**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure residents had accurate advance directive orders in place throughout their medical record and implement the facilities advance directive policy. This affected two (Residents #4 and #109) of 33 residents reviewed for advance directives. The facility census was 112. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure and fracture of the fibula. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of the physician's orders for Resident #4 revealed an order dated 02/06/25 for a Do Not Resuscitate Comfort Care Arrest (DNRCCA) (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated) code status. Review of the electronic chart for Resident #4 revealed a signed DNRCCA code status dated 02/06/25. Review of the hard medical chart for Resident #4 revealed a signed Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency) dated 05/16/03. An interview on 03/18/25 at 9:06 A.M. with [NAME] Clerk #804 verified Resident #4's hard medical record had a signed advance directive for DNRCC, and the electronic chart had a signed DNRCCA code status. 2. Review of medical record for Resident #109 revealed an admission date of 12/14/24. Diagnoses included Alzheimer's disease and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 was moderately impaired cognitively. Review of DNR (Do Not Resuscitate) Comfort Care document, signed and dated 12/11/24 by a nurse practitioner, revealed Resident #109's code status was a DNR Comfort Care-Arrest (DNRCCA), which meant the provider would treat the resident as any other without a DNR order until the point of cardiac arrest, at which point all other interventions would cease and the DNR Comfort Care protocol would be implemented. Review of Resident #109's physician orders revealed there was no order indicating Resident #109's code status was a DNRCCA. Interview on 03/18/25 at 3:16 PM with Registered Nurse # 814 confirmed Resident #109 didn't have a physician order in the medical record indicating Resident #109 was a DNRCCA. She stated the facility audited charts monthly to ensure the signed DNR form matched the physician order in the medical record and could not give a reason why Resident #109 didn't have a physician order for DNRCCA order in place. Review of facilities policy titled DNR Status Policy and Procedure, updated 07/19/24, revealed every resident should have clearly stated on their chart if they wish to be a DNRCC or DNRCCA, a physician's order, and a DNR form completed and signed by the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure the residents had activities to meet their needs, especially on the weekends and evenings. This affected two (Residents #20 and #51) of two residents reviewed for activities. The facility census was 112. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted [DATE] with diagnoses including legal blindness, anxiety disorder and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 exhibited intact cognition. Review of the activity care plan dated 02/03/25 revealed Resident #20 was at risk for social isolation and low activity participation related to blindness and periods of confusion. Interventions dated 02/03/25 included interviewing the resident about past roles, monitor for activity needs, room greetings, respect the resident's preferences and offer to read the daily activity flyer in the resident's room. Interview with Resident #20 on 03/17/25 at 9:08 A.M. stated the facility did not usually have activities on the weekends or evenings. Resident #20 stated they were bored on the weekends without activities. 2. Review of Resident #51's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia, schizoaffective disorder and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 exhibited intact cognition. Review of the activity care plan dated 11/04/24 revealed Resident #51 was at risk for social isolation and low activity participation related to diagnosis of pneumonia and respiratory failure. Interventions dated 11/04/24 included interviewing resident about past roles, provide calendar of daily scheduled activities with times and locations, monitor for activity needs, invite/escort to activities of choice, room greetings, and respect resident preferences. Interview with Resident #51 on 03/17/25 at 8:52 A.M. stated the facility did not have activities on Saturday or Sunday. Resident #51 stated when there were no activities, they were bored. Review of the Activity Calendar from 01/01/25 to 01/31/25 revealed no activities were scheduled for Wednesday 01/01/25 (New Years Day). Only one weekend day, Sunday 01/05/25, had an activity scheduled that was not a movie (Saturday) or church service (Sunday) on the in-house TV channel. The facilities Activity Calendar from 02/01/25 to 02/28/25 revealed Saturday 02/15/25 and Sunday 02/16/25 had no activities scheduled. The other activities offered on Saturday or Sunday for the month of February included a movie on Saturdays on the facility in-house TV channel or a church service on Sundays on the facility in-house TV channel. The facilities Activities Calendar from 03/01/25 to 03/18/25 revealed four evening activities were scheduled. During the rest of the time-period, the latest scheduled activity was 3:45 P.M., which indicated a lack of evening activities. During review of the same dates, no activities were scheduled for Saturday 03/15/25. The Special Events schedule for 03/2025 revealed one evening activity and one weekend activity. Interview with Activities Director #849 on 03/19/25 at 2:56 P.M. stated normal evening activities were typically finished around 4:00 P.M. to 4:30 P.M. Activities on the weekend were normally movies and church service broadcasted on the in-house facility station which residents can watch in their rooms or in the living room area. Director #849 stated activity staff did not normally work on Saturday or Sunday and verified the activity calendars were correct. Review of the facilities Activity Policy revised 08/2006 revealed activity programs were designed to meet the needs of each resident which were available daily. Activities were scheduled seven days a week and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy, and staff interview, the facility failed to ensure Resident #55's oxygen humidification was labeled and dated and Resident #68's oxygen tubing was changed and dated per facility policy. This affected two (Residents #55 and #68) of three residents reviewed for respiratory therapy. Findings include: 1. Review of Resident #55's medical record revealed the resident was admitted on [DATE] with diagnoses including heart failure, hypertensive heart disease with heart failure and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment. Review of Resident #55's respiratory care plan dated 01/25/23 revealed an intervention dated 05/08/23 to administer oxygen as ordered and keep head of bed elevated due to shortness of breath when lying flat. Review of Resident #55's physician orders revealed an order dated 05/25/23 for oxygen therapy per nasal cannula at two liters continuous to maintain a pulse oximetry above 90% every shift. Observation on 03/17/25 at 8:43 A.M. revealed a disposable oxygen humidifier (a medical device used to moisten supplemental oxygen) without an open date. Interview on 03/17/25 at 8:47 A.M. with Licensed Practical Nurse (LPN) #932 verified the disposable oxygen humidifier was missing an open date. Interview on 03/20/25 at 10:08 A.M. with LPN #916 confirmed if a resident did not have an order for humidification, the facility would have to determine who placed the oxygen humidification, would determine if the humidification was needed and obtain an order or remove the humidification as necessary. 2. Review of Resident #68's medical record revealed the resident was admitted on [DATE] with diagnoses including macular degeneration, dementia, and adult failure to thrive. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 seems or appears to have short term memory problems, long term memory problems, and severely impaired cognitive skills for daily decision making per staff assessment for mental status. Review of Resident #68's Respiratory Care plan dated 06/11/24 revealed an intervention to administer and monitor the effectiveness of oxygen therapy as ordered. Review of Resident #68's physician orders dated 06/13/24 revealed an order for humidification to the oxygen every shift; an order dated 05/30/24 for oxygen therapy per nasal cannula at two liters continuous to maintain pulse oximetry above 90% at bedtime and in the afternoon when napping. Observation on 03/17/25 at 8:00 A.M. revealed oxygen tubing labeled with a date of 01/02/25. The tubing labeled 01/02/25 was connected to the resident and in use at the time of observation. Interview on 03/17/25 at 8:05 with Licensed Practical Nurse (LPN) #932 verified the oxygen tubing was labeled 01/02/25. LPN #932 confirmed the oxygen tubing should be changed weekly by the oxygen company. Review of the facilities Oxygen Administration Policy and Procedure revised 08/16/24 revealed the oxygen servicing company would come on a weekly basis and change out tubing, masks and humidifiers. All tubing and masks must be changed weekly and stored in a bag at the resident's bedside. The policy stated to label the humidifier with the date and time opened and change the humidifier and tubing per the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of safety data sheets (SDS), and review of facility policy, the facility failed to ensure personal care items, which could cause harm if consumed, were out of reach of residents who were cognitively impaired and residing in the facility's memory care unit. This affected five residents (#6, #7, #49, #58, and #90) and had the potential to affect 19 residents who the facility identified who have cognitive impairment and were independently mobile. The facility identified one resident (#82) who resided on the memory care unit as being immobile. The facility census was 112. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease, and fatigue. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/19/24, revealed Resident #49 was rarely/never understood and required partial/moderate assistance to walk ten feet. Observation of Resident #49's room located in the memory care unit on 03/17/25 at 8:28 A.M. revealed on the windowsill in Resident #49's room there was one 8.8 ounce metal spray can of air freshener with a keep out of reach of children noted on the label. On the bedside table, there was one 8.8 ounce metal spray can of air freshener with a keep out of reach of children noted on the label. In the bathroom on the open shelving next to the toilet, there was one 4.5 ounce spray can of air freshener with a keep out of reach of children and pets noted on the label, one 16 ounce plastic spray bottle of 70 percent isopropyl alcohol with keep out of reach of children, one 32 ounce plastic bottle of 91% isopropyl alcohol with a keep out of reach of children and pets noted on the label, and one 10 fluid ounce plastic bottle of nail polish remover. Interview on 03/17/25 at 8:30 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS, revised 07/06/15, for Isopropyl Alcohol 70 percent, indicated the product with repeated or prolonged exposure could cause irritation to skin, irritation to eyes upon contact, respiratory irritation upon inhalation, and may be harmful if ingested. If the product was swallowed, the SDS sheet indicated the physician or poison control should be contacted for current information. The SDS for Isopropyl for Alcohol 90 percent, undated, indicated the product can affect the central nervous system, and there were indications that short-term damage could occur in the gastrointestinal system, liver, kidney, and the cardiovascular system. This product was to be kept out of reach of children . The SDS for air freshener, revised 02/24/25, indicated if the product was ingested, the SDS sheet indicated one to two glasses of water should be drunk and vomiting should not be induced. Medical attention should be sought immediately if symptoms occur, and the product should be kept out of reach of children. Review of the SDS for Nail Polish Remover, dated 08/24/16, indicated prolonged or repeated contact could dry skin and cause irritation. Exposure to the product could increase toxic effects, and inhalation could cause central nervous system effects. The SDS indicated when the product was inhaled vomiting should not be induced, and the physician should be consulted. For skin contact, the skin must be rinsed and monitored for irritation, and the product should be kept out of reach of children. 2. Review of Resident #58's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 01/26/25, revealed Resident #58 exhibited severe cognitive impairment and required supervision or touching assistance to walk ten feet. Observation of Resident #58's room located in the memory care unit on 03/17/25 at 7:49 A.M. revealed on the open shelving next to the toilet in the bathroom revealed, there was one air refresher 8.3 ounce metal can with keep out of reach of children and pets noted on the label, one 188 milliliter (ml) bottle of Brand #1 Aftershave Conditioner Fresh Scent with keep out of reach of children., two three fluid ounce bottle of Brand #2 After Shave Skin Conditioner Fresh Scent with a keep out of reach on the label, one 3.5 ounce of bottle of All Day Fresh Body Spray Cool Blast with keep out of reach of children. Interview on 03/17/25 at 8:32 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for air refresher dated 08/01/18, indicated this product was to be kept away from children and would cause skin irritation. The SDS for Brand #1 Aftershave, revised date of 03/27/15, indicated the product was extremely flammable, would cause mild skin irritation, and was to be kept out of reach of children. The SDS for Power Stick Body Spray, dated 10/11/23, indicated the product could cause acute toxicity if not used as indicated. This product could cause mild skin irritation, and the physician should be contacted if irritation persisted. The SDS for Brand #2 After Shave Lotion dated 04/29/15 indicated this product contained hazardous substances and should not be swallowed. If ingested, a physician should be consulted. 3. Review of Resident #90's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/07/25, revealed Resident #90 exhibited severe cognitive impairment, required supervision or touching assistance to walk ten feet, and wandered one to three days during the assessment reference period. Observation of Resident #90's room located in memory care unit on 03/17/25 at 7:57 A.M. revealed on the open shelving in the bathroom sitting next to the toilet was one 8.8 fluid ounce plastic bottle of Beach fragrance mist with a keep out of reach of children noted on the label and one plastic two fluid ounce plastic bottle of Everlasting Love body mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:33 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for fragrance spray, dated 09/10/24, indicated the product could cause serious eye irritation and mild skin irritation. 4. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was rarely/never understood and required supervision or touching assistance to walk ten feet. Observation of Resident #6's room located in the memory care unit on 03/17/25 at 7:59 A.M. revealed on the open shelving in the bathroom next to the toilet was one seven fluid ounce plastic bottle of Vanilla Scent Body Mist with keep out of reach of children noted on the label and one two fluid ounce plastic bottle of Gingerbread Latte Fragrance mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:34 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of SDS for fragrance spray dated 09/10/24 indicated the product could cause serious eye irritation and mild skin irritation. 5. Review of Resident #7's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/03/24, revealed Resident #7 exhibited severe cognitive impairment and required supervision with transfers and can walk with supervision. Observation of Resident #7's room located in the memory care unit on 03/17/25 at 7:54 A.M. revealed on the open shelving in the bathroom next to the toilet was one seven fluid ounce plastic bottle of body mist with a keep out of reach of children noted on the label and one two fluid ounce Gingerbread Latte fragrance mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:35 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for fragrance spray dated 09/10/24 indicated the product could cause serious eye irritation and mild skin irritation. Review of the facility policy titled Safety and Environmental Policy, updated 05/14/24, revealed the director of the unit would perform environmental rounds daily, which included inspecting all residents' rooms and bathrooms. If personal care products were deemed a safety concern for the resident, it would be discussed with family, and all personal care items would be removed from resident bathrooms. The director would provide ongoing education to staff and family members regarding unsafe items or situations found on the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician was notified and responded timely to Resident #116's complaints of pain following a fall. This finding affected one (Resident #116) of three residents reviewed for falls. Findings include: Review of Resident #116's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and essential tremors. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #116's fall Incident form dated 11/11/24 at 7:50 P.M. revealed Certified Nursing Assistant (CNA) #918 reported she saw the resident in the Centrum (main television lounge area) when she saw the resident stand up and attempt to walk. Before she could reach her, the resident had fallen on the floor and landed on her right side. The alarm was present in the wheelchair and alarming. CNA #918 stated she did not hit her head. Review of Resident #116's fall Investigation/Follow-Up form dated 11/12/24 at 9:27 A.M. authored by Licensed Practical Nurse (LPN) #956 revealed CNA #918 reported she was in the Centrum when she saw the resident stand up and attempt to walk. Before she could reach her, she had fallen on the floor and landed on her right side. The alarm was present in the wheelchair and was alarming. See the nursing notes regarding the fall. Continue to encourage the resident to be in the Centrum when up in a wheelchair. Continue with current interventions in place which include one-hour visual checks, chair tender and falling star program. Review of Resident #116's progress note dated 11/12/24 at 3:05 A.M. revealed the resident was resting in the Centrum and denied any needs or complaints of pain. Neurological checks were unremarkable, and range of motion (ROM) was as per normal. Staff would continue to monitor. Review of Resident #116's progress note dated 11/12/24 at 3:35 A.M. revealed the resident was assisted back to bed with the assist of two staff members and reported pain to the right hip/thigh area. The resident was able to move the leg with no swelling or bruising noted. A small bruise was noted below the knee. The resident did not rate the pain and the floor nurse to medicate the resident. The on-call service was contacted to ask for a X-ray and the answering service said to call the office in the morning. Review of Resident #116's progress note dated 11/12/24 at 8:49 A.M. revealed a call was placed to the physician to update on the resident's complaints of pain in the right hip and right leg area. New orders were received for an X-ray of the right hip, pelvic and right femur. Review of Resident #116's progress notes dated 11/12/24 at 8:52 A.M. revealed the resident's daughter was notified of the new orders and of complaints of right hip and right leg pain. Review of Resident #116's progress note dated 11/12/24 at 11:51 A.M. revealed at 11:30 A.M. the results of the X-ray was received and was noted with an acute subcapital hip fracture. A call was placed to the physician with orders to send the resident to the emergency department (ED). Interview on 01/14/25 at 10:30 A.M. with the Director of Nursing (DON) indicated the on 11/11/24, Resident #116 fell in the Centrum or common area and sustained a fracture at approximately 7:50 P.M. The DON stated the investigation revealed CNA #918 had observed the resident stand up and attempt to walk and subsequently fell on the floor on her right side. The DON confirmed the chair alarm was sounding, and the resident did not hit her head. He stated Resident #116 did not answer questions but was awake and alert. Interview 01/14/25 at 12:08 P.M. with Resident #116's daughter revealed concerns related to the resident being left in bed from the time of the fall until 12:30 P.M. the next day with a hip fracture. Telephone interview on 01/14/25 at 12:11 P.M. with CNA #918 revealed she was walking through the Centrum with a tray on 11/11/24 when she had observed Resident #116 trying to get out of her wheelchair. She stated she assisted the resident back into her wheelchair and then told her she would be with her in a second. She stated she felt the resident was settled back into her wheelchair, so she went to the food cart off the Centrum and placed a food tray on the cart. She stated as she turned, she heard Resident #116's chair alarm and the resident was almost on the floor. She stated it was a split second, and she did not see the actual fall but had observed as the resident fell to the floor. She stated she immediately went and got the nurse who was at the nursing station off the Centrum who then assessed the resident. CNA #918 indicated she did not observe any bruising or external rotation of Resident #116's legs and the resident did not complain of pain. She stated RN #856 assessed the resident and no injuries were noted so they helped the resident stand and placed her back into her wheelchair. CNA #918 revealed she took the resident to her room in the wheelchair and CNA #955 was going into the room to provide care to the resident. She was unaware of any other details. Interview on 01/14/25 at 12:40 P.M. with the DON indicated Resident #116 fell on [DATE] at 7:50 P.M., was assessed for injury and pain and nothing negative was identified. He stated on 11/12/24 at 8:49 A.M. the resident complained of pain and an X-ray was obtained which showed a left hip fracture. The DON confirmed Resident #116 was transferred to the ER on [DATE] at 11:40 A.M. Telephone interview on 01/14/25 at 2:44 P.M. with Registered Nurse (RN) #856 revealed she was at the nursing station on 11/11/24 when she heard the CNA call out for assistance. RN #856 confirmed she had observed Resident #116 lying on her right side by the wheelchair. The CNA indicated the resident attempted to walk out of the wheelchair and had fallen on her right side. RN #856 revealed the resident denied pain, did not have external hip rotation, was able to move her hip and was able to get back into her wheelchair and be toileted. RN #856 denied Resident #116 had any injuries noted and she denied the resident had reported she hit her head at any point. She revealed Resident #116's neurological checks were negative. She stated she called the daughter to report the fall. She stated she went home around 11:00 P.M. and had to come back into the facility for dayshift on 11/12/24. She could not state the exact time she left and returned to the facility. RN #856 revealed when she returned on the morning shift on 11/12/24 she was told in report the resident had reported complaints of pain around 4:00 A.M. to 5:30 A.M. and an X-ray of her hip was obtained. She stated she had assessed Resident #116 early in the morning at an unknown time and the resident was sleeping. She stated she went back into the room a short while later and the resident complained of pain. RN #856 revealed Resident #116's X-ray results came back, and she called the physician with the results of the left hip fracture and obtained an order to send the resident to the emergency room. She stated she called the daughter to let her know of the new orders. Telephone interview on 01/15/25 at 1:54 P.M. with the Administrator in attendance of RN #865 (nightshift nurse on 01/12/24) revealed she had the called the on-call physician when Resident #116 complained of pain and they told her to call the physician back in the morning. She confirmed Resident #116 was sleeping once she was put in bed and medicated for pain. She denied concerns with the resident's care. Interview on 01/15/25 at 2:06 P.M. with the Administrator and the DON indicated the facility attempted to call Resident #116's physician and they on-call agency refused to put the nurse through to the physician. The Administrator stated she felt it was because the on call answering service was not willing to disrupt the physician at night. Interview on 01/15/25 at 2:14 P.M. with the DON indicated the staff would call him if it was a critical emergency and Resident #116 did not have any signs of a broken hip during the night on 01/12/24. He revealed if she would have had any signs such as a rotated hip or screaming in pain, then they would have immediately sent her out to the hospital. He stated the facility staff felt they had called the physician, was told to call back in the morning, the resident was stable and no immediate needs were not addressed. This deficiency represents non-compliance investigated under Complaint Number OH00160374.

Based on record review and interviews the facility failed to provide adequate and appropriate quality of care and services when transferring Resident #22 into bed after a fall incident. This affected one resident (Resident #22) of four residents reviewed for assistance with transfers. The facility census was 116. Findings include: Review of the medical record for Resident #22 revealed an admission date of 09/10/20. Diagnoses included Alzheimer's disease, dementia with behavior disorder, left shoulder pain, hyperlipidemia, aphasia, anxiety, major depressive disorder (MDD), and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/05/23, revealed the resident had severely impaired cognition. Resident #22 required extensive assist by one staff member for for bed mobility, wheelchair mobility, dressing, and eating and was totally dependent on two staff members for transfers, toileting, and personal hygiene. Review of the plan of care dated 09/10/20 revealed the resident was at risk for falls due to dementia, Alzheimer's disease, anxiety, MDD, and decreased mobility. Interventions included bed in lowest position, clutter free pathways, call light within reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of physician orders for May 2023 identified orders for Resident #22's bed to be in the lowest position, clutter free pathways, call light with in reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of the nurses notes dated 03/27/23 at 8:00 P.M. Licensed Piratical Nurse (LPN) #814 documented Resident #22 was found on the floor next to right side of bed. She documented injuries to residents mouth, bruising to right side of face and bruising with swelling to right hand including her second digit. The physician was contacted and gave orders to send resident to the local emergency room (ER) for evaluation and treatment. Resident #22's family was updated about the fall and new orders to send the resident to the ER. Nurse to nurse was called to the local ER. Review of nurses noted dated 03/27/23 at 11:32 P.M. Resident #22 returned from the ER with no new orders, all scans completed at the hospital including x-rays, and Computed Tomography scans revealed no fractures. Resident #22 had bruising to right side of face and to her right hand including her second digit. Review of the fall investigation dated 03/27/23 revealed all ordered fall interventions were in place, alarm was sounding when nurse entered room and found Resident #22 on the floor next to her bed. Staff witness statements revealed State Tested Nursing Assistant (STNA) #804 and STNA #805 assisted Resident #22 to bed prior to her fall by using a two person transfer per her plan of care, then left the room together. LPN #814 entered Resident #22's room to give the resident her medicine and heard the alarm sounding and found the resident on the floor. LPN #814's statement included she ensured the resident was safe and did a quick assessment. LPN #814 noted bruising and swelling to resident right side of face, bleeding from her mouth and bruising and swelling to right hand including her second digit. LPN #814 yelled for help, found there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 alone in the room with Resident #22, STNA #805 was standing next to the residents bed and Resident #22 was already in bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at at the time of the fall. Interviews completed throughout the survey on 05/09/23 through 05/11/23 with the Administrator and Director of Nursing revealed on 03/28/23 via phone interview with STNA #805, STNA #805 told them he transferred Resident #22 off of the floor by himself even though he knew the resident was a two person transfer per her plan of care. He stated he lied the night before when she fell because he did not want to get in trouble for her falling. At the time of the phone interview STNA #805 was terminated due to his actions. Interview on 05/10/23 at 3:10 P.M. with LPN #814 verified she found Resident #22 on the floor next to her bed laying on her right side. LPN #814 noted bruising and swelling to right side of face, bleeding from her mouth, and bruising and swelling to her right hand including her second digit. LPN #814 yelled for help there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 standing next to the residents bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at time of the fall. This deficiency represents non-compliance investigated under Complaint Number OH000141625.

Based on medical record review, policy review and staff interview, the facility failed to ensure resident re-weights were obtained to verify accuracey of weight changes per facility policy. This affected one (Resident #101) of five residents reviewed for nutrition. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record including weight recording identified on 03/26/22 the resident's weight was 280.4 pounds. The next weight recorded on 04/14/22 was 286.8 pounds, a difference of 6.4 pounds from the prior weight. On 04/28/22 the weight recorded was 293.8 pounds, a difference of seven pounds from the prior weight. On 05/07/22 the weight recorded was 279.6 pounds, a difference of 14.2 pounds from the prior weight. On 05/14/22 the weight recorded was 286.6 pounds, a difference of seven pounds from the prior weight. On 05/21/22 the weight recorded was 284.6 pounds. On 07/02/22 the weight recorded was 274.6 pounds, a difference of 10 pounds from the prior weight. On 07/16/22 the weight recorded was 289.6 pounds, a difference of 15 pounds from the prior weight. On 07/30/22 the weight recorded was 273.6 pounds, a difference of 16 pounds from the prior weight. On 08/06/22 the weight recorded was 290.0 pounds, a difference of 16.4 pounds from the prior weight. On 08/13/22 the weight recorded was 264.8 pounds, a difference of 25.2 pounds from the prior weight. On 08/20/22 the weight recorded was 266.2 pounds. On 08/27/22 the weight recorded was 259.2 pounds, a difference of seven pounds from the prior weight. Review of the facility policy Weight Policy and Procedure with an updated date of 07/13/22 indicated if the weight had a five pound variance or more, either up or down, the nurse aide would be responsible to re-weigh the resident in 24 hours. Interview with the Director of Nursing on 08/31/22 at 1:10 P.M. verified staff did not obtained re-weights for Resident #101 to confirm accuracy of weights per the facility policy.

Based on medical record review and staff interview the facility failed to ensure hospice records including certification, assessments and visitation notes were available to the facility staff for collaborative care and services to Resident #101. This affected one (Resident #101) of two residents reviewed for hospice services. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admission date of 03/17/22 with diagnoses including end stage renal disease and hypertension. Further review of the medical record revealed a physician's order dated 08/05/22 to admit the resident to hospice services by Southern Hospice. Further review of the medical record including paper medical chart in the nursing office found no evidence of any type of hospice certification paperwork, hospice assessments or hospice visitation notes. Interview with Unit Secretary #504 on 09/01/22 at 9:45 A.M. verified there was no evidence of any hospice certification paperwork, assessments and/or visitation notes in the resident's medical record or a separate binder located in the nursing office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed as required. This affected three residents (#3, #11 and #12)of 14 residents whose medical records were reviewed for completion of assessments. Findings include: On [DATE] beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted related to the completion of annual MDS 3.0 assessments: 1. Review of Resident #3's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of [DATE]. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #3 had an annual MDS assessment with a ARD of [DATE] which had not been completed. 2. Review of Resident #11's Assessment Lookup information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #11 had a MDS with a ARD of [DATE] which was not completed. 3. Review of Resident #12's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 revealed Resident #12 had expired on [DATE]. Resident #12 had an annual MDS assessment with a ARD date of [DATE] that had never been completed.

Based on record review and interview the facility failed to conduct quarterly Minimum Data Set (MDS) 3.0 assessments in a timely manner. This affected four residents (#9, #10, #13 and #15) of 14 residents whose medical records were reviewed for completion of assessments. Findings include: On 09/24/19 beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted regarding quarterly MDS 3.0 assessments: 1. Review of Resident #9's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of 07/23/19. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #9 had a quarterly MDS assessment with an ARD of 07/23/19 which had not been completed. 2. Review of Resident #10's Assessment Lookup information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/29/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #10 had a MDS with a ARD of 07/29/19 which was not completed. 3. Review of Resident #13's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/31/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #13's quarterly MDS with an ARD of 07/31/19 had not been completed. 4. Review of Resident #15's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment with an ARD of 08/18/19 had not been completed. MDS Coordinator #350 verified Resident #15's quarterly MDS with an ARD of 08/18/19 was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident Minimum Data Set (MDS) 3.0 assessments were transmitted in the required time frames. This affected seven residents (#1, #2, #4, #5, #6, #7, and #8) of 14 residents reviewed for submission of assessments. Findings include: On 09/24/19 beginning at 4:30 P.M., submission of Minimum Data Set (MDS) 3.0 assessments were reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350 with the following concerns identified regarding submission of assessment data: 1. Review of Assessment Lookup logs for Resident #1 indicated there was a quarterly MDS 3.0 assessment dated [DATE]. The log indicated data entry was completed 07/26/19 but the assessment had not been submitted. MDS Coordinator #350 verified Resident #1 had a MDS with an ARD of 07/05/19 which was completed 07/26/19 but had not been submitted. 2. Review of Assessment Lookup logs for Resident #2 indicated there was an annual MDS 3.0 assessment with an ARD of 07/06/19. The log indicated data entry was completed 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #2 had a MDS with an ARD of 07/06/19 which was not completed until 08/02/19 and which had not been submitted yet. 3. Review of Assessment Lookup logs for Resident #4 indicated there was a significant change MDS 3.0 assessment with an ARD of 07/03/19. The log indicated a data entry complete date of 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #4 had a MDS with an ARD of 07/03/19 which was marked as complete 08/02/19 but not submitted yet. 4. Review of Assessment Lookup logs for Resident #5 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/04/19. The log indicated a data entry date of 09/15/19. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #5 had a MDS with an ARD of 07/04/19 which was completed late (09/15/19) and submitted late (09/20/19). 5. Review of Assessment Lookup Information for Resident #6 revealed there was a comprehensive annual MDS 3.0 assessment with an ARD of 08/10/19. Data entry was completed 09/23/19 but had not been submitted. MDS Coordinator #350 verified Resident #6 had a MDS with an ARD of 08/10/19 which was marked as completed 09/23/19 but which had not been submitted yet. 6. Review of Assessment Lookup information for Resident #7 revealed there was a quarterly MDS 3.0 assessment dated [DATE]. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #7 had a MDS with an Assessment Reference Date of 07/05/19. The MDS was not completed until 09/13/19 and was not submitted until 9/20/19. 7. Review of Assessment Lookup information for Resident #8 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/10/19. The log indicated data entry was not completed until 09/22/19 and not been submitted. MDS Coordinator #350 verified Resident #8 had a MDS with a ARD of 07/10/19 which was not completed until 09/22/19 so it was done late and not yet submitted.