Every finding on record at Wood Haven Health Care Senior Living & Rehab

Based on observation, record review, staff interview, resident interview, review of manufacturer's instructions, and policy review, the facility failed to ensure mechanical lift slings were monitored and inspected per the manufacturer's instructions. This affected six (#83, #34, #15, #74, #23 and #3) and had the potential to affect 13 other residents (#11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) who the facility identified as requiring the use of a mechanical lift with slings for transfer. The facility census was 83.Findings include:1. Review of Resident #83's medical record revealed an admission date of 07/14/23. Diagnoses included muscle weakness, dementia, hypertension, major depressive disorder, and polyneuropathy.Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had a memory problem. Furthermore, Resident #83 required substantial or maximum assistance for chair to bed, bed to chair, and toilet transfers.Review of Resident #83's care plan dated 09/15/25 revealed Resident #83 required partial to dependent assistance with daily care and to provide adaptive equipment per therapy recommendations.Observation on 04/07/26 at 12:59 P.M. of a mechanical lift transfer from wheelchair to bed for Resident #83 completed by Certified Nurse Aide (CNA) #372 and CNA #390 revealed the sling used was worn and no longer had a tag attached. Concurrent interview with CNA #390 verified the sling utilized to transfer Resident #83 was worn and no longer had a tag attached to the sling. Further interview with CNA #372 and #390 revealed they were not aware of who was responsible for monitoring the integrity of the mechanical lift slings. Interview on 04/07/26 at 1:20 P.M. with Environmental Services Aide (ESA) #336 and Environmental Services Supervisor (ESS) #407 revealed the facility washed the mechanical lift slings separately from the residents' clothes. The slings were not machine dried but air dried on a clothes line. ESA #336 stated the CNAs are responsible for checking the mechanical lift slings prior to use. ESA #336 stated that whatever the CNA's send down to laundry gets washed. ESA #336 stated the light blue slings had tags stating that they were disposable. Furthermore, ESA #336 verified they did not have any documentation regarding integrity monitoring for the slings. Continued observation and interview on 04/07/26 at 1:29 P.M. with ESS #407 verified there were two light blue slings that were worn, discolored and frayed hanging on the clothesline in the laundry area. ESS #407 verified the tags on the two slings that had been washed were labeled as disposable.Interview on 04/07/26 at 1:36 P.M. with CNA #386 verified she was not aware of who was supposed to monitor the integrity of the slings.2. Review of Resident #34's medical record revealed an initial admission date of 12/15/15 and a re-admission date of 06/30/23. Diagnoses included hemiplegia and hemiparesis, anemia, gastroesophageal reflux disease (GERD), and hypokalemia.Review of Resident #34's quarterly MDS assessment dated [DATE] revealed Resident #34 had severely impaired cognition. Furthermore, Resident #34 was dependent for chair to bed, bed to chair, and toilet transfers.Review of Resident #34's care plan dated 08/20/25 revealed Resident #34 had an ADL self-care deficit related to a history of cerebrovascular accident with interventions that included the resident to use a mechanical lift for safe transfers, and to receive assistance with personal hygiene.Observation and concurrent interview with Registered Nurse (RN) Unit Supervisor #416 on 04/07/26 at 2:02 P.M. verified the mechanical lift sling at the bedside of Resident #34 was being used for Resident #34. RN #416 verified the straps of the sling were worn and were frayed. 3. Review of Resident #15's medical record revealed an initial admission date of 04/28/21 and a re-entry date of 03/27/24. Diagnoses included chronic respiratory failure with hypoxia, shortness of breath, pulmonary hypertension, major depressive disorder, and muscle weakness.Review of Resident #15's annual MDS assessment date 04/06/26 revealed Resident #15 had intact cognition. Furthermore, Resident #15 was dependent for chair to bed transfers, bed to chair transfers, and toilet transfers.Review of Resident #15's care plan with an initiated date of 01/06/22 revealed Resident #15 had an ADL self-care deficit with interventions that included staff were to transfer Resident #15 with a mechanical lift and staff were to provide assistance with personal hygiene.Observation and concurrent interview on 04/07/26 at 2:05 P.M. with RN #416 verified Resident #15's mechanical lift sling had significant fraying and the tag was unreadable. 4. Review of Resident #74's medical record revealed an admission date of 03/23/22. Diagnoses included heart failure, anemia, hypocalcemia, weakness, and stage three chronic kidney disease.Review of Resident #74's quarterly MDS assessment dated [DATE] revealed Resident #74 had moderately impaired cognition. Furthermore, Resident #74 was dependent for chair to bed, bed to chair, and toilet transfers.Review of Resident #74's care plan dated 07/01/25 revealed Resident #74 had an ADL self-care deficit with interventions that included the use a mechanical lift for safe transfers.Observation and concurrent interview with RN #416 on 04/07/26 at 2:10 P.M. verified the sling at the bedside of Resident #74 was used for Resident #74 and that the mechanical lift sling had extreme fraying, was extremely worn, and the tag unreadable. 5. Review of Resident #23's medical record revealed an admission date of 10/28/21. Diagnoses included major depressive disorder, hypertension, type two diabetes mellitus, obesity, and dementia.Review of Resident #23's quarterly MDS assessment dated [DATE] revealed Resident #23 had severely impaired cognition. Furthermore, Resident #23 was dependent for chair to bed, bed to chair, and toilet transfers.Review of Resident 23's care plan dated 08/13/25 revealed Resident #23 had an ADL self-care deficit with interventions that included to use a mechanical lift for all transfers and staff to assist with ADL tasks as needed.Observation and concurrent interview with RN #416 on 04/07/26 at 2:13 P.M. verified the mechanical lift sling at the bedside of Resident #23 was used for Resident #23 and that the mechanical lift sling contained no tag, had worn straps, and contained fraying.6. Review of Resident #3's medical record revealed an admission date of 07/12/25. Diagnoses included type two diabetes mellitus, anemia, schizoaffective disorder, paraplegia, and hypertension.Review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had intact cognition. Furthermore, Resident #3 was dependent for chair to bed, bed to chair, and toilet transfers.Review of Resident #3's care plan dated 07/16/25 revealed Resident #3 had an ADL self-care deficit related to transferring, interventions included for the resident to use a mechanical lift as needed for transfers and to assist with ADL tasks as needed.Observation and concurrent interview with RN #416 on 04/07/26 at 2:15 P.M. verified the mechanical lift sling at the bedside of Resident #3 was used for Resident #3 and that the mechanical lift sling was a disposable sling that had been washed and reused. RN #416 also verified the tag was worn and the words present on the tag could not be read. Interview on 04/07/26 at 2:20 P.M. with Medical Records and Inventory Specialist (MRIS) #415 verified the disposable slings come from either transport, the hospital, or the Emergency Medical Services (EMS). Furthermore, MRIS #415 stated the CNAs were expected to monitor the slings before each use. MRIS #415 verified the facility had 26 brand new slings in the medical supply room.Interview on 04/07/26 at 2:48 P.M. with Resident #34 revealed she was nervous every time they used the mechanical lift to transfer her as she fears the staff may drop her.Interview on 04/08/26 at 8:11 A.M. with the Director of Nursing (DON) revealed laundry staff were responsible for monitoring the integrity of the mechanical lift slings. The DON verified they did not have any documentation regarding monitoring of the slings. Furthermore, the DON was unaware the facility was utilizing disposable slings.Review of the Liko manufacturer's instructions revealed the slings had an expected lifetime of one to five years during normal use. Furthermore, the slings must be inspected at least once every six months.Review of the Guldmann manufacturer's instructions revealed slings must be inspected before each use. Inspection should include determining if the tag/label is present, are the stitches intact, is the fabric intact, and if any concerns are identified, the sling should be removed from use. Furthermore, slings should be inspected at least once every six months.Review of the undated facility policy titled Safe Resident Handling/Transfers, revealed damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. Furthermore, staff will inspect the equipment prior to each use.

Based on observation, staff interview, and policy review, the facility failed to ensure routine monitoring was implemented for mechanical lift slings and stand assist devices in the facility. This had the potential to affect 31 (#3, #15, #23, #34, #74, #83, #30, #43, #80, #9, #31, #63, #29, #12, #54, #61, #72, #25 #11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) that the facility identified as requiring the use of a mechanical lift slings or stand assist devices. The facility census was 83.Findings include:Observation on 04/07/26 at 12:59 P.M. of a mechanical lift transfer from wheelchair to bed for Resident #83 completed by Certified Nurse Aide (CNA) #372 and CNA #390 revealed the sling used was worn and no longer had a tag attached. Concurrent interview with CNA #390 verified the sling utilized to transfer Resident #83 was worn and no longer had a tag attached to the sling. Further interview with CNA #372 and #390 revealed they were not aware of who was responsible for monitoring the integrity of the mechanical lift slings. Interview on 04/07/26 at 1:20 P.M. with Environmental Services Aide (ESA) #336 and Environmental Services Supervisor (ESS) #407 revealed the facility washed the mechanical lift slings separately from the residents' clothes. The slings were not machine dried but air dried on a clothes line. ESA #336 stated the CNAs are responsible for checking the mechanical lift slings prior to use. ESA #336 stated that whatever the CNA's send down to laundry gets washed. ESA #336 stated the light blue slings had tags stating that they were disposable. Furthermore, ESA #336 verified they did not have any documentation regarding integrity monitoring for the slings. Continued observation and interview on 04/07/26 at 1:29 P.M. with ESS #407 verified there were two light blue slings that were worn, discolored and frayed hanging on the clothesline in the laundry area. ESS #407 verified the tags on the two slings that had been washed were labeled as disposable. Interview on 04/07/26 at 1:36 P.M. with CNA #386 verified she was not aware of who was supposed to monitor the integrity of the slings. Interview on 04/07/26 at 2:20 P.M. with Medical Records and Inventory Specialist (MRIS) #415 verified the disposable slings come from either transport, the hospital, or the Emergency Medical Services (EMS). Furthermore, MRIS #415 stated the CNAs were expected to monitor the slings before each use. MRIS #415 verified the facility had 26 brand new slings in the medical supply room. Interview on 04/08/26 at 8:11 A.M. with the Director of Nursing (DON) revealed laundry staff were responsible for monitoring the integrity of the mechanical lift slings. The DON verified they did not have any documentation regarding monitoring of the slings. Furthermore, the DON was unaware the facility was utilizing disposable slings. Interview on 04/09/26 at 12:16 P.M. with the Administrator verified the Administrator assumed the mechanical lift slings were inspected at least monthly or quarterly. Furthermore, the Administrator verified the CNAs should check the slings before each use and laundry staff should be monitoring the slings each time they are washed. Review of the Liko manufacturer's instructions revealed the slings had an expected lifetime of one to five years during normal use. Furthermore, the slings must be inspected at least once every six months. Review of the Guldmann manufacturer's instructions revealed slings must be inspected before each use. Inspection should include determining if the tag/label is present, are the stitches intact, is the fabric intact, and if any concerns are identified, the sling should be removed from use. Furthermore, slings should be inspected at least once every six months. 2. Review of the incident accident log revealed Resident #80 experienced a fall on 01/01/26 when the Sara Steady (stand assist) left seat cushion broke off the device while in use. Interview on 04/08/26 at 12:41 P.M. with Maintenance Manager (MM) #451 revealed he received a report there was an issue with a Sara Steady and staff had removed the device from the floor. MM #451 explained although he generally does not work on medical equipment, another maintenance person did replace a left seat bolt on the device. Phone interview on 04/08/26 at 12:47 P.M. in the presence of MM #451, Maintenance Staff (MS) #452 acknowledged he had welded a left seat bolt on a Sara Steady that had broken off approximately two weeks ago. Interview on 04/08/26 at 2:49 P.M. with MM #451 immediately following the phone call, revealed MM #451 recalled the [NAME] of a Sara Steady but believed there was a second device that was repaired. Follow up interview on 04/08/26 at 1:43 P.M. with MM #451 confirmed there were two different Sara Steady's that had an issue with the left seat cushion bolt. MM #451 acknowledged he was unaware until the day of the interview that the same bolt for the left seat of two separate devices had been repaired. MM #451 explained there was a third-party company who inspected and serviced the mechanical lifts but verified the company does not inspect the Sara Steady's. MM #451 stated there were four Sara Steady's used at the facility. MM #451verified he had not inspected the other two but would do so following the interview. Interview on 04/09/26 at 12:16 P.M. with the Administrator confirmed the facility had a third party company to inspect the mechanical lifts at the facility, but there was not anyone assigned to inspect the Sara Steady's. The Administrator shared if the staff find something wrong with any piece of equipment they should alert maintenance. If the equipment issue is something maintenance can fix, they will make the repairs, if not the equipment will be removed from resident care. Review of the LF1600 Stand Assist (Sara Steady) Assembly and Operational Manual documented under the Maintenance Heading To ensure safety and proper use, perform the following steps monthly: check all fasteners to ensure they are securely fastened and no wear and tear is evident. Replace and tighten any worn fasteners before using the Stand Assist. Check the two seat assemblies to make sure they are not worn or damaged, and that the bolts are tight. Replace any worn or damaged seat components before using the Stand Assist. Check the casters to make sure they are in working order and are secured firmly to the stand assist. Replace and worn or damaged casters before using the stand assist. If any maintenance procedure is not clear to you, ask your authorized distributer for assistance. Review of the undated facility policy titled Safe Resident Handling/Transfers, revealed damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. Furthermore, staff will inspect the equipment prior to each use. Review of the Facility Administrator job description dated 2014 documented the Administrator would monitor facility operations to ensure compliance with applicable federal, state and local standards, regulations and guideline, coordinate and monitor inspections pertaining to life safety code requirements, monitor facility operations, overall functionality of the facility, including maintaining equipment in good repair, cleanliness, and aesthetics.

Based on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects. This affected five (#1, #11, #12, #44, and #62) of five residents reviewed for unnecessary medications. The facility census was 83. Findings include:1. Review of Resident #1's medical record revealed an admission date of 09/18/26. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, type two diabetes mellitus, and major depressive disorder. Review of resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Additionally, Resident #1 took antianxiety, antidepressant, diuretic, opioid, and hypoglycemic medications. Review of Resident #1's care plan dated 08/28/25 revealed Resident #1 was at risk for side effects of psychotropic medication used for the diagnoses of depression and anxiety. Interventions for psychotropic medications included to monitor for any changes in mental status, observe for potential side effects of psychotropic medication used for anxiety and depression, and to notify physician if side occur. Review of current physician orders for Resident #1 revealed an order for Xanax oral tablet 0.25 milligrams (mg), one tablet by mouth one time a day every Monday, Wednesday, and Friday related to anxiety disorder and Duloxetine capsule delayed release 30 mg, one capsule by mouth two times a day related to major depressive disorder. Review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of March 2026 revealed no monitoring was in place for side effects of psychotropic medications. 2. Review of medical record for Resident #11 revealed admission date of 10/13/25. The resident was admitted with Alzheimer's disease, dementia with behaviors, dementia with psychotic disturbances, anxiety and depression. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 10 indicating impaired cognition, required set up assistance for eating and was dependent upon staff with toileting hygiene, transfers and bed mobility. No physical or verbal behaviors were marked on the look the behavioral symptoms during the lookback period. Review of the care plan revealed a risk for side effects of psychotropic medications used for the diagnosis of anxiety, depression and Alzheimer's disease initiated 10/21/25. Interventions included to observe for potential side effects of anti-depressant medications including nausea, insomnia, tremors, sweating, anxiety, restlessness, dizziness, weight gain, sleepiness, fatigue, dry mouth, diarrhea, constipation, or headaches. Potential for side effects of antipsychotic medications: blurred vision, dry mouth, drowsiness, muscle spasms, tremors, weight gain, sedation, headaches, dizziness, anxiety, diarrhea, orthostatic hypotension, constipation, and tardive dyskinesia. Review of the physician orders revealed an order for Lorazepam one mg by mouth three times a day related to anxiety disorder with a start date of 03/06/26 and an order for Risperidone one mg per (/) milliliter (ml) by mouth two times daily for psychosis behaviors with a start date of 03/06/26. Review of the MAR and TAR was silent for any medication side effect monitoring. 3. Review of the medical record for Resident #12 revealed an admission date of 01/31/24. Diagnoses included Alzheimer's, schizophrenia, anxiety, and psychotic disorder with hallucinations. Review of the current physician orders for 04/26 for Resident #12 revealed she was prescribed Ativan 0.5 mg twice daily and as needed for anxiety, Zoloft 100 mg daily for depression and anxiety, and Buspar 10 mg three times daily for anxiety. Review of the quarterly MDS assessment dated [DATE] for Resident #12 revealed she was cognitively impaired, had behaviors of hitting, scratching, and throwing items, and was receiving medication for anxiety and depression.Review of the care plan initiated 01/24 for Resident #12 revealed she was care planned for risks for side effects of psychotropic medications used for the diagnosis of dementia with behavior disturbances, psychosis, hallucinations, nightmares, insomnia, and anxiety. Interventions included monitor for changes in mood and behavior, notify physician if any side effects occur, observe for any potential side effects of anti-depressant medication: such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, and blurred vision. Review of the MAR and TAR for 02/26, 03/26, and 04/16 for Resident #12 revealed there were no orders and no mechanism in place for monitoring behaviors for Resident #12 or for monitoring for any side effects from administration of psychotropic medications. Interview on 04/07/2026 at 2:32 P.M. with Registered Nurse (RN) #416 verified Resident #12 was prescribed antipsychotic medications. RN #416 stated the facility does not conduct routine monitoring for behaviors, and the facility does not monitor for side effects of psychotropic medications. 4. Review of Resident #44's medical record revealed an initial admission date of 02/26/24 and a re-entry date of 01/04/26. Diagnoses included polyneuropathy, hypoxemia, morbid obesity due to excess calories, rheumatic heart disease, major depressive disorder, and anxiety. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed Resident #44 had intact cognition with a BIMS score of 13. Furthermore, Resident #44 took antianxiety, antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications. Review of Resident #44's care plan dated 09/10/25 revealed Resident #44 was at risk for side effects of psychotropic medication used for the diagnoses of depression, anxiety, and insomnia with interventions that included to monitor for changes in the resident's mood and to observe for potential side effects of anti-anxiety, hypnotic, and anti-depressant medications. Review of Resident #44's physician orders revealed an order for Zoloft 75 mg by mouth one time a day related to major depressive disorder, Mirtazapine 7.5 mg by mouth one time a day related to major depressive disorder, and buspirone 10 mg by mouth one time a day related to anxiety. Review of Resident #44's MAR and TAR for the month of March 2026 revealed no orders or monitoring were in place for side effects of psychotropic medications. 5. Review of resident #62's medical record revealed an admission date of 02/20/25. Diagnoses included metabolic encephalopathy, psychotic disorder with delusions, hypocalcemia, anxiety, type two diabetes mellitus, hypertension, and dementia. Review of Resident #62's quarterly MDS assessment dated [DATE] revealed Resident #62 had severely impaired cognition with a BIMS score of three. Furthermore, Resident #62 took antipsychotic, antidepressant, and hypoglycemic medications. Review of Resident #62's care plan dated 08/06/25 revealed Resident #62 was at risk for side effects of psychotropic medication used for the diagnoses of insomnia with interventions that included to administer medications per the physician orders, and to monitor for changes in the resident's mood. Review of Resident #62's physician orders revealed orders for Zoloft 100 mg by mouth one time a day related to anxiety and Nuplazid 34 mg by mouth one time a day related to multiple psychotic disorders. Review of Resident #62's MAR and TAR for the month of March 2026 revealed no orders or monitoring were in place for side effects of psychotropic medications. Interview on 04/07/2026 at 2:32 P.M. with RN #416 verified the facility does not conduct routine monitoring for behaviors and the facility does not monitor for side effects of psychotropic medications. Further interview with RN #416 verified that there is no monitoring of behaviors or side effects of psychotropic medications for Residents #1, # 11, #12, #44, and #62. Interview on 04/07/26 at 2:40 P.M. with Licensed Practical Nurse (LPN) #450 stated she was unaware of a specific place for charting of resident behaviors. LPN #450 acknowledged there was not a specific place to prompt nurses to monitor for the side effects of psychotropic medications. Interview on 04/07/26 at 2:44 P.M. with LPN Unit Manager #341 stated the Certified Nursing Assistants (CNA's) chart behaviors in the Point Of Care (POC) electronic charting. The nurses are able to chart behavior in the progress note if there are specific behaviors of concern. LPN Unit Manager #341 acknowledged there was no place in the electronic charting to verify a resident had been assessed for the side effects of psychotropic medications as care planned. Review of the undated facility policy titled Unnecessary Drugs revealed each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration dose, duration of use, indications and clinical need for medication, adequate monitoring for efficacy and adverse consequences, preventing identifying and responding to adverse consequences, or any combination of the reasons stated above.

Based on observation, review of the medical record, staff interview, and review of the facility policy, the facility failed to administer oxygen at the correct rate. This affected one resident (#15) reviewed for oxygen. The facility identified 11 residents (#1, #2, #13, #15, #19, #21, #40 #50, #57, #65, and #84) that required the use of oxygen. The facility census was 83.Findings include:Review of the medical record for Resident #15 revealed an admission date of 04/28/21. Diagnoses included chronic respiratory failure, shortness of breath, pulmonary hypertension, and congestive heart failure.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 revealed she was cognitively intact and required the use of oxygen therapy.Review of the care plan revised 04/26 for Resident #15 revealed she was care planned for respiratory status and difficulty breathing related to asthma, chronic respiratory failure, and congestive heart failure with intervention in place to administer oxygen as ordered.Review of the current physician orders dated 04/26 for Resident #15 revealed she was ordered oxygen to be administered at two to three liters per minute via (by way of) nasal cannula. Further review of the physician orders revealed the oxygen orders were updated on 04/07/26 to reflect oxygen to be administered at two to four liters per minute.Observation on 04/06/2026 at 12:43 P.M. of Resident #15 revealed the resident was sitting in her wheelchair with oxygen running at four and half liters per minute via nasal cannula.Observation on 04/07/2026 at 9:38 A.M. of Resident #15 revealed the resident was sitting in her wheelchair and had oxygen running at four liters per minute via nasal cannula. Concurrent interview with Licensed Practical Nurse (LPN) #454 verified oxygen running for Resident was running at four liters per minute via nasal cannula and verified the oxygen order for Resident #15 was two to three liters. LPN #454 adjusted the oxygen rate to the correct rate.Review of the facility policy titled, Oxygen Administration, undated revealed oxygen is administered to residents who need it, consistent with professional standards of practice. Oxygen is administered under orders of a physician.

Based on record review, staff interviews, and review of manufacturer guidelines, the facility failed to maintain and inspect resident transfer equipment to ensure safe transfers. This affected one (#80) of three residents reviewed for falls. The facility census was 83.Findings include:Review of medical record for Resident #80 revealed admission date of 04/04/23. The resident was admitted with type II diabetes mellitus, anxiety, anemia, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 8 indicating impaired cognition. Resident #80 required supervision with eating, maximum assistance with toileting hygiene, bed mobility and was dependent upon staff with transfers.Review of the care plan dated 09/26/25 for Resident #80 revealed the resident had an activity of daily living self-care performance deficit related to diabetes mellitus, neuropathy and a mood disorder. Interventions included for the resident to use the mechanical lift or a stand assist device (Sara Steady) for safe transfers.Record review of the progress note dated 01/01/26 documented a commotion was heard and noted resident was lying on the floor, on his back with his arms out to his sides. The Sara Steady (stand assist) was in front of the resident with a broken seat cushion. An aide and nurse were present in the room. Resident #80 was assessed and vitals were taken and found to be within normal limits. There was an abrasion observed to Resident #80's right lower quadrant measuring 12 centimeters (cm) by (x) 10 cm from the right bar of the stand assist.Record review of the 01/01/26 episodic charting revealed blood pressure was 107 systolic over (/) 73 diastolic, pulse was 80 beats per minute, temperature was 98.2 Fahrenheit, oxygen saturation was 95 percent. Skin check and range of motion (ROM) were documented as within normal limits, and an abrasion was noted to his right lower quadrant measuring 12 cm x 10 cm. Resident #80 had no complaints of pain. The intervention was to remove the broken Sara Steady to the basement to prevent future use.Record review of the 01/01/26 fall investigation documented the fall occurred in Resident #80's room during a two-person assisted transfer using the Sara Steady. Immediate action taken was to assess the resident and provide notifications to the Director of Nursing, Administrator, family and physician.Interview on 04/08/26 at 12:41 P.M. with Maintenance Manager (MM) #451 revealed he received a report there was an issue with a Sara Steady and staff had removed the device from the floor. MM #451 explained although he generally does not work on medical equipment, another maintenance person did replace a bolt on the device.Phone interview on 04/08/26 at 12:47 P.M. in the presence of MM #451, Maintenance Staff (MS) #452 acknowledged he had welded a bolt on a Sara Steady that had broken off approximately two weeks ago. In a follow up interview on 04/08/26 at 12:49 P.M. with MM #451 immediately following the phone call, MM #451 stated he recalled the [NAME] of a Sara Steady but believed there was a second device that was repaired.Interview on 04/08/26 at 1:43 P.M. with MM #451 confirmed there were two different Sara Steady's that had an issue with the left seat cushion bolt. MM #451 acknowledged he was unaware until the day of the interview the same bolt on two separate devices had been repaired. MM #451 explained there was a third-party company who inspected and serviced the mechanical lifts but verified the company does not inspect the Sara Steady's. MM #451 stated there were four Sara Steady's used at the facility. MM #451verified he had not inspected the other two but would do so following the interview.Interview on 04/09/26 at 3:33 P.M. with Registered Nurse (RN) #417 confirmed she had worked on 01/01/26 and was present when Resident #80 fell. RN #417 explained the Sara Steady required two staff members for operation and Certified Nursing Assistant (CNA) #419 had requested her assistance to transfer Resident #80. RN #417 stated Resident #80 had grabbed the bar of the Sara Steady and pulled himself into the standing position. The seat cushions were then lowered. She explained Resident #80 then sat back heavily onto the seat cushions, and one of the seat cushions immediately gave way causing Resident #80 to fall. Resident #80 was assessed and an abrasion was noted to his right side; no other injuries were observed. RN #417 stated after she attended to Resident #80, she removed the Sara Steady from the unit so it would not be used for other residents.Review of the LF1600 Stand Assist (Sara Steady) Assembly and Operational Manual documented under the Maintenance Heading To ensure safety and proper use, perform the following steps monthly: check all fasteners to ensure they are securely fastened and no wear and tear is evident. Replace and tighten any worn fasteners before using the Stand Assist. Check the two seat assemblies to make sure they are not worn or damaged, and that the bolts are tight. Replace any worn or damaged seat components before using the Stand Assist. Check the casters to make sure they are in working order and are secured firmly to the stand assist. Replace and worn or damaged casters before using the stand assist. If any maintenance procedure is not clear to you, ask your authorized distributer for assistance.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed when an allegation of verbal abuse and neglect was reported. This affected one (#95) of one resident reviewed for verbal abuse and neglect. The facility census was 83.Findings include:Review of medical record for Resident #95 revealed admission date of [DATE]. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, depression, stroke and dysphasia. The resident was admitted to hospice on [DATE] and died in the facility on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 had a Brief Interview Mental Status (BIMS) score of five indicating severely impaired cognition. Furthermore, Resident #95 required set up for eating, moderate assistance with toileting hygiene, bed transfers and transfers.Interview on [DATE] at 2:16 P.M. with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #380, revealed the facility submitted a self-reported incident (SRI) to the state agency in [DATE]. Review of SRI #267859 revealed Resident #95's spouse alleged there was physical and mental abuse occurring by the nursing staff prior to the resident's death on [DATE]. Resident #95's spouse provided the names of three staff members but would not elaborate specifically on what abuse occurred. Review of the facilities investigation included one interview with Resident #95's Power of Attorney (POA), and two interviews with Resident #95's spouse. Follow up interview with the Administrator and the DON on [DATE] at 2:35 P.M. verified the facility did not complete a thorough investigation on the allegation of abuse for Resident #95. Interview revealed the three staff members identified were not placed on leave, no other residents were interviewed, skin assessments were not completed, staff members were not interviewed, and no staff education was completed regarding the allegation. At the conclusion of the interview the DON stated she wished she had not submitted the SRI because she did not feel the abuse occurred.Review of the facility policy with a reviewed date of [DATE] titled Abuse, Neglect, and Exploitation revealed an immediate investigation is warranted when reports of abuse, neglect, or exploitation occur. Written procedures for investigations include identifying staff responsible for the investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations. Also having complete and thorough documentation of the investigation.

Based on medical record review, staff interview, and review of the facility policy the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II following a new diagnosis of schizophrenia. This affected one (#12) of one resident reviewed for PASRR level II. The facility census was 83.Findings include:Review of the medical record for Resident #12 revealed an admission date of 01/31/24. Diagnoses included Alzheimer's disease, dementia, schizophrenia, psychotic disorder with hallucinations, anxiety, adult failure to thrive, and breast cancer.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 revealed the resident had severe cognitive impairment, had a diagnosis of schizophrenia, and was not receiving any anti-psychotic medications.Review of the care plan initiated 06/25 for Resident #12 revealed she was care planned for schizophrenia. Interventions included to administer medications as ordered, monitor for changes in the resident's mood, observe for potential side effects like drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, nausea, upset stomach, blurred or double vision, and to notify the physician if side effects occur.Review of an electronic communication dated 07/31/24 authored by Nurse Practitioner (NP) #453 for Resident #12 revealed the content of the communication from NP #453 requested the diagnosis of schizophrenia be added to the resident's diagnosis list.Review of the medical record for Resident #12 revealed no evidence of Preadmission Screening and Resident Review (PASRR) level II being completed when the resident had a new diagnosis of schizophrenia added on 07/31/24.Interview on 04/07/26 at 3:03 P.M. with Social Worker #389 verified that Resident #12 had a new diagnosis of schizophrenia in 07/31/24. Social Worker #389 also verified a PASRR level II should have been completed for the new diagnosis of schizophrenia and further verified that a PASRR level II screening was not completed for Resident #12.Review of the facility policy titled, Behavioral Health Services, revised 09/25 revealed all residents are to receive the necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: PASRR screening, history obtained from medical records, the resident, and as appropriate the resident's family and friends, MDS and care area assessments, care plan development and implementation, and evaluation.

Review of the medical record for Resident #19 revealed an admission date of 07/12/25 with diagnoses including, but not limited, to seborrheic dermatitis, pressure ulcer of sacral region stage three (full thickness to fat), pressure ulcer of right buttock stage three, pressure ulcer of left buttock stage three, and paraplegia.Review of the Minimum Data Set (MDS) assessment, dated 12/02/25, revealed the resident was cognitively intact. Resident #19 had two stage three pressure ulcers that were present on admission.Review of the care plan dated 07/16/25 revealed the resident had two stage three pressure ulcers upon admission and dermatitis/fungal infection related to disease processes- paraplegic, non-compliant with care and getting up out of bed. Interventions included administer treatments as ordered, low air loss (LAL) alternating pressure mattress, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, and type of tissue and exudate.Review of the weekly skin assessment dated [DATE] revealed the stage three pressure to the right buttock measured 5.0 centimeters (cm) in width by (x) 2.1 cm in length x 0.1 cm in width. Wounds number two and three were measured together, with the measurements being a combined 8.0 cm width x 8.1 cm in length x 0.1 cm in depth. Wounds number three and four were measured together, with a combined measurement of 8.9 cm in width x 4.9 cm in length x 0.1 cm in depth. The stage three pressure ulcer to the left buttock was resolved. There was a moderate amount of serosanguinous drainage to all areas. Treatment included Silvadene to all areas and cover with abdominal (ABD) pads. Wound beds were beefy red with much improvement noted. Review of the weekly skin assessment dated [DATE] revealed the stage three pressure to the right buttock measured 5.0 centimeters (cm) in width by (x) 2.1 cm in length x 0.1 cm in width. Wounds number two and three were measured together, with the measurements being a combined 8.0 cm width x 8.1 cm in length x 0.1 cm in depth. Wounds number three and four were measured together, with a combined measurement of 8.9 cm in width x 4.9 cm in length x 0.1 cm in depth. The stage three pressure ulcer to the left buttock was resolved. There was a moderate amount of serosanguinous drainage to all areas. Treatment included Silvadene to all areas and cover with abdominal (ABD) pads. Wound beds were beefy red with much improvement noted. Interview on 12/04/25 at 2:30 P.M. with Unit Manager (UM) #290 revealed she completed wound rounds with the NP weekly. UM #290 stated the NP usually came on Fridays to do wound rounds. UM #290 stated the NP always came on Mondays to do regular rounds and she would do wound rounds if she knew she would not be in on Friday. UM #290 stated she was always present in the room when the NP completed wound rounds and would write down the measurements. UM #290 verified the NP came in and completed rounds on 11/03/25 and when the weekly skin assessment came up in the electronic record on 11/06/25, she documented the same measurement as 11/03/25 during rounds. UM #290 verified on 11/06/25 she did not remeasure or assess the wounds. This deficiency represents non-compliance investigated under Complaint Number 2668796.

Based on medical record review and staff interview, the facility failed to ensure accurate assessments were completed. This affected one (#65) of three residents reviewed for assessments. The facility census was 76.Findings include:Review of the medical record for Resident #65 revealed an admission date of 02/20/25 with diagnoses including, but not limited to, psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies.Review of the Nursing admission Assessment completed on 02/20/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Oral Status and Dental assessment completed on 02/21/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Oral Status and Dental assessment completed on 05/22/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Minimum Data Set (MDS) assessment, dated 11/04/25, revealed the resident had severe cognitive impairment. The assessment indicated Resident #65 had no broken or loosely fitting full or partial dentures. The resident had no mouth or facial pain, discomfort, or difficulty chewing.Interview on 12/08/25 at 11:24 A.M. with Certified Nursing Assistant (CNA) #308 revealed that Resident #65 had partial dentures.Interview on 12/08/25 at 1:35 P.M. with Unit Manager (UM) #290 verified the dental assessments completed for Resident #65 stated the resident had natural teeth and did not have dentures. This deficiency represents non-compliance investigated under Master Complaint Number 2669641.

Based on staff interviews, resident interviews, record review, and facility policy review revealed facility staff failed to report an allegation of abuse. This affected two residents (#10 and #11) of two residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included intellectual disabilities, encephalopathy, and altered mental status. Review of Resident #11's quarterly Minimum Data Set (MDS) revealed the resident had a moderate decline in cognition. The resident had no behaviors documented. Review of Resident #11's behavior note dated 12/08/24 revealed the resident was in the activity room and displayed inappropriate actions and required redirection from staff back to his room. The actions were not specified. Review of Resident #11's physician note dated 12/10/24 revealed the resident had developed more aggressive behaviors since being off Abilify (antipsychotic). Review of Resident #11's behavior note dated 12/13/24 revealed the resident was removed from music entertainment for disruptive behavior. Review of Resident #11's psychiatric note dated 12/16/24 revealed the resident was seen at the request of staff for a follow-up on medication management due to disruptive behavior in group settings which included hitting others with his wheelchair. An additional note dated 12/18/24 revealed Resident #11 was removed from morning coffee bar for disruptive behavior. Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included schizophrenia, psychosis, and congestive heart failure. Review of Resident #10's annual MDS dated [DATE] revealed he had an intact cognition. No behaviors were documented. Review of Resident #10's most recent care plan revealed he had a history of trauma that carried negative effects. Interventions included to encourage the resident to express feelings, concerns, and thoughts in a safe space and identify items that lessen the effect of trauma and provide comfort. Review of Resident #10's medical record revealed a nurse's note dated 12/08/24 informing Licensed Practical Nurse (LPN) # 230 Resident #10 was in an activity with another male resident who came up to him with a clenched fist. Resident #10 was upset and stated he had not done anything to the other resident. Interview with Activity Director on 01/06/24 at 8:20 A.M. revealed there was an incident on 12/08/24 between Residents #10 and #11. The residents were arguing and separated. The Activity Director revealed Activity Aide #105 wrote a letter regarding the incident and gave it to the Director of Nursing (DON). Interview with Resident #10 on 01/06/24 at 8:48 A.M. revealed Resident #11 swung his fists at him multiple times but never made contact. Resident #10 stated he was unable to attend activities due to Resident #11's behavior towards him. Resident #10 stated he had reported the situation to everyone but no one would do anything regarding the threats. Interview with the DON and Administrator on 01/07/25 at 3:13 P.M. revealed neither had notified of the incident between Residents #10 and #11 on 12/08/24 nor had the DON received a letter regarding the incident. Attempted interview with Activity Aide #105 revealed she was unavailable. Review of the Self-Reported Incidents revealed no information was reported to the State of Ohio regarding the abuse. Review of the facility policy titled Abuse, Neglect, and Exploitation dated 07/20/22 revealed mental abuse includes, but not limited to humiliation, harassment, threats of punishment or deprivation. This violation represents non-compliance investigated under Complaint Number OH00160615.

Based on staff interview, nurse practitioner interview, family interview, and review of facility policy revealed the facility failed to follow documented medication orders in resident records. This affected one (#84) resident of three residents reviewed for medication orders. The facility census was 71. Findings included: Review of Former Resident (FR) #84's medical record revealed an admitted [DATE]. Diagnoses included thyroid cancer, urinary tract infection, and cystitis. Review of FR #84's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition. Review of FR #84's care plan revealed the resident had a temporary placement in the facility and planned on returning home after the completion of therapies. Review of FR #84's nursing note dated 11/22/24 revealed the resident was admitted from a local hospital and was alert, oriented and able to make needs known. Review of FR #84's Medication Administration Record (MAR) dated 11/22/24 revealed the resident refused Gavreto. On 11/23/24 Gavreto was administered. On 11/24/24 Gavreto was not administered due to parameters by Registered Nurse (RN) #141. On 11/25/24 the MAR was documented 9 which represented see nurses notes and on 11/26/24 the drug was marked as refused. Review of FR #84's nurses note dated 11/24/24 revealed two capsules of Gavreto 100 milligrams each for medullary thyroid carcinoma was held per FR #84's daughter. The daughter stated the oncologist ordered to hold the Gavreto until Resident #84 completed the intravenous antibiotic ordered for the urinary tract infection. Telephone interview with the hospital Certified Nurse Practitioner (CNP) #400 on 01/02/25 at 10:07 A.M. revealed FR #84's chemotherapy medication was on hold and that information was written on the hospital discharge summary. CNP #400 stated Gavreto was on the medication list but since it was only on hold it was not removed from the residents medication list. Adding, if there was any questions, the staff should have notified the oncologist. Interview with RN #141 on 01/06/25 at 10:14 A.M. verified she charted on 11/24/24 that the medication (Gavreto) was out of parameters but failed to chart the reason in the nurses notes. RN #141 stated Resident #84's daughter and the resident informed the staff that the physician had discontinued the chemotherapy medication while receiving the antibiotic therapy, but were unaware of why. The nurse revealed she failed to contact the oncologist office to verify the medication order. Telephone interview with Unit Manager #149 on 01/06/25 revealed she attempted to contact FR #84's oncologist to verify the chemotherapy medication, but the office failed to return the phone call. In the meantime, a verbal order was given to staff to hold the medication. Unit Manager #149 verified she failed to document the order to hold the medication and staff attempted to administer the medication to the resident daily. Unit Manager #149 verified FR #84 did receive Gavreto on 11/22/24 and the medication should have been held. Review of the facility policy titled Medication Administration dated 05/2024 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. Report and document any adverse side effects or refusals. This violation represents non-compliance investigated under Complaint Number OH00160942.

Based on record review, resident interview, staff interview and review of facility policy the facility failed to ensure residents were free from abuse. This affected one resident (#10) of two residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included schizophrenia, psychosis, and congestive heart failure. Review of Resident #10's annual MDS dated [DATE] revealed he had an intact cognition. No behaviors were documented. Review of Resident #10's most recent care plan revealed he had a history of trauma that carried negative effects. Interventions included to encourage the resident to express feelings, concerns, and thoughts in a safe space and identify items that lessen the effect of trauma and provide comfort. Review of Resident #10's medical record revealed a nurse's note dated 12/08/24 informing Licensed Practical Nurse (LPN) # 230 Resident #10 was in an activity with another male resident who came up to him with a clenched fist. Resident #10 was upset and stated he had not done anything to the other resident. Interview with Activity Director on 01/06/24 at 8:20 A.M. revealed there was an incident on 12/08/24 between Residents #10 and #11. The residents were arguing and separated. The Activity Director revealed Activity Aide #105 wrote a letter regarding the incident and gave it to the Director of Nursing (DON). Interview with Resident #10 on 01/06/24 at 8:48 A.M. revealed Resident #11 swung his fists at him multiple times but never made contact. Resident #10 stated he was unable to attend activities due to Resident #11's behavior towards him. Resident #10 stated he had reported the situation to everyone but no one would do anything regarding the threats. Interview with the DON and Administrator on 01/07/25 at 3:13 P.M. revealed neither had notified of the incident between Residents #10 and #11 on 12/08/24 nor had the DON received a letter regarding the incident. Review of the Self-Reported Incidents revealed no information was reported to the State of Ohio regarding the abuse. Review of the facility policy titled Abuse, Neglect, and Exploitation dated 07/20/22 revealed mental abuse includes, but not limited to humiliation, harassment, threats of punishment or deprivation. This violation represents non-compliance investigated under Complaint Number OH00160615.

Based on staff interview, record review, review of the facility's incident reports, and review of the facility's policies, the facility failed to complete thorough investigations into wandering/elopement and fall incidents. This affected one (#11) of two residents reviewed for elopement and one (#11) of three residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included dementia, anxiety, and transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/24, revealed Resident #11 had impaired cognition, used a walker and wheelchair, and required substantial/maximal assistance for bed mobility and transfers. Resident #11 demonstrated wandering behaviors four to six days during the look-back period. Resident #11 had two or more falls without injury since the previous assessment/admission. 1. Review of the Exit Seeking Assessment completed upon admission, dated 11/29/23, revealed no score or level of risk for exit seeking behaviors for Resident #11. Review of an incident report dated 01/11/24 at 5:45 P.M. revealed Resident #11 was found by the family member of another resident in the parking lot in a wheelchair, and Resident #11 was unable to provide any information regarding his purpose. Review of the care plan for Resident #11 revealed it was updated 01/12/24 identifying Resident #11 was at risk for wandering. Interventions included a Secure Care (a device worn by the resident to notify staff when the resident approaches a facility exit). Review of a Weekly Skin Assessment signed 01/12/24 revealed Resident #11 was discovered in the parking lot by another resident's family member on 01/11/24 at 5:45 P.M. The document further revealed the weather at the time was above freezing and not raining. A Secure Care was placed on Resident #11. Interview on 02/26/24 at 10:51 A.M. with MDS Coordinator #502 and MDS Coordinator #503 confirmed the care plan for Resident #11 was updated on 01/12/24 for wandering, but could not provide any information regarding why they updated the care plan. MDS Coordinator #502 and MDS Coordinator #503 denied knowledge of Resident #11 exiting the facility independently. Interview on 02/26/24 at 10:57 A.M. with the Director of Nursing (DON) revealed the incident with Resident #11 going outside was not considered an elopement because Resident #11 was not at risk for wandering. Telephone interview on 02/26/24 at 12:08 P.M. with Licensed Practical Nurse (LPN) #201 confirmed she completed the skin assessment on Resident #11 after he was found outside the facility on 01/11/24. LPN #201 did not see him outside, and could not remember who brought Resident #11 back into the facility. LPN #201 notified the physician and DON and completed a physical and mental assessment on Resident #11 who suffered no injuries from this incident. LPN #201 could not state how long Resident #11 was outside. Interview on 02/26/24 at 4:29 P.M. with the DON revealed she did not know how long Resident #11 was outside on 01/11/24. The DON did not know who brought Resident #11 in from outside. The DON stated LPN #201 could be interviewed to determine who brought Resident #11 inside. The DON confirmed the facility did not investigate how Resident #11 got outside on 01/11/24, how long he was outside, where he was in the parking lot, or who brought him back into the facility. Review of the facility's policy titled Elopements and Wandering Residents, revised 12/18/23, revealed no guidance regarding investigating the cause or circumstances of the wandering or elopement incident. 2. Review of the current care plan for Resident #11 revealed he was at risk for falls with multiple interventions, including a fall mat, perimeter mattress, and low bed. Review of the incident log dated 12/01/23 through 02/18/24 revealed Resident #11 fell , resulting in a fracture on 01/17/24. Further review revealed Resident #11 fell and had no injuries on 12/04/23, 12/13/23, 01/09/24, 01/12/24, 01/22/24, 01/24/24, 01/28/24, 01/31/24, 02/04/24, 02/06/24, and 02/14/24. Review of the incident report dated 12/04/23 revealed Resident #11 was found face down on the floor between the chair and the bed. An intervention was developed to put a fall mat next to the bed and lower the bed to the floor. Review of a progress note dated 12/05/23 revealed the interdisciplinary team (IDT) reviewed incident and new intervention for low bed and mat at side. The incident report and progress note did not state whether Resident #11 was in the bed or the chair prior to the fall. Review of the incident report dated 12/13/23 at 9:30 P.M. revealed Resident #11 was found on the floor in front of his recliner. Resident #11 stated he was trying to get up to go to bed. An intervention was developed to place call for assistance signs. Review of a progress note dated 12/15/23 revealed the IDT reviewed and new intervention for call for assistance sign. The incident report and progress note did not indicate whether Resident #11 had his call light within reach at the time of the fall. Review of the incident report dated 01/12/24 revealed Resident #11 was seated on the floor next to his bed in a wet brief. Resident #11 stated he was trying to get up, but could provide no additional information. Review of a progress note dated 01/16/24 revealed the IDT reviewed and continue low bed with mat at side. The incident report and progress note did not include if the fall mat and low bed were in place at the time of the fall. Review of the incident report dated 01/17/24 revealed Resident #11 was found with his head on the floor in his doorway. Resident #11 was unable to provide details regarding the fall. Resident #11 was assessed to be oriented to person, place and time, but not to situation. The physical assessment revealed a skin tear to his left forearm. Resident #11 was brought to bed by three staff. Review of the progress notes dated 01/17/24 and 01/18/24 revealed Resident #11 was observed on 01/17/24 at 7:10 P.M. with his head on the floor in his doorway. Resident #11 was assessed for injuries, including a skin tear to his left forearm. Resident #11 reported pain to his hip, and was transported to the local hospital by Emergency Medical Services (EMS). The incident report and progress note not show the facility investigated the cause of the fall, the whereabouts of the fall mat, or what Resident #11 was doing prior to the fall. Review of the hospital records for Resident #11 dated 01/17/24 revealed Resident #11 was identified with a left hip fracture, but due to previous hardware already in the vicinity, no operation was performed. Interview on 02/26/24 at 3:04 P.M. with the DON regarding fall investigations revealed the facility discussed falls during an IDT meeting and reviewed the circumstances, developed interventions, and updated the care plan as needed. The DON stated the evidence of their investigation into each fall was an IDT note in each resident's record. Continued interview with the DON confirmed all fall investigations were verbal and no additional documentation regarding their investigation was available. Further interview with the DON and concurrent review of the incident report for the fall on 01/12/24 revealed Resident #11 was found seated on the floor next to his bed. The DON was unable to verify whether the fall mat was in place. The DON directed Assistant Director of Nursing (ADON) #501 to interview LPN #201, who documented the fall on 01/12/24 and was working in the facility during the interview, and have LPN #201 write a statement regarding whether Resident #11 was on the fall mat when LPN #201 observed him on 01/12/24. On 02/26/24 at approximately 3:25 P.M., ADON #501 provided a statement, handwritten by LPN #201, dated 02/26/24. Review of the statement revealed Resident #11 was found on the floor next to his bed on 01/12/24 at 6:10 P.M. Resident #11 was seated on a floormat, and had no injuries. Further interview on 02/26/24 at 3:40 P.M. with the DON regarding the fall incident report for Resident #11 dated 01/17/24 at 7:10 P.M., resulting in a fracture, revealed the facility could provide no evidence they investigated the cause of the fall, the whereabouts of the fall mat, or what Resident #11 was doing prior to the fall. Interview on 02/26/24 at 4:29 P.M. with the DON, and concurrent review of a fall incident report for Resident #11 dated 12/04/23 at 3:20 P.M. revealed Resident #11 was found between the bed and the chair. The intervention was implemented was a fall mat and low bed. Interview with the DON revealed she could not verify whether Resident #11 was in the bed or the chair prior to the fall. The DON stated she would have to follow up with the nurse who documented the fall to determine where Resident #11 was prior to the fall. Continued interview at that time with the DON, and concurrent review of the fall incident report for Resident #11 dated 12/13/23 revealed the new intervention was to hang call for assistance signs. The DON could not verify whether Resident #11 had his call light within reach at the time of the fall. The DON stated call lights should be in reach, and staff would only document by exception; therefore, she would expect the call light was within reach. Review of the facility policy titled Fall Guidelines, revised 05/11/23, revealed the IDT would seek to identify and document resident risk factors for falls. Additionally, a plan would be developed after the information was gathered regarding a fall. This deficiency represents non-compliance investigated under Complaint Number OH00150753.

Based on observations, resident, resident representative, and staff interviews, record reviews, review of resident council notes, review of staff schedules, and review of facility policies, the facility failed to ensure there was sufficient nursing staff to meet the resident care needs. This affected three residents (#10, #34, and #45), and had the potential to affect all 74 residents residing in the facility. Findings include: Review of the Facility Assessment Tool, updated 01/05/23, revealed the competent staffing support to provide care for the resident population every day and during emergency range from three to nine direct care nurse aides per shift and two to four direct care nurses per shift. Review of the facility's Resident Census and Conditions of Residents dated 03/27/23 revealed 65 of 74 residents required staff assistance with transferring, 71 of 74 residents required assistance with toileting, and 74 residents required staff assistance with bathing. 1. Review of Resident #45's medical record revealed the resident was admitted on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance from staff with transferring and toilet use. Review of the progress notes dated 03/04/23 revealed Resident #45 sustained an unwitnessed fall with injury and was sent to the emergency room for evaluation. Review of the facility's incident report revealed Resident #45 fell on [DATE] at 7:58 A.M. Resident #45 was found by an STNA on the floor and hit her head. Resident #45 had a bump noted to her forehead and was complaining of pain to left hand and left forehead. There was no mention if Resident #45's call light was on or off at the time Resident #45 was found on the floor. Observation and interview on 03/27/23 at 12:02 P.M. revealed Resident #45 had bruising to the left inner corner of her eye. Resident #45 stated she remembered falling on 03/04/23 and stated she placed her call light on and waited for 45 minutes and then couldn't wait any longer to use the restroom and got up on her own. Resident #45 stated she fell , hit her face and head, and was sent out to the emergency room . Resident #45 stated she timed her call light waiting time by watching the clock in her room. Interview on 03/28/23 at 7:43 A.M. with State tested Nursing Assistant (STNA) #582 revealed she was working on 03/04/23 and was the only STNA on the hall when Resident #45 had tried to get up and fell on the floor. STNA #582 stated she was the only STNA on the hall and could not get to Resident #45 timely. Observation on 03/28/23 at 9:30 A.M. revealed Resident #45's clock in her room displayed the accurate time of day and appeared to be functioning. Review of the staffing schedule, dated 03/04/23, revealed three agency STNAs were scheduled for the hall Resident #45 resided on and two of the STNAs were marked as call offs. Interview on 03/30/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) #519 verified on 03/04/23, two agency aides had called off on Resident #45's hall. LPN #519 verified according to the schedule, there was only one STNA working on Resident #45's hall and there were three STNAs assigned to work on the hall on 03/04/23. 2. Review of Resident #34's medical record revealed the resident was admitted on [DATE]. Review of the care plan, dated 08/22/22, revealed Resident #34 required assistance with activities of daily living and preferred his showers two days per week and as needed on first shift. Review of the Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #34 was moderately cognitively impaired. Resident #34 was totally dependent on staff for bathing. Review of the facility's shower/whirlpool/bed bath documentation, dated 03/01/23 to 03/30/23, revealed Resident #34 received one shower on 03/30/23. Interview on 03/30/23 at 9:47 A.M. with State tested Nursing Assistant (STNA) #528 verified according to the documentation, Resident #34 has not had a shower in the last 30 days. STNA #528 stated Resident #34 was a confused and when they were short staffed, showers were more likely to be provided for the residents that were nagging about it. Interview on 03/30/23 at 12:13 P.M. with Resident #34 verified he would much rather have a shower then a washcloth to clean himself. 3. Review of Resident #10's medical record revealed Resident #10 was admitted on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 01/02/23, revealed Resident #10 was cognitively intact. Resident #10 required extensive one person assistance with bed mobility, transfers, and toilet use. Continuous observation on 03/28/23 from 7:09 A.M. to 7:36 A.M. revealed Resident #10's call light turned on at 7:09 A.M. and the call light remained on until it was answered at 7:36 A.M. (27 minutes). Interview on 03/28/23 at 7:43 A.M. with State tested Nursing Assistant (STNA) #582 verified it took staff a longer time to answer the call light at times but was not aware of the exact amount of time a resident would have to wait. STNA #582 stated Resident #10 utilized the call light for assistance out of bed to use the bathroom. Interview on 03/28/23 at 12:36 P.M. with Resident #10 verified this morning she pressed her call light to get up and use the bathroom but had to wait a while. Resident #10 did not know how long but stated that it was nothing compared to the weekends which were really lousy. 4. Interview on 03/27/23 at 9:45 A.M. with Resident #7 revealed there were not enough staff and there were supposed to be two state tested nursing aides (STNA) on the hall. Interviews on 03/27/23 revealed at 9:56 A.M., Resident #61 stated he has recently waited up to one hour for his call light to be answered. At 10:05 A.M., Resident #1 stated it takes a long time to get to the bathroom because of waiting on call lights. At 10:09 A.M., Resident #62 stated she has waited over 30 minutes for call lights, and it usually occurred on third shift. At 10:18 A.M., Resident #6 stated she had her call light on for one hour and ten minutes this morning (03/27/23) at 6:20 A.M. to go to the bathroom. Resident #6 reported when staff came into the resident room they took her roommate to the bathroom first and she did not even have her call light on and can walk to the bathroom herself. Interview on 03/27/23 at 12:00 P.M. with Resident #23's Resident Representative revealed the facility was very short of staff and every time they leave, they worried about Resident #23. Interview on 03/27/23 at 12:12 P.M. with Resident #26 revealed sometimes she waits so long for help she just does it herself. Resident #26 stated she knows she should not do it herself, but she gets tired or waiting or cannot wait any longer. Interview on 03/27/23 at 1:50 P.M. with Resident #35 revealed the facility was short staffed on second shift. Interview on 03/28/23 at 8:00 A.M. with STNA #587 revealed it was really difficult to meet the resident needs when there were only two STNAs working on a hall with about 30 residents when most of them required Hoyer lifts for transferring and were dependent on staff for care. Interview on 03/28/23 at 2:31 P.M. with Licensed Practical Nurse (LPN) #514 revealed the facility was often short of staff and agency staff called off frequently. LPN #514 reported they do their best but call lights can be on as long as 30 minutes. LPN #514 denied the residents had to wait one hour. Interview on 03/29/23 at 4:11 P.M. with STNA #583 verified she has worked first and second shift at the facility and had two halls (approximately 30 residents) to provide care to by herself. Interview on 03/30/23 at 9:47 A.M. with STNA #528 stated the facility often utilized agency staff and agency staff often called off or does not show up. Interview on 03/30/23 at 10:02 A.M. with LPN #519 revealed the first shift and second shift were ideally staffed with four nurses and eight to ten STNAs with a bare minimum of three nurses and five STNAs. Third shift was ideally staffed with three nurses and five aides. LPN #519 stated the schedule was posted four to six weeks in advance but the facility had a lot of as needed (PRN) staff. LPN #519 will contact PRN staff a week or two in advance to have them fill in. The facility utilized agency staff and LPN #519 stated they were attempting to to make them more accountable and send replacement staff if someone calls off. The agency was on-call 24 hours and LPN #519 communicated with them about their staffing needs. Interview on 03/30/23 at 1:50 P.M. with Resident #54's Resident Representative revealed concerns of staffing related to Resident #54's care. Resident #54 has a personal aide for 30 hours a week to ensure the minimum care and services were provided and there were continued concerns for staffing when they cannot be at the facility. Interview on 03/30/23 at 12:22 P.M. with the Administrator revealed the facility has prioritized recruiting new employees and discussed retention plans. The Administrator verified there has been challenges utilizing agency staff, specifically related to call offs, and has talked to the owner but has not had the positive result they hoped for. The Administrator discussed staffing expectations stating the facility expects to have an eight to one staff ratio on first and second shifts and a ten or twelve to one resident to staff ratio on third shift but when the facility goes below the state minimum or there were call offs, they send out a mass text to the leaders of the facility. The Administrator reported staffing has been the main priority. Review of the Resident Council Meeting Minutes, dated 12/27/22, revealed concerns included STNAs and nurses being understaffed and the Northwest hall needed more help with care. One resident stated she was left to finish sitting down alone as there was only one STNA available. Review of the facility policy titled Provision of Quality of Care, dated 10/11/22, revealed the facility will ensure residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Review of the facility policy titled Nursing Department- Staffing, dated 02/08/22, revealed the facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the nursing department, taking into consideration the resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with regulations and the facility assessment. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the nursing department. This deficiency represents non-compliance investigated under Master Complaint Number OH00141590 and Complaint Number OH00141316.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were properly sealed, labeled, and dated in the freezer and failed to maintain the refrigerator and freezer in a sanitary condition. This had the potential to affect all 74 residents identified by the facility as reviewing food from the kitchen. The facility census was 74. Findings include: Observations on 03/27/23 at 9:00 A.M. in the upright freezer revealed there were opened and unlabeled foods including a bag of grilled chicken breast, bag of chicken tenders. There was an opened, unlabeled, and undated food items which included bag of chocolate chip cookies and bag of french fries. Interview with Dining Services Manager (DSM) #559 at the time of the observation verified the opened, unlabeled and undated food items. Observations on 03/27/23 at 9:10 A.M. in the walk-in freezer revealed there was frost build up at the bottom of the fan unit inside the walk-in freezer with a nearby pipe with water that dripped and froze into two separate icicles hanging down. Interview with DSM #559 at the time of the observation verified findings. Observations on 03/27/23 at 9:12 A.M. in the walk-in cooler revealed metal storage racks with white crusty looking build-up on two separate racks, and milk crates containing gallons of milk seated directly on the floor. Interview with DSM #559 at the time of the observation verified findings. Review of the facility policy titled Date and Marking for Food Safety, dated 01/2023, revealed the facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for food safety. The guidelines for staffing indicate the marking system shall consist of a color-coded label, the day/date of opening and the day/date the item must be consumed or discarded. Review of the facility policy titled Food Safety Requirements, dated 01/2023, revealed the food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. The policy guidelines revealed for food will be stored in a manner that helps prevent from deterioration or contamination of the food including growth from microorganisms. Review of the facility policy titled Routine Cleaning and Disinfecting of Cooler/Freezer Racks, dated 11/2022, revealed the facility to ensure the provision of routing cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development of transmission of infections to the extent possible. The policy guidelines indicated routine cleaning and disinfection of cooler/freezer racks or visibly soiled surfaces will be performed quarterly or as needed.

Based on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure call lights were answered timely and the residents requiring assistance had access to call lights. This affected four (#10, #22, #54, and #60) of four residents reviewed for call lights. The facility census was 74. Findings include: 1. Review of Resident #10's medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included spastic hemiplegic cerebral palsy, mixed hyperlipidemia, pure hypercholesterolemia, essential (primary) hypertension, and unspecified convulsions. Review of the Minimum Data Set (MDS) assessment, dated 01/02/23, revealed Resident #10 was cognitively intact. Resident #10 required extensive one person assistance with bed mobility, transfers, walking in room, walking in corridor, dressing, toilet use, and personal hygiene. Resident #10 was always continent of bowel and bladder. Review of the care plan, updated 02/08/19, revealed Resident #10 was at risk for falls. Interventions included to ensure the call light was within reach, encourage the resident to transfer and change positions slowly, and to ambulate with gait belt and one assist. Continuous observation on 03/28/23 from 7:09 A.M. to 7:36 A.M. revealed Resident #10's call light turned on at 7:09 A.M. and the call light remained on until it was answered at 7:36 A.M. (27 minutes). Interview on 03/28/23 at 7:43 A.M. with State tested Nursing Assistant (STNA) #582 verified it took staff a longer time to answer the call light at times but was not aware of the exact amount of time a resident would have to wait. STNA #582 stated Resident #10 utilized the call light for assistance out of bed to use the bathroom and did not become incontinent while waiting. Interview on 03/28/23 at 12:36 P.M. with Resident #10 verified this morning she pressed her call light to get up and use the bathroom but had to wait a while. Resident #10 did not know how long but stated that it was nothing compared to the weekends which were really lousy. 2. Review of Resident #54's medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, essential (primary) hypertension, epilepsy, restlessness and agitation, and dementia without behavioral disturbance psychotic disturbance. Review of the MDS assessment, dated 02/14/23, revealed Resident #54 was unable to complete the interview. Resident #54 required extensive two person assistance with bed mobility and transfers and was required total dependence with locomotion on and off the unit, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 05/07/22, revealed Resident #54 required assistance with activities of daily living and one intervention was to keep the call light within reach at all times. Observation on 03/27/23 at 10:32 A.M. revealed Resident #54 was lying in bed with the call light on the floor next to the bed and out of reach. Interview on 03/27/23 at 10:35 P.M. with the Director of Nursing (DON) verified the call light was out of reach of Resident #54. 45751 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia, overactive bladder, sensorineural hearing loss, and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #22 had severely impaired cognition. Resident #22 required extensive assist of one for activities of daily living. Resident #22 required extensive assist of two for transfers. Observation on 03/29/23 at 2:29 P.M. of the call light for Resident #22 revealed the call light was dangling down towards the floor from the bedside enabler bar out of reach of the resident. Interview on 03/29/23 at 2:30 P.M. with Resident #22 verified she could not reach the call light and did not know where it was. Interview on 03/29/23 at 2:36 P.M. with Licensed Practical Nurse (LPN) #519 verified Resident #22's call light was not in reach. LPN #519 stated that she was unsure if Resident #22 could utilize the call light. 4. Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, major depressive disorder, dementia, altered mental status, and history of falling. Review of the MDS assessment dated [DATE] revealed Resident #60 was severely impaired cognition. Resident #60 required extensive assist of one for activities of daily living. Observation on 03/29/23 at 2:29 P.M. revealed Resident #60 was up in wheelchair facing away from the bed. Resident #60's call light was laying on the bed with the activator facing the wall. Interview on 03/29/23 at 2:36 P.M. with LPN #519 verified the call light was out of reach of Resident #60. LPN #519 asked Resident #60 what she would do if she could not use her call light and Resident #60 did not respond. LPN #519 cued Resident #60 to call out if she needed help if her call light was not within reach. Review of the facility policy titled Call Lights: Accessibility and Timely Response, reviewed 01/17/23, revealed staff will ensure the call light is within reach of the resident and secured as needed. This deficiency represents non-compliance investigated under Master Complaint Number OH00141590 and Complaint Number OH00141316.

Based on medical record review, resident interview, resident representative interview ,staff interview, and review of the facility policy, the facility failed to ensure residents received their choice of showers or bed baths. This affected two (#34 and #54) of two residents reviewed for choices. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic kidney disease stage three, dementia moderate with psychotic disturbance, anxiety disorder, restlessness and agitation, and muscle weakness. Review of the care plan, dated 08/22/22, revealed Resident #34 required assistance with activities of daily living and preferred his showers two days per week and as needed on first shift. Review of the Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #34 was moderately cognitively impaired. Resident #34 was totally dependent on staff for bathing. Review of the facility's shower/whirlpool/bed bath documentation, dated 03/01/23 to 03/30/23, revealed Resident #34 received one shower on 03/30/23. Review of the documentation revealed 56 bed baths were documented in the record, many were documented once on each shift on the same day. Interview on 03/27/23 at 10:49 A.M. with Resident #34 revealed staff will tell him it was his shower day but then he will not get one or they will tell him his blood sugar was too low to have one. Resident #34 stated he has not had a shower in a long time. Interview on 03/30/23 at 9:47 A.M. with State tested Nursing Assistant (STNA) #528 verified according to the documentation, Resident #34 has not had a shower in the last 30 days. STNA #528 stated Resident #34 was a confused and when they were short staffed, showers were more likely to be provided for the residents that were nagging about it. Interview on 03/30/23 at 12:13 P.M. with Resident #34 verified he would much rather have a shower then a washcloth to clean himself. Resident #34 stated he could not believe it but he received a shower this morning and it felt great. Resident #34 verified every evening staff provide him a washcloth and soap for him to clean up. Resident #34 verified staff do not give him the bed bath. 2. Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, epilepsy, restlessness and agitation, and dementia without behavioral disturbance psychotic disturbance. Review of the MDS Assessment, dated 02/14/23, revealed Resident #54 was unable to complete the interview. Resident #54 required extensive two-person assistance with bathing. Review of the care plan, dated 05/07/22, revealed Resident #54 required assistance with activities of daily living and interventions included to assist Resident #54 with all bathing needs based on the resident's preference. Resident #54 preferred her showers two days per week and as needed second shift. Review of the facility's shower/whirlpool/bed bath documentation, dated 03/01/23 to 03/30/23, revealed Resident #54 received three showers on 03/01/23, 03/15/23, and 03/23/23. Review of the documentation revealed 52 bed baths were documented in the record, many were documented once on each shift on the same day. Interview on 03/28/23 at 12:11 P.M. with Resident #54's personal aide verified Resident #54 was not able to refuse showers and showers were beneficial for the resident. Interview on 03/29/23 at 4:11 P.M. with State tested Nursing Assistant (STNA) #583 verified Resident #54's shower documentation for the last 30 days showed three showers have been provided. Review of the facility policy titled Resident Showers, dated 09/22/22, revealed the residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00141590 and Complaint Number OH00141316.

Based on record review, staff and resident interview, and review of the facility policy, the facility failed to develop a comprehensive care plan to address a resident's psychosocial needs. This affected one (Resident #37) of four residents reviewed for care planning. The facility census was 74. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included acute on chronic heart failure, chronic kidney disease, and peripheral vascular disease. Review of the physician order dated 01/20/23 revealed an order for psychiatric services for evaluation or follow up. services. Review of the baseline care plan for Resident #37 dated 01/24/23 revealed it was silent for psychological or behavioral health needs. Review of the comprehensive Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact, had experienced little interest or pleasure in doing things for the last 12 to 14 days, felt down or depressed two to six days and felt tired and had little to no energy the last seven to 11 days prior to the assessment. Review of the care conference summary dated 02/01/23 revealed Resident #37 was feeling down, tired, had changes in moving, and was feeling bad about self. Review of Resident #37's comprehensive care plan dated 02/07/23 revealed the care plan was silent for psychological or behavioral health needs. Interview on 03/28/23 at 10:30 A.M. with Licensed Practical Nurse (LPN) #518 verified Resident #37 refused care and LPN #518 stated Resident #37 was just giving up. Interview on 03/30/23 at 9:55 A.M. with Resident #37 revealed feeling down, having no energy and acknowledgement of refusals of care. Resident #37 stated willingness to talk to someone about the feelings. Interview with the Assistant Director of Nursing (ADON) #600 on 03/30/23 at 9:30 A.M. verified there was not a comprehensive care plan developed to meet the psychological needs of Resident #37. Review of the facility policy titled Provisions of Quality Care, dated 10/01/22, stated based on comprehensive assessment, the facility will ensure the resident receives treatment and care by qualified persons in accordance with professional standards of practice and a comprehensive person-centered care plans will be developed for each resident to ensure care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Based on medical record review, observations, resident representative and staff interview, and review of the facility policy, the facility failed to ensure a resident received activities upon the preference of the resident and choices of activities. This affected one (Resident #54) of one resident reviewed for activities. The facility census was 74. Findings include: Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, epilepsy, major depressive disorder recurrent, restlessness and agitation, and dementia without behavioral disturbance psychotic disturbance. Review of the Minimum Data Set (MDS) assessment, dated 02/14/23, revealed Resident #54 was unable to complete the interview. Resident #54 required extensive two-person assistance with bed mobility and transfers and required total dependence from staff with locomotion on and off the unit and personal hygiene. Review of the care plan, dated 05/18/22, revealed Resident #54 was care planned for specific music preferences including religious music, ABBA, 50's music, and finds comfort with prayer. The goal was to hear preferred types of music daily in her room as desired. Interventions include to arrange spiritual room visits as tolerated, assist and praise all efforts to participate in music as needed, invite the resident outside to the courtyard for music when the weather was nice as she tolerates, provide CDs with preferred type of music, keep radio on 99.5 FM, and send/escort resident to group musical activities that were appropriate and fit with the resident's taste. Review of the activity progress note, dated 08/18/22, revealed the note was a care conference note for the care conference meeting held on 08/18/22. Resident's behavior was disruptive due to her yelling out and grabbing. Activities will continue to provide room visits with music and stimulation. Review of the activity progress note, dated 11/09/22, revealed the note was a care conference note for the meeting to be held on 11/10/22. Resident #54 showed satisfaction in spiritual visits and music. Activities will continue to provide Resident #54 with room visits as tolerated to include music and hand massages/aromatherapy. Review of Resident #54's medical record revealed there was no documentation that Resident #54 attended any activities from 11/20/22 to 03/27/23. Observation on 03/27/23 at 10:32 A.M. of Resident #54 revealed the resident was lying in bed awake, and alone in her room with no music playing. Subsequent observations on 03/27/23 at 2:05 P.M. revealed Resident #54 awake and alert and alone in her room. Resident #54 was in a broda chair with no music playing. Resident #54 alternated between appearing calm and restless in the room. Observation on 03/27/23 at 3:40 P.M. revealed Resident #54 awake, alert and alone in her room with the television on to an unknown channel. Interview on 03/28/23 at 10:05 A.M. with State tested Nursing Assistant (STNA) #537 verified they had not observed Resident #54 involved in activities in or out of the resident room. Interview on 03/28/23 at 12:00 P.M. with Resident #54's personal aide reported she comes to the facility everyday and spends time with the resident. Resident #54 was always in her room and does not see staff offer activities to Resident #54. Interview on 03/29/23 at 11:34 A.M. with Activities Director #578 verified Resident #54 does better in a smaller group settings and one-on-one visits. Activities Director #578 verified all activity department resident documentation was documented in the resident progress notes. Activities Director #578 did not know the last date Resident #54 had activities participation. Interview on 03/29/23 at 11:41 A.M. with Activities Aide #580 reported Resident #54 had a personal aide and the family come in and then verified there were no documented activities with Resident #54. Review of the facility's undated policy titled Activities revealed it was the policy of the facility to provide ongoing program to support the residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Activities will be designed with the intent to enhance the resident's sense of well-being, belonging, and usefulness. Activities may be conducted in different ways including one-to-one programs.

Based on record review, observation, staff and resident interviews, and review of facility policy, the facility failed implement the facility policy for self-medication administration for Resident #76 and further failed to obtain physician orders for the medications being self-administered by Resident #76. This affected one (Resident #76) of three residents reviewed for choices. The facility census was 74. Findings include: Review of the medical record for Resident #76 revealed an admitted [DATE]. Diagnoses included a displaced intertrochanteric fracture of left femur, and macular degeneration. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. Further review of the medical record from 03/06/23 to 03/27/23 revealed there was no medication self-administration for Resident #76. There was no physician order for Resident #76 to self-administer his medications until 03/27/23. Observation on 03/27/23 at 9:24 A.M. revealed a bottle of over the counter eye drops and an over the counter bottle eye vitamins sitting on the right hand corner of the tray table in Resident #76's room. Additional observation made on 03/27/23 at 10:05 A.M. revealed the over the counter eye drops and an over the counter bottle eye vitamins were no longer on the tray table. Interview with Resident #76 on 03/27/23 at 10:05 A.M., at the time of the observation revealed the nurse removed the eye drops and eye vitamins explaining to Resident #76 they could no be kept at bedside. Resident #76 was visibly upset and did not understand why the eye drops and vitamins could not remain at the bedside since they had been at the bedside since admission. Interview with Licensed Practical Nurse (LPN) #518 on 03/27/23 at 11:00 A.M. verified the bottle of over the counter eye drops and an over the counter bottle of eye vitamins had been removed the tray table in Resident #76's room. LPN #518 stated orders did not exist for the medications and a medication self-assessment was not available for Resident #76. Further observation on 03/29/23 at 8:00 A.M. revealed the over-the-counter eye drops and the over-the-counter eye vitamins were on the tray table in Resident #76's room. Interview with Resident #76 at the time of the observation on 03/29/23 at 8:00 A.M. revealed the nurse had returned the eye drops and vitamins after an order had been obtained. Further review of the medical record for Resident #76 on 03/29/23 at 8:30 A.M. revealed a medication self-administration assessment was scanned into the electronic medical record on 03/28/23 and physician orders dated 03/27/23 for an eye vitamin (Preservision AREDS 2), one tablet twice a day and cooling comfort ophthalmic eye drops, two drops each eye as needed for dry, may keep at bedside. Review of the facility policy titled Resident Self-Administration of Medication, dated 06/15/22, revealed a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered, is care planned and an order exists for the medications being self-administered.