chef #112 on 06/17/25 at 11:04 A.M. revealed that all pureed foods should be served at a smooth pudding-like consistency with no chunks. Observation and interview on 06/17/25 at 11:03 A.M. revealed Line [NAME] #115 began the preparation of the pureed chicken tenders. At 11:10 A.M., Line [NAME] #115 indicated verbally that the chicken tenders were at puree consistency and ready to be tested. Observation via taste of the pureed chicken tenders on 06/17/25 at 11:10 A.M. revealed that there were visible lumps and chunks in the puree chicken tenders, and that the consistency was not homogenous. Interview with Sous Chef #112 on 06/17/25 at 11:10 A.M. verified that the puree chicken tenders had chunks in them. Observation and interview on 06/17/25 from 11:10 A.M. to 11:17 A.M. revealed that Line [NAME] #115 continued to process the pureed chicken tenders. At 11:17 A.M., Line [NAME] #115 indicated that the food was ready to be tested again. Observation via taste of the pureed chicken tenders on 06/17/25 at 11:17 A.M. revealed that there were still visible lumps and chunks in the puree chicken tenders, and that the consistency was still not homogenous. Interview with Sous Chef #112 on 06/17/25 at 11:17 A.M. confirmed that there were still chunks in the pureed chicken tenders. Interview with Executive Chef #150 on 06/17/25 at 11:30 A.M. revealed that the pureed chicken for the meal should have been unbreaded chicken, as the breading on the cooked chicken tenders is tough to break down mechanically into a pureed texture. He indicated that he would educate the dietary staff about not using breaded chicken for pureed textures. Review of the undated facility policy titled Texture and Consistency Modified Diets revealed that the food and nutrition services department will be responsible for preparing and serving the correct consistency of food and beverages as ordered.

Based on review of personnel files and interviews the facility failed to complete employee evaluations for four of four State tested Nurse's Aides (STNAs) reviewed for personnel files (STNAs #130, #134, #148, and #164). This had the potential to affect all facility residents. The facility census was 22. Findings include: 1. Review of personnel file for STNA #164 hired on 02/01/21 had no evidence of a 90-day evaluation or an annual evaluation since hire. 2. Review of personnel file for STNA #130 hired on 03/21/22 had no evidence of a 90-day evaluation or an annual evaluation since hire. 3. Review of personnel file for STNA #134 hired on 04/21/22 had no evidence of a 90-day evaluation or an annual evaluation since hire. 4. Review of personnel file for STNA #148 hired on 02/21/23 had no evidence of a 90-day evaluation since hire. Interview on 06/01/23 at 3:20 P.M. with Director of Human Resources #175 revealed facility was not doing any performance evaluations since the start of the COVID-19 pandemic and revealed they had recently restarted performance evaluations for newly hired staff but revealed no process in place to evaluate previously hired employees. Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the facility had no policy related to staff evaluations.

Based on observation, staff interview, and policy review the facility failed to ensure safe and sanitary storage of all food materials in the dry storage, refrigerator, and freezer areas. This had the potential to affect all 22 residents as they all received food from the kitchen. The facility census was 22. Findings include: Observation and interview on [DATE] at 9:39 A.M. with Dining Staff #144 in the unit kitchenettes revealed: frozen pancakes with no date unsealed ice cream a yellow liquid substance in a bottle in dry storage with no label and no date several spice containers that expired [DATE] Interview with Dining Staff #144 at the time of the observations confirmed the above findings. Observation and interview on [DATE] at 10:45 A.M. with Dietary Manager #136 in the main kitchen revealed six bottles of lime juice were found to have expired [DATE]. Dietary Manager #136 confirmed the finding at the time of the observation. Review of the facility policy titled Food Supply and Storage Procedures, dated [DATE], revealed all food shall be stored in such a manner as to maintain the safety for human consumption. Products should be discarded after the used by date has passed and cannot be served to residents after the sell by date has passed. All food items should be covered, labeled, and dated as appropriate.

Based on observation, staff interview, and policy review the facility failed to ensure pureed foods were made to the correct consistency and according to the recipe. This affected one resident (#6) who was the only resident with pureed diet orders. The facility census was 22. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnosis including a stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and required limited assistance from staff for eating. Observation on 05/31/23 at 11:19 A.M. revealed Dietary Staff #180 when making the puree pasta with meat sauce, placed two handfuls of pasta noodles into the food processor. Then added 2.5 scoops of spaghetti with meat sauce using a 6-ounce (oz) scoop and blended the mixture. Then Dietary Staff #180 added approximately one-half tablespoon of thickener to the mixture. After blending the mixture, the pureed food was at the bottom of the food processor and pieces of food and noodle that had not been blended or pureed were on the top and sides of the food processor. When Dietary Staff #180 scraped the pureed mixture into the dishes to be placed on the warming cart, the chunks of noodle were also scraped into the metal container and were visible sticking out of the pureed food. Interview on 05/31/23 at 11:23 A.M. with Dietary Staff #180 and Dietary Manager #136 confirmed the pureed food contained whole pieces of about 1-inch-long noodles. Review of the Pureed Recipe instructions revealed food should be processed until fine in texture and instructions to scrape down sides with a spatula and reprocess. Review of the undated facility policy titled Therapeutic Diet revealed a purpose to assure residents receive and consume food in the appropriate form as prescribed. Review of the undated facility policy titled Texture and Consistency Modified Diets revealed a purpose for texture and consistency-modified diets should be individualized with modifications. The policy revealed the food and nutrition services department would be responsible for preparing and serving the correct consistency of food as ordered and per the recipe.

Based on observation, staff interview, record review, and facility policy review the facility failed to ensure Resident #21 received timely and appropriate care to prevent weight loss including obtaining weights as ordered, providing supplements as ordered, and providing meals according to the meal ticket. This affected one resident (#21) of one resident reviewed for nutrition. The facility census was 22. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included normal pressure hydrocephalus, muscle weakness, malnutrition, and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required extensive assistance of two staff members for transfers. The MDS revealed the resident had a deep tissue injury (DTI) pressure ulcer to the right heel (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear.) Review of the plan of care dated 05/25/23 revealed Resident #21 was at risk for alteration in nutrition with a goal to maintain weight without significant weight loss with interventions to provide supplements as ordered, nutrition to be monitored as needed (labs, weights, and intakes), and menu with preferences. Review of physician orders for revealed the following orders: 04/26/23 to 05/10/23 revealed diet order of regular texture and regular consistency. 04/27/23 Remeron 15 milligrams (mg) tablet with instructions to give one-half tablet at bedtime for appetite stimulant. 05/01/23 Ensure with meals for supplement. 05/03/23 weekly weights for four weeks then monthly with instructions to notify the provider and reweigh for a two-to-five-pound weight difference. 05/10/23 regular diet mechanical soft texture. 05/24/23 Magic cup (supplement) twice daily 120 milliliters (ml) with instructions to give at lunch and dinner. 05/25/23 for Marinol oral capsule 2.5 mg twice daily for appetite stimulant. Review of resident weights included: 04/26/23 - 94.8 pounds (lbs.) 05/03/23 - 93.4 lbs. 05/10/23 - 94.4 lbs. 05/24/23 - 85.0 lbs. There was a significant weight loss of 10.34 percent (%) in 30 days, and review of medical record found no documented evidence a reweight being obtained. Review of the progress notes dated 05/24/23 revealed a weight change reflecting a significant weight loss of 10.3% over 30 days, resident with poor intake with supplements and an unstageable DTI pressure wound to the right heel with plan to add Magic cup 120 ml with lunch and dinner for nutritional support. On 05/26/23 Marinol oral capsule 2.5 mg was added with instructions for one capsule by mouth every morning and at bedtime for appetite stimulant. On 05/27/23, Marinol oral capsule 2.5 mg with instructions to give one capsule in morning and night for appetite stimulant was ordered, and the facility was waiting for it to be delivered. Observation on 05/30/23 at 11:58 A.M. of the lunch meal revealed Resident #21 did not receive the Magic cup supplement on her tray. Review of Resident #21's meal ticket dated 05/31/23 for lunch revealed the resident had an order for mechanical soft food and instructions for food to be cut into bite size pieces. The supplements were not included on the meal ticket. Observation on 05/31/23 at 11:47 A.M. of the lunch meal revealed Resident #21 did not receive the Magic cup supplement on her tray. Resident #21's meal ticket also stated a mechanically soft diet order and instructions for food to be cut into bite size pieces. Interview on 05/31/23 at 12:01 P.M. with State tested Nursing Aide (STNA) #119 revealed the kitchen staff make sure Magic cups are available and placed on the trays, and aides pass out the Ensure supplements. STNA #119 confirmed Resident #21's Magic cup was not provided with the lunch meal as ordered and confirmed the resident's dessert was not cut into bite size pieces and reported typically resident's food had not been cup up. STNA #119 revealed typically Resident #21 ate about 25% of her meals and required significant encouragement. STNA #119 verified all weights taken by STNA's were entered into the electronic medical record. Interview on 05/31/23 at 2:28 P.M. with Dietitian #177 revealed being scheduled at the facility two days weekly and meets with residents at the beginning of their admission to discuss preferences and dietary concerns. Dietitian #177 revealed Resident #21 was not able to participate in the assessment due to poor cognition. Dietitian #177 reported she reviewed weights for Resident #21 and recognized a weight was missing on 05/17/23 and requested that nursing staff get this weight the next day. Dietitian #177 reported the weight was not obtained until 05/24/23 and was found to have a significant weight loss. Dietitian #177 revealed all residents should have orders for weekly weights for four weeks and then monthly weights ongoing and revealed regular issues with getting staff to complete resident weights as ordered. Dietitian #177 revealed she was unaware of medication recommendations for an appetite stimulant and confirmed several progress notes related to medication Marinol not being provided due to awaiting pharmacy delivery. Dietitian #177 revealed she was unaware of the Magic cup was not being given as ordered. Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the Magic cup was marked off as given with breakfast. The DON confirmed this did not match the physician's order. Review of the undated facility policy titled Weights and Weight Change Management revealed residents would be weight monthly unless ordered by a physician or recommended by a dietitian. The weight will be documented in the medical record and weight changes will be addressed by the dietitian and interdisciplinary team. Residents would be re-weighed if a significant weight loss was noted.

Based on observation and staff interview the facility failed to ensure Resident #129's indwelling urinary catheter bag was covered for dignity and privacy. This affected one resident (#129) of one resident reviewed for dignity related to urinary catheter bags. The facility identified four residents (#6, #12, #129, and #178) with urinary catheters. The facility census was 22. Findings include: Review of the medical record for the Resident #129 revealed an admitted [DATE]. Diagnoses included wedge compression fracture, diabetes, epidural hemorrhage, dementia, and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] was still in process and had not yet been completed. Review of the physician's order dated 05/24/23 revealed resident had an indwelling urinary catheter and required catheter care. Observation on 05/30/23 at 2:20 P.M. revealed Resident #129 had a urinary catheter. The urinary catheter bag contained urine and was hanging below the bed and visible from the hallway. Resident #129's urinary catheter bag did not have a privacy cover. Observation on 05/31/23 at 9:19 A.M., 10:50 A.M., 2:00 P.M. and 3:40 P.M. revealed Resident #129 had a urinary catheter bag that was left uncovered and visible from the hallway. Interview on 05/31/23 at 3:40 P.M. with Unit Manager #173 and the Director of Nursing (DON) confirmed the facility had urinary catheter bag covers, and urinary catheter bags should be maintained with a privacy cover. Unit Manager #173 and the DON confirmed Resident #129 did not have a urinary catheter bag privacy cover in place.

Based on resident interview, staff interview, record review, and facility policy review the facility failed to ensure Resident #14 was offered an initial care conference. This affected one resident (#14) of two residents reviewed for care conferences. The facility census was 22. Findings include: Review of the medical record for Resident #14 revealed a readmitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, Fournier's gangrene, vascular disease, muscle weakness, and colostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact with and required limited to extensive assistance of one staff member for all activities of daily living and mobility. Interview on 05/30/23 at 1:52 P.M. with Resident #14 revealed he would like to participate in care conference meetings and would like his daughter to be invited as well. Resident #14 reported he had not been invited to any care conferences since admission in 04/2023 and reported he was hospitalized and returned 05/09/23. Review of the medical record revealed no documented evidence of a care conference for Resident #14. Interviews on 05/31/23 at 2:08 P.M. and 3:09 P.M. with Social Services (SS) #160 revealed the facility offers a care conference within two weeks of admission to discuss the plan for admission. SS #160 revealed a large majority of residents are short-term and are admitted for rehabilitation services. SS #160 confirmed Resident #14 did not have a care conference due to SS #160 being on vacation. SS #160 revealed no current plan to hold a care conference for Resident #14. Review of the undated facility policy titled Care Conference revealed a purpose to include residents and representatives in the planning process.

Based on interviews, medical record review, and review of the facility's discharge policy and procedure, the facility failed to notify the Ombudsman when residents were discharged from the facility. This affected three residents (#10, #16 and #78) out of three residents reviewed for discharges. The facility census was 22. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] with a fractured right clavicle, cerebral infarction, and type two diabetes. He was discharged on [DATE]. Review of Resident #16's medical record revealed an admitted [DATE]. Diagnoses of unspecified fracture part of the neck, osteoporosis with pathological fracture of the vertebra, and emphysema. Resident #16 was discharged home on 5/15/23. Review of Resident #78's medical record revealed an admitted [DATE] for rehabilitation. Diagnoses included chronic cholecystitis, type two diabetes, emphysema, and congestive heart failure. He was discharged from the facility on 04/18/23. Interview on 05/31/23 at 11:49 A.M. with Licensed Social Worker (LSW) #179 revealed she does not notify the Ombudsman when residents are discharged from the facility to home. Interview on 05/31/23 at 2:00 P.M. with the Administrator revealed it is not policy to notify the ombudsman when residents are discharged to home. Review of the undated Facility's Discharge Planning policy revealed no indication the Ombudsman should be notified when a resident was to be discharged from the facility.

Based on record review and staff interview the facility failed to provide timely and adequate monitoring and treatment following an acute change in Resident #24's condition. This affected one resident (#24) of three residents reviewed for change in condition. Findings Include: Review of Resident #24's medical record revealed an admitted [DATE]. The resident was discharged on [DATE] to an assisted living facility. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation, dated 01/07/22 revealed the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's blood urea nitrogen (BUN) was elevated at 39 (normal 6 to 24) and creatinine was elevated at 2.74 (0.5 to 1.05). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/13/22 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the nurse's note, dated 02/17/22 at 11:02 A.M. revealed the Certified Nurse Practitioner (CNP) was notified the resident was lethargic, had a lack of appetite and low motivation. The CNP ordered blood work/laboratory testing including a complete blood count (CBC) and B-tide natriuretic peptide (BNP) to be completed on 02/21/22. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was also noted for a chest x-ray to be completed. Review of the medical record failed to provide evidence the physician ordered BNP and CBC were drawn as ordered on 02/21/22. However, the Director of Nursing (DON) provided a lab requisition that documented the resident had refused the laboratory tests. Review of the chest x-ray results, dated 02/18/22 revealed bilateral heterogeneous airspace disease. The results revealed pneumonia should be considered in the appropriate clinical setting. Recommend follow up examination to confirm resolution of findings. The results, handwritten on the form revealed the Physician Assistant (PA) was notified of the results on 02/19/22 with no new orders. The resident's physician signed the results sheet on 02/23/22. Review of Certified Nurse Practitioner's (CNP) #135 progress note, dated 02/23/22 revealed the CNP documented a CBC, BNP and basic metabolic panel (BMP) were pending from 02/21/22, despite the resident refusing the laboratory testing. Review of the medical record failed to provide evidence of a follow up assessment/evaluation of the resident to confirm resolution of findings or to assess the resident for any new acute findings or health changes. Further review of the medical record revealed no evidence the physician and family were notified of the resident refusing the laboratory tests for further instructions related to the resident's identified lethargy, low motivation and poor appetite (decreased oral intake of food/fluids). In addition, there was no evidence of any comprehensive follow up from the chest x-ray results, dated 02/18/22. Review of the resident's nursing progress notes revealed entries dated 02/25/22, 02/26/22, 02/28/22 and 03/02/22 documenting the resident refusing medications, food, fluids and to get out of bed. There was no additional follow up or notification of these changes in the resident's condition to the physician or resident's family. Review of a nursing progress note, dated 03/02/22 at 10:38 A.M. revealed the resident was discharged to an assisted living on this date despite the above identified change in the resident's condition. Review of the nursing progress note, dated 03/02/22 at 10:54 A.M. revealed the nurse called the assisted living to provide a report and a message was left with a number and request to return call. Further review of the medical record failed to provide any evidence the assisted living was provided a report prior to the resident's arrival. On 04/08/22 at 10:22 A.M. interview with Resident #24's daughter revealed concerns the facility had not provided proper and/or timely care following a change in the resident's condition which resulted in the resident being sent to the hospital shortly after being transferred to the assisted living (where she resided prior to the hospitalization and nursing home admission) on 03/02/22. The resident's daughter revealed the resident was admitted to the facility on [DATE] after breaking her pelvis on 01/01/2022. The resident was discharged from the nursing home back to the assisted living on 03/02/22. On 03/03/22 at 7:00 A.M. the resident's daughter revealed she was called from staff at the assisted living and notified her mother's blood pressure was low at 70/48 and they wanted to call an ambulance to take her to the hospital. The resident was transferred to the hospital and admitted with [CONDITION(S)] and very resistant pseudomonas infection. The resident was extremely dehydrated from the infection that it tanked her kidneys, her kidney function (creatinine level) was elevated at nine when she got to the hospital and nothing more could be done. The resident was admitted to hospice services and passed away on 03/10/22. The resident's daughter indicated in her opinion the resident was transferred from the facility to the assisted living in critical condition. On 04/08/22 at 1:42 P.M. interview with the Director of Nursing (DON) verified the lack of comprehensive assessment, monitoring and/or physician notification of the acute change in resident's condition prior to the resident's discharge. This deficiency substantiates Complaint Number OH 404.

Based on record review and staff interview the facility failed to ensure Resident #24's physician and family were notified timely of refusal of laboratory testing and a decline in the resident's condition including a decrease in intake of food and fluids and increased lethargy. This affected one resident (#24) of three sampled residents reviewed for infections. Findings Include: Review of Resident #24's closed medical record revealed an admitted [DATE]. The resident was discharged on [DATE] to an assisted living facility. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation dated 01/07/22 revealed the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's blood urea nitrogen (BUN) was elevated at 39 (normal 6 to 24) and creatinine was elevated at 2.74 (normal 0.5 to 1.05). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/13/22 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. Review of the nurse's note, dated 02/17/22 at 11:02 A.M. revealed the Certified Nurse Practitioner (CNP) was notified the resident was lethargic, had a lack of appetite and had low motivation. The CNP ordered blood work including a complete blood count (CBC) and B-type natriuretic peptide (BNP) to be drawn on 02/21/22. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record failed to provide evidence the ordered BNP and CBC were drawn as ordered on 02/21/22. However, during the investigation the Director of Nursing (DON) provided a lab requisition that documented the resident refused the laboratory tests. Further review of the medical record failed to provide evidence the physician and family were notified of the resident refusing the laboratory tests for further instructions related to the resident's identified lethargy, low motivation and poor appetite. Review of the resident's nurse progress notes revealed entries dated 02/25/22, 02/26/22, 02/28/22 and 03/02/22 documenting the resident refusing medications, food, fluids and to get out of bed. Further review of the resident's medical record failed to provide any documented evidence the resident's physician or family were notified of the refusals of medication, food, fluids and getting out of bed. On 04/08/22 at 1:42 P.M. interview with the DON verified the physician was not notified of the refusal of the laboratory tests, medications, food, fluids and getting out of bed. Review of the policy titled Change in a Resident's Condition or Status, dated 10/2021 revealed the facility would promptly notify the resident, physician and representative of changes in the resident's medical/mental condition. This deficiency substantiates Complaint Number OH 404.

Based on record review, facility policy and procedure review and interview the facility failed to complete a discharge summary for Resident #24 detailing a recapitulation of the resident's stay and treatment. This affected one resident (#24) of three residents reviewed for discharge. Findings Include: Review of the closed medical record for Resident #24 revealed an admitted [DATE]. The resident was discharged on [DATE] to an assisted living facility. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/13/22 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of seven. The assessment revealed the resident was expected to discharge to the community. Review of the discharge care plan, dated 01/21/22 revealed the resident's plan was to discharge to her prior living arrangement at an assisted living. Review of the physician's orders revealed an order, dated 02/28/22 to discharge the resident back to assisted living with home health care, physical therapy and occupational therapy. Review of the nursing progress note, dated 03/02/22 at 10:38 A.M. revealed the resident was discharged to the assisted living with all personal belongings and written discharge instructions. The resident's discharge medication list was reviewed with the resident's daughter. Review of the nursing progress note, dated 03/02/22 at 10:54 A.M. revealed the nurse called the assisted living to provide a report and a message was left with a number and request to return call. Further review of the medical record failed to provide any evidence the assisted living was provided a report prior to the resident's arrival. Review of the medical record revealed no discharge summary documenting the resident's stay or recapitulation at the facility. On 04/08/22 at 1:42 P.M. interview with the Director of Nursing (DON) verified the facility had not provided a discharge summary detailing a recapitulation of the resident's stay and treatment. Review of the facility policy titled Discharge Summary and Plan, dated 10/2019 revealed when the facility anticipated a resident's discharge to a private residence or another nursing care facility, a discharge summary and post-discharge plan would be developed which would assist the resident to adjust to his or her new living environment. The discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations. This deficiency substantiates Complaint Number OH 404.

Based on interview and record review, the facility failed to thoroughly document concerns and rational for treatment changes related to Resident #1's catheter. This affected one (Resident #1) of three residents reviewed for catheter care. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #1's base line care plan, dated 02/27/22, revealed treatment would be executed as ordered by physician, treatment would be monitored for healing, and to administer medication as directed by resident's physician. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record contained no evidence as to why the frequency of Foley catheter changes were increased. Interview on 03/14/22 at 12:10 P.M. with Unit Manger/Licensed Practical Nurse (LPN) #101 and Director of Nursing (DON) regarding the change in Resident #1's frequency of Foley catheter changes, revealed they felt the change was due to a concern related to blood in the resident's urine. DON revealed there was no documentation confirming the reason for a change in catheter care or documentation blood was noticed in Resident #1 urine. Interview on 03/14/22 at 2:29 P.M. with Certified Nurse Practitioner (CNP) #110 revealed she does not recall facility staff calling her about finding blood in Resident #1's urine and did not see any documentation in their system for the resident having any blood in his urine. She revealed if the staff call came in on the weekend then it was possibly responded by telehealth but still their conversations should have been documented in their system for them to see. She revealed looking through their progress notes did not see any information about the resident's blood in the urine bag. This deficiency substantiates Complaint Number OH 731.

Based on interview, record review, and facility policy review, the facility failed to provide Resident #1's pressure ulcer treatment as ordered by the physician. This affected one resident (Resident #1) of three residents reviewed for pressure ulcers. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged on [DATE]. Review of Resident #1's based line care plan, dated 02/27/22, revealed treatment would be executed as ordered by physician, treatment would be monitored for healing, and administer medication as directed by resident's physician. Review of Resident #1's physician orders for 02/27/22 revealed Resident #1 was ordered Triad cream at dime thickness, apply fluff and abdominal (ABD) gauze and change as needed if soiled one time a day every three days for wound treatment. The order was next due on 03/02/22. Review of Resident #1's March 2022 Treatment Administration Record (TAR) revealed documentation Triad cream was administered on 02/28/22 and again on 03/03/22. Interview on 03/14/2022 at 12:10 P.M. with Unit Manager/Licensed Practical Nurse (LPN) #101 and Director of Nursing (DON) revealed Resident #1's Triad cream did not arrive to the facility until 03/02/22. Interview on 03/15/22 at 12:22 P.M. with DON revealed the Triad cream was reordered on 03/03/22 but was delivered on 03/02/22. She revealed on 02/28/22 the nurse applied an alternate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON revealed the nurse did not receive any authorization from the physician to administer the zinc. Review of the facility policy titled, Wound Care Policy, dated October 2018, revealed wound treatment will be provided in accordance with physician order. This deficiency substantiates Complaint Number OH 731.

Based on medical record review, observation, interview, and facility policy review, the facility failed to wear a N95 mask in a resident's room under quarantine precautions for COVID-19, and failed to maintain personal protective equipment (PPE) carts outside a quarantine room free from contamination. This had the potential to affect all 20 residents residing in the facility. Findings include: Interview on 03/13/22 at 9:15 A.M. with Director of Nursing (DON) revealed the facility did not have any active COVID-19 cases but they did have newly admitted residents who were in quarantine to rule out COVID-19. DON revealed a surgical mask, and face shield or goggles were required when in the facility. When entering into an quarantine or isolation room, staff were required to wear a N95 mask. Observation on 03/13/22 at 11:39 A.M. of medication administration for Resident #11 revealed the resident was in quarantine as a new admit. Licensed Practice Nurse (LPN) #100 put a gown on, had two surgical masks on, and put on a new face shield. LPN #100 entered into the quarantine room to check the resident's blood sugar. She then took off her PPE but kept her face shield still on while she came out of the room. LPN #100 then removed the face shield and laid it on top of the clean PPE cart where the gloves and surgical mask were stored. LPN #100 then proceeded to pull the resident's medication, gown up again, put on two surgical masks, and the same face shield she laid on top of the PPE cart without cleaning the cart or shield between and entered the quarantine room again. LPN #100 administered the medication to the resident, took off her PPE, and came outside the room with the face shield on. She laid the shield on top of the clean PPE cart again where the clean gloves and surgical mask were. Interview on 03/13/22 at 11:42 with LPN #100 confirmed they were required to wear N95 when entering quarantine rooms. LPN #100 also verified she shouldn't have laid the used face shield on top of the clean PPE cart. She revealed she had contaminated the area. Interview on 03/13/22 at 1:00 PM confirmed with DON confirmed N95 masks were required when entering quarantine rooms and a used faced shield should not have been placed on the clean PPE cart. Review of the facility policy titled, Don and Doffing of Personal Protective Equipment (PPE)-COVID-19 Pandemic, dated 04/03/20, revealed it was the policy of the facility to put on and remove personal protective in the correct sequence in accordance with best practice approach to infection and prevention and control when caring for a resident with confirmed or suspected COVID-19.

Based on record review, resident interview, staff interview, review of facility Self-Reported Incidents (SRI), and facility policy and procedure, the facility failed to implement their abuse policy and procedure. This affected one Resident (#232) out of one resident reviewed for abuse. The census was 15. Findings Include: The medical record review for Resident #232 revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and he required extensive assistance of two staff for bed mobility, transfers, and toileting, and limited assistance of one staff for personal hygiene. The care plan dated 07/07/21 revealed the resident doesn't like to be rushed during care and would like communication of what is being done during care and would like to be given choices with interventions to communicate with staff when feeling rushed, communicate immediate needs, and staff will communicate with the resident during care to address immediate needs and they will pace themselves during care. The care plan dated 07/06/21 revealed the resident had the potential for pain related to stroke and right lower leg [CONDITION(S)] with interventions to monitor and record pain characteristics. It further stated the resident had a self care deficit related to stroke with right sided weakness and right lower leg cellulitus requiring assistance with bed mobility, transfers, toileting, bathing and eating with interventions to praise all efforts at self care, therapy evaluations, encourage participation to the fullest extent possible and monitor/document/report any changes, improvements, reasons for deficits, expected course and declines in function. The resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received the PRN [MEDICATION(S)] on 07/03/21, 07/04/21, 07/06/21, 07/07/21, and 07/08/21 and he received the PRN [MEDICATION(S)] Gel on 07/01/21, 07/02/21, and 07/03/21 for pain ranging from four to seven out of ten (on a zero to ten scale, zero meaning no pain and ten meaning the worst pain). Review of the staff schedule revealed State tested Nurse Assistant (STNA) #107 worked on 07/02/21, 07/03/21, 07/04/21 and 07/05/21. Interview on 07/06/21 at 1:50 P.M. with Resident #232 revealed he had no ability to move his right side and when STNA #107 would care for him she was rough. He stated he could never move fast enough for her and she would cause him pain during care because she was too fast at providing care, and he would need Volteren Gel (referring to [MEDICATION(S)] Gel) and [MEDICATION(S)] (referring to [MEDICATION(S)]) after. He revealed he notified the UM about it and stated she would make a sign to post about staff going slower and taking their time, but she never did. Interview on 07/07/21 at 11:59 A.M. with Registered Nurse (RN)/Unit Manager (UM) #104 revealed Resident #232 is thoroughly unhappy with STNA #107. On 07/06/21, early in the day, Resident #232 stated to her that STNA #107 was rough with him, and she didn't take her time with him. She stated she spoke to the night shift nurses and told them they need to be present when the aides go in to assist him (including STNA #107). She revealed that staff need to do things/care slowly because it hurts him if they go too fast. She spoke to Resident #232 about the plan to have more staff in his room with him during care to assist and staff to be slower with care and he stated he was fine with that response. RN/UM #104 had a conversation with STNA #107 where she told her the concerns that he brought up. She apologized and said she didn't realize she was rough. She stated there was never any issues with STNA #107 and they advised her though to take a nurse with her when she needs to provide care. RN/UM #104 stated she notified the DON and the Administrator of the allegations and she doesn't know why an SRI was never submitted with the state agency. She revealed she did tell him she would make a sign and that she would post it. Interview on 07/07/21 at 12:36 P.M. with the Director of Nursing (DON) revealed they were now doing an investigation for the allegation and getting statements from STNA #107. He stated he was not sure why an SRI was not completed for it. Interview on 07/08/21 at 10:43 A.M. with the Administrator revealed she completed an SRI yesterday (07/07/21) since it was finally conveyed to her that he alleged rough treatment. She stated she spoke to STNA #107 and asked her if he ever asked her to stop providing care and she said no, but he would make oo and ah sounds when washing him, the wife was present, and he never said stop or you're hurting me. She revealed once all the staff came to her yesterday, they started the investigation. She stated he was vague about what day it happened. They are now interviewing other residents and staff currently. The surveyor informed her of the interview on 07/07/21 with RN/UM #104 where she had said that she spoke to Resident #232 on 07/06/21 and he told her staff was rough with him. Review of the SRI # 8, dated 07/07/21 at 3:36 P.M. under the category of neglect/mistreatment revealed the surveyor reported to us today (7/7) that during resident interview on 7/6 the resident stated that a night staff was 'rough' with him during care on Monday evening (7/5). No report was made to staff by resident and so investigation started as of knowledge today. and Resident stated to surveyor that staff 'caused him pain' Staff has been suspended investigation. Review of the undated facility policy and procedure titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed abuse was defined as the wilful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish. It further revealed if a staff member was accused or suspected of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property, the facility will immediately remove the staff from the facility and schedule pending the outcome of the investigation. It further revealed the Administrator or their designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown origin as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. The policy further stated once the Administrator and ODH are notified, an investigation of the allegation violation would be conducted.

Based on record review, resident interview, staff interview, review of facility Self Reported Incidents (SRI), and facility policy and procedure, the facility failed to ensure the state agency was notified of an allegation of rough treatment and failed to conduct a complete investigation into the allegation. This affected one resident (#232) out of one resident reviewed for abuse. The census was 15. Findings Include: The medical record review for Resident #232 revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and he required extensive assistance of two staff for bed mobility, transfers, and toileting, and limited assistance of one staff for personal hygiene. The care plan dated 07/07/21 revealed the resident doesn't like to be rushed during care and would like communication of what is being done during care and would like to be given choices with interventions to communicate with staff when feeling rushed, communicate immediate needs, and staff will communicate with the resident during care to address immediate needs and they will pace themselves during care. The care plan dated 07/06/21 revealed the resident had the potential for pain related to stroke and right lower leg [CONDITION(S)] with interventions to monitor and record pain characteristics. It further stated the resident had a self care deficit related to stroke with right sided weakness and right lower leg cellulitus requiring assistance with bed mobility, transfers, toileting, bathing and eating with interventions to praise all efforts at self care, therapy evaluations, encourage participation to the fullest extent possible and monitor/document/report any changes, improvements, reasons for deficits, expected course and declines in function. The resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received the PRN [MEDICATION(S)] on 07/03/21, 07/04/21, 07/06/21, 07/07/21, and 07/08/21 and he received the PRN [MEDICATION(S)] Gel on 07/01/21, 07/02/21, and 07/03/21 for pain ranging from four to seven out of ten (on a zero to ten scale, zero meaning no pain and ten meaning the worst pain). Review of the staff schedule revealed State tested Nurse Assistant (STNA) #107 worked on 07/02/21, 07/03/21, 07/04/21 and 07/05/21. Interview on 07/06/21 at 1:50 P.M. with Resident #232 revealed he had no ability to move his right side and when STNA #107 would care for him she was rough. He stated he could never move fast enough for her and she would cause him pain during care because she was too fast at providing care, and he would need Volteren Gel (referring to [MEDICATION(S)] Gel) and [MEDICATION(S)] (referring to [MEDICATION(S)]) after. He revealed he notified the UM about it and stated she would make a sign to post about staff going slower and taking their time, but she never did. Interview on 07/07/21 at 11:59 A.M. with Registered Nurse (RN)/Unit Manager (UM) #104 revealed Resident #232 is thoroughly unhappy with STNA #107. On 07/06/21, early in the day, Resident #232 stated to her that STNA #107 was rough with him, and she didn't take her time with him. She stated she spoke to the night shift nurses and told them they need to be present when the aides go in to assist him (including STNA #107). She revealed that staff need to do things/care slowly because it hurts him if they go too fast. She spoke to Resident #232 about the plan to have more staff in his room with him during care to assist and staff to be slower with care and he stated he was fine with that response. RN/UM #104 had a conversation with STNA #107 where she told her the concerns that he brought up. She apologized and said she didn't realize she was rough. She stated there was never any issues with STNA #107 and they advised her though to take a nurse with her when she needs to provide care. RN/UM #104 stated she notified the DON and the Administrator of the allegations and she doesn't know why an SRI was never submitted with the state agency. She revealed she did tell him she would make a sign and that she would post it. Interview on 07/07/21 at 12:36 P.M. with the Director of Nursing (DON) revealed they were now doing an investigation for the allegation and getting statements from STNA #107. He stated he was not sure why an SRI was not completed for it. Interview on 07/08/21 at 10:43 A.M. with the Administrator revealed she completed an SRI yesterday (07/07/21) since it was finally conveyed to her that he alleged rough treatment. She stated she spoke to STNA #107 and asked her if he ever asked her to stop providing care and she said no, but he would make oo and ah sounds when washing him, the wife was present, and he never said stop or you're hurting me. She revealed once all the staff came to her yesterday, they started the investigation. She stated he was vague about what day it happened. They are now interviewing other residents and staff currently. The surveyor informed her of the interview on 07/07/21 with RN/UM #104 where she had said that she spoke to Resident #232 on 07/06/21 and he told her staff was rough with him. Review of the SRI # 8, dated 07/07/21 at 3:36 P.M. under the category of neglect/mistreatment revealed the surveyor reported to us today (7/7) that during resident interview on 7/6 the resident stated that a night staff was 'rough' with him during care on Monday evening (7/5). No report was made to staff by resident and so investigation started as of knowledge today. and Resident stated to surveyor that staff 'caused him pain' Staff has been suspended investigation. Review of the undated facility policy and procedure titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed abuse was defined as the wilful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish. It further revealed if a staff member was accused or suspected of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property, the facility will immediately remove the staff from the facility and schedule pending the outcome of the investigation. It further revealed the Administrator or their designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown origin as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. The policy further stated once the Administrator and ODH are notified, an investigation of the allegation violation would be conducted.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to properly investigate a fall, ensure fall interventions were in place, and failed to implement new fall interventions after a fall with serious injury. This resulted in harm for Resident #46 when the resident fell at the facility which resulted in a hip fracture and a subdural hematoma. This affected two Residents (#16 and #46) of three residents reviewed for accidents. The census was 21. Findings include: Resident #46 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital records stated the resident had a recent history of falls. Resident #46 was assessed to be at a low fall risk on [DATE]. A review of the admission minimum data set assessment revealed the residents mental status was mildly impaired, required extensive assistance with one person physical assistance with bed mobility, transferring, and walking in room, and that the resident did have a history of falls in the last two to six months. A fall plan of care was created on [DATE] and it stated the resident was at increased risk for falling due to unsteady gait, impaired cognition, history of falls, and impaired mobility. The goal was for the resident not to suffer any fall with injury and interventions included were for the bed to be in the low position, a clutter free room, place personal items within the resident's reach for ease and accessibility, provide adequate lighting, and provide and assist with wearing proper foot wear. A review of the nursing progress note dated on [DATE] at 5:50 A.M. revealed the resident was sent to the hospital due to trying to get up out of the bed to go to the bathroom on her own and fell and obtained injuries to the left hip and her head. The resident was complaining of pain and there was bleeding from the head injury. A review of another progress note dated on [DATE] at 11:33 A.M. stated the resident was transferred to another hospital and was admitted with a bleed in her head and will require traction on her hip. A review of the fall incident report revealed the resident paged for assistance and when the staff member entered the room she heard the resident yelling and the resident was on the floor beside her bed. The resident stated "I fell out of bed. Help me I am hurting so bad." The nurse assessed her injuries and her vital signs, due to her extensive injuries she was transported to the hospital for further evaluation. The injuries observed were left hip trochanter and back of her head, the level of her pain was the most severe at "hurts worst" on the facility's pain scale. The level of consciousness at the time of the fall was alert and oriented to person and situation and the resident was ambulatory with assistance. The fall was unwitnessed. The fall incident report nor the medical record did not include any investigation as to if the fall interventions stated in the plan of care were in place at the time of the fall including if the bed was in the low position, the room was free of clutter, did the resident have proper footwear on, and was the residents call light within reach. Resident #46 was readmitted to the facility on [DATE] with new [DIAGNOSES REDACTED]. The medical record did not reveal any new fall interventions were implemented. An interview with the Director of Nursing (DON) on [DATE] at 10:45 A.M. confirmed the fall risk assessment on [DATE] was inaccurate and the resident should have been scored at a higher risk due to the medications the resident was on and her history of falls. The DON confirmed the facility did not investigate if the fall interventions were in place at the time of the fall nor did the facility implement any new interventions when the resident was readmitted to the facility status [REDACTED]. The resident went under hospice care on [DATE] and expired on [DATE] at the facility. A review of the facility's policy on fall and accident prevention dated [DATE] stated the facility must ensure that the resident environment remains as free of accident hazards as is possible. The facility will identify each resident who is at risk for falls and will plan care and implement interventions to prevent falls. The facility must ensure that each resident receives adequate supervision and assistive devices to prevent accidents. A fall prevention program will be implemented that educates staff in creative, functional strategies to reduce risk while recognizing the resident's rights and the need to maintain the highest practicable level of function. The fall plan of care will be revised or initiated at this time reflecting any new interventions to prevent future falls or accidents. The Fall Committee will meet as needed to review new falls and develop interventions. 2. Review of Resident # 16's medical record revealed they were admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the fall assessment dated [DATE] identified the resident as a minimal fall risk. Review of the minimum data set assessment dated [DATE] revealed Resident #16 was an extensive assist with transfers and walking in the room with the physical assistance of one person. Review of the fall plan of care revealed on [DATE] the facility initiated a low bed and on [DATE] a clutter free room. On [DATE] Resident #16 was found on floor on her left side near the bathroom. Resident #16 complained of right hip pain and was sent to the emergency room for an evaluation. The new intervention by the facility was to educate the resident on the importance of using a cane. (The resident was an extensive assistance with transfer and walking in her room and required one person to physically assist them). The resident was admitted to the hospital with [REDACTED]. Resident #16 returned to the facility on [DATE]. On [DATE] Resident #16 was found lying on the floor in her room on her back . The facility added a new intervention of a low bed and a mat to the floor (the low bed was already in place) This was verified on [DATE] at 2:25 P.M. during interview with the Assistant Director of Nursing.