Every finding on record at Keene Center, Genesis Healthcare

Based on observation, interview and record review the facility failed to ensure that food was stored in a refrigeration at or below 41 degrees Fahrenheit (F) for 1 of 2 kitchenette refrigerators and 1 of 1 main kitchen walk in refrigerators. Findings include:Observation on 5/12/26 at approximately 8:20 a.m. with Staff H (Dietary Manager) revealed that the temperature logs for the walk-in refrigerator in the main kitchen had high temperature recordings. Review on 5/13/26 of the refrigerator temperature logs for the main kitchen walk- in refrigerator revealed the following: a.m. temperatures greater than 41 degrees on 4/24/26 (48), 4/25/26 (45), 4/27/26 (48), 5/5/26 (48), 5/6/26 (50), 5/7/26 (52), 5/8/26 (52), 5/9/26 (46), and 5/11/26 (52).Review on 5/13/26 of the refrigerator temperature logs for the main kitchen walk- in refrigerator revealed the following: p.m. temperatures greater than 41 degrees on 4/26/26 (45), 5/5/26 (52), 5/6/26 (58), 5/8/26 (50), and 5/9/26 (49).Observation on 5/12/26 at approximately 8:50 a.m. with Staff H revealed that the temperature logs for the third-floor kitchenette refrigerator revealed that there were high temperatures. Further observation revealed that the refrigerator was placed out of service on 5/12/26. Inside the refrigerator was a jug of orange juice with an open date of 5/10/26, 3 20-ounce diet cokes and 1 unopened Gatorade bottle.Review on 5/13/26 of the refrigerator temperature logs for the Third-floor kitchenette refrigerator revealed the following: a.m. temperatures greater than 41 degrees on 4/9/26 (49), 4/10/26 (57.5), 4/11/26 (52.5), 4/12/26 (49), 4/18/26 (48), 4/24/26 (55), 4/25/26 (53), 4/26/26 (47.5), 5/5/26 (54.5), 5/8/26 (65), and 5/10/26 (55.5).Review on 5/13/26 of the refrigerator temperature logs for the Third-floor kitchenette refrigerator revealed the following: p.m. temperatures greater than 41 degrees on 4/5/26 (52.5), 4/6/26 (45.5), 4/7/26 (46.5), 4/8/26 (44), 4/9/26 (43), 4/10/26 (50), 4/16/26 (65.5), 4/18/26 (46), 4/19/26 (54), 4/22/26 (48), 4/23/26 (52), 4/25/26 (46), 5/3/26 (54.5), 5/5/26 (54.5), 5/8/26 (64.5), and 5/11/26 (69).Interview on 5/14/26 at approximately 9:33 a.m. with Staff I (Dietary Aide) revealed that he/she completed the temperature check on 5/8/26 in the a.m. of 45 degrees and recorded the digital temperature from the outside of the refrigerator prior to stocking. Staff I further revealed that he/she did not report the elevated temperature of 45 degrees to anyone as he/she was not aware of reportable temperatures. Interview on 5/14/26 at approximately 9:38 a.m. with Staff J (Maintenance Director) revealed that they were unaware of elevated temperatures for the third-floor kitchenette refrigerator. Further interview revealed that the refrigerators were in use on the days they were above 41 degrees F.Review on 5/14/26 of the facility's policy Food Storage: Cold Foods, undated, revealed, A written record of daily temperatures will be recorded. If temperatures are higher than acceptable range, foods must be removed and stored safely in other refrigerators, and maintenance notified. (TELS work order)

Based on record review and interview, it was determined that the facility failed to ensure that a resident had an accurate Preadmission Screening and Resident Review (PASARR) screening for an individual with a mental health disorder for 2 of 3 residents reviewed for PASARR in a final sample of 18 residents (Resident Identifiers are #6 and #100). Findings include:Resident #6 Review on 5/13/26 of Resident #6's medical record revealed that he/she had been admitted to the facility in 11/2025 with a known diagnosis of Bipolar disorder. Review of PASARR, dated 11/11/25, section 2. Screening for mental illness (MI) 2A. Suspected diagnosis was marked No, and no check mark was placed next to Bipolar in the listed possible ICD-10 codes for MI, and no further information was completed for Section 2A,2B or 2C. Interview on 5/14/26 at approximately 9:30 a.m. with Staff F (Social Services) confirmed the above pre admission PASARR was inaccurate. Resident #100 Review on 5/12/26 of Resident #100's medical record revealed that he/she had been admitted to the facility approximately one week ago with a known diagnosis of Major Depressive Disorder, Recurrent, Moderate. Review on 5/12/26 of Resident #100's PASARR, dated 5/6/26, section 2. Screening for mental illness (MI) 2A. Suspected diagnosis was marked No, and no check mark was placed next to Major Depression in the listed possible ICD-10 codes for MI, and no further information was completed for Section 2A, 2B or 2C. Interview on 5/13/26 at approximately 1:29 p.m. with Staff F confirmed that the above pre-admission PASSAR was inaccurate. Review on 5/14/26 of the facility's policy: Pre-admission Screening for Mental Disorder and/or [Sic] Intellectual disability patients revealed . Center Social Worker or designated staff will assure that all patients with Mental Disorders (MD) and or Intellectual Disability (ID) receive appropriate pre-admission screenings .

Based on observation, interview and record review, the facility failed to label an eye medication with an open expiration date, in 1 of 3 medication carts observed (Third Floor North High Cart. Resident Identifier #17).Findings include:Observation on 5/12/26 at approximately 8:10 a.m. of the third floor North High Medication Cart revealed an open Latanoprost eye drops for Resident #17, with no open date or open expiration date on the box or bottle. Further observation revealed the box had a pharmacy label with the refill date 1/6/26.Interview on 5/12/26 at approximately 8:10 a.m. with Staff G (Registered Nurse) confirmed no open date or open expiration date present and revealed the date the eye drops would have come from the pharmacy would be 1/6/26.Review on 5/12/26 of Latanoprost manufacturer instructions revealed, Once a bottle is opened for use, it may be stored at room temperature.for 6 weeks.

Based on observation, interview, and record review, the facility failed to provide adaptive eating equipment for 1 of 1 resident reviewed for Activities of Daily Living in a final sample of 18 residents. (Resident identifier is #68.)Findings include:Observation on 5/13/26 at approximately 8:12 a.m. of Resident #68 in the second-floor day room revealed Resident #68 eating breakfast. Resident #68 was using a spouted cup for liquids, lip plate and standard utensils. Further observation revealed that Resident #68 had difficulties manipulating the fork and experienced spillage of food from the fork.Review on 5/13/26 of Resident #68's care plan revealed an intervention to provide lip plate and built-up utensils for every meal. Review on 5/13/26 of Resident #68's physician orders revealed an order dated 4/21/26- Pt to utilize AE (Adaptive Equipment) as ordered (lip plate and built ups).Interview on 5/13/26 at approximately 1:07 p.m. with Staff B (Occupational Therapist) revealed that Resident #68 had an order for the lip plate and built-up utensils secondary to need for change in hand dominance for eating. Interview on 5/14/26 at approximately 8:17 a.m. with Resident #68 revealed that the built-up utensils made eating much easier and Resident #68 inquired where he/she could get more.Review on 5/14/26 of the facility's policy Assistive Devices, revised 10/2022, revealed Assistive Devices/utensils will be provided as identified in the individualized plan of care to maintain or improve resident's/patient's ability to eat or drink independently.

Based on interview and record review it was determined that the facility failed to provide a notice of transfer and discharge that contained the required information for 2 of 2 residents reviewed for hospitalization in a final sample of 18 residents.(Resident identifiers are #12 and #97). Findings include: Resident #12 Review on 5/14/26 of Resident #12's progress notes revealed that Resident #12 was sent to the hospital on [DATE] for acute kidney injury, and on 12/25/25 for abdominal pain. Review on 5/14/26 of Resident #12's medical record revealed a one page typed notice titled Hospital Transfer dated 12/11/25 and 12/25/25, that did not contain the following required information: a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, and the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Resident #97 Review on 5/13/26 of Resident #97's medical record revealed they had been transferred and admitted to the hospital on [DATE]. Further review revealed a one page typed notice of Hospital transfer, dated 3/27/26, that did not contain the following required information: a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, and the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. Interview on 5/14/26 at approximately 9:45 a.m. with Staff D (Admissions Director) and Staff E (Director of Nursing) confirmed that the facility does not provide the notice of transfer and discharge to residents who transfer to the hospital.

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 2 of 6 residents reviewed for EBP. (Residents identifier are #71 and #135.) Findings include: Resident #71 Observation on 4/6/25 at approximately 10:30 a.m. in Resident #71's room revealed that Resident #71 had a catheter drainage bag hanging on his/her wheelchair. Observation on 4/8/25 at approximately 9:10 a.m. in Resident #71's room revealed that Staff D (Licensed Nursing Assistant (LNA)) was adjusting Resident #71's bed linens without wearing a gown and gloves. After adjusting the linens, Staff D donned gloves and assisted Resident #71 to the bathroom. Further observation revealed a cart containing Personal Protective Equipment. Observation also revealed a sign beside Resident #71's door indicating the use of EBP (wear gown and gloves prior to activities such as dressing, transferring, providing hygiene, changing linens, and changing briefs or assisting with toileting). Interview on 4/8/25 at approximately 9:10 a.m. with Staff D confirmed the above finding. Review on 4/8/25 of Resident #71's care plan revealed that Resident #71 has an indwelling Foley catheter. Further review of the care plan revealed that were no care plan interventions for EBP. Interview on 4/8/25 at approximately 1:25 p.m. with Staff B (Director of Nursing) confirmed the above finding. 40522 Resident #135 Review on 4/8/25 of Resident #135's profile in the medical record revealed that Resident #135 was on EBP. Observation on 4/8/25 at approximately 10:30 a.m. in Resident #135's room revealed that Staff F (LNA) was with Resident #135 wearing gloves and no gown. Interview on 4/8/25 at approximately 10:30 a.m. with Staff F revealed that he/she was in the middle of Resident #135's morning care and getting Resident #135 up in the wheelchair. Interview on 4/8/25 at approximately 10:30 a.m. with Staff G (Licensed Practical Nurse) confirmed that Resident was on EBP and that Staff F was providing morning care to Resident #135 with gloves and no gown. Review on 4/8/25 of Resident #135's skin and wound evaluations, dated 4/7/25, revealed that Resident #135 had wounds on their left lateral calf and rear left thigh. Review on 4/8/25 of Resident #135's progress notes, dated 4/8/25, revealed that EBP was initiated for Resident #135's chronic wounds and that Resident #135 has a wound older than 30 days to his/her left posterior thigh and left calf. Interview on 4/8/25 at approximately 10:45 a.m. with Staff B revealed that Resident #135 was on EBP for his/her wounds. Interview on 4/8/25 at approximately 10:45 a.m. with Staff H (Advanced Practical Registered Nurse) revealed that Resident #135 has a history of Methicillin-resistant Staphylococcus aureas (MRSA) on their wounds and should be on EBP. Review on 4/8/25 of the facility's policy titled, Enhanced Barrier Precautions, revision date of 1216/24, revealed .Implementation of EBP .Patient Status .Has a wound or indwelling medical device .Use EBP Yes, if they do not meet criteria for Contact Precautions .

Based on interview, observation, and record review, it was determined that the facility failed to maintain an equipment per manufacturer's instruction for 1 of 1 room air conditioner observed. (Resident identifier is #22.) Findings include: Observation on 4/6/25 at approximately 10:30 a.m. of Resident #22's room revealed an air conditioning unit that was vented outside through the window. Further observation revealed that Resident #22's room was significantly cooler than other resident rooms. Observation on 4/8/25 at approximately 12:20 p.m. in Resident #22's room revealed an air conditioning unit filter that had gray discoloration and was covered with dust. Interview on 4/8/2025 at approximately 12:20 p.m. of Resident #22 revealed he/she had been using the air conditioning unit within that last 2 weeks. Interview on 4/8/25 at approximately 12:20 p.m. with Staff E (Maintenance Director) confirmed the above observation. Staff E stated that the air conditioning unit filter in Resident #22's room had not been cleaned. Review on 4/8/25 of the Manufacturer's instructions for the air conditioner revealed .Air Filter .Air filters should be cleaned every two weeks . Interview on 4/8/25 at approximately 1:00 p.m. with Staff E confirmed the above air conditioner manufacturer's instructions.

Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 4 residents reviewed for nutrition and 1 of 5 residents reviewed for unnecessary medications in a final sample of 28 residents (Resident Identifiers #27 and #67). Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #67 Review on 4/17/24 of Resident #67's Medication Administration Record (MAR) for April 2024 revealed a physician's order, with a start date of 4/3/24, Weigh every day shift every Wednesday for 4 weeks. Further review of the MAR revealed the following: 4/3/24 - NN (No / See nurse's note) 4/10/24 - marked done; no weight recorded 4/17/24- NN (No / See nurse's note) Review on 4/18/24 of Resident #67's nurses' notes revealed the following: 4/3/24 Weight not obtained with no further reason documented, written by Staff A (Licensed Practical Nurse (LPN)); 4/17/24 Weight not obtained with no further reason documented, written by Staff A. Review on 4/18/24 of Resident #67's Weights tab in the electronic record revealed a weight on 4/1/24 of 175.6 pounds. Further review revealed no other weights were documented under the weights tab. Review on 4/19/24 of Resident #67's Nutritional assessment dated [DATE] revealed the Registered Dietitian's evaluation [Resident's name omitted] is consuming meals fairly well since admission however, not meeting increased needs with wound .Will monitor intake, weight, and wound healing for additional interventions if necessary . Interview on 4/19/24 at 11:20 a.m. with Staff B (Unit Manager) confirmed the above findings. 43002 Resident #27 Review on 4/18/24 of Resident #27's Medication Administration Record (MAR) for April 2024 revealed a physician's order, with a start date of 4/12/24, for Novolog insulin per sliding scale before meals and at bedtime; if over 351 recheck the blood sugar in 2 hours; if the blood sugar was over 400 to notify the provider. Further review revealed the following: 4/13/24 at 4:30 p.m. the blood sugar was 379; 4/14/24 at 11:30 a.m. the blood sugar was 425 and at 4:30 p.m. was 399; 4/15/24 at 4:30 p.m. the blood sugar was 362 and at 9:00 p.m. was 466; 4/16/24 at 9:00 p.m. the blood sugar was 384; 4/17/24 at 11:30 a.m. the blood sugar was recorded as NA and at 4:30 p.m. the blood sugar was 577; 4/18/24 at 7:30 a.m. the blood sugar was 385, at 11:30 a.m. was 452, and at 9:30 p.m. was 399; 4/19/24 at 11:30 a.m. the blood sugar was 396. Further review revealed that there was no documentation that the blood sugars were rechecked after 2 hours per the physician's order. Review on 4/18/24 of Resident #27's progress notes for the above dates revealed; 1. No documentation that the provider was notified of the blood sugar above 400; 2. No documentation that a follow up blood sugar was done after 2 hours of blood sugar above 351; 3. No documentation that on 4/17/24 at 11:30 a.m. the physician was aware the blood sugar was not checked. Interview on 4/19/24 at 1:03 p.m. with Staff B (Unit Manager) confirmed the above findings. Review on 4/19/24 of Resident #27's Care Plan revealed .Focus .diagnosis of diabetes: Insulin Dependent . Interventions .Access and record blood glucose levels as ordered .Administer hypoglycemic medications as ordered .

Based on observation, interview, and record review, it was determined that the facility failed to ensure the medication error rate was not greater than 5% (percent) for 2 of 36 medication opportunities observed (Resident Identifier #11). Findings include: Review on 4/19/24 of Resident #11's Medication Administration Record (MAR) included a physician's order for: Losartan potassium 25 milligrams (mg) 2 tabs [tablets] once daily and Sertraline 100 mg 2 tabs once daily. Observation on 4/19/24 at 7:40 a.m. of Staff C (Licensed Practical Nurse (LPN)) during medication administration revealed that Staff C had prepared Resident #11's medication and was going to administer one tab of Losartan 25 mg and one tab of Sertraline 100 mg. Interview on 4/19/24 at 7:45 a.m. with Staff C (LPN) confirmed the above findings. Review on 4/19/24 of the facility's policy 6.0 General Dose Preparation and Medication Administration revised 1/1/22 revealed: .Facility staff should: .4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, . as set forth in facility's medication administration schedule . There were 2 medication errors out of 36 medication administration opportunities resulting in a 5.56% error rate.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were secured in 2 of 3 medication carts observed and that medications were labeled in accordance with professional principles in 1 of 3 medication carts observed. Findings include: Observation on 4/19/24 at 7:40 a.m. of Staff C (Licensed Practical Nurse (LPN)), during medication administration revealed Staff C left the medication cart unlocked and no staff were within the line of sight of the medication cart. Further observation at 7:50 a.m. revealed that a second medication cart down the hall from the first medication cart was unlocked and no staff were within the line of sight of the medication cart. Interview on 4/19/24 at 8:00 a.m. with Staff C confirmed that he/she was the nurse for both hallways on the unit and was administering medications to residents from both carts. Staff C confirmed the medication carts were unlocked and unattended. Review on 4/19/24 of the facility's policy titled 6.0 General Dose Preparation and Medication Administration revised 1/1/22, revealed: .Procedure .3.10 Facility staff should not leave medications or chemicals unattended .7. Facility should ensure that medication carts are always locked when out of sight or unattended . Interview on 4/19/24 at 10:10 a.m. with Staff E (Director of Nursing) confirmed medication carts should be locked when unattended. 43002 Observation on 4/17/24 at 9:46 a.m. of the third floor North Medication Cart revealed an opened bottle of Latanoprost Ophthalmic Solution for Resident #56. There were instructions written on the outside container that read do not use after 42 days. There was no open or open expiration date written on the container. The pharmacy label indicated this medication had been filled on 12/30/23. Interview on 4/17/24 at 9:46 a.m. with Staff D (LPN) confirmed the above finding. Review on 4/17/24 of Resident #56's April 2024 Medication Administration Record revealed Latanoprost Ophthalmic solution 0.005% [percent] instill 1 drop in both eyes at bedtime for glaucoma. Further review revealed the medication had been signed off as administered daily through 4/18/24. Review on 4/19/24 of the facility's policy Storage and Expiration Dating of Medications, Biologicals revised on 8/7/23, revealed .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shorted expiration date once opened .5.4 When an ophthalmic solution or suspension has a manufacturer's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that hand hygiene procedures were followed in direct resident contact for 1 resident in a census of 84 residents (Resident identifier is #60) and the facility failed to follow Centers for Disease Control and Prevention's (CDC) guidance on Enhanced Barrier Precaution (EBP) for 6 residents in a census of 84 residents observed for infection control (Resident identifiers are #8, #26, #51, #59, #60, and #72). Findings include: Review on 11/14/23 of the CDC's website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug[1]resistant Organisms (MDROs), dated 7/12/22, retrieved from:https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html#:~:text=Contact%20Precautions%20are%20intended%20to,entry%20into%20a%20resident's%20room., revealed that .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization . Observation on 11/14/23 at approximately 9:45 a.m. at the facility elevator revealed a posting from the CDC about EBPs and how to keep our residents safe. Interview on 11/14/23 at approximately 9:50 a.m. with Staff I (Licensed Practical Nurse (LPN)) revealed that Resident #8, #26, and #51 had urinary catheters and #59 had facility-acquired pressure injuries. Staff I stated that he/she utilized EBP on residents with open wounds and indwelling catheters and he/she would wear a gown and gloves for PPE. Staff I also stated that there were no signs indicating which residents required EBP. Resident #8 Observation on 11/14/23 at approximately 10:22 a.m. in Resident #8's room revealed that Resident #8 had a urinary drainage bag hanging on the side of the bed. Further observation revealed that there was no supply of gowns inside or outside of Resident #8's room and/or bathroom. Interview on 11/14/23 at 10:22 a.m. with Resident #8 confirmed that he/she has an indwelling catheter. Resident #8 stated he/she was unaware of EBP, such as utilizing a gown, during indwelling catheter care. Review on 11/15/23 of Resident #8's medical records revealed that Resident #8 has a care plan for an indwelling catheter with no interventions for EMPs. Resident #26 Observation on 11/14/23 at 10:30 a.m. in Resident #26's room revealed that Resident #26 had a urinary drainage bag hanging in his/her walker. Further observation revealed that there was no supply of gowns inside or outside of Resident #26's room and/or bathroom. Interview on 11/14/23 at approximately 10:30 a.m. with Resident #26 confirmed that he/she has a suprapubic catheter. Resident #26 stated he/she was unaware of EBP, such as utilizing a gown, during indwelling catheter care. Observation on 11/14/23 at approximately 10:34 a.m. revealed that Staff A (Licensed Nursing Assistant (LNA)) went into Resident #26's room with no gown or gloves. Resident #26 had his/her urinary drainage bag hanging on his/her walker then he/she went into the bathroom with Staff A. Further observation revealed that Staff A went into the bathroom with no gown and gloves. Further observation also revealed that Resident #26 came out of the bathroom with no urinary drainage bag hanging on his/her walker. Interview on 11/14/23 at 10:50 a.m. with Staff A confirmed that he/she was changing Resident #26's urinary drainage bag to a leg bag with gloves and no gown. Staff A stated that he/she would only use gloves for PPE while providing catheter care, leg bag change, and emptying a urinary drainage bag. Staff A was unaware of EBPs for residents with indwelling catheters. Review on 11/15/23 of Resident #26's medical records revealed that Resident #26 has a care plan for a suprapubic catheter with no interventions for EMPs. Resident #51 Observation on 11/14/23 at 1:15 p.m. in Resident #51's room revealed that Resident #51 had a urinary drainage bag hanging from his/her electric wheelchair. Further observation revealed that there was no supply of gowns inside or outside of Resident #51's room and/or bathroom. Interview on 11/14/23 at approximately 11:15 p.m. with Resident #51 confirmed that he/she has a suprapubic catheter. Resident #26 stated he/she was unaware of EBP, such as utilizing a gown, during indwelling catheter care. Review on 11/15/23 of Resident #51's medical records revealed that Resident #51 has a care plan for a suprapubic catheter with no interventions for EMPs. Resident #59 Observation on 11/14/23 at approximately 10:30 a.m. in Resident #59's room revealed no supply of gowns inside or outside of Resident #59's room. Review on 11/15/23 of Resident #59's medical records revealed that Resident #59 has an open unstageable pressure injury at the Middle-Thoracic spine which was new on 11/8/23. Further review of Resident #59's medical record revealed no documentation of Resident #59 on EBP. Interview on 11/16/23 at 9:43 a.m. with Staff J (LNA) revealed that he/she was not aware of EBP for residents with indwelling catheters and open wounds until 11/16/23. Interview on 11/16/23 at 11:00 a.m. with Staff H (Director of Nursing) confirmed above findings on Resident #59's unstageable pressure injury. 28881 Resident #72 Observation on 11/14/23 of Resident #72 revealed he/she had a suprapubic catheter. Review on 11/14/23 of Resident #72 medical record revealed no EBP in place since admission on 5/20/23. Observation on 11/15/23 at approximately 8:00 a.m. of Resident #72's door revealed a newly placed EBP sign that instructed staff to hand sanitize prior to entry into the room, Staff G (LPN) was observed entering the room without sanitizing hands. Interview on 11/15/23 at 2:20 p.m. with Staff C (Nurse Manager) revealed that Resident #72 should have been on EBPs since admission, as he/she was admitted with a catheter. 45419 Resident #60 Observation on 11/16/23 at 09:30 a.m. of Resident #60's room, has a sign posted at the doorway for EBPs due to having an open wound. Further observation revealed Staff A was providing care to Resident #60 and was not wearing a gown for PPE. Interview on 11/16/23 at 11:45 a.m. with Staff A revealed that he/she was not aware of the need for EBP with Resident #60.

Based on interview and record review, it was determined that the facility failed to make a Level II Pre-Admission Screening and Resident Review (PASRR) referral for a resident with a newly evident mental disorder for 1 of 3 residents reviewed for PASRR in a final sample of 28 residents (Resident identifier is #8). Findings include: Review on 11/16/23 of Resident #8's medical record revealed an admitted [DATE] without a recorded diagnosis of a severe mental illness. Review on 11/16/23 of Resident #8's Level I PASRR form completed on 6/20/18 revealed: Section 2: Screening for Mental Illness (MI), No was checked. Section 6: Dementia Exclusion, Dementia - only for MI was not checked. Section 8: Level Screening Summary, Not requiring PASRR involvement was checked. Review on 11/16/23 of Resident #8's record revealed a diagnosis of Bipolar Disorder. Further review revealed that from 9/9/20 when Resident #8 was diagnosed with Bipolar Disorder to 11/16/23, the facility failed to make a PASRR referral to the appropriate state agency. Interview on 11/16/23 at 1:50 p.m. with Staff F (Regional Nurse) confirmed the above finding. Review on 11/16/23 of facility policy titled SS108 Pre-Admission Screening for Mental Health Disorders and or Intellectual Disability Patients, last revised 1/15/21 revealed: 2. Social Services will review PASRR to determine appropriate care needs. 2.1 Refer to the appropriate state designated authority when a patient is identified as having an evident or possible MD, ID, or related condition.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that food was prepared in accordance with professional standards for food service safety for 1 of 1 kitchens observed and the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 walk-in refrigerators observed. Findings include: Observation on 11/14/23 at 9:16 a.m. in the main kitchen with Staff E (Food Service Manager) revealed that the range hood over the stove had accumulated gray dust and grease debris on the grates located on the surface of the hood. Interview on 11/14/23 at 8:40 a.m. with Staff E confirmed the above finding. Review on 11/16/23 of the Food and Drug Administration (FDA) Food Code, retrieved from https://www.fda.gov/media/110822/download, revealed 4-601.11. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Observation on 11/14/23 at approximately 9:30 a.m. of the walk-in refrigerator with Staff E revealed a box of celery containing numerous wilted discolored stalks of celery, without a use by/expiration date. Interview on 11/14/23 at approximately 9:30 a.m. with Staff E confirmed the above findings.

Based on observation, record review, and interview, it was determined, that the facility failed to follow established smoking policies for 1 of 1 resident reviewed for smoking in a final sample of 28 residents (Resident identifier is #44). Findings include: Review on 11/16/23 of Resident #44's medical record revealed that the resident was a smoker. Further review revealed that the resident utilized oxygen on an as needed basis. Review on 11/16/23 of Resident #44's Safe Smoking Evaluation dated 11/15/23 revealed that independent smoking was allowed. Review on 11/16/23 of Resident #44's care plan revealed an intervention stating .Maintain (first name omitted) smoking materials at Main Reception Desk. Interview on 11/16/23 at approximately 9:30 am with Staff C (Unit Manager) revealed that Resident #44's smoking material is kept at the Main Reception Desk. Staff C further stated that Resident #44 can smoke independently. Staff C also stated that Resident #44 would retrieve smoking materials at the Main Reception Desk and when finished smoking would return smoking materials to the receptionist. Interview and observation on 11/16/23 at approximately 9:45 a.m. with Resident #44 revealed that the resident keeps his/her smoking materials in his/her jacket pocket. Observation revealed that Resident #44's jacket was hanging from a wheeled walker at the end of Resident #44's bed. Observation also revealed Resident #44's jacket pocket had a pack of cigarettes and a lighter. Resident#44 further stated that he/she used to leave his/her smoking materials with the receptionist but the company made staff cuts and there was rarely a receptionist there. Resident #44 also stated that he/she was supposed to leave the smoking materials with nursing staff but they told Resident #44 to just keep them. Interview on 11/16/2023 at approximately 9:55 a.m. with Staff C confirmed the above findings. Review on 11/16/23 of Policy titled OPS 137 Smoking revealed . 2.6 Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .

Based on observation, interview, and record review it was determined that the facility failed to employ sufficient dietary staff to safely and effectively carry out the functions of the food and nutrition service for 2 out of 2 units observed for dining and the main kitchen observed for meal tray line service (Resident Identifiers are #4, #7, #13, #16, #17, #18, and #19). Findings include: Review on 6/12/23 of the facility's meal deliver times revealed the following: Breakfast - 2North 7:15 a.m., 2South 7:30 a.m., 3North 7:45 a.m., and 3South 8:00 a.m. Lunch - 2North 11:30 a.m., 2South 11:45 a.m., 3North 12:00 p.m., and 3South 12:30 a.m. Supper - 2North 5:15 p.m., 2 South 5:30 p.m., 3North 5:45 p.m., and 3South 6:00 p.m. Scheduled Times may vary plus/minus 10 minutes. Second Floor Unit Interview on 6/12/23 at 9:00 a.m. with Resident #7 revealed that meals were served late. Resident #7 stated that this past week breakfast was served past 8:00 a.m., lunch was served past 1:00 p.m., this past weekend lunch was served at 2:00 p.m., and supper was served past 6:00 p.m. at one time it was 8:00 p.m. Resident #7 also stated that the nursing staff would tell them that the meal cart has not come up on the second floor unit. Interview on 6/12/23 at 9:10 a.m. with Resident #4 revealed meals were served late. Resident #4 stated that this past week breakfast was served past 8:00 a.m, lunch was served past 1:30 p.m., and supper was served past 6:00 p.m. Resident #4 also stated that last night (6/11/23) supper was served at approximately 6:30 p.m. Interview on 6/12/23 at 9:45 a.m. with Resident #16 and Resident #17 revealed that breakfast meals were served between 8:00 a.m and 8:20 a.m., lunch meals were served past 1:00 p.m., and supper meals were served between 6:00 p.m. and 8:00 p.m. Resident #16 stated that meal carts were delivered late. Interview on 6/12/23 at 9:20 a.m. with Staff E (Registered Nurse (RN)) and Staff G (Licensed Nursing Assistant (LNA)) revealed that meals carts were delivered late to the second floor unit. Staff E stated that breakfast meal carts were brought up to the unit after 8:00 a.m., lunch meal carts were brought up to the unit after 1:00 p.m., and supper meal carts were brought up to the unit after 6:00 p.m. Staff G stated that last night (6/11/23) dinner was brought up at approximately 7:00 p.m. with no drinks to be served and Staff G had to ask dietary staff for it. Staff E and Staff G also stated that they were told by the dietary manager that meal carts were served late as the nursing staff could not get the resident meal trays back to the kitchen on time for the next service. Staff E and Staff G also stated that approximately last week Resident #18 and Resident #19 received meals with regular texture and not ground or chopped and both residents' diet was for ground texture. Review on 6/12/13 of Resident #18's diet slip revealed Regular/Liberalized-Special Consistency ground meats with exception of cut up fish and ground beef like (meatloaf, Salisbury steak, meatball). Review on 6/12/23 of Resident #19's diet slip revealed Regular/Liberalized-Dysphagia Advanced. Review on 6/12/23 of facility's diet descriptions, updated date 10/27/19, revealed Consistency Levels: Dysphagia Advanced (Level 3) . Intended for individuals with mild chewing or swallowing difficulty . Meat is ground and moistened. Ground meat is the size of a grain of rice .Chopped meats, vegetables and fruit are the size of pea . Interview on 6/12/23 at 9:35 a.m. with Staff J (RN) and Staff H (RN) revealed that breakfast meals were served after 8:00 a.m., lunch meals were served between 1:00 p.m. and 2:00 p.m., and supper meals were served between 6:30 p.m. and 8:00 p.m. as meal carts were delivered late to the second floor unit. Staff J stated that there was a weekend that he/she was notified, between 9:30 a.m. to 10:00 a.m., that meal carts were not delivered to the second floor unit. Interview on 6/12/23 at 9:40 a.m. with Staff I (LNA) revealed that meal carts were delivered late to the second floor unit. Observation on 6/12/23 of the lunch meal service to the second floor revealed that the first lunch cart was delivered to the floor at 12:10 p.m. and the second cart was delivered at 12:20 p.m. Observation on 6/12/23 at approximately 12:25 p.m. at the second floor unit revealed that parallel to the elevator were 2 carts of empty breakfast trays. Observation also revealed that one of the meal carts had 4 empty breakfast trays that were taken out from the resident's rooms. Interview on 6/12/23 at approximately 12:25 p.m. with Staff I confirmed above observations on the empty breakfast trays on the second floor unit. Third Floor Unit Observation on 6/12/23 at 12:30 p.m. at the third floor unit revealed that no meal carts were delivered in the unit. 37488 Interview on 6/12/23 at approximately 8:30 a.m. with Resident #13 revealed that on 6/11/23 lunch was not served until 2:00 p.m. Interview on 6/12/23 at approximately 9:30 a.m. with Staff J who stated that meal tray delivery times were sporadic and that staff never know when the trays will be delivered to the units. Observation on 6/12/23 of meal service to the third floor unit revealed that the residents in the dining room were served at 1:05 p.m. 45419 Observation on 6/12/23 at 11:20 a.m. of the lunch service line in the main kitchen revealed that the tray service started at 11:30 a.m. for the second floor north wing meal cart and was completed at 12:00 noon.

Based on observation, interview, and record review it was determined that the facility failed to store food and drinks in a manner that would prevent cross contaminations by having uncovered, undated, and expired food and drinks observed in the main kitchen. Finding include: Observation on [DATE] at 8:20 a.m. of the main kitchen with Staff B (Food Service Director) revealed that in the dry storage room there was a package of 24 English muffins that had green fuzzy-like matter on them and with a use by date of [DATE]. Observation on [DATE] at 8:30 of the facility's main kitchen refrigerator with Staff B revealed 3 opened half gallons of 2 percent milk with use by dates of [DATE], [DATE], and [DATE]. Further observation revealed 1 large box of cucumbers that were wet, soft, and had white fuzzy-like matter as well as black soft circular spots on the cucumbers. Observation also revealed 2 open uncovered/unwrapped packages of cheese that had hard edges, 1 container with watery-yellow substance on top of the mashed potatoes that was dated [DATE], 2 uncovered/unwrapped plates containing sliced tomatoes and lettuce with no prep date or use by date, 3 open bags of uncovered/unwrapped boiled sliced ham with no prep date or use by date, 1 large bowl of mixed salad dated [DATE] that was sitting in water and the lettuce was soft and brown, and 1 small container of scrambled eggs dated [DATE] with water at the bottom of the container. Observation on [DATE] at 9:00 a.m. of the main kitchen's walk-in freezer with Staff B revealed 1 opened uncovered/unwrapped bag of collard greens with no prep date or use by date, 1 opened unsealed bag of 4 pounds kielbasa with no open date, 1 opened unsealed bag with three vegetable burgers with no open date, and an opened unsealed bag of 4 pounds pepperoni with no open date. Observation on [DATE] at 9:10 a.m. with Staff B reveled that on the top of the milk cooler was a case of 23 bananas that were soft and dark, black-like. Interview on [DATE] at 9:10 a.m. with Staff B confirmed above findings. Staff B stated that above mentioned items should have been thrown out and items that were open should have been covered or wrapped, and dated with an open date. Observation on [DATE] at approximately 11:20 a.m. during the lunch service line revealed that food removed from the ovens and steamers were placed into steam table at 11:20 a.m. Further observation revealed that dietary staff did not obtain food temperatures of the sweet mash potatoes, broccoli, parslied potatoes, and glazed ham slices prior to meal service. Review on [DATE] at 11:45 a.m. of the meal food temperature logs revealed missing data for [DATE] on all meal service and [DATE] breakfast and lunch meal service. Interview on [DATE] at 12:00 noon with Staff B confirmed the above findings. Staff B stated that dietary staff should take the food temperature prior to serving food.

Based on interview and record review it was determined that the facility failed to ensure that alleged violations involving abuse, and/or neglect, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, to the State Survey Agency (SSA) for 1 incident reviewed for alleged abuse (Resident Identifier is #1). Findings include: Review on 6/12/23 of the initial report sent to the SSA on 6/7/23 revealed Resident #1 had an allergic reaction that required epinephrine. Further review of the report revealed that staff were aware of the incident on 6/4/23 at 6:00 p.m., 3 days before the report was sent. Review on 6/12/23 of Resident #1's nursing notes revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 ate a strawberry that was on his/her dinner tray from the kitchen and experienced throat tightness, shortness of breath, and difficulty breathing. Epinephrine was administered as resident was noted grabbing his/her throat. Interview on 6/12/23 at approximately 1:30 p.m. with Staff A (Director of Nursing) revealed that Staff D (Registered Nurse) confirmed that the incident was reported to the SSA on 6/7/23.

Based on observation, interview, and record review it was determined that the facility failed to follow physician's order for daily weight for 1 of 2 residents reviewed for nutrition (Resident #8), and wound dressing changes for 1 of 4 residents reviewed for skin (Resident #6). Findings include: The [NAME]-[NAME], 2009, Fundamentals of Nursing 7th Edition, St. [NAME], Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #6 Review on 6/12/23 of Resident #6's Electronic Medical Record (EMR) revealed that Resident #6 was initially admitted to the facility on [DATE] and Resident #6 had an open lesion to their right lateral malleolus that was present on admission. Review on 6/12/23 of Resident #6's May 2023 Electronic Medication Administration Record (EMAR) revealed that Resident #6 had an order for wound dressing changes every Monday and Thursday to cleanse wound with wound cleanser, pat dry, place liquid lidocaine on gauze and place onto wounds for adequate pain relief for 3-5 minutes, remove lidocaine gauze, place purocol to right lateral malleolus wound, moistened lightly with normal saline, cover with optifoam border, and case padding from toes to tibial tuberosity, followed by coban 50 percent stretch from base of toes to tibial tuberosity with a start date of 5/7/23 and discontinued date of 5/31/23. Further review of Resident #6's May 2023 EMAR revealed that the wound dressing change were scheduled for 5/25/23 and 5/29/23 with no documentation that the wound dressings were changed. Review on 6/12/23 of Resident #6's wound evaluation note, dated 5/31/23, revealed that open lesion to right lateral malleolus was deteriorating, faint odor, moderate purulent drainage, fragile and macerated surrounding tissues. Further review of Resident #6's 5/31/23 wound evaluation note revealed that nurse practitioner assessed right lower extremity wound, dressing saturated with purulent drainage, and discontinue cast padding/coban wrap. Review on 6/12/23 of Resident #6's wound evaluation note, dated 6/6/23, revealed a new open area to the right medial malleolus observed on 6/5/23. Wound was swollen, boggy, draining light serous fluid, wound area extending into medial shin graft with a few small scattered open areas, increase pain, increase warmth, and increase baseline discoloration in lower right extremity. Nurse practitioner assessed and swabbed wound for culture and new wound orders placed. Interview on 6/15/23 at approximately 12:00 p.m. with Staff L (Advanced Practice Registered Nurse) confirmed above findings on Resident #6. Staff L stated that the last week of May 2023, Staff L and the wound nurse assessed Resident #6's wound to the right lateral malleolus and observed an old dressing, approximately 3-5 days old, and the wound had deteriorated. Staff L also stated that last week (6/6/23), he/she assessed Resident #6's wound to the right lateral malleolus and a new open area was noted to the right medial malleolus which he/she obtained a culture, prescribed new dressing orders and antibiotics. Resident #8 Review on 6/12/23 of Resident #8's May 2023 Electronic Medication Administration Record (EMAR) revealed a physician's order to weigh daily in the morning and notify physician of weight gain of 4 pounds or greater with a start date of 5/26/23. Further review of Resident #8's May 2023 EMAR revealed no documented weight on 5/26/23 and NA [not applicable] documented on 5/27/23 to 5/30/23. First recorded weight was on 5/31/23 which as 485.3 pounds. Review on 6/12/23 of Resident #8's progress notes revealed no documentation of weights or documentation of Resident #8's refusal to be weighed from 5/26/23 to 5/30/23. Review on 6/12/23 of Resident #8's nurse practitioner note dated 5/30/23 revealed that Resident #8 reported to nurse practitioner that he/she has not had daily weights. Interview on 6/12/23 at approximately 12:30 p.m. with Staff D (Registered Nurse) revealed that NA EMAR documentation meant that weight was not obtained. Interview on 6/12/23 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview on 6/15/23 at approximately 12:00 p.m. with Staff L revealed that he/she did not remember getting notification from nurse staff that weights were not done between 5/27/23 to 5/30/23. Staff L stated that Resident #8 reported to him/her that daily weights were not done

Based on interview and record review it was determined that the facility failed to provide residents with food that accommodated resident allergies for 2 of 2 residents reviewed for dining (Resident Identifiers are #1 and #2). 37488 Findings include: Resident #1 Interview on 6/12/23 at approximately 8:15 a.m. with Resident #1 revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 was eating ambrosia and believed that there were raspberries in it. Resident #1 stated that he/she then experienced difficulty breathing and required an injection of epinephrine. Review on 6/12/23 of Resident #1's kitchen diet slip revealed an allergy to strawberry. Review on 6/12/23 of Resident #1's Clinical Care Profile revealed that Resident #1 has an allergy to strawberries with anaphylaxis as a reaction. Review on 6/12/23 of Resident #1's care plan revealed a nutrition care plan for a therapeutic diet for diabetes management with an intervention of Allergy to strawberries and garlic causes anaphylaxis created on 5/26/23. Review on 6/12/23 of Resident #1's medical diagnosis list revealed that Resident #1 has a diagnosis of legal blindness. Review on 6/12/23 of Resident #1's nursing notes revealed that on 6/4/23 at approximately 6:00 p.m. Resident #1 ate a strawberry that was on his/her dinner tray from the kitchen and experienced throat tightness, shortness of breath, and difficulty breathing. Epinephrine was administered as resident was noted grabbing his/her throat. 45419 Interview on 6/12/23 at approximately 11:20 a.m. with Staff N (Cook) revealed that they use the kitchen diet slip to serve meals and determine residents' diet orders and allergies. Observation on 6/12/23 at approximately between 11:25 a.m. and 11:45 a.m. during a meal tray line service revealed that Staff N read the diet slip to the cook to prepare the meal tray for the resident. Staff N read the kitchen diet slip with the resident's diet order, meal choice, and allergies. Interview on 6/12/23 at approximately 12:30 p.m. with Staff M (Cook) revealed that they use the kitchen diet slip for the meal tray line service to determine residents' diet orders, preferences, meal choices, diet texture, and allergies. Resident #2 Interview on 6/12/23 at approximately 9:40 a.m. with Staff K (Registered Nurse (RN)) revealed that last week Resident #2 received a breakfast tray from the kitchen that had eggs with peppers. Staff K stated that Resident #2 has peppers listed as an allergy in their medical record. Interview on 6/12/23 at 12:30 p.m. with Resident #2 revealed that he/she has an allergy to red and green peppers. Resident #2 stated that last week he/she had gotten red and green peppers in his/her meal from the kitchen. Resident #2 stated that he/she has also received red and green peppers in his/her eggs at breakfast and they needed to take Benadryl. Resident #2 stated they also have received red and green peppers at a lunch meal mixed with chicken and another occasion where they were mixed in vegetables. Review on 6/12/23 of Resident #2's Clinical Care Profile revealed that Resident #2 has an allergy to peppers. Review on 6/12/23 of Resident #2's kitchen diet slip revealed allergies to green/red peppers. Review on 6/12/23 of Resident #2's Medication Administration Record revealed that on 6/7/23 Resident #2 received 25 milligrams of Benadryl. Review on 6/12/23 of Resident #2's nurses note, dated 6/7/23, revealed that Resident #2 received food containing red and green peppers during lunch. Resident #2 was given Benadryl at 1:34 p.m. as Resident #2 reported that he/she was not feeling well. Interview on 6/12/23 at 12:30 with Staff E (RN) confirmed the above findings.

Based on observation, interview, and record review it was determined that the facility failed to ensure that there was a communication process between the facility and the hospice provider to ensure that the needs of the residents were addressed and met 24 hours per day for 1 of 1 residents reviewed for hospice (Resident Identifier #3). Review on 6/12/23 of Resident #3's physician's orders revealed an order for a regular diet with dysphagia advanced texture, thick liquids-nectar consistency. Review on 6/12/23 of facility's diet descriptions, updated date of 10/27/19, revealed Consistency Levels: Dysphagia Advanced (Level 3) .Intended for individuals with mild chewing or swallowing difficulty .Meat is ground and moistened. Ground meat is the size of a grain of rice .Chopped meats, vegetables and fruit are the size of pea . Observation on 6/12/23 at approximately 12:10 p.m. of the second floor dining room revealed Resident #3 was served a lunch tray with chopped broccoli and ground meat. Review on 6/12/23 at approximately 12:10 p.m. of Resident #3's meal ticket revealed a diet order for dysphagia advanced texture, thick liquids-nectar consistency. Interview on 6/12/23 at approximately 12:15 p.m. with Staff C (Hospice Nurse) who assists Resident #3 with meals revealed that the meal tray that was delivered had the wrong diet order and that the hospice agency received a phone call from the facility on 6/11/23 at approximately 5:12 p.m. with a request to change Resident #3's diet order to a puree texture. Further interview with Staff C revealed that on 6/11/23 at 5:43 p.m. the hospice agency faxed a new order to change Resident #3's diet to puree texture. Interview on 6/12/23 at approximately 12:15 p.m. with Staff D (Registered Nurse (RN)) revealed that Staff C asked Staff D about the new order Staff D checked the fax machine and confirmed that the order was there and had been received on 6/11/23 at 5:43 p.m. and that facility nurse staff did not enter the new order into the computer. Interview on 6/12/23 at approximately 4:00 p.m. with Staff F (Licensed Practical Nurse) confirmed that he/she noted that Resident #3 had trouble with solid food and was on a dysphagia diet. Staff F confirmed that he/she contacted the hospice agency to request an order to downgrade Resident #3's diet to puree texture. Interview on 6/12/23 at approximately 4:00 p.m. with Staff A (Director of Nursing) confirmed that the new diet order from the hospice agency had been received on 6/11/23 at 5:43 p.m. and that it had not been entered into the computer. Staff A further confirmed that Resident #3 received the wrong diet consistency on 6/12/23.

Based on record review and interview, the facility failed to provide appropriate supervision and assistance to prevent accidents resulting in a fracture for 1 Resident in a survey sample of 5 Residents. (Resident identifier is #1.) Findings include: All record review and interview took place on 10/4/12. Review of Resident #1's medical record on 10/4/12 revealed a "Lift-Transfer-Repositioning Evaluation" dated 3/17/12 that states a "Sit to Stand" lift is required for transfers with the assistance of one staff member. Review of Resident #1's Plan of Care for focus area of assistance for Activities of Daily Living (ADL) care revealed the intervention: "(Resident #1) transfers with 2 person assist, with a total lift when fatigue, sit to stand lift if not fatigued. Instructions how to use stand lift on wall in room." Further review of Resident #1's medical record revealed a "Change in Condition" note dated 8/25/12 stating that Resident #1 had a witnessed fall on 8/25/12 at 6:45 a.m. Review of the facility generated incident and investigation report dated 8/25/12 revealed that Resident #1 was being transferred by Staff A (LNA) using the stand-pivot method and not the Sit to Stand lift as indicated in the plan of care. Resident #1 was lowered to the floor and reported left knee pain. Further review of Resident #1's medical record revealed a nursing noted dated 8/25/12 that stated Resident #1 complained of left hip pain, was unable to bend the left leg due to pain and the left leg was shorter than the right leg. Resident #1 was transferred to the hospital for evaluation and admitted for a left hip fracture. Interview with Staff B (DON) confirmed that the appropriate plan of care was in place, but that Staff A did not utilize the proper transfer method resulting in an injury to Resident #1.