Based on observation, interview, record review and facility policy review, the facility failed to treat Resident #51 with dignity and respect. This affected one (Resident #51) of three residents reviewed for resident rights and had the potential to affect all 88 residents who resided in the facility. Findings include: Review of the medical record for Resident #51 revealed an admission date of 09/12/22. Diagnoses included diabetes mellitus type two, congestive heart failure, dementia and peripheral vascular disease. Observation on 06/09/25 at 6:54 A.M. of 200-hall back unit revealed Certified Nursing Assistant (CNA) #631 entered the unit and stood in the center of the hallway in front of Resident #51's room. Interview with CNA #631 reported arriving for day shift and was training and looking for the right area to be in. During the interview, Resident #51 was heard yelling out repeatedly from the room Help. Please come help me. CNA #631 then left the unit and did not make any attempt to inquire with Resident #51 to see what was needed. Observation on 06/09/25 at 6:56 A.M. on 200-hall back unit revealed Resident #51 quieted and ceased from repeated yelling out for assistance. Observation on 06/09/25 at 6:57 A.M. on 200-hall back unit revealed Licensed Practical Nurse (LPN) #513 entered the unit. Interview at the time of the observation confirmed LPN #513 revealed she was working day shift as a nursing assistant for the unit and was the only one. LPN #513 then passed in front of Resident #51's room, who was hollering out for help and inquired with the resident, who was in bed, asking for some tea. There was also no cup of water in the room. LPN #513 responded to Resident #51 of needing to get report first and then would get the tea. Observation on 06/09/25 at 7:06 A.M. on 200-hall back unit revealed Resident #51 was still waiting for the requested cup of tea. Observation on 06/09/25 at 7:17 A.M. on 200-hall back unit revealed Resident #51 was still waiting for the requested cup of tea. Observation on 06/09/25 at 7:43 A.M. of 200-hall back unit revealed Resident #51 was still waiting for the requested cup of tea. Observation on 06/09/25 at 7:53 A.M. of 200-hall back unit revealed Resident #51 remained in bed with no bedside table in reach, no requested tea and no water at the bedside. Interview on 06/09/25 at 7:56 A.M. with LPN #513 confirmed not having yet obtained Resident #51's requested tea, but stated the resident would get it on her breakfast tray anyway. Interview on 06/09/25 at 8:19 A.M. with Resident #51 complained about wanting the previously requested tea. The resident indicated probably getting it with breakfast but preferred to have it already. Observation on 06/09/25 at 8:25 A.M. of 200-hall back unit revealed a cart of four breakfast trays were brought onto the unit by LPN #513 who proceeded to pass them out; however, there was no tray on the cart for Resident #51 who was waiting for tea. Observation on 06/09/25 at 8:31 A.M. of 200-hall back unit revealed LPN #513 entered Resident #51's room and indicated going to get the resident dressed and up to have breakfast in the dining room. Observation on 06/09/25 at 8:39 A.M. of 200-hall back unit revealed LPN #513 left Resident #51's room with the resident dressed and still lying in bed with no bedside table in reach, water or tea. Interview at the time of the observation with LPN #513 indicated having to wait to get Resident #51 transferred out of bed because of needing a second staff member for the transfer. Observation on 06/09/25 at 8:47 A.M. of 200-hall back unit revealed Resident #51 remained in bed awaiting staff assistance to get up for breakfast in the dining room. Interview at the time of the observation with Resident #51 confirmed wanting to eat breakfast in the dining room, not the resident's room. Resident #51 complained of still not having a drink of tea. Interview with LPN #513 after speaking with Resident #51 verified having to wait for another staff member, but indicated the nurse aide who could help was busy, so LPN #513 was waiting for someone to become available. LPN #513 made no attempt to get Resident #51 some tea. Observation on 06/09/25 at 8:49 A.M. of Rosewood's main dining room revealed breakfast service had started and on 200-hall back unit, Resident #51 remained in bed. Interview on 06/09/25 at 8:54 A.M. with LPN #513 confirmed Resident #51 was still waiting to get out of bed for the dining room but indicated it was too late now because dining room service had finished so a tray would be ordered for Resident #51 to eat breakfast in the resident's room. Interview on 06/09/25 at 8:59 A.M. with Resident #51 on 200-back hall unit complained about having to eat breakfast in the resident's room instead of the dining room and further complained about being made to wait so long for tea. Interview on 06/09/25 at 9:06 A.M. with LPN #513 verified Resident #51's was made to eat breakfast in the resident's room because of not getting the resident out of bed quickly enough. LPN #513 made no attempt to get Resident #51 some tea. Observation on 06/09/25 at 9:13 A.M. on 200-back hall unit revealed LPN #513 with CNA #621 entered Resident #51's room and transferred the resident into a wheelchair. Observation on 06/09/25 at 9:18 A.M. on 200-back hall unit revealed Resident #51 who was sitting up in a wheelchair received a breakfast tray in the resident's room. Interview at the time of the observation with Resident #51 who expressed disappointment in having to remain in the room to eat but was glad to at least be out of bed. Observation and interview on 06/09/25 at 9:44 A.M. with Resident #51 on 200-hall back unit revealed there was no tea on the resident's breakfast tray as requested but instead received coffee. Resident #51 complained about receiving coffee instead of tea and did not want the coffee but wanted the tea now. Interview on 06/09/25 at 9:45 A.M. with LPN #513 on 200-hall back unit confirmed not checking to make sure Resident #51 received the requested tea but stated she would get the tea from the kitchen now and then left the unit. Observation on 06/09/25 at 9:49 A.M. of 200-hall back unit revealed LPN #513 returned to the unit and delivered a cup of hot tea to Resident #51, nearly three hours after the original request. This deficiency represents non-compliance investigated under Complaint Numbers OH00164344 and OH00165145.

Based on record review, observation, interview and facility policy review, the facility failed to maintain call lights within reach of Residents #24 and #50. This affected two (Residents #24 and #50) of 88 residents reviewed for call light accessibility. The facility census was 88. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 04/29/25. Diagnoses included Parkinson's disease, diabetes mellitus type two, dementia and overactive bladder. Observation on 06/09/25 at 5:06 A.M. of 200-hall middle unit revealed Resident #24 was hollering out for help. Upon room entrance, the resident was lying diagonally in bed with no sheet or blanket. A sheet appeared to be bunched up underneath both legs. There was no call light within reach as it was seen on the floor behind Resident #24's headboard of the bed. Interview with Resident #24 complained of needing changed because of feeling wet but could not find the call light. The resident accused staff of hiding the call light away because of using it too much and complained the staff made him get out of bed into a chair if he urinated too much in the bed, but he could not help it. Interview at the time of the observation with Registered Nurse (RN) #542 verified the observation and stated remembering leaving the resident's call light in reach but was uncertain how it ended up behind the headboard. Interview on 06/09/25 at 5:13 A.M. with Certified Nursing Assistant (CNA) #629 on 200-hall middle unit verified being the only nurse aide assigned to the unit and denied placing Resident #24's call light out of reach to prevent frequent calling, stating being unaware of how the resident's call light was placed behind the headboard. 2. Review of the medical record for Resident #50 revealed an admission date of 09/22/23. Diagnoses included chronic atrial fibrillation, sick sinus syndrome and cognitive communication deficit. Observation on 06/09/25 at 5:00 A.M. of 200-hall back unit revealed no staff on the unit. Resident #50's call light was on. Observation on 06/09/25 at 5:15 A.M. of 200-back hall unit revealed there continued to be no staff on the unit, and Resident #50's call light was still sounding. Observation on 06/09/25 at 5:18 A.M. of 200-back hall unit revealed there continued to be no staff on the unit, and Resident #50's call light remained on. Upon entering the resident's room, there was a strong odor of urine. Resident #50 was in a recliner chair located to the left of the bed. The resident's call light was not in reach and was seen on the floor located to the right of the bed. Resident #50 was holding her head and had a furrowed brow. Interview with the resident revealed a complaint of a terrible headache. When Resident #50 was asked how she was able to put the call light on since it was not in reach, she described having to get up from the recliner, walk around the bed, and pick up the call light from the floor to turn it on. Resident #50 complained about wishing the call light was next to her but could not figure out how to pull it over around the bed to where she was sitting, so she had no choice but to keep getting up to go use it. The resident then requested assistance to find staff to help. Observation on 06/09/25 at 5:20 A.M. of 200-hall back unit revealed there continued to be no staff on the unit, and Resident #50's call light remained sounding. Observation on 06/09/25 at 5:23 A.M. of 200-hall back unit revealed RN #542 enter the unit and answer Resident #50's call light. Interview at the time of the observation with RN #542 verified the strong odor of urine in the resident's room and the call light out of reach. Review of the facility policy, Use of Call Light, reviewed 01/06/25, revealed staff were to never make the resident feel you are too busy to give assistance, and be sure call lights were placed within reach of the resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00164344 and OH00165145.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility did not ensure Resident #52 was assisted with eating and drinking. This affected one (Resident #52) out of two residents reviewed that required feeding assistance. This had the potential to affect four (Residents #4, #36, #52, and #67) identified by the facility requiring assistance with feeding on the secured unit. Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/26/24 with diagnoses including Alzheimer's disease, diabetes, hypertension, right hip fracture, and anxiety disorder. Review of the weight record revealed Resident #52's weight recorded on 08/08/24 was 99.8 pounds and on 06/10/25 her weight was 89.6 pounds. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had impaired cognition as she was rarely or never understood. She required partial to moderate assistance with eating and substantial to maximum assistance with transfers. She was dependent on staff for toileting hygiene, lower dressing, showering and personal hygiene. Her weight was 92 pounds. Review of the June 2025 physician orders revealed Resident #52 was on a regular diet, received hospice services due to Alzheimer's disorder, and resided on the secure dementia unit. Review of the task bar in the electronic medical record (EMR) for meal intake percentage from 06/03/25 to 06/10/25 revealed Resident #52 had a varied appetite as either refusing to eat or ate up to 75 percent. On 06/06/25, Resident #52 ate less than 75 percent of breakfast and refused lunch and dinner. On 06/07/25 there was only one entry at 7:00 P.M. for one meal and that she ate less than 25 percent. There was no other documentation for 06/07/25. On 06/08/25 Resident #52 refused breakfast and only one other meal was documented as eating less than 25 percent. There was no documentation for 06/09/25 of any meal intakes and/or refusals. On 06/10/25, Resident #52 ate 50 percent at breakfast and 75 percent at lunch. Review of the task bar in the EMR for eating assistance from 06/03/25 to 06/10/25 revealed Resident #52 required substantial to maximum assistance and or was dependent on staff for eating. There was nothing documented for 06/09/25. Review of the care plan last revised 06/05/25 revealed Resident #52 had altered nutritional status evidenced by cognitive impairment related to Alzheimer's disease and diabetes. She was admitted to hospice. Interventions included alert dietician if consumption was poor for more than 72 hours, encourage adequate fluid and oral intake, supplements as ordered, and monitor and record the resident's intake after each meal. Review of the Nutritional assessment dated [DATE] and completed by Dietitian Tech #500 revealed Resident #52 was on a regular diet and was unable to make her needs known. Observation on 06/09/25 at 8:32 A.M. revealed trays came to the secured dementia care unit and Licensed Practical Nurse (LPN) #626 (working as an aide on the secured unit) and Certified Nursing Assistant (CNA) #554 began passing the trays. Resident #52 was sitting in the lounge/dining area in a Broda chair (a specialized recliner on wheels that was able to recline) that was reclined back with her eyes open sitting at a table. Staff placed the tray in front of her with the lid covering the plate, and silverware in the cloth napkin. Staff opened her milk but did not pour it in a cup or place a straw, and Resident #52 remained in a reclined position unable to reach her tray. Observation on 06/09/25 at 9:08 A.M. revealed LPN #626 and CNA #554 completed passing all the trays on the unit in the dining room and on the hall and proceeded to pick up the trays from residents that were finished. Resident #52 continued to be positioned in a reclined position in her Broda chair with her plate covered with a plastic lid, silverware continued to be wrapped in the cloth napkin, milk container open without a straw, all food and drink were out of reach of Resident #52 and no assistance and/or encouragement was offered. CNA #554 walked up to Resident #52's table and said, you not going to eat and Resident #52 mumbled what appeared nonsensical but this surveyor (approximately five feet away) was unable to hear what Resident #52 stated. CNA #554 proceeded to pick up her tray and placed it back on the cart without attempting to position Resident #52 from a reclined position, uncover her food, unwrap her silverware, and/or provide assistance with eating or drinking. Interview on 06/09/25 at 9:08 A.M. with CNA #554 revealed she had only worked at the facility three days, and she was told that Resident #52 does not eat breakfast and stated, so, no I do not try to get to eat. She then replied she did ask her, and she stated she did not want her food. She verified that she did not attempt to position Resident #52 properly to eat from a reclined position, uncover her food, unwrap her silverware, place a straw in her milk and/or pour her milk into a cup, provide food and/or drink within reach, attempt to encourage and/or assist Resident #52 to drink and/or eat. CNA #554 stated again, I was told she does not eat breakfast. Interview on 06/09/25 at 9:10 A.M. with LPN #624 (nurse assigned to the secured unit) who was passing medications on the hallway and in the area was asked about Resident #52 and not being assisted and encouraged with her breakfast and if there was anything regarding Resident #52 not eating breakfast. LPN #624 revealed, I really am not sure as she looked down and continued to prepare medications. Interview on 06/09/25 at 10:13 A.M. and 10:41 A.M. with Dietitian #589 and Registered Nurse (RN)/Unit Manager/Infection Control #531 verified per the nutritional assessment completed per Dietary Technician #500, Resident #52 was unable to make her needs known, her cognitive status per the MDS was impaired as she was rarely or never able to make needs known, and she required partial to moderate assistance with eating. RN/ Unit Manager/ Infection Control #531 revealed that since she had been back from the hospital, she was dependent on staff for eating and drinking. They verified staff should have positioned her in the Broda chair from a reclined position to upright, uncovered her food, unwrapped her silverware, applied a straw to her milk and assisted with encouraging and feeding her breakfast. Observation on 06/10/25 at 8:23 A.M. revealed the dietary cart came to the secured unit with trays on it. Observation revealed Resident #52 who was already sitting in an upright position in the lounge/dining room received her tray from CNA #622. CNA #622 proceeded to sit in a chair next to Resident #52 and apply butter and syrup to the waffle and cut into bite size pieces. She then prompted Resident #52 to open her mouth as she fed her breakfast. She proceeded in between bites to offer her a drink of water through a straw. CNA #52 had to encourage Resident #52 to open her mouth with each bite and drink. Resident #52 ate 50 percent of her breakfast after total assistance from staff. Interview on 06/10/25 at 8:33 A.M. with CNA #622 revealed Resident #52 was always dependent on staff to assist her with eating and drinking. She revealed somedays she did better with breakfast and others she did better with lunch and dinner. Review of the facility policy labeled, Dining and Meal Service, dated 06/08/22, revealed the dining experience would be person centered with the purpose of enhancing each individual resident's quality of life. Residents would be positioned comfortably for the meal and in a way that would assist with eating and drinking. The policy revealed staff would offer to open containers, remove lids, and cut food, as needed. The policy revealed appropriate staff would assist as needed to ensure adequate intake of food and fluids at the meal. This deficiency represents non-compliance investigated under Complaint Numbers OH00165146 and OH00164464.

Based on observation, interview, record review and review of facility policy, the facility did not ensure residents had proper signage upon entry to their room indicating oxygen was in use and/or there was a physician order for the use of oxygen. This affected two (Residents #24 and #33) out of three residents reviewed for oxygen use. This had the potential to affect 14 (Residents #3, #7, #14, #24, #27, #28, #33, #35, #41, #44, #49, #51, #65, and #71) identified by the facility on oxygen. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 06/06/25 with diagnoses including emphysema, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and acute and chronic respiratory failure. Review of the undated care plan revealed Resident #33 had ineffective breathing patterns as evidenced by shortness of breath, labored respirations due to COPD, emphysema and respiratory failure. Interventions included adjusting the head of bed and body positioning to assist with the ease of respirations, administering oxygen as ordered, administering respiratory treatments as ordered, monitoring and documenting signs of shortness of breath and reporting abnormal findings to the physician. Review of the June 2025 Physician Orders revealed Resident #33 had an order for oxygen at two liters per minute per nasal cannula as needed for COPD. Observation on 06/09/25 at 5:43 A.M. revealed Resident #33 was lying in his bed wearing oxygen per nasal cannula at two liters per minute. There was no sign indicating oxygen was in use upon the entry to Resident #33's room. Interview on 06/09/25 at 5:46 A.M. with Licensed Practical Nurse (LPN) #627 verified Resident #33 was utilizing oxygen in his room and there was no signage on the outside of the door indicating oxygen was in use. Review of the facility policy labeled, Oxygen Administration, dated 01/06/25, revealed the nurse was to check the physician order for liter flow and method of administration of the oxygen, and an oxygen in use sign was to be placed. 2. Observation on 06/09/25 at 5:06 A.M. of Resident #24 in bed with oxygen being administered via nasal cannula by a concentrator. Observation on 06/09/25 at 6:05 A.M. of Resident #24 in bed with oxygen being administered via nasal cannula by a concentrator. There was no oxygen safety sign displayed within the room or on the doorway. Interview at the time of the observation with Registered Nurse (RN) #542 verified there was no oxygen safety sign in place as required. Review of the medical record for Resident #24 revealed an admission date of 04/29/25. Diagnoses included Parkinson's disease, diabetes mellitus type two, dementia and overactive bladder. Review of Resident #24's physician orders effective June 2025 revealed no oxygen administration orders. Interview on 06/11/25 with LPN #632 verified Resident #24 received oxygen administration without active physician orders within the resident's medical record. Review of the facility policy Oxygen Administration, reviewed 01/06/25, revealed to check the physician's order for liter flow and method of administration, and place an oxygen in use sign. This deficiency represents non-compliance investigated under Complaint Number OH00164344.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of a self-reported incident (SRI), observation, and review of the facility policy, the facility did not ensure Resident #36 received trauma-informed care in accordance with professional standards of practice. This affected one (Resident #36) out of one resident reviewed for trauma informed care. This had the potential to affect four (Residents #36, #64, #84, and #87) identified by the facility with post-traumatic stress disorder (PTSD) and/or trauma. Findings include: Review of the medical record for Resident #36 revealed an admission date of 08/11/23 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), anxiety disorder, mood disorder, and depression. There was not a diagnosis of PTSD listed. Review of the Social Service admission assessment dated [DATE] and completed by Social Service Designee (SSD) #533 revealed he asked Resident #36 if she experienced any trauma or witnessed a traumatic event, and she stated no. Review of Social Service Quarterly Assessments completed by SSD #533 revealed he assessed Resident #36 on 11/08/24, 02/04/24, and 04/28/24. There was nothing on the assessments regarding assessing for trauma. Review of care plan dated 03/26/25 revealed Resident #36 demonstrated paranoia, hallucinations and unrealistic fears due to mood disorder, anxiety disorder, and dementia with agitation. Interventions included administering medications as ordered, referring to psych services as needed, encouraging the resident to participate in activities, and educating the resident on changes prior to making changes. There was nothing in the care plan regarding Resident #36 reporting she was sexually abused by a family member, any triggers identified (including soft mattresses) and/or any interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of the SRI with tracking number 258656 dated 03/26/25 revealed the Administrator filed an allegation of abuse as Resident #36 alleged Certified Nursing Assistant (CNA) #682 was rough during care as she laid her down abruptly. During the investigation, Resident #36 recanted her statement stating she was confused and continued to have flashbacks from her childhood trauma. The SRI revealed Resident #36 had delusions from when she was assaulted by a family member when she was younger. The SRI revealed Nurse Practitioner (NP) #643 and social service assessed the resident and psych services followed the resident. The SRI revealed the police department was notified. Review of the witness statement dated 03/26/25 and completed by Licensed Practical Nurse (LPN)/Unit Manager #632 revealed Resident #36 reported that CNA #682 threw her into the bed, a travel trailer with a hammock that folded into three pieces. Resident #36 then stated she was having flashbacks from when a family member raped her at the age of 13. The statement revealed Resident #36 stated soft mattresses scare her due to the rape. Resident #36 revealed the family member almost pulled her into the trailer and raped her again, but her dog had saved her. Resident #36 revealed she thinks her flashbacks were causing hallucinations and delusions. The statement revealed Resident #36 would like therapy for her flashbacks. Review of the police report dated 03/26/25 and completed by Police Officer #683 revealed Resident #36 stated a CNA #682 threw her on the bed. The report revealed Resident #36 was diagnosed with PTSD, hallucinations and other medical conditions. The report revealed the facility was investigating and would update the police on their findings. Review of the progress note dated 03/26/25 at 1:42 P.M. stated NP #643 revealed Resident #36 was making delusional statements as Resident #36 stated she was placed in a box with high sides and felt claustrophobic. Resident #36 also complained of insomnia as she was tossing and turning at night due to pain and thinking about things from the past. The note revealed she was talking about past sexual trauma when she was 13. NP #643 increased the trazodone (anti-depressant) to 150 milligrams at night and Resident #36 would benefit from psychiatric services. Review of Psych NP #645 progress note dated 04/15/25 revealed she collaborated with the floor nurse who revealed Resident #36 was at baseline but continued to experience hallucinations almost daily. Psych NP #645 evaluated and there was no documentation regarding the incident that was reported on 03/25/25 related to flashbacks of a family member sexually abusing her. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition with hallucinations and delusions. Review of the Social Service Quarterly assessment dated [DATE] and completed by SSD #533 revealed there were no psychosocial changes that may affect mood and there was no documentation that trauma was assessed. There was also no other documentation from 03/25/25 to 04/28/25 by SSD #533. Review of the progress note dated 05/13/25 revealed Psych NP #645 evaluated Resident #36, and there was no documentation regarding the incident that was reported on 03/25/25 related to flashbacks of a family member sexually abusing her. Review of the Kardex (guidelines provided to the staff regarding a resident's care) dated 06/11/25 revealed Resident #36 did not have anything regarding her history of potential trauma, triggers and/or interventions. Interview on 06/11/25 at 9:26 A.M., 9:50 A.M. and 1:28 P.M. with the Administrator verified the SRI dated 03/26/25 stated SSD #533 assessed Resident #36 after she stated she had been sexually abused as a child. She verified SSD #533 was never told about the incident as she just asked SSD #533 to do a routine psychosocial assessment as she did not want SSD #533 to have a biased opinion when he assessed her. When asked how SSD #533 could have assessed Resident #36 for trauma if he routinely does not assess for trauma during a routine psychosocial assessment unless there was a need, she did not reply. She verified Resident #36 stated she was sexually abused as a child, but the facility felt it was one of her delusions as Resident #36 had a history of delusions and hallucinations. She verified she did not have any documentation that SSD #533 assessed Resident #36 for trauma after the incident on 03/25/25. She also had no documentation stating psych services (a psychologist, counseling, and/or Psych NP #645) was consulted regarding Resident #36's statements of sexual trauma as a child. Interview on 06/11/25 at 9:45 A.M. with SSD #533 revealed he assessed Resident 36 on admission, 11/24/23, and she denied trauma. He revealed he does not assess any further for trauma unless there is a need. He revealed he was not aware of the SRI dated 03/26/25 regarding Resident #36 stating she was sexually abused in the past by a family member. The SRI dated 03/26/25 revealed SSD #553 assessed her after the incident; he verified he did not assess her for trauma as he did not know about her reporting she was sexually abused in the past. Interview on 06/11/25 at 10:18 A.M. with CNA #607 revealed she worked on the secured unit and revealed she was not aware of any past trauma events for Resident #36 including sexual abuse, any triggers and/or any interventions. She revealed if there was it would show up on the Kardex. She reviewed Resident #36's Kardex with this surveyor and stated there was nothing on the Kardex related to history of sexual abuse, any triggers and/or any interventions Interview on 06/11/25 at 10:38 A.M. with Resident #36 she appeared happy and smiling as she talked about how she trained dogs and how she loved animals. When asked if she ever had any trauma in her life, Resident #36 stated lots of things and many things that she cared not to remember. She revealed a family member that she specifically identified was a bad man as when her mother worked night shift, the man would come into her room when she was young, and she stated molested her. During the interview, Resident #36's mood changed as she looked down, avoided eye contact and seemed upset. She then proceeded to state that she would rather not talk about it as nobody can do anything now as he no longer was on earth. Interview on 06/11/25 at 10:42 A.M. with Psych NP #645 revealed she comes into the facility once a week, and she sees each resident in need of services approximately every one to two months or as needed. She revealed she does not recall the facility notifying her regarding Resident #36 talking about a past trauma that included sexual abuse. This surveyor reviewed the SRI dated 03/26/25 and witness statement by LPN/ Unit Manager #632 and she again revealed she did not recall being notified. She stated she would have documented that in her notes if she was notified. Review of the facility policy labeled, Trauma- Informed Care and Post- Traumatic Stress Disorder (PTSD), dated 01/06/25, revealed PTSD was a trauma- related disorder caused by an individual's exposure to actual or threatened death, serious injury, or sexual violence in one or more ways including directly experiencing the traumatic event or witnessing the event in person. The policy revealed residents would be referred to psych services. The policy did not include anything regarding assessing residents for trauma and ensuring triggers were identified in a resident's plan of care. This deficiency is an incidental finding identified during the complaint investigation.

Based on review of medical record, observation, interview, review of Center for Disease Control and Prevention (CDC) guidelines and review of facility policy, the facility did not ensure proper signage was utilized to identify Resident #78 was on transmission-based precautions (TBP) and did not ensure medical equipment was cleaned properly between resident use. This affected one (Resident #78) out of one resident identified by the facility on TBP and two (Residents #31 and #80) of three residents observed for proper infection control during the use of medical equipment. The facility census was 88. Findings include: 1. Review of the medical record for Resident #78 revealed an admission date of 06/07/25, and she had no diagnoses listed. On 06/09/25, diagnoses were added that included malignant neoplasm of the bone, adult failure to thrive, malignant neoplasm of the breast, hypertension, and depression. Review of lab report completed at the hospital prior to admission for Resident #78 revealed a specimen was collected on 06/04/25 and resulted on 06/06/25 indicating Resident #78's parvovirus (a seasonal respiratory virus that was transmitted through respiratory droplets by people with symptomatic and asymptomatic infection. Isolation precautions were recommended in healthcare settings) B19 immunoglobulin G (igG) was 1.82 (a level 1.10 or greater indicated it was positive which may indicate a current or past infection). Review of the care plan dated 06/07/25 revealed Resident #78 was on strict droplet isolation due to parvovirus. Interventions included all services to be in her room, droplet TBP, post sign on door to see the nurse before entering, resident to reside in private room, and monitor for sign and symptoms of depression due to isolation status. Review of the physician order dated 06/07/25 revealed Resident #78 was on droplet TBP and to post a sign on entry door to see the nurse before entering and wear gloves, mask, and gown as needed. The order also included to provide personal blood pressure cuff, stethoscope, and thermometer. The order revealed to wash hands when touching environment and with direct patient care and all care activities and therapies were to be provided in her room. Observation on 06/09/25 at 5:35 A.M. revealed Resident #78's door was closed, and a yellow bag was on the outside of the door that contained personal protective equipment (PPE) that included gloves, gown, and masks. There was no signage on the outside of the door indicating Resident #78 was on TBP or what type of TBP. Interview on 06/09/25 at 5:28 A.M. with Certified Nursing Assistant (CNA) revealed she was the CNA assigned to Resident #78 and stated she thought Resident #78 was on isolation but was unsure of what type. She verified there was no signage on the entrance of the room indicating type of TBP. Interview on 06/09/25 at 5:40 A.M. with Licensed Practical Nurse (LPN) #627 revealed he had gotten in report that Resident #78 was on TBP due to breast cancer but was unsure. He checked through her electronic medical record and stated he did not find anything regarding why she was on TBP including what type. Interview on 06/09/25 at 5:43 A.M. with LPN #627 revealed he had found out that Resident #78 was on droplet TBP due to parvovirus. He verified that there was no signage on the entry of Resident #78's room, just the yellow bag with PPE. Interview on 06/09/25 at 12:08 P.M. with Registered Nurse (RN)/Unit Manager/Infection Control Designee #531 verified Resident #78 had no diagnoses listed in her electronic medical record indicating type of infection. She revealed medical records usually inputted the diagnoses after a resident was admitted . She revealed the admitting nurse should have placed proper signage on the entrance of the doorframe to her room indicating the type of TBP. She revealed in the report the nurse should have communicated with the oncoming nurse the type of TBP and reason of. She verified Resident #78 was on droplet TBP due to parvovirus. Review of the facility policy labeled, Isolation Precautions, dated 01/06/25, revealed TBP would be used for known or suspected infections for which the route of transmission/prevention was known. TBP categories were airborne, droplet, or contact. The policy had nothing in the policy regarding proper signage upon entry to the room or regarding ensuring staff/visitors were aware of type of TBP to be utilized. Review of the facility policy labeled, Antibiotic Stewardship Program, dated 01/06/25, revealed nursing staff would notify the infection preventionist or designee when an infection was suspected as this would allow early detection and management of a potential infection as well as implementation of appropriate TBP. The policy did not include anything regarding proper signage upon entry to the room or regarding ensuring staff/visitors were aware of type of TBP to be utilized. Review of the CDC guidelines labeled Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Condition, dated 02/07/25, revealed droplet TBP per recommended for parvovirus. The guidelines recommended maintaining precautions for the duration of the stay when chronic disease occurs in an immunocompromised patient. 2. Observation on 06/10/25 at 7:55 A.M. of medication administration revealed LPN #630 entered Resident #80's room with eight prepared medications for administration while pulling the vital signs monitor on wheels retrieved from the hallway. LPN #630 removed the blood pressure cuff from the monitor's storage basket and without sanitizing it prior to use, applied it to Resident #80's left arm and obtained a blood pressure reading. LPN #630 then placed the cuff back into the monitor's storage basket, administered the resident's medications and left the room pulling the vital signs monitor back into the hallway without sanitizing it after use. LPN #630 then entered Resident #31's room while pulling the same uncleaned vital signs monitor from the hallway, removed the soiled blood pressure cuff from the monitor's storage basket, and obtained the resident's blood pressure reading without sanitizing it prior to use. LPN #630 then returned it to the same storage basket, left the room without sanitizing the equipment and stored the monitor back in the hallway before proceeding on with medication administration to Resident #31. Interview on 06/10/25 at 8:24 A.M. with LPN #630 confirmed the vital signs monitor was not sanitized appropriately prior to or after use between Residents #80 and #31 but indicated there were sanitizing wipes usually available on the medication cart for that purpose. Review of the medical record for Resident #80 revealed an admission date of 06/03/25. Hospital discharged records dated 06/03/25 indicated the resident had B-cell lymphoma with bone involvement, was status post chemotherapy, and was immunocompromised. Review of the medical record for Resident #31 revealed an admission date of 04/20/25 with diagnoses including diabetes mellitus type two, malignant neoplasm of the pancreas and heart failure. This deficiency represents non-compliance investigated under Complaint Number OH00164974.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, review of the PBJ (Payroll-Based Journal) Staffing Data Report, and review of facility assessment, schedules, incidents logs, resident care lists, policies and the staffing tool, the facility failed to provide adequate staffing to meet resident needs in the Rosewood residential area which contained three units, 200-hall front (a secured memory care unit), 200-hall middle, and 200-hall back. This affected 47 residents (#2, #3, #4, #5, #7, #8, #9, #10, #12, #14, #19, #20, #22, #24, #25, #27, #28, #30, #35, #36, #38, #40, #42, #45, #47, #49, #50, #51, #52, #55, #57, #58, #59, #60, #61, #62, #67, #68, #70, #71, #72, #75, #76, #79, #83, #84 and #85) who resided in the Rosewood residential area. The facility census was 88. Findings include: Review of the facility census effective 06/08/25 revealed the Rosewood residential area, 200-hall front unit had 17 residents residing there, 200-hall middle unit had 16 residents, and 200-hall back unit had 14 residents. Observation on 06/09/25 at 4:58 A.M. of the night shift in the Rosewood residential area revealed upon entering through the double doors leading to all three units was a strong odor of urine which lingered. There was one nurse for all three units, one nursing assistant for 200-hall front (secured) unit, one nursing assistant for 200-hall middle unit, and no nursing assistant assigned to 200-hall back unit. Interview at the time of the observation with Registered Nurse (RN) #542 verified the staffing assignments and indicated not only being the nurse for all three units, but also having to work as the nursing assistant for 200-hall back unit. Observation on 06/09/25 at 5:00 A.M. of 200-hall back unit revealed no staff on the unit. Resident #50's call light was on, and Resident #27 was lying in bed with the light on leaning to the left in a fetal-like position. Observation on 06/09/25 at 5:06 A.M. of 200-hall middle unit revealed Resident #24 was hollering out for help. Upon entering the room, the resident was lying diagonally in bed with no sheet or blanket. A sheet appeared to be bunched up underneath both legs. There was no call light within reach as it was seen on the floor behind Resident #24's headboard of the bed. Interview with Resident #24 complained of needing changed because of feeling wet but could not find the call light. The resident accused staff of hiding the call light away because he used it too much and complained the staff made him get out of bed into a chair if he urinated too much in the bed, but he could not help it. Visible on the left knee was a small red discolored area which appeared to be an abrasion. Resident #24 indicated falling but could not remember when. Interview at the time of the observation with RN #542, who had pharmacy packaged medications in hand, verified the observation and stated remembering leaving the resident's call light in reach but was uncertain how it ended up behind the headboard. RN #542 indicated needing to handle the pharmacy medication delivery and then would return to provide incontinence care. Observation on 06/09/25 at 5:12 A.M. of 200-back hall unit revealed no staff on the unit, and Resident #50's call light was still on. RN #542 completed the pharmacy delivery at the nurse's station area and then went onto 200-hall middle unit, obtained clean linens, and entered Resident #24's room. Interview on 06/09/25 at 5:13 A.M. with Certified Nursing Assistant (CNA) #629 on 200-hall middle unit verified being the only nurse aide assigned to the unit, and residents who needed two staff assistance for care or mechanical lifts would wait until the nurse or nurse aide from the secured unit (200-hall front) came over to help. CNA #629 insisted on only working on 200-hall middle unit and denied knowing who was attending the 200-hall back unit because she was not going over there. CNA #629 complained about how difficult it was to complete care because of being alone and newly hired but would leave the unit to find help when needed. The nurse aide denied placing Resident #24's call light out of reach to prevent frequent calling and reported being unaware of how the resident's call light was placed behind the headboard. Observation on 06/09/25 at 5:15 A.M. of 200-back hall unit revealed there continued to be no staff on the unit, and Resident #50's call light which was initially seen on at 5:00 A.M. was still sounding. Observation on 06/09/25 at 5:18 A.M. of 200-back hall unit revealed there continued to be no staff on the unit, and Resident #50's call light remained on. Upon entering the resident's room, there was a strong odor of urine. Resident #50 was in a recliner chair located to the left of the bed. The resident's call light was not in reach and was seen on the floor located to the right of the bed. Resident #50 was holding her head and had a furrowed brow. Interview with the resident revealed a complaint of a terrible headache. When Resident #50 was asked how she was able to put the call light on since it was not in reach, she described having to get up from the recliner, walk around the bed, and pick up the call light from the floor to turn it on. Resident #50 complained about wishing the call light was next to her but could not figure out how to pull it over around the bed to where she was sitting, so she had no choice but to keep getting up to go use it. The resident then requested assistance to find staff to help. Observation on 06/09/25 at 5:20 A.M. of 200-hall back unit revealed there continued to be no staff on the unit, and Resident #50's call light remained sounding. Peering through the 200-hall front (secured) unit entrance door window, no staff was seen. On 200-hall middle unit, there was no staff seen in the hallway. Observation on 06/09/25 at 5:23 A.M. of 200-hall back unit revealed RN #542 enter the unit and answer Resident #50's call light. Interview at the time of the observation with RN #542 verified the strong odor of urine in the resident's room and the call light out of reach. RN #542 did not check for incontinence care need but put the call light in the resident's reach and assessed the pain level. After exiting Resident #50's room, RN #542 reported the resident was known to change her own briefs at times and had a tendency to put used briefs in the bathroom but continued down the unit's hallway without investigating the resident's need for incontinence care and left the unit. Observation on 06/09/25 at 5:25 A.M. of 200-hall front (secured) unit revealed one nurse aide present, CNA #517. Interview at the time of the observation with CNA #517 verified being the only staff member on the secured unit and not permitted to leave it unless it was covered by another staff member but admitted to having no choice but leave long enough to find another staff member for assistance or find the nurse when needed. CNA #517 described the unit as having several residents who required two staff assistance with care or mechanical lifts, and one resident (#8) who had behaviors at times requiring up to three staff members to complete care, so it was difficult to get enough help together for that resident. CNA #517 stated being unable to adequately monitor wanderers for safety or be present to redirect behaviors like wandering in and out of or rummaging in other resident rooms because of being alone on the unit. CNA #517 expressed a belief that falls had increased lately because the unit was full of 17 residents and there once was always two nurse aides on the unit but now there was only one nurse aide, and since the nurse covers all three units, the nurse was not able to be on the unit helping with resident behaviors or watching for safety. CNA #517 reluctantly acknowledged, in general, there were times when a second staff member could not be found so mechanical lifts or care would be completed with one staff member because there were no other options. At the time of the interview, CNA #517 looked across the hallway into Resident #79's room and saw the resident had self-transferred from the bed for toileting. The nurse aide entered the room and encouraged the resident to call for assistance to prevent falls then proceeded to address Resident #79's needs. Interview at 06/09/25 at 5:33 A.M. with RN #542 on 200-hall middle confirmed being responsible for completing nurse aide responsibilities on 200-hall back as well as the nurse but was not able to make it back on the unit yet. RN #542 verified being the only one available to provide incontinence care or rounds to check and change but stated there were not too many incontinent residents there. RN #542 was unable to report the last time 200-hall back received any rounds or assistance with incontinence care but confirmed it was at some time prior to 5:00 A.M. RN #542 acknowledged it was difficult to perform nurse aide tasks for an entire unit in addition to doing all the nursing responsibilities for all three units and still be able to keep up timely with resident needs as some tasks may be late or not get done. Observation on 06/09/25 at 5:35 A.M. of 200-hall back revealed no staff on the unit. Observation on 06/09/25 at 5:40 A.M. of 200-hall back revealed RN #542 returned to the unit with a medication cart and administered pain medication to Resident #50 in fulfillment of the request made at 5:23 A.M. Observation on 06/09/25 at 5:44 A.M. revealed RN #542 exited Resident #50's room, left the 200-hall back unit and entered the 200-hall front (secured) unit, leaving no staff on the 200-hall back unit. Observation on 06/09/25 at 5:48 A.M. of 200-hall middle unit revealed at the center of the unit was a small common area with chairs and an adjacent hallway table between the rooms for Residents #30 and #68. Setting on the chair next to the hallway table was an opened package of barbeque potato chips, and a wadded-up blanket. Setting on the hallway table was a portable space heater plugged in and blowing warm air toward the chair with the wadded-up blanket and opened bag of potato chips. Setting next to the space heater on the table was a cellphone with ear buds attached, and an ear bud case was located on the chair seat near the potato chips. Underneath the chair with the opened bag of potato chips there were multiple pieces of food debris on the floor. Nearby were some personal items including a bag with reading books. Interview at the time of the observation with CNA #629 confirmed the personal belongings, food items, cellphone and running space heater belonged to her, as she was using the spot to watch the unit because of not being able to take breaks away from the unit. Observation on 06/09/25 at 5:51 A.M. of 200-hall middle unit revealed a lingering faint smell of urine within the hallway. Interview at the time of the observation with CNA #629 verified the observation. Observation on 06/09/25 at 5:55 A.M. at the front of 200-hall back unit revealed a strong urine odor. RN #542 was seen administering medications, and no other staff were on the unit to address incontinence care needs. Observation on 06/09/25 at 6:04 A.M. of 200-hall middle unit revealed CNA #629 entered Resident #28's room with the mechanical lift and transferred the resident from the bed to Geri chair with the assistance of Resident #28's private aide, CNA #646 who was present in the room, in lieu of obtaining assistance from a facility staff member. Observation on 06/09/25 at 6:13 A.M. of 200-hall back unit revealed no staff were present on the unit. Interview with Resident #51 complained of feeling wet and not being changed during the night. There was no water at the bedside. Observation on 06/09/25 at 6:15 A.M. of 200-hall back unit revealed Resident #71 self-transferring to the bathroom for toileting and no call light on. Interview at the time of the observation with Resident #71 complained the facility was short on staff and many residents who cannot help themselves wait a long time for help. Observation on 06/09/25 at 6:21 A.M. of 200-hall back unit revealed no staff on the unit. CNA #517 left 200-hall front (secured) unit unattended to find RN #542 who was on 200-hall middle unit and discussed an unknown resident on the secured unit who was in pain and needed medication. CNA #517 then returned to the secured unit within three minutes. Observation on 06/09/25 at 6:25 A.M. of 200-hall middle unit revealed CNA #629 in the middle of the hallway at the common area sitting in the chair with a blanket and space heater blowing heat toward her and manipulating the screen of the cellphone with the attached earbuds. RN #542 approached CNA #629 and spoke unknown words to the nurse aide who shortly thereafter stood up and returned to working within the unit. Interview on 06/09/25 at 6:29 A.M. with Resident #28's private aide, CNA #646, on 200-hall middle unit who complained there was usually only one nurse aide assigned to the hallway especially at night so it was a typical scenario of not enough help for those who need more than one staff member for assistance, which was why CNA #646 assisted the facility nurse aide with the resident's mechanical lift transfer. CNA #646 stated it was likely why Resident #28's family hired private aides to make certain care was received. Observation on 06/09/25 at 6:31 A.M. of 200-hall back unit revealed no staff on the unit and no rounds to check for incontinence yet seen. RN #542 was observed to be on 200-hall front (secured) unit through the unit's window. Observation on 06/09/25 at 6:35 A.M. of 200-hall back unit revealed no staff remained on the unit. Interview on 06/09/25 at 6:38 A.M. with Resident #71 on 200-hall back unit, who complained about not having enough staff and no one in the hallway for help and described call lights being on for long periods or not being able to find any staff when needed. Interview on 06/09/25 at 6:40 A.M. with Resident #47 on 200-hall back who requested help to put a sweater on and complained about not being able to find any staff on the unit to help, then turned on the call light. Observation on 06/09/25 at 6:42 A.M. of 200-hall back unit revealed RN #542 entered the unit and assisted Resident #47 then left the unit and returned to 200-hall front (secured unit) when Resident #55's call light turned on who resided on 200-hall back unit. Observation on 06/09/25 at 6:48 A.M. of 200-hall back unit revealed Resident #55's call light remained on and there were no staff on the unit. Observation on 06/09/25 at 6:54 A.M. of 200-hall back unit revealed Resident #55's call light remained on, and there were no staff on the unit. CNA #631 entered the unit and stood in the center of the hallway in front of Resident #51's room. An interview with CNA #631 reported arriving for day shift and was training and looking for the right area to be in. During the interview, Resident #51 was heard yelling out repeatedly from the room Help. Please come help me. CNA #631 then left the unit and did not make any attempt to answer Resident #55's call light or inquire with Resident #51 to see what was needed. Observation on 06/09/25 at 6:56 A.M. on 200-hall back unit revealed Resident #51 quieted and ceased from repeated yelling out for assistance. There were no staff on the unit, and Resident #55's call light remained on. Observation on 06/09/25 at 6:57 A.M. on 200-hall back unit revealed Licensed Practical Nurse (LPN) #513 entered the unit. Interview at the time of the observation confirmed LPN #513 was the day shift nurse assigned to work as a nursing assistant for the unit and would be the only one. LPN #513 then passed in front of Resident #51's room, who was hollering out for help and inquired with the resident, who was in bed, and asked for some tea. There was no cup of water in the room. LPN #513 responded to Resident #51 of needing to get report first and then would get the tea then left the room and the unit. Resident #55's call light remained on. Observation on 06/09/25 at 6:59 A.M. on 200-hall back unit revealed Resident #55's call light remained on. Interview with Resident #55 at the time of the observation complained of wanting to get out of bed and was waiting a long time for help. Observation on 06/09/25 at 7:00 A.M. on 200-hall back unit revealed LPN #513 returned to the unit and entered Resident #55's room to provide assistance. Day shift staff were now observed in the Rosewood area. There were two nurses for all three units, and one nurse aide for each of the three units with an additional trainee on 200-hall front (secured) unit. Observation on 06/09/25 at 7:06 A.M. on 200-hall back unit revealed Resident #50's call light went on, and Resident #51 was still waiting for the requested cup of tea. Observation on 06/09/25 at 7:07 A.M. on 200-hall back unit revealed LPN #513 exited Resident #55's room, left the unit and returned with another staff member to Resident #55's room. Observation on 06/09/25 at 7:13 A.M. on 200-hall back unit revealed LPN #513, and the unknown staff member exited Resident #55's room who was now up in a wheelchair and both staff left the unit. Resident #50's call light was still on and no rounds to check for or provide incontinent care or repositioning had been completed since prior to 5:00 A.M. as stated by RN #542. Observation on 06/09/25 at 7:17 A.M. on 200-hall back unit revealed LPN #513 returned to the unit and answered Resident #50's call light. Resident #27 was still lying in bed, leaning to the left in a fetal-like position as originally observed at 5:00 A.M, and Resident #51 was still waiting for the requested cup of tea. Observation on 06/09/25 at 7:23 A.M. of 200-hall back unit revealed LPN #513 entered Resident #27's room and asked if the resident desired to get up, which Resident #27 responded affirmatively and then LPN #513 left the room stating the resident required a mechanical lift for transferring so she would have to find help from another staff member. LPN #513 then left the unit. Interview on 06/09/25 at 7:24 A.M. with Resident #27 complained about being wet and needing changed stating it had been a long since being helped last. Observation on 06/09/25 at 7:26 A.M. of 200-hall back unit revealed Resident #45 yelling out from the room repeatedly, get me up. There were no staff seen on the unit. Interview at the time of the observation with Resident #45 complained of needing changed and stated it had been a long time. The resident also requested breakfast. Observation on 06/09/25 at 7:30 A.M. of 200-hall back unit revealed no staff on the unit. Observation on 06/09/25 at 7:35 A.M. of 200-hall back unit revealed LPN #513 returned to the unit and went into Resident #45's room who was yelling out, exited the room at 7:38 A.M., and then left the unit. Observation on 06/09/25 at 7:43 A.M. of 200-hall back unit revealed no staff on the unit. Rounds to check for or provide incontinent care or repositioning had not yet been completed since prior to 5:00 A.M. as stated by RN #542. Residents #27, #45 and #51 continued to wait for assistance. Observation on 06/09/25 at 7:46 A.M. of 200-hall back unit revealed LPN #624 entered the unit with a medication cart and began administering medications. LPN #513 then re-entered the unit, spoke with LPN #624 and started having to go find stuff indicating having not been a nurse aide for about 12 years. LPN #513 then left the unit. Observation on 06/09/25 at 7:53 A.M. of 200-hall back unit revealed Resident #51 remained in bed with no bedside table in reach, no requested tea and no water at the bedside. Observation on 06/09/25 at 7:56 A.M. of 200-hall back unit revealed LPN #513 returned to the unit and entered Resident #27's room for incontinent care. LPN #513 reported never having been a nurse aide on the floor before and was not warned ahead of time to prepare for the day. LPN #513 removed Resident #27's heavily soiled brief with urine and stool. The outermost portion of the stool appeared dried, and upon cleansing the buttocks area it appeared reddened. LPN #513 verified the area was reddened and appeared to be irritated from the stool being on the skin. Barrier cream was applied to the area followed by a clean brief and repositioning. At the time, Resident #27 expressed concern to LPN #513 of never wanting another pressure ulcer and asked if she was okay. In response, LPN #513 provided encouragement and answered affirmatively. Continued interview with LPN #513 confirmed there was not enough staff for incontinent rounds stating no knowledge of when the residents last received incontinent checks or care since she had not received any report from the off going night shift staff. LPN #513 additionally stated being uncertain when any rounds could be performed because she had to concentrate on getting residents ready for breakfast. Resident #27 was repositioned to the right side and upon LPN #513 leaving the room confirmed not having yet obtained Resident #51's requested tea, but stated the resident would get it on her breakfast tray. Observation on 06/09/25 at 8:08 A.M. of 200-hall back unit revealed LPN #513 entered Resident #45's room, transferred the resident into a shower chair and went to the shower room. Interview on 06/09/25 at 8:19 A.M. with Resident #51 complained about wanting the previously requested tea. The resident indicated probably getting it with breakfast but preferred to have it already. Observation on 06/09/25 at 8:23 A.M. of 200-hall back unit revealed LPN #513 returned from the shower room with Resident #45 and then transported her to the dining room for breakfast. Observation on 06/09/25 at 8:25 A.M. of 200-hall back unit revealed a cart of four breakfast trays were brought onto the unit by LPN #513 who proceeded to pass them out; however, there was no tray on the cart for Resident #51 who was waiting for tea. Observation on 06/09/25 at 8:31 A.M. of 200-hall back unit revealed LPN #513 entered Resident #51's room and indicated going to get the resident dressed and up to have breakfast in the dining room. Observation on 06/09/25 at 8:38 A.M. of 200-hall front (secured) unit revealed Resident #4's call light was on. Observation on 06/09/25 at 8:39 A.M. of 200-hall back unit revealed LPN #513 left Resident #51's room with the resident dressed and still lying in bed with no bedside table in reach and no water or tea. Interview at the time of the observation with LPN #513 indicated having to wait to get Resident #51 transferred out of bed because of needing a second staff member for the transfer. Observation on 06/09/25 at 8:45 A.M. of 200-hall front (secured) unit revealed Resident #4's call light remained on. Observation on 06/09/25 at 8:47 A.M. of 200-hall back unit revealed Resident #51 remained in bed awaiting staff assistance to get up for breakfast in the dining room. Interview at the time of the observation with Resident #51 confirmed wanting to eat breakfast in the dining room, not the resident's room. Resident #51 complained of still not having a drink of tea. Interview with LPN #513 after speaking with Resident #51 verified having to wait for another staff member to help transfer the resident because of requiring two staff assistance, but the nurse aide who was to help was busy on the secured unit assisting to feed residents, so LPN #513 was waiting for someone to become available. Observation on 06/09/25 at 8:49 A.M. of Rosewood's main dining room revealed breakfast service had started and on 200-hall back unit, Resident #51 remained in bed with no staff visible on the unit. On the 200-hall front (secured) unit, Resident #4's call light was answered. Observation on 06/09/25 at 8:53 A.M. on the 200-back hall unit revealed Resident #75 emerged from the resident's room. Interview at the time of the observation with Resident #75 loudly complained about not yet receiving any breakfast which was supposed to be served around 8:00 A.M. Interview on 06/09/25 at 8:54 A.M. with LPN #513 who returned to the 200-back hall unit stated the unit had not received enough breakfast trays and was trying to figure out why and who still needed breakfast. LPN #513 confirmed Resident #51 was still waiting to get out of bed for the dining room but indicated it was too late now because dining room service had finished so a tray would be ordered for Resident #51 to eat breakfast in the resident's room. LPN #513 proceeded to round through the unit and make note of which residents still needed breakfast which were Residents #19, #50, #51, #58 and #75 and then left the unit. No staff remained on the unit. Rounds to check for or provide incontinent care or repositioning had not yet been completed since prior to 5:00 A.M. as stated by RN #542. Interview on 06/09/25 at 8:59 A.M. with Resident #51 on the 200-back hall unit complained about having to eat breakfast in the resident's room instead of the dining room and further complained about being made to wait so long for tea. Observation on 06/09/25 at 9:01 A.M. on the 200-back hall unit revealed Resident #58 emerged from the resident's room. Interview at the time of the observation with Resident #58 complained about not yet receiving any breakfast. There were no staff visible on the unit. Observation on 06/09/25 at 9:06 A.M. on 200-back hall unit revealed LPN #513 returned to the unit. Interview at the time of the observation with LPN #513 verified Resident #51 was made to eat breakfast in the resident's room because of missing dining room service. There was not enough staff to get Resident #51 out of bed quickly enough. The resident was on the list for night shift to get her up for breakfast, but night shift did not do it because there was no nurse aide on the unit. LPN #513 further stated there was not enough staff to get morning rounds done either because of being the only nurse aide, and it appeared the unit's breakfast trays were ordered incorrectly because it was done by a staff member not assigned to the unit. Interview on 06/09/25 at 9:10 A.M. with Resident #19 on the 200-back hall unit complained about staffing being routinely short and sometimes no staff on the unit in the late evenings or during the night. The resident also complained about water not being passed out every shift and only getting it after asking. Resident #19 expressed feeling fortunate to have the ability to request help because there were many residents on the unit who could not and did not get assistance. Observation on 06/09/25 at 9:13 A.M. on 200-back hall unit revealed LPN #513 with CNA #621 entered Resident #51's room and transferred the resident into a wheelchair. Concurrently, the missing resident breakfast trays were delivered to the unit and various staff from other areas passed out the trays. Observation on 06/09/25 at 9:18 A.M. on 200-back hall unit revealed Resident #51 who was sitting up in a wheelchair received a breakfast tray in the resident's room. Interview at the time of the observation with Resident #51 who expressed disappointment in having to remain in the room to eat but was glad to at least be out of bed. Interview on 06/09/25 at 9:20 A.M. with CNA #621 who was the only nurse aide assigned to the 200-hall middle unit reported Residents #30 and #61 were not taken to the dining room for breakfast because night shift could not get them up. CNA #621 confirmed there was not enough staff to manage the amount of care needed in the different units, with the middle unit having the most residents who required two staff assistance, especially for mechanical lifts and incontinent care. CNA #621 indicated staff reported staffing needs to administration but were told the census was too low so the staff would have to make do with what they had. Observation and interview on 06/09/25 at 9:44 A.M. with Resident #51 on the 200-hall back unit revealed there was no tea on the resident's breakfast tray as requested but instead received coffee. Resident #51 complained about receiving coffee instead of tea and did not want the coffee but wanted the tea now. Interview on 06/09/25 at 9:45 A.M. with LPN #513 on 200-hall back unit confirmed not checking to make sure Resident #51 received the requested tea but stated she would get the tea from the kitchen now and then left the unit. Observation on 06/09/25 at 9:49 A.M. of 200-hall back unit revealed LPN #513 returned to the unit and delivered a cup of hot tea to Resident #51. Review of the facility get up list for Rosewood provided 06/09/25 revealed on 200-hall front (secured) unit there were four residents (#25, #52, #57 and #67) scheduled for night shift to get up each morning. On 200-hall middle unit, there were three residents (#28, #30 and #61) on the list, and 200-hall back unit had one resident (#51) on the list. Review of the list of residents who required moderate staff assistance or were dependent on staff with activities of daily living, provided 06/11/25, revealed 200-hall front (secured) unit had 17 residents (#4, #5, #8, #9, #10, #20, #22, #25, #36, #38, #52, #57, #67, #70, #72, #76 and #79) out of 17 residents who had those care needs. On 200-hall middle unit, 13 residents (#3, #12, #14, #24, #28, #30, #35, #40, #42, #60, #61, #62 and #68) out of 16 residents who had those care needs, and on 200-hall back unit, 11 residents (#2, #19, #27, #45, #49, #50, #51, #55, #58, #71 and #84) out of 14 residents who had those care needs. Review of the list of residents who were incontinent, provided 06/09/25, revealed 200-hall front (secured) unit had nine residents (#4, #5, #20, #25, #52, #67, #70, #76 and #86) out of 17 residents who required incontinence care. On 200-hall middle unit, 12 residents (#3, #12, #24, #28, #35, #40, #42, #59, #60, #61, #62 and #68) out of 16 residents who required incontinence care, and on 200-hall back unit, eight residents (#19, #27, #45, #47, #50, #51, #55 and #85) out of 14 residents who required incontinence care. Review of the list of residents who required mechanical lifts for transfers, provided 06/09/25, revealed 200-hall front (secured) unit had four residents (#4, #25, #52 and #67) out of 17 residents who required mechanical lifts. On 200-hall middle unit, eight residents (#12, #28, #42, #59, #60, #61, #62 and #68) out of 16 residents who required mechanical lifts, and on 200-hall back unit, two residents (#19 and #27) out of 14 residents who required mechanical lifts. Review of the facility incident logs from 12/09/24 to 06/09/25 revealed there was an increasing trend in falls from seven in March, to 17 in April, and 32 in May. From 06/01/25 to 06/09/25, 14 falls had already occurred. Review of the facility PBJ Staffing Data Report from 01/01/25 to 03/31/25 revealed the facility triggered for one star staffing rating and excessively low weekend staffing. Review of the staffing tool from 06/03/25 to 06/09/25 revealed the facility exceeded the daily direct care requirement of 2.50 hours per resident; however, the lowest hours were on Saturday 06/07/25 at 2.93, and on Sunday 06/08/25 at 2.51 being just above the minimum requirement. Interview on 06/10/25 at 1:02 P.M. with the Administrator verified the staffing tool results. Review of facility schedules from 05/12/25 to 06/09/25 revealed three eight-hour shifts, days, evenings and nights. Rosewood's three units (front, middle and back) typically had two nurses for days and evenings and one nurse for nights covering all three units, and one nurse aide for each unit on each shift. Review of the facility assessment dated [DATE] revealed the facility considered staffing needs for each resident unit for each shift and adjusted as necessary based upon resident population. For unplanned staffing need, the facility utilized on-call management to either fill the shift or find appropriate replacements. In the event no facility staff were available, staff from sister facilities were utilized. Review of the facility policy, Incontinence Care, reviewed 01/06/25, revealed the purpose was to keep the skin clean, dry and free of irritation and odor, and to prevent skin breakdown. Review of the facility policy, Use of Call Light, reviewed

Based on observation, interview, record review and facility policy review, the facility failed to properly complete medication administration by leaving uncapped eye drops and nasal spray with pain relief gel at Resident #16's bedside and failed to administer medications to Resident #16 as ordered by the physician by error of omission or being late. This affected one resident (#16) of three residents reviewed for medication administration. The facility census was 81. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/01/16. Diagnoses included spinal stenosis, restless legs syndrome, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), radiculopathy, and chronic pain. The quarterly Minimum Data Set (MDS) assessment completed 09/25/24 indicated no cognitive impairment. Observation on 11/06/24 at 9:09 A.M. of Resident #16 in bed with a bedside table positioned across the bed within the resident's reach. On the table was a tube of Voltaren pain relief gel, a vial of uncapped artificial tears eye drops, and a vial of uncapped nasal saline spray. The bedside table was visibly soiled with food debris. Interview at the time of the observation with Resident #16 complained that the nurse left the medications there because he was eating breakfast and would return later to administer them. Resident #16 denied self-administering medications, and further complained there were times when his noon medication was given late, or some medications were not given at all. The nurse was not visible on the unit. Review of Resident #16's physician orders from October to November 2024 revealed artificial tears ophthalmic solution one percent, one drop in both eyes twice daily for dry eyes; sodium chloride nasal spray 0.65 percent, two sprays in both nostrils daily for dryness; and Voltaren external gel one percent to neck and shoulders topically three times daily for pain. There was no evidence of an order for self-administration of medications or to keep medications at bedside. Observation on 11/06/24 at 9:27 A.M. revealed Resident #16 had not changed position, and the uncapped eye drops and nasal spray with the tube of pain relief gel were still on the soiled bedside table within Resident #16's reach. Interview at the time of the observation with Resident #16 confirmed the nurse had not yet administered the medications. The nurse had returned but the resident told the nurse to forget it and give them around 11:30 A.M., but the nurse still left the medications on the bedside table. The nurse was not visible on the unit but was located on a nearby secured memory care unit administering medications. Interview on 11/06/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #245 confirmed Resident #16's eye drops and nasal spray were left uncapped on the bedside table with the pain relief gel, stating the medication caps were kept in the medication drawer of the cart until given. LPN #245 described preparing Resident #16's medications, taking the caps off the eye drops and nasal spray, then carried them into the room, but the resident was busy eating breakfast. LPN #245 gave the oral medications and forgot to bring the eye drops, nasal spray, and pain relief gel back to the medication cart, leaving it on the soiled bedside table. LPN #245 indicated returning later but Resident #16 did not want the medications, so LPN #245 left them at the bedside and kept the medication caps in the medication cart drawer for later. Interview on 11/06/24 at 11:03 A.M. with Assistant Director of Nursing (ADON) #254 verified medications being administered should not be left at the bedside, and the protective caps on eye drops and nasal sprays should only be removed at the time of administration and replaced immediately to prevent infection. Further review of Resident #16's medical record revealed physician orders for omeprazole 40 milligrams (mg) daily for GERD, gabapentin 800 mg three times daily for nerve pain, hydroxyzine 25 mg four times daily for anxiety, and tramadol 50 mg every six hours for moderate to severe pain. The medication administration record (MAR) for October 2024 indicated omeprazole was not administered on 10/25/24 at 6:00 A.M.; gabapentin was not administered on 10/15/24 at 5:00 P.M.; hydroxyzine was not administered on 10/15/24 at 5:00 P.M. and at 9:00 P.M.; and tramadol was not administered on 10/15/24 at 6:00 P.M. and on 10/25/24 at 6:00 A.M. The MAR also showed a weekly course of antibiotic eye drops that were administered to Resident #16 for an eye infection initiated on 10/08/24. Review of the medication administration audit report from 10/01/24 to 11/06/24 for Resident #16 revealed the 12:00 P.M. (noon) doses of tramadol were given late on 10/03/24 at 3:08 P.M., on 10/09/24 at 1:26 P.M., on 10/25/24 at 1:50 P.M., on 10/27/24 at 1:29 P.M., on 10/28/24 at 1:40 P.M., on 11/02/24 at 1:35 P.M., and on 11/03/24 at 1:44 P.M. Review of Resident #16's nursing progress note dated 10/16/24 at 11:01 A.M. revealed a dose of tramadol was missed last night; however, the resident was stable and not in any current pain. Interview on 11/07/24 at 1:22 P.M. with ADON #254 confirmed all the medication administration findings listed above for Resident #16 being omitted or given late indicating medications were administered one hour prior to or after the scheduled administration time. Review of the facility policy, Specific Medication Administration Procedures - Nasal Administration, revised January 2018, revealed for administration, remove the cap and place it on the barrier or a clean dry surface. After administration, replace the cap/cover. Review of the facility policy, Specific Medication Administration Procedures - Eye Drop Administration, revised December 2019, revealed for administration, remove the cap, taking care to avoid touching the dropper tip and place the cap on the barrier or a clean, dry surface. After administration, recap the bottle. Review of the facility policy, Medication Storage in the Facility - Storage of Medications, revised January 2018, revealed except for medications requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. Review of the facility policy, Medication Storage in the Facility - Bedside Medication Storage, revised January 2018, revealed bedside medication storage is permitted for residents who wish to self-administer medications, and a written order for the bedside storage of medication placed in the medical record. Review of the facility policy, Specific Medication Administration Procedures - Administration Procedures for All Medications, revised January 2018, revealed after administration of a medication, return it to the cart and document administration in the medication or treatment administration record. This deficiency represents non-compliance investigated under Master Complaint Number OH00158519.

Based on observation, interview, record review, and facility policy review, the facility failed to properly store medications by leaving eye drops, nasal spray, and pain relief gel at the bedside for later administration when Resident #16 did not participate in or have an order for self-medication administration. This affected one resident (#16) of three residents reviewed for medication administration. The facility census was 81. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/01/16. Diagnoses included spinal stenosis, restless legs syndrome, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), radiculopathy, and chronic pain. The quarterly Minimum Data Set (MDS) assessment completed 09/25/24 indicated no cognitive impairment. Observation on 11/06/24 at 9:09 A.M. of Resident #16 in bed with a bedside table positioned across the bed within the resident's reach. On the table was a tube of Voltaren pain relief gel, a vial of uncapped artificial tears eye drops, and a vial of uncapped nasal saline spray. The bedside table was visibly soiled with food debris. Interview at the time of the observation with Resident #16 complained that the nurse had left the medications there because he was eating breakfast and would return later to administer them. Resident #16 denied self-administering medications. The nurse was not visible on the unit. Review of Resident #16's physician orders from October to November 2024 revealed artificial tears ophthalmic solution one percent, one drop in both eyes twice daily for dry eyes; sodium chloride nasal spray 0.65 percent, two sprays in both nostrils daily for dryness; and Voltaren external gel one percent to neck and shoulders topically three times daily for pain. There was no evidence of an order for self-administration of medications or to keep medications at bedside. Observation on 11/06/24 at 9:27 A.M. revealed Resident #16 had not changed position, and the uncapped eye drops and nasal spray, and the tube of pain relief gel were still on the soiled bedside table within Resident #16's reach. Interview at the time of the observation with Resident #16 confirmed the nurse had not yet administered the medications. The nurse had returned but the resident told the nurse to forget it and give them around 11:30 A.M., but the nurse still left the medications on the bedside table. The nurse was not visible on the unit but was located on a nearby secured memory care unit administering medications. Interview on 11/06/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #245 confirmed Resident #16's eye drops and nasal spray were left uncapped on the bedside table with the pain relief gel, stating the medication caps were kept in the medication drawer of the cart until given. LPN #245 described preparing Resident #16's medications, taking the caps off the eye drops and nasal spray, then carried them into the room but the resident was busy eating breakfast. LPN #245 gave the oral medications and forgot to bring the eye drops, nasal spray, and pain relief gel back to the medication cart, leaving them on the bedside table. LPN #245 indicated returning later, but Resident #16 did not want the medications, so LPN #245 left them at the bedside and kept the medication caps in the medication cart drawer for later. Interview on 11/06/24 at 11:03 A.M. with Assistant Director of Nursing (ADON) #254 verified medications being administered should not be left at the bedside, and the protective caps on eye drops and nasal sprays should only be removed at the time of administration and replaced immediately to prevent infection. Further review of Resident #16's medical record revealed the medication administration record for October 2024 indicated a weekly course of antibiotic eye drops were administered to Resident #16 for an eye infection initiated on 10/08/24. Review of the facility policy, Specific Medication Administration Procedures - Nasal Administration, revised January 2018, revealed for administration, remove the cap and place it on the barrier or a clean dry surface. After administration, replace the cap/cover. Review of the facility policy, Specific Medication Administration Procedures - Eye Drop Administration, revised December 2019, revealed for administration, remove the cap, taking care to avoid touching the dropper tip and place the cap on the barrier or a clean, dry surface. After administration, recap the bottle. Review of the facility policy, Medication Storage in the Facility - Storage of Medications, revised January 2018, revealed except for medications requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. Review of the facility policy, Medication Storage in the Facility - Bedside Medication Storage, revised January 2018, revealed bedside medication storage is permitted for residents who wish to self-administer medications, and a written order for the bedside storage of medication placed in the medical record. This deficiency represents non-compliance investigated under Master Complaint Number OH00158519.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the interventions of the comprehensive care plan related to pacemaker care for Resident #92. This affected one resident (#92) of nineteen residents reviewed for comprehensive care plans. The facility census was 90. Findings include: Review of the medical record for Resident #92 revealed an admission date of 04/30/24. Diagnoses included cardiac pacemaker, syncope collapse, and atrioventricular block. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had intact cognition and required supervision with activities of daily living. Review of Resident #92's care plan revealed a plan for decreased cardiac output related to pacemaker placement. Interventions included assessing for signs and symptoms of pacemaker failure that include dizziness, fainting, heart palpations, prolonged hiccups, and chest pain. Monitor and document signs of shortness of breath. Check oxygen saturation. Monitor for signs of elevated blood pressure including headache, dizziness, nosebleed, and visual changes. Review of the hospital discharge orders dated 04/30/24 revealed Resident #92 had a new pacemaker inserted on 04/24/24. There was a follow-up appointment scheduled for 05/24/24 for the pacemaker device. Review of the physician orders for May 2023 revealed no monitoring orders for a new pacemaker. Review of the skilled nursing assessments from 04/30/24 through 05/21/24 revealed there were no skilled nursing assessments on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, 05/16/24, and 05/20/24. Review of the vital signs tab in the electronic medical record (eMAR) from 04/30/24 through 4/21/22 revealed blood pressure, oxygen saturation, and temperatures were not documented on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, 05/16/24, and 05/20/24. Interview with Licensed Practical Nurse (LPN) #524, the unit manager, on 05/22/24 at 2:00 P.M. stated the skilled nursing assessment was where nurses would assess and document signs and symptoms of pacemaker failure. Further interview on 05/22/24 at 2:22 P.M. verified skilled nursing assessments and vital signs were not completed on 05/09/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, 05/15/24, 05/16/24, and 05/20/24.

Based on record review and interview, the facility failed to thoroughly complete a discharge recapitulation of stay for Resident #96. This affected one resident (#96) of three residents reviewed for discharge. The facility census was 90. Findings include: Review of the closed medical record for Resident #96 revealed an admission date of 03/13/24 with diagnoses including chronic obstructive pulmonary disease (COPD), myocardial infarction, chronic pulmonary edema, acute respiratory failure with hypoxia, congestive heart failure, chronic kidney disease, and muscle weakness. Resident #96 was discharged on 03/15/24. Further review of the medical record revealed documentation of care and treatments provided for Resident #96 from 03/13/24 through 03/15/24. Review of the progress note dated 03/15/24 at 1:08 P.M. revealed Resident #96 discharged to the community and the nursing summary indicated no care was provided. Review of the assessment titled Discharge Summary - V 6, dated 03/15/24, revealed the summary of stay, which the form indicated should have included at a minimum the diagnoses, course of illness and treatments, therapy, pertinent laboratory and radiology reports, and consultations, was summarized as no care provided. On 05/21/24 at 4:32 P.M., interview with the Administrator verified the discharge summary for Resident #96 indicated no care was provided during his two-day stay at the facility. On 05/21/24 at 4:49 P.M., interview with the Director of Nursing (DON) verified the discharge summary did not summarize the care Resident #96 received during his stay at the facility. The DON stated Resident #96 initiated his own discharge and Registered Nurse (RN) #700, who completed the discharge summary form, did not understand what the question was asking regarding the summary of stay. The DON confirmed the discharge summary should have included all care and treatments provided throughout the stay and that Resident #96's discharge summary included only no care provided and no additional information regarding the care he received while a resident at the facility.

Based on observation, staff interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary and food items were not expired. In addition, the hot water dish machine thermometer did not reach the appropriate rinse temperature, and the sanitizing sink was not at correct level to effectively kill virus or bacteria. This had the potential to affect all residents receiving food from the kitchen. The facility identified no residents were deemed no food by mouth. The facility census was 90. Finding include: 1. Observation during the initial kitchen tour on 05/19/24 between 9:00 A.M. and 11:00 A.M. with Dietary Manager #688 revealed the following concerns: • The dairy walk-in cooler was observed to have six expired milk pints for resident use. The expired milk cartons were dated 05/18/24 and out for resident use. • The hot water temperature dish machine rinse cycle was 172 degrees Fahrenheit. This was below the recommended 180 degrees Fahrenheit to ensure dishes were safe to eat from. • The dry food storage area revealed six packages of bread that were not dated when opened and had no expiration dates. • Food Service Manager #688 performed a test strip of the three-sink sanitizer station which revealed the amount of sanitizer read at 100 parts per million. This was below the recommended 200 parts per million to ensure the sanitizer was effective in killing virus or bacteria. Interview at the time of the observations, Food Service Manager #688 verified the above areas of concern. Review of the undated policy titled Food Preparation and Storage revealed food items would be prepared to keep free of harmful organisms. 2. Observation of facility refrigerator located in the front lobby during the initial tour on 05/19/24 at 10:30 A.M. revealed an expired barbeque sandwich dated 05/16/24, an expired chicken and cheese sandwich dated 05/13/24, an expired cheese sandwich dated 05/14/24, and an expired sandwich dated 05/15/24 all for resident consumption. Interview with Registered Nurse #553 on 05/19/24 at 10:35 A.M. revealed the staff was to discard food after three days of the date on the food label. Interview on 05/19/24 at 10:45 A.M. with the Administrator verified resident food was mixed with staff food in the front lobby refrigerator, and the sandwiches were dated greater than three days of the date on the food label. Review of the facility policy titled Food Brought in From the Community, revised 11/30/24, revealed all cooked or prepared food for the residents stored in the facility refrigerator will be dated when accepted for storage and discarded after 72 hours or three days.

Based on observation, record review, and interview the facility failed to ensure proper serving sizes were served according to the menu spreadsheet for the corn, creamed corn, pureed corn, and the pureed Spanish rice served at lunch. This had the potential to affect all residents one resident (#92) who received nothing by mouth. The facility census was 93. Findings include: Observation on 11/28/23 at 12:05 P.M. of tray line service revealed [NAME] #508 serving corn using a three-ounce white handled serving spoon, a red handled serving spoon for the creamed corn, a blue handled scoop to serve the pureed Spanish rice, and a blue handled scoop to serve the pureed corn. Review of the lunch menu and spread sheet dated 11/28/23 revealed the serving utensil for the corn was a #8 scoop equaling four-ounce. The serving for the creamed corn was a #8 scoop equaling four-ounce serving. The serving for the pureed Spanish rice and pureed corn was a #8 scoop equaling four-ounce. Interview on 11/28/23 at 12:30 P.M. with Dietary Manager (DM) #513 verified the observation and stated the red handled serving spoon for the creamed corn provided two-ounce servings. DM #513 stated the blue handled scoop used to serve the pureed corn and pureed Spanish rice was a #16 scoop providing two ounces. DM #513 stated they had the color-coded chart on the wall to identify what the servings each handled colored scoop served. Review of the color-coded chart used to identify the scoop serving sizes indicated the blue handled #16 scoop provided two-ounce servings and the grey handled #8 scoop provided four-ounce servings. This chart did not indicate serving sizes for the spoons. This deficiency was an incidental finding discovered during the course of the complaint investigation.

Based on observation and interview the facility failed to ensure staff wore hair nets prior to entering the kitchen. This had the potential to affect all residents except one resident (#92) who received nothing by mouth. The facility census was 93. Findings include: Observation on 11/28/23 at 12:41 P.M. of Laundry Staff (LS) #234 with long hair in a ponytail enter the kitchen without a hairnet, carrying clean brown folded napkins. LS #234 stopped near the steam table and handed dietary staff the folded napkins and had them sign a piece of paper. Interview at this time with Assistant Administrator (AA) #504 verified the observation and stated she will ensure LS #234 was educated on putting on a hairnet prior to entering the kitchen. Interview on 11/28/23 at 12:42 P.M. with Dietary Manager (DM) #513 stated they were to come to the door, and dietary staff were to get the napkins and sign off at the door. DM #513 stated only dietary staff were allowed in the kitchen. This deficiency was an incidental finding discovered during the course of the complaint investigation.

Based on observation, record review, interview, and facility policy review the facility failed to prepare and store food items to prevent contamination and potential food borne illness. This had the potential to affect all 94 residents residing in the facility who consumed food prepared in the facility kitchen, including those with puree diets: Residents # 57, #50, #59, #70, #41, #1, and #51. There were no residents at the facility unable to consume food by mouth. Findings include: An observation on 05/16/23 at 4:03 P. M. in the kitchen revealed [NAME] #685 was beginning the puree process using a spatula placed directly on an unclean counter surface. There were obvious crumbs, dried liquid spots, and debris on the surface where she set the spatula to scrape the sides of the (Robot coupe) food processor blending breaded chicken strips. [NAME] #685 picked up the spatula from the unclean counter surface and stirred and scraped the side of the food processor. [NAME] #685 then placed the spatula down again directly on the unclean surface with a paste of pureed breaded chicken strips on it. [NAME] #685 ran the food processor again and picked up the spatula and used it second time to stir and scrape the breaded chicken fingers then put the spatula down on the unclean surface again. An interview on 05/16/23 at 4:10 P.M. with [NAME] #685 revealed she forgot to put the spatula on a clean surface and would throw out all the puree breaded chicken fingers. An interview on 05/16/23 at 4:11 P.M. with Dietary Manager #645 revealed the staff should never put the spatula down on an unclean surface and then reuse it to stir/scrape food in food processor. DM #645 then put a sheet of waxed paper down on the surface and two clean spatulas. The pureed breaded chicken fingers were thrown out and a new puree was started. An observation on 05/16/21 at 4:15 P.M. in the facility kitchen, Dietary Manager #645 was observed making peanut butter and jelly sandwiches on white bread. DM #645 then went from making sandwiches to pushing down the trash in an open garbage can with her bare hands. After pushing down the garbage with her bare hands without washing her hands or using hand sanitizer, she went back to finishing making the peanut butter and jelly sandwiches and then stored them for later, grabbing and cleaning off the peanut butter and jelly jars with and a kitchen towel and placing them back in storage. An interview on 05/16/23 with the Dietary Manager #645 at 4:17 P.M. revealed she should not have pushed the trash down with her bare hand and then failed to wash her hands before returning to the food preparation and storage. DM #645 stated she usually washes her hands all the time. Interview on 05/18/23 at2:05 P.M. with Dietary Tech #601 revealed a spatula used in food processer should never be placed on an unclean, unsanitary surface like an unclean countertop, and a clean and sanitized surface like a spoon holder or plate should always be used to avoid contamination. Dietary Tech #601 also stated that a staff member's hands should always be washed after touching garbage, especially before and/or during food preparation. Review of the facility policy titled Hand Hygiene, dated 06/08/22, revealed hand hygiene should be done before and after handling food trays. Review of the policy titled General Sanitation of Kitchen, dated 01/13/21, did not speak to the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure physician orders and care planned interventions for two staff assistance for mechanical lift transfers were followed to ensure Resident #37 was safely transferred using a mechanical lift. This affected one resident (#37) out of three residents reviewed for mechanical lift transfers. The facility census was 86. Findings include: Review of Resident #37's medical record revealed an admission date of 03/07/19 with diagnoses including encounter for orthopedic aftercare following surgical amputation, type two diabetes mellitus with hyperglycemia, congestive heart failure, and dementia. Review of Resident #37's physician orders dated 09/01/22 revealed an order for mechanical lift transfers at all times with assist of two staff. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 required extensive assistance of two staff members for bed mobility, required extensive assistance of one staff for toilet use, and had total dependence of two staff members for transfers. Review of the care plan dated 02/01/23 included Resident #37 had an ADL (Activities of Daily Living) deficit related to activity intolerance and fatigue. Resident #37 would maintain current functional status related to ADL. Interventions included mechanical lift transfers with two staff assistance. Observation on 02/23/23 at 1:26 PM. of State Tested Nursing Assistant (STNA) #200 revealed she walked out of the memory care unit and stated she was moved out of the memory care unit and assigned to different residents until she left at 3:00 P.M. STNA #200 walked to the nursing unit of her new resident assignment and began checking on the residents. Observation revealed Resident #37 was sitting in a wheelchair in his room and told STNA #200 he would like to lay down because he needed changed. STNA #200 found a mechanical lift and pushed it into Resident #37's room, shut the door and proceeded to attach Resident #37's mechanical lift pad to the mechanical lift. STNA #200 did not have another staff member assist her with the mechanical lift. After attaching Resident #37's mechanical lift pad to the mechanical lift, STNA #200 transferred Resident #37 from the wheelchair to his bed. STNA #200 stated she knew there should have been two staff members using the mechanical lift to transfer Resident #37, but they were short-staffed and there was no one to ask. STNA #200 indicated Resident #37 was comfortable with her and she thought one staff assisting him was alright. STNA #200 stated she had training a while back and there should be two staff members assisting with mechanical lift transfers. STNA #200 stated she usually asked other staff to help but today they were short-staffed, there was no one to ask and she was not going to get any help. Observation on 02/23/23 at 2:30 P.M. of STNA #200 revealed Resident #37 was lying in bed and told STNA #200 he needed changed. STNA #200 proceeded to change Resident #37's incontinence brief using appropriate incontinence care standards of practice. After Resident #37's incontinence brief was changed, he stated he would like to get out of bed. STNA #200 found a mechanical lift, pushed it into Resident #37's room, proceeded to attach Resident #37's mechanical lift pad to the mechanical lift, and without the help of a second staff member operated the lift to transfer Resident #37 from the bed to his wheelchair. STNA #200 confirmed she used the mechanical lift without a second staff member assisting her. STNA #200 stated there was not enough staff and she did not know who she could ask to help her. Interview on 02/23/23 at 2:59 P.M. with the Director of Nursing (DON) and the Administrator revealed they were informed STNA #200 transferred Resident #37 using a mechanical lift without the assistance of a second staff member. The DON and the Administrator indicated it was not okay to have one STNA using a mechanical lift to transfer a resident without the assistance of a second staff member. The DON and Administrator stated they would immediately begin educating the staff that two staff were required to transfer residents when a mechanical lift was needed. Review of the facility policy titled Mechanical Lift, revised 06/08/22, included the purpose was to safely lift and transfer residents with the assistance of two individuals. For bed to chair transfers and chair to bed transfers, get help, a mechanical lift required two people to assist. This deficiency represents noncompliance investigated under Complaint Number OH00139852.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility staff assignment documents the facility failed to ensure sufficient staffing to meet the needs of the residents. The facility failed to ensure Resident #13 who required a mechanical lift for transfers was able to be transferred out of bed per her wishes, and the facility failed to ensure Resident's #16 and #81 who required a mechanical lift for transfers and were incontinent had their incontinence briefs changed timely. This affected three residents (#13, #16, and #81) and had the potential to affect all 13 residents (#3, #6, #8, #12, #16, #27, #36, #41, #66, #69, #70, #78, #81) on the memory unit and all 16 residents (#13, #14, #31, #37, #39, #40, #42, #52, #53, #71, #72, #75, #76, #77, #80, #86) residing in the back hall of the long-term care nursing unit. The facility census was 86. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 06/24/22 with diagnoses including multiple sclerosis, depression, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 required extensive assistance of two staff members for bed mobility, total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #13 used a wheelchair. Review of the care plan dated 07/12/22 included Resident #13 experienced changes, altered sleeping pattern. Resident #13 would have at least five to six hours of uninterrupted, restful sleep at night. Interventions included to attempt to provide exercise, activities in the afternoon; encourage daytime activities and socialization. 2. Review of Resident #81's medical record revealed an admission date of 01/07/21 with diagnoses including collapsed vertebra, thoracic region, subsequent encounter for fracture with routine healing, hypertensive chronic kidney disease, depression, and dementia. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #81 had severe cognitive impairment. Resident #81 required extensive assistance of two staff members for bed mobility, total dependence of two staff members for transfers, and required extensive assistance of two staff members for toilet use. Resident #81 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan revised 01/19/23 included Resident #81 had the potential for alteration in skin integrity related to decrease in ADL (activity of daily living) function, peripheral vascular disease, poor oral intake, and incontinence status. Resident #81 would not develop any new areas of skin breakdown through the review date. Interventions included to remove wet or soiled clothing, briefs, provide incontinence care, and apply protective barrier after each incontinent episode. 3. Review of Resident #16's medical record revealed an admission date of 04/12/22 with diagnoses including dementia with behavioral disturbance, schizophrenia, and calculus of kidney. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 had severe cognitive impairment. Resident #16 required extensive assistance of two staff members for bed mobility and toilet use, use, total dependence of two staff members for transfers. Resident #16 was always incontinent of urine and bowel and used a wheelchair. Interview on 02/23/23 at 11:00 A.M. with Registered Nurse (RN) #201 revealed she usually was assigned to work in the memory care unit. RN #201 stated there were currently 13 residents (#3, #6, #8, #12, #16, #27, #36, #41, #66, #69, #70, #78, #81) on the memory care unit and it was typically staffed with one nurse and two state tested nurse aides (STNAs). RN #201 stated the Activity Director sometimes assisted with things like passing meal trays depending on her schedule. RN #201 stated staffing the unit was challenging at times. RN #201 stated all residents on memory care required a lot of care. Interview on 02/23/23 at 11:20 A.M. with the Director of Nursing (DON) and the Administrator revealed staffing agencies were used to help fill holes in the schedule. Interview on 02/23/23 at 12:35 P.M. with STNA #202 revealed she worked for a staffing agency and today was the first time she worked in the facility. STNA #202 stated she was assigned to the memory care unit, she did not know the residents, but she was working with STNA #200 who knew the residents. STNA #202 stated after the lunch meal was served, she would work with STNA #200 to provide care for the residents for things such as changing incontinence briefs, using a mechanical lift to assist residents to their beds, and assist residents to use the toilet. Observation on 02/23/23 at 1:16 P.M. with STNA #203 revealed she was standing at the nurse's station with her coat on. STNA #203 stated she worked for a staffing agency and was leaving for the day as soon as a nurse signed her time sheet. STNA #203 indicated she worked from 8:00 A.M. until 1:00 P.M. today. Interview on 02/23/23 at 1:25 P.M. with RN #201 revealed STNA #200 was taken out of the memory care unit and was assigned to take over STNA #203's assignment on the long-term care unit. RN #201 stated STNA #202 was the only STNA in memory care at this time. Observation on 02/23/23 at 1:25 P.M. revealed RN #201 was not in the memory care unit but on the long-term care nursing unit. RN #201 revealed she was not in the memory care unit right now because part of her assignment included the residents who resided on the odd numbered rooms on the long-term care unit. Interview on 02/23/23 at 1:26 P.M. with STNA #200 revealed she was taken off of the memory care unit and assigned to residents residing on the long-term care unit. STNA #200 stated the facility was trying to find help for STNA #202 who was by herself on the memory care unit and was also from a staffing agency. Observation on 02/23/23 at 1:40 P.M. revealed STNA #200 entered Resident #13's room. Resident #13 told STNA #200 she needed her incontinence brief changed. STNA #200 proceeded to provide incontinence care for Resident #13. STNA #200 finished providing Resident #13's incontinence care and Resident #13 stated she would like to get out of bed. STNA #200 told Resident #13 she would get her out of bed later. Resident #13 stated she would like to be moved up in bed, and STNA #200 did not find another staff member to assist her to move Resident #13 up in bed, even though she required two staff members for bed mobility. When STNA #200 pulled Resident #13 up in bed she used to much force and hit Resident #13's head on the headboard, and Resident #13 cried out ouch, that hurt. Resident #13 stated she wanted to get out of bed, who would not want to get out of bed? Observation revealed Resident #13's sheets were stained and had pieces of food lying on them. STNA #200 confirmed Resident #13's sheets were dirty and there were food pieces on them. STNA #200 stated they were short-staffed right now, and she did not have anyone to help her. Observation on 02/23/23 at 2:35 P.M. of STNA #202 revealed she was sitting in the common area of the memory care unit with residents sitting around the table. STNA #202 stated she was by herself right now on the memory unit because STNA #200 was moved to the long-term care unit, and the nurse assigned to the memory care unit was also on the long-term care unit. STNA #202 stated she had not changed any of the resident's incontinence briefs since before lunch because some of the residents required two staff members for transfers to their beds to be changed. STNA #202 stated she did not know the residents' names because this was her first day in the facility. STNA #202 stated one aide needed to supervise the residents in the common area, and she was told by a nurse to stay in the common area. STNA #202 did not know the name of the nurse who told her to stay in the common area. STNA #202 stated the residents were changed before lunch except for two residents that did not get changed due to needing a mechanical lift, and mechanical lifts required two staff for transfers. STNA #202 stated the last time residents sitting in the common area who required a mechanical lift were changed was after breakfast. STNA #202 stated STNA #200 told her there were two residents needing a mechanical lift who needed their incontinence briefs changed. STNA #202 stated the nurse who was supposed to help her transfer the residents needing a mechanical lift to their beds to be changed was busy writing a report, was not in memory care now, and could not help her at this time. STNA #202 stated Resident #81 required a mechanical lift and had not been changed since breakfast, and she was not sure who the other resident was but thought it might be the resident sitting in a wheelchair at the table wearing a green shirt (later identified as Resident #16). Interview on 02/23/23 at 3:23 P.M. with STNA #204 revealed she was the only aide on the memory care unit at this time and could not transfer residents needing a mechanical lift. STNA #204 stated the nurse was supposed to be on the memory care unit until 5:30 P.M., she was not here now, but when she arrived, she would have her help transfer residents to their beds who required a mechanical lift and needed their incontinence briefs changed. Observation on 02/23/23 at 3:59 P.M. revealed RN #201 was sitting at the nurse's station on the long-term care unit finishing up her work. RN #201 finished her work and walked onto the memory care unit. RN #201 confirmed Resident's #16 and #81 needed a mechanical lift for transfers. Observation on 02/23/23 at 4:02 P.M. of RN #201 and STNA #204 revealed they used a mechanical lift to transfer Resident #81 to her bed. RN #201 and STNA #204 provided Resident #81's incontinence care and observation revealed Resident #81's buttocks were reddened and her incontinence brief was soaked with urine. Observation on 02/23/23 at 4:26 P.M. of RN #201 and STNA #204 revealed they used a mechanical lift to transfer Resident #16 to her bed. RN #201 and STNA #204 provided incontinence care for Resident #16 and observation revealed her incontinence brief was very wet with urine, her bottom was reddened with patches of shiny red areas were noted. Review of the facility staff assignment document dated 02/23/23 revealed STNA #200 was assigned to memory care until 1:00 P.M. At 1:00 P.M. STNA #200 was assigned to the long-term care nursing unit until 3:00 P.M. Although Activities Director/State Tested Nursing Assistant (AD/STNA) #206 was assigned to the memory care unit from 1:00 P.M. to 4:00 P.M. there was no observation of AD/STNA #206 providing care to the residents on the memory unit. STNA #202 was assigned to the memory care unit from 9:00 A.M. to 3:00 P.M. STNA #203 was assigned to the long-term care nursing unit from 8:20 A.M. to 1:00 P.M. STNA #204 was assigned to the memory care unit from 3:00 P.M. until 11:00 P.M. RN #201 was assigned to the memory unit from 4:00 P.M. until 7:00 P.M. This deficiency represents noncompliance investigated under Complaint Number OH00139852.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy the facility failed to ensure complete and accurate documentation in resident medication administration records for Residents #1, #57 and #60 and for application of elbow and hand splints for Resident #20. This affected four of nine residents reviewed for documentation. The facility census was 72. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, high blood pressure (HTN), and unspecified dementia without behavioral disturbance. Physician orders included an order dated 12/30/20 for Humulin R Solution 100 UNIT/ML (Insulin Regular Human), inject as per sliding scale: if 0 - 70, follow Hypoglycemic Protocol; 71 - 150 No Coverage; 151 - 200 = 3 units (u); 201 - 250 = 5u; 251 - 300 = 8u; 301 - 350 = 10u; 351 - 400 = 13u; 401+ = 16u Notify MD/NP, to be given subcutaneously before meals and at bedtime. The Minimum Data Summary (MDS) 3.0 dated 03/26/21 revealed Resident #1 was cognitively intact with fluctuating periods of inattention, and required supervision and setup for Activities of Daily Living (ADL). Review of the Medication Administration Record (MAR) for Resident #1 from 01/01/21 to 04/19/21 revealed blood sugar levels of 404 on 02/02/21, 418 on 02/20/21 and 404 on 03/02/21. Review of the progress notes from 01/01/21 to 04/19/21 revealed no documentation that the medical doctor (MD) or nurse practitioner (NP) were notified. Interview on 04/19/21 with Licensed Practical Nurse (LPN) #200 at 12:30 P.M. revealed she would usually text the NP right after receiving a blood sugar if the order specified it, then document it in progress notes. Interview on 04/19/21 at 12:38 P.M. with Registered Nurse (RN) #302 verified the blood sugar readings above 400 for Resident #1 and contact with the NP should have been documented in progress notes but it was not done for 02/02/21, 02/20/21 and 03/02/21. 2. Resident #57 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, Alzheimer's disease, hypertensive heart disease and vascular dementia. Physician orders included an order for Atenolol-Chlorthalidone Tablet 100-25 milligrams (mg), give 0.5 tablet by mouth two times a day for HTN, hold for systolic blood pressure (SBP) < 90 or a heart rate (HR) < 60 with a start date of 11/17/20. The care plan dated 01/24/21 revealed care areas for risk of fluid imbalance, at risk for decreased cardiac output and abnormal lab values related to atrial fibrillation, congestive heart failure, high cholesterol, anticoagulant use and HTN. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired, and required extensive assist of one for ADLs. Review of the MAR for Resident #57 from 01/01/21 to 04/19/20 revealed on 02/02/21 and 02/13/21 there were no entries for blood pressure and HR but the medication was recorded as given. Interview on 04/19/21 at 12:38 P.M. with RN #302 revealed medications should be administered according to ordered parameters and verified lack of documentation of BP and HR on 02/02/21 and 02/13/21 on Resident #57's MAR. Interview on 04/20/21 at 11:10 A.M. with the Director of Nursing (DON) revealed there was no further documentation for the dates specified. 3. Resident #60 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, Alzheimer's disease, hypertensive heart disease and vascular dementia. Physician orders included an order for Metoprolol Tartrate Tablet 25 mg. Give 25 mg by mouth two times a day for HTN hold if SBP < 110 or pulse < 60 with a start date of 07/18/20 and an end date of 03/04/21. The MDS dated [DATE] revealed the resident was severely cognitively impaired, with periods of disorganized thinking and altered levels of consciousness and required extensive assist of one for ADLs. The care plan dated 01/24/21 revealed care areas for risk for decreased cardiac output and abnormal lab values related to hyperlipidemia, hypertension; chronic hypernatremia and risk of fluid imbalance. Review of the MAR for Resident #60 from 01/01/21 to 04/19/20 revealed on 01/05/21, 01/06/21, 01/07/21, 01/10/21, 01/11/21 and 01/14/21 the medication was held due to low parameters with the MAR indicating no entries for BP or HR on those dates. Interview on 04/19/21 at 12:38 P.M. with RN #302 verified medication should be administered according to ordered parameters and should not be given outside of vital sign parameters. Interview on 04/20/21 at 11:10 A.M. with the DON revealed there was no further documentation for the dates specified. The DON added she was confident the nurses were following ordered parameters for administration of medications but they were not documenting appropriately 4. Review of the medical record for Resident #20 revealed admission to the facility on [DATE] with diagnoses including leukemia, cerebral infarction, hemiparesis and hemiplegia following cerebral infarction effecting the left, non-dominant side and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessments dated 01/27/21 and 04/01/21 revealed Resident #20 had moderate cognitive impairment and required extensive one to two person assistance for all ADLs. Review of the occupational therapy note dated 02/17/21 revealed Resident #20 would benefit from a restorative program for passive range of motion and the use of hand and elbow splints for her left upper extremity that would decrease the risk of further contractures and reduce caregiver burden during ADL care. Review of prescriber orders revealed an order dated 04/01/21, for Resident #20 to wear a left elbow splint and a left-hand grip splint every day as tolerated by the resident without signs and symptoms of discomfort. Review of the plan of care dated 04/02/21 revealed activities of daily living self-care deficit performance related to contracture of left upper extremities with an intervention to wear left elbow and left-hand grip splints daily as tolerated. Review of MARs and Treatment Administration Records (TARs) for April 2021 revealed no documentation of treatments for splints for Resident #20. Review of Restorative Nursing treatments for April 2021 revealed no documentation for restorative nursing services inclusive of the use of elbow and hand splints for the resident. Observations on 04/14/21 at 10:40 A.M. and 04/19/21 at 8:26 A.M. revealed Resident #20 was not wearing a brace on her left hand or her left elbow. The elbow and hand braces were observed sitting on the resident's bedside table. Interview on 04/14/21 at 10:40 A.M. with RN #300 verified Resident #20 was not wearing splints on her left elbow and left hand. RN #300 confirmed Resident #20's left hand and elbow braces were applied every day, but she only tolerated their use for a short period before she started screaming and wanting the braces removed. RN #300 stated she was not sure where the administration of the braces and splints were documented. Interview on 04/19/21 at 08:26 A.M. with State Tested Nurse Aide (STNA) #500 revealed on days she had worked, she applied the elbow and hand splints to Resident #20, but the resident only kept them on for a short time before she wanted the splints taken off. STNA #500 said until today (04/19/21) there had been no areas for documentation of left elbow and left hand splints in the restorative nursing documentation in the resident's records. Interview on 04/19/21 at 08:46 A.M. with the DON revealed staff had been applying the splints daily as tolerated by the resident and verified, between 04/01/21 and 04/18/21, there had been no documentation of the application of the left elbow splint or the hand splint for Resident #20 in the medical records. Review of the undated Administration Procedure for All Medications revealed nurses were to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration.