Every finding on record at Colonial Acres of Humboldt

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure that expired foods were discarded and open packages of dry food were dated with month, date, and year. This had the potential to affect all residents.Findings are: An observation on 3/9/26 at 8:50 AM of the storage room revealed that:Best used by date of 2/17/26 for 4 cans of Condensed milk Best used by date of 3/8/26 of a bag of opened SplendaBest used by date of 2/28/26 of 2 plastic containers of Poppy seeds A bag of 4 regular graham cracker pie crust with a date of 3/27, with no year markedA plastic container of cake sprinkles, with the top of the cap dated 6/24 or 6/04 with no year marked2 Bags of vanilla pudding opened marked 10/16 date and no year markedA 4 lb (pound) bag of Cheese cake mix opened with a date of 11/4 with no year markedA 3.2 oz (ounce) bag of a Ranch dressing package dated Nov. 25 with no year marked A record review of the facility policy titled Food Receiving and Storage with a date of 12/21/2023 on the bottom of the page revealed:Dry Food Storage:4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (used by date) A record review of the Food Code 2022 revealedThe day or date marked by the Food Establishment may not exceed a manufacturer's used by date. An interview on 03/10/2026 at 12:09 PM with the Dietary Manager confirmed (gender) is not aware of the year that the package of vanilla pudding, cheesecake mix or the ranch dressing had been opened. The Dietary Manager confirms (gender) believes it was this year that (gender) had opened that packages. The Dietary Manager confirmed that the graham cracker's pie crust had expired and should be thrown away and the condensed [NAME] and poppy seed should be tossed out. The Dietary manager confirmed that all the opened packages with just a month and date on them should be thrown out.

Based on record reviews and interviews the facility failed to maintain staff documentation of offering the COVID-19 vaccine, education on the COVID-19 vaccine, and current vaccine status for 5 of the 5 sampled employees. This had the potential to affect all residents and staff who live and work at the facility. Findings are: Record review of Medication Aide (MA) D's employee file revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine or a record of the employee's current vaccine status. Record review of Medication Aide (MA) C's employee file revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine or a record of the employee's current vaccine status. Record review of Medication Aide (MA) F's employee file revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine or a record of the employee's current vaccine status. Record review of Medication Aide (MA) B's employee file revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine or a record of the employee's current vaccine status. Record review of Nursing Aide (NA) E's employee file revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine or a record of the employee's current vaccine status. Record review of facility's Infection Prevention and Control Program with a revised date of 2018, in section 12 titled Immunization and section 13 titled Monitoring Employee Health and Safety encourages the COVID 19 Vaccine but reveals no policy regarding COVID 19 education, offering of the COVID 19 vaccine, or documentation of staff vaccine status. Interview with the Infection Preventionist (IP) on 03/11/2026 at 11:46 AM confirmed that staff is provided education on the COVID 19 vaccine during their orientation and information is posted annually by the time clock. IP confirmed that there is no documentation that the facility has offered the COVID 19 vaccine, provided education on the vaccine or that the facility maintains current vaccine status on the employees.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record reviews and interviews, the facility failed to ensure the required 12 hours of annual ongoing training was provided for nurse aides. This had the potential to affect all residents. The facility census was 30. Findings are:A record review of Medication Aide (MA) B's employee file revealed a Monthly Education Calendar 2025 with a box for each month that contained the topic of education, a first name, and a space for initials. MA B's calendar had initials in the boxes for January, March, April, May, July, September, October, November, and December. The record of training did not include the length of the training.A record review of MA C's employee file revealed a Monthly Education Calendar 2025 with a box for each month that contained the topic of education, a first name, and a space for initials. MA C's calendar had initials in the boxes for April, July, August, October, and December. The record of training did not include the length of the training.A record review of MA D's employee file revealed a Monthly Education Calendar 2025 with a box for each month that contained the topic of education, a first name, and a space for initials. MA D's calendar had initials in the boxes for March, May, June, August, September, October, November, and December. There was a note in the February box that stated Leave-Medical. The record of training did not include the length of the training.A record review of Nurse Aide (NA) E's employee file revealed a Monthly Education Calendar 2025 with a box for each month that contained the topic of education, a first name, and a space for initials. NA E's calendar had initials in all boxes except December. The record of training did not include the length of the training.A record review of MA F's employee file revealed there was no Monthly Education Calendar 2025 present.An interview on 03/11/2026 at 12:20 PM with Human Resources (HR) confirmed the facility did not have documentation that the required 12 hours of annual ongoing training was completed in 2025 for MA B, MA C, MA D NA E, or MA F.

Licensure Reference Number 175 NAC 12-006.19(c)Based on observations and interviews, the facility failed to ensure clean linens were delivered in a covered cart to prevent potential cross contamination. This had the potential to affect all 30 residents who resided at the facility. Findings are: An observation on 3/9/26 at 3:00 PM of the laundry staff passing clean linens on a cart down the 200 hallway, with no cover over the clean linens.An observation on 3/10/26 at 1:30 PM of the laundry staff passing clean linens on a cart down the 300 hallway with no cover over the clean linens. A record review of the Environmental Services Standard Operating Policy Dates January 13,2026 revealed:Deliveries:Clean items must be in a covered cart or truck that is specifically designed for clean laundry only. An interview on 3/10/26 at 1:30 PM with the Director of Nursing confirmed that the clean linen cart did not have a cover over the clean linens and the clean linen cart should be covered when delivering clean linens down the hallways.

Licensure Reference Number 175 NAC 12-006.09(G)(i) Based on record reviews and interviews, the facility failed to provide a notice of transfer to the hospital and a bed hold policy to the resident and the resident's representative. The facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their wellbeing) of the transfer for 3 of 3 sampled residents (Resident 3, Resident 5, and Resident 30). The facility failed to ensure a discharge summary including a recapitulation (summary) of stay was completed for Resident 31 upon death. The facility census was 30.Findings are: Record review of facility's policy titled Transfer and Discharge dated 11/06/2025 revealed in section 3 that a transfer/discharge notice will be provided to the resident and resident's representative including information regarding the specific reason for the transfer, the effective date, the location of the transfer, an explanation of the right to appeal the transfer, and contact information for the Ombudsman. Section 10 g of the policy titled Emergency Transfer to Acute Care revealed that the facility will provides notice of transfer and the facility's bed hold policy to the resident. Section 10 h of the policy revealed that the Social Services Director or designee will provide copies of the notices for the emergency transfer to the Ombudsman. A. Record review of Resident 3's admission Record revealed that Resident 3 was admitted to the facility on [DATE] with a primary diagnosis of pneumonia. Record review of Resident 3's Emergency Transfer Form revealed that Resident 3 was transferred to the hospital on [DATE] with a respiratory infection. Record review Resident 3's Census List revealed that Resident 3 had a Hospital Paid Leave on 01/03/2026. Record reviews of Resident 3's medical records revealed no notification of transfer to the hospital or notification of the bed hold policy was provided to the resident or the resident's representative. B. Record review of Resident 5's admission Record dated 03/12/2026 revealed that the resident was admitted on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD: a pulmonary disease that is characterized by chronic, typically irreversible airway obstruction resulting in difficulty or discomfort in breathing). Record review of Resident 5's Census List revealed that the resident had Hospital Paid Leave on: 10/31/2025, 11/11/2025, 12/11/2025, and 03/02/2026. Record reviews of Resident 5's medical records revealed no notification of transfer to the hospital or notification of the bed hold policy was provided to the resident or the resident's representative for the above dates. C. Record review of Resident 30's admission Record dated 03/11/2026 revealed that the resident was admitted on [DATE] with a primary diagnosis rhabdomyolysis (a serious condition caused by rapid muscle breakdown releasing damaging chemicals in the blood). Record review of Resident 30's Census List revealed that the resident had a Therapeutic Paid Leave on 12/29/2025. Record review of Resident 30's Emergency Transfer Form revealed that the resident was transferred to the hospital for shortness of breath on 12/29/2025. Record reviews of Resident 30's medical records revealed no notification of transfer to the hospital or notification of the bed hold policy was provided to the resident or the resident's representative An interview on 03/11/2026 at 2:06 PM with LPN-H, the Social Services designee, confirmed that since November of 2025 no written notice of transfer or bed holds have been provided to the residents or their representatives, and that the Ombudsman had not been notified of any facility transfers as required. D. A record review of Resident 31's admission Record printed 03/11/2026 revealed the resident was admitted to the facility on [DATE]. Under the Miscellaneous Information section, the Date of Discharge was given as 02/08/2026 and Resident 31 was discharged to a mortuary. A record review of the document provided by the facility as the Discharge Summary revealed it was the admission Record printed 02/08/2026 with handwritten information regarding time of death and items sent with the family and the mortician. There was no recapitulation of stay on this document. A record review of the facility's Transfer and Discharge (Including AMA) policy with implementation date of 11/1/25 revealed no mention of the procedure to follow for a resident death. A record review of the facility's Post Mortem Care policy with implementation date of 11/1/25 revealed no mention of a discharge summary or recapitulation of stay. The policy listed required documentation in the medical record as follows: Date and time resident was pronounced and by whom. Notifications to the physician or designee, family, funeral home, or other designated disposition location, coroner, and/or authorities (if indicated). Post mortem care and disposition of belongings. Date and time body was transported to the funeral home or other designated location. An interview on 03/11/2026 at 9:55 AM with the Director of Nursing (DON) confirmed there was no discharge summary that included a recapitulation of stay for Resident 31.

Licensure Reference Number 175 NAC 12-007.04DBased on observations and interviews, the facility failed to ensure bathroom ventilation systems were functioning to prevent odors for rooms 200, 201, 203, 205, 207, 209, 211 and 213 and the ventilation was clean from debris. This had the potential to affect all residents who reside on the 200 hall. The facility census was 30. Findings are:An observation on 3/9/2026 at 9:30 AM of rooms 200, 201, 203, 205, 207, 209, 211 and 213 bathrooms revealed that the vents did not draw up a 1 ply sheet of toilet paper.An observation on 3/9/2026 at 9:30 AM of rooms 200, 201, 203, 205, 207, 209, 211 and 213 revealed a whitish, brown substance in the vents.An observation on 3/10/2026 at 9:00 AM of rooms 200, 201, 203, 205, 207, 209, 211 and 213 revealed that the bathroom ventilation did not draw up a 1 ply sheet of toilet paper.An observation on 3/10/2026 at 9:00 AM of rooms 200, 201, 203, 205, 207, 209, 211 and 213 revealed a whitish, brown substance in the vents.An interview 03/10/2026 11:17 AM with the Administrator confirmed that (gender) does the water temperature weekly and confirmed that they will have the Maintenance Director check on why the vents were not working. An interview on 3/10/2026 at 2:30 PM with the Maintenance Director confirmed that the bathroom vents in rooms 200, 201, 203, 205, 207, 209, 211 and 213 were not working and the Maintenance Director confirmed that there was debris in the vents. The Maintenance Director confirmed that the ventilation system has not been checked in a few months. The Maintenance Director confirmed there is no record of the vents being checked. The Maintenance Director confirmed that the vents in the bathrooms should be working and the vents should be cleaned.

Licensure Reference Number 175 NAC 12-006.05(D)Licensure Reference Number 175 NAC 12-006.05(E)Based on record reviews and interviews the facility failed to ensure that the resident or the resident representative was informed of the risks, benefits and alternative treatments for the use of psychotropic medications (any medication that affects behavior, mood, thought, or perception, used to manage mental health conditions) as required, for 2 of 2 sampled residents (Resident 1 and Resident 8). The facility census was 30. Findings are: A. A record review of Resident 8's admission Record dated 03/11/2026 revealed that the resident was admitted to the facility on [DATE]. A record review of Resident 8'sMinimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 11/26/25 revealed in Section I Active Diagnoses that Resident 8 had a diagnosis of unspecified dementia (a usually progressive condition marked by the development of multiple cognitive deficits, such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) with agitation, anxiety disorder, and depression. Resident 8's MDS also revealed in Section C Cognitive Patterns that resident 8 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 2 showing extreme impairment. Record review of Resident 8's Order Summary dated 03/11/2026 revealed that Resident 8 had a medication order for 0.5 MG (milligram) of Risperidone (an atypical antipsychotic) to be taken at bedtime starting 11/13/2025, and 10 MG of Escitalopram (used to treat depression and anxiety) to be taken daily starting 10/16/2023. A record review of Resident 8's Medication Administration Record (MAR) revealed that both medications were administered as ordered for the month of January 2026. A record review of Resident 8's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) printed on 03/11/2026 revealed that Resident 8 used psychotropic medication for flat affect and delusions. Interventions include: monitoring for sided effects, non-pharmacological interventions such as one-on-one attention, offer snacks and fluids, call daughter, and behavior monitoring. A record review of Resident 8's medication records revealed no evidence of a consent for use of psychotropic medications (Risperidone and Escitalopram) . An interview with the Director of Nursing 03/11/2026 9:48 AM confirmed that there is no consent for Resident 8's psychotropic medications (Risperidone and Escitalopram) as required. B. A record review of the Order Summary Report revealed that Resident 1 was admitted to facility on 1/20/2025 with medical diagnoses that included Depression (a mood disorder characterized by persistent feelings of sadness and a loss of interest), Anxiety disorder (a condition with symptoms like a racing heart, sweating, and difficulty concentrating, as well as emotional symptoms such as excessive worry and irritability) and Bipolar Disorder (a mental health condition characterized by significant mood swings, including periods of abnormally elevated, extreme moods or emotions and energy level and episodes of depression). A review of the Order Summary Report revealed Resident 1's medication orders include Pregabalin (a medication that treats nerve pain by calming overactive nerves in your body. It can also treat seizures), Hydroxyzine (a medication used to relieve itching, to relieve anxiety and tension), Donepezil (a medication to treat mild to severe dementia associated with Alzheimer's disease), Fluoxetine (an antidepressant medication used to treat depression). A record review of the Annual Minimum Data Set (MDS, a federally mandated assessment process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes that is also used for care planning) for Resident 1 with Assessment Reference Date of 1/22/26, revealed in Section N0415 that that Resident 1 is taking High-Risk Drugs (medications that have an increased risk of adverse effects to elderly patients). Section C0500 of the MDS revealed a Brief Interview of Mental Status (BIMS, a 0–15 point cognitive screening tool (max score 15) used primarily in nursing homes to assess memory and orientation. Scores are interpreted as: 13–15 (intact), 8–12 (moderate impairment), and 0–7 (severe impairment) score of 15. Section E0300 of the MDS for Resident 1 revealed no adverse behaviors (patterns of conduct that are harmful, disruptive, or counterproductive to oneself or others) or rejection of care. A review of Resident 1's Care Plan Report printed 3/11/2026 revealed goals and interventions for anxiety, depression and bipolar disorder. A review of Resident 1's the Medication Administration Record for March 2026 indicated no indication of target behaviors for Antidepressant nor for Antianxiety medications. A review of Resident 1's admission Record and Record of Resident 1's Medication Administration Record for March 2026 revealed no diagnoses to support use of Donepezil nor to support use of Pregabalin. A review of Resident 1's electronic medical record did not reveal documentation of informed consent for psychotropic medications (Risperidone and Escitalopram). A copy of the Informed Consent document for Resident 1 was requested from facility Administrator on 3/10/26; however, no informed consent for psychotropic medication for Resident 1 was provided. An interview on 3/11/2026 at 1:07 PM with Regional Corporate Nurse revealed that there is no documentation of informed consent for the medications for Resident 1.

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (a document that serves as initial instruction and guidance for the resident's care), for 1 resident (Resident 33) of 2 sampled residents. The baseline care plan did not contain information and interventions for the use of psychotropic medications. The facility's census was 30. Findings are: A record review of the Medical Diagnoses for Resident 33 revealed that Resident 33 was admitted on [DATE] with the diagnoses of traumatic subdural hemorrhage with loss of consciousness (a condition with bleeding near the brain that can happen after a head injury), dementia (a progressive decline in mental ability-including memory, thinking, and behavior-that interferes with daily life and is not a normal part of aging), and depression (a mood disorder characterized by persistent feelings of sadness and a loss of interest). A record review of Physician Admission/re-admission Orders dated 3/3/26 for Resident 33 revealed medications to include Bupropion (a medication to treat depression), Divalproex sodium (a medication used to treat seizure disorder), Donepezil (a medication for treatment of dementia), Quetiapine (a medication used in the treatment of schizophrenia, bipolar disorder and major depression), and Venlafaxine (a medication used to treat depression). Section C of the admission Minimum Data Set (MDS, a standardized assessment tool used in long-term care facilities) for Resident 33 was completed on 3-11-2026. Review of Section C0500 of the MDS revealed a Brief Interview of Mental Status (BIMS, a 0-15 point cognitive screening tool (max score 15) used primarily in nursing homes to assess memory and orientation. Scores are interpreted as: 13-15 (intact), 8-12 (moderate impairment), and 0-7 (severe impairment), revealed Resident 33 had a score of 7, indicating severe impairment. A record review of the baseline care plan for Resident 33, dated 3/5/2026, revealed that the baseline careplan for Resident 33 did not reflect any of Resident 33's psychoactive medications nor any interventions related to psychoactive medications. A record review of the Facility's Policy for Baseline Care Plans dated December 2016 revealed:A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission2) continues to indicate that orders, such as for medications, will be used to implement the baseline care plan and be used until3) staff can conduct the comprehensive assessment and develop the interdisciplinary person-centered care plan4) to indicate that any services and treatments to be administered by the facility will be included. An interview on 3/11/26 at 2:00 PM with the Director of Nursing confirmed that Resident 33's baseline care plan did not contain information and interventions for this individual's psychotropic medications.

Based on observations and record reviews, the facility failed to ensure staffing information was posted as required. This had the potential to affect all residents. The facility census was 30. Findings are:An observation on 03/09/2026 at 1:30 PM revealed no staffing information was posted on either hallway, around the nurses' station, in the lobby or entrance areas, or around the front offices.An observation on 03/10/2026 at 7:49 AM revealed no staffing information was posted on either hallway, around the nurses' station, in the lobby or entrance areas, or around the front offices.An observation on 03/10/2026 at 9:46 AM revealed no staffing information was posted on either hallway, around the nurses' station, in the lobby or entrance areas, or around the front offices. There was a whiteboard near the nurses' station that had staff names written on it. There were no hours or census information written on the whiteboard. An interview on 03/10/2026 at 9:50 AM with Licensed Practical Nurse (LPN) A confirmed there was no written staffing sheet posted. The LPN further confirmed the facility wrote the staff scheduled to work on the whiteboard daily.An interview on 03/10/2026 at 9:56 AM with the Administrator (ADM) confirmed the facility did not have a staffing sheet including census and total hours posted, and that the staff scheduled to work were written on the white board.

Licensure Reference Number 175 NAC 12-006.18(B) & 1-005.06 Based on observations, interviews, and record reviews; the facility failed to utilize Enhanced Barrier Precautions (EBP, a set of infection control measures that aim to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes), to reduce the potential for transmission of infection during high contact resident care activities related to Resident 27's indwelling urinary catheter, Resident 22's wound, urostomy, and colostomy, Resident 129's tube feeding, Resident 131's wound, and Resident 18's wound. The sample size of residents was 27. The facility census was 27. Findings are: A review of the facility's Personal Protective Equipment policy statement dated 2001 and revised October 2018 revealed the following: Policy Interpretion and Implementation: -Personnel who perform task that may involve exposure to blood/body fluids are provided appropriate personal protective equipement at no charge. -Personal protective equipment provided to our personnel includes but is not necessarily limited to: gowns/aprons/lab coats (disposable, cloth, and or plastic),gloves (sterile, non-sterile, heavy duty, and or puncture resistant),masks and,eye wear (goggles, and or face shields). -A supply of protective clothing and equipment is maintained at the nurse's station. PPE required for transmission-based precautions (TBP) is maintained outside and inside of resident's rooms, as needed. A. A record review of Resident 18's wound-weekly observation tool dated 8/15/24 revealed Resident 18 had wound areas to Resident 18's right and left buttocks. A record review of Resident 18's diagnosis list with the printed dated of 10/1/24 revealed a pressue ulcer (a localized injury to the skin and tissue caused by prolonged pressure on the skin) dated 7/23/24. A record review of a follow up document from the wound physician, dated 9/19/24 revealed Resident 18 had a decubitus ulcer (a localized injury to the skin and tissue caused by prolonged pressure on the skin) to Resident 18's right and left buttocks. On 10/1/24 at 8:30 AM, Resident 18 was observed sitting in their wheelchair in their room. There were no EBP supplies in Resident 18's room or signage by Resident 18's door indicating the need for EBP. On 10/1/24 at 9:30 AM an observation was made of the Director of Nursing (DON) assisting Resident 18 to the bathroom and with gloved hands, cleansed the resident's peri-area after use of toilet. There was no dressing covering the open areas on Resident 18's buttocks. There were no EBP supplies in the resident's room. There was no signage on Resident 18's door indicating the need for EBP. B. On 9/30/24 at 11:42 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. There was no Enhanced Barrier Precautions (EBP) are a set of infection control measures that aim to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) in the room or a sign by the Residents door. On 10/1/24 at 9:00 AM Resident 27 was observed sitting in (genders) room in (genders) wheelchair with a catheter bag hanging from the wheelchair. There was no EBP in Resident 27's room or signage by Resident 27's door indicating the need for EBP. A record review of Resident 27's physician's orders dated 9/14/24 revealed an order to Flush Foley catheter with 60 milliliters (ml) normal saline daily. A record review of Resident 27's physician's orders dated 9/13/24 revealed an order to Change the catheter every 30 days and as needed. Replace with same size catheter and bulb fill as per physician's orders. May irrigate catheter with 120 cubic centimeters (cc) of normal saline/sterile water as needed. C. A record review of Resident 22's Admission Record revealed that Resident 22 returned to the facility on [DATE]. Resident 22 had a urostomy (a surgical procedure that creates a new opening in the abdomen to allow urine to exit the body) and a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) and Resident 22 had a wound vac (a medical device that uses suction to help wounds heal). An observation on 10/2/24 at 12:00 PM of Resident 22's room revealed that there was no EBP supplies in Resident 22's room or outside of Resident 22's room nor any signs posted inside or outside Resident 22's room indicating the need for EBP. D. On 9/30/24 at 1:22 PM an observation of Resident 129 revealed the resident sitting in bed with a G-Tube (a tube that's surgically inserted through the abdominal wall and into the stomach) showing outside of (gender's) shirt. There was no EBP supplies in Resident 129's room or outside of Resident 129's room nor any signs posted inside or outside Resident 129's room indicating that EBP was needed. An interview on 10/02/24 at 11:05 AM with the DON (Director of Nursing) confirmed that the facility was not following the EBP for indwelling catheters/devices or wound cares. There were no EBP signs on the residents' doors that had indwelling catheters/devices or wounds and there was no PPE in the rooms or outside of the rooms for Resident 27(catheter), Resident 22 (wounds, colostomy,urostomy), Resident 131 (wounds), Resident 18 (wounds) and Resident 129 (tube feeding) and there should have been EBP for residents who had indwelling appliances and wound care. 49380 E. An observation on 10/01/2024 at 12:58 PM revealed missing signage and Personal protective equipment (PPE) for Enhanced Barrier precautions (EBP) for wound cares and wound vacuum treatments for Resident 131's right lower extremity. An observation on 10/02/2024 at 3:11 PM with the Director of nursing (DON) providing cares to Resident 131's right lower leg wound and wound vacuum. The DON pealed back the temporary dressing of a folded 4x4 and paper tape to expose the right lower extremity wound. When preforming this action, the DON did not have on all of the required PPE, the DON had donned gloves to their bilateral hands. An interview with the Director of Nursing on 10/2/2024 at 12:27 PM confirmed that there was not EBP posted signage and/or supplies of PPE, (Staff and/or visitors are required to wear to minimize possible exposure to hazards that cause serious workplace injuries and illnesses) for residents who have indwelling appliances or wound care.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and observations, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning purposes) reflected the status of Resident 27's catheter at the time of admission. The sample size was 13. The facility census was 27. Findings Are: On 9/30/24 at 11:42 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. On 10/1/24 at 9:00 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. A record review of an Admission Record with the printed date of 9/30/24 indicated the facility admitted Resident 27 on 5/15/24 with diagnoses of Malignant Neoplasm of Bladder (also known as bladder cancer, is a cancerous tumor that forms in the lining of the bladder), Calculus of Kidney (a hard deposit of minerals and salts that forms in the kidney), Hematuria (the presence of red blood cells in the urine), Retention of Urine(a condition that makes it difficult or impossible to empty the bladder), Obstructive and Reflux Uropathy(when urine can't drain through the urinary tract, causing urine to back up into the kidneys). A record review of Resident 27's History and Physical dated 5/20/24 revealed that Resident 27 was admitted with a urinary catheter. A record review of Resident 27's physician's orders with a revision date of 9/14/24 revealed an order to Flush Foley catheter with 60 ml normal saline daily. A record review of Resident 27's physician's orders with a revision date of 9/13/24 revealed an order to Change the catheter every 30 days and as needed. Replace with same size catheter and bulb fill as per physicians orders. May irrigate catheter with 120 cc (cubic centimeters) of normal saline/sterile water as needed. A record review of Resident 27's MDS dated [DATE] revealed documentation in Section H-Bladder and Bowel stating None of the above in reference to whether the resident had an indwelling catheter, an external catheter, an ostomy, or intermittent catheterization. An interview on 10/2/24 with the DON (Director of Nursing) confirmed that the catheter should have been marked on the MDS and that the catheter was not marked on the MDS.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP-written instructions needed to provide effective and person centered care of a resident that meet professional standards of quality care) for 1 (Resident 27) of 2 sampled resident's catheter cares. The facility census was 27. Findings Are: On 9/30/24 at 11:42 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. On 10/1/24 at 9:00 AM Resident 27 was observed sitting in (gender's) room in (gender's) wheelchair with a catheter bag hanging from the wheelchair. A record review of an Admission Record with the printed date of 9/30/24 indicated the facility admitted Resident 27 on 5/15/24 with diagnoses of Malignant Neoplasm of Bladder (also known as bladder cancer, is a cancerous tumor that forms in the lining of the bladder), Calculus of Kidney (a hard deposit of minerals and salts that forms in the kidney), Hematuria (the presence of red blood cells in the urine), Retention of Urine(a condition that makes it difficult or impossible to empty the bladder), Obstructive and Reflux Uropathy(when urine can't drain through the urinary tract, causing urine to back up into the kidneys). A record review of Resident 27's History and Physical dated 5/20/24 revealed the resident was admitted with a urinary catheter. A record review of Resident 27's physician's order dated 9/14/24 revealed an order to Flush Foley catheter with 60 milliliters (ml) of normal saline daily. A record review of Resident 27's physician's order dated 9/13/24 revealed an order to Change the catheter every 30 days and as needed. Replace with same size catheter and bulb fill as per physician's orders. May irrigate catheter with 120 cubic centimeters (cc) of normal saline/sterile water as needed. A record review of Resident 27's CCP dated 5/16/24 revealed the following: A) Focus: The resident has urge, functional, mixed bladder incontinence related to disease process bladder cancer. B) Interventions: 1) Brief Use: The resident is very resistant to utilizing incontinency products. Offer different types to achieve comfort zone, 2) Check bathroom and room for wet clothing frequently and place soiled clothing in laundry, 3) Clean peri-area with each incontinence episode, 4) Incontinent: Check between meals and as required for incontinence. C) Goals: 1) The resident will remain free from skin breakdown due to incontinence and brief use through the review date: Target date 7/19/24. An interview on 10/2/14 at 12:27 PM with the DON (Director of Nursing) confirmed that Resident 27's catheter care should have been on the care plan and the catheter care was not on the care plan.

LICENSURE REFERENCE NUMBER 175 NAC-,d+[DATE]. 11E Based on observation, interview and record review; the facility failed to ensure outdated foods were not available for use, failed to label and date opened food and failed to utilize handwashing and gloving techniques to prevent the potential for food borne illness This had the potential to affect all the residents. Facility census was 31. Findings are: A. Observation on [DATE] at 9:10 AM with the Dietary Manager (DM) during initial kitchen tour revealed the following: -A open bag of shredded mozzarella cheese with no open date. -A open bag of shredded cheddar cheese with no open date. -Cheddar cheese slices wrapped in saran wrap with no open date. -A open bag of cabbage heads not closed shut with one head of cabbage to have dark brown/black discoloration. -A open bag of lettuce heads not closed shut with one head appearing wet/slimy with brown leaves. -A large bag of open shredded lettuce with no open date. -A open horseradish container with expiration date of [DATE]. -A jug of salsa with open date of [DATE] with expiration date of [DATE]. -A jug of lime juice with open date of [DATE] with expiration date of [DATE]. -A open bag of powdered sugar with no open date. -Record review of the facility policy Food Procurement, Receiving and Storage dated 2021 stated label, date, and monitor refrigerated food, including leftovers, so that it is consumed by its use-by-date, frozen (where applicable), or discarded. -Interview on [DATE] at 9:15 AM with the DM confirmed that all food packages should be labeled and dated when opened and all food packages that have expired should be disposed of to prevent food borne illness. B. Observation on [DATE] at 11:50 AM revealed Dietary Manager DM) washed hands at sink with soap and water for 15 seconds. Observation on [DATE] at 12:20 PM revealed DM washed hands at sink with soap and water for 10 seconds. Observation on [DATE] at 12:40 PM revealed Cook rinsed their hands at sink with water only and dried hands. Interview on [DATE] at 2:00 PM with DM revealed ,d+[DATE] seconds was not long enough to wash hands with soap and water to prevent cross contamination or food borne illness. DM also confirmed that rinsing hands with water only is not appropriate hand hygiene.

Based on record review and interviews, the facility failed to complete a level 2 PASARR (necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) assessment for 2 of 2 sampled residents (Resident 22 and Resident 23) after a new diagnosis of a serious mental disorder was received. The facility had a census of 31. Findings are: A. Record review of Resident 22's Admission Record reviewed on 11/14/2023 shows an admitted to facility on 5/1/2022 with a diagnosis of Generalized Anxiety Disorder (GAD) (persistent feeling of anxiety or dread) with an onset date of 5/1/2022. Record review of Resident 22's Admission Orders dated 5/1/2022 shows an order for hydroxyzine (an antihistamine that can be used to treat anxiety) 12.5 mg (milligram) at bedtime for anxiety (intense, excessive and persistent worry and fear) and insomnia (inability to sleep). Record review of Resident 22's preadmission PASARR dated 5/1/22 reported there were no signs of a serious mental illness, intellectual disability, or a related diagnoses found during the Level 1 screen. Record review of Resident 22's Admission MDS (Minimum Data Set, a comprehensive assessment of a resident's functional abilities) dated 5/7/22 under Section A1500, read: is the resident currently considered by the state level II PASARR to have a serious mental illness and/or intellectual disability or a related condition is marked with an answer of 'no.' Section I5700 of the MDS is marked yes for active diagnosis of Anxiety Disorder. Record review of Resident 22's Admission Record printed 11/14/2023 revealed a new diagnoses of Delusional Disorders (type of psychotic disorder in which a person can't tell what's real from what's imagined) and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) both added 7/8/2022. Record review of Resident 22's Care Plan (document that provides direction on the type of nursing care a resident needs) dated 8/8/2023 showed that Mirtazapine (medication for depression) and Seroquel (antipsychotic medication for depression and delusional disorder) was initiated 6/2/2022. Record review of Resident 22's Quarterly MDS dated [DATE] 22 under Section A1500, is the resident currently considered by the state level II PASARR to have a serious mental illness and/or intellectual disability or a related condition is marked 'no,' with Section I5700 marked yes for active diagnosis of Anxiety Disorder, 15800 Depression and I5950 Psychotic disorder. Interview on 11/15/2023 at 4:30 PM with Social Services (SS) confirmed that no level II PASARR was initiated with additional diagnosis of Delusional Disorder and Major Depressive Disorder on 7/8/2022 and should have been done. 42861 B. A record review of the PASARR dated 11/11/2022 for Resident 23 indicated no serious mental illness or intellectual disability or related condition. The PASARR contained a diagnosis of mild depressive disorder (continuous low mood or sadness; feeling hopeless and helpless; having low self-esteem; feeling tearful) for Resident 23. The PASARR for Resident 23 contained a question which read as follows: -Does the individual have a diagnosis of dementia (progressive or persistent loss of intellectual functioning) or neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) that is considered advanced, primary, or late stage with an answer of no. A record review of the MDS dated [DATE], section A had the following question and answer regarding Resident 23's PASARR: -A1500. PASARR, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? with an answer of no. -Section I5950 was documented as a Psychotic disorder (a group of serious illnesses that affect the mind) (other than schizophrenia) with an answer of yes. A record review of the diagnosis list for Resident 23 revealed a diagnosis of unspecified dementia with agitation dated 11/9/22, delusional disorder (a type of serious mental called a psychotic disorder illness), dated 8/2/22, generalized anxiety disorder (Persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events) dated 7/7/23, and major depressive disorder (a mood disorder that interferes with daily life) dated 7/7/23. An interview on 11/15/23 at 2:20 PM with the MDS Coordinator confirmed that no level 2 PASARR had been initiated with the additional diagnosis of generalized anxiety disorder dated 7/7/23, and major depressive disorder dated 7/7/23.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C3 Based on interview and record review the facility failed to complete a recapitulation of stay for 2 (Residents 32 and 33) of 2 sampled residents. The facility staff identified a census of 31. Findings are: A. A record review of the facility Admission Record revealed Resident 32 had been admitted into the facility on [DATE] with a primary diagnosis of Cellulitis (a common, potentially serious bacterial skin infection). A record review of the Progress Notes dated 9/6/23 revealed Resident 32 had been sent to the emergency room (ER) due to respiratory distress and low blood pressure. A request was made on 11/15/23 at 1:35 PM for the recapitulation of stay for Resident 32. An interview with the facility Director of Nursing (DON) on 11/15/23 at 4:00 PM confirmed that the facility had not completed a recapitulation of stay for Resident 32. B. A record review of the demographic information for Resident 33 revealed Resident 33 admitted on [DATE] with a primary diagnosis of Atrial Fibrillation (an irregular and often very rapid heart rhythm). A record review of the Progress Notes dated 10/14/23 revealed Resident 33 had left the facility with the representative. A record review of the Progress Notes dated 10/14/23 revealed Resident 33 had been admitted to the hospital and did not return to the facility. A request was made on 11/15/23 at 1:35 PM for the recapitulation of stay for Resident 33. An interview with the facility DON on 11/15/23 at 4:00 PM confirmed that the facility had not completed a recapitulation of stay for Resident 33. Record review of the undated facility policy titled Discharge Summary and Plan of Care read as follows: 3. Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider. The Discharge Summary should include: a. An overview of the resident's stay that includes but not limited to: diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c. Reconciliation of all pre-discharge medications with the resident's post discharge medications to include prescription and over the counter medications.

Based on record review and interview, the facility failed to ensure that the resident and/or resident's representative was notified in writing of the reason for transfer to the hospital for 3 residents (Resident 4, 15, and 29) out of 3 sampled for transfer notices, and the facility failed to notify the ombudsman of transfer for 1 resident (Resident 4) out of 3 sampled for Ombudsman notification. The facility census was 36. Findings are: A. In the initial interview on 11/14/22 at 4:40 PM, Resident 4 revealed that they had gone to the emergency room (ER) after they fell off the toilet. A review of the resident's Electronic Health Record (EHR) revealed that the resident was transferred to theER on [DATE] after a fall and returned later that day. A review of Resident 4's Progress Notes from 9/21/22 to 10/1/22 revealed no documentation of Written Notice of Transfer being given to the resident or their representative. An interview with the Social Service Designee (SSD) on 11/16/22 at 2:25 PM confirmed that they had not provided the resident or their representative a Written Notice of Transfer when the resident went to the hospital ER. A review of the list of Ombudsman notifications for September 2022 revealed Resident 4 was not on the list provided to the Ombudsman. An interview with the SSD on 11/17/22 at 11:21 AM confirmed that the Ombudsman was not notified of Resident 4's transfer to the hospital ER in September 2022. B. In the initial interview on 11/15/22 at 10:45 AM Resident 15 revealed that they had gone to the ER after a fall. A review of the resident's EHR revealed that the resident was transferred to theER on [DATE] after falling and was in the hospital from 8/28/22 to 8/31/22. A review of Resident 15's Progress Notes from 8/28/22 to 9/1/22 revealed no documentation of Written Notice of Transfer being given to the resident or their representative. An interview with the Social Service Designee (SSD) on 11/16/22 at 2:25 PM confirmed that they had not provided the resident or their representative a Written Notice of Transfer when the resident went to the hospital ER. C. A review of Resident 29's medical record revealed on 8/9/22 the resident was transferred to the emergency room after the resident fell , had an injury, and then had hip surgery. Interview on 11/17/22 at 9:00 AM an interview with the Director of Nursing revealed the status of the resident and accident; were telephoned to the family and no written documentation was completed.

Based on record review and interview, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold upon transfer to the hospital for 3 Residents (4, 15, and 29) out of 3 sampled for bed hold notices. The facility census was 36. Findings are: A. In the initial interview on 11/14/22 at 4:40 PM, Resident 4 revealed that they had gone to the emergency room (ER) after they fell off the toilet. A review of the resident's Electronic Health Record (EHR) revealed that the resident was transferred to theER on [DATE] after a fall and returned later that day. A review of Resident 4's Progress Notes from 9/21/22 to 10/1/22 revealed no documentation of the facility's Policy for Bed Hold being given to the resident or their representative. An interview with the Social Service Designee (SSD) on 11/16/22 at 2:25 PM confirmed that they had not provided the resident or their representative a copy of the facility's Policy for Bed Hold when the resident went to the hospital ER. B. In the initial interview on 11/15/22 at 10:45 AM Resident 15 revealed that they had gone to the ER after a fall. A review of the resident's EHR revealed that the resident was transferred to theER on [DATE] after falling and was in the hospital from 8/28/22 to 8/31/22. A review of Resident 15's Progress Notes from 8/28/22 to 9/1/22 revealed no documentation of the facility's Policy for Bed Hold being given to the resident or their representative. An interview with the Social Service Designee (SSD) on 11/16/22 at 2:25 PM confirmed that they had not provided the resident or their representative a copy of the facility's Policy for Bed Hold when the resident went to the hospital ER. C. A review of Residents 29's medical record revealed Resident 29 was hospitalized from a fall and injury on 8/9/22 and the resident had hip surgery on 8/10/22. A review of Resident 29's medical record did not reveal documentation that Resident 29's or representative were provided documentation from facility for a bed hold policy. An interview on 11/17/22 at 9:00 AM with the Director of nursing confirmed no written bed hold policy was given to Resident 29 or representative for hospital stay starting 8/9/22.

NAC 175 12-006.09C Based on record review and interview, the facility failed to ensure that a Comprehensive Care Plan (CCP-- written instructions needed to provide effective and person-centered care of the resident including care needs, goals, and interventions) for Resident 28 included target behaviors and non-pharmalogical interventions relating to the use of [CONDITION(S)] (a drug that affects behavior, mood, thoughts, or perception) medications. This affected 1 of 12 residents sampled for Comprehensive Care Plans. The facility census was 36. Findings are: A record review of Resident 28's Admission Face Sheet revealed that the resident was admitted to the facility on [DATE] and that his list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 28's Order Summary dated 11/15/22 revealed the resident was on the following [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (an antipsychotic) 25 milligrams (mg) take one tablet by mouth at bedtime; and [MEDICATION(S)] (an antidepressant) 15 mg take one tablet by mouth at bedtime. Record review of the pharmacy's Note to Attending Physician/Prescriber signed by the provider on 11/2/22, revealed that the [MEDICATION(S)] was for Delusional Dementia with [CONDITION(S)], and the [MEDICATION(S)] was for mood, Dementia, sleep, and appetite. A review of the resident's CCP revealed a focus that addressed the resident's use of psychotropics. One of the listed interventions for this, dated 3/16/22, was to Monitor/record occurrence of for target behavior symptoms and document per facility protocol. The CCP did not identify specific target behaviors for staff to monitor. The CCP also did not contain information regarding any interventions to be used for the use of antipsychotic and antidepressant medications. A review of Resident 28's Treatment Administration Record (TAR) for November 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR did not contain any specified target behaviors to monitor or any non-pharmalogical interventions to use. An interview with Registered Nurse (RN) A on 11/17/22 at 1:19 PM confirmed there were no target behaviors or non-pharmalogical interventions listed in Resident 28's CCP or TAR for staff to monitor or document.

LICENSURE REFERENCE 12-007-04D Based on observation and interview, the facility failed to provide ventilation in the residents' bathrooms for rooms 204 and 209. The facility census was 36. Findings are: Observation on 11/14/22 at 11:00 AM, in room 204 and 209 bathroom's; the vents did not draw air for 1 ply toilet paper. Observation on 11/17/22 at 3:00 PM, in 204 and 209's bathroom; the vents did not draw air for 1 ply toilet paper. Interview on 11/17/22 at 3:15 PM with the Maintenance Director revealed at times the vent did not pull air into the system.

Based on record review and interview, the facility failed to ensure a level 2 PASRR (Preadmission Screening and Resident Review) program had been completed on 3 residents (Resident 3, 16 and 24) out of 13 Resident sampled when diagnosed with a mental illness. The facility census was 31. Findings are: A. Record review of Resident 3's PASARR dated 3/26/18 revealed; no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 exhibited no behaviors, had no mental health services and had not experienced significant disruption in life related to mental health symptoms and had no psychoactive medications in use. Record review of Resident 3's Face Sheet revealed; - admitted d was 11/18/19. - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 3's MAR (Medication Administration Record) dated April 2021 and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 3's MDS MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) Annual assessment dated [DATE] revealed; -Section A 1500 Resident 3 was not currently considered by the state level II PASRR process to have serious mental illness and or intellectual disability or related condition. -Section I Active Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Section N medications: [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 5/6/21 at 12:48 PM with the MDS coordinator confirmed the facility was unable to locate a new PASRR with new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] B. Record review of Resident 16's PASARR dated 11/26/10 revealed; no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 16's Face sheet revealed Resident 16 was admitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review Resident 16's of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 16's Continuum of Care Transfer Report dated 3/19/21 revealed Resident 3 had a diagnoses of mood disorder, vascular dementia without behavioral disturbance, and dementia. Record review of MDS dated [DATE] for Resident 16 revealed; - Section A 1500 revealed resident 16 had not currently been considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or related condition. - Section I Active Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Section N Antidepressant use daily. An interview on 05/06/21 12:30 PM with the MDS coordinator confirmed the facility was unable to locate a PASRR dated after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 5/6/21 at 12:48 PM with the MDS coordinator confirmed the facility was unable to locate a new PASRR with new diagnosis. C. Record review of Resident 24's PASARR Level I dated 10/09/20 revealed; no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NO level II was recommended. Record review of Resident 24's Faces Sheet revealed; Resident 24 admitted on [DATE]. Record review of Resident 24's Psychotherapy consult dated 9/16/20 revealed; Resident 24 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A new medication [MEDICATION(S)] ( an antidepressant) 25 mg was initiated for functional motor recovery assistance as well as depressive symptoms. Record review of Admission MDS dated [DATE] for Resident 24 revealed: - section A PASARR A1500- revealed; Resident 24 was not currently considered by the state Level II PASRR process to have serious mental illness and or intellectual disability or a related condition. - Section I Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Section N -6 days antidepressant use. An interview on 05/04/21 at 04:30 PM with the MDS coordinator confirmed Resident 24 had admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Licensure reference number 175 NAC 12-006.09D7 Based on observations, interviews with staff, medical record review of 4 residents and review of 3 newly hired employee personnel files, and training records for professional nursing staff; the facility failed to assure that staff received training on protocol for use of newly initiated hydrocollator pack treatments resulting in a thermal burn injury for 1 of 4 residents - Resident 1. Facility census 40. Findings are: A. Review of the History and Physical dated 8/25/10 for Resident 1 revealed the resident was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Comprehensive Care Plan developed for Resident 1 on 10/11/10 stated "resident total assist with all activities of daily living related to dementia", with goal for "No skin breakdown". Review of nursing notes revealed on the early morning of 2/1/11, Licensed nurse charted "summoned to room by CNAs (Certified Nursing Assistant) resident noted at 0630 (6:30am) to have left knee red area with ruptured blister in center measuring - red area 9 cm ( centimeters) by 8 cm. Blister area 2.5 cm X 5.5 cm. Right knee red area measuring 2.5 by 3 cm. Areas cleansed with normal saline and telfa applied wrapped with kling and fax sent to physician office." Physician ordered on [DATE] during rounds in facility "Wash left knee daily with antibacterial soap, apply polysporin and telfa daily until healed." physician progress notes [REDACTED]. ~ (approximately) 3 - 4 cm (centimeters) diameter. Clean No purulence or surrounding [DIAGNOSES REDACTED]." Facility investigation revealed that resident was receiving warm moist packs to bilateral knees for 20 minutes and then apply icy hot every am at rising. Warm moist packs (hydrocollator - heated thermal pad) was provided on the morning of 2/1/11 by Nurse A and then icy hot applied following Warm moist pack removal as per usual. However, the proper amount of towel layers was apparently not utilized in this instance and thus a thermal injury occurred for Resident 1, as the combination of the heat packs and the icy hot rub caused the skin injury. Nurse A related to social service director conducting investigation into injury for Resident 1,from the night shift on 2/1/11 "(Nurse A name) applied the warm moist pack per usual to residents knees. This treatment was initiated at about 5:00am so that it would be completed prior to resident getting up for the day. She returned to remove the pack in approximately 10-15 minutes per the scheduled routine, removed the pack and observed both knees at this time with no sign of blistering on either knee. Did state that the areas were somewhat pink but nothing inconsistent with the norm. Nurse A then proceeded to apply icy hot to both knees and massage it into the knees. When finished again observed both knees and saw no sign of blistering or damaged tissue prior to exiting room." The facility had no protocol for how many layers of towel padding were to be wrapped around the warm hot packs prior to use on residents affected areas. The facility investigation completed on 2/9/11 concluded with "discontinue use of warm moist packs and less aggressive methods such as Aqua-K pad will be utilized by facility staff. Only the physical therapy staff will utilize warm moist packs as a course of treatment." Observation of Resident 1 at 10:25am on 2/17/11 with Assistant Director of Nursing present, revealed resident resting in bed with residents knees flexion contracture position. Three small scabs dime size or smaller, red in color, dry and healing were observed with healthy surrounding tissue. Right knee was normal color with skin intact. Resident one appeared to be in no distress and was resting comfortably. B. The facility had no record of training the licensed nursing staff on the use of the hydrocollator warm moist packs. Review of 3 personnel files for newly hired Licensed Practical Nurses (LPN) A, B and C, revealed that staff had not completed professional nurse orientation checklist upon hire. Staff A - hired 12/27/10 had no record of orientation checklist in personnel file. Staff B - hired 12/1/10 had no record of orientation checklist in personnel file. Staff C - hired 10/18/10 had no record of orientation checklist in personnel file. Interview with 3 staff nurses D, E and F, on 2/17/11 between 10:15am - 10:42am, revealed the "machine" (hydrocollator) just showed up in the front medication room directly behind the nursing station and no protocol on use of the specialized hydrocollator packs was provided nor any inservice training. The facility provided an inservice on 2/8/11 to nursing staff which included "warm moist packs" no longer used by nursing and the machine located in the front medication room was unplugged.