Every finding on record at Panora Specialty Care

Based on clinical record review, staff interview, policy review, and Resident Assessment Instrument (RAI) Manual, the facility failed to ensure proper Minimum Data Set (MDS) coding for three of fifteen residents reviewed for MDS assessments by not coding resident's diagnoses when indicated, and improperly coded medication and tobacco use (Resident #1, #3, and #4). The facility reported a census of 38 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of chronic obstructive pulmonary disease (COPD). The MDS failed to indicate the resident had a multi-drug resistant organism (MDRO). The Care Plan initiated 12/18/24 revealed the resident had a risk for potential infection related to a MDRO. The Care Plan directed staff to assess for signs and symptoms of infection, administer antibiotics per the physician orders, and use enhanced barrier precautions (EBP) when performing high-contact care activities. The Treatment Administration Record dated 12/1/25 to 12/31/25 revealed to use enhanced barrier precautions due to a MDRO like resistant organism ESBL (extended spectrum beta-lactamase) (an infection caused by bacteria producing enzymes that destroy many antibiotics making the infection harder to treat). In an interview on 12/31/25 at 12:25 PM, the MDS Coordinator reported she completed the residents MDS assessments at least quarterly. She reported she got information to complete MDS assessments and care plans from the medical records and an interview with the resident. She reviewed the resident's diagnoses, and then she marked the applicable diagnoses under section I. She had a goal to try to be as accurate as possible when she filled out the MDS. The Director of Nursing reviewed the assessment and signed off on everything indicating the MDS completion and accuracy. The MDS Coordinator confirmed if a resident had an MDRO, the MDS assessment needed coded to indicate a MDRO. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual updated 10/2025 revealed the disease conditions in section I require a physician-documented diagnosis in the past 60 days. Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 2. The MDS completed on 12/11/25 listed Resident #3's facility admission date of 12/3/25. Resident #3 was coded for the use of an anticoagulant, which slows down the body's ability to clot blood. Review of Physicians Orders noted an order for aspirin extended delayed release 81mg one time daily. This was initiated on 12/4/25. Aspirin is classified as an antiplatelet, a medication that stops platelets from sticking together to form blood clots. No anticoagulant medications, like Coumadin, were identified in Physician Orders either in current or discontinued medications since resident admission. In an interview on 12/31/25 at 12:25 PM, the MDS Coordinator explained they were directed to code aspirin as an anticoagulant by staff associated with a facility mock survey. The MDS Coordinator was unable to recall a timeframe when they were informed of this coding procedure. The Long-Term Care Facility RAI User's Manual updated 10/2025 (page N-9) noted antiplatelet medications, like aspirin/extended release, should not be coded as an anticoagulant. 3. The admission MDS completed on 6/9/25 listed Resident #10's facility admission date as 6/2/25 from another nursing home. Under Section J Health Conditions, item number J1300 Current Tobacco Use was checked as no. On 6/2/25 a diagnosis of cigarette nicotine dependence was documented. A copy of the previous nursing home's Care Plan for Resident #10 indicated they were actively smoking up until the resident was discharged . Interventions included the ability to smoke unsupervised. The Progress Note dated 6/2/25 at 9:59 PM documented Resident #10 taking themselves in/out of the building to smoke. In an interview on 12/31/25 at 12:25 PM, the MDS Coordinator explained Resident #10's smoking status was not well known upon admission and thus coded as no on the MDS for tobacco use. The Long-Term Care Facility RAI User's Manual updated 10/2025 (page J-27) noted tobacco information can be obtained from the resident themselves or with information from the medical record. If there are indications of tobacco use, in any form, question J1300 should be marked yes for tobacco use.

Based on observations, electronic health record (EHR) review, staff interview, and policy review, the facility failed to complete an admission smoking evaluation for 1 of 2 residents reviewed for smoking (Resident #1). The facility reported a census of 38. Findings include: The EHR census tab for Resident #1 showed the current admission date of 12/5/25. Resident #1 had previously been admitted from 2/5/25 to 3/11/25.The Minimum Data Set (MDS) assessment completed on 12/8/25 revealed Resident #1 with a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Diagnoses included a recent pneumonia diagnosis, dyspnea (shortness of breath), anxiety, bipolar disorder, and depression. Resident #1 noted to use a manual wheelchair independently but requiring staff assistance for transfers. The MDS indicated the use of tobacco products.The Care Plan, last updated 12/26/25, documented Resident #1 smokes. Interventions included completing a Smoking Evaluation on admission and as needed. During an observation on 12/31/25 at 8:00 AM, Resident #1 seen smoking a cigarette outside the facility unsupervised. A smoking evaluation for this current admission was not identified in the EHR.During an interview on 12/31/25 at 9:00 AM, the Director of Nursing (DON) indicated smoking evaluations are completed upon admission and quarterly. The DON or the MDS Coordinator both collaborate to complete the evaluations. The policy Smoking-Residents (version 2.0 H5MAPL0828) documented the following: 1. Residents will be evaluated upon admission to determine if they are a smoker or non-smoker; 2. If a smoker, staff will evaluate the ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation); 3. A resident's ability to smoke safely will be reevaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff.

Based on observations, electronic record review, staff interviews, and policy review, the facility failed to follow infection control practices to prevent cross contamination by not completing hand hygiene and glove change during resident cares (Resident #15). The facility reported a census of 38. Findings include: The Minimum Data Set (MDS) Assessment completed on 11/13/25 revealed Resident #15 with Brief Interview for Metal Status score of 15, indicating intact cognition. Diagnoses include multidrug-resistant organism, neurogenic bladder (nerve damage causing poor bladder control), and paraplegia. The MDS indicated the presence of a urinary catheter. The Care Plan, last updated 11/26/25, included a focus area related to the risk of infection due to the presence of a drug-resistant microorganism. Interventions included the use of enhanced barrier precautions (EBP) when performing high-contact care activities. EBP included the use of gowns and gloves. During an observation on 12/29/25 at 4:00 PM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, completed catheter and personal cares on Resident #15. Both staff members put on gowns and gloves and completed hand hygiene. Staff A proceeded to empty the resident's catheter drainage bag and disposed of the collected urine. After this was completed, Staff A transitioned to cleaning around the resident's suprapubic catheter (tube inserted through a small opening in the low abdomen directly into the bladder) site. No hand hygiene or glove change observed prior to initiating catheter cares. After catheter site cares completed, Staff A transitioned to providing perineal cares, which included cleaning of the genital and anal areas. No hand hygiene or glove change observed prior to initiating the perineal cares. Once completed Staff B assisted Staff A in repositioning Resident #15 in bed, placed pillows on the bed, and rearranged blankets. No hand hygiene or glove change observed when perineal cares was completed. During an interview on 12/31/25 at 9:00 AM, the Director of Nursing (DON) noted hand hygiene and glove change should be completed at the end of a specific task or care. If staff completing multiple cares during a single visit, gloves should be changed after each different task or cares. Staff should not wear the same pair of gloves when completing multiple or different types of cares. The policy Catheter Care, Urinary (version 1.1 H5MAPR0048) documented the following: 1. Use standard precautions when handling or manipulating the catheter drainage systems; 2. Wash and hands thoroughly and put on clean gloves before initiating catheter site cares as well as perineal cares; 3. Wash and dry hands thoroughly upon completion of catheter site cares as well as perineal cares.

Based on clinical record reviews, staff interviews, and policy review the facility failed to review and revise the Care Plan for 3 of 4 residents reviewed (Resident #1, Resident #3, Resident #4). The facility failed to revise the Care Plan to include recommendations from the PASRR Level II (Resident #1, Resident #3, Resident #4). The facility reported a census of 35 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had an unscorable Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. The document revealed diagnoses of diabetes mellitus, anxiety, depression, schizophrenia, Post Traumatic Stress Disorder (PTSD), drug induced akathasia, and insomnia. The document disclosed the resident took antianxiety and antidepressant medications. The facility provided document, Preadmission Screening and Resident Resident Review (PASRR) Level II Outcome dated 3/9/25 identified Resident #1 had a time limited approval beginning on 3/9/25 and ending on 9/5/25. The document identified the resident had a diagnosis of a mental health condition that the PASRR program was designed to assess. The document revealed Resident #1 needed to be provided the following specialized services: A. Ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP) to monitor mental health symptoms and manage psychiatric medications. B. Individual therapy by a licensed behavioral health profession. C. Rehabilitative services and/or supports: including evaluation for a diagnosis of neurocognitive disorder/dementia, or other organic mental disorder, community living skills, facilitation of family involvement in the resident's Care Plan, obtaining archived psychiatric/behavioral health treatment records, and supportive counseling from the nursing facility staff. D. Community placement supports including home health aide services, home health nurse services, access to community resources, shopping, meal preparation, and behavioral health supports. The document further revealed ServiceMatters reviews dated 2/6/25 and 3/8/25 had been completed and found the December 2024 PASRR report identifying PASRR services and support services had not been included in the resident's Care Plan. Resident #1's Care Plan dated 4/25/25 revealed a PASRR focus area initiated on 11/7/24. The interventions identified following PASRR recommendations and contact any agencies recommended. The Care Plan failed to identify the resident's specific recommendations made from the PASRR Level II dated 3/9/25. 2. According to the MDS dated [DATE] Resident #3 had a BIMS score of 15/15 indicating normal cognitive function. The document revealed diagnoses of anxiety, depression, and schizoaffective disorder. The document disclosed the resident took antipsychotic, antianxiety, and antidepressant medications. The facility provided document, PASRR Level II Outcome dated 1/15/25 identified Resident #3 had a time limited approval beginning on 1/15/25 and ending on 7/14/25. The document identified the resident had a diagnosis of a mental health condition that the PASRR program was designed to assess. The document revealed Resident #3 needed to be provided the following specialized services: A. Ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP) due to long-standing history of schizoaffective disorder, major depression, anxiety and alcohol abuse in remission, and prescribed multiple medications to treat mental health symptoms. B. Rehabilitative services and/or supports including designation of [NAME] of Attorney for Healthcare and Financial matters, services to pursue community living, referral to Integrated Health Home (IHH), self-health care management training, referral for eligibility determination for Medicaid coverage including Home and Community Based (HCBS) waivers, and facilitation of family involvement in the Care Plan process. C. Community placement supports including home health aide services, home health nurse services, referral to HCBS waivers, access to community resources (transportation), shopping, meal preparation, and behavioral health supports. Resident #3's Care Plan dated 4/14/25 revealed a PASRR focus area identifying need for specialized services due to mental illness with a revision of 2/1/24. The goal area for the intervention was last revised on 4/14/25 with a target date of 7/31/25. The interventions included psychiatric medication management initiated 8/27/24 with a duration of 12 months and staff members to make appointments with a revision date of 8/15/23. The document further revealed rehabilitative services to be implemented to address rehabilitation with an initiation date of 8/27/24. The goal area was revised on 4/14/25 with a target date of 7/31/25. The interventions included the resident's goal of discharge to the community with a tentative discharge date of [DATE], and discharge planning with the resident with a tentative discharge date of [DATE] with implementation dates of 8/27/24. The Care Plan contained 3 additional focus areas related to rehabilitation with initiation dates for 8/27/24 with specific goal areas of referral for HCBS waivers, IHH/referrals to Managed Care Organizations, and designation of [NAME] of Attorney for Health and Financial matters. With each of the 3 focus areas the interventions/tasks were not completed to identify Resident #3's specific needs. The Care Plan failed to identify the resident's specific recommendations made from the PASRR Level II dated 4/14/25 and identify specific complete interventions for each of the focus areas. 3. According to the MDS dated [DATE] Resident #4 had a BIMS score of 15/15 indicating normal cognitive function. The document revealed diagnoses of anxiety disorder, depression, schizophrenia, and PTSD. The document disclosed the resident took antipsychotic, antianxiety, antidepressant, anticoagulant, antibiotic, opioid, hypoglycemic, and anticonvulsant medications. The facility provided document, PASRR Level II Outcome dated 3/7/25 identified Resident #4 had a time limited approval beginning on 3/7/25 and ending on 8/4/25. The document identified the resident had a diagnosis of a mental health condition that the PASRR program was designed to assess. The document revealed Resident #4 needed to be provided the following specialized services: A. Ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP) due to a longstanding history of major mental illness, past and recent symptoms that can impact daily functioning, and prescribed multiple medications to treat mental health symptoms. B. Individual therapy. C. Rehabilitative services and/or supports including services pursue community living, referral for eligibility for HCBS waivers, and work with the case manager through the MCO to assist with discharge planning. D. Community placement supports including environmental management, home health aide services, home health nurse services, referral to HCBS waivers, access to community resources (transportation), shopping, meal preparation, and behavioral health supports. Resident #4's Care Plan dated 4/11/25 revealed a PASRR focus area initiated on 1/8/25. The interventions identified following PASRR recommendations and contact any agencies recommended with an initiation date of 1/8/25. The Care Plan failed to identify the resident's specific recommendations made from the PASRR Level II dated 3/7/25. On 5/14/25 at 2:53 PM Staff F, Licensed Practical Nurse (LPN) MDS/Care Plan Coordinator, stated if the PASRR Level II had recommendations for a resident they should be reflected on the Care Plan. The staff acknowledged Resident #1's was not complete as she was needing to do research for it to be completed. On 5/14/25 at 3:00 PM Staff G, Registered Nurse (RN), Sr. Director of Nursing (DON) stated she did not know a lot about implementing the recommendations from the PASRR Level II into the Care Plan, and she relied on Staff F. The DON did further state that she thought there had been recent training that specifics regarding the Level II recommendations were not required on the Care Plan, but could not immediately find that training. On 5/14/25 at 10:36 AM Staff H, Interim Administrator, expected that the Care Plan would have the information and the recommendations from the PASRR Level II, and the interventions be centered to a specific resident. The Administrator stated the Care Plan should not have a general statement to follow PASRR recommendations. The facility's Care Plans - Comprehensive Person-Centered Policy, revised 12/16, revealed Care Plans include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. The document further revealed the Care Plan should describe the services needed for the resident to attain the highest level of practicable physical, mental and psychosocial well-being. The document revealed care plans were to be revised as information about the residents and residents' conditions changed. The facility's Behavioral Assessment, Intervention and Monitoring Policy, revised 3/19, revealed the Level II evaluation report will be used when conducting the resident assessment and developing the care plan. The document indicated current Level II residents will be referred for an additional PASARR Level II evaluation upon a significant change in status assessment. It disclosed the Care Plan will incorporate findings from the comprehensive assessment and PASARR Level II determinations (as appropriate), and be consistent with current standards of practice.

Based on clinical record reviews, staff interviews, and policy review the facility failed to identify and document target behaviors and/or side effects of medications prescribed to promote or maintain a resident's highest practical mental and psychosocial well-being for 4 of 4 residents reviewed (Resident #1, Resident #2, Resident #3, Resident #4). The facility failed to identify the target behaviors and/or the side effects of medications on either the Electronic Medical Administration Record (EMAR) or the Care Plan. The facility reported a census of 35 residents. 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had an unscorable Brief Interview for Mental Status (BIMS) assessment indicating severe cognitive impairment. The document revealed diagnoses of diabetes mellitus, anxiety, depression, schizophrenia, Post Traumatic Stress Disorder (PTSD), drug induced akathasia, and insomnia. The document disclosed the resident took antianxiety and antidepressant medications. Resident #1's Care Plan dated 4/25/25 failed to identify target behaviors associated with taking an antianxiety medication. Resident #1's EMAR for 5/25 failed to identify target behaviors for the antianxiety medication, and side effects for the antidepressant medication. 2. According to the MDS assessment dated [DATE] Resident #2 had a BIMS score indicating severe cognitive impairment and required staff input for completion. The staff identified the resident had moderately impaired cognitive functioning for daily decision making. The document revealed diagnoses of anxiety disorder, depression, bipolar disorder, and obsessive compulsive disorder (OCD). The document disclosed the resident took antipsychotic, antianxiety, antidepressant, diuretic, and anticonvulsant medications. Resident #2's Care Plan dated 11/14/24 failed to identify target behaviors associated with the antidepressant and antipsychotic medications. Resident #2's EMAR for 5/25 failed to identify the side effects for the antidepressant and antianxiety medications. 3. According to the MDS dated [DATE] Resident #3 had a BIMS score of 15/15 indicating normal cognitive function. The document revealed diagnoses of anxiety, depression, and schizoaffective disorder. The document disclosed the resident took antipsychotic, antianxiety, and antidepressant medications. Resident #3's Care Plan dated 4/14/25 failed to identify target behaviors for the antianxiety, antipsychotic, and antidepressant medications. Resident #3's EMAR for 5/25 failed to identify side effects for the antidepressant and antianxiety medications. 4. According to the MDS dated [DATE] Resident #4 had a BIMS score of 15/15 indicating normal cognitive function. The document revealed diagnoses of anxiety disorder, depression, schizophrenia, and PTSD. The document disclosed the resident took antipsychotic, antianxiety, antidepressant, anticoagulant, antibiotic, opioid, hypoglycemic, and anticonvulsant medications. Resident #4's Care Plan dated 4/11/25 failed to identify target behaviors for the antianxiety and antipsychotic medications. Resident #4's EMAR for 5/25 failed to identify the target behaviors and side effects for antianxiety, antidepressant, and antipsychotic medications. On 5/13/25 at 1:40 PM Staff A, Certified Medication Aide (CMA), stated documentation for behaviors would be completed on the EMAR if they were observed or if reported by a Certified Nursing Assistant (CNA). On 5/13/25 at 1:52 PM, Staff B, CNA/CMA, stated when behaviors were observed she would document them and notify the nurse. On 5/14/25 at 1:50 PM Staff C, CNA, stated they were unaware of where to locate a resident's individualized target behaviors or medication side effects. The staff stated they learned new things about residents by word of mouth or possibly the dashboard of the electronic medical record. On 5/14/25 at 2:00 PM Staff D, CNA, stated she wasn't a nurse therefore didn't know about target behaviors or medication side effects for residents. The staff stated if a resident appeared off notification would be made to the nurse. Staff D stated the Care Plan might contain information about medications. On 5/14/25 at 2:10 PM Staff E, CNA, stated she would recognize medication size effects by a resident not acting right, but could not identify where that information about a resident acting right would be available. The staff stated target behaviors for a specific resident would be known by knowing how the resident behaves. On 5/15/25 at 2:53 PM Staff F, Licensed Practical Nurse (LPN) MDS/Care Plan Coordinator, stated CNAs should be aware of any behaviors a resident is having and report them to the nurse. Staff F stated behaviors were being added to the Care Plans, but not specifically relating a behavior to a medication. The staff further stated the nurse should know if a medication was effective and be aware of the side effects of the medication. On 5/15/25 at 3:00 PM Staff G, Registered Nurse (RN), Sr. Director of Nursing (DON), stated target behaviors and side effects should be the same on the EMAR and the Care Plan. The DON acknowledged that not all the Care Plans may reflect the target behaviors for a medication as it was a work in progress. The staff stated when a resident was admitted to the facility a general order was placed on the EMAR for documentation of side effects and general behaviors, but then the EMAR and Care Plan should be updated to specify side effects and target behaviors for each appropriate medication. The DON acknowledged Resident #4's EMAR contained the general order from admittance and was not updated to reflect individualized side effects and behaviors for medications. On 5/15/25 at 3:40 PM, Staff H, Interim Administrator, expected the EMAR and Care Plan have the resident's target behaviors and side effects related to each identified antidepressant/ antipsychotic/ antianxiety medication, and the documentation would be completed on the EMAR. The facility's Behavioral Assessment, Intervention and Monitoring Policy, revised 3/19, revealed the facility identify and document onset, intensity and frequency of behaviors, It disclosed the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The document indicated the Care Plan at a minimum would include a description of the behavioral symptoms (frequency, intensity, duration, outcomes, location, environment and precipitating factors), individualized interventions, rationale for interventions, measurable goals, and how to monitor for effectiveness of the interventions. The policy reported documentation for medications prescribed for behavioral symptoms include rationale, underlying causes of behavior, other interventions tried prior to use of antipsychotic medications, risks and benefits discussed with resident/family, dosage, duration, monitoring for efficacy and adverse effects, and gradual dose reductions.

Based on observation, resident and staff interviews, staff schedules, and facility assessment review, the facility staff failed to ensure sufficient nursing staff present during scheduled shifts and to ensure call lights were consistently answered within a reasonable amount of time, within 15 minutes, for 5 of 5 nursing halls. The facility reported a census of 40 residents. Findings include: 1. During a continuous observation on 1/14/25 starting at 8:50 AM and ending at 9:40 AM on the 100 and 300 nursing halls, a total of 6 call lights were observed. Breakfast was served in the dining room during this time. Call lights were primarily addressed by one Certified Nursing Assistant (CNA). Two CNA were helping residents during the meal. One was a CNA from the 400 hallway and the other was the Restorative Aide. By the end of the observation period, 1 call light remained unanswered which had been on since 9:20 AM. During confidential resident interviews starting on 1/12/25 at 11:00 AM, 6 of 11 interviewable residents reported prolonged responses to call lights and receiving the requested cares. Several residents stated there have been times when call light responses may be anywhere from 30-60 minutes throughout the day. Two residents reported wait times were so long that their buttock went to sleep or legs go numb due to sitting on the toilet too long. During a confidential interview on 1/14/25 at 12:15 PM, a resident acknowledged that they had pushed the call light earlier in the morning (at approximately 9:20 AM) with no response in 15 minutes. Upon further questioning, the resident indicated the call light was eventually cleared by 10:30 AM. However the resident indicated the wait time was too long and they had urinated in their incontinence brief prior to staff assistance. During an interview on 1/14/25 at 8:15 AM with Staff B, CNA, she reported 1 CNA is assigned to both the 100 and 300 halls, 1 CNA to both the 500 and 600 halls, and 1 CNA to the 400 hall. The CNA on the 400 hall is to assist on the 100 and 300 halls when needed. During an interview on 1/15/25 at 12:00 PM with the Director of Nursing (DON), the facility goal time is to respond to call lights in 15 minutes. The DON acknowledged that certain times of the day, such as meal times, are more challenging than others to ensure call lights are answered in a timely manner. The policy Answering the Call Light, version 1.2 (H5MAPR0016), states the purpose of the policy is to ensure timely responses to residents' requests and needs. 48886 2. Review of the Payroll Based Journal (PBJ) report revealed the facility triggered for excessively low weekend staffing and a one star staffing rating for the fiscal year quarter 4 for 2024, July 1 to September 30. During an interview 1/15/25 at 9:00 AM, the Administrator and DON advised their census averages between 37 and 41 residents. For this census, to be adequately staffed, they need 2 nursing staff on the 6 am to 6 pm shift, or 1 nurse and 1 Certified Medication Aide (CMA) and they need 3-4 CNA's. For the 2 pm to 10 pm shift they need 3 CNA's and from the 10 pm to 6 am shift they need 2 CNA's. They have 1 nurse from the 6 pm to 6 am shift. Review of the staffing schedule and daily posting for nursing staff for the time period of July 1 to September 30, 2024 revealed the facility only had two CNA's on the 2 pm to 10 pm shift for Saturday the 13th of July. On Sunday, the 4th of August, the facility only had two CNA's from 2 pm to 6 pm. On Sunday, the 18th of August, the facility only had two CNA's from 2 pm to 5:48 pm. On Saturday, the 24th of August, the facility only had two CNA's on the 2 pm to 10 pm shift. On Sunday, the 1st of September, the facility had 2 CNA's on the 2 pm to 10 pm shift. On Sunday, the 15th of September, the facility only had two CNA's on the 2 pm to 10 pm shift. On Sunday, the 29th of September, the facility only had two CNA's on the 2 pm to 10 pm shift. During an interview 1/15/25 at 12:42 PM, the DON acknowledged the low weekend staffing for CNA coverage for the weekends showing low staffing on their schedule and daily posting. On Sunday, the 1st of September, the DON stated she came in to the facility to help cover from 4 pm to 8:30 pm due to low staffing, this was not reported to PBJ. Review of the Facility Assessment report, dated 6/13/24, documented under the staffing plan nursing services and staffing are evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population.

Based on record review, observations, staff interview, and policy review, the facility failed to provide peri-care in a manner to prevent cross-contamination and infection for one of three residents observed for peri-care. The facility also failed to ensure staff changed gloves and sanitized hands in accordance with proper infection control techniques when contaminated to protect against cross contamination and potential infection for four of twelve residents observed in the sample. The staff failed to utilize a barrier when emptied one of two catheters observed for catheter care, and failed to remove personal protective equipment prior to exit from an enhanced barrier precautions room for one of five halls observed. The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of a pressure ulcer and osteomyelitis (a bone infection and inflammation) to the sacrum and coccyx, neurogenic bladder, and multidrug resistant organism (MDRO). The MDS revealed the resident had an indwelling catheter and ostomy. The MDS revealed the resident took an antibiotic. The Care Plan initiated 11/25/24 revealed the resident had pressure ulcers on his sacrum and coccyx and a MDRO. The resident had a suprapubic catheter and took an antibiotic related to a bacterial infection. The Care Plan directed staff to provide catheter care each shift and used Enhanced Barrier Precautions (EBP). During observations on 1/12/25 at 11:19 AM, Staff A, Certified Nursing Assistant (CNA) entered Resident #2's room, then left the room and donned a yellow gown, N95 mask and gloves. Staff A returned to the room and reported she was going to empty the resident's catheter. Staff A obtained a graduate container from the bathroom, unclamped the catheter, then drained the urine contents into graduate container, and clamped the catheter port. Staff A held the graduate full of urine with her gloved hands and took it to the bathroom. Staff A lifted the glasses on her face with her right gloved hand to check the amount of urine in the graduate, then placed her glasses back down over her eyes. Staff A emptied the graduate into the toilet, turned the faucet on, filled the graduate with water to rinse the container, then emptied the graduate into the toilet. Staff A placed the graduate on the back of the toilet. At 11:23 AM, Staff A continued to wear the same gloves, opened the top drawer and obtained an alcohol swab, then cleansed the end of the catheter port with the alcohol swab. Staff A placed the catheter port into the holder, removed one glove, then opened the door to the room and walked down the hall wearing a yellow gown and N95 mask. At 11:24 AM, Staff A removed the yellow gown and placed the gown in a lidded cart in the hallway, then removed the N95 mask, and threw the mask in a lidded cart in the hallway. Staff A proceeded to walk down the hall and did not sanitize her hands. During an interview 1/15/25 at 9:45 AM, the Director of Nursing (DON) reported she expected staff to use a barrier whenever a catheter is emptied. She also expected staff to change gloves and sanitize hands whenever they completed a dirty task and before they moved to a clean area. She expected staff remove the gown and mask before they left the resident's room whenever a resident on EBP's. An Enhanced Barrier Precautions policy dated 3/28/24 revealed EBP's designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Personal protective equipment (PPE) removed prior to exiting the room or before provided care for another resident. An Emptying a Urinary Drainage Bag policy revised 10/2010 revealed the following procedural steps: 1. Assemble the equipment and supplies as needed, including PPE such as gowns, gloves, and mask. 2. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 3. Wash and dry hands. 4. [NAME] gloves 5. Place a paper towel on the floor beneath the drainage bag and position the measuring container under the drainage bag. 6. Remove the drain tube from the holder. 7. Open the drainage bag and drain urine into the measuring container. 8. Close the drain. 9. Wipe the drain with an alcohol sponge or swab. 10. Replace the drain tube back into the catheter bag holder. 11. Measure and record the urinary output, if indicated. 12. Pour urine down the commode. 13. Rinse out the measuring container and return to its designated storage area. 14. Discard all disposable items into designated containers. 15. Remove gloves and discard in designated container. 16. Wash hands. A Handwashing/Hand Hygiene policy revised 8/2019 revealed hand hygiene is the primary means to prevent the spread of infections. Hands washed with soap and water or an alcohol-based hand rub used before and after direct contact with residents, before and after handling a catheter, before moving from a contaminated body site to a clean body site during resident care, before and after isolation precautions, and after gloves removed. Hand hygiene is the final step after PPE removed and disposed. Glove use does not replace hand washing/hand hygiene. 2. The Admission MDS assessment dated [DATE] revealed Resident #39 had diagnoses of Parkinson's Disease, diabetes, and dementia. The MDS revealed the resident had a Brief Interview for Mental Status score of 10 which indicated moderately impaired cognition. The resident had incontinence and required partial to moderate assistance for toileting. The Care Plan initiated 12/26/24 revealed the resident required assistance with activities of daily living (ADL's) and had urinary incontinence. The Care Plan directed staff to provide assistance of one for bed mobility, toileting and provide perineal cleansing as needed. During observations on 1/12/25 at 10:47 AM, Staff A, CNA, donned gloves, removed tabs on the resident's brief, then took disposable wipes and cleansed the resident buttocks from front to back. Staff A then applied barrier ointment to the buttock area. Staff A assisted the resident to roll onto his back then removed the brief over the front (groin). Staff A took disposable wipes and cleansed the resident's penis and scrotum, then applied barrier ointment to the area. Staff A rolled the resident onto his right side, rolled the soiled brief up under him, then applied a clean brief. Staff A did not change her gloves or sanitize her hands when she provided pericare. At 10:50 AM, Staff A applied gloves, rolled the resident onto his left side, tucked a clean pad under his bottom, then rolled the resident onto his right side, and removed the soiled pad. Staff A continued to wear the same gloves and proceeded to open and close dresser drawers, then opened the closet door and obtained a pair of pants. Staff A donned the clean pants on the resident then removed her gloves. At 10:54 AM, after Staff A completed cares with the resident, she left the room but did not wash her hands. During an interview on 1/15/25 at 9:45 AM, the DON reported she expected staff changed their gloves and sanitize their hands whenever they completed a dirty task and before they moved to a clean area. 3. The MDS assessment dated [DATE] revealed Resident #40 had diagnoses of anemia, diabetes, and hemiplegia (paralysis on one side of the body). The MDS documented the resident had a catheter. The Care Plan initiated 1/1/25 revealed the resident had a catheter. The Care Plan directed staff to use EBP's and provide catheter care each shift. During observation on 1/12/25 at 11:10 AM, observed Resident #40 lying in bed and had a catheter bag hung on the bedframe. The catheter bag had amber colored urine in it. At 2:05 PM, a CNA exited the resident's room wearing a yellow gown. The CNA walked down the hall to the soiled linen cart, removed the gown, and placed the gown in the lidded cart. During an interview 1/15/25 at 9:45 AM, the DON reported she expected the yellow gown be removed before staff left the resident's room whenever a resident is on EBP's. 50500 4. During a continuous meal time observation on 1/14/25 at 9:00 AM and ending at 9:40 AM, Staff A provided feeding assistance to a total of 3 residents. While assisting the first resident to eat, Staff A got up from the table to answer the front door alarm. No hand hygiene was observed when Staff A returned to the table and resumed assisting the resident. When the first resident was done eating, Staff A got up and sat in-between two other residents who needed feeding assistance. No hygiene observed during this transition. While assisting the residents, Staff A got up to obtain a glass of milk and proceeded to pour a small amount in the residents' cereal. Once completed, Staff A resumed feeding assistance, which included not only touching eating utensils but also glasses/mugs with no hygiene observed. During an interview on 1/15/25 at 12:30 PM the DON reported an expectation that staff will perform hand hygiene in-between feeding different residents. A Handwashing/Hand Hygiene revised 8/2019 revealed hand hygiene is the primary means to prevent the spread of infections. An alcohol-based hand rub used before and after direct contact with resident, after contact with objects in the immediate vicinity of the resident, before and after eating or handling food, or before and after assisting a resident with meals.

Based on clinical record review, observation, staff interview and policy review the facility failed to ensure staff transferred a resident safely and utilized a gait belt for one of three residents reviewed for transfers (Resident #39). The facility reported a census of 40 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had diagnoses of Parkinson's Disease, diabetes, and dementia. The MDS revealed the resident had a Brief Interview for Mental Status score of 10 which indicated moderately impaired cognition. The resident required partial to moderate assistance for transfers, The Care Plan initiated 12/26/24 revealed the resident had poor safety awareness related to cognition and had a risk for falls. The resident required assistance with activities of daily living (ADL's). The Care Plan directed staff to provide assistance of one for bed mobility and transfers. The Progress Notes revealed the following: a. On 1/8/25 at 4:00 AM revealed the resident found on the floor by CNA (certified nursing assistant). Resident was incontinent of stool and had an abrasion to the forehead and his knees. Resident running a 100.6 fever. Currently on antibiotic for pneumonia. Resident stated he did not know why he fell . b. On 1/13/25 at 5:42 PM, the resident is on skilled level of care following hospitalization for falls. Resident alert and oriented x 3 (person, place, time) with moments of confusion and forgetfulness. He is able to make needs known but had some difficulty communicating due to memory issues. Resident has poor safety awareness, and has had a recent and past history of falls. Resident needed reminders to not ambulate without assistance. During observations on 1/12/25 at 10:54 AM, Staff A, CNA moved Resident #39's feet over the edge of the bed, held the resident's hand, and pulled on the resident's right arm. The resident hollered out. Staff A asked the resident if it would be better for him to get up from the other side of the bed. The resident said it would probably be better. Staff A placed the wheelchair on the left side of bed. Staff A pulled the resident's right arm and pulled the resident up to a sitting position on the edge of the bed. Staff A then placed a front wheeled walker in front of the resident and assisted the resident to stand. Staff A pulled the resident's pants up. Staff A transferred the resident into the wheelchair then wheeled the resident backward in the wheelchair without foot pedals to the opposite side of the room. The resident had a pair of white socks on his feet (no gripper socks or shoes on) when Staff A transferred him from the bed to the wheelchair. Staff A left the room. The call light was left out of the resident's reach. During an interview on 1/15/25 at 9:45 AM, the Director of Nursing (DON) reported she expected a gait belt used for transfers for safety reasons. A gait belt used and encouraged even if it wasn't on the resident's care plan. The DON reported the call light should be placed within the resident's reach. The facility's Assisting a Resident policy revised 2/2018 revealed the following steps: 1. Assemble equipment and supplies as needed, including a gait belt. 2. Position the bed so that the resident can get out of bed easily. 3. Assist the resident to sit up on the edge of the bed as necessary. 4. Assist the resident in putting on slippers/shoes, 5. Place the gait belt around the resident for safety 6. Assist the resident to a standing position. 7. Assist the resident into the chair or bed. 8. Place the call light within easy reach of the resident. 9. Wash and dry hands.

Based on observation, clinical record review, resident interviews, staff interviews and policy review, the facility failed to keep all areas clean in the facility and in good repair. The facility reported a census of 36 residents. Findings include: Observations during the dates of 4/9/24 and 4/10/24 revealed the following: 1. On 4/9/24 at 9:00 AM, the bathroom in room [ROOM NUMBER] observed to have fecal matter on the rim of the toilet bowl and inside the toilet bowl. What appeared to be fecal matter observed on the wall in the bathroom and on the floor, next to the floor trim. Observed rust around the toilet rim on the floor. The toilet had a bar attached under the toilet seat with handles. The bar covered in rust, leaving rust stains on the rim of the toilet under the bar. 2. On 4/9/24 at 9:27 AM, a section of the lower wall by the shower room in the 100 hallway had wallpaper peeling and the plaster coming off by the floor board. The section of wall loose, and when touched would move several inches inward. 3. On 4/9/24 at 9:35 AM, a section of the ceiling in the dining room covered by a piece of plastic, with water damage and a section of the ceiling missing. 4. On 4/10/24 at 9:30 AM, a resident observed coming out of the shower room with a staff member in the 100 hallway. The door jamb when opened observed to be splintered and broken, the door had splintered wood around the door handle and the frame by the door jamb broken and splintered. 5. On 4/10/24 at 1:30 PM, a section of the ceiling in room [ROOM NUMBER] covered with black plastic and blue tape, the section approximately a foot and a half, by four feet. Observed the room occupied by one resident. 6. On 4/10/24 at 1:35 PM, the privacy curtain located next to a resident's bed in room [ROOM NUMBER] observed to have a yellow stain from formula from tube feeding covering a section of the curtain approximately two inches across and five feet down, the curtain next to the resident's head and the head of the bed. During an interview 4/9/24 at 9:00 AM with Resident #12, with a review of the Minimum Data Set (MDS) completed 1/11/24 showing a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, the resident stated the bathroom in room [ROOM NUMBER] is not cleaned very often and the toilet leaks. During an interview 4/9/24 at 9:10 AM with Resident #13, with a review of the MDS completed 1/12/24 showing a BIMS score of 13, indicating intact cognition, the resident stated the bathroom in room [ROOM NUMBER] is not cleaned very often. During an interview 4/9/24 at 1:25 PM, Staff D, housekeeping, stated the facility used to have two housekeeping staff working during the day, however since their census lowered they normally only have one housekeeping staff work during the day. Today there is only one housekeeping staff working, as far as cleaning. Staff D stated room [ROOM NUMBER] has not been cleaned yet today. Staff D was going to show the supervisor the room before cleaning it as Staff D felt the room and bathroom appeared as though it had not been cleaned in a few days. Staff D stated the bathroom in room [ROOM NUMBER] has feces on the wall and in the toilet and the toilet bar needs replaced. Staff D advised the bar on the toilet is rusted and Staff D asked maintenance about two months ago to replace the bar. The bar has not been replaced yet. During an observation on 4/9/24 at 1:35 PM, with Staff D present, the bathroom in room [ROOM NUMBER] observed to have fecal matter on the toilet rim and in the bowl, and what appeared to be fecal matter on the wall and floor, next to the floor board. Staff D stated the spots on the wall and floor in between the toilet and the sink appear to be fecal matter. Staff D got a spray cleaner and a rag and sprayed the areas, it came off with a rag. Observed a few splattered spots on the wall by the toilet and on the floor, next to the floor board. The toilet bowl and rim had fecal matter. The bar that goes under the toilet seat which is attached to handles for assistance while on the toilet had rust covering the length of it, which also left rust spots on the toilet rim. During an interview 4/10/24 at 2:15 PM, the Administrator stated the ceiling had a leak around February of this year and they have a contractor coming on the 15th of April to fix the ceiling and to fix the wall by the shower room in the 100 hallway. The 100 hallway has damage by the shower room due to the shower leaking into the wall. The Administrator stated she did not know when the wall flooded by the shower room as it was like this when she started at the end of November of 2023. The shower also flooded into the room next door, room [ROOM NUMBER]. room [ROOM NUMBER] is not being used and has not been used for a long time due to water damage. Observation of room [ROOM NUMBER] with the Administrator present showed what appeared to be black mold on the wall connected to the shower room. The room did not have a moldy smell. The Administrator stated the maintenance person sprayed it with Kiltz and the mold has not spread. They were going to fix this in house and then this was taking so long they decided to have the contractor that is fixing the ceiling fix this room, the room will be gutted and new sheet rock put in. Inquired from the Administrator about the shower room door being splintered and she advised she was just told about this yesterday and is not sure how this happened or when this happened. They do have a resident who likes to use this shower room, however they have limited the use of this shower room given the water issue. The Administrator advised they received a grievance in February regarding the cleanliness of the room and bathroom in room [ROOM NUMBER]. They resolved this by having the room added to the daily cleaning list. Inquired from the Administrator how she knows if the bathroom is being cleaned daily, she said it should be marked on the cleaning list. Inquired from the Administrator about the toilet handle and the rust, she acknowledged this was not pretty and was not homelike. The Administrator advised there is a crack in the ceiling in room [ROOM NUMBER] from a unit being dropped on the roof. She is not sure when this happened, stating the ceiling was like this when she started at the end of November of 2023. The black plastic with blue tape has been on the ceiling since she started. The contractor will fix this on the 15th of April. The tape noted to be peeling on the corners. The Administrator advised she was not aware of the privacy curtain having formula stains in room [ROOM NUMBER] and stated someone should have noticed this and taken the curtain down to clean it. The Administrator stated this was not homelike. The Administrator stated there was a slow leak in the pipe in the ceiling in the dining room and then the pipe flooded the ceiling, this took place on the 27th of January, 2024. A contractor came out and gave a bid in February, this was a high bid and they had a local person give them another bid. During an interview 4/10/24 at 2:45 PM, the Administrator advised she found out a staff member kicked the shower room door in the 100 hallway because it was stuck and they needed a shower chair. She is not sure when this happened, but thinks it happened recently. There was not a resident in the shower room when this occurred. Review of the facility policy Homelike Environment, with a revision date of February 2021, documents residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, which include a clean, sanitary and orderly environment.

Based on observation, policy review, and staff interview, staff failed to prepare and serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 36 residents. Findings include: 1. On 4/10/24 at 11:40 AM, during continuous observation of the lunch service, Staff A, Cook placed the serving utensils of scoops and tongs, for service of the food, on the counter attached to the front of the steam table. Staff A repeatedly leaned over to scoop food touching the front of her apron to the serving utensils and continued to use the same utensils to serve the food. Staff A applied gloves, opened the refrigerator with the gloved hand, with the same gloved hands touched a slice of cheese, placed the cheese on a plate, and proceeded to open a package of buns, remove a bun, placed bun on a plate and then placed slice of cheese on the bun. 2. On 4/10/24 with meal starting at 11:40 AM, Staff B, Kitchen Aide, scooped a piece of cake onto a plate sitting on the counter, leaned across to scoop another piece of cake touching the first piece of cake with the front of her shirt. Both pieces of cake were served to residents. Facility policy, Food Preparation and Service revised April 2019, documented gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Interview on 4/10/24 at 1:25 PM, the Dietary Manager stated expectation for gloves to be 1-time use, not touch other items when touching the food or use tongs to pick up the food items and to not allow clothing to touch the serving utensils. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on observation, staff interviews and policy review, the facility failed to perform appropriate infection prevention and control practices during medication administration, including hand hygiene. The facility reported a census of 36 residents. Findings include: During an observation for medication administration 4/10/24 at 11:01 AM, Staff C, RN, applied gloves, placed a wax barrier down on a resident's bedside table, placed alcohol wipes and then a blood glucose meter with a test strip and needle on the wax barrier in preparation to obtain a blood sugar reading for a resident. Staff C realized she forgot a cotton ball and returned to the medication cart to obtain a cotton ball, then using the same gloves inserted the needle to obtain blood, massaged the resident's finger to bring blood to the surface, and then inserted the test strip into the glucose meter and obtained blood on the test strip. The meter read an error. Staff C then took off her gloves and placed them on table, the gloves were not placed on the wax barrier, they were placed directly on the resident's bedside table surface. Staff C returned to the medication cart to obtain a new needle and test strip, did not sanitize her hands before or after getting into the medication cart and returned to the resident's room, putting the same gloves back on her hands. Staff C used the new needle and a new strip and again received an error on the meter. Staff C removed her gloves, placing them on the bedside table, not on the wax barrier and returned to the medication cart for another needle, she did not sanitize her hands before or after using the medication cart. Staff C then put the same gloves back on, used the needle to obtain more blood from the finger and a new strip and was able to obtain a blood glucose reading. During an interview 4/10/24 at 1:08 PM, Staff C acknowledged she did not change gloves or sanitize hands in between using a new needle and strip to obtain the blood sugar with the blood glucose meter. Staff C stated she should have used new gloves and should not have placed the gloves on the bedside table and re-used them. Staff C further acknowledged she should have sanitized her hands before and after using the medication cart. Staff C acknowledged this as an infection control concern. During an interview 4/11/24 at 9:36 AM, the Director of Nursing (DON), acknowledged concerns for infection control with gloves not being changed and placed directly on the bed side table during medication administration and obtaining a blood glucose reading, as well as an infection control concern with not sanitizing hands before and after touching the medication cart. Review of the facility Handwashing/Hand Hygiene policy, revised August 2019, documents under policy interpretation and implementation, the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on clinical record review, staff interview, and facility policy review the facility failed to revise and update the Care Plan to include adequate interventions for a resident that was at high risk for elopement for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of schizophrenia, psychotic disorder, hypertension, and thyroid disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the Progress Notes for Resident #6 showed documentation of exit seeking for the following dates: 6/7/23 Resident exit seeked times two this shift. 6/8/23 Resident attempted numerous times to exit several exits. 6/17/23 Resident had been exit seeking off and on this evening and pacing in the hallways frequently this shift. 6/22/23 Resident attempted to exit the building this morning by himself. 6/23/23 Resident restless this evening, wandering, and exit seeking, had attempted to exit the building three times. An Incident Report dated 6/28/23 for Resident #6 revealed Resident #6 got outside without staff knowledge. Resident's Wandering Evaluation V2 dated 1/4/23 revealed a score of 13, a high risk of wandering and has had attempts to leave the facility. Resident's Wandering Evaluations V2 dated 3/15/23 revealed a score of 13, a high risk of wandering and has had attempts to leave the facility. Resident's Wandering Evaluations V3 dated 5/30/23 revealed a score of 7, a low risk of wandering and has had attempts to leave the facility. Resident's Wandering Evaluations V4 dated 6/30/23 revealed a score of 10, a high risk of wandering and has had attempts to leave the facility. Resident's Closed Care Plan dated 8/24/23 lacked documentation of exit seeking occurrences or behaviors until 7/3/23. The facility policy Care Plan, Comprehensive Person-Centered Policy revised December 2016 revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Interview on 2/5/24 at 4:00 PM, the MDS Coordinator stated the Care Plan should have been updated with the exit seeking behaviors prior to the incident. Interview on 2/5/24 at 4:30 PM, with the Administrator stated their expectation would be to update the Care Plan with any change in condition.

Based on observation, interviews, record review, and policy review, the facility failed to maintain a resident's dignity during the meal service for 1 of 5 sampled residents (Resident #2) who required assistance with meals. Specifically, a staff member stood while assisting Resident #2 while eating lunch. The facility reported a census of 35 residents. Findings include: Review of a facility policy titled, Assistance with Meals, revised July 2017, instructed, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Further, the policy section related to Dining Room Residents specified, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. Resident #2's Admission Record listed diagnoses of cerebral infarction (stroke), unspecified dementia, and dysphagia (difficulty swallowing). Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified that she had short- and long-term memory impairments with severely impaired cognitive skills for daily decision making. Per the MDS, Resident #4 required total dependence on staff for eating. Resident #2's Comprehensive Care Plans revised 3/22/23 addressing the resident's diet needs. The Care Plan indicated that Resident #4 had a diet order for puree with honey thick liquids and would eat foods as able for comfort. The Care Plan directed the staff to assist Resident #2 with eating. During an observation of the lunch meal service on 4/25/23 at 12:07 PM, Resident #2 sat in a wheelchair, in the main dining room, getting help to eat by Licensed Practical Nurse (LPN) #1. LPN #1 stood beside Resident #2 while assisting her to eat. Upon inquiry into the practice, LPN #1 stated he considered standing while helping a resident eat a dignity issue but indicated that his knees hurt. LPN #1 reported that as the reason he stood to help Resident #2 eat. During a follow-up interview on 4/26/23 at 10:53 AM, LPN #1 indicated he knew standing while helping Resident #2 eat was not good practice. He reported himself as selfish due to standing up and feeding Resident #2 and he expected a resident's dignity to always be maintained. During an interview on 4/27/23 at 10:34 AM, the Director of Nursing (DON) stated she expected staff to sit by a resident to assist with eating. She stated she considered it a dignity issue/concern to help a resident eat while standing. During an interview on 4/27/23 at 10:37 AM, the Administrator stated LPN #1 and all other staff should follow the facility policy which directs staff to sit by a resident to provide eating assistance and engage with the resident. She stated Resident #2 required total care by staff. The Administrator identified that she expected a resident's dignity to be always maintained.

Based on record review, resident and staff interviews, the facility did not ensure access to personal funds for 1 of 1 resident (Resident # 10) in the sample reviewed for personal funds. The facility reported a census of 43 at the time of the survey. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] showed Resident # 10's Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. On 3/1/22 at 2:23 PM, Resident # 10 reported that the facility receives money on her/his behalf every 3rd of each month. However, Resident # 10 verbalized that the facility would not release the said money until the 8th to the 10th of the month. Resident # 10 also reported that the Business Office Manager (BOM) who is responsible for giving out the money was not attending to the task, instead the BOM would only be at the facility to do work in the kitchen and on the floor. On 3/7/22 at 10:25 AM, during a follow-up interview, Resident # 10 stated that last November and December of 2021, she/he ran out of cigarettes and had phone bills due on the 5th of the month, but did not get the money to pay for these because the BOM did not have time to do the paper work. Resident # 10 also stated wanting to get the money as they are available to buy cigarettes and pay phone bills. Resident # 10 further stated, [BOM] does not like to be bothered and would always I say have to wait, because she is working in the kitchen. Resident # 10's personal funds' records titled, TRUST STATEMENT showed 3 of 4 months reviewed where there was a delay in Resident # 10 withdrawing money from her/his account, as follows: November 2021, there was a balance of $50 on 11/4/21 but withdrawal was on 11/7/21; December 2021, there was a balance of $50 on 12/7/21 but the withdrawal was on 12/10/21; and February 2022, there was a balance of $50 on 2/4/22 but withdrawal was on 2/9/22. On 3/3/22 at 12:00 PM , the BOM said that residents cannot get money unless she or the Administrator is present at the facility. The BOM also said that Resident # 10's money arrives by the 3rd of the month, with the $20 as a physical check that needs to be manually deposited and the $30 that is deposited automatically. The BOM verified that Resident # 10 had money on the 3rd and 4th of November 2021 but withdrawn on the 7th, and Resident # 10's money was posted on the 7th of December 2021, and withdrawal was on the 10th. The BOM stated that it was not her intention to delay or not to give Resident # 10's money but that she just got busy helping in the kitchen due to short staffing. The BOM also said that she was the only one who could release the money when the facility had a switch of administrators but tried to get Resident # 10 the money as soon as she can. The facility's policy titled, Resident Trust Fund revised on 8/20/21, defines an account that is held by a long-term care or senior living facility in order to manage the finances of the resident. The policy policy indicates that the facility does not have the option of refusing to handle resident's personal funds if requested to do so. The policy also indicates that residents may elect to handle their own funds if they wish.

Based on record review, staff, resident and family interview, the facility failed to enable resident and family participation in care plan conferences for three (#3, #12, and #42) of three residents reviewed. The facility reported a census of 43 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] for Resident #3, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/02/22 at 12:09 PM, Resident #3 revealed not receiving an invitation to a care plan conference and would attend if invited. Review of Resident #3's clinical record lacked documentation of the resident attending or declining to attend resident's care plan conferences on the following dates: 12/16/21 and 12/30/21. 2. A MDS dated [DATE] for Resident #12, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A BIMS score of 13 indicated no cognitive impairment. On 3/02/22 at 9:35 AM, Resident #12 revealed not receiving an invitation to care conferences and would like to try attending. Review of Resident #12's clinical record lacked documentation of the resident attending or declining to attend resident's care plan conferences on the following dates: 2/11/21, 5/6/21, 6/17/21, 9/2/21, 11/18/21, and 2/1/22. 3. A MDS dated [DATE] for Resident #42, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/01/22 at 2:34 PM, Resident #42's wife/responsible party revealed the facility did not have care conferences for quite a while, attended conferences regularly before Covid with visiting restrictions, but did not receive an invitation except for one. Resident #42's wife stated did have one conference in resident's room. Review of clinical record lacks documentation of Resident #42's wife attending or declining to attend resident's care plan conferences on the following dates: 2/4/21, 4/15/21, 5/6/21, 5/24/21, 7/22/21, 9/2/21, and 10/14/21; with wife's attendance documented on 12/30/21. On 3/02/22 at 2:59 PM, the MDS Coordinator stated the facility sends the resident/family a letter containing an invitation to care plans. If the resident/family attends, they sign the care plan signature page or document attendance in the resident's progress note. The MDS Coordinator could not provide documentation confirming resident/family invited to or declining to attend care plan conferences. On 3/03/22 at 1:53 PM, the Administrator stated the expectation is for residents and families to receive an invitation to care conferences.

Based on observation, record and policy review, and staff interview, the facility failed to implement appropriate infection prevention and control practices during medication administration for hand hygiene. The facility also failed to provide appropriate hand hygiene during Foley catheter care for 1 of 1 resident's observed. (Resident #44) The facility reported a census of 43 residents. Findings include: 1. Observation during medication pass on 03/02/22 at 08:44 AM revealed Staff B, LPN (licensed practical nurse) did not sanitize hands or use gloves when physically touching the medications during 2 instances of removing medication from the blister pack and when one pill fell into the lap of the resident during medication pass. Staff B, LPN picked up the medication with bare hands and handed it back to the resident. On 03/03/22 at 11:02 AM the Director Of Nursing (DON) stated it was an expectation that nursing staff use hand hygiene before and after medication passes and to use gloves when physically touching medications. On 03/07/22 at 10:39 AM review of the Policy titled Administering Medications, dated April 2019 states staff follows established infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 2. A Minimum Data Set (MDS) for Resident #44, dated 2/25/22, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented an indwelling urinary catheter and a Brief Interview for Mental Status (BIMS) score of 14 (no cognitive impairment) Observation on 3/02/22 at 2:20 PM, Staff A, Certified Nursing Assistant (CNA) sanitized hands, gloved, then removed a trash bag with trash inside from a trashcan, tied the trash bag shut and placed the bag on the floor. Staff A, CNA, with the same gloves, removed an empty trash bag from the bottom of the trashcan, placed the trash bag under a graduate and onto the floor. Staff A, CNA, then with the same gloves, opened the catheter tube drain, drained urine into the graduate, cleansed catheter tube tip with alcohol swab, and closed the tube drain. Staff A, CNA emptied and rinsed the graduate and removed gloves. Staff A, CNA picked up trash bags, touch own hair, went down hall and opened door to shower room, no hand hygiene performed. Review of facility policy, Handwashing revised 3/9/20, documented recommendations for handwashing (per CDC guidelines), after glove removal. On 3/02/22 at 2:25 PM, the DON stated staff is expected to change gloves after handling trash and before emptying catheter and hand hygiene after removing gloves.

Based on observations, clinical record review, and staff interview the facility failed to adequately supervise residents &/or implement interventions while in the dining room for 2 of 2 residents reviewed (Resident #1 and #2) which resulted in second degree [CONDITION(S)]. Resident #1 in the dining room on 12/15/21, received supper meal and the resident swiped hand through the hot mashed potatoes. Staff stated the resident would frequently reach out to staff &/or objects, and would move arms and hands randomly. Resident #2 in the dining room on 12/17/21, received coffee in a cup without a lid and spilled the coffee on lap. The Minimum Data Set (MDS) identified the resident required set-up and supervision with eating. The incident report identified two witnesses to the incident, however, those two witnesses reported they did not observe the resident spill the coffee, had heard him holler out after the incident occurred. Two staff who have worked at the facility for over 5 years reported the resident had tremors to bilateral hands since they had worked at the facility and the resident had a history of spilled drinks while at the dining room table. He also had a red raised warm area to the right thigh that staff questioned as a possible coffee burn 8/17/20 which required [MEDICATION(S)] Cream (for [CONDITION(S)]) that the facility failed to investigate as to cause. Incident report for Resident #1 identified no witnesses found to the burn incident. Incident report for Resident #2's incident identified 2 witnesses who, when interviewed, denied witnessing the burn incident. Both residents required supervision at meals. The facility reported a census of 42 residents. Findings include: 1. The MDS for Resident #1 with a completed date of 11/23/21, identified the resident with severely impaired cognitive skills for daily decision making and the resident never/rarely made decisions. The MDS coded the resident as dependent on one staff for eating. The MDS listed diagnoses that included: spastic quadriplegic [CONDITION(S)], post traumatic [CONDITION(S)], [CONDITION(S)], and intellectual disabilities. The Care Plan revised date of 9/2/21, identified the resident received a pureed diet, did not have a good appetite, and cried or got upset at meals. The care plan included the intervention of total assistance with eating. The Care Plan revised 4/2/21, identified the resident unable to feed self independently related to spastic movements. The care plan directed staff to provide verbal cues to help prompt. The Care Plan revised 11/3/21, identified the resident at risk for pressure ulcers due to incontinence and poor intake. The care plan directed staff to observe skin daily with routine cares. The Incident report titled Injury dated 12/15/21 at 6:30 PM, revealed: Nursing description: the aide reported the resident stuck right hand in hot mashed potatoes Resident description: the resident unable to give description. Immediate Action Taken: placed cold rag on the resident right hand, assessed the resident, and obtained vital signs. Injuries observed at time of incident: no injuries observed at the time of the incident. Level of Pain: Numerical: 5 (0/10 scale with 10 being the worse pain). Level of Consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person. Injuries Report post incident: injury location right hand Level of pain: Numerical: 4. Level of consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person Predisposing Environmental Factors: None. Predisposing Physiological Factors: confused, impaired memory, and none. Predisposing Situation Factors: None. Witnesses: No witnesses found. Agencies/People Notified: Family member-attempt one on 12/15/21 at 7:41 PM, Physician on 12/16/21 at 4:48 AM, and Facility manager on 12/15/21 at 7:40 PM. The Incident report titled Injury dated 12/17/21 at 11:40 AM, revealed: Nursing description: the resident noted with blistered open areas to the 3rd and 4th digits right hand, unmeasurable due to the resident refusal. Resident description: the resident unable to give description. Immediate Action Taken: initial treatment [MEDICATION(S)] wrap (non-adherent dressing) with coban (self-adherent elastic wrap used to secure dressings). Injuries observed at time of incident: blister Level of Pain: section left blank Mental Status: left blank. Notes: blisters noted to the right 3rd and 4th digits Injuries Report Post Incident: no injuries observed post incident. Level of Pain: section blank Mental Status: section blank Predisposing Environmental Factors: None. Predisposing Physiological Factors: None. Predisposing Situation Factors: None. Witnesses: No witnesses found. Agencies/People Notified: Family member and Physician on 12/17/21 at 10:50 AM and Facility manager on 12/17/21 at 11:00 AM. The Progress Notes revealed: a. 12/16/21 at 4:02 AM, focused evaluation - during supper the resident accidentally put hand in food and the food appeared hot. No injuries noted at that time. The nurse attempted to place cold rag on the resident hand and the resident refused. The resident refused as needed pain medication. The Director of Nursing notified. Continue to monitor. b. 12/16/21 at 4:50 AM, nurses note - during supper the resident accidentally stuck right hand in food, mashed potatoes, and appeared hot. No injuries noted. The nurse attempted to place cold rag on hand and the resident refused. The resident refused pain medication. The DON and physician notified. Unable to reach the family, passed to the oncoming nurse. No further follow up until: c. 12/17/21 at 2:50 PM, nurses note - found the resident to have two blistered open areas to the 3rd and 4th digits of the right hand. Faxed the physician and called the residents family about the situation. d. 12/21/21 at 6:25 PM, nurses note - signed fax received regarding dressing to the open areas to the right hand/fingers. Order: [MEDICATION(S)] cream (antibiotic cream used to prevent and treat wound infections in 2nd and 3rd degree [CONDITION(S)]) to open areas daily, cover with [MEDICATION(S)], and wrap with cast padding and coban to keep from getting wet. The document titled Skin & Wound Evaluation dated 12/17/21 at 11:37 AM identified: Description: blister Location: right hand, 4th digit (ring finger) Acquired: in house on 12/17/21. Wound measurements: Length 2 centimeters (cm) x Width 3.6 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: blank. Evidence of infection: increased pain. Other: ruptured serum filled blister. Exudate: light amount of sanguineous/bloody and no odor. Peri-wound: edges attached, appeared flush with the wound bed or as a sloping edge. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: cognitively impaired. Breathing normal. Negative vocalization: occasional moan or groan, low level of speech with a negative or disapproving quality. Facial expression: sad/frightened/frown. Body language tense, distressed, & fidgeting. Consolability: distracted or reassured by voice or touch. Pain Score - 4. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, non-adherent synthetic and other. Secondary dressing, dry. Modalities, none. Additional care, none. Progress: new Notifications: Physician and responsible party notified. Picture included contained open blistered areas to the 3rd & 4th digits. The document titled Skin & Wound Evaluation dated 12/23/21 at 8:17 AM revealed: Description: blister Location: right hand, 4th digit (ring finger) Acquired: in house on 12/17/21. Wound measurements: Length 1.8 cm x Width 1.2 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: 100% granulation (new tissue). Evidence of infection: none. Other: none. Exudate: none. Peri-wound: edges attached, appeared flush with the wound bed or as a sloping edge. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: 0. Orders: goal of care, healable. Treatment: dressing appearance, dry and intact. Cleansing solution, normal saline. Debridement, none. Primary dressing, non-adherent synthetic and other. Secondary dressing, dry. Modalities, none. Additional care, compression and other. Progress: improving. Picture included contained open blistered areas to the 3rd & 4th digits. The record failed to show any measurements of the 3rd digit. Classifications of [CONDITION(S)]: a. First degree (superficial) burn - affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and often consists of an increase or decrease in the skin color. b. Second degree (partial thickness) burn - involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. c. Third degree (full thickness) burn - destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred. d. Fourth degree burn - go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed. The document titled Food Temperature log dated 12/15/21 revealed the temperature of the starch (mashed potato) at the supper meal tempted at 203 degrees prior to the meal service. Observation on 12/21/21 at 11:49 AM revealed the resident in room with 2 staff present, crying out. Staff attempted to calm the resident and propelled the resident in the wheelchair to the front door and then to the back hall of the facility. The resident continued to cry out off and on. Observation showed a tan colored dressing to the residents 3rd & 4th digits of the right hand. Observation on 12/21/21 at 12:10 PM, revealed the resident sitting up in wheelchair with head rest in place, leaning back and forth with arms moving about with no intention. The resident did not have any food or fluids present. Observation on 12/21/21 at 12:15 PM, nursing staff sat with Resident #1 and the resident received her food. The nursing staff turned the resident's back to the table and assisted with dessert. Resident #1's arms moved about frequently without purpose and reached out to staff while they assisted the resident with eating. Temperature of the noon meal on a test tray served in the dining room on 12/21/21 at 12:20 PM revealed: the chicken tamale casserole 160 degrees Fahrenheit and the stewed tomatoes 166 degrees Fahrenheit. Observation on 12/21/21 at 1:30 PM revealed the resident lying on back, in bed holding electric toothbrush in mouth with the bed in the lowest position and beveled padded mat beside it, touch call light within reach. Observation on 12/22/21 at 11:57 AM revealed start of the noon meal service. Staff first served the residents able to eat independently and at times informed the residents to be careful the food would be hot. At 12:05 PM, two nursing staff sat with 2 residents and awaited for the meal delivery. At 12:07 PM, staff assisted the residents eat dessert and while in between bites of dessert, staff stirred the main meal pureed hot food. The staff continued to stir the hot food off and on while feeding the resident dessert. At 12:15 PM, one staff member turned to the other staff member to ask if the hot food had cooled off. The staff member leaned over to look at the food from an angle, stirred again and then assisted the resident to eat the hot food. Observation on 12/22/21 at 8:15 AM, revealed Resident #1 in wheelchair in room listening to music on an IPad. The resident appeared well groomed, alert, and looked out the window. Observation showed a tan colored dressing in place to 3rd & 4th digits right hand. Observations on 12/22/21 at 1:49 PM of the medication and treatment carts with the DON revealed Resident #1 did not have a tube or container of [MEDICATION(S)] cream. The DON reviewed the pharmacy delivery log and stated the resident did not have [MEDICATION(S)] cream delivered. The DON stated the facility did not use stock supply of [MEDICATION(S)] cream. Therefore indicating the resident had not received the [MEDICATION(S)] burn Cream the physician ordered on 12/17/21 (5 days prior). Observation on 12/22/21 at 4:35 PM, revealed Resident #1 lying in bed on right side with tan colored dressing to 3rd & 4th digit right hand. Resident #1 had her hands up by her mouth. Observation on 12/27/21 at 9:28 AM, revealed Resident #1 in wheelchair in main dining room with head rest in place. The DON assisted the resident with eating and the resident hollered out off and on. Observation showed no dressing in place to the right hand. The DON stated the resident removed the dressing and refused to allow observation of fingers. The resident pulled the hand away and formed a fist. Observation on 12/27/21 at 12:05 PM, with the DON, revealed dark pink, pale red colored nickel sized areas to the 3rd and 4th digits of the right hand. The nickel sized area to both fingers revealed peeling skin, no drainage, no yellow slough, and no increased redness. On 12/21/21 at 12:23 PM, the family member for Resident #1 stated the facility notified her of the incident on 12/17/21. Staff informed the family an incident occurred a couple of days prior resulting in blisters. The family member stated staff informed her ointment was being applied to the affected areas and the fingers wrapped. The family member stated she did not know if Resident #1 saw the physician. The family member stated she arrived at the facility on 12/18/21, however, Resident #1 sleeping. The family member stated she attempted to look at the resident's right hand, however, the resident pulled back when touched. The family member stated she believed the resident pulled back due to not wanting the area touched and the area tender. The family member stated the 3rd & 4th digits of the right hand appeared burned, looked irritated and red, and no dressing in place. The family member stated the staff assisted the resident with eating as the resident could not feed self. The family member expressed concern regarding staff failure to notify her of the burn incident for 2 days and why the resident did not see a doctor or go to the hospital if the burn was that bad. The family member stated staff informed her that staff placed the mashed potatoes beside the resident and the resident placed her hand in the mashed potatoes. The family member questioned why the mashed potatoes would be that hot. The family member stated she had been informed the blistered areas had gotten redder, the physician notified and why the facility decided to treat the [CONDITION(S)] to the 3rd and 4th digits. The family member stated the [CONDITION(S)] should have been treated initially when the burned occurred on 12/15/21. On 12/21/21 at 1:41 PM, Staff A Certified Nurse's Aide (CNA) confirmed working on 12/15/21 when Resident #1 burned fingers on the right hand. Staff A stated he assisted another resident with his back to Resident #1 and heard the resident cry out and turned to see what occurred. Staff A stated the incident occurred at the supper meal, as his shift ended. Staff A identified Staff D CNA as with Resident #1 when he turned around. Staff D attempted to get the mashed potatoes off the residents hand. Staff A stated the damage had been done, however, unaware of injuries at the time the incident occurred. Staff A stated Resident #1 fidgets and moves hands and arms frequently. Staff A stated Resident #1 cries out frequently, however, unsure if crying related to pain, discomfort or behaviors. On 12/21/21 at 2:49 PM, Staff D CNA stated she assisted Resident #1 with the supper meal on 12/15/21. Staff D stated she sat with the resident when the food delivered and Staff D smoothed out the food to cool it off. Staff D stated Resident #1 reached out during meals, while feeding, and on 12/15/21 the resident swiped the mashed potatoes with her hand. Staff D stated Resident #1 cried out instantly when mashed potatoes touched. Staff D stated she took Resident #1 to Staff G Licensed Practical Nurse (LPN) immediately when the incident occurred. Staff D stated Staff G assessed Resident #1's fingers and requested the resident's hand placed in a basin with water. Staff D stated the resident allowed it for a few minutes and then placed fingers in mouth. Staff D stated she stayed with Resident #1 in room for approximately 30 minutes in an attempt to calm down the resident. Staff D stated during that time Staff G LPN checked on the resident. Staff D stated Resident #1's 3rd & 4th fingers turned red immediately after the incident occurred, however, Staff D did not observe blisters. Staff D stated she observed a red area on the tip of the finger to approximately the 1st knuckle. Staff D stated she worked on 12/18/21, and gave Resident #1 a bath and the resident had a dressing in place to the 3rd & 4th fingers. On 12/21/21 at 5:47 PM, Staff G LPN confirmed she worked on 12/15/21 when Resident #1 put her hand into the mashed potatoes at supper. Staff G observed the area and no redness or blisters were present. Staff G stated Resident #1 cried out and attempted to place fingers in mouth. Staff G stated the resident cried out in pain, however, refused pain medication. Staff G stated attempted to placed Resident #1's hand in water, however, the resident refused so Staff G used a cold wash cloth. Staff G attempted to administer as needed pain medication, however, the resident refused it. Staff G stated Staff D CNA stayed with Resident #1 in her room in an attempt to calm her down. Staff G stated the resident calmed down and Staff G checked on the resident while Staff D sat with the resident in her room and the resident continued to have no redness or blisters. Staff G stated she called the DON (Director of Nursing) due to Resident #1 not having redness or blisters and the DON directed Staff G to complete an incident report. Staff G stated she checked on Resident #1 throughout the night and no redness or blisters noted. Staff G stated reported to the morning shift on 12/16/21 what occurred and inability to reach the resident's family member and told day shift on 12/16/21, to call them. Staff G stated she worked the following day on 12/16/21 at 6:00 PM and checked Resident #1's hand. Staff G stated the little finger did not appear blistered but looked different. Staff G stated she did not document findings in the resident's medical record. Staff G stated unable to describe the appearance from 12/16/21. On 12/21/21 at 2:12 PM, Staff C LPN stated on 12/17/21 Staff F LPN questioned what treatment being done for Resident #1 due to putting fingers in mouth. Staff C stated observed Resident #1's 3rd & 4th fingers for the first time on 12/17/21, noted the skin peeled back, red, moist, and clear drainage. Staff C stated could tell the area contained blisters at one time. Staff C stated Staff F sent a fax to the physician and requested [MEDICATION(S)] cream, however, did not know if the physician ordered the treatment. On 12/21/21 at 3:39 PM, Staff F LPN identified first observing Resident #1's burnt fingers on 12/17/21. Staff F stated she notified Staff G LPN that Resident #1 had skin sloughing off the end of the 3rd & 4th fingers of the right hand. Staff F stated she worked as a CNA on 12/17/21, however, assessed the area with Staff C LPN. They took a picture, and sent a fax to the physician. Staff F stated she sent the fax and requested treatment for [MEDICATION(S)] cream. Staff F stated the fax returned the same day it was sent, with the signed [MEDICATION(S)] order and she gave the order to the nurse on duty for noting. Staff F stated on 12/17/21, herself and Staff C applied [MEDICATION(S)] cream and dressing to the [CONDITION(S)]. Staff F stated she did not know the signed order did not contain frequency for how often to complete the dressing change. Staff F stated the nurse on duty should have clarified the treatment order and placed it in the resident's electronic health record. On 12/21/21 at 1:54 PM, Staff B LPN stated she had been made aware of the [CONDITION(S)] to Resident #1's fingers on 12/18/21. Staff B stated the resident did not have a dressing in place on 12/18/21, so she applied a dressing at that time. Staff B stated the TAR (treatment administration record) did not contain a treatment order on 12/18/21, however, a fax had been sent to the resident's physician requesting [MEDICATION(S)] (antibiotic cream used to prevent and treat wound infections in 2nd and 3rd degree [CONDITION(S)]) so she applied [MEDICATION(S)] on 12/18/21. On 12/22/21 at 8:55 AM, Staff H LPN stated he worked on 12/18/21 and assisted to place a dressing on Resident #1's right hand 3rd & 4th digits. Staff H stated Resident #1 did not have a dressing in place at supper time and frequently put fingers in mouth. Staff H stated he assisted to clean the areas, placed [MEDICATION(S)], and wrapped with coban. Staff H stated no [MEDICATION(S)] applied on 12/18/21 when dressing placed. On 12/21/21 at 3:01 PM, Staff E CNA stated when Resident #1 assisted at meals, the resident would frequently reach out and move her arms around. Staff E stated Resident #1 frequently put fingers in her mouth and cried out. On 12/21/21 at 3:15 PM, the Director of Nursing (DON) stated Staff G LPN had called on 12/15/21 regarding Resident #1 putting fingers in mashed potatoes. The DON stated Staff G reported no injuries at the time and questioned if an incident report needed to be completed. The DON stated she requested incident report be completed in case an injury developed at a later time. The DON confirmed unable to reach the family member for Resident #1's on 12/15/21 when incident occurred, and not notified of the incident until 12/17/21. The DON confirmed no treatment order on the TAR for Resident #1. The DON verified the fax sent on 12/17/21 with signed order from the physician for [MEDICATION(S)] cream. On 12/22/21 at 8:30 AM, the DON stated Resident #1's treatment completed for the day. On 12/22/21 at 1:58 PM, Staff I Dietary Manager stated food is served from the steam table in the kitchen. Staff I stated supper is served at 5:30 PM and food is placed in the steam table approximately 30-45 minutes prior to service. Staff I identified the starch served on 12/15/21 as the mashed potatoes containing a temperature of 203 degrees prior to service. On 12/22/21 at 2:33 PM, the DON stated she called the local pharmacy and requested stock supply (for facility not an individual resident) of [MEDICATION(S)] cream and the pharmacy denied the order. The DON stated did not want to remove the resident's dressing due to not having [MEDICATION(S)]. The DON stated she called the delivering pharmacy and requested they deliver [MEDICATION(S)] cream. On 12/22/21 at 3:07 PM, the DON stated she attempted to remove the dressing on Resident #1's right hand while the resident laid in bed and the resident refused. On 12/28/21 at 4:15 PM, the DON stated when dietary delivers hot food to Resident #1, staff are instructed to keep out the food out of the resident's reach and added the intervention to the resident's care plan. The DON stated she made staff more cognizant as Resident #1 does move arms around frequently whether the resident is upset or not. The DON stated she was glad food came out of the kitchen hot, above the required temperature and not below temp. 2. The MDS assessment for Resident #2 with a completed date of 12/2/21, identified a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS revealed the resident required set-up and supervision for eating. The MDS revealed the resident required extensive assist of one staff for bed mobility, transfers, toileting, and personal hygiene. The MDS listed diagnoses of [CONDITION(S)], intellectual disabilities, and [CONDITION(S)] ([CONDITION(S)]). The Care Plan revised date of 12/23/21, identified the resident coughed on drinks & at risk for aspiration, required a mechanical soft diet with nectar thick liquids, had a history of drinking large amounts of fluids too fast & then vomiting, and at risk for [CONDITION(S)] with hot liquids. The care plan included the following interventions dated 12/23/21: provide hot fluids in blue weighted mug with lid, mug can be used for cold fluids as well and provide hot liquids half full and with a lid, let stand for 5 minutes to let the hot fluids cool slightly. The Care plan revised date of 8/25/21, identified the resident at risk for skin breakdown due to use of [CONDITION(S)] and suprapubic catheter. The care plan included an intervention dated 12/17/21, need a lid applied to coffee cup and occupational therapy to evaluate for possibility of need for adaptive equipment. The Incident report dated 12/17/21 at 9:00 AM, revealed: Nursing description: the resident in the dining room and the Administrator and a nurse heard the resident scream. The resident spilled coffee on lap while sitting at the table. Resident description: the resident unable to give description. Immediate Action Taken: the nurse assisted the resident to room immediately, changed pants, assessed the area for injury, and no immediate injury noted. The resident placed on 72 hour check for injury. A blister later noted and the physician notified for treatment orders. A lid to be placed on all coffee cups and Occupational therapy (OT) evaluated for possibility of adaptive equipment needed. OT screened and observed the resident on 12/18/21 and full evaluation completed 12/21/21. Injuries observed at time of incident: no injuries observed at the time of the incident. Level of Pain: left blank. Mental Status: left blank Injuries Report Post Incident: blister to front of the right thigh and blister to the front of the left thigh Level of Pain: left blank Mental Status: left blank Predisposing Environmental Factors: None. Predisposing Physiological Factors: impaired memory Predisposing Situation Factors: None. Witnesses: the Administrator and Staff F LPN Agencies/People Notified: the facility manager on 12/17/21 at 10:39 AM and the physician and family on 12/17/21 at 11:39 AM. The Progress Notes revealed: a. 12/17/21 at 10:51 AM, nurses note - the resident spilled coffee in lap this morning. The area reddened, no blisters noted. A fax sent to the physician. b. 12/19/21 at 4:10 AM, nurses note - [MEDICATION(S)] cream applied to the burn on the lap. The blister on the right thigh burst and healing appropriately. The area on the left thigh contained 3 fluid filled blisters. Continued to monitor. c. 12/23/21 at 2:36 PM, IDT (interdisciplinary team) note - blue weighted mug with lid for all hot liquids added to the care plan. d. 12/27/21 at 4:39 AM, nurses note - [MEDICATION(S)] cream applied to the burn on the resident's lap. The burn appeared to be dried and crusted. Continued to monitor. The document titled Skin & Wound Evaluation dated 12/17/21 at 3:50 PM, revealed: Description: blister Location: front of the left thigh Acquired: in house on 12/17/21. Wound measurements: Length 5.5 cm x Width 3.4 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: left blank. Evidence of infection: None. Other: intact serum filled blister. Exudate: none. Peri-wound: Edges, left blank. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: 0. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, other. No Secondary dressing. Modalities, none. Additional care, none. Progress: new. Picture included showed 2 fluid filled blistered areas. The document titled Skin & Wound Evaluation dated 12/17/21 at 3:51 PM, revealed: Description: blister Location: medial right thigh Acquired: in house on 12/17/21. Wound measurements: Length 4.2 cm x Width 1.2 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: left blank. Evidence of infection: None. Other: intact serum filled blister. Exudate: none. Peri-wound: Edges, left blank. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: 0. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, other. No Secondary dressing. Modalities, none. Additional care, other. Progress: new. Picture included showed 1 fluid filled blistered areas. The document titled Skin & Wound Evaluation dated 12/23/21 at 8:38 AM, revealed: Description: blister Location: front of the left thigh Acquired: in house on 12/17/21. Wound measurements: Length 8.0 cm x Width 3.6 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: 100% granulation. Evidence of infection: redness/inflammation. Other: ruptured serum filled blister. Exudate: light amount of serous (clear, slightly yellow) drainage. No odor noted after cleansing. Peri-wound: Edges, attached. Surrounding tissue dry/flaky and normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: 0. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, other. No Secondary dressing. Modalities, none. Additional care, other. Progress: improving. The document titled Skin & Wound Evaluation dated 12/23/21 at 8:37 AM, revealed: Description: blister Location: medial right thigh Acquired: in house on 12/17/21. Wound measurements: Length 2.8 cm x Width 1.4 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: 100% granulation. Evidence of infection: redness/inflammation. Other: ruptured serum filled blister. Exudate: light amount of serous drainage, no odor noted after cleansing. Peri-wound: Edges, attached. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: 0. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, other. No Secondary dressing. Modalities, none. Additional care, other. Progress: improving. Picture included showed 1 fluid filled blistered areas. Classifications of [CONDITION(S)]: a. First degree (superficial) burn - affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and often consists of an increase or decrease in the skin color. b. Second degree (partial thickness) burn - involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. c. Third degree (full thickness) burn - destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred. d. Fourth degree burn - go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed. The Treatment Administration Record (TAR) dated December 2021, contained an order with a start date of 12/18/21 for [MEDICATION(S)] Cream daily to the affected area/thighs daily for skin breakdown until 12/25/21. The Medication Administration Record (MAR) dated December 2021, revealed orders for: a. [MEDICATION(S)] 0.25 milligrams (mg) one time a day with a start date of 7/10/18. [MEDICATION(

Based on record and policy review, family and staff interview, the facility failed to notify the family &/or the residents' representative of a change in condition for 1 of 2 (Residents #1) residents reviewed that sustained a burn during a meal. The facility reported a census of 42 residents. Findings Include: The Minimum Data Set (MDS) for Resident #1 with a completed date of 11/23/21, identified the resident with severely impaired cognitive skills for daily decision making and the resident never/rarely made decisions. The MDS coded the resident as dependent on one staff for eating. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised date of 9/2/21, identified the resident received a pureed diet, did not have a good appetite, and cried or got upset at meals. The care plan included the intervention of total assistance with eating. The Care Plan revised 4/2/21, identified the resident unable to feed self independently related to spastic movements. The care plan directed staff to provide verbal cues to help prompt. The Care Plan revised 11/3/21, identified the resident at risk for pressure ulcers due to incontinence and poor intake. The care plan directed staff to observe skin daily with routine cares. The Incident report titled Injury dated 12/15/21 at 6:30 PM, revealed: Nursing description: the aide reported the resident stuck right hand in hot mashed potatoes Resident description: the resident unable to give description. Immediate Action Taken: placed cold rag on the resident right hand, assessed the resident, and obtained vital signs. Injuries observed at time of incident: no injuries observed at the time of the incident. Level of Pain: Numerical: 5 (0/10 scale with 10 being the worse pain). Level of Consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person. Injuries Report post incident: injury location right hand Level of pain: Numerical: 4. Level of consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person Predisposing Environmental Factors: None. Predisposing Physiological Factors: confused, impaired memory, and none. Predisposing Situation Factors: None. Witnesses: No witnesses found. Agencies/People Notified: Family member-attempt one on 12/15/21 at 7:41 PM, Physician on 12/16/21 at 4:48 AM, and Facility manager on 12/15/21 at 7:40 PM. The Progress Notes revealed: a. 12/16/21 at 4:02 AM, focused evaluation - during supper the resident accidentally put hand in food and the food appeared hot. No injuries noted at that time. The nurse attempted to place cold rag on the resident hand and the resident refused. The resident refused as needed pain medication. The Director of Nursing notified. Continue to monitor. b. 12/16/21 at 4:50 AM, nurses note - during supper the resident accidentally stuck right hand in food, mashed potatoes, and appeared hot. No injuries noted. The nurse attempted to place cold rag on hand and the resident refused. The resident refused pain medication. The DON and physician notified. Unable to reach the family, passed to the oncoming nurse. No further follow up until: c. 12/17/21 at 2:50 PM, nurses note - found the resident to have two blistered open areas to the 3rd and 4th digits of the right hand. Faxed the physician and called the residents family about the situation. d. 12/21/21 at 6:25 PM, nurses note - signed fax received regarding dressing to the open areas to the right hand/fingers. Order: [MEDICATION(S)] cream (antibiotic cream used to prevent and treat wound infections in 2nd and 3rd degree [CONDITION(S)]) to open areas daily, cover with [MEDICATION(S)], and wrap with cast padding and coban to keep from getting wet. Review of the clinical record revealed the facility failed to notify the residents' family &/or responsible party of the incident on 12/15/21 that resulted in a burn until 12/17/21. The document titled Point Click Care (PCC) Process: Risk Management revised date of 7/14/17 stated the purpose: to provide direction for entry of documentation in PCC. Action tab: a. Agency/People notified - choose from the drop down and add all agency's/people notified of the incident. b. Progress note - complete an incident/accident/unusual occurrence progress note that would generate into the progress note section of the residents permanent chart. This is a summary of the incident, injuries, and notification to the physician and the family. The Policy titled Change of Condition/Hot Chart Protocol dated January 2015 stated the purpose to provide care to the residents through nursing assessments, interventions, and appropriate follow-up. Definition: condition change is an alteration from normal status. Could include, but not limited to: accidents, incidents without without injury, noted reaction to medication, skin changes, vital sign changes, decreased urinary output, signs and symptoms of dehydration, physical decline in the resident's condition, cognitive &/or emotional changes in the resident. Guidelines: a. Observe/assess the resident to determine the resident's status b. Notify the attending physician as appropriate c. Notify the resident's family &/or responsible party d. Carry out new orders received e. Monitor the resident for response f. Establish the advanced directive status as needed Documentation: a. Date & time of the assessment and any intervention provided b. Date & time of the physician notification and if orders were received c. Date & time of the family &/or responsible party notification d. Observation and assessment of the resident, to include the response to the interventions until the problem resolves e. Signature and title On 12/21/21 at 12:23 PM, the family member for Resident #1 stated the facility notified her of the incident on 12/17/21. Staff informed the family an incident occurred a couple of days prior resulting in blisters. The family member stated staff informed her ointment was being applied to the affected areas and the fingers wrapped. The family member stated she did not know if Resident #1 saw the physician. The family member stated she arrived at the facility on 12/18/21, however, Resident #1 sleeping. The family member stated she attempted to look at the resident's right hand, however, the resident pulled back when touched. The family member stated she believed the resident pulled back due to not wanting the area touched and the area tender. The family member stated the 3rd & 4th digits of the right hand appeared burned, looked irritated and red, and no dressing in place. The family member stated the staff assisted the resident with eating as the resident could not feed self. The family member expressed concern regarding staff failure to notify her of the burn incident for 2 days and why the resident did not see a doctor or go to the hospital if the burn was that bad. The family member stated staff informed her that staff placed the mashed potatoes beside the resident and the resident placed her hand in the mashed potatoes. The family member questioned why the mashed potatoes would be that hot. The family member stated she had been informed the blistered areas had gotten redder, the physician notified and why the facility decided to treat the [CONDITION(S)] to the 3rd and 4th digits. The family member stated the [CONDITION(S)] should have been treated initially when the burned occurred on 12/15/21. On 12/21/21 at 3:15 PM, the Director of Nursing (DON) stated staff attempted to call Resident #1's family member on 12/15/21 when the incident occurred, however, unable to reach and no documentation of message left to return the call. The DON confirmed Resident #1's family not notified of the incident until 12/17/21. The DON stated the facility had difficulty reaching the family for Resident #1 at times, however, stated she expected the facility nursing staff to attempt multiple times to notify the family of the incident on 12/15/21. The DON stated she expected the facility nursing staff to follow-up on the incident on 12/16/21.

Based on observation, record and policy review, and staff interviews the facility failed to assure a complete and thorough follow-up assessment and intervention when a burn occurred for 2 of 2 residents reviewed (Resident #1 and Resident #2). The facility failed to complete a follow-up assessment of Resident #1's fingers on 12/16/21 following an incident on 12/15/21. The facility failed to implement the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to complete a thorough assessment of an identified skin impairment or follow up on 12/16/21 after the burn occurred, that required physician notification and treatment. The facility notified the physician of Resident #2 having a possible burn on 8/17/20, and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to investigate the cause of Resident#2's skin area which was a potential burn. On 12/17/21 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 42 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #1 with a completed date of 11/23/21, identified the resident with severely impaired cognitive skills for daily decision making and the resident never/rarely made decisions. The MDS coded the resident as dependent on one staff for eating. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised date of 9/2/21, identified the resident received a pureed diet, did not have a good appetite, and cried or got upset at meals. The care plan included the intervention of total assistance with eating. The Care Plan revised 4/2/21, identified the resident unable to feed self independently related to spastic movements. The care plan directed staff to provide verbal cues to help prompt. The Care Plan revised 11/3/21, identified the resident at risk for pressure ulcers due to incontinence and poor intake. The care plan directed staff to observe skin daily with routine cares. The Incident report titled Injury dated 12/15/21 at 6:30 PM, revealed: Nursing description: the aide reported the resident stuck right hand in hot mashed potatoes Resident description: the resident unable to give description. Immediate Action Taken: placed cold rag on the resident right hand, assessed the resident, and obtained vital signs. Injuries observed at time of incident: no injuries observed at the time of the incident. Level of Pain: Numerical: 5 (0/10 scale with 10 being the worse pain). Level of Consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person. Injuries Report post incident: injury location right hand Level of pain: Numerical: 4. Level of consciousness: alert. Mobility: wheelchair bound. Mental Status: orientated to person Predisposing Environmental Factors: None. Predisposing Physiological Factors: confused, impaired memory, and none. Predisposing Situation Factors: None. Witnesses: No witnesses found. Agencies/People Notified: Family member-attempt one on 12/15/21 at 7:41 PM, Physician on 12/16/21 at 4:48 AM, and Facility manager on 12/15/21 at 7:40 PM. The Incident report titled Injury dated 12/17/21 at 11:40 AM, revealed: Nursing description: the resident noted with blistered open areas to the 3rd and 4th digits right hand, unmeasurable due to the resident refusal. Resident description: the resident unable to give description. Immediate Action Taken: initial treatment [MEDICATION(S)] wrap (non-adherent dressing) with coban (self-adherent elastic wrap used to secure dressings). Injuries observed at time of incident: blister Level of Pain: section left blank Mental Status: left blank. Notes: blisters noted to the right 3rd and 4th digits Injuries Report Post Incident: no injuries observed post incident. Level of Pain: section blank Mental Status: section blank Predisposing Environmental Factors: None. Predisposing Physiological Factors: None. Predisposing Situation Factors: None. Witnesses: No witnesses found. Agencies/People Notified: Family member and Physician on 12/17/21 at 10:50 AM and Facility manager on 12/17/21 at 11:00 AM. The Progress Notes revealed: a. 12/16/21 at 4:02 AM, focused evaluation - during supper the resident accidentally put hand in food and the food appeared hot. No injuries noted at that time. The nurse attempted to place cold rag on the resident hand and the resident refused. The resident refused as needed pain medication. The Director of Nursing notified. Continue to monitor. b. 12/16/21 at 4:50 AM, nurses note - during supper the resident accidentally stuck right hand in food, mashed potatoes, and appeared hot. No injuries noted. The nurse attempted to place cold rag on hand and the resident refused. The resident refused pain medication. The DON and physician notified. Unable to reach the family, passed to the oncoming nurse. No further follow up until: c. 12/17/21 at 2:50 PM, nurses note - found the resident to have two blistered open areas to the 3rd and 4th digits of the right hand. Faxed the physician and called the residents family about the situation. d. 12/21/21 at 6:25 PM, nurses note - signed fax received regarding dressing to the open areas to the right hand/fingers. Order: [MEDICATION(S)] cream (antibiotic cream used to prevent and treat wound infections in 2nd and 3rd degree [CONDITION(S)]) to open areas daily, cover with [MEDICATION(S)], and wrap with cast padding and coban to keep from getting wet. The document titled Skin & Wound Evaluation dated 12/17/21 at 11:37 AM identified: Description: blister Location: right hand, 4th digit (ring finger) Acquired: in house on 12/17/21. Wound measurements: Length 2 centimeters (cm) x Width 3.6 cm. Depth not applicable (NA). Undermining NA. Tunneling NA. Wound bed: blank. Evidence of infection: increased pain. Other: ruptured serum filled blister. Exudate: light amount of sanguineous/bloody and no odor. Peri-wound: edges attached, appeared flush with the wound bed or as a sloping edge. Surrounding tissue normal in color. Induration none. No swelling or [CONDITION(S)]. Temperature normal. Wound Pain: cognitively impaired. Breathing normal. Negative vocalization: occasional moan or groan, low level of speech with a negative or disapproving quality. Facial expression: sad/frightened/frown. Body language tense, distressed, & fidgeting. Consolability: distracted or reassured by voice or touch. Pain Score - 4. Orders: goal of care, healable. Treatment: dressing appearance, none. Cleansing solution, normal saline. Debridement, none. Primary dressing, non-adherent synthetic and other. Secondary dressing, dry. Modalities, none. Additional care, none. Progress: new Notifications: Physician and responsible party notified. Picture included contained open blistered areas to the 3rd & 4th digits. A skin/wound evaluation dated 12/23/21 measured the 4th digit of the right hand: 1.8 cm. by 1.2 cm. The Physician notification fax form dated 12/17/21, identified the resident with blistered open areas to 3rd & 4th digit of the right hand. Staff requested order for [MEDICATION(S)] cream, cover with [MEDICATION(S)], wrap with cast padding and coban. The Physician agreed and signed the order on 12/17/21. The fax form lacked a facility nurse signature that the facility nursing staff noted the order. The Treatment Administration Record (TAR) dated December 2021, contained an order with a start date of 12/22/21 (5 days after physician order) for: [MEDICATION(S)] Cream daily to the open areas on the 3rd & 4th digits of the right hand, cover with [MEDICATION(S)], wrap in cast padding, and coban to keep from getting wet. Observation on 12/21/21 at 11:49 AM revealed the resident in room with 2 staff present, crying out. Staff attempted to calm the resident and propelled the resident in the wheelchair to the front door and then to the back hall of the facility. The resident continued to cry out off and on. Observation showed a tan colored dressing to the residents 3rd & 4th digits of the right hand. Observation on 12/21/21 at 12:10 PM, revealed the resident sitting up in wheelchair with head rest in place, leaning back and forth with arms moving about with no intention. The resident did not have any food or fluids present. Observation on 12/21/21 at 12:15 PM, nursing staff sat with Resident #1 and the resident received her food. The nursing staff turned the resident's back to the table and assisted with dessert. Resident #1's arms moved about frequently without purpose and reached out to staff while they assisted the resident with eating. Observation on 12/21/21 at 1:30 PM revealed the resident lying on back, in bed holding electric toothbrush in mouth with the bed in the lowest position and beveled padded mat beside it, touch call light within reach. Observation on 12/22/21 at 11:57 AM revealed start of the noon meal service. Staff first served the residents able to eat independently and at times informed the residents to be careful the food would be hot. At 12:05 PM, two nursing staff sat with 2 residents and awaited for the meal delivery. At 12:07 PM, staff assisted the residents eat dessert and while in between bites of dessert, staff stirred the main meal pureed hot food. The staff continued to stir the hot food off and on while feeding the resident dessert. At 12:15 PM, one staff member turned to the other staff member to ask if the hot food had cooled off. The staff member leaned over to look at the food from an angle, stirred again and then assisted the resident to eat the hot food. Observation on 12/22/21 at 8:15 AM, revealed Resident #1 in wheelchair in room listening to music on an IPad. The resident appeared well groomed, alert, and looked out the window. Observation showed a tan colored dressing in place to 3rd & 4th digits right hand. Observations on 12/22/21 at 1:49 PM of the medication and treatment carts with the DON revealed Resident #1 did not have a tube or container of [MEDICATION(S)] cream. The DON reviewed the pharmacy delivery log and stated the resident did not have [MEDICATION(S)] cream delivered. The DON stated the facility did not use stock supply of [MEDICATION(S)] cream. Therefore indicating the resident had not received the [MEDICATION(S)] burn Cream the physician ordered on 12/17/21 (5 days prior). Observation on 12/22/21 at 4:35 PM, revealed Resident #1 lying in bed on right side with tan colored dressing to 3rd & 4th digit right hand. Resident #1 had her hands up by her mouth. Observation on 12/27/21 at 9:28 AM, revealed Resident #1 in wheelchair in main dining room with head rest in place. The DON assisted the resident with eating and the resident hollered out off and on. Observation showed no dressing in place to the right hand. The DON stated the resident removed the dressing and refused to allow observation of fingers. The resident pulled the hand away and formed a fist. Observation on 12/27/21 at 12:05 PM, with the DON, revealed dark pink, pale red colored nickel sized areas to the 3rd and 4th digits of the right hand. The nickel sized area to both fingers revealed peeling skin, no drainage, no yellow slough, and no increased redness. The document titled Point Click Care (PCC) Process: Risk Management revised date of 7/14/17 stated the purpose: to provide direction for entry of documentation in PCC. Follow up documentation: a. All incident/accident/unusual occurrence follow up charting should be documented by using the evaluation Nursing Focused Evaluation b. Follow up charting should be completed every shift for 24-72 hours or until the resident stable. The facility document titled Change of Condition/Hot Chart Protocol dated January 2015 stated the purpose to provide care to the residents through nursing assessments, interventions, and appropriate follow-up. Definition: condition change is an alteration from normal status. Could include, but not limited to: accidents, incidents without injury, noted reaction to medication, skin changes, vital sign changes, decreased urinary output, signs and symptoms of dehydration, physical decline in the resident's condition, cognitive &/or emotional changes in the resident. Guidelines: a. Observe/assess the resident to determine the resident's status b. Notify the attending physician as appropriate c. Notify the resident's family &/or responsible party d. Carry out new orders received e. Monitor the resident for response f. Establish the advanced directive status as needed Documentation: a. Date & time of the assessment and any intervention provided b. Date & time of the physician notification and if orders were received c. Date & time of the family &/or responsible party notification d. Observation and assessment of the resident, to include the response to the interventions until the problem resolves e. Signature and title On 12/21/21 at 1:54 PM, Staff B LPN stated she had been made aware of the [CONDITION(S)] to Resident #1's fingers on 12/18/21. Staff B stated the resident did not have a dressing in place on 12/18/21, so she applied a dressing at that time. Staff B stated the TAR (treatment administration record) did not contain a treatment order on 12/18/21, however, a fax had been sent to the resident's physician requesting [MEDICATION(S)] (antibiotic cream used to prevent and treat wound infections in 2nd and 3rd degree [CONDITION(S)]) so she applied [MEDICATION(S)] on 12/18/21. On 12/21/21 at 2:12 PM, Staff C LPN stated on 12/17/21 Staff F LPN questioned what treatment being done for Resident #1 due to putting fingers in mouth. Staff C stated observed Resident #1's 3rd & 4th fingers for the first time on 12/17/21, noted the skin peeled back, red, moist, and clear drainage. Staff C stated could tell the area contained blisters at one time. Staff C stated Staff F sent a fax to the physician and requested [MEDICATION(S)] cream, however, did not know if the physician ordered the treatment. On 12/21/21 at 2:49 PM, Staff D CNA stated she assisted Resident #1 with the supper meal on 12/15/21. Staff D stated she sat with the resident when the food delivered and Staff D smoothed out the food to cool it off. Staff D stated Resident #1 reached out during meals, while feeding, and on 12/15/21 the resident swiped the mashed potatoes with her hand. Staff D stated Resident #1 cried out instantly when mashed potatoes touched. Staff D stated she took Resident #1 to Staff G Licensed Practical Nurse (LPN) immediately when the incident occurred. Staff D stated Staff G assessed Resident #1's fingers and requested the resident's hand placed in a basin with water. Staff D stated the resident allowed it for a few minutes and then placed fingers in mouth. Staff D stated she stayed with Resident #1 in room for approximately 30 minutes in an attempt to calm down the resident. Staff D stated during that time Staff G LPN checked on the resident. Staff D stated Resident #1's 3rd & 4th fingers turned red immediately after the incident occurred, however, Staff D did not observe blisters. Staff D stated she observed a red area on the tip of the finger to approximately the 1st knuckle. Staff D stated she worked on 12/18/21, and gave Resident #1 a bath and the resident had a dressing in place to the 3rd & 4th fingers. On 12/21/21 at 3:15 PM, the Director of Nursing (DON) stated Staff G LPN had called on 12/15/21 regarding Resident #1 putting fingers in mashed potatoes. The DON stated Staff G reported no injuries at the time and questioned if an incident report needed to be completed. The DON stated she requested incident report be completed in case an injury developed at a later time. The DON confirmed unable to reach the family member for Resident #1's on 12/15/21 when incident occurred, and not notified of the incident until 12/17/21. The DON confirmed no treatment order on the TAR for Resident #1. The DON verified the fax sent on 12/17/21 with signed order from the physician for [MEDICATION(S)] cream. The Director of Nursing (DON) stated expected the facility nursing staff to follow-up on the incident on 12/16/21. On 12/21/21 at 3:39 PM, Staff F LPN identified first observing Resident #1's burnt fingers on 12/17/21. Staff F stated she notified Staff G LPN that Resident #1 had skin sloughing off the end of the 3rd & 4th fingers of the right hand. Staff F stated she worked as a CNA on 12/17/21, however, assessed the area with Staff C LPN. They took a picture, and sent a fax to the physician. Staff F stated she sent the fax and requested treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff F stated the fax returned the same day it was sent, with the signed [MEDICATION(S)] order and she gave the order to the nurse on duty for noting. Staff F stated on 12/17/21, herself and Staff C applied [MEDICATION(S)] cream and dressing to the [CONDITION(S)]. Staff F stated she did not know the signed order did not contain frequency for how often to complete the dressing change. Staff F stated the nurse on duty should have clarified the treatment order and placed it in the resident's electronic health record. On 12/21/21 at 5:47 PM, Staff G LPN confirmed she worked on 12/15/21 when Resident #1 put her hand into the mashed potatoes at supper. Staff G observed the area and no redness or blisters were present. Staff G stated Resident #1 cried out and attempted to place fingers in mouth. Staff G stated the resident cried out in pain, however, refused pain medication. Staff G stated attempted to placed Resident #1's hand in water, however, the resident refused so Staff G used a cold wash cloth. Staff G attempted to administer as needed pain medication, however, the resident refused it. Staff G stated Staff D CNA stayed with Resident #1 in her room in an attempt to calm her down. Staff G stated the resident calmed down and Staff G checked on the resident while Staff D sat with the resident in her room and the resident continued to have no redness or blisters. Staff G stated she called the DON (Director of Nursing) due to Resident #1 not having redness or blisters and the DON directed Staff G to complete an incident report. Staff G stated she checked on Resident #1 throughout the night and no redness or blisters noted. Staff G stated reported to the morning shift on 12/16/21 what occurred and inability to reach the resident's family member and told day shift on 12/16/21, to call them. Staff G stated she worked the following day on 12/16/21 at 6:00 PM and checked Resident #1's hand. Staff G stated the little finger did not appear blistered but looked different. Staff G stated she did not document findings in the resident's medical record. Staff G stated unable to describe the appearance from 12/16/21. On 12/22/21 at 8:30 AM, the DON stated Resident #1's treatment to the 3rd & 4th fingers of the right hand completed for the day. On 12/22/21 at 8:55 AM, Staff H LPN stated he worked on 12/18/21 and assisted to place a dressing on Resident #1's right hand 3rd & 4th digits. Staff H stated Resident #1 did not have a dressing in place at supper time and frequently put fingers in mouth. Staff H stated he assisted to clean the areas, placed [MEDICATION(S)], and wrapped with coban. Staff H stated no [MEDICATION(S)] applied on 12/18/21 when dressing placed. On 12/22/21 at 1:58 PM, Staff I Dietary Manager stated food is served from the steam table in the kitchen. Staff I stated supper is served at 5:30 PM and food is placed in the steam table approximately 30-45 minutes prior to service. Staff I identified the starch served on 12/15/21 as the mashed potatoes containing a temperature of 203 degrees prior to service. On 12/22/21 at 2:33 PM, the DON stated she called the local pharmacy and requested stock supply (for facility not an individual resident) of [MEDICATION(S)] cream and the pharmacy denied the order. The DON stated did not want to remove the resident's dressing due to not having [MEDICATION(S)]. The DON stated she called the delivering pharmacy and requested they deliver [MEDICATION(S)] cream. On 12/28/21 at 4:15 PM, the DON stated when dietary delivers hot food to Resident #1, staff are instructed to keep out the food out of the resident's reach and added the intervention to the resident's care plan. The DON stated she made staff more cognizant as Resident #1 does move arms around frequently whether the resident is upset or not. The DON stated she was glad food came out of the kitchen hot, above the required temperature and not below temp. The record lacked assessment of the 3rd digit of the right hand. 2. The MDS assessment for Resident #2 with a completed date of 8/7/20, identified a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS revealed the resident independent with supervision for eating. The MDS revealed the resident required extensive assist of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised date of 2/5/19, identified the resident at risk for skin breakdown due to use of [CONDITION(S)] and suprapubic catheter. The care plan interventions included: encourage the resident not to scratch & seek assistance from the nursing staff for irritation as needed, encourage barrier cream morning and at bedtime, complete treatments as doctor ordered, if change in the condition of skin report to the charge nurse and the physician, monitor skin with routine cares & bathing, and offer/assist to apply lotion with routine cares. The Progress Notes dated 8/17/20 at 10:11 AM, order note - new order received for [MEDICATION(S)] Cream two times a day until healed to right thigh area of redness. The pharmacy and the family updated regarding the same. The Facility Fax Form sent to the physician dated 8/17/20, stated: reddened area noted to the right thigh, area raised and warm possibly due to coffee spilled or excoriation from bag leaking. Order requested to apply [MEDICATION(S)] cream to the area two times a day until healed. The physician signed the order on 8/17/20. The Treatment Administration Record (TAR) dated September 2020 revealed an order with a start date of 8/17/20 and discontinued date of 9/16/20, for [MEDICATION(S)] cream apply topically to right thigh redness two times a day until healed. The clinical record lacked documentation &/or assessment/investigation related to any skin impairments from 8/17 - 9/16/20. The facility document titled Change of Condition/Hot Chart Protocol dated January 2015 stated the purpose to provide care to the residents through nursing assessments, interventions, and appropriate follow-up. Definition: condition change is an alteration from normal status. Could include, but not limited to: accidents, incidents without injury, noted reaction to medication, skin changes, vital sign changes, decreased urinary output, signs and symptoms of dehydration, physical decline in the resident's condition, cognitive &/or emotional changes in the resident. Guidelines: a. Observe/assess the resident to determine the resident's status b. Notify the attending physician as appropriate c. Notify the resident's family &/or responsible party d. Carry out new orders received e. Monitor the resident for response f. Establish the advanced directive status as needed Documentation: a. Date & time of the assessment and any intervention provided b. Date & time of the physician notification and if orders were received c. Date & time of the family &/or responsible party notification d. Observation and assessment of the resident, to include the response to the interventions until the problem resolves e. Signature and title On 12/29/21 at 3:50 PM the DON stated she did not know of the [MEDICATION(S)] order dated 8/17/20. The DON stated staff completed skin assessments on paper at that time and not in the resident's electronic health record. The DON identified the only documentation related to a skin impairment for Resident #2 in the progress notes as the entry that stated the physician ordered [MEDICATION(S)] cream. The DON confirmed no documentation available related to an assessment or investigation of the skin impairment. On 12/30/21 at 7:55 AM, the Administrator stated she could not locate any additional documentation related to the skin impairment & order received on 8/17/20. The Administrator stated she could not determine the cause of the red area to Resident #2's thigh on 8/17/20 due to the lack of an assessment. The Administrator confirmed no skin assessments for Resident #2 related to the red raised warm area to the right thigh.

Based on observation, record review, family and staff interview the facility failed to provide outside resource dental services to meet the needs for 1 of 3 (Residents #1) residents reviewed. The facility reported a census of 42 residents. Findings Include: The Minimum Data Set (MDS) with a completed date of 11/23/21, identified Resident #1 with severely impaired cognitive skills for daily decision making and never/rarely made decisions. The MDS identified the resident displayed other behavioral symptoms not directed towards others included: hitting or scratching self, verbal/vocal symptoms like screaming and disruptive sounds on a daily basis .The MDS coded the resident being dependent on one staff for eating. The MDS listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident displayed indicators of pain or possible pain in the last 5 days; non-verbal sounds (crying, whining, gasping, moaning, or groaning). The MDS indicated the resident did not have dental concerns. The Care Plan revised 1/12/21, identified the resident with acute pain related to wisdom teeth and would often cry out when experiencing discomfort. The care plan interventions included: anticipate need for pain relief and respond immediately, evaluate the effectiveness of the pain interventions, enjoyed music from the radio to calm during episodes of pain, liked the vibrating tooth brush to bite down on in order to alleviate discomfort, monitor/document/report to the nurse as needed any signs or symptoms of non-verbal pain, notify the physician if the interventions unsuccessful, and at times liked to be wheeled around in wheelchair to look out the window. The Progress Notes revealed: a. 2/15/21 at 3:23 PM, nurses note - spoke to the resident's family member regarding need for dental exam. The family member agreed the resident would need sedation for exam and an oral surgeon referral b. 2/22/21 at 11:11 AM, nurses note - call placed to dental office regarding sedated dental exam for oral surgery referral. Appointment tentatively scheduled for 3/17/21. The Progress Note from the local dentist dated 3/17/21, stated: Problem: the resident needed referred for wisdom teeth extraction and would refer out. The family member present at the appointment wanted a referral for everything, not just wisdom teeth. The resident special needs and in a wheelchair. Evaluation: the physician able to do quick peek with mirror and the family member held the resident's head and hands. The resident uncooperative for the exam and unable to obtain x-rays. The resident had multiple carious [CONDITION(S)] (breakdown in the tooth surface, visible hole) and fractured teeth. The resident would need oral sedation. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Assessment/Plan: [CONDITION(S)], [CONDITION(S)], anxiety, dysmenorrhea, and dental pain. Monitor restlessness, continue current medications & therapies, and keep follow-up with oral surgery/dental. Review of the clinical record revealed the facility failed to arrange the follow up dental appointment &/or follow up with the residents' family regarding appointment options. Observation on 12/21/21 at 11:49 AM revealed the resident in room with 2 staff present, crying out. Staff attempted to calm the resident and propelled the resident in the wheelchair to the front door and then to the back hall of the facility. The resident continued to cry out off and on. Observation on 12/21/21 at 12:10 PM, revealed the resident sitting up in wheelchair with head rest in place, leaning back and forth with arms moving about with no intention. The resident did not have any food or fluids present. Observation on 12/21/21 at 12:15 PM, nursing staff sat with Resident #1 and the resident received her food. The nursing staff turned the resident's back to the table and assisted with dessert. Resident #1's arms moved about frequently without purpose and reached out to staff while they assisted the resident with eating. Observation on 12/21/21 at 1:30 PM revealed the resident lying on back, in bed holding electric toothbrush in mouth with the bed in the lowest position and beveled padded mat beside it, touch call light within reach. Observation on 12/22/21 at 8:15 AM, revealed Resident #1 in wheelchair in room listening to music on an IPad. The resident appeared well groomed, alert, and looked out the window. Observation showed a tan colored dressing in place to 3rd & 4th digits right hand. Observation on 12/22/21 at 4:35 PM, revealed Resident #1 lying in bed on right side with tan colored dressing to 3rd & 4th digit right hand. Resident #1 had her hands up by her mouth. Observation on 12/27/21 at 9:28 AM, revealed Resident #1 in wheelchair in main dining room with head rest in place. The DON assisted the resident with eating and the resident hollered out off and on. On 12/21/21 at 12:23 PM, the family member for Resident #1 stated the resident required sedation and requested x-rays completed at the hospital. The family member stated Resident #1 experienced pain and hurt related to the poor condition of the teeth. On 12/21/21 at 1:41 PM, Staff A Certified Nurse's Aide (CNA) stated the resident cried out frequently and unaware of why due to the resident's condition. Staff A stated she did not know if the resident cried out due to pain, discomfort, or behaviors. On 12/21/21 at 1:54 PM, Staff B Licensed Practical Nurse (LPN) stated she was aware Resident #1's family member wanted the resident to have dental services and recalled the resident needed to go to the hospital due to sedation required. Staff B did not know if the appointment had been made. Staff B stated she was unsure if the resident cried out due to behaviors or if related to teeth. On 12/21/21 at 2:12 PM, Staff C LPN stated she recalled on admission the resident's family member mentioned the resident cried out frequently due to wisdom teeth, however, unaware of details related to an appointment. On 12/22/21 at 8:55 AM, Staff H LPN stated she recalled Resident #1 went to a dentist and nothing done. Staff H stated when Resident #1 first admitted to the facility they applied [MEDICATION(S)], however, did not feel the [MEDICATION(S)] calmed the resident. Staff H stated the resident liked a vibrating toothbrush which seemed to calm the resident. On 12/27/21 at 3:06 PM, the DON stated Resident #1 went to a local dentist due to the resident's teeth requiring work. The DON spoke with the hospital due to the resident complexity and they informed the DON the resident would need a dental referral. The DON stated the local dentist could not complete a full evaluation. The DON stated she spoke with the hospital again and had been informed the resident would not be seen by the dental surgeon due to no full exam, however, full exam could be scheduled with them. The DON stated she had been informed the hospital scheduling out a year for full exams, April 2022. The DON stated she had left a message for the family member regarding wait time and did not receive a call back. The DON stated she had not followed up with the family member since March 2021.

Based on observation, policy review, record review, and staff interviews, the facility failed to use shin straps on an EZ Stand lift during a transfer, resulting in the resident's right foot coming off the foot plate and being wedged between the foot plate and recliner chair, causing fractures of the distal fibula, tibia, and fifth metatarsal in 1 of 3 residents reviewed for falls (Resident #26). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS), test identified the resident with a score of 9 indicating moderately impaired cognition. The MDS identified the resident transferred with extensive assist of 2 and did not walk. A care plan focus dated 3/5/19 and revised on 12/11/19, identified the resident with a problem of risk for injury related to weakness and immobility. The care plan revealed the resident did not walk and transferred with the EZ stand and assistance of 2. The care plan contained an intervention dated 12/6/19 (after discovery of fracture) that directed staff to ensure the resident's feet stay on the platform during the entire transfer when using the EZ stand. The EZ Way Smart Stand operator's instructions dated 7/30/18 directed the operator to apply shin straps prior to a transfer if deemed necessary. The facility did not have an EZ Stand policy. On 12/17/19, Staff F, LPN, (licensed practical nurse) typed a late entry progress note with an effective date of 11/28/19 at 12:31 pm which revealed Staff F assessed Resident #26 following a CNA (certified nurse aide) report that the resident stepped off the EZ Stand lift foot plate and then reported discomfort to the foot. Staff F, LPN, documented the resident's feet appeared without discoloration, had 1+ [MEDICAL CONDITION] to both lower extremities, and following a massage, the resident denied pain. The record contained no other documentation of any assessment of the feet in the nursing progress notes until 12/6/19. On 1/21/20 at 4:25 pm, Staff F, LPN, verified that a CNA, uncertain of which CNA, notified him on 11/28/19 of the resident stepping off the footplate of the EZ Lift with the right foot. Staff F reported he went directly to the resident's room to assess her and found the resident seated in her recliner with feet elevated on the foot rest. Staff F said he assessed range of motion (ROM) to the right foot as well as signs of visible injury and noted no problems with ROM and no abrasions or bruising. Staff F stated the [MEDICAL CONDITION] observed would not be unusual for the resident. The resident reported pain which subsided with massage to the right foot. The resident also received a scheduled pain medication around this time. Resident #26 informed Staff F her foot caught under the lift during the transfer. Staff F stated he did not feel the resident sustained [REDACTED]. He also did not document anything in the progress notes. On 1/23/20 at 8:27 am during a phone interview, Staff F reported the daughter of Resident #26 visited on 11/28/19. He did not recall informing the daughter of the incident. He stated he verbally informed the oncoming nurse in report of the resident's incident with the lift. On 1/22/20 at 11:00 AM, Staff D, CNA, reported she operated the EZ lift on 11/28/19 when the resident's foot came off of the platform. An agency CNA assisted but did not witness the resident's foot come off the lift. As Staff D pushed the resident in the lift to the resident's recliner, the resident yelled. Staff D stopped and noticed the resident's right foot came off the back of the footrest platform. She observed the top of foot wedged against the back of the platform and bottom of the foot against the recliner with the toes pointed towards the floor. Staff D reported noting no signs of injury, specifically no marks or bruising on the foot. Staff D placed the resident's foot back on the platform and completed the transfer. The resident bore weight without difficulty or report of pain. She positioned the resident in the recliner and then immediately notified Staff F, LPN, of the incident. Staff D reported she did not have the leg/calf straps in place to secure the resident's feet/legs while on the lift. On 1/23/20 at 8:17 am, Staff D reported the resident's daughter visited an hour or an hour and a half after the resident stepped off the EZ Stand and came to Staff D to clarify what occurred because the resident informed the daughter she fell . Staff D stated she informed the daughter no fall occurred and then informed her of the incident. A verbal employee coaching document for Staff D, Certified Nursing Assistant (CNA), completed by the Director of Nursing (DON) and dated 12/6/19 recorded that that the expectation is that the leg strap is to be used with all EZ Stand transfers. The coaching document also indicated that Staff F, Licensed Practical Nurse (LPN), addressed the expectation of the leg strap being used with Staff D on 11/28/19. In addition, a Five Minute Meeting for Employees sheet dated 12/18/19 stated that the leg strap is to be used with all EZ Stand transfers. On 1/23/19 at 8:10 am the DON and administrator stated the DON completed the Five Minute Meeting and the verbal employee coaching documents because the expectation is, and had been at the time of the incident, for staff to secure the leg straps on the EZ Stand. On 1/22/20 at 6:20 pm, Staff G, LPN, reported working the 6 pm to 6 am shift from 11/28/19 to 11/29/19 and received report from Staff F, LPN, hours after the EZ Stand incident occurred on Staff F's shift. Staff G stated she could not recall that Staff F informed her the resident stepped off the lift earlier in the day. Staff G felt if he received the information in report that he would have assessed the foot/leg if he had known about the resident stepping off the lift. On 1/22/20 at 9:15 am, Staff C, LPN, who worked the 6 am to 6 pm shift on 11/29/19, the day following the lift incident, stated she received nothing through report about the lift incident and nothing was documented about the lift incident until weeks later. On 1/22/20 at 5:50 pm, Staff C stated she would have assessed the resident's foot on 11/29/19 if she had known of the resident's foot coming off the lift. The Director of Nursing (DON) and the Administrator stated on 1/23/20 at 8:10 am, they did not have knowledge of the resident stepping off of the lift from 11/28/19 until 12/6/19. Clinical record review revealed no right foot/leg assessments documented following the late entry note on 11/28/19 through 12/5/19. Staff F, LPN, documented the late entry on 12/17/19. The Treatment Administration Record (TAR) contained pain assessments from 11/28/19 through 12/5/19. Staff documented the resident without pain. The MDS pain interview, completed on 12/3/19 on a pain evaluation form and signed on the MDS on 12/4/19, revealed that the resident answered that over the preceding 5 days she had occasional pain, rated a 4 on a 0-10 scale at its worst, and that the pain did not affect sleep or day-to-day activities. The pain evaluation form did not indicate where on the body the resident felt pain. Resident #26 received showers on 11/30/19 and 12/4/19, and the skin assessments completed by CNAs with the showers noted no skin concerns, such as discoloration. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Following the fracture [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. On 1/23/20 at 8:10 am, the DON reported doing rounds with the resident's PCP (primary care physician) on 12/4/19. The physician moved the resident's feet around, while assessing [MEDICAL CONDITION], without the resident verbalizing any discomfort. The DON reported she was not aware of the incident on 12/4/9 so she did not notify the physician of the resident stepping off the lift. A nursing home visit progress note signed by the physician on 12/4/19 identified the resident's extremities as weak with no standing or walking. The physician did not change any orders after the visit. Progress notes revealed Staff C, LPN, documented on 12/6/19, in the progress notes that Resident #26's right ankle contained an 11 centimeter (cm) by 7 cm bruise along the anterior aspect of the ankle that appeared to have been there for a few days. The resident voiced increased pain in the right foot and not able to bear weight on the ankle. The facility notified the PCP who ordered an x-ray of the right foot and ankle. The findings of the x-rays, dated 12/6/19, included: non-displaced fractures of the distal fibula, tibia, and the fifth metatarsal. The on-call physician, updated 12/6/19 on the x-ray results, ordered an ace wrap and non-weight bearing status to the right lower extremity and set up an appointment with the orthopedic doctor. Staff C also updated the resident's son. The 12/6/19 x-ray report revealed a history of bruising, pain and unable to bear weight. The findings included: 2 views of the right ankle demonstrated vertically oriented fracture through the medial malleolus. There was also a [MEDICATION NAME] fibula. Considerable tissue swelling noted. 2 views of the right foot demonstrated soft tissue swelling over the dorsum of the foot on lateral view. The previously described tibia and fibular fractures were not well visualized. however there appeared to be an acute [MEDICATION NAME] fracture at the base of the fifth metatarsal. Old second and third metatarsal fractures noted. Following the x-ray, the physician ordered an ace wrap for support and nonweight bearing to the lower right extremity. An appointment was arranged with an orthopedic physician. On 12/11/19 the orthopedic physician saw the resident for the right foot and ankle injury. the physician documented the resident injured the right foot and ankle a few weeks ago. The nursing home staff attempted to transfer the resident from wheelchair to recliner and somehow the resident fell and got the foot and ankle drawn up underneath her and when she landed, it further complicated things. The resident thought the nurse fell on the ankle. Due to increasing pain and swelling of the ankle over the ensuing few days, a mobile x-ray was performed which showed a bimalleolar [MEDICAL CONDITION] as well as a proximal fifth metatarsal fracture. The physician stated he would treat the fractures conservatively and continued the ace wrap and also initiated a boot. The resident could bear weight for transfers. Staff should use ice and elevate the right foot and ankle as needed. The resident should return in 6 weeks. On 1/22/20 at 9:15 am, Staff C, LPN, stated she assessed the resident on 12/6/19 following CNAs reporting that the resident complained of pain and did not bear weight. She reported the bruise looked as if it was there a few days but no staff reported any bruising prior to 12/6/19. Staff C completed an incident report and notified the DON after she received the x-ray reports. She also notified the resident's son. Staff C stated when she updated the son, he said he visited earlier in the day and the resident did not make mention of pain or foot concerns. On 1/22/20 at 11:00 am, Staff D, CNA, reported the resident had a slight bruise to her right foot on 12/5/19 but she did not notify anyone. Staff D reported the resident voiced no complaints of foot or leg pain to her from the initial 11/28/19 incident with the lift through 12/5/19. On 1/22/20 at 12:00 pm the DON reported the physician completed the major injury determination form as not a major injury (the resident should return to prior functional status) so the facility did not self-report it. Record review showed that Staff C, LPN, completed an incident report on 12/6/19 with nothing documented as to cause of the fractures. The major injury determination form, completed on 12/7/19 listed the fractures to the distal fibula, tibia, and fifth metatarsal as the injuries with circumstances of the incident causing the injury as: transfer with EZ Stand. The Administrator wrote in unknown for the date and time of the injury. On 1/22/20 at 4:50 pm, the Administrator stated she began the investigation on 12/6/19 as to the cause of the fractures. The electronic health record contained no documentation for the resident as to any incident which may have caused the injuries. She discovered the resident stepped off of the platform of the lift but did not know the definite day/time when she completed the form. She stated she wrote the EZ lift as the cause of the injury because the resident stepping off the lift was the only possible cause she could find; the resident did not move much on her own to cause a fracture. Clinical record review revealed Resident #26 with an appointment with the orthopedic physician on 12/11/19. The dictated physician report revealed the resident's daughter accompanied the resident to the appointment. The physician documented moderate swelling and bruising consistent with the injuries. The physician chose conservative treatment and placed the resident in a low tide boot walker since the resident did not walk. On 1/23/20 at 10:40 am, the orthopedic physician reported vaguely remembering Resident #26 coming into his office. He was at a different clinic without access to the resident's records. He stated that generally speaking, if an injury occurred causing the fractures that the resident has, he would expect pain initially but bruising can be delayed. It is conceivable that scheduled pain medication and the resident being non-ambulatory could delay pain. Observation: On 1/21/20 at 1:32 p.m. the resident stated her right leg broke. She stated a lady tried to get her from one the chair to another and the lady slipped and landed on the resident's leg. The resident denied falling. On the same date at 1:35 p.m. observation showed 2 staff use the stand lift to stand the resident for incontience cares. The resident hung onto the lift with her upper extremities and did not bear full weight on the lower extremities. Staff used the shin/leg strap and all other straps required for the transfer.

Relates to # -I: Based on record review, physician interview, and staff interviews, the facility failed to adequately and timely assess and provide interventions for 1 of 2 residents with fractures (Resident #9). The facility reported a census of 52 residents. Resident #9 experienced a fall and staff then performed an assessment. The resident began to experience a decline in condition and staff did not adequately and timely reassess range of motion with the change in condition. Although the resident had an upper respiratory infection, the resident also could not bear weight and moaned with pain during range of motion exercises. It was determined the resident had a [MEDICAL CONDITION]. Finding include: 1. Resident #9 had a Minimum Data set (MDS) assessment with a reference date of 5/29/13 which identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two staff for transfers and walking. The MDS documented the resident received scheduled pain medication. The care plan with a target date of 4/2/13 identified a problem for at risk of pain regarding to decreased mobility. The goal reflected the resident would have no signs or symptoms of pain. The approaches directed staff to monitor for signs and symptoms of pain; facial grimacing, guarding, crying, moaning, etc. The care plan with a target date of 4/2/13 documented the resident required one assist for activities of daily living. The Activity of Daily Living used by the Certified Nursing Assistants Plan of Care dated 4/26/13 required extensive assistance of two staff for bed mobility and one staff member to provide extensive assistance for transfers. The Pain Evaluation dated 5/30/13 documented the resident exhibited no pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received as needed APAP once on the 13th, 14th, 15th, 16th, 17th, and the 18th for a fever. The Restorative Program Flow Sheet for June 2013 documented the resident walked to meals once to twice a day until 713/13, the day after the resident fell . The resident refused on 6/4/2013 and at the noon meal on 6/7/2013. The Nurse's Notes dated 6/12/13 at 10:00 p.m. documented the resident fell and sustained a bump on the left side of the forehead. The resident complained of head pain. Staff Q, Licensed Practical Nurse, obtained vital signs and assessed range of motion of the extremities. At 10:30 p.m. Staff Q spoke with the resident's family. At 10:40 p.m. the resident had a .7 by .4 abrasions to the resident's left forehead. The Nurse's Notes dated 6/13/13 at 2:00 a.m. documented staff continued with neurological checks and the resident complained of discomfort. A neurological assessment included vital signs, pupil evaluation, consciousness, speech, and response to pain or environment, presence of [MEDICAL CONDITION], headache, and vomiting. During an interview on 7/2/13 at 3:07 p.m. the Director of Nursing (DON) stated after a fall, staff assesses the resident and documents vital signs, head to toe assessment, pain assessment, range of motion, and a skin assessment for at least 72 hours after the fall. For unwitnessed falls or falls with head trauma, the documentation would include a neurological assessment. The Nurse ' s Notes dated 6/13/13 at 11:08 a.m. documented the physician responded to the facsimile regarding the fall. At 7:00 p.m. the Nurse's Notes documented the resident had a fever and the nurse gave APAP (The neurological assessment continued. The Nurse's Notes dated 6/14/13 at 10:00 a.m. documented the physician ordered a urinalysis. At 9:45 a.m. the Nurse's Notes documented vital signs and the resident had a fever. The neurological assessment continued. At 11:00 a.m. the physician responded " No new order " to a facsimile regarding the resident noted on the floor. For the 5:00 p.m. to 5:00 a.m. shift the resident did not have a fever and did not complain of pain. The Nurse's Notes dated 6/15/13 at 2:00 p.m. documented vital signs, a lack of [MEDICAL CONDITION], and clear lung sounds. At 8:30 p.m. the notes documented the resident had no cough, no [MEDICAL CONDITION], and had no complaints of pain. The charting 72 hours after the resident's fall failed to address range of motion assessments and failed to consistently assess pain. The Nurse's Notes dated 6/16/13 at 2:00 p.m. indicated the resident up in chair for meals in room. The family fed resident for breakfast and staff fed the resident at lunch due to poor appetite. The notes documented the resident had diminished lung sounds, hypoactive bowel sounds, no cough, and no [MEDICAL CONDITION]. The notes documented bruising around the left eye. The resident opens eyes to verbal stimuli. More alert at lunch. Fluids were encouraged for lunch with only sips taken. At 3:15 p.m. the notes documented staff administered APAP ([MEDICATION NAME]) for a fever. The resident very sleepy at this time but answered questions and opens eyes to loud stimuli. At 8:30 p.m. the notes documented the resident had diminished lung sounds, non-distended abdomen, and no cough. The Nurse's Notes dated 6/17/13 at 1:00 p.m. documented staff obtained a urine sample and was given APAP 1000 milligrams for joint pain. The Nurse's Notes dated 6/18/13 at 2:30 a.m. documented the resident had no fever and sat up for the evening meal. At 4:20 p.m. staff contacted the resident's physician to inform him the resident had wheezes in the lungs, runny nose, cough, and very sleepy. The physician ordered a chest x-ray and an antibiotic. At 5:30 p.m. the notes documented portable x-ray obtained the chest x-ray. At 7:30 p.m. the notes documented vital signs, diminished lung sounds, and a cough. The Nurse ' s Notes on 6/19/2013 at 4:10 p.m. the notes documented vital signs and had clear lung sounds. At 8:00 p.m. the notes documented vital signs, lung sounds, no cough, and no [MEDICAL CONDITION] to lower extremities. The Nurse's Notes dated 6/20/13 at 3:25 p.m. at 8:00 p.m. the notes documented vital signs, lung sounds, absence of [MEDICAL CONDITION], and active bowel sounds. The Nurse's Notes dated 6/22/13 at 2:00 a.m. documented the nurse aide reported the resident had pain in the groin area when turning on rounds. At 4:00 a.m. the notes documented the resident had no complains of pain. At 2:30 p.m. the notes documented vitals and diminished lung sounds. At 8:00 p.m. documented vital signs, lung sounds and had [MEDICAL CONDITION] in the resident lower extremities. The Nurse's Notes dated 6/23/13 at 4:05 p.m. documented vital signs; lung sounds and had a cough. The resident made multiple attempts to stand from the wheelchair. At 8:30 p.m. the notes documented vital signs, lung sounds and an absence of cough. The Nurse's Notes dated 6/24/13 at 2:15 p.m. documented vital signs, lung sounds, and an absence of a cough. The resident went out to lunch in dining room. At 2:30 p.m. the notes informed the family the resident is doing better. At 8:20 p.m. the notes documented vital signs, lung sounds, non-destined abdomen, and absence of [MEDICAL CONDITION]. The Nurse's Notes dated 6/26/13 at 7:00 a.m. documented the restorative aide informed the nurse the resident screamed during lower extremities range of motion and complained of left pelvic pain. Staff sent a facsimile to the physician. At 2:30 p.m. the physician ordered a pelvic x-ray. At 2:40 p.m. staff called portable x-ray. At 5:00 p.m. staff notified the resident's family of the skin tear and x-ray. At 5:50 p.m. portable x-ray obtained the pelvic x-ray. The Nurse's Notes dated 6/27/13 at 7:30 a.m. documented staff sent a facsimile to the physician regarding the x-ray. At 11:10 a.m. staff spoke to the resident's physician and the physician ordered the resident to transfer to the hospital at 12:10 p.m. An X-ray dated 6/26/13 documented a minimally displaced left subcapital femoral neck (hip) fracture. The hospital History and Physical report indicated the resident was seen in the emergency roiagnom on [DATE]. The report indicated the resident ' s symptoms occurred 27 days ago with associated injuries. The patient sustained injury to the head, contusion, hematoma, left hip, decreased range of motion, painful injury and she/she has been very lethargic and not up and around since the fall. The resident had been up and about with a walker until this incident on the first of June 2013. The plan was for surgical repair of the fractured left hip. The physician orders [REDACTED]. The Physician documented the resident did well with the surgical procedure and post operatively. On 7/2/13 at 9:05 a.m. Staff D, Certified Nursing Assistant and restorative aide was interviewed and stated she performed range of motion exercises on 6/17/13. Staff D stated she had not performed range of motion exercises since 6/14/2013 because the resident had an upper respiratory infection. Another staff person did exercises on the 19th and then and then she next saw the resident on the 21st since she/he was getting better. Staff D performed range of motion exercises in the resident's bed instead of in the wheelchair as the resident usually did. Staff D stated the Certified Nursing Assistants completed the walk to dine program but the assistants reported the resident had difficulty walking. On the 22nd and 23rd, Staff D assisted the transfer with the resident. It usually only took one staff member but the resident required more assistance and required two staff members. The resident could not bear weight as before. Staff D felt the resident had been ill but thought the resident had something more wrong. Staff D told Staff A, Licensed Practical Nurse, but Staff A informed Staff D the resident had difficulties due to recent illness. Staff D did not know if Staff A assessed the resident. On the 26th, Staff D completed range of motion exercises to the right leg but when she attempted to exercise the left leg, the resident screamed out in pain. Staff D informed Staff G, Registered Nurse. On 7/2/13 at 11:20 a.m. Staff C, Certified Nursing Assistant was interviewed and stated the resident had been sick. It took two staff members to transfer the resident and the resident usually walked to the bathroom and walked to meals. The resident had stopped walking. During an interview on 7/2/13 at 11:32 a.m. Staff E, Certified Nursing Assistants stated the resident required one staff person to transfer prior to the fall on 6/12/13. After the fall the resident required two staff members and did not bear weight. The resident complained of pelvic pain. Staff E reported the pain to the nurse. Staff E felt the resident had a broken bone and not simply sick with the flu. During an interview on 7/2/13 at 11:42 a.m. Staff B, Certified Nursing Assistant, stated the resident walked to the bathroom the night of the fall on 6/12/13 but four days later the resident required two staff members to transfer and had stopped walking. The resident would moan with movement. The resident's illness improved but continued to need two staff members to transfer. During an interview on 7/2/13 at 11:54 a.m. Staff F, Certified Nursing Assistant, stated the resident required one staff person for transfers prior to the fall but then required two staff members to transfer and no longer walked as the resident used to prior to the fall. During an interview on 7/2/13 at 1:43 p.m. Staff G, Registered Nurse, stated the resident required one or two staff and would not bear weight at times. On 6/13/13, Staff G continued with neurological checks. Staff G stated the Certified Nursing Assistants told her about the resident's difficulty to transfers. Staff G stated she did not complete a range of motion assessment. Staff G stated the resident appeared comfortable. The resident had a temperature and given Tylenol (APAP). During an interview on 7/2/13 p.m. at 2:14 p.m., Staff H, Certified Nursing Assistant, stated prior to the resident's fall, the resident easily transferred with one to two staff members. Staff G stated after the fall the resident could not bear weight during the transfer and stopped walking. During an interview on 7:2:14 p.m. Staff I Certified Nursing Assistant, stated prior to the fall, the resident transferred with one person and could walk. The nurse told her the resident was sick and to perform a bed bath. The resident complained of pain when lying on the left side when staff tried to roll the resident while doing the bed bath. Staff L stated she saw a decline in the ability to transfer and walk. After the fall, the resident required two staff members to transfer. During an interview on 7/2/13 at 2:28 p.m. Staff J, Certified Nursing Assistant, stated prior to the fall, the resident transferred with one staff person, could stand, and walked. The resident had been talkative but during the bed bath would not talk just moaned. On 6/12/13, the nurse told her the resident was bedridden and to give the resident a bed bath. During the bath, the resident groaned and moaned when staff turned the resident. The resident was not talkative as before. The next bath day, Staff A told her to get the resident up for a shower. During the transfer to the shower room, the resident would not bear weight. Staff J stated the resident looked uncomfortable in the shower chair. Staff J stated she asked the resident if they had pain. The resident said no but continued to display non-verbal signs of pain. During an interview on 7/2/13 at 2:50 p.m. Staff K, Certified Nursing Assistant, stated prior to the fall the resident required one staff member but after the fall the resident required two staff members. The resident stopped talking and stopped walking. The resident moaned with movement. During an interview on 7/2/13 at 5:01 p.m. Staff L, Registered Nurse, stated prior to the fall, the resident walked and self- propelled in the wheelchair. After the fall, the resident complained of the head hurting. Staff L gave the resident Tylenol. Staff L stated after a fall, staff document lung sounds, bowel sounds, and presence of [MEDICAL CONDITION], pain assessment, and range of motion. Staff L stated staff obtained a hip x-ray on the 26th at 5:00 p.m. A return fax documenting the resident had a left [MEDICAL CONDITION] at 11:00 p.m. Staff L stated she did not call the physician but did send a facsimile regarding the fall prior to having the x-ray report.. Staff L stated she should have called the physician regarding the x-ray and obtained pain medication for the resident. On 7/2/2013 at 5:29 p.m., Staff M, Registered Nurse was interviewed and stated a few days after the fall, the resident required to be fed in room, not bearing eight and not transferring well. The resident had an upper respiratory infection. Staff M stated she asked the resident if she/he had pain and the resident replied " no " . Staff M stated she did not assess range of motion. After the resident fell , she/he did not attempt to stand from the wheelchair. The resident would put hands on the arm rests to stand but then would sit back down. During an interview on 7/3/13 at 9:10 a.m. Staff O, Certified Nursing Assistant stated prior to the fall, the resident required one staff member to transfer, walked, and talkative. After the fall, the resident required two staff members, did not walk, and did not communicate as the resident usually had. The resident had incontinence, and moaned with movement. Staff O spoke to Staff A. Staff A stated he had obtained a catheter urinalysis and the resident did not complain of pain. Staff O stated she continued to tell the nurses about the resident decline. Staff O stated staff thought the resident had the flu but Staff O believed the resident had something else wrong. During an interview on 7/3/13 at 9:29 a.m. Staff A, Licensed Practical Nurse, stated prior to the resident's fall, the resident walked, very talkative, and continent. After the fall, the resident would not bear weight during transfers. The Certified Nursing Assistants informed him the resident acted not like usual (unusual). Staff A stated another nurse obtained a urine sample through a catheter. Staff A stated he could not obtain the specimen because the resident was incontinent and normally she/he used the toilet and would alert staff. Staff A stated the resident did not complain of pain. Staff A did perform range of motion. During an interview on 7/1/13 at 10:40 a.m. the resident's physician stated he expected a phone call if resident had a fracture. The physician stated he would have ordered pain medication and bed rest until he spoke to the family on how to proceed. During an interview on 7/3/13 at 10:47 a.m. Staff P, licensed practical nurse, stated after the fall the resident did not eat well, less talkative and would not assist with transfers. Staff P stated she assessed for pain but did not perform range of motion. During an interview on 7/3/13 at 11:00 a.m. Staff Q, Licensed Practical Nurse, stated on 6/12/13 the resident's alarm sounded. When she got to the room, she performed range of motion. The resident complained of left inner thigh pain. Staff Q assisted the resident to the recliner at the nurse's station to perform neurological checks. Staff Q stated she did not further assess range of motion. Staff Q thought the decline in the resident's abilities to transfer and walk had been due to illness. Post fall documentation included pain assessment, activities of daily living, and neurological checks.

Based on record review and staff interviews, the facility failed to assess the resident with a change of condition and provide timely intervention by the notification to the physician for 1 of 2 discharged residents (Resident #6). The facility identified a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had an admission into the facility for skilled services due to a [DIAGNOSES REDACTED]. The MDS did not document the resident had a surgical wound, but the Resident Assessment-Data Collection Form/Initial Care Plan form completed on admission of 8/16/12 documented the resident had 32 intact staples to the left hip. The Transfer Sheet documented the resident to be only touch-toe weight bearing (TTWB) on the left leg and an appointment for the resident to have surgical follow-up on 8/29/12 at 10:00 AM. The Resident Initial Care Plan dated 8/16/12 directed staff to use 2 assistants to transfer the resident, the resident assisted/dependent for toileting and perineal care and utilized a wheelchair. This care plan did not identify the presence of a surgical wound. The Nurse's Notes entry dated 8/18/12 at 11:00 PM documented the resident's incision site with no signs of infection and the staples intact. The Nurse's Notes entry dated 8/20/12 at 8:00 PM documented the resident's incision site red but without drainage or warmth. The Nurse's Notes entry dated 8/22/12 at 1:00 AM documented the staples intact and no signs of infection of the incision. The Nurse's Notes entry dated 8/24/12 at 10:35 AM again documented the resident's left hip incision dry and intact with no drainage and the incision left open to air. The Nurse's Notes entry dated 8/27/12 at 10:25 AM documented the resident had 1-2+ [MEDICAL CONDITION] of the right lower leg and 2-3+ [MEDICAL CONDITION] of the left lower leg. The Notes documented the incision site with some redness around the site and had a few dry scabs. The next entry dated 8/28/12, no time documented, did not address the resident's incision site. The Nurse's Notes entry dated 8/29/12 at 4:10 AM documented the resident's wound had opened in a small area and staff cleansed the incision and placed a [MEDICATION NAME] pad over the area. This entry contained no further assessment of the resident. The Nurse's Notes entry dated 8/29/12 at 9:00 AM documented the resident left the facility for a follow-up appointment with the surgeon. At noon, staff documented the resident would not be returning to the facility as the resident would be having surgery this afternoon as the resident's left hip not in place. Review of the Nurse's Notes contained in the resident's clinical record revealed no documentation of a physical assessment of the resident's position and length of the left leg (as compared to the length of right leg) or physician notification of the opening of the incision as documented on 8/24/12, or physician notification of the noted [MEDICAL CONDITION] of the right and left leg as documented on 8/27/12. The Physical Therapy (PT) Daily Treatment Notes dated 8/20 and 8/22/12 documented the resident unable to maintain TTWB on the left leg. The PT Daily Treatment Notes signed by the physical therapy assistant (PTA) on 8/30/12 documented the resident unable to maintain TTWB on the left but provided sit-to stand-transfer training. The resident required the maximum assistance of 2 for completion of a stand pivot transfer to the bed and the resident continued to sit with the left lower extremity adducted and internally rotated. The treatment grid documented PTA treated the resident on 8/28/12 for a total of 75 minutes. Review of the clinical record revealed no physician notification of the resident's inability to maintain TTWB on the left leg and the noted adduction and internal rotation of this leg. On 9/6/12 at 3:45 PM, the resident ' s surgeon was interviewed and stated he saw the resident for a follow-up exam on 8/29/12 at the hospital. The examination revealed the resident's left leg as obviously shortened and internally rotated which is an indication of possible fracture or dislocation. The x-ray of the resident's left hip confirmed dislocation. The physician also stated the resident's left hip incision was infected, reddened and warm to the touch, with a fluid-filled bulge in the middle of the incision that leaked gross purulent thick drainage from under the staples in this area. The physician stated the incision appeared infected, even to the untrained eye, and the resident had a temperature of 102 degrees F. The physician stated the changes in the resident's incision did not happen overnight and he would have expected the facility nursing staff to notify him of any changes in the appearance. The physician stated he had to do surgery on the resident's left hip on the afternoon of 8/29/12 to drain the infection from the hip. During the procedure, he discovered the infection extended deep into the left hip and involved the hip prosthesis and a large amount of serous and dark fluid had to be removed. He also repeated the incision and drainage of the left hip on 8/31/12 and revised the resident's hip prosthesis. The physician stated if the resident could not maintain TTWB on the left leg he would expected to have been notified of this and would have ordered the resident to be non-weight bearing (NWB). The physician related the resident's family had told him they had witnessed the physical therapist and nursing staff stand the resident and they had related to staff the doctor had told them the resident should not stand on the left leg but were ignored. The physician stated he did educate the family in regards to the resident's condition and weight-bearing status and would have expected staff to clarify with him if a concern had been expressed by the family. The physician also stated he would have expected to be notified of any change in the length and/or positioning of the left leg and expected the nursing staff to assess the resident for length and positioning on a routine basis in order to recognize changes and provide prompt notification of abnormalities. On 9/24/12 at 4:55 PM Staff L (Licensed Practical Nurse) stated she assessed the resident and completed the Nurse's Notes entry on 8/29/12 at 4:10 AM which documented the resident's hip incision opened. Staff L stated the resident's incision line looked "pinkish" in color upon initial assessment earlier in her shift on 8/28/12 and had documented this finding in the untimed entry for 8/28/12. During the initial assessment, she observed blood on the resident's bed pad but the incision had not yet opened up but she did not document this finding in her entry in the resident's clinical record. Staff L stated she did not document her checks on the resident through the night but she reported the unusual finding to Staff F, Registered Nurse (RN), the oncoming nurse in the morning of 8/29/12 because she knew the resident had an appointment to see his/her physician. On 9/25/12 at 9:15 AM Staff F was interviewed and stated she could not recall if Staff L had reported the resident's incision had opened or if she had assessed the area prior to the time the resident left for an appointment with the surgeon on the morning of 8/29/12. On 9/25/12 at 10:00 AM Staff G, Physical Therapy Assistant (PTA), stated the resident had significant dementia and staff had difficulty in keeping the resident seated in a neutral position and the resident preferred to keep his/her left leg rotated and drawn inward to the body. Staff G also stated the resident could not maintain TTWB on the left leg independently so s/he required maximum assistance of 2 persons and the use of parallel bars to stand for very brief periods of time.

Based on record review, observations and staff and resident interviews, the facility failed to provide adequate nursing supervision to ensure against hazards from self and elements in the environment and the Director of Nursing failed to supervise the implementation of the written care plan for 3 of 5 residents (Resident #1, #2, #8). The facility reported a census of 55 residents. Findings include: 1. Resident #8 had an MDS (Minimum Data Set) assessment, with a reference date of 7/18/12 which identified a [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMS scored of 8 which indicated moderately impaired cognition. The MDS indicated the resident required extensive assistance for completion of transfers and ambulation. The MDS identified the resident as not steady with moving from a seated to standing position, walking, turning around, moving off the toilet or moving from one surface to another without staff assistance. The Care Plan dated 5/25/122 identified a problem with the resident to be at risk for falls due to poor safety awareness and impulsivity. The Care Plan directed staff to utilize bed and chair alarms. The Nurse's Notes entry dated 9/23/12 at 3:45 PM documented the resident was found sitting in the floor, leaning against the second door on the right side of the 200 hallway. The CNA reported she witnessed the resident enter the hallway from a room at the other end of the hallway with a front-wheeled walker and could not reach the resident before the resident turned, lost balance and stumbled backward and slid down the door and landed on the floor. The resident repeated "hurt, hurt, hurt" in stammered speech and could not bear weight on the right leg. Staff transported the resident to his/her room with a wheelchair and transferred the resident into bed. The facility notified the physician and the resident transported to the hospital at 4:10 PM. The physician history and physical hospital report dated 9/24/2012 indicated the resident had a right hip fracture and required an open reduction and internal fixation to repair the fracture. On 9/24/12 at 1:15 PM Staff K, agency CNA (certified nursing assistant) staff was interviewed and stated she worked the 2:00 PM-10:00 PM shift on 9/23/12 and had been assigned to the 100 hallway. Staff K stated the nurse requested she take the resident to his/her room on the 200 hall after an activity. Staff K stated the nurse instructed her to lay the resident in bed, but the resident refused and wanted to sit in the recliner. Staff K stated the nurse did not tell her the resident required an alarm. Staff K also stated she did not receive orientation to the facility/residents prior to the start of her shift and did not know each resident had a care card posted in the bathroom of each room. On 9/25/12 at 9:50 AM the facility's corporate nurse was interviewed and stated the facility did not have a formal agency (pool) CNA orientation until yesterday. She stated the facility developed a checklist to be completed for each agency CNA prior to starting their assigned shift and provided a copy of the checklist for review. 2. The admission MDS assessment dated [DATE] documented the [DIAGNOSES REDACTED]. The same MDS documented the residents with short and long term memory loss, required extensive assistance of two persons for transfer and ambulation, utilized a walker and a wheelchair, had experienced falls in the last 30 days and 31-180 days prior to admission on 8/13/12, and the facility utilized a trunk restraint daily in the 7 day assessment period ending 8/20/12. A Fall Risk assessment dated [DATE] identified the resident had a score of 18. A score of 10 or greater indicated the resident at high risk for falls. The Care Plan dated 8/13/12 identified a problem for at risk for falls. The goal with an end date of 12/5/12 established the resident would not experience any injuries related to falls. The approaches directed staff to use 1 assist for ambulation and to review the need for the trunk restraint at least every 30 days and document findings. The Care Plan did not address the resident ' s use of a Merry Walker, which is an assistive device used to promote ambulation for resident ' s at risk for falls. Observation on 9/4/12 at 9:20 AM revealed the resident ambulating back and forth in the 400 hallway while in a Merry Walker. Observation revealed the safety belt which is to be placed through the resident ' s legs to assist with breaking a fall off to side of the resident's right leg. Observation revealed the resident ambulating on the recently mopped wet side of the hallway. A sign marked " wet floor " stood in the hallway. The resident walked at a fast pace with short steps. Observation on 9/4/2012 at 11:25 AM revealed the resident placed him/herself in the Merry Walker with his/her left side against the wall between the treatment cart and a moveable water dispenser in the area of the 400 and 600 halls nursing desk. Observation revealed no staff at the desk or on the 600 hall. Observation revealed the resident lowered him/herself to kneel on the floor, placed hands on the floor and crawled out of the Merry Walker between the top and bottom support rails. The resident used his/her head to move the water dispenser out of the way and crawled on the floor in front of the nursing desk. At 11:28 AM. and at 11:30 AM Staff E, CNA entered the area from the 400 hall and assisted the resident off the floor, placed a gait belt around his/her waist and ambulated the resident to his/her room. Observation at 11:40 AM revealed the resident in a wheelchair with a pressure alarm and an alarmed seat belt in place. Observation revealed the resident moved the wheelchair with his/her feet or by pulling him/herself along the handrails in the hallway. On 9/6/12 at 10:00 AM, Staff G, PTA (Physical Therapy Assistant), stated the Merry Walker is a restraint but does allow the resident to move around independently and is less restrictive to the resident than a wheelchair. Staff G stated she posted a note at the nursing desk regarding the resident ' s trial use of the Merry Walker. Review of the note revealed the resident could be placed in the Merry Walker during times of restlessness but needed to be supervised to monitor for attempts to get out of it and if she/he attempted to get out of it, the resident should go back to the use of a wheelchair. The note requested staff notify the nurse of any attempts to escape the Merry Walker and the therapy department would communicate when the resident is safe to be left in the Merry Walker unsupervised. Staff G stated she had not been made aware that Resident #12 actually got him/herself out of the Merry Walker by crawling out between the bars, only reported the resident had only attempted to get out. Staff G further stated she would not consider the method of crawling out between the bars as a safe method for the resident to remove him/herself from the Merry Walker and she stated she had placed a bag on the front inside of the Merry Walker to hide the open space but had observed the bag not in place on Sunday (9/2/12), but put it back on today. Review of the Nurse ' s Notes entries for 9/4/12 revealed no documentation of the resident removing him/herself from the Merry Walker. Observation on 9/4/2012 at 2:55 PM revealed the Administrator pushing Resident #1 up and down the 100 hallway in the wheelchair. Observation revealed no wheelchair pedals in place and the resident's right toe of his/her shoe dragging on the floor. The Administrator then pushed the resident across the main lounge/dining area of the facility and down the 400 hall to the nursing desk for the 400 and 600 halls. Observation revealed the resident's left heel touched the floor while being pushed in the wheelchair. Observation on 9/5/12 at 11:17 AM revealed Resident #1 seated in a wheelchair and dependently pushed across the main dining area by Staff D, CNA. Observation revealed no wheelchair pedals in place and the resident displayed agitation and argumentative with Staff D. The resident suddenly placed both feet flat on the floor while being pushed in the wheelchair which caused the resident's torso to go forward in the wheelchair. Staff D then asked the resident to pick up his/her feet and then Staff D continued to push the resident in the wheelchair to the assisted dining area approximately 100 feet away. On 9/5/12 at 3:12 PM, the Director of Nursing was interviewed and stated when a resident needed to be pushed in a wheelchair, staff are to use wheelchair pedals. She stated they are stored in bags on the back of each resident's wheelchair specifically for this purpose. 3. The MDS dated [DATE] documented [DIAGNOSES REDACTED].#2. The MDS documented the resident required extensive assistance for transfer and toileting, non-ambulatory and had loss of functional range of motion of one leg. The Care Plan problem dated 8/30/11 identified the resident required staff assistance for completion of all activities of daily living and directed staff toilet the resident is relation to his/her daily routine and per request and identified the resident required assistance of 2 for transfer. The Incident/Accident Unusual Occurrences Form dated 8/18/12 at 9:30 PM documented staff witnessed resident placed him/herself from the toilet to the floor in the bathing area on the 100 Hall. The Internal Quality Assurance Investigation Form dated 8/18/12 and signed by the Administrator on 8/21/12 and Director of Nursing on 8/22/12 identified the preventative measure implemented as the resident should not be left on the toilet unattended. The resident ' s care plan did not document this intervention. Observation on 9/5/12 at 12:15 PM, Staff D, CNA transferred the resident from a dining room chair to a wheelchair and dependently pushed the resident to the shower room on the 100 hall. Observation revealed no w/c pedals present on the wheelchair and the resident crossed his/her legs at the ankle, right leg over the left, with the resident ' s toes of the left foot rubbing on the floor. The resident wore socks only on both feet. Staff D left the bathing room and stated she placed the resident on the toilet. At 12:17 PM the resident turned on the call light in the 100 hall shower room. Staff D entered the shower area. Staff D pushed the resident down the entire length of the 100 hall while the resident held the right leg up and the left leg and the toes of the left foot observed to rub on the floor at times. On 9/6/12 at 9:40 AM, Resident #2 was interviewed and stated she/he did not lower himself/herself to the floor from the toilet on 8/18/12 but had slipped off the toilet seat soiled with urine. The resident further stated staff leave him/her on the toilet unattended all the time.

Based on record review, staff, physician and family interviews and review of facility policy/procedures and personnel file, the facility failed to provide adequate supervision to ensure against hazards by failing to utilize all safety straps and to utilize adequate and planned numbers of staff while transferring the resident with the mechanical stand. Resident #1 had displayed a decline in cognition and activities of daily living skills and the facility failed to plan for and meet the resident's needs by ensuring the mechanical stand was suitable for the resident and did not pose as a hazard for the resident. As a result of the transfer with the mechanical stand, the resident obtained a fracture above the left knee. Concerns were noted for one of four residents reviewed (Resident #1). The facility reported a census of 50 residents. Findings include: 1. The Face Sheet Resident #1 identified an original admitted as 3/29/08. The admission sheet identified the admission [DIAGNOSES REDACTED]. A History and Physical dated 3/16/08 noted the physician evaluated this resident due to a fracture of the distal femur fracture. The resident had sustained a fall in his/her own home and landed on his/her right knee. This resident's surgical history included bilateral total knee replacements performed in 1996. This physician's [DIAGNOSES REDACTED]." A History dated 11/9/11 included this resident's past history. This history included bilateral knee replacement, open reduction internal fixation of a right distal femur fracture, depression and questionable Alzheimer's disease. A Quarterly MDS (Minimum Data Set) assessment with a reference date of 8/24/11, noted this resident required maximum assistance with his/her daily cares. The resident participated as able with simple upper body tasks. The resident ' s mobility remained impaired due to the effects of arthritis. The resident ' s upper extremities had limited ROM (range of motion/movement of the joints) at the shoulders and could bear weight with the use of the stand up lift but was no longer able to walk. Chronic pain remained stable with the use of Tramadol 50 milligrams twice daily. This was changed from Aleve on 7/1/11. No improvement expected due to chronic health issues. A Departmental Notes dated 11/13/11 noted this resident had been hospitalized from [DATE] through 11/3/11 for the treatment of [REDACTED]. This resident showed some mental status changes on 10/2/11. The resident showed decreased awareness to his/her surroundings and needed more cues/reminders to perform cares. Things that he/she used to do on own, he/she was not doing any more. By 10/20/11 the declines continued to persist and the physician increased the Aricept and Namenda. By 10/27/11 the resident still wasn't doing any better and family felt he/she was more depressed and the physician increased the Celexa. By 10/31/11 the resident continued to still have no improvement in cognitive (mental) status and showing increased weakness. The physician ordered blood laboratory work which showed elevated WBC (white blood cells) and decreased sodium. The facility received a physician's order [REDACTED]. Prior to hospitalization he/she was frequently incontinent of urine and had required maximum assistance with toileting cares. His/her nutritional status showed problems as he/she was having poor intakes and needed increased assistance with meals. He/she was moved to the assisted dining room on 10/28/11 so he/she could have increased assistance with his/her meals. This resident had become dependent for all aspects of cares and mobility. He/she had significant cognitive declines and problems expressing self. The resident just sat there and smiled. The resident showed little recognition of what was being said to him/her. Staff anticipated his/her needs and made sure the resident was appropriately groomed and dressed daily. This resident's mobility had been impaired due to effects of arthritis and had used a stand up lift in the past without problems. This resident was no longer able to propel self in the wheelchair especially since the cognitive decline noted in mid October. The resident had a fall on 10/31/11 with complaints of left leg pain. The most recent Minimum Data Set (MDS assessment tool) dated 8/17/11 assessed this resident as totally dependent on two staff members for assistance with transfers and toilet use. This assessment noted this resident's active medical [DIAGNOSES REDACTED]. This assessment documented the resident weighed 241 pounds. The updated plan of care for Resident #1 dated 8/31/11 identified a problem with short and long-term memory deficit related to dementia, self-care deficit due to debility and weakness related to effects of arthritis and impaired mobility related to debility and weakness related to effects of arthritis, a potential to falls and a history of falls. This plan of care instructed the facility staff to transfer the resident with the easy stand lift and with assistance of two people. The approach to use the E-Z Stand with 2 person assistance was first added to the plan of care on 9/31/09. The facility policy and procedure for Lift-Mechanical: Sit-to-stand, updated on 10/19/10 instructed the facility to use one to two staff members, fasten the safety strap around the resident to secure and for added stability, fasten strap around calves. When interviewed on 11/29/11 at 10:30 a.m. a certified nursing assistant, Staff A, stated she was assisting this resident with his/her shower on 10/31/11. She used the mechanical easy lift to transfer the resident from the shower chair when she noticed the resident's left foot was off the platform of the lift. Staff A attempted to put the resident's foot back on the platform without success. The resident let go of the E-Z Stand and began to slide down. Staff A yelled for help and lowered the resident to the floor. The resident said, "Oh my God, Oh my God." When interviewed a second time on 11/30/11 at 1:21 p.m. Staff A stated on 10/31/11, "That day I just needed to get my work done." Staff A stated she knew she was to use 2 persons with this transfer. Staff A transferred this resident from the wheelchair to the shower chair with the E-Z Stand. She then gave this resident a shower, dried him/her off and dressed the resident while in the shower chair. Staff A did not fasten the safety strap around the resident's waist, nor did she fasten the safety strap around the resident's calves. Staff A stated they knew they were to use these safety straps. She only used the sling/strap that went under the resident's arms. The resident was hanging on to the handle bars of the stand. She began to transfer this resident. She looked down and noticed the resident's left foot was off the platform. She moved the resident/stand sideways and tried to put the resident's left leg/foot back on the platform. She then decided to transfer the resident back to the shower chair, however the shower chair tipped forward. The resident never stood upright on the stand. The resident was in a slouched over position. She then went to pull out the shower chair and obtain the resident's wheelchair when the resident let go of the handles of the stand. She knew right away she was in trouble. She yelled out for assistance. The sling under the resident's arms held on to the resident a little bit. Staff A stated the resident hung from the stand like a chicken. The resident's left leg was still off of the platform and the resident's knees buckled down. A nurse, Staff B came into the shower room. Staff A told the resident she was sorry. In her written statement, Staff A documented they as she lifted this resident on the mechanical stand, she noted the resident's left leg was off the platform. She tried to put the leg back on the platform, but was unable. Staff A tried to put the resident back into the shower chair, but it tipped forward, so she called in the hallway for help. The resident then let go of the handles and started slipping. The resident's arms were stretched and the left leg was bent, so she lowered the lift to the lowest position, then she and two nurses lowered the resident to the floor by unhooking the arm straps. Review of the personnel file for Staff A revealed Incontinence/peri care/grooming audits were performed on Staff A on 2/8/11, 4/23/11 and on 10/8/11. Two of the audits included the use of the Hoyer lift, one audit did not include a transfer and none of the audits included the use of this E-Z Stand/Lift. A Care Initiative, Inc. Disciplinary Action Form dated 11/1/11 noted the facility disciplined Staff A for failure to follow policy and procedure regarding to the two person transfer while utilizing the EZ Stand. This document noted Staff A transferred Resident #1 by herself with the EZ stand, and did not use the safety belt around the resident's waist and did not use the safety belt around the resident's legs which resulted in the resident being placed in a compromising position and had to be lowered to the floor. When interviewed on 11/30/11 at 1:57 p.m. the restorative nurse, Staff B stated on 10/31/11 at 7:00 a.m. she heard a noise and Staff A asked her to come to the shower room. Staff B opened the shower room door and observed Resident #1 hanging in the lift. The resident's feet were not on the platform. Staff B stated she could not recall if the resident's knees were on the platform or not. She could not recall if the resident was dressed or undressed. Staff A told her she needed her help. They lowered the lift. Staff B could not recall if they unfastened the resident from the lift. Another nurse, Staff C came into the shower room. Staff C took this resident's blood pressure. Staff B could not recall if the resident's joints were assessed or if any range in motion was tested . Staff B assisted the resident in transferring this resident up off the floor with the use of the Hoyer lift. Staff B assisted the resident with the breakfast meal. Staff B did not assist this resident again that day. This nurse denied documenting this incident, and her assistance in this resident's clinical record. In her written statement, Staff B documented on 10/31/11 at 7:00 a.m. heard Staff A holler for help from the shower room. She entered the shower room and noted Resident #1 with the EZ Stand sling under his/her arms. The resident's arms were up in the air. The resident's legs were off the base of the stand to the left of the stand. The EZ stand was utilized to lower the resident as far to the floor as possible then eased the rest of the way to the floor by herself, Staff A and Staff C. When interviewed on 11/30/11 at 11:29 a.m. a Licensed Practical Nurse, Staff C stated on 10/31/11 she went to the shower room, due to she had seen Staff B run to the shower room. When she entered the shower room, she saw Resident #1 hooked to the E-Z stand. The resident's arms were up in the air. The resident's knees were on the platform of the stand. She quickly assessed the situation and determined due to the position of the resident's arms and legs, they needed to lower the resident to the floor. The resident seemed scared. Staff C assessed the resident by obtaining the resident's vital signs. Staff C checked the resident's arms. The resident denied any pain. Staff A told Staff C the resident had slipped. Later that day, at 2:30 p.m. she noticed this resident's left leg was beginning to swell and showed bruising. When asked where was the resident's pain at this time, Staff C stated, "I think it was the knee." Staff C stated she called this resident's physician and informed the physician the resident complained of left leg pain. Staff C denied recalling what she told the physician regarding the pain. When asked what she thought when the physician ordered x-rays of the resident's hip and pelvis when she thought the resident had pain in his/her knee, the nurse stated it did not click with her at the time. Staff C stated the resident showed signs of pressure on his/her knees from where he/she had been kneeling on the platform of the lift. Staff C denied documenting her assessment of this resident's knees. Staff C stated they did not make out a skin assessment sheet of this resident's knee discoloration and swelling due to she thought the discoloration and swelling was a result of the trauma to the knees from being on the platform. When interviewed a second time, on 12/1/11 at 9:16 a.m. Staff C stated on 10/31/11 at 7:00 a.m. it was upsetting to her when she entered the shower room and found Resident #1 handing on the E-Z stand. She saw the resident with his/her arms straight up in the air. This was upsetting due to the resident normally did not straighten up their arm/shoulders. The resident's knees were on the platform. The resident's right foot was positioned directly behind the knee in a normal position. The left foot was off the platform to the side. The position of the left lower leg, including the foot was not in a natural position. The left foot/lower leg was not in a natural position when the resident was lowered to the floor. When asked if the position of the left foot, lower leg concerned her when they lowered the resident to the floor, the nurse responded, "Not as much as (his/her) shoulders." They laid the resident on the floor. The resident's knees remained flexed. Prior to this incident the resident had been sick, and his/her gazed was fixed. The resident had not been his/herself. Staff C then stated they left the shower room prior to the staff assisting the resident off the floor. Staff C stated they did not assess this resident's range of movement of the lower legs. Staff C stated they had no reason to check the range of motion of this resident's lower legs. The nurse stated the resident went to breakfast after the incident. The nurse stated she did not have anything to document/chart after the incident until 2:30 p.m. at which time she was informed the resident complained of pain in the left leg. Staff C denied who informed her of this resident's pain. Staff C went to this resident's room. She asked the resident if he/she could move his/her legs. The resident was lying in the bed with his/her knees bent approximately at a 45 degree angle. The resident then moved their legs slightly, by moving his/her heels on the bed approximately two to three inches. The resident did not respond when she asked the resident where was the pain. Staff C then pushed on the outside of the resident's thigh. The resident grimaced. Staff C then stated, "I just got the thought in my head it was her hip." The resident's left leg was a little bigger than the right. This was a change from prior to the incident. The swelling of the left leg went from the groin to just above the knee. Staff C could tell the resident had been kneeling on the platform. Staff C stated, "I could tell they were going to bruise." Staff C described the resident's knees as faint blue in color, more so on the left than the right. Staff C did not assess this resident's movement (range of motion) of the lower legs. Staff C stated she had worked in long-term care since 1983. Staff C stated, "When you have a situation like this you just have to make a judgement call." Staff C stated she reported the situation to the Director of Nursing. She told the Director of Nursing that there might be something more to the fall. The Director of Nursing instructed Staff C to call this resident's physician. Staff C stated she called the physician and informed the physician the resident was complaining of pain in the upper left leg. Staff C stated she could not recall if she had informed the resident's physician of the new discoloration of this resident's knees. Staff C stated when she informed the resident's physician of pain in the left upper leg, the physician gave a new order to obtain an x-ray of this resident's left hip and pelvis. Staff C stated she was on duty when this resident returned to the facility on [DATE]; she did not fill out a Data Collection Assessment Tool, due to she was informed to put her assessment in the nurse's notes. Staff C documented an extensive assessment of the bruising of the left knee and thigh. Staff C stated, "It hurt me to see (him/her) like that, to see (him/her) so bruised and hurt like that." Staff C also stated, "I really thought there was a lot more trauma to the EZ Stand than I thought." She showed this resident's family members the bruising of the lower extremity. Staff C then told this resident's family that she was not surprised with the leg due to how it was bent under (him/her) off to the side of the platform in an unnatural position. Staff C asked Staff A what happened. Staff A told her that Resident #1 had slipped. Staff C stated she was surprised the hospital had not x-rayed this resident's knee. When asked if she had assessed the resident's range of motion of this now bruised knee and thigh, Staff C stated she did not assess the range of motion due to she was afraid to touch it. A few days later, Staff C informed the Director of Nursing the resident's left lower leg did not lay correctly at which time the Director of Nursing instructed her to call this resident's physician. The physician then ordered an x-ray of the left knee. This x-ray revealed a fracture just above the left knee. When asked if she could redo this whole incident would she do anything differently. Staff C stated if she could do it over she would do three things differently. First she would be more thorough with her assessment. Staff C stated she had been taught to do a thorough assessment. Second she would have filled out a skin assessment sheet for the new bruising/swelling of the left leg/knee. And third, Staff C stated she would have obtained an x-ray of the left knee. Staff C stated she was informed after the fact that Staff A had attempted to move the resident's left leg, "If i had known this, I would have ordered a knee x-ray." Staff C stated they are instructed on what to do for different situations. She stated these directions are kept in a green notebook at the nurse's station. When interviewed on 11/30/11 at 2:45 p.m. a concerned family member of Resident #1 stated Staff C had told them that she would not be surprised if the resident had a knee injury due to the way it was under (him/her) when (he/she) fell . The Nurse's Notes dated 10/31/11 at 7:00 a.m. documented the nurse was summoned to the shower room. The nurse found the resident hooked to the EZ Stand. The resident's eyes were straight ahead and the resident's arms were straight up holding onto the EZ Stand handles. The resident's knees were flexed on the floor. The resident was eased to the floor. The nurse documented a set of vital signs that included blood pressure, temperature, pulse and respirations. The resident was assisted to the wheelchair with a Hoyer Lift. The resident remained with no response to pain or situation, no verbal responses, smiled. At 9:30 a.m. the physician was updated and ordered blood laboratory work. At 2:30 p.m. the resident complained of pain in the left leg. The resident was difficult to assess, knees slightly contracted, does not lie with body supine and in alignment. Resident able to slightly flex both knees and move lower extremities but poor extension/flexion. Telephone call to the physician with new order for x-ray of the resident's left hip and pelvis. At 4:30 p.m. the physician called, reviewed the laboratory results and gave an order to send this resident to the hospital via ambulance. When interviewed on 11/30/11 at 4:50 p.m. Staff D stated on 10/31/11 she received report from Staff C who informed her of the incident where Staff A transferred Resident #1 with the EZ Stand and eased the resident to the floor. She was informed there were no visible injuries. She denied being informed of the new bruising and swelling of the left leg. Staff D stated she then assessed the resident. She did a full body assessment of Resident #1. The resident was in bed. The resident's legs were together. She noted the left leg was inward, pressed against the right leg. The resident made no grimacing or signs of pain with movement. The resident had swelling of the lower legs. Staff D then stated she could not recall if the swelling she observed was on 10/31/11 or on 11/3/11. Staff D stated she documented her full body assessment in the nurse's notes on 10/31/11. Staff D was then showed the clinical record and was asked to identify where she documented her assessment on 10/31/11. Staff D reviewed the record and then stated, "No, I didn't do an assessment. No, I didn't do the assessment." Staff D then stated she did assess the resident on 11/3/11 after the resident was readmitted to the facility. Staff D stated she did not recall this resident having any bruises when he/she returned from the hospital on [DATE]. A Nurse's Notes dated 11/3/11 at 3:30 p.m. noted this resident returned from the hospital at 1:45 p.m. The resident had edema (swelling) of the left arm and left leg, skin intact with bruising. The left inner knee had purple bruising measuring 7 cm (centimeters) by 5 cm extending into the inner thigh measuring 13 cm by 10 cm. Area swollen. Left arm swollen and bruised, right knee bruised. A Portable X-Ray dated 11/8/11 noted an x-ray of the left knee due to pain and swelling. The results read, "Portable radiographs of the left knee demonstrate obliquely oriented comminuted fracture of the distal femoral metadiaphysis. There is overriding of the fracture fragments. The patient status [REDACTED]. Extensive soft tissue swelling is appreciated. A Radiology Report dated 11/9/11 read, "A comminuted impacted fracture of the distal femur is demonstrated with considerable anterior foreshortening of the femoral shaft with respect to the femoral condyles, which are replaced with a bicondylar total knee prothesis. The proximal femoral shaft and left hip appear intact. A Major Injury Determination Form dated 11/10/11 noted Resident #1 sustained a fracture of the distal femur on 10/31/11 at 7:00 a.m. when the resident was eased to the floor after the resident let go of the hand grips of the EZ Stand. The physician marked he determined this injury to be a major injury. A hospital History dated 11/9/11 noted the resident was admitted to the hospital with [REDACTED]. AS best can be determined, the injury happened approximately 10 days ago. The patient was admitted to the hospital at the time with a [DIAGNOSES REDACTED]. (He/She) was unable to tell anyone at the time that (he/she) was hurting in (his/her) knee, and concern at the time was over (his/her) pelvis and hip which were x-rayed. No fractures were seen. Subsequently, the patient had more swelling and deformity around the knee site and x-rays showed a fracture of the same. Due to (his/her) age and infirmities, it is doubtful (he/she) could survive surgery for [REDACTED]. A Fall Investigation report written by Staff C dated 10/31/11 noted the resident was confused at all times, had a decline in function, loss of limb movement, decline in cognition, and had a recent decline in mental status. The nurse documented the environment contributed to this incident due to the shower room was cluttered with unneeded equipment such as two shower chairs and commode. The nurse documented Staff A reported the resident began to slip and then let go of the handle bars. The document read, "According to the staff, what contributed to the fall?" The nurse wrote, "C.N.A. trying to cut corners with another staff down with nose bleed." When interviewed on 11/30/11 at 12:57 p.m. this resident's physician stated on 10/31/11 he was never informed about the swelling and discoloration of this resident's knees. The physician had reviewed his records and found nothing was reported about the change in the color and swelling of the left leg/knee. The physician stated on 10/31/11 at 2:30 p.m. he would have expected the nurse to inform him of her assessment findings, including the new signs of bruising and swelling of the left leg/knee. The physician stated he felt this information would have been beneficial and he would have ordered an x-ray of the knee had he know of the signs of swelling and bruising, especially when the resident had sustained a fall and was complaining of pain. The facility had not assessed the resident to determine if the standing lift would have been suitable for this resident after the resident began to display signs of a decline.