Every finding on record at Azria Health Rose Vista

Based on observation, provider interview, staff interviews, record review and policy review, the facility failed to provide timely and adequate skin care to prevent worsening of pressure ulcers for 2 of 3 residents reviewed. Resident #6 developed a pressure injury on her heel and staff failed to call the doctor when there was a change in the wound. Resident #71 was admitted to the facility with an identified Moisture Associated Skin (MASD), and staff failed to get a doctor's order for treatments. The facility reported a census of 69 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound bed.Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had severely impaired cognitive skills for daily decision making. She was totally dependent on staff for toileting hygiene, sit to stand and toilet transfers. Resident #6 had an unstageable pressure injury. The Care Plan updated on 8/30/25, for Resident #6 showed that she had the potential for impaired skin integrity and an existing left heel pressure injury. Staff were directed to float the left heel or apply heel protectors while in bed. Staff were to notify the physician with changes and signs of infection such as redness, odor or increased drainage. As of 10/16/25, Resident #6 was receiving end of life care, related to terminal prognosis and had elected hospice services. The Progress Note dated 8/26/25 documented a foot evaluation was completed to Resident #6. It documented the resident has a skin tear to her right shin with no other areas noted. The Fax form to the physician dated 8/31/25 documented Resident #6 has a sore on her left heel that looks like it is an old blister that is now hard and scabbed over. Resident denies pain. Measures 2cm x 1.2cm in size. Skin prep applied and will continue to be applied daily until healed. The Medication/Treatment Administration (MAR/TAR) record for Resident #6 showed that on 9/2/25 at 3:13 PM, they started an order for skin prep daily to the left heel area. The October MAR/TAR showed on 10/2/25 at 12:29 PM, the order changed to Marathon skin prep three times a daily.According to Wound Source Product Guide. Skin Prep forms a protective interface to prepare intact skin for attachment sites and protects kin from incontinence, tape stripping and friction. Retrieved on 11/24/25 at 7:40 AM from: SKIN-PREP* Protective Dressing | Wound Liquid ProtectantThe following documentation was found in the Nursing Notes (NN) and on the Nursing Services Basic Skin Assessment (NSBSA):a. NN; 8/31/25 at 5:56 PM, staff noted sore on resident left heel, it was scabbed over, the skin was dark yellow and brown. A Skin Prep treatment was applied and Primary Care Physician (PCP) notified. b. NN; 8/31/25 at 5:57 PM, new skin issue on the left heel, pressure injury, unstageable and measured 2centimeter (cm) length x 1.2 cm width.c. NN; 9/2/25 at 1:56 PM, left heel wound measured 2 cm x 1.5 cm. Clean, dry and intact scab. d. NN; 9/2/25 at 3:12 PM, PCP okay with current treatment (skin prep) and heel protectors in bed. e. NSBSA; 9/9/25, left heel ulcer measured 2 cm x 2 cm. f. NSBSA; 9/16/25 left heel ulcer measured 3 cm x 1 cm. g. NSBSA; 9/23/25 left heel ulcer measured 4 cm x 1.5 cm. h. NN; 9/24/25 at 4:32 PM, no skin issues worsening at this time. The resident record lacked information regarding doctor notification of change in wound. i. NN; 9/26/25 at 8:40 AM, the resident was being monitored for skin concerns on left heel. No concerns for worsening integumentary status, no signs or symptoms of infection. Current treatment: skin prep to left heel daily, heel protectors in place when resident in bed. j. NN; 9/29/25 at 2:49 PM, The Certified Nurse Aide (CNA) provided bath today and noticed the area on the left heel was bigger and left ankle swollen and warm. k. NSBSA; 9/30/25 at 9:23 AM, ulcer measured 5 cm x 2 cm. l. NN; 9/30/25 at 1:33 PM, fax sent to the PCP and requested application of Marathon (skin protectant) every shift until resolved. m. NN; 10/1/25 at 1:45 PM resident left heel is deteriorating. Moderate drainage on her dressing slight odor. n. NN; 10/1/25 at 3:34 AM the resident continued on antibiotic for left ankle redness. A Skin assessment dated [DATE] 11:36 AM, lacked measurements or description of the wound.A Nursing Progress Noted dated 10/11/25 at 10:25 AM, showed that the unstageable pressure contained 90% eschar (dark, crusty tissue) and the wound measure 4.5 cm x 2.3 cm. There was increased redness, warmth and odor. Resident #6 verbalized discomfort with dressing removal. Rolled edges to the wound, change of condition in agreement. A NN dated 10/11/25 at 10:30 AM, showed that Resident #6 was lethargic, and there was increased odor from the heel. Staff attempted to remove the dressing and the resident displayed increased pain. The resident was sent to the emergency room for further treatment. On 11/19/2025 at 11:39 AM, a nurse for the PCP said that from 8/31 - 9/22/25, the doctor had not been contacted about a change in status and that the wound had been getting bigger. She said that on 9/29 they were contacted regarding a change and the doctor gave an order for an antibiotic. She said that it was their understanding that Resident #6 had been under the care of Hospice during that timeframe and they were monitoring and giving treatment orders for the wounds. In an observation on 11/19/2025 at 9:08 AM, Staff A Licensed Practical Nurse (LPN) and Staff B, Registered Nurse (RN), provided a dressing change on the left heel for Resident #6. The resident pulled her foot back and displayed some pain. The wound had mostly black eschar and some peeling skin around the outsides of the ulcer. On 11/20/25 at 10:30 AM, Staff F, Registered Nurse (RN) said she remembered when Resident #6 had the treatment order for skin prep. She said she had some concerns that the same treatment order had been in place for so long. She said there was a period of time that she hadn't worked and when she came back, the wound had deteriorated significantly, including some drainage. Staff F said that with skin prep application, they should have left it open to air. She believed that by wrapping it, the moisture stayed in the wound and hampered healing. On 11/20/25 at 10:04 AM, Staff E, LPN said that she would do the skin prep treatment and leave it open to air, but she had seen that many times, it was wrapped. A review of the nursing progress notes showed that from 10/1/25 - 10/11/25 the nurses made reference to a dressing applied over the wound on 5 separate days. On 11/20/2025 at 10:39 AM, the Director of Nursing (DON) said that the doctor should have been contacted for new treatment orders when there was a change in the wound. She said that if the treatment order did not include a wrapping, staff would understand that it should have been left open to air. 2) According to the MDS dated [DATE], Resident #71 was admitted to the facility on [DATE] with a BIMS score of 12 (moderate cognitive deficits). The Baseline Care Plan for Resident #71, dated 11/10/25, showed that he required one person assistance with toileting hygiene, and two-person physical assist with transfers and ambulation. The Care Plan dated 11/10/25, showed that Resident #71 had Activities of Daily Living (ADL) self-care performance deficits related to dementia. The resident had the potential for impaired skin integrity/pressure injury, and had a MASD on the coccyx. An addition was made to the Care Plan on 11/17/25, to apply barrier cream as needed and follow physicians wound care orders. Skin Check dated 11/11/25 at 8:25 AM, showed that Resident #71 had moisture associated skin damage on his coccyx that was present upon admission. The area measured; 0.5 cm x 0.2 cm. The Medication/Treatment Administration Record (MAR/TAR) and Orders tab lacked reference to treatment orders for the developing skin issue. A Skin Check document dated 11/18/25 at 5:33 AM, lacked measurements of the MASD on the coccyx. On 11/18/25 at 6:45 AM, Certified Medication Aide (CMA), Staff C, assisted Resident #71 to the bathroom. After assisting the resident to the toilet, Staff C stayed in the room with him until the resident indicated that he was done. Resident #71 used disposable wipes to clean himself. Without offering a barrier cream, Staff C then helped him pull up his pants and escorted the resident to the chair. At 8:30 AM, and at 10:19 AM the resident was still in the chair.On 11/19/2025 at 1:26 PM, Staff B and Staff A transferred Resident #71 to the bed and let him know that they wanted to checked his bottom. The coccyx area was red and Staff A stated that there was a slight open slit down the middle of the reddened area. Staff A stated they would contact the doctor to get an order for twice a day application of barrier cream. On 11/20/25 at 10:39 AM the DON and Administrator agreed that Resident #71 should have gotten an order for barrier cream as soon as the issues was identified. A facility policy titled: Pressure Ulcers/Skin Breakdown - Clinical Protocol, updated on April 2018, the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, debridement approaches, dressings and application of topical agents. The physician would guide the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds develop despite existing interventions. Current approaches would be reviewed for whether they remain pertinent to the residents' medical conditions are affected by factor influencing wound development or healing and the impact of specific treatment choice made by the resident.

Based on facility document review, staff interviews and clinical record review the facility failed to establish and implement a restorative nursing program to help prevent residents from decline for residents discharged from Physical Therapy/Occupational Therapy (PT/OT) services. The facility reported a census of 69 residents.Findings include: According to the Beneficiary Notice-Residents discharged within the Last Six Months, the facility had 25 resident that were discharged from a Medicare covered Part A stay and remained in the facility. The Minimum Data Set (MDS) dated [DATE], showed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8 (severe cognitive deficit.) He required partial assistance with hygiene, dressing, sit to stand and transfers. The Care Plan for Resident #39, updated on 9/21/25, showed that Resident #39 had unwitnessed falls on 4/4/25, 6/24/25 and 9/21/25. Resident #39 was at risk for injury related to weakness, balance problems medications and neurodegenerative changes. The resident required assistance with Activities of Daily Living (ADL) related to vascular dementia, emphysema, pulmonary fibrosis and Chronic Obstructive Pulmonary Disease (COPD). On 10/26/25 the resident required assistance of 1 staff with staff were directed to encourage the resident to participate in ADLS, and to do as much for self as able. On 11/17/25 at 10:59 AM, Resident #39 was in bed and his wife sat in a wheel chair near the bed. The resident did not respond to questions and his wife said that he'd had some falls and needed assistance with ADL's. She said that used the bed rail up, to pull himself up out of bed. According to the Census Details Report, Resident #39 was discharged from Physical Therapy and Occupational Therapy services on 9/24/25. A Fax form sent to the physician dated 11/18/25, showed that staff requested orders for OT to evaluate and treat Resident #39 to assist with dressing. The request was signed by physician on 11/18/25. On 11/20/2025 at 9:06 AM, Staff G, PT/OT staff, said that the facility did not have a restorative program. She said that there were residents at the facility that could benefit from a restorative plan with exercises to help them maintain their Range of Motion (ROM.) On 11/20/2025 at 10:54 AM, Staff G said that Resident #39 was referred back to OT because he had a decline in ADL's, specifically with dressing himself. She said that the PT/OT director would complete regular reviews of the resident to determine if there were any declines in status and then get an order for a new evaluation. Staff G stated that regular exercises could have helped maintain the upper body strength and ROM for Resident #39.On 11/20/2025 at 9:17AM, the Director of Nursing (DON) stated the facility did not have a restorative program and agreed that some residents could benefit from regular, planned exercises to help them maintain their strength. The DON said that if there was a functional decline, they would contact the doctor and ask for an evaluation from PT/OT. The Facility Assessment updated 11/18/25, showed under the section titled: Specific Care or Practices, that they would provide: Mobility and fall/fall with injury prevention. Therapy and restorative nursing. A facility policy titled: Restorative Nursing Services, revised in July of 2017, residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of the stay, or when discharged form rehabilitative care. The restorative goals and objectives were individualized and resident-centered, and were outline in the resident plan of care.

Based on Electronic Health Record (EHR) review, document review, resident interview, staff interview and policy review, the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #8, #12, #20 and #38). The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 11/17/25 at 3:48 PM Resident #12 stated the facility had added several residents to the census recently and the facility could use more staff. Resident #12 stated usually at least once a week it takes longer to answer the call light than 15 minutes. 2. The MDS dated [DATE] documented Resident #20 had a BIMS of 15 indicating no cognitive impairment. On 11/17/25 at 11:42 AM Resident #20 said it takes longer than 15 minutes to get help when she turns the call light on. Resident #20 stated she has had to wait up to an hour to have her call light answered. Resident #20 explained that she had to wait longer than 15 minutes daily depending on the staffing. Resident #20 stated when the staff come in to answer the call light they tell her they can't help they are running behind because there was a call in and they do not have enough staff. Resident #20 said the staff take her back to her bedroom after meals and she needs to use the restroom. Resident #20 said she is told the staff have to go across the hall to the other room because someone is on the toilet. Resident #20 acknowledged she had been incontinent of bowel and bladder because of having to wait for assistance to the toilet. On 11/19/25 at 3:28 PM Staff I, Certified Nursing Assistant (CNA) stated at times the call lights take longer than 15 minutes to answer. Staff I explained it takes longer than 15 minutes because they do not have enough staff. 3. Review of Resident #8's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognitive functioning. The MDS further revealed diagnoses of diabetes mellitus, fracture of one rib, weakness, repeated falls, and fatigue. Interview 11/17/2025 at 10:58 AM with Resident #8 revealed that call lights can take awhile at times. Resident #8 further revealed that sometimes the call lights are over 15 minutes, and he knows this because he can read a clock in his room. 4. Review of Resident #38's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive functioning. The MDS further revealed diagnoses of history of falling, muscle weakness, and fatigue. Interview 11/17/2025 at 10:43 AM with Resident #38 revealed that call lights often take over 15 minutes. Resident #38 then revealed that she can read the clock, and that's how she knows it takes over 15 minutes. Interview 11/20/2025 at 10:14 AM with the Administrator and the Director of Nursing (DON) revealed that they would like to see staff answer residents' call lights in a timely manner. The Administrator further revealed that call lights should be answered in 15 minutes or less. Review of a facility provided document titled, Past Calls 11/10/25-11/16/25 revealed several call lights ranging from 16 minutes to 49 minutes in length of time. Review of a facility policy titled, Answering the Call Light with a revision date of September 2022 revealed: a. Answer the resident call system timely.

Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 4 of 4 residents with a pureed diet (Resident #6, #13, #26, and #52) reviewed and also all the residents that ate the lunch meal on 11/19/25. The facility reported a census of 69 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia oropharyngeal phase. Review of Resident #6's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 10/22/25.2. The MDS dated [DATE] documented Resident #13 had a BIMS of 1 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia following cerebrovascular disease. Review of Resident #13's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 2/8/22.3. The MDS dated [DATE] documented Resident #20 had a BIMS of 15 indicating no cognitive impairment. On 11/17/25 at 11:40 AM Resident #20 explained she ate meals in the front dining room. Resident #20 stated the staff rarely give them condiments in the front dining room like butter. Resident #20 said in the front dining room they didn't even have brown sugar for the hot cereal in the morning. 4. The MDS dated [DATE] documented Resident #26 had a BIMS of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia.Review of Resident #26's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 9/25/24.5. The MDS dated [DATE] documented Resident #52 had a BIMS of 3 indicating severe cognitive impairment. The MDS documented a diagnosis of dysphagia following cerebral infarction.Review of Resident #52's EHR titled, Orders documented a physician's order for a general diet with pureed texture dated 11/12/25.Review of document titled, Diet Spreadsheet Week 4 documented lunch meal included rosemary herbed baked chicken, roasted red potatoes, cauliflower au gratin, pumpkin cake with whipped topping, dinner roll and margarine for the regular diets. Ground rosemary boneless chicken with gravy, mashed potatoes with gravy, chopped cauliflower au gratin, pumpkin cake with whipped topping and buttered soft dinner roll for the mechanical soft diets. Pureed rosemary boneless chicken, mashed potatoes with thick gravy, pureed cauliflower au gratin, pureed pumpkin cake with whipped topping and pureed dinner roll/margarine for the pureed diets. On 11/19/25 at 10:45 AM a continuous observation by Staff K, [NAME] completed the puree food process. 5 servings pureed but only 4 serving to serve. Chicken (Rosemary) measured 2.5 cups / #8 for scoops, cauliflower measured 3 cups / #8 slightly heaping scoop, Pumpkin cake 20oz measured out / 4 oz / #8 scoop. Rolls were not pureed for residents on a puree diet.A continuous observation on 11/9/25 at 11:45 AM revealed Staff K, [NAME] serving the lunch meal revealed at 12:11 PM food was delivered to the front dining room. No butter served to the front dining room. At 12:14 PM no butter passed out with all meals served in the back dining room. No pureed roll passed to any of the residents on pureed diet. At 12:27 PM a pad of butter was requested by a resident in the back dining room.On 11/19/25 at 12:30 PM Staff L, Certified Dietary Manager (CDM) stated butter was usually sat in the window and staff waited for a resident to request the butter. Staff L stated the facility had run out of butter pads and currently did not have any in the facility. Staff L stated they would give liquid butter in condiment cups to the resident. Staff L explained the butter would usually be served with the lunch trays.On 11/19/25 at 12:32 PM Staff M, Medical Records acknowledged she frequently passed meal trays to the residents in the front dining room. Staff M stated she didn't serve butter to the residents during meals unless the residents asked for it. Staff M acknowledged there was no butter available in the front dining room even if the residents wanted any butter that day. On 11/19/25 at 12:40 PM Staff K acknowledged rolls were not pureed for the residents on pureed diets during the lunch meal. Staff K stated usually he would puree the bread/roll with the chicken or the vegetable but did not do that at the lunch meal on 11/19/25.On 11/19/25 at 1:00 PM Staff L stated the facility's expectation was that the menu would be followed. Staff L stated the facility's expectation was rolls would have been pureed for the residents that required a pureed diet. Staff L asked Staff K if rolls had been served to the resident requiring a pureed diet. Staff K acknowledged he did not puree any rolls. Staff L told Staff K to puree rolls for the residents that required a pureed diet. Staff K told Staff L the residents did not like to eat the bread anyways. Staff L told Staff K he still needed to puree the rolls. On 11/19/25 at 2:00 PM the Administrator stated the facility's expectation was that the menu would be followed. The Administrator stated butter should have been served to the residents. The Administrator stated she was unaware the facility was out of pads of butter. The Administrator stated she could have bought butter for the facility that day. The Administrator stated the facility's expectation was the residents that required a pureed diet would have been served rolls if the rolls were on the menu.Review of policy revised 10/17 titled, Therapeutic Diets documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. Diet order should match the terminology used by the food and nutrition services department.

Based on clinical record review, document review, and staff interviews the facility failed to notify the resident's representative / family / Power of Attorney (POA) and the resident's primary care physician of a stage 2 pressure ulcer for 1 of 3 residents (Residents #1) reviewed. The facility reported a census of 69 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of Resident #1's Electronic Health Record (EHR) titled, Orders documented a physician's order to cleanse pressure ulcer to coccyx with saline and 4x4, apply xeroform to wound bed only and cover with Opti foam started 11/4/25.Review of Resident #1's EHR titled, Progress Notes at 2:00 AM on 10/31/25 Staff H, Licensed Practical Nurse (LPN) titled, Progress Notes documented Resident #1 had complaints of sacral pain. The area was documented as red but blanching. Directly over Resident #1's tailbone was an open area with white tissue. Review of Progress Notes documented no family or physician notification by Staff H.On 11/19/25 at 1:29 PM the Director of Nursing (DON) acknowledged the overnight nurse Staff H, LPN found the area on 10/31/25. The DON stated Staff H put his assessment in for Resident #1. The DON explained that Staff H reached out on 11/3/25 and asked if she had seen the note he had left. The DON stated 10/31/25 was the date that Resident #1's area on coccyx was determined to be a stage 2 pressure ulcer. The DON explained that education was provided to Staff H about completing a skin evaluation, getting any new orders, and notification to family and physician. The DON stated she expected that the risk management and skin evaluation would be completed right away, call the provider, take the order if needed and call the family to notify them in a timely manner. The DON acknowledged that she came in on 11/3/25, completed the risk evaluation, notified the physician and notified the family. The DON acknowledged Staff H had not notified the physician or the family of the stage 2 pressure ulcer on Resident #1's coccyx. Review of policy revised 3/18 titled, Acute Condition Changes - Clinical Protocol documented phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Based on observation, family interview, staff interviews, clinical record review and policy review, the facility failed to implement the established interventions to prevent falls for 2 of 3 residents reviewed. Residents #39 and #1 had frequent falls and interventions included gripper strips on the floor to prevent slipping. Observations revealed that the staff failed to apply the safety strips. The facility reported a census of 69 residents. Findings include:1) The Minimum Data Set (MDS) dated [DATE], showed that Resident #39 had a Brief Interview for Mental Status (BIMS) score of 8 (severe cognitive deficit.) He required partial assistance with hygiene, dressing, sit to stand and transfers. The Care Plan for Resident #39, updated on 9/21/25, showed that Resident #39 had unwitnessed falls on 4/4/25, 6/24/25 and 9/21/25. The intervention for the fall 6/24/25, was to have nonskid strips applied on the floor near the bed. Resident #39 was at risk for injury related to weakness, balance problems medications and neurodegenerative changes. He was on antipsychotic medications related to diagnosis of hallucinations at night, Alzheimer's disease and anxiety. Resident #39 required assistance with Activities of Daily Living (ADL) related to vascular dementia, emphysema, pulmonary fibrosis and Chronic Obstructive Pulmonary Disease (COPD). On 10/26/25 the resident required assistance of 1 staff with staff were directed to encourage the resident to participate in ADLS, and to do as much for self as able. On 11/17/2025 at 10:59 AM, Resident #39 was lying in bed, and there was a wheel chair and commode close to the bed. The resident did not respond when spoken to, and his wife said that he didn't speak much. She said that he'd had several falls in his room. The area lacked safety strips on the floor. An incident report dated 6/24/25 at 6:45 PM, showed that on that date, staff found Resident #39 on the floor in front of his wheel chair and commode, lying on his back. Resident #39 stated he needed to use the commode and was transferring self. Intervention/action taken included; nonskid strips applied to floor. On 11/20/25 at 10:00 AM, Staff E, Licensed Practical Nurse (LPN) said that Resident #39 did not use his call light and he would often attempt to self-transfer from the bed to the commode without waiting for help. Staff E said that they needed to keep a close eye on him. On 11/20/25 at 10:39 AM, the Director of Nursing (DON) and the Administrator said that they went for a period of time without a maintenance department and some tasks, such as applying safety strips, did not get completed. They agreed that this intervention should have been in place to help prevent further falls for Resident #39. According to the facility policy titled: Falls and Fall Risk Managing, updated on 3/2018, based on previous evaluations and current data, the staff would identity interventions related to the resident's specific risk and causes to try to prevent the resident form falling and try to minimize complications from falling. Environmental factors that contribute to the risk of falls included; wet floors and footwear that was unsafe of absent. If underlying causes cannot be readily identified or corrected, staff would try various interventions, based on assessment of the nature of category of falling, until falling was reduced or stopped or until the reason for the continuation of the falling was identified as unavoidable. 2. The MDS dated [DATE] documented Resident #1 had a BIMS of 6 indicating severe cognitive impairment. Review of Resident #1's Progress Notes from 10/15/25 at 5:30 PM Resident #1 had an unwitnessed fall, subsequently transferred to the emergency department, and fractures of the 5th lumbar vertebra, superior rim of left pubis, sacrum and surgical neck of left humerus. Review of Resident #1's Care Plan documented an intervention dated 10/15/25 for fall intervention that non-skid strips would be applied to the floor by bed. On 11/18/25 at 3:06 PM an observation in Resident #1's room revealed no non-slip strips on the floor next to the bed. Review of Resident #1's document dated 10/15/25 titled, Risk Management Assessment recorded an immediate action taken of non-skid strips applied in front of the recliner and next to bed. On 11/19/25 at 1:29 PM the Director of Nursing (DON) acknowledged there should have been non-skid strips in place beside Resident #1's bed. Stated she did not know there were no non-skid strips in place on 11/18/25 next to Resident #1's bed. The DON explained when reviewed at clinical start up the skid strips were applied by maintenance right away and if it was after hours the nurse would apply them. The DON stated it is the nursing department job now instead of maintenance because the intervention needed to be instituted immediately. The DON said when weekly guardian angel rounds were completed by department heads they ensured fall prevention interventions were in place. The DON stated rounds were completed weekly so the interventions should be looked at weekly. The DON stated her expectation was the non-slip strip in place beside Resident #1's bed. The DON acknowledged she had been the staff that originally placed the non-skid strips on the floor next to Resident #1's bed originally. On 11/19/25 at 1:33 PM the Administrator stated Resident #1 should have had the non-skid strips in place on the floor beside her bed. Review of policy revised 3/18 titled, Assessing Falls and Their Causes documented when the resident falls, the following information should be recorded in the resident's medical record interventions in place and appropriate interventions taken to prevent future falls.

Based on staff interview, Electronic Health Records (EHR), document review, staff interview and policy review the facility failed to maintain medical records on a resident that were complete and accurate by failing to document a pressure ulcer in the EHR appropriately for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 69 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of Resident #1's EHR at 2:00 AM on 10/31/25 Staff H, Licensed Practical Nurse (LPN) titled, Progress Notes documented Resident #1 had complaints of sacral pain. The area was documented as red but blanching. Directly over Resident #1's tailbone was an open area with white tissue. Review of Resident #1's EHR titled, Progress Notes documented an inaccurate description of wound on 10/28/25, 10/24/25, 10/23/25, 10/21/25 with description of stage 2 pressure that was found on 10/31/25 overnight shift. Review of progress notes documented late charting for all the days for inaccurate description. Review of Progress Notes further documented in the skin portion of assessments completed on 11/1/23 and 11/2/23 after the stage 2 pressure ulcer was discovered did not describe a stage 2 pressure but only described as a Moisture Associated Skin Damage (MASD).On 11/19/25 at 11:05 AM Staff A, LPN / Wound Nurse / Unit Manager stated she had entered several assessments later. Staff A stated the DON had educated her on entering the assessments in a timely manner. On 11/19/25 at 1:29 PM the Director of Nursing (DON) acknowledged Resident #1 the overnight nurse Staff H, LPN found the area on 10/31/25. The DON stated Staff H put his assessment in for Resident #1. The DON explained that Staff H reached out on 11/3/25 and asked if she had seen the note he had left. The DON stated 10/31/25 was the date that Resident #1's area on coccyx was determined to be a stage 2 pressure ulcer. The DON explained several wound assessments entered by Staff A were entered late. The DON continued to explain when the wound assessments were entered late the description of the wound would auto populate into the documentation. The DON stated when the description of the wound auto populated it would describe the wound on the day the late entry was entered. The DON stated Staff A was new to the position. The DON stated Staff A was educated on the policy and the routine. The DON stated the facility's expectation was wound assessments would be entered accurately with size and description. The DON stated her expectation was that wound assessments would be entered in a timely manner with an accurate assessment.Review of policy revised 4/18 titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol documented during the assessment and recognition the nurse shall describe and document/report a full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. Current treatments will also be documented.

Based on clinical record review, observation, staff interview, and policy review the facility failed to properly use universal infection control measures (hand hygiene and proper glove use) while completing peri cares and catheter cares for 1 of 3 residents (Resident #32) reviewed. The facility further failed to properly wear personal protective equipment (PPE) while completing personal cares for a resident with Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #1). The facility reported a census of 69 residents.Findings include: 1. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of progressive neurological conditions, obstructive uropathy, paraplegia, and Multiple Sclerosis. Review of Resident #32's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for a 16 french (fr) 10cc foley catheter to be changed every 30 days on day shift dated 11/14/25. This page further revealed an order for catheter cares to be completed every shift dated 11/14/25. Observation 11/19/2025 at 9:09 AM Staff D Certified Nursing Assistant completed hand hygiene and donned gloves and a gown. Staff D then proceeded to complete peri cares for Resident #32. Staff D was then observed replacing Resident #32's brief without changing gloves after peri cares. Staff D while still wearing the same gloves from the peri cares, and brief change then cleansed the catheter tubing and finished cleaning the peri area. Staff D then applied powder to Resident #32's peri area while wearing the same gloves without hand hygiene completed. Staff D then doffed her gloves. Staff D then did not complete proper hand hygiene and then donned new gloves prior to draining Resident #32's catheter drainage bag. Interview 11/19/2025 at 12:51 PM with the Director of Nursing (DON), and the Administrator revealed they would expect staff to complete hand hygiene at the appropriate times for catheter cares and peri cares. The DON further revealed that she would have liked to have staff wear gloves and take off gloves at the appropriate times during catheter and peri cares. Review of a facility provided policy titled, Handwashing/Hand Hygiene with a revision date of August 2019 revealed: 1. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents b. Before and after handling an invasive device (e.g., urinary catheters) c. Before moving from a contaminated body site to a clean body site during resident care 2. The MDS dated [DATE] documented Resident #1 had a BIMS score of 6 indicating severe cognitive impairment. On 11/18/25 at 3:10 PM an observation of a sign for EBP hanging on the door frame outside of Resident #1's room. On 11/18/25 at 3:11 PM an observation of Staff J, Certified Nursing Assistant (CNA) assisting Resident #1 with personal cares in the bathroom of Resident #1's room. On 11/18/25 on 3:12 PM Staff J stated she was not sure why Resident #1 had an EBP sign outside her door. Staff J acknowledged she did not have a gown on when assisting Resident #1 with toileting or when completing personal cares on Resident #1. Review of Resident #1's EHR titled, Orders documented a physician's order to cleanse pressure ulcer to coccyx with saline and 4x4, apply xeroform to wound bed only and cover with Opti foam started 11/4/25. Review of Resident #1's EHR titled, Progress Notes at 2:00 AM on 10/31/25 Staff H, Licensed Practical Nurse (LPN) titled, Progress Notes documented Resident #1 had complaints of sacral pain. The area was documented as red but blanching. Directly over Resident #1's tailbone was an open area with white tissue. On 11/19/25 at 1:29 PM the Director of Nursing (DON) explained 10/31/25 was the date that Resident #1's area on coccyx was determined to be a stage 2 pressure ulcer. The DON acknowledged Resident #1 was in EBP related to the wound on her coccyx. The DON stated EBP was reviewed with nursing staff during monthly meetings and in the information book. The DON stated there was a resident list at each nurses station and the bath house for the CNA's that identified the residents on EBP. The DON said she expected that Staff J would have worn the appropriate PPE in Resident #1's room. Review of policy reviewed 8/22 titled, Enhanced Barrier Precautions documented enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, transferring, changing briefs and assisting with toileting.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portion of fried rice for 13 of 15 residents who received carbohydrate controlled or consistent carbohydrate diets. The facility reported a census of 49 residents. Findings include: On 11/05/24 at 11:57 AM, Staff A, cook, identified the following lunch menu items and corresponding serving size scoop size: a) Sweet & Sour chicken - 6-ounce (oz) scoop b) Oriental vegetables - 4 oz scoop c) Fried rice - 4 oz scoop A review of the Diet Type Report indicated 15 residents were ordered carbohydrate controlled/consistent carbohydrate diets. On 11/05/24 beginning at 12:09 pm, a continuous lunch service observation revealed 13 residents with Carbohydrate Controlled/Consistent Carbohydrate (CCHO) diets were served 4-ounce (oz) servings of fried rice instead of 2 2/3 oz servings as ordered. Four (4) of the residents with CCHO diets received full 3 x 2.5 servings of mandarin orange cake instead of a 0.5 serving size. One (1) resident was out of the facility with family and one (1) resident ate a chef salad as an alternate menu option. On 11/05/24 at 12:58 PM, Staff A stated the [NAME] Brothers conversion chart was used to identify serving size scoops. A review of the Diet Spreadsheet indicated CCHO residents' fried rice portion size required a #12 scoop. The [NAME] Brothers conversion chart revealed a #12 scoop was 2 2/3 oz. A policy titled Therapeutic Diets revised 10/2017 indicated therapeutic diets will be determined in accordance with the resident's treatment goals. It identified diabetic/calorie-controlled diets as therapeutic diets. On 11/06/24 at 4:05 PM, the Administrator stated staff should follow the diet spreadsheets.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food. The facility reported a census of 49 residents. Findings include: On 11/04/24 at 9:45 AM, a kitchen observation identified the following findings: 1. Three (3) unlabeled plastic containers with cereal-like contents on a kitchen counter. Two (2) were not dated. 2. An unlabeled bowl of macaroni-like substance in an Arctic Air refrigerator. 3. An undated, unlabeled bag of hamburger bun-like items in the dry goods storage area. 4. An unlabeled bag of hot dog bun-like items. 5. A rack of trays with multiple undated & unlabeled plates of yellow, pie-like items in the Norlake walk-in refrigerator. 6. A tube of undated & unlabeled ground beef-like meat in the Norlake walk-in refrigerator. 7. Seven (7) trays of multiple bowls of undated, unlabeled, and uncovered salad-like substance. The bowls' contents were in direct contact with the bottom surface of the tray placed directly on them. 8. A bag of unlabeled and undated waffle-like items in the Norlake walk-in freezer. 9. An unlabeled, undated, and uncovered barrel of solid, white substance in the Norlake walk-in freezer stored on the floor. The Certified Dietary Manager (CDM) identified the barrel substance as old grease that was to be thrown away when the garbage was picked-up. On 11/05/24 at 12:40 pm, a follow-up kitchen observation identified the following findings: 1. A tray of round pans with unlabeled pink, pie-like substance. The Certified Dietary Manager identified the items as creamy cherry pie and stated the probably should be labeled. 2. A bag of unlabeled and undated waffle-like items in the Norlake walk-in freezer. 3. An unlabeled, undated, and uncovered barrel of solid, white substance in the Norlake walk-in freezer stored on a crate. A policy titled Food Receiving and Storage revised 10/2017 indicated all foods stored in the refrigerator or freezer will be covered, labeled, and dated. It also indicated dry foods that are stored in bins will be removed from original packaging, labeled and dated. On 11/06/24 at 4:05 PM, the Administrator stated food that is removed from an identifying box must be dated, labeled and stored properly.

Based on observations, clinical record review, staff interview and resident interview, the facility failed to follow physician's positioning orders for 1 of 1 resident's (#16) reviewed. The facility reported a census of 49 residents. Findings Include: On 11/04/24 at 10:51 AM, Resident #16 was observed lying supine (flat on the back) in bed. A sign was observed at the head of her bed that directed staff to keep the head of her bed elevated above a 30-degree angle at all times. The resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease, Non-Alzheimer's dementia, dysphagia (difficulty swallowing), Gastro-Esophageal Reflux Disease (GERD), and Calculus of Gallbladder (gallstones). It indicated the resident was dependent with all aspects of Activities of Daily Living (ADL's). The Electronic Health Record (EHR) included a physician order dated 7/19/22 to elevate the head-of-bed (HOB) to 30 degrees when in bed. The Care Plan dated 7/19/22 listed an intervention for head-of-bed to be elevated 30 degrees. It also included an intervention revised 10/26/24 which directed staff to elevate the resident's HOB related to emesis (vomiting). The Progress Notes included long term care evaluations dated 7/21/24 and 10/23/24 which confirmed the resident's HOB was elevated. The progress note dated 7/21/24 indicated the resident's HOB was elevated related to emesis. On 11/06/24 at 8:58 AM, Staff F, Certified Nurse Aide (CNA) stated she did not know why the resident required her HOB to be elevated. The facility did not have a policy specific to following physician's orders. On 11/06/24 at 4:05 PM, the Administrator stated staff should follow the Care Plan.

Based on observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter and peri-care to prevent the development of communicable disease and infection for 2 of 2 residents (#16 & #27) reviewed. The facility reported a census of 49 residents. Findings include: 1. On 11/04/24 at 3:16 pm, Resident #16 was observed with an indwelling catheter. The Minimum Data Set (MDS) assessment for Resident #16 dated 9/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderately impaired cognition. It included diagnoses of heart failure, peripheral vascular disease, Non-Alzheimer's dementia, Stage 4 Chronic Kidney Disease, and neurogenic bladder (condition that affects bladder control due to damage to the brain, spinal cord, or nerve). The MDS indicated Resident #16 required setup assistance with eating, was dependent with toileting hygiene, required moderate assistance with personal hygiene. It indicated the resident had an indwelling catheter. The Care Plan revised 7/26/24 revealed the resident had bacteria in her urine on 7/21/24. It included a goal that the resident would be free from catheter related trauma through the review date of 12/03/24. On 11/06/24 at 9:46 AM, Staff B, Licensed Practical Nurse (LPN) and Staff C, Certified Nurse Aide (CNA) donned Personal Protective Equipment (PPE - gown, gloves, and face shield). Staff C got hygiene wipes, removed the trash bag from the resident's trash bin, tore off a new trash bag stored under the active bag, and replaced the active bag back in the trash bin. Staff B got a brief from the resident's cabinet and placed it on the resident's bed. Staff B & Staff C pulled the resident's covers off the resident and instructed the resident to relax her legs and warned her that a cold cloth would be used. At 9:50 am, Staff C moved the resident's right leg and the catheter tubing was observed not secured to the resident. Staff C grabbed some hygiene wipes from the packaging and wiped the resident's left groin from top to bottom. She grabbed another hygiene wipe and wiped the resident's right groin from top to bottom. She repeated the process for the perineal area and wiped from front to back four (4) times and included wiping the catheter tubing. No hand hygiene or glove change was performed between touching the trash bin and performing perineal care. Staff C grabbed the urine drain bag and hung it from her left front pocket. Staff C removed her gloves, grabbed another pack of hygiene wipes, performed hand hygiene with sanitizer, and donned new gloves. Staff B & C repositioned the resident on her left side. Staff C grabbed a hygiene wipe and wiped the resident's perianal area. She repeated this process six (6) times. Staff C removed her gloves, performed hand hygiene, donned new gloves and repositioned the resident on her right side. The catheter tubing was observed partially under the resident's draw pad and put tension on the catheter tubing. Staff C removed her gloves, performed hand hygiene, donned new gloves, entered the resident's restroom, got several napkins, and the urine drain cylinder. She placed the cylinder on a few of the napkins on the floor. She opened the alcohol (ETOH) swab pack and placed it on the bedside table. She opened the drain bag spigot with the napkins, drained the urine into the cylinder, grabbed the ETOH swab, and wiped the spigot. She emptied the urine, removed her gloves and performed hand hygiene. No hand hygiene or a glove change was performed between getting the napkins, drainage cylinder, and ETOH swab and accessing the urine drainage spigot. On 11/06/24 at 10:04 AM, Staff C stated she should've changed gloves and performed hand hygiene before wiping the resident's catheter tubing. She also stated urinary catheters should be secured but didn't know where the resident's securement device was. She didn't secure it when she was finished. 2. On 11/04/24 at 3:27 PM, Resident #27 was observed with a urinary catheter. The MDS assessment for Resident #27 dated 9/04/24 revealed a BIMS score of 10 out of 15 which indicated moderately impaired cognition. It included diagnoses of peripheral vascular disease, vascular dementia, Parkinsonism, and obstructive uropathy. The MDS indicated Resident #27 required setup assistance with eating and oral hygiene, was dependent with toileting hygiene, required supervision with personal hygiene, and required moderate-to-maximal assistance with all other Activities of Daily Living (ADLs). It indicated the resident had an indwelling catheter. The Care Plan dated 4/23/24 included the resident's urinary catheter and directed staff to utilize proper hand hygiene techniques. The Electronic Health Record (EHR) included a urinalysis dated 11/01/24 that indicated the resident had greater than (>) 100,000 colony-forming units/milliliter (cfu/ml) of Proteus Mirabilis Extended Spectrum Beta-Lactamase (ESBL - multi-drug resistant organism). It also included the following physician's orders: a) 10/17/24 Ciprofloxacin tablet 250 milligrams (mg) take 1 tablet by mouth twice daily for 7 days for Urinary Tract Infection (UTI). b) 11/05/24 Gentamicin injection 40 mg/ml inject 2.5 ml (100 mg) intramuscular (IM) three time daily for 3 total days for UTI. On 11/06/24 at 9:30 AM, Staff D, Certified Nurse Aide (CNA) and Staff E, CNA donned PPE and entered Resident #27's room. Staff E gave Staff D a face shield. Staff D removed the face shield from the plastic packaging, and pulled the protective film from the shield. Staff D & E donned gloves. Staff D entered the resident's restroom and got some napkins and a drainage cylinder. She placed the napkins on the floor and the cylinder on the napkins. She opened an alcohol (ETOH) swab pack and placed it on the napkins beside the collection cylinder. She grabbed the resident's urine drainage bag, stood up, lifted the catheter drainage bag above the resident's bladder, pulled the spigot from the spigot chamber, lowered the bag over the cylinder, unlocked the spigot and drained the urine into the cylinder. While the urine was draining, some urine splashed over onto the napkin directly in front of the opened end of the ETOH swab package. When the urine bag was empty, Staff D locked the spigot, grabbed the ETOH swab from the opened package, wiped the spigot tip, and secured it back in the spigot chamber. No hand hygiene or glove change was performed during the procedure. A facility policy titled Handwashing/Hand Hygiene revised 8/2019 directed all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It also directed staff to use alcohol-based hand rub or soap and water before and after handling an invasive device and after contact with objects in the immediate vicinity of the resident. On 11/06/24 at 4:05 PM, the Administrator stated staff should follow the facility's hand hygiene policy.

Based on clinical record review, family interview, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not completing an x-ray ordered by a physician in a timely manner for 1 of 3 (Resident #1) residents reviewed. The facility reported a census of 45 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #1, dated 4/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS further revealed Resident #1 totally dependent on staff for assistance with sitting to lying, sitting to standing, the ability to transfer to or from bed to chair, and transferring to the toilet. Review of the Progress Notes for Resident #1 documented the following: On 5/1/24 at 10:30 PM Resident #1 found in the sitting position facing her bed on the floor. Range of motion per Resident #1's normal per progress notes. Neurological assessments initiated and hospice services, the Director of Nursing (DON), and primary care physician notified. On 5/2/24 at 12:18 AM Resident #1 complaining of left wrist pain and rated the pain at a 2 on a scale of 0-10. The nurse further documented the left wrist swollen with yellow/purple bruising measuring 5.5 cm x 4 cm and the area raised and had a hard bump. Ice applied to the site and as needed Tylenol was given at this time. On 5/2/24 at 2:14 PM Hospice services at the facility and discussed the issue with the left arm, and left knee and agreed to obtain an order to obtain an x-ray. On 5/4/24 at 10:00 AM the x-ray company in the building and had obtained the x-rays as ordered. Review of facility provided radiology reports dated 5/4/24 revealed Resident #1 had sustained an acute fracture of the distal radius (arm bone by the wrist), and a recent fracture to the left femoral neck (upper leg bone by the hip). During an interview 5/16/24 at 1:45 with Resident #1's family member revealed they had heard the facility had not obtained an x-ray until 5/4/24. During an interview 5/21/24 at 9:08 AM with Staff A revealed that she agreed with Staff B's assessment of Resident #1 showing no signs of pain and that the facility had treated Resident #1's wrist with ice and stabilized the area. Staff A then revealed that when she came back to the facility on [DATE] that the x-ray had still not been completed and that she would no longer wait to get this x-ray obtained. Staff A further reveal that Resident #1 had no external or internal rotation or shortening on the left lower extremity at this time. Staff A then revealed that while Resident #1 in bed post fall that pain medications were increased for Resident #1's comfort. During an interview 5/21/24 at 9:37 AM with Staff B revealed that she had been notified by the facility on 5/2/24 and assessed Resident #1 at the facility around 1:40 AM. Staff B stated Resident #1 sitting in a wheelchair when she arrived and was showing no signs or symptoms of discomfort. Staff B further revealed that an x-ray order was obtained the morning of 5/2/24, and further revealed that the x-ray was not obtained until 5/4/24. During an interview 5/21/24 with the DON revealed her expectation would be for physician's orders to be followed in a timely manner. The DON further revealed that she would expect an x-ray to be obtained within 24 hours, and if it was a stat x-ray order to be carried out immediately. Review of a facility provided policy titled, Medication and Treatment Orders, with a revision date of July 2016 documented: Physician orders shall be followed, if unable to follow physician orders, notify Director of Nursing Services/Designee and physician as appropriate.

Based on clinical record review, staff interview, family interview and policy review the facility failed to notify the Power of Attorney (POA) with resident medication changes for 1 of 3 residents (Residents #4) reviewed. The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The BIMS documented Resident #4 frequently incontinent of urine and always incontinent of bowel. The Progress Notes dated 3/21/24 at 10:14 PM documented new orders for a tapered dose of Quetiapine. The notes lacked documentation of family notification. Review of Resident #4's medication administration record (MAR) documented Quetiapine 100 mg give 1 tablet by mouth and Quetiapine 25 mg give 1.5 tablets by mouth. Both medications ordered 3/21/24 and started 3/22/24. On 3/26/24 at 9:50 AM Resident #4's family member, power of attorney (POA) stated the facility is supposed to call her every single time with any medication changes and any changes in conditions. The family member stated the facility failed many times at notifying her of medication changes. She stated she was not notified of the taper dose of Quetiapine from 3/21/24. She stated she wants to be notified of all medication changes and condition changes and not being notified of these changes is an issue to her. On 3/26/24 at 11:45 AM the DON stated the facility's expectation is every new order the family, if POA, would be updated. Review of the policy titled, Change in a Resident's Condition or Status revised 2/21 documented the facility would promptly notify the resident representative of changes in the resident's medical/mental condition and/or status. Except in medical emergencies notifications will be made within 24 hours of a change occurring in the resident's medical/mental conditions or status.

Based on clinical record review, staff interviews and facility policy review, the facility failed to obtain consent from the Power of Attorney (POA) to start a psychotropic medication for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The Progress Notes dated 1/3/24 at 11:56 AM documented the facility received a new order for Rexulti 0.5mg every day for one week and then increase the medication to 1 mg daily if family consents. Nurse called the family member and explained this. Family member stated she would speak with her family and get back to the facility. Order faxed, hold this if the pharmacy does deliver tonight until we receive the okay from the family member. Review of document titled, Fax Cover Sheet with date of 1/3/24 documented physicians response to fax to start Resident #1 on Rexulti 0.5 mg every day for 1 week then 1 mg daily if Resident #1's family consents. The Progress Notes dated on 1/10/24 at 12:08 PM by the Director of Nursing (DON) documented the family member at the facility that day to see Resident #1. DON documented Rexulti started on 1/4/24. DON documented resident #1's family member did not want the resident on Rexulti. DON documented the medication orders were discontinued and medication returned to the pharmacy. DON documented an update sent to the physician and she explained the situation to the family member in the facility. The DON documented Resident #1's family member upset the medication started but is glad it had been stopped. Review of document titled, Fax Cover Sheet with date of 1/10/24 from DON documented Resident #1 started on Rexulti 0.5 mg for 7 days. DON documented the family was not sure if they wanted Resident #1 started on the medication. DON documented the resident's family at the facility 1/10/24 and wants medication stopped. The DON documented orders discontinued and medication returned to the pharmacy. DON documented request for any recommendations to help flush medication out of Resident #1 system. Resident is very tired. The physician responded that time will help to flush the medication. Review of Resident #1's medication administration records (MAR) for Month of January 2024 documented Rexulti 0.5 mg tablet started on 1/4/24 and stopped on 1/10/24. On 3/26/24 at 11:45 AM the DON stated the facility's expectation is consent should have been obtained from resident family member (POA) prior to starting the medication Rexulti for Resident #1. Review of policy titled, Psychotropic Medication Use revised 7/22 documented that residents, family, and or representatives are involved in the medication management process.

Based on observations, policy review, resident interview, and staff interview the facility failed to provide appropriate infection prevention practices when providing personal care for 2 of 3 residents reviewed (Resident #2 and #4). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS documented Resident #2 always incontinent of urine and bowel. On 3/25/24 at 1:45 PM observed Staff A, Certified Nurses Assistant (CNA) and Staff B, CNA complete hand hygiene and apply gloves. Staff B provided personal care to Resident #2 and then removed her gloves. She did not perform hand hygiene and no gloves applied. Staff B turned Resident #2 over to his left side and applied a clean brief. Staff B provided assistance to Resident #2 when turning to his right side. Staff B unrolled the brief, pulled the front of the brief up and completed the application. Staff B pulled the sheet and blanket up over the resident, gathered garbage and dirty linen. Staff B completed hand hygiene and exited Resident #2's room. On 3/26/24 at 9:10 AM observed personal cares on Resident #2 by Staff A, CNA and Staff D, CNA. Staff A and Staff D completed hand hygiene. Staff D cleansed and dried the peri area, removed gloves and failed to complete hand hygiene. Staff D applied Resident #2's brief without gloves, gathered garbage, turned the resident's television on with the remote, and clipped his call light to the blanket. Staff D completed hand hygiene and exited the room. 2. The MDS dated [DATE] documented Resident #4 had a BIMS score of 15 indicating no cognitive impairment. The MDS documented Resident #4 frequently incontinent of urine and always incontinent of bowel. On 3/25/24 at 1:30 PM Resident #4 stated that he would like his foreskin retracted and the area cleansed and the foreskin replaced during personal care. Resident #4 stated he is not crazy about the care being completed but it needs to be done to keep the area clean. On 3/25/24 at 1:05 PM observed personal cares on Resident #4 by Staff A and Staff E CNA/ Certified Medication Assistant (CMA). Staff A applied the lift cloth for transfer and transfer completed without difficulties. Staff E offered Resident #4 to use the toilet but the resident refused. Staff A and Staff E both completed hand hygiene and applied gloves. Staff E cleansed Resident #4's penis, but failed to retract the foreskin during personal care. Staff E completed perineal care and then completed hand hygiene. On 3/26/24 at 8:50 AM observed personal cares on Resident #4 by Staff A and Staff D. Staff A and Staff D both completed hand hygiene. Staff A applied the lift cloth for transfer and transfer completed without difficulties. Staff A removed the lift cloth. Staff D cleansed Resident #4's penis but failed to retract Resident #4's foreskin. Staff D continued perineal care. Staff D removed her gloves but failed to perform hand hygiene. Staff D with the help of the resident and Staff A turned to his right side. Staff D placed a brief under the resident without any gloves on. Staff D gathered dirty linen and garbage and then completed hand hygiene and exited the room. On 3/26/24 at 11:45 AM the DON stated the facility's expectation is for staff to complete hand hygiene when they enter the room and apply gloves. The DON stated once the gloves are soiled the gloves would be removed, hand hygiene completed, and new gloves applied. The DON stated the facility's expectation is the foreskin on an uncircumcised male would be retracted during peri care and then replaced to previous position. Review of policy titled, Hand Washing / Hand Hygiene revised 8/19 documented the use of alcohol-based hand rub or soap and water before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident ' s intact skin, and after contact with bodily fluids. Review of policy titled, Perineal Care revised 2/18 documented when cares are completed on a male resident to retract the foreskin of the uncircumcised male, wash area, rinse area, and reposition foreskin of the uncircumcised male.

Based on observations, staff interview, and policy review the facility failed to treat residents with dignity while providing assistance with meals. The facility reported a census of 49 residents. Findings include: During continuous observation of lunch service on 9/25/23 from 12:20 through 12:40 PM observed two staff standing over residents while feeding them. During continuous observation of lunch service on 9/26/23 from 12:20 PM through 1:00 PM observed Staff B Certified Nursing Assistant (CNA) standing and assisting a resident to eat. Staff B then moved and stood between two residents and assisted both residents to eat. During continuous observation on 9/26/23 of lunch service, at 12:37 PM observed Staff C CNA standing between two residents assisting to dine. During an interview on 9/26/23 at 3:27 PM with the Administrator revealed her expectations are for staff to sit while feeding residents. Review of the facility provided policy titled, Assistance with Meals with a revision date of 3/2022 documented: Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals.

Based on personnel file review, facility record review, facility policy review, and staff interview the facility failed to complete a back-ground check for a new employee, prior to employment, for 1 of 5 staff reviewed. The facility reported a census of 49 residents. Findings Include: Facility New Employee Data form documented the facility hired Staff D, Registered Nurse on 4/28/23. Single Contact License & Background Check for Staff D, documented completion on 5/1/23 at 8:17 AM. Facility payroll record for Staff D, revealed Staff D worked 4/29/23 at 1:45 PM - 6:30 PM and 4/30/23 at 11:45 AM - 6:30 PM. Facility policy Background Check Investigations, revised 3/2019, documented background and criminal checks are initiated with offer of employment or contract agreement, and completed prior to employment. Interview on 9/27/23 at 3:16 PM, the Business Office Manager confirmed Staff D worked 2 days prior to Staff D's background check being completed and stated the background check should have been completed prior to Staff D being allowed to work. Interview on 9/27/23 at 3:20 PM, the Administrator stated expectation for background check to be completed before an employee is hired.

Based on clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of three residents reviewed (Resident #20). The facility reported a census of 49 residents. Findings include: The Minimum Data Set assessment for Resident #20, dated 7/12/23, included diagnoses of anxiety disorder, depression, and psychotic disorder. Review of Resident #20's PASARR Level I Screen form dated 12/17/20, documented anxiety disorder and dementia only. Review of Resident #20's Medication Administration Records dated 9/1/23 - 9/30/23, documented the resident received Sertraline (antidepressant medication) 37.5 milligrams daily related to major depressive disorder. Review of Resident #20's medical diagnosis sheet revealed diagnoses of unspecified psychosis not due to a substance or known physiological condition starting 7/9/21,during facility stay, and major depressive disorder, recurrent starting 7/19/21. Interview on 9/27/23 at 3:42 PM, the Social Services Director (SSD) confirmed the resident was diagnosed with psychosis and major depressive disorder after admission to the facility and a status change was not submitted. The SSD stated expectation for a status change to be submitted with new diagnoses.

Based on clinical record review, staff interviews, and policy review the facility failed to provide a comprehensive care plan related to edema for a resident with an order for a diuretic with a diagnosis of localized edema for 1 of 1 residents reviewed (Resident #47). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #47 dated 7/1/23 revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. The MDS further revealed Resident #47 re-entered the facility 6/26/23. Review of the Electronic Health Record (EHR) page titled Clinical Physician Orders revealed an order for Furosemide 40 mg tab take one tablet by mouth daily for a related diagnosis of localized edema (swelling). Review of the Care Plan dated 7/7/23 for Resident #47 revealed no comprehensive care plan for diuretic use or edema. During an interview 9/26/23 at 3:08 PM with the MDS Coordinator revealed her expectations are to update the care plans when there are changes with the residents status. During an interview 9/26/23 at 3:15 PM with the Director of Nursing (DON) revealed her expectation is to update the care plan as changes occur with residents. Review of a facility provided policy titled Care Plans, Comprehensive Person-Centered with a revision date of 3/2022 documented: The interdisciplinary team reviews and updates the care plan: When the resident has been readmitted to the facility from a hospital stay; and at least quarterly, and in conjunction with the required quarterly MDS assessment.

Based on record review and staff interview, the facility failed to meet the professional standards of medication administration 1 of 16 residents reviewed (Resident #311). On 3/29/19, Staff D administered Resident #311 another resident's medication (an antipsychotic and an antidepressant) in addition to her own (a narcotic pain reliever). The result, the resident became unresponsive, staff called 911, and the ambulance took her to the emergency room (ER). The resident then admitted to the intensive care unit (ICU) for treatment. The facility reported a census of 56 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 4/19/19, Resident #311 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident displayed moderately impaired cognitive skills. The MDS documented the resident required extensive assist of two staff for bed mobility, transfers, ambulation (walking) in room/corridor, toilet use, and bathing. The resident remained independent with eating. The MDS listed [DIAGNOSES REDACTED]. Resident #311's (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Resident #3's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #311's progress notes dated 4/5/19 at 3:58 PM contained a late entry summary report of medication error. The note documented staff administered Resident #311 her scheduled [MEDICATION NAME] 100 mg, and then mistakenly administered Resident #311 another resident's (Resident #3) [MEDICATION NAME] (antipsychotic) 550 mg and [MEDICATION NAME] (antidepressant) 200 mg. The progress notes also revealed the critical access hospital (CAH) transferred the resident to a Level 3 Trauma Hospital where she admitted to ICU (intensive care unit) on a [MEDICAL CONDITION] (Bi-level positive airway pressure). The progress notes dated 3/29/19 at 10:50 PM documented the resident ingested Trazadone and [MEDICATION NAME] at approximately 8:15 PM. The nurse called the emergency room and the physician gave parameters to monitor vital signs every two hours and transport Resident #311 to the emergency room with blood pressure below 80/40 or pulse less than 40. The notes revealed at 9:00 PM, staff checked the resident who slept with periods of apnea (temporary cessation of breathing) per resident's usual, however, staff could not rouse her. The record failed to contain any information related to the resident's temperature, pulse, respirations, or blood pressure at or around the time of the medication error. A progress note dated 3/29/19 at 9:15 PM revealed the facility obtained an order to send Resident #311 to the emergency room for evaluation. At 9:17 PM, staff called 911 and resident transferred by ambulance to the ER at 9:30 PM. The Rose Vista Home Transfer Report documented the facility transferred the resident on 3/29/19 due to decreased breathing with periods of apnea and unresponsive episode after ingesting the wrong medications. The facility medication administration guidelines with an effective date of 6/1/07, directed staff to administer medications in accordance with written orders of the attending physician. The policy also directed staff to identify the residents receiving medications, and do not give medications supplied for one resident to another resident. In an interview with Staff D RN on 4/23/19 at 12:11 PM, she stated on 3/29/19 she set up 8:00 PM medications for both Resident #3 and Resident #311, entered Resident #311's room, and administered Resident #311 her 8:00 PM medications. Staff D RN reported she then became distracted while in Resident #311's room and subsequently administered Resident #3's 8:00 PM medications to Resident #311. She acknowledged she knew how medications were supposed to be given and also knew never to take two residents' medications with her at the same time. She reported as soon as she gave the medications to the resident she knew she gave them to the wrong resident, but Resident #311 cold not spit them out because she had already swallowed them. Staff D also she reported she called the emergency room within minutes and received an order to stay with the resident. In an interview with Director of Nursing (DON) on 4/25/19 at 7:33 AM stated she expected staff that passed medications to follow the 5 rights of medication administration (a nursing professional standard) and follow the facility medication administration policy. The DON stated staff should prepare one resident's medications, administer those medications, then move to a second resident to set up and pass medications without preparing two resident's medications at the same time.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards when providing assistance with bathing for 1 of 4 residents (Resident #3) who needed assistance with transfer and ambulation. The facility reported a census of 59 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The resident needed extensive assistance of 2 staff with bed mobility, transfers and bathing. According to the MDS the resident had impairments on both sides of the lower extremity and utilized a wheelchair for mobility. The test for balance identified the resident could not stabilize/balance him/herself without staff assistance when moving from seated to standing position, when moving on or off the toilet and when moving from surface to surface transfer. A Brief Interview for Mental Status (BIMS) identified a score of 4. A score of 4 identified the resident had severe cognitive problems. The resident's updated care plan dated 9/15/16 indicated a focus area of self-care performance deficit related to dementia, left upper shoulder and right lower leg amputation. The interventions dated 4/4/15 and 9/13/16 respectively directed staff to provide shower/bed baths 1-2 times weekly if south tub not available; and 10/28/16, noted the resident may bath in the north tub. An incident report dated 11/8/16 at 8:50 a.m. revealed staff had given the resident a bath in the north tub room. Staff A, a certified nursing assistant released the tub door and didn't realize the resident had been leaning against the inside door. Upon opening the door the resident fell out onto the floor, hitting his/her head. The resident sustained [REDACTED]. The resident complained of pain after the incident and the physician would be notified. The intervention after the incident was to closely monitor residents when releasing tub door and no more tubs baths. The incident report noted 11/11/16, computed tomography (CT) scan identified fractured clavicle/scapula. On 11/14/16, the physician determined there was not a major injury. Progress notes dated 11/8/16 at 9:39 a.m. indicated there resident fell out of the bathtub and hit the left side of the head, sustained a laceration and complained of left shoulder pain. A clinic note dated 11/8/16 at 9:08 a.m. indicated the resident had been seen by his/her physician due to fall after his/her bath. The resident fell less than 3 feet and struck his/her head on the tile floor and left shoulder at the same time. A small scrape to the scalp with the resident reporting his/her head felt fine and did not lose consciousness. The resident reported left shoulder pain. A 3 cm superficial laceration to the left side of the scalp in the occipital region. The physician ordered a left should x-ray. Radiology report dated 11/8/16 revealed the bones osteopenic (bone loss). A physician telephone order dated 11/8/16 ordered Hydrocodone/Acetaminophen 5 milligrams (mg)/325 mg - 1 tablet every six hours as needed (prn) for pain. A computerized tomography (CT) scan taken 11/11/16 indicated an acute fracture of the medial aspect of the left clavicle, non-displaced. The CT showed there is a poorly visualized fracture involving the scapula extending into the base of the glenoid (socket of shoulder). The fracture appears to extend into the coracoid (shoulder). Progress notes dated 11/12/16 at 6:32 a.m. indicated the resident had much difficulty during the evening meal, unable to swallow liquids and spits out into a napkin. The resident is only able to verbalized one word at a time and difficulty following directions. The facility notified the resident's family member; suggesting the resident's condition could be from the medication Hydrocodone. A physician's telephone order dated 11/11/16 ordered to change Vicodin (similar to Hydrocodone) 5mg/325 mg - 1 tablet every 4 hours prn for pain. Progress notes dated 11/13/16 at 8:27 a.m. revealed the resident had been restless, moaning and groaning and wouldn't take a medication orally. A physician's telephone order dated 11/13/16 ordered Morphine 10 mg - 1 tablet every 4 hours prn for pain and oxygen per nasal cannula to keep oxygen saturation levels greater than 90%. A patient report dated 11/15/16 revealed a chest x-ray of the chest indicated hypoxia (shortness of breath). A telephone order dated 11/14/16 ordered the initial order of Morphine 10 mg be discontinued with a new order for Morphine 2.5 mg - 1 tablet every 4 hours prn for pain. A telephone order dated 11/16/16 admitted the resident to hospice care. During an interview dated 8:58 a.m. on 12/21/16 Staff A, a certified nursing assistant (CNA) reported she had been employed at the facility for 3 years and assists residents with bathing. On 11/8/16 she gave the resident a bath; as it was the resident's normal bath day. The resident is normally given a bath in the South Hall tub room but it wasn't available as it was under repair. Staff had to give baths in the North Hall tub room. She and another CNA (she doesn't remember who) brought the resident into the tub room and transferred the resident into the tub and the staff helping her left the room. Staff A reported she gave the resident a bath and when finished she drained the tub, placed towels over the resident's upper torso and at the same time, pushed the button that releases the side door to the tub. As the door lowered the resident slid out of the tub and fell on to the floor, hitting his/her head and left shoulder. The resident cried out in pain and held his/her left shoulder. She reported she hadn't realized the resident had leaned against the door when she lowered the door. Staff A reported she had been alone during the bath and when the incident occurred. She reported the South Hall tub had a security belt that is used to secure residents during a bath, but the North Hall tub didn't have such a device. Staff A reported that after this incident the facility requires 2 staff to be present at all times with bathing. During an interview dated 12/21/16 at 8:50 a.m. Staff B, a registered nurse (RN) reported she had been called to the North Hall tub room. When she entered she saw the resident on the floor lying on h/her left side/shoulder and the left side of the resident's head bleeding. The resident's physician had been in the building at the time and evaluated the resident. Staff transferred the resident from the floor to a wheelchair and taken to his/her room. Staff B reported she had been a CNA and recently became an RN. She reported as a CNA and now as an RN she expected 2 staff to assist with bathing and to be present at all times. During an interview dated 12/21/16 at 9:15 a.m., Staff C, RN and MDS coordinator reported the resident had been given bed baths because he/she had reported staff had been too rough with transfer. She recalled family or someone else wanted the resident to resume a tub bath (whirlpool). She reported the MDS dated [DATE] reflected the resident needing 2 staff to physically help with bathing and two staff to provide continuous support with the task of bathing. During an interview dated 12/21/16 at 10:07 a.m., Staff D, LPN and restorative nurse stated the section of the MDS indicating extensive assist of two staff with bathing meant that only 2 staff were needed to transfer the resident and not to assist with bathing. During an interview dated 12/21/16 at 9:30 a.m., the Director of Nursing reported the resident needed 2 staff assist with transfer to the tub and the second staff need not be present during the bath. She reported that after the resident's fall from the tub the facility procedure is for 2 staff be present before the tub door is opened. In a typed statement dated 12/21/16, the Director of Nursing stated when the MDS indicated two staff assist with bathing, it is expected that 2 staff will assist with transfer and not for 2 staff to remain in the tub room for the entire bath, but be present for the transfer in and out of the tub. Since the resident's fall of 11/8/16 the facility had begun requiring 2 staff to be present before the tub door is lowered. The operating instructions for the tub used by the facility titled Operating Instructions directs staff to secure the security belt firmly around the individual's chest by inserting the attachment knob located behind the individual's back through the appropriate hole at the end of the belt. Adjust the belt and comfort pads as necessary for the individual's security and comfort. At the end of the bath cycle, open the drain and allow the tub to drain. After the water is completely drained, open the tub door by pushing down on the open button and allow the door to rotate to a fully open position until it stops. Dry as much of the individual as possible. When completed remove the chest belt from the individual and transfer the individual out of the bath seat. During a follow-up interview dated 12/26/16 at 6:30 a.m., Staff A reported the South tub had security belt to place around the resident but the North tub did not have the same safety device. During an interview dated 12/27/16 at 8:13 a.m., the resident's physician reported the computerized tomography taken 11/11/16 revealed a non-displaced fracture to the left clavicle and a fracture to the clavicle. The resident had increased pain and health decline. The resident had been prescribed increased doses of Hydrocodone/Acetaminophen and Morphine.

Based on clinical record review and interviews with resident and staff, the facility failed to plan for and direct nursing services to ensure Resident #2 received adequate supervision with wheelchair transfers to protect against hazards in the environment. The facility identified a census of 64 residents with 13 current residents reviewed. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The resident did not ambulate (walk). According to the MDS the resident had impairments on both sides of the lower extremity and utilized a wheelchair for mobility. The resident scored 14 out of 15 on the Brief Interview for Mental Status test (BIMS); which revealed his/her cognition was intact. A prior MDS assessment dated [DATE] revealed Resident #2 required two (2) staff to physically assist with bed mobility and transfers. The assessment indicated the resident used a wheelchair for mobility and had impairments on both sides of his/her lower extremity (hip/knee/ankle and or feet). The resident's BIMS score assessed his/her cognition was intact. A care plan dated 4/18/13 indicated Resident #2 propelled his/her own wheelchair. The same care plan had been updated on 7/25/13 and revealed the resident requested the left foot pedal (from wheelchair) be off. Review of the Accident/Incident Form dated 7/14/13 at 6:00 AM revealed the resident reported yesterday (7/13/13) before the parade, a Certified Nursing Assistant (CNA) pushed his/her wheelchair and all of a sudden the resident felt a sharp pain to the right ankle area. The document revealed an 11 x 4 centimeter (cm) bruise to the posterior calf at 6:00 AM and a 10 x 9 cm red area to the anterior ankle. The intervention for the incident included to use wheelchair pedals at all times. Review of the Nurses Notes dated 7/13/13 revealed a late entry for 1:00 PM. The note revealed the resident complained of pain to the right ankle area with no redness or bruising noted. The nurse completed range of motion, with little pain to both ankles and pedal pulses positive bilaterally. The resident reported staff took him/her to the parade and suddenly something happened and the resident felt pain to his/her right ankle. The CNA (Certified Nursing Assistant) reported she pushed the resident ' s wheelchair to the parade and the resident shouted "Ouch". The CNA stated she then immediately stopped the wheelchair and the resident stated his/her right ankle hurt. The resident then sat at the front window and watched the parade. The resident encouraged to elevate his/her legs in bed and keep staff informed of his/her pain. Review of the Nurses Notes dated 7/14/13 at 6:00 AM revealed 1+ edema noted to bilateral ankles and feet. A 11 x 4 cm (centimeter) bruise to posterior right calf. The resident expressed much pain with movement of the right ankle. The resident's family and physician notified and the resident sent to the emergency room . Review of the History and Physical dated 7/14/13 revealed the [AGE] year old resident had been transferred from the emergency room (ER) in Missouri Valley to this hospital for further care. The resident had been given pain medication (toradol) IM (Intramuscular Injection) while at the ER to address his/her pain. The hospital Discharge Summary dated 7/15/13 revealed the x-ray showed the resident had a distal shaft fracture of the right tibia and fibula which were non-displaced. The report documented while being pushed in the wheelchair, the resident ' s right leg got caught underneath the wheelchair. The resident had immediate pain and small amount of bruising. The resident had been transferred for an orthopedic consultation. The orthopedic consultation resulted in a cast placed (on the resident's right foot). The resident would return to the nursing home on 7/15/13, with physician's order [REDACTED]. Review of the Ankle Complete Results Report dated 7/14/13 revealed the resident's right ankle with a transverse fracture of the distal right tibia and fibula. During an interview with Resident #2 on 8/29/13 at 8:05 a.m. he/she reported the incident happened so fast and he/she broke two bones. The resident reported he/she did not know what happened and his/her foot flew off (the resident did not say what his/her foot had been resting on if anything). The facility investigation dated 7/15/13, Staff B reported the wheelchair pedal(s) were not on (the wheelchair on 7/13/13). The investigation revealed multiple staff reported the resident refused his/her right wheelchair pedal repeatedly. The investigation revealed there was no documentation of the resident ' s refusal in the record. During an interview with Staff B, CNA on 8/26/13 at 12:00 PM she stated that a parade held outside of the facility and she pushed the resident's wheelchair out of their room. The wheel chair had just got out of the room and she felt a little tug on the chair and the resident stated that his/her leg got caught. Staff asked if he/she was OK and the resident stated he/she was fine. Staff continued to push the resident. She then went to tell the nurse, Staff D, LPN (Licensed Practical Nurse) and she went to look at the resident's leg. Later they assisted the resident to bed with the Hoyer lift. (usual way to transfer) The resident complained of pain as usual in the legs and she told Staff C, LPN about the incident earlier. She also stated that the resident did not have wheelchair pedals on and he/she refused pedals and she did not see wheelchair pedals in the resident's room. During an interview with Staff C, LPN on 8/27/13 at 11:30 AM she stated that Staff B, CNA came to get her after lunch to look at the resident's leg. The resident stated to her that something happened going down the hall and it hurt. She stated that range of motion completed with no changes and no injury noted. The next morning she stated that the resident complained of pain in the leg and she noted bruising and redness and sent the resident to the emergency room . During an interview with Staff D, LPN on 8/28/13 at 10:00 AM she stated that the resident in the lobby and Staff B, CNA told her the resident hurt his/her foot. Staff went to the resident and the resident told her it was the left foot. The CNA had told her that they were going down the hall and the resident's foot caught on the carpet. Staff D reported the resident did not have wheelchair petals (on his/her chair when the incident occurred). She stated residents now have bags on the back of the wheelchair for pedals. Staff D reported, if a resident wheeled themselves and there were no wheelchair pedals, if they could hold their feet up, staff would push the wheelchair. Since this incident occurred, staff now use pedals on the wheelchair if they need to push the resident. During an interview with the Director of Nursing on 8/28/13 at 3:15 PM she stated after Resident #2's incident the facility changed the way they push residents ' in wheelchairs (that normally do not use wheelchair pedals.) If a resident had to go to the bathroom or needed to go somewhere fast, the staff would instruct them to hold up their feet as staff pushed their wheelchair. The DON reported they do not do the prior anymore. The DON further stated that all residents had wheelchair pedals in their room or closets. Now the facility put bags on the back of the wheelchairs and the wheelchair pedals are stored in there. Staff now use the wheelchair pedals when pushing a resident's wheelchair.