Every finding on record at Western Hills Retirement Village

Based on observation, staff interview, and policy review, the facility failed to ensure food was procured, stored, and prepared in a sanitary condition. This had the potential to affect all of the residents residing in the facility. The facility census was 105 residents. Findings include:1. Observation on 08/17/26 at 9:18 A.M. of the walk-in refrigerator revealed it contained a box of diced cabbage with a delivery date of 07/24/26 and a best if used by date of 08/02/26 written on the box.Interview on 08/17/26 at 9:18 A.M. with Dietary Director (DD) #791 confirmed the box of cabbage was expired and should have been discarded. Review of the facility policy titled Food Storage undated revealed proper storage would prevent food contamination, reduce foodborne illness risks, maintain product quality, and ensure compliance with applicable Ohio food safety requirements.2. Observation on 08/17/26 at 9:20 A.M. of the walk-in freezer revealed there was a box of bread sticks on the floor of the freezer.Interview on 08/17/26 at 9:20 A.M. with DD #791 confirmed the box of bread sticks were on the floor and should not have been stored on the floor.Review of a facility policy titled Food Storage undated revealed food should be stored at least six inches above the floor.3. Observation on 08/17/26 at 9:34 A.M. of the ice machine located in the kitchen revealed there were black spots located on the inside of the front lid of the ice machine which could be removed from the lid by wiping the lid.Interview on 08/17/26 at 9:34 A.M. with DD #791 confirmed the black spots were located on the inside of the front lid of the ice machine.Interview on 08/17/26 at 1:36 P.M. with the Administrator confirmed the facility did not have a policy on cleaning the ice machine and the facility should follow manufacturing guidelines concerning cleaning and maintenance of the ice machine.4. Observation on 08/17/26 at 9:34 A.M. of the reach in ice cream freezer revealed there was water dripping from the compressor at the top of the freezer onto a box of individually packaged vanilla ice cream. There was a thin layer of ice on this box of vanilla ice cream cups as well as a thin layer of ice located on the bottom of the freezer.Interview on 08/17/26 at 9:34 A.M. with DD #791 confirmed water was dripping from the freezer compressor onto a box of individually packaged vanilla ice cream in the reach in ice cream freezer. DD #791 also confirmed a thin layer of ice buildup on the bottom of the freezer. DD #791 reported he was not aware of this dripping water in the reach-in ice cream freezer previously.Review of the facility titled Food Storage undated revealed food should not be stored in leaking, damaged, or contaminated packaging.5. Review of tray line food temperature logs on 08/17/26 at 9:47 A.M. revealed tray line food temperatures were not documented on the following dates for the following meals: 06/20/26 breakfast and lunch, 06/22/26 lunch, 06/26/26 lunch, 07/01/26 breakfast and lunch, 07/04/26 lunch, 07/05/26 breakfast and lunch, 07/08/26 breakfast and lunch, 07/10/26 breakfast and lunch, 07/14/26 breakfast and lunch, 07/15/26 breakfast and lunch, 07/18/26 breakfast, lunch and dinner, 07/27/26 lunch, 07/28/26 lunch, 07/29/26 breakfast and lunch, 07/30 breakfast and lunch, 07/31/26 breakfast and lunch, 08/01/26 breakfast and lunch, 08/06/26 lunch.Interview on 08/17/26 at 9:47 A.M. with Kitchen Manager (KM) #825 confirmed tray line food temperature documentation was not present for multiple dates and meals in June, July, and August 2026.Review of the facility policy titled Trayline Food Temperature Control undated revealed all time/temperature controlled for safety (TCS) foods should be maintained at safe temperatures throughout preparation, trayline assembly, transportation, and service. Food should be checked at the beginning of trayline service.6. Review of refrigerator and freezer temperature logs revealed missing documentation of temperatures for the following dates in July for the following refrigerators and freezers.The dessert freezer temperature log was missing A.M. temperatures on 07/03/26, 07/06/26, 07/11/26, 07/12/26, 07/17/26, 07/25/26, 07/31/26.The walk-in freezer temperature log was missing A.M. temperatures on 07/11/26, 07/12/26, 07/17/26, 07/20/26, 07/25/26, 07/26/26 and 07/31/26.The milk refrigerator temperature log was missing both A.M. and P.M. temperatures on 07/03/26 through 07/18/26, and from 07/20/26 through 07/31/26. The milk refrigerator also was missing P.M. temperatures for 07/01/26, 07/02/26 and 07/19/26.The walk-in refrigerator temperature log was missing A.M. temperatures on 07/11/26, 07/12/26, 07/20/26, 07/25/26, 07/26/26, and 07/31/26.The drink refrigerator temperature log was missing A.M. temperatures on 07/03/26, 07/06/26, 07/11/26, 07/12/26, 07/17/26, 07/25/26, 07/26/26, and 07/31/26.The first-floor nurses' station refrigerator temperature log was missing A.M. temperatures for 07/20/26, 07/22/26 and P.M. temperatures for 07/09/26, 07/15/26, and 07/23/26.The second-floor nurses' station refrigerator temperature log was missing A.M. temperatures on 07/20/26, 07/27/26, and 07/28/26. The second-floor nurses' station refrigerator was also missing P.M. temperatures for 07/23/26. The Shelter Point refrigerator temperature log was missing A.M. temperatures on 07/06/26, 07/20/26, and P.M. temperatures for the full month of July 2026.Interview on 08/17/26 at 9:47 A.M. KM with #825 confirmed the missing temperature documentation on multiple dates and in multiple refrigerators and freezers throughout the facility in July 2026.Review of the facility policy titled Food Storage undated revealed refrigerator and freezer temperatures should be checked and documented at least twice daily. 7. Review of dishwasher temperature logs revealed missing documentation of dishwasher temperatures for the following dates and for the following mealtimes. 07/01/26 breakfast and lunch, 07/02/26 through 07/05/26 breakfast, lunch, and dinner, 07/06/26 dinner, 07/08/26 dinner, 07/09/26 breakfast, lunch, and dinner, 07/10/26 through 07/12/26 dinner, 07/13/26 breakfast, lunch, and dinner, 07/14/26 through 07/18/26 dinner, 07/19/26 breakfast and lunch, 07/20/26 dinner, 07/21/26 dinner, 07/22/26 lunch and dinner, 07/23/26 lunch, 07/24/26 breakfast, lunch, and dinner, 07/25/26 through 07/28/26 dinner, 07/29/26 breakfast lunch and dinner, and 07/30/26 dinner. Interview on 08/17/26 at 9:47 A.M. with KM #825 confirmed there were multiple missing dishwasher temperatures throughout July 2026. Review of the facility policy titled Dish Machine undated revealed temperatures should be documented on the facility's Dish Machine Temperature Log and the facility should operate the dish machine in accordance with current Ohio food safety requirements and applicable Ohio Department of Health requirements. 8. Observation on 08/19/26 at 9:04 A.M. revealed DD #791 was present in the kitchen work area monitoring kitchen operations without a beard net in place. DD #791 had a beard which was approximately one fourth of an inch in length.Interview on 08/19/26 at 9:27 A.M. with DD #791 confirmed he did not have a beard net in place while in the kitchen food prep area. Review of the facility policy titled Hair Restraint and [NAME] Guard revealed employees with facial hair should wear an appropriate beard guard when facial hair could come into contact with food, food-contact surfaces, or clean equipment and utensils.

Based on observation and staff interview the facility failed to ensure that residents were served meals in a manner that created a home-like environment. This affected 18 of 18 residents observed during lunch in the second-floor dining area. The facility census was 105 residents.Findings include:Observation on 08/17/26 at 12:27 P.M. revealed lunch was served to all 18 residents in the dining area on the second floor on trays. During an interview on 08/17/26 at 1:07 P.M. Licensed Practical Nurse (LPN) #591 confirmed all 18 residents present in the second-floor dining area were served their lunch meal on trays. LPN #591 stated all meals served to residents in the second-floor dining area are served on trays.During an interview on 08/20/26 at 2:46 P.M. Dietary Director (DD) #791 stated a good standard practice for meal service would be to serve residents meals on the table and not to have residents eat their meals off of trays. DD #791 also reported the facility did not have a policy describing how meals should be served to residents.

Based on medical record review, resident interview, and staff interview, the facility failed to provide appropriate notification (Advanced Beneficiary Notification) to three (Residents #66, #85, #107) of five residents reviewed for changes made to coverage of services. The facility census was 105 residents. Findings include: Review of medical record for Resident #66 revealed resident was admitted on [DATE] with diagnoses including lymphedema, acidosis, bacteremia, severe septic shock, spinal stenosis and cardiomegaly. Review of the medical record for Resident #66 revealed the resident received a Notice of Medicare Non-Coverage (NOMNC) revealed the resident received a NOMNC on 08/01/26 and again on 08/08/26. Interview on 08/17/26 at 10:23 A.M. with Resident #66 verified she was at the facility for a skilled stay with the plan to return home when skilled time ended and she was functionally ready. Resident #66 expressed confusion over whether she was still under her Medicare payor or if she was expected to pay privately. Review of the medical record for Resident #85 revealed the facility issued the resident a NOMNC dated 08/16/26 and the resident remained in the facility. Resident #85's record did not include an ABN. Review of the medical record for Resident #107 revealed the facility issued the resident a NOMNC dated 08/08/26 and the resident remained in the facility. Resident #107's record did not include an ABN. Interview on 08/20/26 at 8:35 A.M. with Case Manager (CM) #554 verified the facility issued a NOMNC to Resident #66 on 08/01/26. Resident #66 signed the NOMNC, appealed the decision, and won her appeal. Resident was provided additional therapy and care until 08/08/26 when she was deemed to be at her baseline functional level. The facility issued the next NOMNC to Resident #66 on 08/08/26. Resident #66 signed the NOMNC dated 08/08/26 but did not appeal. CM #554 verified she had discussed private pay charges with Resident #66, but the facility did not provide the resident with an Advanced Beneficiary Notification (ABN) CM #554 also confirmed the facility issued NOMNCs to Residents #85 and #107 and both residents remained in the facility despite their skilled time ending. CM #554 verified the facility had not issued ABNs to Residents #85 and #107.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected one (Resident #60) out of 21 sampled residents. The facility census was 105 residents. Findings include: Review of the medical record for Resident #60 revealed an admission date of 07/15/23 with diagnoses including type two diabetes mellitus, hypothyroidism, and tremors. Review of the Minimum Data Set (MDS) assessment for Resident #60 dated 07/24/26 revealed the resident had severe cognitive impairment and required staff assistance with personal hygiene. Review of the care plan for Resident #60 dated 07/26/26 revealed the resident required substantial staff assistance with ADLs and mobility Observation on 08/17/26 at 12:29 P.M of Resident #60 the resident had a visible growth of hairs to her chin and to her upper lip. Interview on 08/17/26 at 12:30 P.M with Resident #60 confirmed she was self-conscious about the growth of hairs to her chin and her upper lip. Interview on 08/17/26 at 12:56 P.M. with Licensed Practical Nurse (LPN) #828 confirmed the facility should have shaved Resident #60's face on her shower days, and staff should check at least check daily. LPN #541 also stated that sometimes Resident #60's personal hygiene sometimes gets overlooked. Review of the facility policy titled Activities of Daily Living (ADL) Care dated January 2004 revealed nursing staff will assist residents with receiving care and services with ADL needs which may include bathing and other self-care tasks.

Based on medical record review, observation, staff interview, and review of the facility policy the facility to ensure staff donned appropriate personal protective equipment (PPE) prior to caring for residents with orders for Enhanced Barrier Precautions (EBP) and also failed to ensure proper hand hygiene during catheter care. This affected two (Residents #2 and #23) of 11 facility-identified residents on transmission-based precautions and one (Resident #2) of three facility-identified residents with indwelling catheters. The facility census was 105 residents. Findings include: 1.Review of the medical record for Resident #23 revealed an admission date of 11/09/23 with diagnoses including cerebral infarction and obstructive and reflux uropathy.Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 05/12/26 revealed the resident had moderate cognitive impairment and was dependent on staff for toileting and bathing.Observation on 08/20/26 at 11:01 A.M. of incontinence care for Resident #23 per Certified Nursing Assistant (CNA) #520 revealed the aide performed hand hygiene and donned gloves but did not don a gown prior to care. CNA #520 removed Resident #23's incontinence brief and performed incontinence care. Without doffing her gloves, CNA #520 retrieved a clean brief from the closet, retrieved a tube of barrier cream from the resident's drawer, put extra towels on the resident's wheelchair, placed a pillow on the resident's bed, adjusted the resident's shirt, and lowered the bed. CNA #520 then removed her gloves and performed hand hygiene.Interview on 08/20/26 at 11:32 A.M with CNA #520 confirmed Resident #23 was on EBP and she should have donned a gown prior to providing care. CNA #520 also stated she performed incontinence care for Resident #23 and did not doff her gloves and perform hand hygiene immediately following care. CNA #520 stated she touched clean items and also touched the resident wearing the same gloves the aide had worn during provision of incontinence care. 2.Review of the medical record for Resident #2 revealed an admission date of 02/14/26 with diagnoses including cerebral infarction, dysphagia, and major depressive disorder.Review of the MDS assessment for Resident #2 dated 07/01/26 revealed the resident had severe cognitive impairment was dependent on staff for eating and personal hygiene.Observation on 08/20/26 at 11:35 A.M of tube feeding for Resident #2 per Licensed Practical Nurse (LPN) #811 revealed the nurse did not don a gown prior to provision of the tube feeding.Interview on 08/20/26 at 11:50 PM with LPN #811 confirmed Resident #2 was on EBP, and she had not worn a gown during provision of tube feeding. Review of facility policy titled Enhanced Barrier Precautions dated on 03/21/24 revealed staff members were expected to wear a gown and gloves when performing high-contact resident care for residents with orders for EBP.

Based on interview and record review, the facility failed to provide wound care as ordered. This affected one resident (#10) out of three residents reviewed for wounds. The facility census was 100.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses include lymphedema, cerebral infarction, hemiplegia, type II diabetes, mild protein-calorie malnutrition, cellulitis, and heart failure.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander.Review of the medical record for Resident #10 revealed wound care orders as follows:Bilateral dorsal feet, cleanse with normal saline (NS), pat dry, apply xeroform and follow by kerlix every day shift for arterial ulcers dated 06/03/26.Review of the Treatment Administration Record (TAR) for June revealed the ordered wound care was not completed on 06/04/26, 06/05/26, 06/07/26, 06/09/26, 06/11/26, and 06/12/26.Interview with Resident #10 on 06/16/26 at 9:25 A.M. revealed sometimes dressing changes were missed but could not recall exact dates.Interview with the Administrator on 06/17/26 at 10:38 A.M. revealed there was no documentation of wound care being completed on the above dates and should have been completed. The Administrator confirmed the facility does not have a policy on wound care. This deficiency represents non-compliance investigated under Complaint Numbers 1379015 and 3029923.

Based on observation and staff interview, the facility failed to ensure vents in the kitchen were maintained in a clean and sanitary manner. This had the potential to affect all 100 residents in the facility. The facility census was 100. Findings include: Observation on 10/21/24 at 8:55 A.M. revealed a duct in the center of the kitchen food preparation and service area with two vents on each side, fully coated in a dark gray and fuzzy substance. Interview at the same time with Dietary Director (DD) #65 verified the four vents were coated in a dark gray fuzzy substance. DD #65 stated the vents were cleaned monthly and needed to be cleaned again. Observation on 10/23/24 at 11:55 A.M. revealed the duct in the center of the kitchen food preparation and service area had an additional five vents that were coated in varying levels of a dark gray and fuzzy substance. Interview at the same time with DD #65 verified all vents were coated in varying levels of a dark gray and fuzzy substance. DD #65 stated the vents had been cleaned within the last month but needed to be cleaned again. Interview on 10/24/24 at approximately 3:30 P.M., the Administrator stated the facility did not have a policy on kitchen sanitation, however the kitchen followed a routine cleaning schedule of all areas of the kitchen.

Based on record review, interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report an allegation of abuse to the state agency. This affected one resident (#29) out of one resident reviewed for abuse. The facility census was 100. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included unspecified dementia, delirium due to known physiological condition, depression, anxiety disorder, gout, type two diabetes mellitus with diabetic polyneuropathy, mild protein-calorie malnutrition, congestive heart failure, hyperlipidemia, neuromuscular dysfunction of bladder, dysphagia, peripheral vascular disease, arthropathy, rheumatoid arthritis, other giant cell arteritis, and disorder of thyroid. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/29/24, revealed Resident #29 had severely impaired cognition. Resident #29 was assessed to require setup assistance for eating and oral hygiene, supervision for bed mobility and transfer, partial to moderate assistance for toileting, bathing, upper body dressing, and personal hygiene, and substantial to maximal assistance for lower body dressing. Review of the SRIs submitted by the facility revealed none had been submitted between 04/14/24 and 07/16/24. Review of the progress note dated 06/16/24 revealed Resident #29 was crying and reported she had been beat up by some guys and she could barely move due to the back pain. The note indicated Resident #29 was assessed and the nurse practitioner was notified with new orders for a urinalysis and blood work. Interview on 10/24/24 at 9:45 A.M. with the Administrator revealed she was not aware of the allegation involving Resident #29. The Administrator stated the facility had started an investigation and filed an SRI regarding the allegation of abuse from Resident #29. Review of the policy titled, Abuse, Neglect, Misappropriation and Exploitation, reviewed 10/16/19, revealed alleged violations would be reported to the Administrator and state agency immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on record review, interview, review of Self-Reported Incidents, and policy review, the facility failed to timely investigate an allegation of abuse. This affected one resident (#29) out of one resident reviewed for abuse. The facility census was 100. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included unspecified dementia, delirium due to known physiological condition, depression, anxiety disorder, gout, type two diabetes mellitus with diabetic polyneuropathy, mild protein-calorie malnutrition, congestive heart failure, hyperlipidemia, neuromuscular dysfunction of bladder, dysphagia, peripheral vascular disease, arthropathy, rheumatoid arthritis, other giant cell arteritis, and disorder of thyroid. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/29/24, revealed Resident #29 had severely impaired cognition. Resident #29 was assessed to require setup assistance for eating, and oral hygiene, supervision for bed mobility, and transfer, partial to moderate assistance for toileting, bathing, upper body dressing, and personal hygiene, and substantial to maximal assistance for lower body dressing. Review of the progress note dated 06/16/24 revealed Resident #29 was crying and reported she had been beat up by some guys and she could barely move due to the back pain. The note indicated Resident #29 was assessed and the nurse practitioner was notified with new orders for a urinalysis and blood work. Review of the facility's Self-Reported Incidents (SRIs) revealed an investigation was not completed. Interview on 10/24/24 at 9:45 A.M. with the Administrator revealed she was not aware of the allegation involving Resident #29, and that the facility had started an investigation. Review of the policy titled, Abuse, Neglect, Misappropriation and Exploitation, reviewed 10/16/19, revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Based on record review and staff interview, the facility failed to ensure care plans reflected the resident's current status. This affected one resident (#91) of five residents reviewed for care planning. The facility census was 100. Findings include: Review of the medical record for Resident #91 revealed an admitted [DATE] with diagnoses of cerebral infarction with hemiplegia and hemiparesis (unspecified side), dementia, diabetes mellitus type II and gastrostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had moderate cognitive impairment and was always continent of bowel and had an indwelling Foley catheter. The resident required set up assistance with eating, supervision with oral and personal hygiene, bed mobility, and transfers, moderate assistance for dressing, and was dependent for toileting and bathing. Review of Resident #91's progress noted dated 07/18/24 at 11:14 A.M. revealed Resident #91 was observed on the floor outside of his room. The State tested Nursing Assistant (STNA) notified the nurse of the fall. Review of Resident #91's fall risk measurement dated 07/18/24 at 11:17 A.M. noted Resident #91 had no history of falls in the past three months and was at risk for falls. Review of Resident #91's plan of care initiated 06/26/26 and completed 09/26/24 revealed Resident #91 had not been identified as a risk for falls. Review of Resident #91's care conference summary dated 09/09/24 made no reference to the fall experienced by Resident #91 on 07/18/24. Interview on 10/24/24 at 12:14 P.M. with the Director of Nursing verified Resident #91's plan of care had not been updated to identify falls as a risk. Review of the policy for, Comprehensive Care Plans, undated, revealed the purpose of the policy was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy stated, the comprehensive care plan will be prepared by an interdisciplinary team and will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment.

Based on medical record review, staff interview, and policy review, the facility failed to ensure fall interventions were in place at the time of a fall. This affected one (Resident #98) of four residents reviewed for falls. The facility census was 100. Findings include: Review of the medical record of Resident #98 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, left hip fracture, anxiety, depression, and cognitive communication deficit. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required partial/moderate assistance with toileting, bed mobility, and transfers. Review of the fall risk assessment dated [DATE] revealed the resident was a moderate risk for falls. Review of the baseline care plan dated 07/23/24 and updated 08/05/24 revealed the resident was at risk for falls and was to have bilateral safety mats and bring to the common area when yelling in room. Review of the incident note dated 08/03/24 at 1:15 A.M. revealed the State tested Nursing Assistant (STNA) reported to the nurse Resident #98 rolled out of bed onto the floor. The bed was in the lowest position. No injuries were noted. Review of the fall investigation dated 08/03/24 revealed a new intervention for fall mats at the bedside when the resident is in bed. Review of the fall investigation dated 08/05/24 at 7:50 P.M. revealed on 08/05/24 at 7:20 P.M., a family member alerted the nurse Resident #98 was on the floor, hollering for help. No injuries were noted. The resident was assisted onto the bed then to the wheelchair and brought to the common area for observation as the resident was restless. Review of the fall investigation dated 08/05/24 revealed the resident was found on the floor, laying on her abdomen and screaming. A new intervention was started to bring the resident to the common area when yelling in the room. Review of the occurrence note dated 08/08/24 at 10:41 A.M. revealed on 08/08/24 at 8:40 A.M., Resident #98 was observed on the floor and it appeared she had rolled out of the bed. The resident was observed on the right side of the bed, lying face down, between the bed and the nightstand, with the flat sheet beneath her and her legs extended outward. The resident complained of 10 out of 10 pain in her lower back and coccyx area. Corrective actions were to send the resident to the hospital for evaluation and for a safety mat to be placed at the right side of the bed. Review of the fall investigation dated 08/08/24 revealed Housekeeper #220 alerted staff that Resident #98 was found lying on the floor face down with the flat sheet below the resident. Staff statements indicated it appeared the resident had rolled out of bed. Staff statements from State tested Nursing Assistant (STNA) #170 and Housekeeper #220 indicated Resident #98 was found laying on the floor/ground. The resident complained of lower back and coccyx area pain and an intervention of a safety mat to the right side of the bed was implemented. Further review revealed, upon IDT (interdisciplinary team) review, the intervention was changed to provide signage in the room to call for assistance with transfers. Interview on 10/23/24 at 4:49 P.M., the Director of Nursing (DON) stated a fall mat is a thicker mat and a safety mat has a beveled edge. The DON verified both would not be used at the same time. Interview on 10/24/24 at 11:38 A.M., Housekeeper #220 confirmed he found Resident #98 on the floor and alerted the nursing staff immediately. Housekeeper #220 stated he did not recall seeing fall mats on the floor next to Resident #98's bed and stated Resident #98 was observed directly on the floor. Interview on 10/24/24 at 1:12 P.M., the DON stated, following the fall on 08/08/24, the intervention was changed from a fall mat to the right side of the bed, to bringing resident to the common area when yelling because the resident was already supposed to have a fall mats to both sides of the bed. Interview on 10/24/24 at 1:31 P.M., Licensed Practical Nurse (LPN) #155 stated, at the time of the fall, Resident #98 had a fall mat present on the left side of the bed, but not the right side of the bed. LPN #155 stated she ordered a fall mat to the right side of the bed since the resident fell out of the right side of the bed and no fall mat was present. LPN #155 stated a fall mat and safety mat was the same thing. Review of the facility policy titled, Fall Management, dated 01/2021, revealed each resident would receive the care and services in accordance with the level of risk to minimize the likelihood of falls. The facility would provide interventions that addressed unique risk factors measured by the risk assessment tool.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure antipsychotic medications were used only when necessary and appropriate. This affected three residents (#22, #29 and #75) of five residents reviewed for unnecessary medications. The facility census was 100. Findings include: 1. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses of vascular dementia, protein-calorie malnutrition, agitation and restlessness and unspecified psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance with eating, maximal assistance with oral hygiene, toileting, bathing, dressing, and transfers and moderate assistance with personal hygiene and bed mobility. Review of Resident #22's physician orders revealed Resident #22 had an order dated 10/18/24 for Seroquel Oral Tablet 25 Milligrams (mg) (Quetiapine Fumarate), give 0.5 tablet by mouth two times a day related to vascular dementia for 7 Days. Review of Resident #22's physician orders revealed Resident #22 had a prior order dated 08/02/24 for Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 3 tablets by mouth at bedtime related to vascular dementia. This physician order was discontinued on 10/18/24. Review of Resident #22's physician order for Seroquel oral tablet (Quetiapine Fumarate) revealed a pharmacy Black Box Warning (BBW) increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Interview on 10/24/24 at 10:28 A.M. with the Director of Nursing verified that Seroquel (Quetiapine Fumarate) was not indicated for residents with a diagnosis of vascular dementia. 2. Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses of diabetes mellitus type II, anxiety, mild protein-calorie malnutrition and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 has severe cognitive impairment and is frequently incontinent of bowel and bladder. The resident requires set up assistance with eating and oral hygiene, moderate assistance with toileting bathing, personal hygiene, and transfers, maximal assistance with dressing, and supervision with bed mobility. Review of Resident #29's admitting history and physical dated 02/27/24 revealed Resident #29 had a history of dementia and depression. The history and physical revealed no mention of Resident #29 having a diagnosis of delirium. Review of Resident #29's nurse practitioner note dated 02/28/24 revealed Resident #29 had diagnoses of non-rheumatic aortic valve stenosis, congestive heart failure, coronary artery disease, dementia, acute respiratory failure with hypoxia, diabetes mellitus type II with polyneuropathy and acute delirium. Review of Resident #29's nurse practitioner note dated 03/15/24 revealed Resident #29 had newly admitted to long-term care (LTC), having intermittent bouts of exit seeking and agitation. Recent labs/urinalysis non-acute. Is redirectable most times, though can become quite agitated per the family. Restarted on Seroquel at admission to LTC. Review of Resident #29's physician orders revealed Resident #29 had an order dated 03/10/24 for Seroquel Oral Tablet 50 mg (Quetiapine Fumarate), give 1 tablet by mouth at bedtime related to delirium. Review of Resident #29's physician order for Seroquel oral tablet 50 mg (Quetiapine Fumarate) revealed a pharmacy Black Box Warning (BBW) which stated increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Interview on 10/24/24 at 10:28 A.M. with the Director of Nursing verified that Seroquel (Quetiapine Fumarate) was not indicated for residents with a diagnosis of delirium. 3. Review of the medical record revealed Resident #75 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia, depression and repeated falls. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #75 had severe cognitive impairment and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required set up assistance for eating, moderate assistance for oral and personal hygiene, toileting, dressing, and bed mobility, was dependent for bathing, and required maximal assistance for transfers. Review of Resident #75's physician orders revealed Resident #75 had an order dated 10/03/24 for Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate), give 12.5 mg by mouth one time a day related to dementia and give 25 mg by mouth at bedtime related to dementia. Review of Resident #75's pharmacy report dated 09/26/24 revealed Resident #75 was receiving Quetiapine 37.5 mg daily (total). Interview on 10/24/24 at 10:28 A.M. with the Director of Nursing verified that Seroquel (Quetiapine Fumarate) was not indicated for residents with a diagnosis of Alzheimer's dementia. Review of the 2021 [NAME] Pocket Drug Guide for Nurses revealed Seroquel (Quetiapine Fumarate) was classified as an antipsychotic and has a Black Box Warning (BBW) stating do not use in elderly patients with dementia-related psychosis; increased risk of cardio-vascular (CV) mortality, including stroke, myocardial infarction (MI). Review of the 2021 [NAME] Pocket Drug Guide for Nurses revealed Seroquel (Quetiapine Fumarate) had indications for treatment of schizophrenia, manic episodes of bipolar 1 disorder, treatment of depressive episodes of bipolar 1 disorder and treatment of major depressive disorder. Review of the facility's psychotropic medication use policy, undated, revealed the facility will comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate related to a change in condition. This affected one resident (#26) out of 20 residents reviewed for resident records. The facility census was 100. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type two diabetes mellitus with diabetic neuropathy, nondisplaced fracture of medial condyle of left femur initial encounter for closed fracture, multiple fractures of pelvis without disruption of pelvic ring initial encounter for closed fracture, age-related osteoporosis without current pathological fracture, chronic obstructive pulmonary disease, generalized anxiety disorder, major depressive disorder, edema, benign prostatic hyperplasia with lower urinary tract symptoms, primary insomnia, hyperlipidemia, and unspecified protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/02/24, revealed Resident #26 was cognitively intact. Resident #26 was assessed to require setup assistance for eating, substantial to maximal assistance for upper body dressing and personal hygiene, and was dependent for oral hygiene, toileting, bathing, lower body dressing, and bed mobility. Review of the progress note dated 08/11/24 revealed Resident #26 was having pain and was offered another x-ray of his leg, which he was agreeable to. Review of the progress notes from 08/11/24 to 08/12/24 revealed no documentation related to Resident #26 being transferred to the emergency room . Review of hospital paperwork dated 08/12/24 revealed Resident #26 was evaluated in the emergency room for a femur fracture. Review of the progress notes from 08/12/24 to 08/14/24 revealed no documentation related to Resident #26 returning from the emergency room , or of any further treatment recommendations for Resident #26's fracture. Interview on 10/24/24 at 1:09 P.M. with the Director of Nursing (DON) verified no documentation related to Resident #26's transfer to the emergency room , or of any treatment recommendations or follow-up related to the fracture.

Based on observation, record review, and interview, the facility failed to ensure Foley catheter bags were managed in a manner to prevent the potential spread of infection. This affected one resident (#32) of two residents reviewed for Foley catheters. The facility census was 100. Findings include: Medical record review of Resident #32 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, chronic atrial fibrillation, heart failure, chronic pancreatitis, neuromuscular dysfunction of bladder, major depressive disorder, personal history of urinary tract infections, general anxiety disorder, sepsis, dysphagia, vascular dementia, and urinary incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had short term memory problems and exhibited no behaviors. Resident #32 required set up assistance from staff for eating, oral hygiene, and personal hygiene. Substantial or maximal assistance was required for toileting, bathing, and lower body dressing. Resident #32 was dependent on staff for putting on and removing footwear and she received assistance of one to two staff for transfers. Review of physicians orders for Resident #32 revealed the resident had an indwelling Foley catheter. Physicians orders included position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift, enhanced barrier precautions per Medical Doctor (MD) order, and monitor and document intake and output as per facility policy. Review of the care plan revealed Resident #32 had an indwelling Foley catheter related to neuromuscular dysfunction of the bladder. Observation on 10/22/24 at 8:53 A.M. of Resident #32 revealed the Foley catheter bag on the floor at the foot of the left side of the resident's bed. This was confirmed by Licensed Practical Nurse (LPN) #149 on 10/22/24 at 9:01 A.M. who stated the catheter bag was supposed to be on the right side of the bed in the privacy cover. Interview with the Administrator on 10/24/24 at 9:59 A.M. revealed the facility does not have a policy for Foley catheter care. She stated the facility follows standard procedures for catheter care. Interview with the Director of Nursing (DON) on 10/24/24 at 1:12 P.M. confirmed the facility does not have a policy for Foley catheter care. She stated the standard procedures for a Foley catheter bag are that it should not be placed on the floor and it should be placed in a privacy bag on the side of the bed away from the door.

Based on medical record review, staff interviews, observations, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to ensure staff followed hand hygiene procedures when providing incontinent care. This affected one (#24) resident of three residents reviewed for incontinent care. The facility census was 106. Findings include Review of the medical record for Resident #24 revealed an admission on 11/20/23 with diagnoses including but not limited to spinal stenosis, Alzheimer's disease, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #24 dated 07/19/24 revealed an impaired cognition. Resident #24 required set up for eating, maximum assistance for bed mobility and was dependent on staff for toileting, toileting hygiene and transfers. Resident #24 was assessed as incontinent of bowel and bladder. Observation of incontinence care for Resident #24 on 09/18/24 at 2:09 P.M., with State tested Nursing Assistant (STNA) #159 revealed the STNA gathered washcloths, two trash bags, and an incontinent garment. STNA #159 went into the resident's bathroom and returned with the washcloths and placed them on the resident's bed side table without a barrier between the two surfaces. Three of the washcloths were in wads and two were opened and laid to the end of the table. STNA #159 instructed the resident of the task, applied gloves and removed the bed sheets. STNA #159 unfastened the incontinent garment rolling it to the center of the perineum and pushed to down towards the bed, exposing the front of the perineal area. STNA #159 used one corner of the washcloth to wipe down the front center of the labia. STNA #159 then noted fecal material on the end of the washcloth. STNA #159 flipped the washcloth over her hand using a clean area to make multiple passes over the inner thighs on both sides without moving washcloth to separate areas. STNA #159 placed the used washcloth into a plastic bag on chair and using a second opened washcloth to make multiple passes over the same perineal area without using a clean area of the washcloth. STNA #159 then asked the resident to roll to her left side exposing the rectal area. Using the third washcloth, the STNA #159 used an upward movement to remove a large portion of the fecal matter from the area and placing it into the trash bag. STNA #159 using a fourth wash cloth that was wadded up wiped the rectal area in multiple passes using different sections of the washcloth by flipping it over her right hand. Resident #24 moaned when STNA #159 cleansed over the right outer sacral area. STNA #159 stating the area was reddened and would apply barrier cream. STNA #159 used the fifth opened washcloth to wipe the rectal area and buttocks without repositioning the washcloth to a clean unused portion. STNA #159 placed the washcloth into the trash bag. STNA #159 then rolled the incontinent garment up and pulled it from underneath the resident and placed it into the second bag on the chair. STNA #159 then opened the nightstand drawer with her gloved hand and removed a tube of barrier cream. STNA #159 flipped the tube open and squeezed the ointment onto her gloved right index finger. STNA #159 then noted a small amount of smeared brown colored material on the tube and on her glove on her right posterior hand. STNA #159 removed the last washcloth from the trash bag on the chair with her left hand and wiped the material off the tube and her glove placing the washcloth back into the trash bag. STNA #159 applied the ointment to the reddened area using her right gloved hand. STNA #159 then removed her gloves placing them into the trash bag and donning new gloves to apply the clean incontinent garment. The resident was repositioned and cover with bed sheets. Interview with STNA #159 on 09/18/24 at 2:35 P.M. verified she removed the smeared brown material from the tube of barrier cream and her gloved hand. STNA #159 placed the tube of barrier cream back on the bed side table of Resident #24. Further verified she did not remove the gloves before applying the barrier cream to the Resident #24 reddened sacral area. STNA #159 verified she did not complete hand hygiene after removing the soiled glove and should have before donning the new gloves. Interview with the Director of Nursing (DON) on 09/18/24 at 4:40 P.M. verified staff should be removing gloves when dirty/wet incontinent garments are removed. The DON verified hand hygiene should be completed every time gloves were removed. Review of the facility policy titled Hand Hygiene, dated 02/28/2020 stated hand hygiene should be completed after removing gloves and if moving from a contaminated body site to a clean body site. Review of online resources from CDC (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) dated 02/27/24 titled Clinical Safety: Hand Hygiene for Healthcare Workers, revealed healthcare personnel should complete hand hygiene immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patients surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. This deficiency represents non-compliance investigated under Complaint Number OH00156660.

Based on medical record review, staff interview, review of the consult/communication sheet, review of the appointment sheet, and review of online medication prescribing information, the facility failed to ensure anticoagulant medication was held prior to a scheduled procedure resulting in the procedure having to be rescheduled. This affected one resident (#105) of three reviewed who received anticoagulant medication. The facility identified 31 residents currently received anticoagulant medications. The facility census was 101. Findings include: Review of the medical record revealed Resident #105 was admitted to the facility on [DATE]. Diagnoses included heart failure, atrial fibrillation, and malignant neoplasm of the kidney. This resident was discharged from the facility on 06/19/23. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 received anticoagulation medication for seven days during the seven day review period. Review of the facility consult/communication sheet dated 05/24/23 revealed Resident #105 was ordered to have an Esophagogastroduodenoscopy (EGD) scheduled to screen for varices (abnormal veins in the lower part of the tube running from the throat to the stomach). Review of the appointment sheet revealed Resident #105 was scheduled to have the ordered EGD completed on 06/15/23 at 10:00 A.M. Instruction included to notify the office or prescribing provider if taking blood thinners. Review of the physicians orders dated 06/08/23 revealed Resident #105 was to have an EGD performed on 06/15/23 and was to have nothing by mouth after midnight on 06/15/23. Review of the Medication Administration Record (MAR) dated June 2023 revealed Resident #105 was documented to have been administered five milligrams (mg) of the medication Eliquis (an anticoagulant, blood thinning medication) at 9:00 A.M. and 9:00 P.M. on 06/13/23 and 06/14/23. Review of the progress note dated 06/14/23 and written by the Director of Nursing (DON), revealed a call was received from the daughter of Resident #105 regarding cancellation and rescheduling of EGD. The daughter sought clarification as to why the cancellation was necessary and blood thinner orders. The daughter was informed the resident took a blood thinner and would not be able to have the procedure so the office rescheduled the appointment. Telephone interview with Licensed Practical Nurse (LPN) #900 on 07/10/23 at 3:05 P.M., revealed Resident #105 returned from the hospital on 06/08/23 and orders were re-initiated for the resident to have the EGD performed on 06/15/23 and to have nothing by mouth after midnight on 06/15/23. LPN #900 stated the orders to hold the residents prescribed medication Eliquis for two days prior to the scheduled EGD had been in place before the resident went to the hospital, but were not re-initiated when he returned to the facility on [DATE] due to being unsure if he was still going to have the EGD done. Interview with the DON on 07/11/23 at 9:30 A.M., verified there had been an order for Resident #105's Eliquis to be held for two days prior to the scheduled EGD before the resident went to the hospital which were not implemented upon the residents return from the hospital. The DON further verified the resident was administered Eliquis within two days of the scheduled EGD resulting in the procedure being rescheduled. Review of the online prescribing information for the medication Eliquis (https://packageinserts.bms.com/pi/pi_eliquis.pdf), not dated, revealed Eliquis should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding. This deficiency represents non-compliance discovered in Complaint Number OH00143839.

Based on medical record review, staff interview, and observation, the facility failed to ensure fall interventions were implemented per the plan of care. This affected two (#07 and #82) of three residents reviewed for falls. The facility census was 90. Findings include: 1. Review of the medical record of Resident #07 revealed an admitted [DATE]. Diagnoses included polyosteoarthritis, overactive bladder, dementia without behavioral disturbance, and [CONDITION(S)]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and toileting. Review of the care plan dated 11/03/21 revealed the resident was at risk for falls related to a history of falls, declines in mobility, strength, transfers, ambulation, and balance. Interventions included a dycem (reusable non-slip, rubber-like plastic material used to stabilize surfaces) above and below wheelchair cushion. Observation on 03/04/22 at 3:30 P.M. revealed Resident #07 seated in her wheelchair in her bathroom preparing to transfer herself to the toilet. Observation at 3:35 P.M. revealed a dycem on top of the cushion, however there was no dycem below the cushion. The Director of Nursing (DON) was present at the time of the observation and verified there was no dycem below the cushion. 2. Review of the medical record of Resident #82 revealed an admitted [DATE]. Diagnoses included urinary tract infection, [CONDITION(S)], dementia without behavioral disturbance, major depressive disorder, anxiety disorder, and unsteadiness on feet. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the care plan dated 02/17/22 revealed the resident was at risk for falls related to impaired ADL ability/mobility following a hospitalization for falls and increased confusion. Interventions included a dycem to wheelchair. Observation on 03/04/22 at 2:09 P.M. revealed Resident #82 seated in her wheelchair in her room. Licensed Practical Nurse (LPN) #300 and State tested Nursing Assistant (STNA) #335 lifted the resident from her wheelchair and verified there was no dycem in place. Interview on 03/04/22 at 3:40 P.M., the DON verified fall interventions should be in place at all times. This deficiency substantiates Complaint Number OH 422.

Based on observation, staff interview and policy review, the facility failed to ensure expired control solution for blood glucose monitors and an expired insulin pen was properly removed from the medication carts. This had the potential to affect five (#17, #24, #43, #74 and #93) residents who utilized glucose monitors and one (#89) of three resident's observed to utilize insulin pens. The facility census was 91. Findings included: 1. Observation on [DATE] at 4:01 P.M. of the medication cart on two-west revealed the blood glucose control monitor solution had expired. The high control solution had an expiration date of [DATE]. The low control solution had an expiration date of [DATE]. Interview on [DATE] at 4:08 P.M. with Licensed Practical Nurse (LPN) #59 confirmed the blood glucose control solutions were expired. LPN # 59 revealed three residents (#24, #43, #74) received blood glucose monitoring on the two-west hallway. LPN #59 denied being aware any unusual blood glucose readings. 2. Observation on [DATE] at 4:22 P.M. of the medication cart on the memory care revealed the blood glucose monitor solution had expired. The high control solution had an expiration date of [DATE] and the low control solution had an expiration date of [DATE]. Interview on [DATE] with LPN #160 confirmed the control solution on the memory care medication cart was expired. The LPN #160 revealed two residents (#93 and #17) received blood glucose monitoring on the unit. LPN #160 denied being aware of any concerns related to unusual blood glucose readings. 3. Observation on [DATE] at 11:48 A.M. of the one-north medication cart revealed Resident #89's insulin [MEDICATION(S)] injectable pen with an opened date of [DATE]. Interview with Registered Nurse (RN) #59 confirmed Resident #89's insulin pen was expired and should have been discarded twenty-eight days after opening. The RN #59 confirmed the resident had a new unopened insulin injectable pen. Review of the facility policy titled, Medication Administration, dated [DATE] revealed outdated medications are immediately removed from stock and disposed.

Based on record review, observation, resident and staff interview, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected one (#9) of 24 facility-identified residents dependent on staff with bathing. The census was 91. Findings include: Review of record for Resident #9 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) assessment for Resident #9 dated 06/26/21 revealed resident was cognitively intact, was coded as negative for rejection of care, and required extensive assistance of one staff with bathing and personal hygiene. Review of care plan for Resident #9 dated 06/26/21 revealed resident had a self-care performance deficit related to declines in mobility, strength, transfers, ambulation, range of motion to bilateral upper extremities, balance, and activities of daily living (ADL) participation. Resident received supervision to assistance of two staff with all ADL's. Interventions included the following: assist with ADL's as needed, praise participation in ADL's as able, watch for fatigue, allow time for completion of ADL's, keep call light in reach, keep skin, clothes, and linens clean and dry, inform charge nurse of any changes. Review of nurse progress notes for Resident #9 dated 09/09/21 through 09/20/21 revealed the notes contained no documentation regarding refusal of shower and/or refusal of resident to have her hair washed. Review of bathing records for Resident #9 for 09/09/21 through 09/20/21 revealed resident received a shower on 09/09/21 and a bed bath on 09/15/21. Observation of Resident #9 on 09/20/21 at 12:21 P.M. revealed the resident's hair was greasy and did not appear to have been washed recently. Interview on 09/20/21 at 12:21 P.M. with Resident #9 confirmed staff gave her bed baths when they didn't have time to give her a shower and when she got a bed bath, she didn't get her hair washed. Resident #9 confirmed it was important for her to have her washed twice weekly and she had not had her hair washed in over a week. Interview on 09/20/21 at 12:41 P.M. with Licensed Practical Nurse (LPN) #59 confirmed Resident #9's hair was greasy and appeared to be unwashed. LPN #59 could not confirm when Resident #9's hair had last been washed. Interview on 09/20/21 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #9's hair appeared unwashed and the last record the facility had of resident's hair being washed was on 09/09/21. The facility did not have a policy regarding bathing but followed standards of care.

Based on record review, observation and resident and staff interview the facility failed to ensure residents wore braces as ordered by the physician to treat limited range of motion. This affected one (#24) of two facility-identified residents with orders for braces to the lower extremities. The census was 91. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 07/14/21 revealed resident was cognitively impaired, required extensive assistance of one to two staff with activities of daily living (ADL's) and had limited range of motion to his lower extremities. Review of the care plan for Resident #24 dated 02/09/21 revealed resident had impaired ADL ability/mobility and required assistance of one to two staff assist in most all areas of care, was non ambulatory using a wheelchair for mobility and had right lower extremity (RLE) foot drop and used an ankle foot orthosis (AFO). Interventions included to provide treatment per the physician orders. Review of September 2021 monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of September 2021 Treatment Administration Record (TAR) for Resident #24 revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physical therapy evaluation for Resident #24 dated 04/06/21 revealed resident had peripheral [CONDITION(S)] with foot drop to the right foot and wore an AFO to the RLE. Observations on 09/20/21 at 12:43 P.M. and on 09/22/21 at 1:55 P.M. revealed Resident #24 was up in his wheelchair and was not wearing the AFO to his RLE. Interview on 09/20/21 at 12:43 P.M. with Resident #24 confirmed he used to wear a brace to his right foot a few months ago but hadn't worn it recently. Interview on 09/22/21 at 1:55 P.M. with Resident #24 confirmed he was not wearing a brace to his right foot and he wasn't sure where the brace was. Observation on 09/20/21 at 2:00 P.M. with the Director of Nursing (DON) revealed the AFO for Resident #24 was being stored inside resident's closet. Interview on 09/20/21 at 2:00 P.M. with the DON confirmed Resident #24 was not wearing the AFO to his RLE, the AFO was being stored inside the resident's closet, and the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/22/21 at 2:57 P.M. with the Administrator confirmed the facility did not have a policy regarding braces and splints but the facility staff should follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]