Every finding on record at Stonebridge Adams Street

Based on observation, interview, and record review, facility staff failed to provide safe mechanical transfer for one resident (Resident #1) and staff failed to transfer one resident (Resident #3) in a safe manner. Census was 47.1. Review of the facility's policy, Safe Lifting and Movement of Residents, dated 07/2017, showed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Review of the facility's policy, Hoyer Safety, undated, showed staff are directed to lock the wheels and widen the base to transfer. The policy did not provide direction for staff when to close the base of the lift.The facility did not provide a policy regarding safe transfers using a gait belt. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact and was dependent on staff with transferring to and from a bed to a chair or wheelchair. Dependent on staff for toileting hygiene.Review of the resident's care plan, dated 02/20/26, showed staff documented the resident required assistance from two staff for transfers.Observation on 03/19/26 at 9:31 A.M., showed Certified Nurse Aide (CNA) A and CNA B entered the resident's room to provide care. CNA A operated the mechanical lift, opened the legs during the tranters. Observation showed during the transfer the legs of the lift closed, and the resident was lowered into his/her wheelchair. During an interview on 03/19/26 at 2:25 P.M., CNA said he/she were educated to open the legs of the mechanical lift when transferring the resident. He/She said he/she open the legs of the mechanical lift, but there had been issues with the mechanical lift and the legs would open and close on their own.During an interview on 03/25/26 at 10:39 A.M., CNA B said the legs of the mechanical lift should be opened during a transfer. He/She said staff were directed to report issues with the mechanical lift to the nurse. He/She said he/she did not think CNA A locked the legs of the mechanical lift when transferring the resident. During an interview on 03/19/26 at 3:09 P.M., the administrator said staff are directed to open the legs of the mechanical lift during a transfer for stability. He/She said if the legs of the mechanical lift were not opened during the transfers, there was a possibility the lift could tip over and cause injury to the resident. He/She said he/she did not know any issues with the mechanical lifts, but staff are directed to report issues to the maintenance department. During an interview on 03/19/26 at 3:10 P.M., the Director of Nursing (DON) said staff are directed to open the legs of the mechanical lift during a transfer for stability. He/She said if the legs of the mechanical lift were not opened during the transfers, there was a possibility the lift could tip over and cause injury to the resident. He/She said he/she did not know any issues with the mechanical lifts, but staff should report issues to the maintenance department. During an interview on 03/25/26 at 10:56 A.M., Licensed Practical Nurse (LPN) E said staff are educated to open and lock the legs of the mechanical lift during tranters for stability.During an interview on 03/25/26 at 11:04 A.M., the ADON said staff are directed to lock the legs of the mechanical lift when in an open position. He/She recently watched staff completing transfers of residents with a mechanical lift and staff were unlocking the legs of the mechanical lift during the transfer process. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired and was dependent on staff with transferring to and from a bed to a chair or wheelchair.Review of the resident's care plan, dated 02/06/26, showed staff documented the resident required assistance from two staff members with transfers.Observation on 03/19/26 at 1:37 P.M., showed CNA A entered the resident's room to provide transfer assistance. CNA A placed his/her arms around the resident's waist, lifted the resident out of the wheelchair, with the resident's feet in the air, and transferred the resident to the bed. The CNA A did not use a gait belt to transfer the resident. Observation showed the gait belt hung inside the resident's room by the door. During an interview on 03/19/26 at 1:37 P.M., the resident said staff did not use a gait belt when transferring him/her. He/She said there was a gait belt hanging by the door.During an interview on 03/19/26 at 2:25 P.M., CNA A said the resident required assistance from one staff member during transfers. He/She said he/she did not use the gait belt because it slipped his/her mind. He/She said the concern with not using a gait belt during a transfer was the potential for the resident to sustain injury.During an interview on 03/19/26 at 2:37 PM, LPN D said staff are required to use a gait belt anytime they are transferring a resident to prevent injury.During an interview on 03/19/26 at 3:09 P.M., the administrator said staff are directed to use a gait belt any time they are transferring a resident. He/She said staff utilized a gait belt to prevent potential injury to the resident.During an interview on 03/19/26 at 3:10 P.M., the DON said staff are required to use a gait belt any time a resident required transfer assistance from staff. He/She said the purpose of using the gait belt was to prevent potential injury to the resident. 2807774

Based on observation, interview and record review, facility staff failed to use appropriate hand hygiene infection control practices during perineal care for one residents (Resident #1) out of two sampled residents, staff failed to follow Enhanced Barrier Precautions ((EBP) the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms), failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen in a manner to prevent the spread of bacteria. The facility census was 47.1. Review of the facility's policy, Oxygen Concentrator, dated 01/2018, showed nursing staff were responsible to change oxygen tubing and mas/cannula weekly and as needed if it becomes soiled or contaminated.Review of the facility's policy, Enhanced Barrier Precautions, dated 04/04/24, showed:-it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms;- Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRA acquisition (e.g., residents with wounds or indwelling medical devices);-High-contact resident care activities include, dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use.Review of the facility's, Handwashing Training Packet, undated, showed staff involved in direct resident contact will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Wash hands before and after handling contaminated items, contact with blood and body fluid, secretions, excretions, mucous membranes, etc. and assisting with/providing personal care.Review of the facility's In-Service Training Guide, Infection Control- Preventing Spread of Infection- Hand Hygiene, undated showed:-The hand hygiene procedures to be followed by staff involved in direct resident contact;-Residents can be exposed to potentially pathogenic organisms in several ways, including but not limited to the following: improper hand hygiene and improper glove use (e.g., utilizing a single pair of gloves for multiple tasks or multiple residents);Contact precautions require the use of appropriate PPE (personal protective equipment), including a gown and gloves upon entering the contact precaution room. Prior to leaving the contact precaution room the PPE is removed and hand hygiene is performed;Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene when hands are visibly soiled, before and after direct resident contact, before and after assisting a resident with personal care, upon and after coming in contact with a resident's intact skin, after contact with a resident's mucous membranes and body fluids or excretions, and after handling soiled or used linens, dressings, bedpans, catheters and urinals. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as cognitively intact, dependent on staff for toileting hygiene assistance and did not contain documentation the resident used oxygen therapy.Review of the resident's care plan, dated 02/01/26, showed the resident required substantial assistance with toileting hygiene, incontinent of bowel and used a foley catheter.Observation on 03/19/26 at 9:31 A.M., showed a sign on the resident's door for EBP use. Observation on 03/19/26 at 9:31 A.M., showed Certified Nurse Aide (CNA) A and CNA B entered the resident room to provide care. CNA A and CNA B did not put on a gown prior to or upon entering the resident's room. CNA B provided perineal care, removed gloves, applied clean gloves from CNA's A pocket filled with gloves and did not perform hand hygiene. CNA B placed a clean brief under the resident and assisted CNA A with repositioning the resident, with the same soiled gloves placed clean pants on the resident. CNA B continued to wear the same soiled gloves and placed the mechanical lift sling under the CNA A continued to wear the same soiled gloves and removed the resident's nasal canula, placed the resident's nasal canula on the bedside table without a protective barrier or in a storage bag and the tubing laid on the floor. CNA B continued to wear the same soiled gloves and removed the resident's shirt, put on a clean shirt, brushed the resident hair, washed his/her face, and brushed the resident tongue. CNA B left the room, did not perform hand hygiene, returned to the room without performing hand hygiene, did not wear a gown, and put on new gloves. CNA B cleaned the resident's dentures, applied denture adhesive to the dentures, and placed the dentures in his/her mouth. The resident did not want his/her dentures, CNA B cleaned the denture adhesive off the dentures without performing hand hygiene or glove change. CNA B picked up the oxygen tubing from the floor, attached the tubing on the portable tank and applied the nasal canula in the resident's nose.During an interview on 03/19/26 at 11:03 A.M., CNA B said staff are educated to use PPE when a resident is on EPB. He/She said he/she did see the signage on the door, but forgot to use the PPE, since the PPE cart was not directly outside the resident's door. CNA B said staff are directed to perform hand hygiene and glove change before care, during care when going from a dirty to clean area, and after providing care. He/She said he/she did miss a hand hygiene opportunity. He/She said he/she had no excuse why he/she did not perform hand hygiene or glove change during care.During an interview on 03/19/26 at 2:37 P.M., Licensed Practical Nurse (LPN) D said there was signage posted on a resident's door who were on EBP to let staff and visitors know what PPE was required to be used when there was physical contact. He/She said the concern with not using PPE when physical contact was involved, was the potential to transfer bacteria and germs. He/She said staff are directed to replace tubing when it touched the floor.During an interview on 03/19/26 at 3:09 P.M. the administrator said oxygen tubing should be changed if touch the floor due to contamination. He/She said there are EBP signage hung on the residents door and PPE carts located outside the resident's room. HE/She said gown and gloves should be using while providing care, due to an infection control issue and to protect residents and staff.During an interview on 03/19/26 at 3:09 P.M. the Director of Nursing (DON) said staff are directed to replace oxygen tubing if it touched the floor to prevent contamination. He/She said there are EBP signage hung on the resident's door and PPE carts located outside the resident's room. HE/She said gown and gloves should be using while providing care, due to an infection control issue and to protect residents and staff. 2807774

Based on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 55. 1. Review of the facility's staffing policy, dated 10/2017, showed the facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.2. Review of the Facility Assessment, dated 10/30/25, showed the assessment includes an evaluation of the resident population and available facility resources and services to ensure person centered care needs are completely met. Review showed the average daily census for the last six months of occupied beds as 54.6. Review showed direct care staff required to care for their facility census for a twenty-four-hour period should include: -Six Certified Nurse Aides/Nurse Aides (CNA's/NA's) on day shift;-Four CNA's/NA's on evening shift;-Three CNA's/NA's on night shift;-Two Certified Medication Technicians (CMT's) scheduled on day and evening shift. Review of employee staffing schedule from 11/08/25 through 11/30/25, with an average daily census of 54, showed: -Saturday, 11/08/25; four CNA's scheduled on day shift; -Sunday, 11/09/25; four CNA's scheduled on day shift;-Wednesday, 11/12/25; four CNA's scheduled on day shift;-Saturday, 11/15/25; four CNA's scheduled on day shift, three CNA and one CMT scheduled on evening shift;-Sunday, 11/16/25; one CMT and four CNA's scheduled on day shift;-Monday, 11/17/25; four CNA's scheduled on day shift;-Thursday, 11/20/25; one CMT scheduled on day shift;-Saturday, 11/22/25; four CNA's scheduled on day shift;-Sunday 11/23/25; one CMT and four CNA's scheduled on day shift;-Thursday, 11/27/25; four CNA's scheduled on day shift and three CNA's scheduled on evening shift;-Friday, 11/28/25; four CNA's scheduled on day shift;-Saturday, 11/29/25; one CMT and four CNA's scheduled on day shift;-Sunday, 11/30/25; four CNA's scheduled on day shift.Review of employee staffing schedule from 12/01/25 through 12/07/25, with an average daily census of 54, showed: -Monday, 12/01/25; four CNA's scheduled on day shift; -Tuesday, 12/02/25; three CNA's scheduled on day shift;-Thursday, 12/04/25; four CNA's scheduled on day shift;-Saturday, 12/06/25; one CMT scheduled on day shift, four CNA's scheduled on day shift, three CNA's scheduled on evening shift and two CNA's scheduled on night shift;-Sunday, 12/07/25; four CNA's scheduled on day shift and two CNA's scheduled on evening shift.During an interview on 12/08/25 at 3:59 P.M., the administrator said he/she was responsible to complete the staffing schedule and was training a new staffing coordinator. He/She said he/she used the facility assessment, census and acuity of needs to determine the number of staff needed to meet the needs of the residents on each shift. He/She said he/she felt the number of staff scheduled each shift was appropriate and was going to change the assessment to reflect how they are currently staffing. Complaint #2675273

Based on observation, interviews and record review, facility staff failed to ensure one resident (Resident #1) who received tube feeds (supplemental liquid nutrition) through a gastrostomy (G-tube) (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received his/her supplemental liquid nutrition as ordered by the physician. The census was 55.1. Review of the facility's Enteral Nutrition policy, undated, showed adequate nutritional support through enteral feeding will be provided to residents as ordered. The policy showed recommendation to initiate the use of a feeding will be based on the results of the comprehensive nutritional assessment, and will be consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies. The policy did not contain direction for staff in regard to documentation of scheduled tube feedings in the resident's medical record.2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/03/25, showed facility staff assessed the resident with severe cognitive impairment and dependent of staff for eating. Review of the resident's care plan, dated 11/18/25, showed the resident required supplemental tube feeds related to Dysphagia (difficulty swallowing).Review of the resident's diagnosis report, dated 12/10/25, showed the resident was diagnosed with dysphagia (difficulty swallowing).Review of the resident's Physician Order Summary (POS), undated, showed an order for Fibersource HN Oral Liquid (nutritional supplements) via G-Tube four times a day.Review of the resident's dietician note, dated 11/13/2025, showed the dietician documented the resident did not receive nutrition by mouth. Review of the resident's Treatment Administration Record (TAR), dated 11/02/25 through 11/30/25, showed the record did not contain documentation staff administered eight ounces of Fibersource HN via G-Tube on 11/01/25-11/08/25, 11/10/25-11/13/25, 11/20/25, 11/23/25 -11/28/25 and 11/30/25 as ordered by the physician. During an interview on 12/08/25 at 3:31 P.M., Registered Nurse (RN) A said staff are directed to document in the resident's medical record after administering the nutritional supplement via the resident's G-Tube. He/She said the resident received tube feedings four times a day. During an interview on 12/08/25 at 3:59 P.M., the administrator said staff are educated to follow physician orders regarding tube feedings. He/She said staff would document in the resident's medical record after administering nutritional supplement via G-Tube. He/She said if staff did not document the order was completed in the TAR, then the order was not completed. During an interview on 12/08/25 at 4:00 P.M., the Director of Nursing (DON) said staff are expected to follow the physician orders. He/She said staff documented in the resident's medical record after administering nutritional supplement via G-Tube. He/She said if staff did not document the order was completed in the TAR, then the order was not administered. During an interview 12/08/25 at 10:54 A.M., the Regional Director of Operations said the DON was responsible to audit resident TARS to verify staff are completing documentation. He/She said they currently do not have a full-time DON, but the Assistant Director of Nursing (ADON) is acting as the interim DON and the permanent DON will begin employment in January. He/She said there have been several changes with DON position, so it was an oversight the weekly audits were not completed.Complaint #2679872

Based on observation, interview and record review, facility staff failed to ensure oxygen tubing and/or nebulizer mask and tubing were changed at least weekly for four residents (Resident #1, #2, #3, and #4) out of four sampled residents and failed to provide orders for oxygen therapy for one resident (Resident #4). The facility's census was 58. 1. Review of the facility's Oxygen Concentrator policy, revised 01/2018, showed: -Oxygen is administered under orders of the attending physician, except in the case of an emergency;-Keep delivery devices covered in plastic bag when not in use;-Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated;-Change humidifier bottle when empty, every 72 hours, or as recommended by the manufacturer;-If applicable, change nebulizer tubing and delivery devices every 72 hours. 2. Review of the facility's policy on Cleaning and Disinfecting Nebulizer equipment, dated 2017, showed staff were directed to replace nebulizer mask and tubing weekly. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/17/25, showed staff assessed the resident as cognitively intact, and received oxygen therapy. Review of the resident's care plan, revised 07/10/25, showed staff assessed the resident to wear oxygen as needed for oxygen saturation below 90%. Review of the resident's Physician Order Sheet (POS), dated 08/22/25, showed an order for oxygen one liter per minute (LPM) via nasal cannula for oxygen saturation for shortness of breath, and to change and date oxygen tubing/nasal cannula and nebulizer mask and tubing every Sunday night shift related to COPD. Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed staff were directed to change and date oxygen tubing/nebulizer mask and tubing every Sunday night shift related to COPD. Observation on 08/22 at 9:05 A.M., showed an oxygen concentrator next to the resident's bed, the nasal cannula unbagged, and tube dated 07/28/25. Observation showed a nebulizer mask on the bed, unbagged, and the tube dated 07/28/25. During an interview on 08/22/25 at 9:05 A.M., the resident said staff administers breathing treatments to him/her via the nebulizer mask, and he/she uses oxygen sometimes. Observation on 08/22/25 at 1:55 P.M., showed a nebulizer mask hung from the nebulizer machine, and the tubing dated 07/28/25. 4. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, received oxygen therapy, and uses a non-invasive mechanical ventilator (Bilevel Positive Airway Pressure (BiPAP)- a machine to help a person breathe). Review of the resident's care plan, revised 08/22/25, showed staff documented the resident to wear oxygen as needed, and to change oxygen tubing and cannister weekly. Review of the resident's POS, dated 08/22/25, showed an order for BiPAP at bedtime, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5, three milligrams (mg)/three milliliters (ml) vial, inhale orally every six hours as needed for shortness of breath. Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed the TAR did not contain documentation to direct staff on when to change the BiPAP and nebulizer masks and tubing. Observation on 08/22/25 at 9:12 A.M., showed a BiPAP mask and a nebulizer mask on the resident's nightstand, unbagged, and the masks and tubing dated 07/29/25. During an interview on 08/22/25 at 9:13 A.M., the resident said he/she wears oxygen via his/her BiPAP at nights. 5. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and received oxygen therapy. Review of the resident's care plan, revised 07/10/25, showed staff documented the resident should wear oxygen at two LPM continuously via nasal cannula, and to change oxygen tubing and water cannister weekly. Review of the resident's POS, dated 08/22/25, showed physician orders as followed: -Oxygen two LPM via nasal cannula for oxygen saturation below 90% or shortness of breath every shift;-Change oxygen tubing/nebulizer mask and tubing every Sunday night shift for prevention of infection;-Ipratropium-Albuterol Inhalation Solution 0.5-2.5, three mg/three ml vial, inhale orally every six hours for productive cough. Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed staff were directed to change oxygen tubing/nebulizer mask and tubing every Sunday night shift for prevention of infection. Observation on 08/22/25 at 9:32 A.M., showed the resident wore his/her oxygen via nasal cannula. Observation showed the oxygen tubing undated, and the humidifier bottle, dated 07/29/25. Observation showed a nebulizer mask on the floor, unbagged, and the tube dated 07/29/25. During an interview on 08/22/25 at 9:32 A.M., the resident said he/she wears oxygen all the time, and staff administers a breathing treatment to him/her a few times per day. 6. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and received oxygen therapy. Review of the resident's care plan, revised 06/12/25, showed staff were directed the resident to wear oxygen at all times. Review of the resident's POS, dated 08/22/25, showed an order to change oxygen tubing and humidifier weekly on Sunday night shift for infection control. The POS did not contain an order for oxygen. Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed staff were directed to change oxygen tubing and humidifier weekly every Sunday on night shift for infection control. Observation on 08/22/25 at 8:40 A.M., showed the resident wore his/her oxygen. Observation showed the nasal canula undated. Observation on 08/22/25 at 11:22 A.M., showed the oxygen concentrator next to the resident's bed and the humidifier bottle undated. During an interview on 08/22/25 at 2:26 P.M., the Director of Nursing (DON) said he/she did not know why the resident did not have an order for oxygen therapy on his/her POS. The DON said the nurses are responsible to enter orders for oxygen therapy on the resident's POS and Treatment Administration Record (TAR), and he/she ensures that the orders are entered. 7. During an interview on 08/22/25 at 1:34 P.M., Licensed Practical Nurse (LPN) A said the nurses are responsible to change residents' oxygen tubing and nebulizer mask and tubing. He/She said the schedule would be documented on the resident's POS and TAR. During an interview on 08/22/25 at 2:26 P.M., the DON said the night shift nurse is responsible to change oxygen tubing, humidifier bottles, and nebulizer masks/tubing on Sundays for all residents with oxygen therapy, and date the tubing when changed. The DON said he/she is responsible to ensure the oxygen and nebulizer masks, and tubing's are being changed weekly, but he/she had not had a chance to audit. During an interview on 08/22/25 at 3:00 P.M., the administrator said the nurses are responsible to document the order for oxygen therapy on the POS and TAR on admission or when received, and the DON to ensure the orders have been entered. The administrator said he/she did not know why the oxygen tubing, humidifier bottles and nebulizer masks and tubing's are not being changed weekly, but they should be changed by the charge nurse on Sunday nights, and the DON should ensure they are being changed. Complaint# 2587511

Based on observation, interview and record review, facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when facility staff failed to serve meals in a timely manner to residents and failed to maintain the internal temperatures of hot food to at least 120 degrees Fahrenheit ( F) upon service to residents who resided on the 300 and 400 halls. The facility census was 58.1.Review of the facility's Food Preparation and Service policy, dated July 2014, showed the danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. 2. Review of the facility's Food Safety Requirements policy, dated 09/2022, showed foods and beverages shall be distributed and served to resident in a manner to prevent contamination and maintain food at the proper temperature and out of the danger zone. This includes timely distribution of all meals and snacks. 3. Observation on 08/22/25 at 12:29 P.M., showed an un-enclosed cart in the dining room with meals served on warm plates, covered with insulated dome plate covers. Observation on 08/22/25 at 12:31 P.M., showed a staff member took the un-enclosed cart with meals and placed the cart across from the nurses' station against the wall between the 300 and 400 halls. Observation on 08/22/25 at 12:35 P.M., showed a staff member delivered a meal tray from the un-enclosed cart to a room on the 300 hall. Observation on 08/22/25 at 12:41 P.M., showed several lunch trays remained on the un-enclosed cart across from the nurses' station. During an interview on 08/22/25 at 1:2 P.M., Certified Nursing Assistant (CNA) B said the nursing staff usually serve the residents in the dining room first, then deliver meal trays to the residents who eat in their rooms. During an interview on 08/22/25 at 2:04 P.M., the resident said his/her breakfast was cold when he/she got it and is often served that way to him/her. He/She said lunch was a bit warmer than breakfast, but not hot. During an interview on 08/22/25 at 2:26 P.M., the Director of Nursing (DON) said the nursing staff is responsible to deliver meals to residents who eat in their rooms, and he/she ensures staff delivers the meals timely, so they are not served cold to the residents. The DON said he/she had not been able to monitor meal service for the past few weeks. During an interview on 08/22/25 at 2:08 P.M., [NAME] C said dietary staff plates the trays, then nursing staff places the drinks and condiments on the trays and serve to the residents. 4. Observation on 08/22/25 at 12:50 P.M., showed the administrator took the temperature of the foods on Resident #8's tray. Observation showed the internal temperature of the fish measured 91.5 F and the internal temperature of the rice measured 98 F. The administrator directed staff to serve the resident his/her tray and take the cart to the 300 hall and serve the remaining lunch trays to the residents who ate in their rooms, after he/she checked the food temperatures. 5. During an interview on 08/22/25 at 1:10 P.M., Resident #8 said by the time he/she got his/her lunch, the food was not hot. During an interview on 08/22/25 at 3:00 P.M., the administrator said hot foods should be above 120 F when served to the residents and he/she should not have directed staff to serve the residents the meals with the food temperatures below 98 F. 9. During an interview on 08/22/25 at 2:08 P.M., [NAME] C said the temperature of hot foods served to the residents should be about 145 F. He/She said if staff notifies dietary staff a resident's meal is below temperature or cold, dietary staff will either serve a new plate from the steamtable or offer an alternative if requested. During an interview on 08/22/25 at 2:26 P.M., the DON said hot foods should be served hot to the residents. The DON said when staff deliver meals to residents in their rooms, staff should check with the residents before leaving the room that the food temperature is ok for them, and if not, offer to get a new plate, or reheat if requested. During an interview on 08/22/25 at 3:00 P.M., the administrator said the nursing staff is responsible to deliver meals to residents' rooms quickly after they are served from the kitchen to ensure appropriate temperatures, and the DON to monitor the nursing staff during meals. Complaint# 2587511 and 2587447

Based on interview and record review, facility staff failed to check the Employee Disqualification List ((EDL) a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) and/or criminal background check (CBC), prior to hire in accordance with their facility policy for eight employee (Certified Nurse Aide (CNA) I, Licensed Practical Nurse (LPN) J, receptionist K, Social Services Director, Certified Medication Technician (CMT) L, housekeeper N, Nurse Aide (NA) B, and Food Service Manager) out of ten sampled employees. Facility staff failed to develop an abuse and neglect policy that directed staff to check the NA registry for all employees, prior to hire, for seven employees (CNA I, LPN J, Receptionist K, Social services director, CMT L, housekeeper N, and NA B) out of 10 employees. The facility census was 53. 1. Review of the Facility's Background Screening Investigations, dated March 2019, showed the director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. Review of the Facility's Credentialing of Nursing Service Personnel, dated May 2019, showed: -Nursing personnel requiring a license/certification are not permitted to perform direct resident care services until all licensing/background checks have been completed; -Upon obtaining the applicants informed consent to conducting a license/certification/background investigation, the director of nursing services, or designee, will: -Contact the facility's authorized vendor/service organization to perform a background check in accordance with current state law and facility policy; -A copy of all documents obtained during the verification and background check are filed in the employee's personnel file. Such records are filed in accordance with current federal and state law and facility policy to protect the confidentiality of information. 2. Review of CNA I's personnel record showed the employee hire date of 12/27/23. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 3. Review of LPN J's personnel record showed the employee with a hire date of 05/22/24. The personnel record did not contain documentation staff completed a EDL check prior to his/her hire date. 4. Review of Receptionist K's personnel record showed the employee with a hire date of 04/23/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 5. Review of Social Services Director's personnel record showed the employee with a hire date of 10/29/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 6. Review of CMT L's personnel record showed the employee with a hire date of 06/12/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 7. Review of Housekeeping N's personnel record showed the employee with a hire date of 02/08/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 8. Review of NA B's personnel record showed the employee with a hire date of 06/03/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 9. Review of Food Service Manager's personnel record showed the employee with a hire date of 07/10/24. The personnel record did not contain documentation staff completed a CBC or EDL check prior to his/her hire date. 10. During an interview on 12/03/24 at 2:50 P.M., the Business Office Manager (BOM) said he/she is responsible for doing EDL and CBC checks for new employees. He/She said six months ago his/her processes changed. He/She said the facility was shorthanded and employees were pushed through the hiring process without back ground screenings prior to hire. He/She said he/she was initiating the paperwork during their orientation. He/She said new employee screenings are supposed to be initiated before the employee steps foot in the building. He/She said the employees are in the building before the checks come back. He/She said he/she is not sure where the missing background checks are. He/She said he/she does do yearly chart audits. He/She said he/she does background screenings when missing background checks are found during those audits. During an interview on 12/03/24 at 3:17 P.M., the Director of Nursing (DON) said EDL and CBC checks should be done prior to hire. He/She said it is the responsibility of the BOM to ensure those checks are completed. He/She said those checks are important because they keep residents safe from people who have been committed of abuse and neglect. He/She said he/she was not aware the BOM was not running background checks on new employees prior to hiring them. During an interview on 12/03/24 at 4:10 P.M., the administrator said the BOM is responsible for checking background screenings. He/She said it is his/her expectation that the CBC and EDL checkes are completed prior to hire. He/She said he/she was not aware the BOM wasn't conducting background screenings prior to hire. 11. Review of the facility's policies showed staff did not provide a policy to direct staff to check the NA registry on all employees prior to hire. 12. Review of CNA I's personnel record showed the employee with a hire date of 12/27/23. The personnel record did not contain documentation staff completed a NA Registry check prior to his/her hire date. 13. Review of LPN J's personnel record showed the employee with a hire date of 05/22/24. The personnel record did not contain documentation staff completed a NA Registry check prior to LPN J's hire date. 14. Review of Receptionist K's personnel record showed the employee with a hire date of 04/23/24. The personnel record did not contain documentation staff completed a NA Registry check prior to Receptionist K's hire date. 15. Review of Social Services Director's personnel record showed the employee with a hire date of 10/29/24. The personnel record did not contain documentation staff completed a NA Registry check prior to Social Services Director's hire date. 16. Review of CMT L's personnel record showed the employee with a hire date of 06/12/24. The personnel record did not contain documentation staff completed a NA Registry check prior to CMT L's hire date. 17. Review of Housekeeping N's personnel record showed the employee with a hire date of 02/08/24. The personnel record did not contain documentation staff completed a NA Registry check prior to Housekeeping N's hire date. 18. Review of NA B's personnel record showed the employee with a hire date of 06/03/24. The personnel record did not contain documentation staff completed a NA Registry check prior [NAME] B's hire date. 19. During an interview on 12/03/24 at 2:50 P.M., the BOM said he/she is responsible for running the NA registry checks. He/She said he/she is aware he/she was supposed to run the NA registry checks prior to hire. He/She said he/she was not sure why the staff members did not have the NA Registry checks done prior to hire. He/She said he/she thought the NA registry was only ran to check if an employee was certified. He/She said he/she was not aware it was to check for federal indicators (a marker given by the federal government to individuals who have committed abuse and/or neglect) against the staff member. During an interview on 12/03/24 at 3:17 P.M., the DON said NA registry checks should be done prior to hire. He/She said the BOM is in charge of ensuring all checks are done prior to hire. He/She said he/she knows that it is important to have them done prior so that residents are not exposed to any employees who may cause them harm. He/She was not aware that the NA registry checks were not being done prior to hire. During an interview on 12/03/24 at 4:10 P.M., the Administrator said the BOM is responsible for checking the NA registry prior to hire on all employees. He/She said he/she was not aware the facility's policy did not direct staff to check all employees prior to hire. He/She said it is his/her expectation that staff check all employees prior to hire. He/She said he/she had instructed the BOM to do checks on all staff prior to hire and he/she was not aware that the BOM was not doing the checks.

Based on observation, interview, and record review, facility staff failed to accurately assess the use of side rails for three residents (Resident #2, #49, and #52), and failed to complete an entrapment risk assessment for five residents (Resident #1, #2, #49, #52, and #106), out of 14 sampled residents. The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's Proper use of Side Rails Policy, dated 09/2022, showed: -Examples of bedrails include, but are not limited to side rails, bed side rails, safety rails, grab bars, and assist bars; -The resident assessment must assess the resident's risk from using bed rails such as entrapment; -The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself; -A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon significant change in status, or a change in the type of bed/mattress/rail. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/27/24, showed staff assessed the resident as: -readmitted on [DATE]; -Severe cognitive impairment; -Impairment on one side of upper extremity (shoulder, elbow, wrist, hand); -Required substantial/moderate assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed, and dependent for transfers from bed to chair. Review of the resident's side rail use assessment, dated 10/29/24, showed staff documented the resident used grab bars to assist with cares and to turn side to side. Review of the resident's medical record showed the record did not contain an entrapment risk assessment for use of side rails/grab bars. Observation on 12/03/24 at 8:33 A.M., showed the resident in bed with grab bars to both sides of the bed in the upright position. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required partial/moderate assist from staff to roll left and right; -Required substantial/maximum assist from staff from sitting to lying in bed and for lying to sitting on side of bed, and dependent of staff for transfers from bed to chair. Review of the resident's side rail use assessment, dated 09/22/24, showed staff documented the resident did not use side rails or assistive devices such as grab bars. Review of the resident's medical record showed the record did not contain an entrapment risk assessment. Observation on 12/01/24 at 2:04 P.M., showed the resident in bed with bilateral hand rails in upright position. Observation on 12/02/24 at 1:33 P.M., showed the resident in bed with bilateral u-bars in upright position. Observation on 12/03/24 at 10:25 A.M., showed the resident in bed with bilateral u-bars in upright position. During an interview on 12/04/24 at 3:13 P.M., the MDS/Care plan Coordinator said the resident's side rail use assessment was incorrect, but knows resident uses u-bars. The charge nurses are responsible to complete the assessment. 4. Review of Resident #49's Admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required partial/moderate assist from staff to roll left and right and from sitting to lying and lying to sitting on side of bed; -Required dependent assist from staff for transfers from bed to chair. Review of the resident's side rail use assessment dated [DATE], showed staff documented the resident did not use side rails or assistive devices such as grab bars. Review of the resident's medical record showed the record did not contain an entrapment risk assessment for use of side rails. Observation on 12/01/24 at 2:28 P.M., showed the resident in bed with bilateral grab bars in upright position. Observation on 12/02/24 at 1:28 P.M., showed the resident in bed with bilateral grab bars in upright position. Observation on 12/04/24 at 09:08 A.M., showed the resident in bed with bilateral grab bars in upright position. During an interview on 12/04/24 at 3:13 P.M., the MDS/Care plan Coordinator said the resident's side rail use assessment was incorrect, but knows resident uses grab bars. 5. Review of Resident #52's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Impairment on one side of upper extremity (shoulder, elbow, wrist, hand); -Required substantial/maximum assist from staff to roll left and right, sitting to lying in bed, dependent for lying to sitting on side of bed and transfers from bed to chair. Review of the resident's side rail use assessment dated [DATE], showed staff documented the resident did not use side rails or assistive devices such as grab bars. Review of the resident's medical record showed the record did not contain an entrapment risk assessment for use of side rails/grab bars. Observation on 12/01/24 at 12:07 P.M., showed the resident held the grab bar on each side of the bed when assisted by staff to roll left and right during care. Observation on 12/02/24 at 8:11 A.M., showed the resident in bed with grab bars to both sides of the bed in the upright position. During an interview on 12/04/24 at 8:50 A.M., the MDS/Care plan Coordinator said the resident's side rail use assessment was incorrect. The charge nurses are responsible to complete the side rail use assessment. 6. Review of Resident #106's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required partial/moderate assist from staff to roll left and right, sitting to lying in bed, lying to sitting on side of bed, and substantial/maximum assist with transfers from bed to chair. Review of the resident's side rail use assessment, dated 11/18/24, showed staff documented the resident used half side rails per family request. Review of the resident's medical record showed the record did not contain an entrapment risk assessment for use of side rails. Observation on 12/01/24 at 11:00 A.M., showed the resident in bed with grab bars to both sides of the bed in the upright position. Observation on 12/03/24 at 8:30 A.M., showed the resident in bed with grab bars to both sides of the bed in the upright position. During an interview on 12/04/24 at 8:50 A.M., the MDS/Care plan Coordinator said he/she could not find documentation that the maintenance staff completed the bed safety measurements. 7. During an interview on 12/04/24 at 8:50 A.M., the MDS/Care plan Coordinator said nurses do the side rail and entrapment assessment and maintenance does the measurements of the side rails monthly. He/She said he/she is unsure if the resident is supposed to be in the bed during entrapment measurements. During an interview on 12/04/24 at 9:00 A.M., Maintenance said he/she does entrapment measurements monthly. He/She said he/she measures without the resident in the bed. He/She agrees that the gaps between side rail and mattress would be different measurements with the resident laying in the bed. He/She said that he/she is unsure if he has read anything that stated that the resident needed to be in the bed for the measurements. During an interview on 12/04/24 at 3:08 P.M., Licensed Practical Nurse (LPN) J said bed rail assessments are done upon admission and quarterly. He/She said he/she is not sure who completes them quarterly. During an interview on 12/04/24 at 4:00 P.M., the Director of Nursing (DON) said maintenance and nursing get together and make sure that the side rail assessment and entrapment measurements are done. He/She said the side rail assessment is part of the admission process or it is completed if a family member asks for side rails. He/She said it is the admitting nurses responsible to complete the side rail assessment. He/She said maintenance is responsible for doing entrapment measurements, but he/she is unsure how often or if the resident should be in the bed during the measurements. During an interview on 12/04/24 at 4:25 P.M., the Administrator said that side rail assessment is done quarterly by a nurse. He/She said maintenance does entrapment measurements monthly or with change of a new bed. He/She assumes the resident should be in the bed during measurements since that's what the diagram shows. He/She said the DON and ADON is responsible for monitoring to ensure assessments are being done. 39644 Surveyor: [NAME], [NAME] 50422

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week. The facility's census was 53. 1. Review of the facility's Nursing Services Registered Nurse Policy, dated October 2022, showed it is the intent of the facility to comply with RN staffing requirements, and the facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. 2. Review of the facility's time-keeping records for consecutive hours worked by an RN for August 2024, showed: -Saturday, 08/17/24: 7.55 hours; -Sunday, 08/18/24: 7.9 hours. Review of the facility's time-keeping records for consecutive hours worked by an RN for September 2024, showed: -Sunday, 09/01/24: 7.83 hours; -Saturday, 09/07/24: 7.6 hours; -Sunday, 09/08/24: seven hours; -Sunday, 09/29/24: did not show a RN in the building. Review of the facility's time-keeping records for consecutive hours worked by an RN for October 2024, showed: -Saturday, 10/05/24: 4.87 hours; -Saturday, 10/19/24: 6.83 hours; -Saturday, 10/26/24: 6.52 hours. During an interview on 12/04/24 at 3:36 P.M., the Director of Nursing (DON) said his/her expectation is for staff to provide eight consecutive hours of RN coverage every day including the weekends, and he/she usually fills in if there is no RN scheduled or if someone called in. The DON said some of the days with less than eight hours of RN coverage on the weekends were likely due to a lunch break, and he/she did not have an explanation for why there was no RN coverage on 09/29/24. During an interview on 12/04/24 at 4:09 P.M., the administrator said there should be an RN at the facility for eight consecutive hours per day, seven days per week. The administrator said he/she realized that there were days where the facility staff did not meet the eight consecutive hours requirement for RN coverage, and he/she did not have an explanation for why there was no RN coverage on 09/29/24.

Based on observation, interview and record review, the facility staff failed to provide each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, when staff failed to follow recipes. The facility census was 53. 1. Review of the facility's Standardized Recipes policy, revised April 2007, showed staff were directed to use only tested , standardized recipes to prepare foods. Review showed standardized recipes will be adjusted to the number of portions required for a meal. Review of the facility's standardized recipe for 52 servings of shepherd's pie showed staff were directed to include 16 pounds of ground beef, one and one-eighth of a #10 (approximately seven pounds) can of tomatoes and one gallon plus one cup of potatoes. Review showed the recipe also included peas and carrots. Review showed a three inch by three inch wide long portion was equal to one serving. Observation on 12/02/24 at 11:36 A.M., showed dietary staff served the residents a #8 scoop (four ounces) of shepherd's pie for the noon meal. Observation showed the shepherd's pie contained more potatoes than ground beef and did not contain tomatoes. Observation showed the shepherd's pie was runny in consistency. During an interview on 12/02/24 at 11:42 A.M., the Dietary Supervisor (DS) said staff used about eight pounds of beef and forgot to add tomatoes. The DS said staff used enough peas, carrots and potatoes for 52 servings. The DS said he/she reduced the amount of beef so there would not be a lot of left overs which would go to waste. During an interview on 12/02/24 at 11:47 A.M., the Registered Dietician (RD) said he/she would expect staff to follow the standardized recipes. The RD said he/she was not aware staff only used half of the beef called for in the recipe. The RD said shepherd's pie should be firm and served as a three inch by three inch wide long portion, not a four ounce scoop. The RD said he/she did not know if a four ounce scoop was the same as a three inch by three inch wide long portion .

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to store ice scoops in a manner to prevent contamination and failed cover resident meals in a manner to prevent contamination. Facility staff failed to maintain the ice machine drain air gap. The census was 53. 1. Review of the facility's Food Receiving and Sorage policy, revised July 2014, showed: -Food in desiganted dry storage areas shall be kept off the floor at least 18 inches; -All foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date; -Other opened containers must be dated and sealed or covered during storage; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated. 2. Observation on 12/01/24 at 9:29 A.M., showed the kitchen refrigerator #1 door contained a sign which read Record open and use by dates on all open items. Follow use by manufacturer's date or seven days. Observation showed the refrigerator contained: -One container of parmesan cheese opened and undated; -One container with chopped garlic open to the air, opened and undated; -An unlabeled and undated container with a yellow substance; -Bottles of Caesar and Italian dressing, opened and undated; -A bottle of ketchup, opened and undated; -A metal container of lettuce leaves open to the air and undated; -A container of chopped onions open to the air and undated; -Two cartons of grape juice, opened and undated; -Two cartons of orange juice, opened and undated; -One 64oz bottle of apple juice, opened and undated; -One gallon bottle of enchilada sauce, opened and undated; -One bottle of salsa, opened and undated. 3. Observation on 12/01/2024 at 9:33 A.M., showed the kitchen refrigerator #2 contained food debris on the bottom shelf and two opened pieces of ham wrapped in plastic, which were dated 11/21. 4. Observation on 12/01/24 at 9:45 A.M., showed the kitchen freezer #1 contained: -Abox of pizza dough open to the air and undated; -A box of dinner rolls open to the air and undated; -A bag of breadsticks open to the air and undated; -A bag of hashbrown patties open to the air and undated; -A bag of cubed potatoes open to the air and undated; -A bag of french fries open to the air and undated. 5. Observation on 12/01/24 at 9:47 A.M., showed the kitchen freezer #2 door contained a sign which read Label and date before putting items in fridge or freezer. Observation showed the freezer contained: -A box of square cod patties with frost, open and undated; -A box of unbreaded raw beef steaks, open and undated; -A box of fajita flavored chicken strips, open and undated; -A box of cookie dough, open and undated; -A box of pork loin steak fritters, open and undated. 6. Observation on 12/01/24 at 9:50 A.M , showed the dry storage room contained: -A package of egg noodles open to the air; -A package of spaghetti noodles, open and undated; -A box of parboiled rice, on the floor, open and undated; -A bag of oatmeal on the floor, open and undated; -A salt storage container which contained an aluminum bowl. Observation on 12/02/24 at 10:44 A.M., showed the dry goods storage area contained a bulk storage bin which contained flour. Observation showed a metal bowl was stored in the bin with the flour. 7. Observation on 12/01/24 at 9:55 A.M., showed under the cooks prep table contained a box of pancake mix with a scoop inside. 8. Observation on 12/02/24 at 10:31 A.M., showed the shelves behind the serving line contained: -A bin of frosted flakes, undated; -A bin of puffed [NAME] cereal, dated 9/30; -A bin of fruit loops, undated. During an interview on 12/01/24 at 9:55 A.M., The Dietary Manager (DM) said all dietary staff were responsible to label and date items when opened, and prior to storing. The DM said he/she was responsible to double check and ensure opened items were resealed and labeled/dated. The DM said scoops should not be left inside containers to prevent risk of bacteria growth. During an interview on 12/02/24 at 12:19 P.M., the Registered Dietician (RD) said food labeling/dating, and kitchen cleanliness have been issues lately and he/she was working with staff to resolve. 10. Observation on 12/01/14 at 12:45 P.M., showed staff served the noon meal. Observation showed the cooler uncovered contained ice with the ice-scoop inside. 11. Observation on 12/02/24 at 11:49 A.M., showed an unidentified staff member prepared drinks for residents in the dining room and placed the ice scoop into an uncovered cooler which contained ice after after each drink. 12. Observation on 12/02/24 at 11:59 A.M., showed shower Aide T used the ice scoop to remove ice from the cooler and placed the ice scoop back into the cooler with ice. During an interview on 12/02/24 at 11:59 A.M., Shower Aide T said he/she helped with lunch everyday. He/She said the ice scoop should go back in the scoop holder and should not be stored in the ice. 13. Observation on 12/02/24 at 12:11 P.M., showed Nurse Aide (NA) D used a ice scoop to remove ice from the dining room cooler and placed the ice scoop back into the cooler with ice. Observation showed NA D served the drink to a resident. NA D then removed the scoop from the ice, prepared another resident drink, and returned the scoop to the ice bin. During an interview on 12/02/24 at 12:12 P.M., NA D said the ice scoop should probably not go in cooler but he/she was not sure where it should go. NA D said he/she helped with lunch daily. 14. Observation on 12/02/24 at 12:11 P.M., showed Housekeeper N removed the ice scoop from the ice, placed ice in a cup and returned the scoop to the ice. During an interview on 12/02/24 at 12:15 P.M., Housekeeper N said the ice scoop should go back in the container next to the cooler. Housekeeper N said the ice scoop should not be stored in the ice. 15. Observation on 12/03/24 at 8:09 A.M., showed an unidentified staff member prepared drinks for residents in the dining room and placed the ice scoop into an uncovered cooler which contained ice after after each drink. During an interview on 12/04/24 at 1:00 P.M., the DM said dietary staff were responsible for ensuring the ice scoop was not stored in the ice. 16. Observation on 12/02/24 at 12:15 P.M., showed staff delivered two metal carts to the hallway near the nurse's station. Observation showed the meal plates were covered with plastic lids which contained a hole in the center, which exposed the food. Observation showed the cart remained in the hallway as staff delivered the meal trays to residents. Observation on 12/03/24 at 12:25 P.M., showed an open metal cart which contained five resident hall trays sat in the main hallway on the 100-hall side of the nurse's station. Observation showed the meal plates were covered with plastic covers, which contained a hole in the center. Observation showed five resident trays contained small cups of pudding and potato salad which were not covered. Observation showed the cart was not attended by staff. During an interview on 12/02/24 at 12:19 P.M., the Registered Dietician (RD) said the hall trays were being covered with lids for cold items and the lids should not have a hole in them. During an interview on 12/04/24 at 1:00 P.M., the DM said the servers were responsible for ensuring food was covered before being placed on delivery carts. The DM said the plate covers should not have holes. The DM said he/she was not aware meal carts were being left in the hall with uncovered food items. 17. Observation on 12/02/24 10:33 A.M., showed the ice machine drain ran to an open floor drain, sat below the finished floor level and did not contain an air gap. During an interview on 12/04/24 at 1:00 P.M., the DM said he/she was not familiar with the ice machine air gap requirement. During an interview on 12/04/24 at 11:30 A.M., the plant supervisor said he/she had never looked at the ice machine drain so he/she didn't realize there was not an air gap. During an interview on 12/04/24 at 2:30 P.M., the administrator said the DM and dietary staff were responsible for food storage. The administrator said dietary and nursing staff were responsible for ensuring food was covered when being delivered to resident rooms. The administrator said anyone serving drinks or using the ice scoop was responsible for not storing the scoop in the ice. The administrator said the DM and Plant Supervisor were responsible for the ice machine air gap. The administrator said the RD has been working with newer kitchen staff on ome of the issues noted.

Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for six employees (Certified Nurse aide (CNA) I, Licensed practical nurse (LPN) J, Receptionist K, transporter M, Housekeeper N, and nurse aide (NA) B) out of ten sampled employees. Staff failed to perform hand hygiene and/or wash hands to prevent the spread of infection during perineal care for four residents (Resident #9, #14, #38, and #52) of four sampled residents. Failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for three (Resident #14, #38, and #52) of three sampled residents. The facility census was 53. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; -Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Risk Management Plan for Legionella Control, reviewed 10/08/24, showed the plan contained a policy template which was not modified to reflect the facility's water system. Review showed the plan did not contain: -Facility specific policies related to water management; -A description of the facility's water system; -Facility specific areas identified as at risk for Legionella growth; -Control measures to include acceptable ranges; -Corrective actions to take if control measures are out of range. Review of Appendix B of the Legionella control plan showed the Appendix contained 30 questions which provided a description of the facility water system. The Appendix did not contain information related to areas identified as risk areas. The Appendix did not contain information related to control measures or corrective actions. During an interview on 12/04/24 at 10:55 A.M., the Housekeeping supervisor said his/her staff flushes toilets and runs water in vacant rooms every couple of days. The housekeeping supervisor said the Plant Supervisor brought up the need to run the water periodically but the Plant Supervisor never provided guidance on four shower rooms which were being used for storage. The housekeeping supervisor said he/she did not know the last time the unused showers were flushed. During an interview on 12/04/24 at 11:30 A.M., the Plant Supervisor said he/she read the Legionella control plan briefly when he/she started work at the facility. The Plant Supervisor said he/she was not familiar with what should be included in the Legionella control plan. The Plant Supervisor said he/she did not know if the plan identified specific risk areas of the facility water system. The Plant Supervisor said he/she believed the four showers and two bathtubs which were not being used would probably be high risk areas. The Plant Supervisor said he/she did not know if the plan addressed low use areas. The Plant Supervisor said he/she had spoken with housekeeping about flushing low use resident room sinks and toilets. During an interview on 12/04/24 at 1:45 P.M., the administrator said maintenance staff were responsible for implementing the Legionella control plan. The administrator said he/she had reviewed the plan but was not very knowledgeable of the contents. The administrator said Appendix B contained facility specifics. The administrator said Appendix B did not contain facility specific risk areas, control measures or corrective actions. 2. Review of the Facility's Employee Screening for Tuberculosis, dated 12/2016, showed: -Each newly hired employee will be screened for TB infection and disease after an employment offer has been made prior to the employee's duty assignment; -The initial TB testing will be a two-step Tuberculin skin test (TST); -If the reaction to the first skin test is negative, the facility will administer a second skin test not before 7 days and no later than 21 days after the first test. The employee may begin duty assignments after the first skin test (if negative) unless prohibited by state regulation. Review of the Center for Disease Control and Prevention's, Clinical Testing Guidance for TB: TB Skin Tests, dated May 14, 2024, showed: -Two-Step testing; -If the first skin test is negative, a second TB skin test should be done one to three weeks later; -The skin test reaction should be read between 48-72 hours after administration by a health care worker trained to read TB skin results. 3. Review of CNA I's employee file showed a hire date of 12/27/23. Review showed the employees file did not contain documentation the first or second step PPD as completed. 4. Review of LPN J's employee file showed a hire date of 05/22/24. Review showed the employee's file did not contain documentation the first or second step PPD as completed. 5. Review of Receptionist K's employee file showed a hire date of 04/23/24. Review showed the employee's file did not contain documentation the first or second step PPD as completed. 6. Review of Transporter M's employee file showed a hire date of 05/15/24. Review showed the employee's file did not contain documentation the first or second step PPD as completed. 7. Review of Housekeeper N's employee file showed a hire date of 02/08/24. Review showed the employee's file did not contain documentation the first or second step PPD as completed. 8. Review of NA B's employee file showed a hire date of 06/03/24. Review showed the employee's file did not contain documentation the first or second step PPD as completed. 9. During an interview on 12/02/24 at 2:50 P.M., the business office manager (BOM) said the director of nursing (DON) and the assistant director of nursing (ADON) are responsible for ensuring the two-step TB's are completed on all new hires. He/She said at new employee orientation he/she has the new employees file out the TB documentation and then either the DON or ADON will administer the first step. He/She said it is the DON's job to keep track of the documentation and ensure the employee completes the TB testing. He/She said all employees should have the first step TB done and read before they come in contact with the residents. He/She is not sure why there are staff members who did not get the two step TB's completed timely. During an interview on 12/02/24 at 3:17 P.M., the DON said all new employees need a two-step TB. He/She said the first step should be given and read before staff come in contact with residents. The second step should be done one to three weeks after the first step is completed. He/She said TB's should be read 48-72 hours after administration. He/She said TB's are started at new employee orientation by either the ADON, Charge nurse, or himself/her/self. He/She is responsible for ensuring the TB's are completed timely. He/She tracks them on a spreadsheet. He/She said he/she is not sure why there are employees without two-step TB's completed. During an interview on 12/02/24 at 4:10 P.M., the administrator said the DON, with the help of the ADON, is responsible for ensuring two-step TB's are completed on all new hires. He/She said after conducting audits in September he/she was made aware that there were staff members who did not have a two-step TB. He/She said he/she thought they had all been fixed and was not sure why there were still staff members who were uncorrected. 10. Review of the facility's Hand Hygiene policy, dated May 2021 showed: -Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating and after using the restroom; -The use of gloves does not replace hand hygiene. If your task require gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 11. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated , showed staff assessed the resident as follows: -Cognitively impaired; -Required substantial/maximum assist from staff with toileting, bathing, and personal hygiene. Observation on 12/01/24 at 3:10 P.M., showed NA A entered the resident's room to provide perineal care. NA A applied his/her gloves, removed the residents soiled brief and wiped the resident's perineal area front and back. With the same soiled gloves, NA A placed a clean brief, clean clothes, and covered the resident with their blanket. NA A removed the gloves and left the room without preforming hand hygiene. During an interview on 12/01/24 at 3:45 P.M., NA A said he/she forgot to change his/her gloves after they removed the dirty items. He/She said they are to wash hands before and after care. 12. Review of Resident #14's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required substantial/maximum assist from staff with personal hygiene, and dependent with toileting. Observation on 12/03/24 at 10:13 A.M., showed CNA E entered the resident's room to provide care. CNA E applied his/her gloves and provided peri-care. CNA E changed his/her gloves, cleaned the bowel movement from the resident's buttock, changed gloves, placed a clean brief and disposable pad underneath the resident, removed gloves, and took the trash from the room. The CNA did not perform hand hygiene before or in between gloves changes during peri-care to prevent the spread of infection. During an interview on 12/03/24 at 10:35 A.M., CNA E said he/she should have sanitized or wash his/her hands prior to applying gloves, and after each glove change, but did not, because he/she was nervous and in a rush. 13. Review of Resident #38's Quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial/maximal assist from staff with personal hygiene and toileting. Observation on 12/02/24 at 3:31 P.M., showed CNA R entered the resident's room to provide catheter care. CNA R washed hands, and applied gloves. CNA R cleaned the resident's catheter and peri area. With the same soiled gloves, the CNA rolled the resident and applied new brief underneath resident. CNA R changed his/her gloves, latched the resident's brief and adjusted the blankets. The CNA did not perform appropriate hand hygiene in between gloves changes during peri-care to prevent the spread of infection. During an interview on 12/02/24 at 3:45 P.M., CNA R said he/she should have washed hands between glove changes, but he/she was nervous. He/She said not washing hands between gloves changes is a risk for infection. 14. Review of Resident #52's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required substantial/maximum assist from staff with personal hygiene, and dependent with toileting. Observation on 12/01/24 at 12:07 P.M., showed CNA E entered the resident's room to provide care and applied gloves. CNA E provided peri-care, changed gloves, and cleaned the bowel movement from the resident's buttock.With the same soiled gloves, CNA E open the dresser drawer and removed a clean brief, changed gloves, placed the brief underneath the resident, covered the resident, and took the trash from the room. CNA E did not perform appropriate hand hygiene before or in between gloves changes during peri-care to prevent the spread of infection. 15. During an interview on 12/04/24 at 3:36 P.M., the DON said staff should perform hand hygiene when they enter a resident's room and prior to putting gloves on. The DON said staff should perform hand hygiene after each glove change, wash hands between dirty and clean tasks, and prior to leaving the resident's room. The DON said staff may use hand sanitizer up to three times, then he/she should wash his/her hands with soap and water. During an interview on 12/04/24 at 4:30 P.M., the administrator said staff are expected to wash their hands when they enter the room and exit the room. Staff should hand sanitize between glove changes or wash hands if they are visibly soiled. Gloves should be changed between dirty task to clean task. 16. Review of the facility's Enhanced Barrier Precautions policy, dated September 2022 showed: -All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident are activities that require the use of gown and gloves; -An order for enhances barrier precautions will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO; -Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precaution do not apply. 17. Review of Resident #14's quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and had one stage three (full thickness tissue loss) pressure ulcer. Observation on 12/01/24 at 11:48 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 12/02/24 at 9:57 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. LPN H and NA C performed incontinence care and wound care to the resident. NA C did not wear a gown when he/she performed incontinence care. The NA did not use appropriate PPE as an EBP during cares. During an interview on 12/02/24 at 10:16 A.M., NA C said he/she did not know what EBP was or that a gown was required when performing incontinence care with the resident. During an interview on 12/02/24 at 10:18 A.M., LPN H said extra PPE should be used with cares for residents with an open wound to protect the residents and staff from cross contamination. The LPN said the charge nurse notifies the NAs and CNAs during shift report of residents who require extra PPE, which requires the NAs/CNAs to wear at least a gown and gloves with incontinence care. The LPN said he/she should have ensured the NA wore a gown when he/she assisted him/her to provide incontinence care to the resident. Observation on 12/03/24 at 10:16 A.M., showed a sign on the resident's door to alert staff on the use of EBP. NA B and CNA E entered the resident's room and did not wear a gown when they transferred the resident via mechanical lift and performed incontinence care. During an interview on 12/03/24 at 10:35 A.M, CNA E said he/she should have worn a gown when he/she transferred the resident via mechanical lift and performed incontinence care since he/she was in contact with the resident's wound. The CNA said he/she was in a rush and forgot to go get a gown. During an interview on 12/03/24 at 10:47 A.M., NA B said he/she did not realize there was an EBP sign on the resident's room door, and he/she did not know to wear a gown when he/she transferred the resident via mechanical lift and performed incontinence care. 18. Review of Resident #38's Quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment; -Indwelling catheter. Observation on 12/02/24 at 3:31 P.M., showed the CNA R entered the resident's room with EBP sign on resident's door, washed hands, and applied gloves. CNA R performed catheter care to resident, removed gloves, and sanitized hands. The CNA did not wear a a gown when he/she performed catheter care. During an interview on 12/02/24 at 3:45 P.M., CNA R said the EBP sign was just put on resident's door today. He/She said he/she was not informed about it at the beginning of his/her shift, but usually the sign means that the resident has a sickness. He/She said he/she is unsure why resident has one on the door today. 19. Review of Resident #52's significant change MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, and had one unstageable (wound depth is undetermined due to being covered with necrotic tissue) pressure ulcer. Observation on 12/01/24 at 12:07 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. Observation on 12/02/24 at 9:39 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP or PPE in close proximity of the room. NA C did not wear a gown when he/she assisted LPN H to hold and reposition the resident's leg while LPN H performed wound care to the resident's leg. During an interview on 12/02/24 at 10:16 A.M., NA C said he/she did not know what EBP was or that a gown was required when he/she assisted to reposition the resident during wound care. During an interview on 12/02/24 at 10:18 A.M., LPN H said the NA did not need to wear a gown since the NA was not the one who performed the wound care to the resident. During an interview on 12/04/24 at 3:36 P.M., the DON said the NA should have worn gown and gloves to protect him/herself, whether he/she was directly involved with the wound care, or not. Observation on 12/02/24 at 1:11 P.M., showed a sign on the resident's door to alert staff on the use of EBP. LPN G and NA C entered the resident's room and did not wear a gown when they transferred the resident via mechanical lift and performed incontinence care. During an interview on 12/02/24 at 1:28 P.M., LPN G said he/she saw a sign on the resident's room door but he/she did not read it. The LPN said he/she had not received an in-service/training on EBP but would personally wear gloves and maybe a gown if he/she performed a treatment for a resident with an infected wound with drainage, or a urinary catheter. The LPN said he/she was not sure where to find extra PPE but he/she would ask staff or search for them if needed. During an interview on 12/04/24 at 3:36 P.M., the DON said he/she had not yet in-serviced all staff on the use of EBP but had begun packaging kits with extra PPE (gloves, gown, mask, and trash bags) for use on each hall. The DON said he/she recently had signs placed on doors for residents with a catheter or wound, that alert staff to wear at least a gown and gloves when they provide transfers, wound care, catheter care, incontinence care for that resident. The DON said not everyone is aware of where the extra PPE kits are stored. During an interview on 12/04/24 at 4:31 P.M., the Administrator said staff should wash hands before placing PPE on, and after it is discarded, wash hands again. The administrator said EBP has been process that the facility is still rolling it out. She said implementation and education has fallen through the cracks, there has been some education, but staff need more. The administrator said if staff see signs, and don't know what it means, they should ask their charge nurse or DON. 39644

Based on record review, and interview, facility staff failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet resident's needs for three residents (Resident #20, #49, and #56) out of 14 sampled residents.The facility census was 53. 1. Review of the facility's Comprehensive Care Plans policy, September 2022, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff used to assess the care needs of the resident, assessment. 2. Review of Resident #20's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted on [DATE]; -Cognitivly impaired; -Diagnoses of Cancer, Cerebrovascular accident (CVA), Transient Ischemic attack (TIA), or Stroke; -Care Area Triggers: Delirium, cognitive loss/dementia, communication, urinary incontinence/indwelling catheter, behavioral symptoms, falls, dental care, pressure ulcer, psychotropic drug use, and pain, Review of the resident's medical record showed the record did not contain documentation of a comprehensive person-centered care plan for the resident, to provide directions for the resident's delirium, cognitive loss/dementia, communication, urinary incontinence/indwelling catheter, behavioral symptoms, dental care, pressure ulcer, psychotropic drug use, and pain. During an interview on 12/04/24 at 8:52 A.M., the MDS/Care Plan Coordinator said the resident's comprehensive care plan should have been completed 21 days after admission, but unsure why this residents comprehensive was not completed. 3. Review of Resident #49's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted on [DATE]; -Moderate cognitive impairment; -Diagnoses: Renal failure, Thyroid disorder, Dementia, and Parkinson's; -Care Area Triggers: Delirium, Cognitive loss, communication, activities of daily living (ADL) care, urinary incontinence/indwelling catheter, psychosocial well-being, mood state, behavioral symptoms, activities, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, and pain. Review of the resident's medical record showed the record did not contain documentation of a comprehensive person-centered care plan for the resident, to provide directions for the resident's communication deficits, ADL care, urinary catheter, psychosocial well-being, mood and behavioral symptoms, nutritional status, dehydration/fluid maintenance, pressure ulcer, and pain. During an interview on 12/04/24 at 8:53 A.M., the MDS/Care Plan Coordinator said the resident's comprehensive care plan should have been completed 21 days after admission, but he/she must have just overlooked it. 4. Review of Resident #56's discharge MDS, dated [DATE], showed staff assessed the resident as follows: -admitted on [DATE] from an acute hospital; -discharged [DATE] to an acute hospital with return anticipated; -Moderate cognitive impairment; -Diagnoses: Obstructive uropathy (blocked urine flow), Diabetes Mellitus, Right hip dislocation, -Care Area Triggers: Cognitive loss, visual function, activities of daily living (ADL) care, urinary incontinence/indwelling catheter, psychosocial well-being, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, and pain, Review of the resident's medical record showed staff documented the resident returned to the facility on [DATE]. The record did not contain documentation of a comprehensive person-centered care plan for the resident, to provide directions for the resident's visual deficits, ADL care, urinary catheter, psychosocial well-being, falls, dental care, and pain. During an interview on 12/04/24 at 8:54 A.M., the MDS/Care Plan Coordinator said the resident's comprehensive care plan should have been completed in October, and he/she must have just overlooked it. 5. During an interview on 12/04/24 at 3:50 P.M., the Director of Nursing (DON) said the MDS coordinator is responsible for the completion of care plans. The DON said he/she and MDS review all the care plans together. The DON said she does not have a good reason for the care plans not being done or updated. During an interview on 12/04/24 at 4:50 P.M., the Administrator said comprehensive care plans are compeleted by MDS coordinator. The administrator said he/she does not have a reason why any of the care plans have not been done or updated, but the DON should monitor that they are. 39644 50422

Based on observation, interview, and record review, facility staff failed to safely transfer two residents (Resident #14 and #52) of two sampled residents via mechanical lift, in a manner to prevent accidents. The facility's census was 53. 1. Review of the facility's policy titled, Using a Mechanical Lift Machine, dated July 2017, showed staff were directed as follows: -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Staff must be trained and demonstrate competency using the specific machines or devices used in the facility; -Gently support the resident as he or she is moved, but do not support any weight; -The policy did not contain direction for position of the base legs during the transfer. 2. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/14/24 showed staff assessed the resident as severe cognitive impairment and dependent on staff for transfers from chair to bed/bed to chair. Review of the resident's care plan, dated 10/30/24, showed two staff are to assist the resident with the mechanical lift for transfers. Observation on 12/03/24 at 10:12 A.M., showed Certified Nursing Aide (CNA) E and Nuring Assistant (NA) B attached the resident's sling to the mechanical lift. NA B raised the resident from his/her wheelchair with the legs in the opened position of the mechanical lift, while CNA E removed the wheelchair from behind the resident. CNA E left the room to gather additional supplies, leaving the resident suspended in the sling without two staff support for three minutes. CNA E returned to the resident's room, closed the legs of the mechanical lift, pushed the lift to the resident's bed, and lowered the resident to the bed. During an interview on 12/03/24 at 10:35 A.M., CNA E said two staff should perform mechanical lift transfers, with one person controlling the lift and the other to guide the resident in the sling to ensure safety and prevent falls or the machine tipping over. The CNA said he/she should have lowered the resident back to the chair prior to leaving the room, for safety, and since only one staff was left with him/her in the room. The CNA said he/she was taught the legs of the mechanical lift should be closed when pushing the resident with the lift for better maneuvering, and to keep staff from tripping over each other. During an interview on 12/03/24 at 10:47 A.M., NA B said two staff should perform mechanical lift transfers, with one person controlling the lift and the other to guide the resident in the sling. The NA said the legs of the mechanical lift should be opened when pushing the resident with the lift for balance and resident safety. The NA said the resident could have fallen while left dangling in the air, but he/she was unsure of what to do since he/she was left alone with the resident. 3. Review of Resident #52's significant change MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and dependent on staff for transfers from chair to bed/bed to chair. Review of the resident's care plan, dated 12/02/24, showed two staff are to assist the resident with the mechanical lift for transfers. Observation on 12/01/24 at 12:07 P.M., showed CNA E widened the legs of the mechanical lift to accommodate the resident's wheelchair. CNA E and CNA F attached the resident's sling to the mechanical lift. CNA E raised the resident from the wheelchair in the sling using the mechanical lift, while CNA F removed the chair from behind the resident. CNA E closed the legs of the lift, pushed the lift to the resident's bed, and lowered the resident to the bed. During an interview on 12/03/24 at 10:35 A.M., CNA E said he/she was taught the legs of the mechanical lift should be closed when pushing the resident with the lift for better maneuvering, and to keep staff from tripping over each other. Observation on 12/02/24 at 8:11 A.M., showed NA C widened the legs of the mechanical lift to accommodate the resident's wheelchair. NA C and NA D attached the resident's sling to the lift. NA D raised the resident from the wheelchair in the sling using the mechanical lift, while NA C removed the chair from behind the resident. NA D closed the legs of the lift, pushed the lift to the resident's bed, and lowered the resident to the bed. During an interview on 12/02/24 at 2:39 P.M., NA C said two staff should always perform mechanical lift transfers, with one person who locks the wheel/controls the lift and the other person to guide the resident in the sling while in the air. The NA said the legs of the mechanical lift should be opened when pushing the resident with the lift for balance and safety. The NA said when he/she realized that NA D was pushing the resident in the lift with the legs closed, it was too late for him/her to intervene. During an interview on 12/04/24 at 10:55 A.M., the Director of Nursing (DON) said NA C and NA D have received training on how to transfer a resident with a mechanical lift. 4. During an interview on 12/04/24 at 3:42 P.M., the DON said two staff are required to transfer a resident via a mechanical lift to ensure resident safety and prevent falls, and one person should always guide the resident in the sling. The DON said it is not appropriate or safe to leave a resident suspended in the sling in the air. He/She said the legs of the mechanical lift should be opened to ensure stability of the lift when pushing a resident.

Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 27 opportunities observed, seven errors occurred, resulting in a 25.93% error rate, which affected two residents (Resident #16, and #36). The facility census was 53. 1. Review of the Facility's Administering Medications policy, dated 12/2012, showed: -Medications must be administered in accordance with the orders including any required time frame; -Individual administering the medication must check to verify right time; -The Expiration/beyond use date on the medication label must be checked prior to administering, when opening a multi-dose container, the date opened shall be recorded on the container; Review of the Facility's Medication Errors policy, dated 04/2017, showed: -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles or the professional providing services; -Example of medication error includes wrong time and/or failure to follow manufacturer instructions and/or accepted professional standards. 2. Review of the Resident #16's physician's order sheets (POS), dated December 2024, showed the directed staff to adminster: -Fiasp (Rapid-acting insulin) inject 25 units subcutaneously (SQ) (under the skin)with meals; -Fiasp inject per sliding scale for a blood sugar of 301-350 inject five units SQ; -Tresiba (Long-acting insulin) inject 65 units SQ with meals. Observation on 12/02/24 at 10:22 A.M., showed Certified Medication Tech (CMT) O prepared and administered Fiasp 30 units and Tresiba 65 units SQ to the resident. The resident's Fiasp and Tresiba insulin pens did not contain an open or beyond use date. During an interview on 12/02/24 at 10:31 A.M., Certified Medication Technician (CMT) O said insulins pens are supposed to be dated when opened. He/She said whoever opens the insulin pen is responsible for making sure resident name and open date is on the pen. He/She said he/she thinks insulin expires after 30 days of being open, but he/she usually has to ask the nurse for sure. He/She said if insulin pens are not dated and he/she has questions about when they were opened or doubts, he/she will go talk with the charge nurse or converse with the other CMT's to see when they were opened. He/She the risk of not dating insulin pens is not knowing how long it's been opened, and it could affect the overall effectiveness of the insulin. He/She said that residents normally going through about one insulin pen a week, so they usually don't expire. 3. Review of Resident #36's POS, dated December 2024, showed staff are directed to administer medications between 0600-1100 A.M.: -ProFe (treat low iron) 391.3 (180 fe) milligrams (mg) daily in the morning between 0700-1100 A.M.; -Pioglitazone (treat diabetes) 30mg one time a day between 0600-1100 A.M.; -Metoprolol Succinate (treat high blood pressure) 25 mg in the morning between 0700-1100 A.M.; -Furosemide (diuretic) 20mg one time a day between 0600-1100 A.M.; -Glimepiride (treat diabetes) 2mg in the morning between 0700-1100 A.M. Observation on 12/02/24 at 12:10 A.M., showed CMT O administered Profe, Pioglitazone, Metoprolol, Furosemide, and Glimepiride to the resident. One hour and 10 minutes after the allotted timeframe. During an interview on 12/02/24 at 12:15 A.M., CMT O said he/she normally gives the resident his/her morning medications during breakfast but said the resident left the dining room before he/she could give them to the resident and then he/she forgot to go back later. He/She said when he/she gives medications late he/she usually puts a progress note in chart and then watches the other medication to make sure they are not given to close together. 4. During an interview on 12/02/24 at 4:03 P.M., License Practical Nurse (LPN) G said if a CMT has a medication error he/she would expect them to report it to charge nurse. He/She said if he/she is notified about a medication error then the physician would be contacted along with the Director of Nursing (DON), resident family, and possible pharmacy to see if anything needed to be done. He/she said there should be a progress note in the chart under risk management for a medication error and there are steps to follow. He/She agreed that administering medications late and given undated insulin is a medication error. He/She said he/she was not informed about any medication errors today. During an interview on 12/04/24 at 3:53 P.M., the DON said when a medication error occurs that it needs to be reported to the charge nurse, DON, notify family, physician and obtain any orders. He/She said administering undated insulin and administering medications late are considered medication errors to him/her because it violates the nine rights of administration. He/She expects a progress note to be in the chart. During an interview on 12/04/24 at 4:25 P.M., the Administrator said when a medication error occurs the charge nurse should be notified along with the doctor and family member. He/She said administering undated insulin and administering medications late would be considered a medication error. He/She expects there to be a progress note in the chart.

Based on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner when staff failed to properly label, and/or discard expired insulin medications from two of two sampled medication carts. The facility census was 53. 1. Review of the facility's policy titled, Administering Medications, dated ,d+[DATE], showed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 2. Observation on [DATE] at 9:26 A.M., showed the ,d+[DATE] hall medication cart contained two Lantus insulin Pens opened and undated. During an interview on [DATE] at 9:30 A.M., Certified Medication Technician (CMT) P said insulin pens are usually only good for 28 days. He/She said the person opening the insulin pen is responsible for putting the open date on the pen. He/She said the risk of not having an open date is you don't know when it expires, and insulin may not be effective if it is expired. 3. Observation on [DATE] at 9:49 A.M., showed the ,d+[DATE] hall medication cart contained: -Six Lantus insulin pens opened and undated; -Three Novolog insulin pens opened and undated; -One Novolin insulin pen opened and undated; -One Glargine insulin pen opened and undated; -One Aspart insulin pen opened and undated; -One Fiasp insulin pen opened and undated; -One Tresiba insulin pen opened and undated. 4. During an interview on [DATE] at 09:55 A.M., CMT Q said there is no explanation why the insulin pens are not dated. He/She said he/she always works, and the residents take their insulin so frequently they go through one pen a week or less. He/She said insulin pens usually expire 28 days after opening. He/She said the person opening the insulin is responsible for dating the pen with the open date. He/She said the risk of not dating the pens is the insulin may not be effective if you do not know when it expires. During an interview on [DATE] at 3:06 P.M., Licensed Practical Nurse (LPN) J said whoever opens the insulin pens should be dating it with the open date. He/She thinks insulin pens are good for 60 days after opening. He/She said the risk for not dating insulin pens when opened is you don't know when it expires, and the insulin may not be effective. During an interview on [DATE] at 3:53 P.M., the Director of Nursing (DON) said insulin pens should be labeled with the pharmacy label and open date when opened. He/She said the person opening the pen is responsible for putting the open date on the pen. He/She said most insulin pens are good for 28 days after opening. He/She said if insulin pens are not dated then you don't know how long it has been opened and risk the insulin losses effectiveness. He/She said the Assistant Director of Nursing (ADON) and the DON should be monitoring if insulin pens are being dated. He/She said he/she was not aware there were several insulin pens opened with no dates on them. During an interview on [DATE] at 4:25 P.M., the administrator said insulin pens should be dated when opened. He/She said whoever opens the insulin pen is responsible for dating it. He/She is unsure when insulin pens expire. He/She said the ADON and DON should be monitoring the pens. He/She is unsure of the risks of having opened and undated insulin pens.

Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate) for four residents (Resident #25, #34, #38, and #54) out of four sampled resident who transfered to the hospital. The facility's census was 53. 1. Review of the facility policies showed the facility did not have a policy for Ombudsman notification. 2. Review of Resident #25's medical record showed the resident transferred to the hospital on 10/15/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 3. Review of Resident #34's medical record showed the resident transferred to the hospital on 10/31/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of Resident #38's medical record showed the resident discharged to the hospital on 08/12/24 and readmitted to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 5. Review of Resident 54's medical record showed the resident discharged to the hospital on 11/07/24 and readmitted to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 6. During an interview on 12/04/24 at 10:10 A.M., the Social Services Director said he/she was not aware of the process for Ombudsman notification of transfered and discharged residents. He/She said he/she does not handle this task. During an interview on 12/04/24 at 4:00 P.M., the Administrator said the Ombudsman notification should be sent monthly and she was the one who did that task but hasn't had time to do it.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #25, #34, #38, and #54) out of 14 sampled residents. The facility's census was 53. 1. Review of the facility's Bed Holds policy, dated March 2022, showed the facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed-hold policy. 2. Review of Resident #25's medical record showed the resident discharged from the facility on 10/15/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #34's medical record showed the resident discharged from the facility on 10/31/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 4. Review of Resident #38's medical record showed the resident discharged from the facility on 08/12/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 5. Review of Resident 54's medical record showed the resident discharged from the facility on 11/07/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 6. During an interview on 12//24 at 10:15 A.M., the Social Services Director (SSD) said he/she knows this is supposed to be done, but to their knowledge the charge nurse does it. The SSD said the nurse would give it to him/her to upload. The SSD said he/she has not completed any bed holds for any residents upon transfer or discharge. During an interview on 12/24 at 11:03 A.M., the Administrator said We are supposed to do bed holds, but it is not happening. The facility found that the last SSD had not been doing this, and the new SSD needs to be trained.

Reviewed AT Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information on a daily basis, which included the facility name, current date, resident census, total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. Facility staff failed to keep the required daily staffing records for 18 months. The facility's census was 53. 1.Review of the facility's policy titled, Nurse Staffing Posting, dated September 2022, showed: -The facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; -It is the policy of the facility to make nurse staffing information readily available in a readable format to resident and visitors at any given time; -The facility will post the Nurse Staffing sheet at the beginning of each shift; -A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current; -The information shall reflect staff absences on that shift due to call-outs and illness, and after the start of each shift, actual hours will be updated to reflect such; - Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater. Review of the facility's records showed the facility did not retain nurse staff posting for: -January 2024; -February 2024; -03/01/24 through 03/14/24; -April 2024; -05/01/24, 05/04/24, 05/05/24, 05/09/24 through 05/15/24, 05/17/24 through 05/21/24, and 05/23/24 through 05/29/24; -06/03/24, 06/06/24 through 06/14/24, 06/18/24 through 06/20/24, 06/25/24, 06/27/24, and 06/28/24; -07/06/24, 07/07/24, and 07/12/24 through 07/31/24; -08/01/24 through 08/15/24, and 08/20/24 through 08/26/24; -09/13/24 through 09/15/24, 09/18/24, and 09/23/24; -10/02/24, 10/07/24, and 10/28/24. 2. Observation on Sunday, 12/01/24 at 9:20 A.M., showed the daily nurse staff posting, dated Friday, 11/22/24. 3. During an interview on 12/04/24 at 10:47 A.M., the Director of Nursing (DON) said the postings should be retained for 18 months. He/She said he/she started working at the facility in April and did not know the process for retaining the staff posting sheets prior to that or why the sheets from January through March were missing. The DON said he/she was not sure why the sheets from 07/01/24 through 07/31/24 were missing either. The DON said at one point, he/she, the administrator, and Assistant Director of Nursing (ADON) shared the responsibility to post the daily Nurse Staffing sheet, but currently, the administrator is responsible to post it on weekdays, and the ADON prepares the ones for Saturday and Sunday ahead of time and directs the weekend charge nurse to post on the weekends. During an interview on 12/04/24 at 10:50 A.M., the ADON said he/she prepares and prints the Nurse Staffing sheets with hall assignments on Fridays for the weekends, and gives the sheets to the charge nurse to post on the weekends. During an interview on 12/04/24 at 4:09 P.M., the administrator said the ADON ensures the daily staff posting is printed, and the charge nurse posts it at the beginning of the shift, but he/she was not sure anyone updates the posting with call-outs or illnesses. The administrator said the daily postings for January through April were not being completed because the facility only had an interim DON and did not have enough staff to keep up with it. The administrator said he/she did not know why the Nurse Staffing sheets were not posted daily from 11/23/24 through 11/30/24.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 53. 1. Review of the facility Food Services Manager policy, updated 9/28/22, showed the director of food and nutrition services must at a minimum meet one of the following qualifications: -A certified dietary manger (CDM); -A certified food service manager; -Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management. During an interview on 12/02/24 at 10:26 A.M., the Dietary Supervisor (DS) said he/she did not have any dietary manager training. The DS said he/she had worked in hotels and restaurants prior to starting at the facility. The DS said he/she was aware of the Certified Dietary Manager requirement and the administrator was working to get him/her certified. The DS said he/she had a food handlers card but he/she had never received any formal food service training. The DS said he/she started as a cook about six months ago and assumed the DS position about two months ago. During an interview on 12/04/24 at 11:05 A.M., the Human Resources (HR) Manager said the DS was hired as a cook on 07/10/24 and assumed the DS role on 09/03/24. The HR manager said he/she was aware the DS did not have previous experience in a nursing facility. The HR manager said he/she was aware of the CDM requirement but did not know the certification was required upon hire. The HR manager said the DS was in his/her 90-day probation period. The HR manager said he/she did not know if the DS was enrolled in any training. During an interview on 12/04/24 at 2:30 P.M., the administrator said he/she was responsible for ensuring the dietary manager had proper training and qualifications. The administrator said he/she thought the dietary manager could complete training after hired to the position and did not realize the dietary manager had to have dietary manager qualifications when hired. The administrator said the DS was enrolled in a food service manager course through the facility food service vendor but had not received a course date yet.

Based on interview and record review, facility staff failed to provide a proper transfer for one resident (Resident #1) in a manner to prevent accidents, when staff did not utilize two staff as directed and the resident sustained an injury to his/her leg. The facility census was 56. 1. Review of the facility's Safe Lifting and Movement of Residents Policy, revised July 2017, showed: -In order to protect the safety and the well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life and move residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 2. Review of Resident #1's Annual minimum data set (MDS), a federally mandated assessment tool, dated 12/13/223, showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent with transfers; -Impairment to bilateral lower extremities; -Utilized wheelchair for mobility. Review of the resident's plan of care, dated 4/21/23, showed staff assessed the resident required all transfers with two person assistance. Review of the resident's nurses notes, dated 2/4/24, showed Licensed Practical Nurse A documented at breakfast the resident said his/her leg was hurting, observed swelling and resident's right foot turned out. Physician and hospice notified and stat Xray ordered, due to increased pain X-Ray cancelled and emergency medical services called. Review of the resident's hospital discharge paperwork, dated 2/4/24, showed a commuted moderately displaced tibia-fibula distal shaft fracture. During an interview on 2/15/24 at 10:18 A.M., LPN A said the resident complained his/her leg hurt and because of the increased pain facility staff consulted with hospice and decided to skip the emergent x-ray and send the resident to the hospital. During an interview on 2/15/24 at 10:46 A.M., Certified Nursing Assistant (CNA) B said before the resident's accident, he/she was a one assist sometimes a two person assist. He/She said he/she does not know what transfer level the resident was actually assessed as. He/She said if he/she has questions on how a resident should be transferred then he/she will ask the charge nurse. He/She said he/she has access to the facility's electronic health records (EHR) but he/she does not know where transfer information is located. During an interview on 2/15/24 at 11:48 A.M., the administrator said the facility policy on transfers is to follow the care plan information for the specific resident. He/She said all staff have access to the careplans on the facilities EHR system and expects staff to follow the care plan. During an interview on 2/15/24 at 12:17 P.M., CNA C said he/she transferred the resident by him/herself on 2/4/24, the resident did say my foot, my foot but he/she thought it was just the residents normal behavior of yelling out and did not know if the resident's foot was hit. He/She said he/she was trained to look at the care plan to know a resident's transfer status and the care plan says he/she is a one or two. He/She said he/she has always transferred the resident as a one person assist During an interview on 2/15/24 at 12:33 P.M., CNA D said he/she has worked with the resident for awhile and he/she has always been a two person assist. He/She said staff are instructed to look at the careplan in the computer to know what the resident is assessed as. He/She said the resident is absolutely a two person assist because his/her body is very still and he/she has impairments to both lower legs, it is for both me and the residents safety to transfer him/her with two people. During an interview on 2/15/24 at 12:41 P.M., CNA E said they are instructed to look at the resident's care plan to know how to safely transfer them. He/She said he/she would be surprised to know the resident has been assessed as a one person assist for over a year because he/she has always transferred the resident by him/hers self. He/She said he/she does not get alerts when there is a change to a care plan. During an interview on 2/15/24 at 12:52 P.M., the physical therapist said there have been multiple changes with the resident on transfers and he/she is hard to assess because he/she is contracted in both legs but gets combative with the use of a mechanical lift. He/She said the resident can be a one person assist with a gait belt if the resident has no behaviors that day but both his/her behaviors and dementia have progress and became more frequent requiring a two assist more often. During an interview on 2/15/23 at 1:26 P.M., the administrator said he/she did not know the resident was assessed as a two person assist in his/her care plan for transfers for almost a year but that is what staff need to follow because that is the facility policy. During an interview on 2/16/24 the residents physician said the resident is very frail but a spontaneous fracture is not likely. He/She said the residents transfer need depends on the day but it is probably best for two person assist. MO00231339

Based on observation, interview, and record review, facility staff failed to ensure one resident(Residents #1) was provided care and treatment in a manner to prevent accidents. Facility staff also failed to have proper policy and procedures in place to prevent harm to the resident. The facility census was 50. 1. Review of the [MEDICATION NAME] (hot pack warmer) instruction guide, dated 4/3/2012, showed: -A [MEDICATION NAME] hot pack is a physical agent modality responsible for producing moist heat. Recommended unit operating temperature is 150-170 degrees Fahrenheit; -Contraindications include [MEDICAL CONDITION], residents with impaired sensation, residents with skin breakdown, and skin infections; -Caution should be taken with the following: confused or disoriented residents who cannot give feedback to temperature/comfort, elderly residents may require more toweling due to fragile skin, and presence of scar tissue; -Utilization should include a thorough explanation of the process to be provided to the resident. Inspection of body part to be treated must be performed and checked for sensation to light touch, hot/cold, and presence of scars or burns, appropriate layers of toweling, and pack is placed on area to be treated. Note: It is recommended to place the hot pack on the resident versus allowing the resident's weight to rest on pack, as this may cause burns; -Additional precautions include; ensure pack is secure and position of pack is correct. Do not leave resident unattended, checking the skin under the hot pack after the first five minutes to ensure it is not too hot, adjusting number of towels as appropriate. Duration of hot pack treatment is 15-20 minutes; -Whenever hot packs are used, the clinician must record treatment and area treated, duration of treatment, residents response to treatment, and change in functional status, at a minimum. It is best practice to include hot packs in the treatment clarification order. 2. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Impaired cognition (score of 10 on 1-15 scale); -Extensive assist of two person with bed mobility, transfers and toilet use; -Total assist of one person with bathing; -Extensive assist of one person with ambulation, locomotion, dressing, and personal hygiene; -At risk for pressure ulcer; -No skin issues identified. Review of the resident's plan of care, dated 1/31/2020, showed staff assessed the resident required assistance from staff with activities of daily living and mobility and dependent on staff for activities, cognitive stimulation, and social interaction. Review showed staff assessed the resident had potential for skin breakdown. The plan of care did not have the intervention for staff to use a heat pack on the resident. Review of the resident's Physician Order Sheet (POS), dated February 2020, did not contain orders or direction for the use of heat packs for the resident. Review of the facility skilled nursing evaluation, dated 2/10/2020 at 5:08 A.M., showed staff documented the resident did not have any skin issues, unsteady gait and balance is poor. Review showed staff assessed the resident is alert and oriented with some confusion at times. Resident has flu like symptoms and tested positive for influenza B. Review of nurse's note, dated 2/11/2020 at 11:30 A.M., showed CNA reported the resident had an open area on his/her bottom. Review showed staff documented the resident had a large open area that was dark/beefy red on the resident's buttocks and other smaller red areas on the right hip and buttock area. Review showed staff documented the Assistant Director of Nursing (ADON) notified, wound doctor was notified and and saw resident for open areas. New orders received and in place. Review of the facility skin evaluation, dated 2/12/2020 at 10:11 A.M., showed nursing staff documented they identified on the right posterior thigh a wound measured 6.5 centimeter (CM)x 4.5 cm x 0.1 cm, maceration (soften or become softened ) to wound bed noted, tissue painful and warm. Review of the wound physician evaluation, dated 2/18/2020, showed the physician assessed the wounds as follows: -Site #1-Burn of the right proximal, posterior thigh measured 5.8 cm x 5.5 cm with 100% necrotic (Death of cells or tissue through disease or injury) tissue. Surgical debridement (removal of damaged tissue ) completed; -Site #2-Burn of the right, distal, posterior thigh measured 8 cm x 7.4 cm - unstagable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.); -Site #3-Burn of the left, posterior thigh measured 3.9 cm x 1.6 cm - unstagable; -Site #4-Wound to the left buttock measured 1.6 cm x 0.3 cm x 0.1 cm; -[MEDICAL CONDITION] (skin infection) of right thigh, Keflex (antibiotic) 500 milligram (mg) twice daily x 10 days. Observation on 2/24/2020 at 1:45 P.M., showed the resident in bed. Observation showed staff provided care to the resident. Observation showed three unstagable open areas to the resident's right buttock and upper thigh. Observation showed an unstagable area on the resident's left buttock/upper thigh. At this time, the ADON/wound nurse said the larger area was debrided when resident was last seen by the wound care specialist, but the resident could not tolerate the other areas to be debrided. The ADON said the wound care specialist will attempt on next visit. The resident has two additional open areas, identified as moisture associated skin damage on the coccyx (upper buttock). During an interview on 2/24/2020 at 11:52 A.M., the resident said a staff member gave him/her a hot pack in his/her wheel chair and it burned me bad. The resident said he/she was not aware it was burning him/her. Resident said his/her bottom is very painful. During an interview on 2/24/2020 at 3:05 P.M., CNA A said he/she worked another hall, but was asked if he/she could get the resident up for supper. The resident told the CNA he/she didn't feel well, was cold, and didn't want to get up. The CNA spoke with the nurse and was told to try to get the resident up as he was a choking risk and needed to get up for supper. The CNA said there was a hot pack lying in the resident's wheel chair, but it was cold. The CNA said he/she took the pack to therapy and they gave him/her another hot pack. The CNA said he/she did not ask how the hot pack should be used and was not instructed by therapy staff on how the hot pack was to be utilized. The CNA said he/she returned to the resident's room, laid the hot pack in the seat of the wheel chair as he/she had found it, and sat the resident on the hot pack. The CNA said he/she assumed that was the way the hot pack was to be utilized. During an interview on 2/24/2020 at 2:40 P.M. the physical therapist said the resident was provided a hot pack earlier in the day by therapy staff. The resident was chilled, coming down with the flu, and was provided a hot pack to lay on the resident's lap and to warm his/her hands. The physical therapist said the resident said the hot pack felt really good. He/She said later CNA A came to therapy and asked to exchange the the pack for a warm one. The physical therapist said it just didn't cross his/her mind the hot pack would not be used as previously utilized. The physical therapist said there was no physician order for [REDACTED]. During an observation/interview on 2/24/2020 at 2:15 P.M., the occupational therapist said he/she is not aware of any policy/protocol for the use of the hot packs prior to this incident. The occupational therapist said no physician order is needed to provide for comfort. The occupational therapist said at other facilities the temperature of [MEDICATION NAME] (a stationary or mobile stainless-steel thermostatically controlled liquid heating device designed to heat bentonite-filled packs in water up to 160 degrees) is routinely monitored, but was unable to find documentation of monitoring at this facility. Observation showed the temperature of the water in the [MEDICATION NAME] was 162 degrees at the time, which is within the recommended range. During an interview on 2/24/2020 at 2:00 P.M., the administrator said the hot pack was provided by therapy and she was not aware of it's use. She said therapy should not have provided the hot pack to the CNA and the CNA should not have applied the hot pack, as the CNAs are not qualified to use the hot pack on residents. The administrator said there is no policy for any nursing staff to utilized a hot pack without a physician order and staff have since in-serviced on not utilizing hot packs. MO 102

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to prevent and treat facility acquired pressure ulcers for six out of 15 sampled residents (Residents #3, #4, #5, #6, #10, and #15). Additionally, staff failed to prevent an infected unstageable pressure ulcer for one resident (Resident #5), notify the physician in a timely manner, obtain a treatment order in a timely manner and administer the treatment once obtained for three resident (Resident #3, #6, and #10), to obtain treatment orders for one resident (Resident #4) placed in an CAM boot (an adjustable orthopedic device used for foot and ankle injuries), to ensure proper placement and fit, The facility census was 59. 1. Review of the facility's Pressure Ulcer/Skin Breakdown clinical protocol, dated 04/13, staff are directed to: -The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcers(s); -The nurse shall assess and document/report vital signs; full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's age and sex; resident's mobility status; current treatments, including support surfaces;and all active diagnoses; -The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents; -The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 2. Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/13/15, showed staff assessed the resident as follows: -Severe cognition impairment; -Required total assistance of two person assist for transfers; -Required extensive assistance of two person assist for bed mobility and toilet use; -Required extensive assistance of one person assist for personal hygiene and dressing; -[DIAGNOSES REDACTED]. -Uses a wheelchair; -Range of motion impairment to upper and lower extremity on one side; -Did not have a pressure ulcer or suspected deep tissue injury; -Pressure reducing device for bed and chair; -Turning/repositioning program. Review of the resident's comprehensive plan of care, reviewed by staff on 05/18/15, showed staff identified the resident's potential for pressure ulcer development related to immobility. Further review showed the resident's plan of care directs staff to: -Administer medications as ordered; -Administer treatments as ordered and monitor for effectiveness; -Educate me/family/caregivers as to causes of skin breakdown, including transfer/position requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; -Assistance with use of bed rails for turning; -Assistance to turn/reposition at least every two hours, more often as needed or as requested; -Monitor/document/report to physician as needed changes in skin status; appearance, color, wound, healing, signs and symptoms of infection, wound size (length x width x depth), and stage. Review of the resident's nursing notes, dated 11/05/14, showed staff documented certified nursing aide (CNA) reported resident's darkened area on right outer foot. Assessed area and appears to be a blood blister, remains intact. Applied gauze and covered with tape to cushion area. Heel protectors on while in bed. Further review showed staff did not notify the resident's physician or family regarding the blood blister on the resident's right foot. Review of the resident's nursing notes, dated 12/01/15, showed staff documented they noted drainage on the dressing to the blister on the outside of the resident's right foot. Further review showed staff did not notify the resident's physician or family of the blood blister on the resident's right foot. Review of the resident's physician order [REDACTED]. Review of the resident's POS, dated 12/19/15-01/18/15, showed a physician ordered a treatment on 01/16/15 to provide [MEDICATION NAME] (spray to treat skin wounds and promote healing) three times daily to the resident's right foot wound. Further review showed a physician ordered treatment on 01/16/15 to leave right foot open to air at bedtime, in morning cover wounds with dressings and place black safety boot, continue to use [MEDICATION NAME] three times daily per previous order. Review of the resident's treatment administration record (TAR), dated 12/19/15-01/18/15, showed a treatment of [REDACTED]. Review showed staff did not provide the treatment as ordered on the following dates: -01/15/16: Morning and afternoon treatment not documented; -01/16/15: No treatment documented as administered; -01/18/15: Morning treatment not documented. Further review of the resident's TAR, dated 12/19/15-01/18/15, showed staff did not include the treatment to leave right foot open to air at bedtime,to cover the wounds with dressings in the morning and place a black safety boot on the resident. Review of the resident's wound assessment sheet, dated 02/02/15 and unsigned by staff, showed staff assessed the resident's right inner foot wound as a stage III deep tissue wound, measured 1.1 centimeters (cm) by 1.0 cm, and with a hundred percent loose adherent yellow slough, moderate amount of serous exudate, and with [DIAGNOSES REDACTED], induration, and rolled edges surrounding wound tissue. Further review showed staff directed to keep the boot on but not tight, provide current treatment as safe gel, [MEDICATION NAME], and wrap lightly with gauze. Review of the resident's wound assessment sheet, dated 02/03/15 and unsigned by staff, showed staff assessed the resident's right outer foot wound as a stage III deep tissue wound, measured 2.0 cm by 1.6 cm, and with a sixty percent loose adherent yellow slough, forty percent granulation, moderate amount of serous exudate, and with rolled edges surrounding wound tissue. Further review showed staff directed to keep boot on but not tight, provide current treatment as safe gel, [MEDICATION NAME], and wrap lightly with gauze. Review showed staff did not assess, stage, or measure the resident's inner or outer right foot wound until eighteen days after a physician ordered the resident's right wound treatments. Review of the resident's POS, dated 01/19/15-02/18/15, showed a physician ordered treatment to provide [MEDICATION NAME] to the right foot wound three times daily, then wrap with kerlix gauze while up. Further Review of the POS [REDACTED]. Review of the resident's TAR, dated 01/19/15-02/18/15, showed no treatment for [REDACTED]. Further review showed no treatment to leave right foot open to air. Review of the resident's TAR, undated, showed the following treatments: -On 02/05/15,[MEDICATION NAME] on inner right foot wound and wrap with gauze; -On 02/05/15, [MEDICATION NAME] on outer right foot wound and wrap with gauze; -On 02/18/15, right foot open to air. Review showed staff did not provide the resident's wound treatments to the right foot as ordered by a physician from 01/19/15-02/04/15. Review of the resident's wound assessment sheet, dated 02/25/15, showed staff did not identify whether the wound assessment was for the inner or outer right foot wound, and did not stage the wound. Review showed staff documented the wound shape as medial .5 cm with dull granulation, and lateral 1 cm with purulent exudate. Further review showed staff documented the current treatment as hydrogel, [MEDICATION NAME], gauze and tape. Review showed staff did not complete wound assessments to the resident's inner and outer right foot wounds during the weeks of 02/09/15-02/13/15 and 02/16/15-02/20/15. Review of the resident's wound assessment sheet, dated 03/16/15 and unsigned by staff, showed staff assessed the resident's inner and outer right foot wounds as a stage II. Review showed staff measured the inner right foot wound as 1.1 cm by 0.9 cm, with a hundred percent bright beefy red granulation, small amount of serous exudate, and normal wound edges. Further review showed staff documented the current treatment as safe gel, [MEDICATION NAME], wrap with gauze, and wears walking boot. Review showed staff did not complete wound assessments to the resident's right foot wounds during the weeks of 03/02/15-03/06/15 and 03/09/15-03/13/15. Review showed the resident with no POS for 02/19/15-03/18/15. Review of the resident's TAR, dated 02/19/15-03/21/15, showed a wound treatment to provide [MEDICATION NAME] to inner right foot and wrap with gauze, and a wound treatment to provide safe gel and [MEDICATION NAME] to right outer foot then wrap with gauze. Review showed no treatment to leave the right foot open to air as ordered by the physician on 01/16/15. Further review showed staff did not provide the treatments as ordered on the following dates: -[MEDICATION NAME] to inner right foot and wrap with gauze on 02/27/15, 03/04/15, 03/11/15, 03/12/15, 03/18/15, 03/19/15, 03/20/15, and 03/21/15; -Safe gel and [MEDICATION NAME] to outer right foot and wrap with gauze on 02/25/15, 02/26/15, 02/27/15, 03/04/15, 03/11/15, 03/12/15, 03/18/15, 03/19/15, 03/20/15, 03/21/15. Review of the resident's POS, dated 03/19/15-04/18/15, showed a physician ordered a treatment on 04/07/15 to remove the dressing to right foot at bed time, leave open to air, and spray [MEDICATION NAME] to site of open areas until [MEDICATION NAME] depletes. Further review showed a physician ordered treatment on 01/22/15 to apply hydrogel to the right foot wounds daily and cover. Review of the resident's TAR, dated 03/19/15-04/18/15, showed the following treatments: -Remove dressing to right foot at bed time, leave open to air, and spray [MEDICATION NAME] to site of open areas until [MEDICATION NAME] deplete; -Apply hydrogel to right foot wounds daily and cover; -Wound on inner right foot and wrap with gauze and [MEDICATION NAME]; -Wound on outer right foot safe gel, [MEDICATION NAME], and wrap with gauze. Review of the resident's TAR, dated 03/19/15-04/18/15, showed staff did not provide the following treatments as ordered on the following dates: -Remove dressing to right foot at bed time daily, apply [MEDICATION NAME] to sites until [MEDICATION NAME] is depleted on 04/09/15, 04/10/15, 04/14/15, 04/15/15, 04/16/15, and 04/18/15; -Staff did not document they applied hydrogel to the right foot wounds daily and cover treatment on the resident's TAR as provided. Review of the resident's POS, dated 04/19/15-05/18/15, showed a physician ordered a treatment to apply hydrogel to right foot wounds daily and cover. Review of the resident's TAR, dated 04/19/15-05/18/15, showed staff did not document the following treatments as ordered on the following dates: -Apply hydrogel to right foot wounds daily and cover on 04/24/15, 05/14/15, 05/18/15, and 05/19/15; -Remove right foot dressing at bedtime and leave dressing off during night on 04/24/15 and 05/19/15. Review showed staff did not assess, stage, or measure the resident's two right foot deep tissue wounds since 03/16/15. During an interview on 07/28/15 at 2:48 P.M., Director of Nursing (DON) said he/she realized in late January or early February nurses were not measuring or assessing resident wounds, but they were providing treatments as ordered. 3. Review of Resident #4's initial MDS, dated [DATE], showed staff assessed the resident as followed: -Severe cognitive impairment; -Required extensive assist of two staff with bed mobility, transfers, dressing, personal hygiene, and toileting; -Required extensive assist of one staff for bathing; -Frequently incontinent of bowel and bladder; -Open [MEDICAL CONDITION] other than ulcers; -Walker, wheelchair, and limb prosthesis; -[DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, initiated on 07/09/15 and revised on 07/28/15, showed staff identified the resident with a potential for pressure ulcer development related to an orthopedic device. Review showed the resident's care plan directs staff to administer medications as ordered, monitor/document side effects and effectiveness, follow the facility's policies/protocols for the prevention/treatment of [REDACTED]. Further review showed staff are directed to complete a skin inspection weekly and observe for redness, open areas, scratches, cuts, or bruises, and report changes to the nurse. Review of the resident's nurses' notes, dated 07/24/15, showed staff documented a new wound observed on the lateral (side) of the right foot. Resident wears a CAM boot, observed on the foot. The wound bed is covered with 100% white non-viable tissue without drainage. The surrounding tissue bright red and blanchable. The wound measurement is 2 cm length by 1.5 cm width by 0.5 cm depth. The resident denied pain or discomfort. Further review showed the staff documented santyl (ointment used to remove dead tissue from wounds) applied to wound bed, zinc (prevents skin irritation/damage) around the edges of wound, and covered with a dry dressing, change daily and as needed. Notified the orthopedic physician. A new order for the resident to be non-weight bearing on the right leg and to keep the follow-up appointment on 07/30/15. The resident's primary physician notified through fax and the resident's spouse called. Review of the resident's POS, dated 07/19/15-08/18/15, showed on 07/24/15, the resident's physician ordered staff to discontinue the CAM boot, for the resident to be non-weight bearing to the right ankle and foot, and to keep the follow-up appointment on 07/30/15. Further Review of the POS [REDACTED]. Review showed the POS did not contain orders for when the resident is to wear the CAM boot, proper application of the CAM boot and when staff are to assess the skin. Review of the resident's TAR, dated 07/19/15-08/18/15, showed staff are to apply santyl to the wound bed of the wound on the right foot, zinc around edges, and cover with a dry dressing, change daily until healed. Further review showed staff did not document the treatment as completed on 07/26/15-07/28/15, and 07/30/15. Review of the resident's hospital progress note, dated 06/25/15, showed the physician documented the right ankle fracture and will treat non-operational. The resident may be weight bearing as tolerated with the CAM walker and for the resident to follow up in six weeks for a new x-ray. Further review showed it did not contain discharge instructions for the facility to follow in regards to when the resident is to wear the CAM boot, assessments of the skin, or application of the boot. Review of the comprehensive CNA shower review, dated 07/14/15 and 07/21/15, staff documented the resident's feet as dry and his/her toes dark in color. Review of the resident's weekly wound assessment, dated 07/24/15, showed staff documented the resident with a stage II pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough) on his/her right foot, 2 cm length by 1.5 cm width by 0.5 cm depth. Review showed staff documented the wound bed as covered with white/gray nonviable tissue. Staff documented a pain assessment of eight out of 10 on the faces scale. Staff documented to keep pressure off of the right foot. Review of the resident's licensed nurse weekly skin assessment, dated 07/24/15, showed staff documented an open area to the resident's left lower hip, 2.5 cm length by 1.5 cm width. Staff documented the open area showed a small amount of bleeding. Further review showed staff did not document the open area to the resident's right foot. Observation on 07/29/15 at 03:15 P.M., showed Licensed Practical Nurse (LPN) L pulled the resident's dressing back. Observation showed a quarter size open area to the resident's right ankle. The wound bed showed a pencil eraser size black circle in the middle of the wound bed with beefy red tissue surrounding. Observation showed serosanguinous (red tinged) drainage. During an interview on 07/28/15 at 03:00 P.M., LPN G said the resident fractured his/her ankle and had orders to wear CAM boot to the right lower extremities. The resident developed a pressure ulcer on his/her right ankle from the CAM boot. He/she understood the physician wanted the resident to wear the CAM boot at all times while up or ambulating. How the CAM boot is suppose to be worn depends on how the physician orders [REDACTED]. During an interview on 07/28/15 at 03:15 P.M., the DON said he/she did not remember a clarification order on how the CAM boot was expected to be worn. He/she said staff should have gotten a clarification order when the resident was discharged from the hospital without orders for the CAM boot. During an interview on 07/30/15 at 01:15 P.M., the orthopedic physician said the following: -He/she expected staff to keep the CAM boot on at all times except during personal hygiene such as showering; -Staff should have clarified how he/she expected staff to place the CAM boot and treatment/care orders upon the resident's admission; -Staff should have assessed the the resident's skin under the boot at least every 48-72 hours; -With the CAM boots is an adjustable air cast that allow the staff to adjust the tension of the boot with the air pump; -He/she believes this is an avoidable pressure ulcer; -He/she said he/she has seen this with a hard cast but never with an CAM boot; -He/she placed the resident in the CAM boot versus the hard cast so that the staff would be able to assess the skin. During an interview on 07/30/15 at 01:30 P.M., CNA O said the resident's showers are on Tuesdays and Fridays. The CNA said he/she removed the resident's CAM boot before every shower and put the boot back on after the shower. When he/she put the boot back on he/she ensured there was finger room in between the straps and the resident's leg, and just pump the boot up a couple times because he/she could not tell how tight it was on the resident's foot. The resident's ankle was red when it was first found, then the next time the ankle had a sore on it. The resident rotates his/her foot to the outer foot/ankle while in bed. The CNA said he/she never received education or training on how to properly put a CAM boot on a resident. 4. Review of Resident #5's annual MDS, dated [DATE], showed staff assessed the resident as followed: -No cognitive impairment; -Required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene; -Dependent on staff for transfers; -Required extensive assist of one staff for dressing and bathing; -At risk for pressure ulcers; -[DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, dated 05/20/15, showed staff are instructed to do the following: -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Use heel protectors when in bed (initiated 05/10/13); -The resident uses pressure preventative boots on his/her heels (initiated 05/10/13); -Requires the mechanical aid of the hoyer lift for transfers and staff assist of two (initiated 11/18/13); -Inspect feet daily for open areas, sore, pressure areas, blisters, [MEDICAL CONDITION] or redness (initiated 02/08/13); -Inform the resident, family, and caregivers of any new area of skin breakdown (initiated 05/10/13) -Lay in recliner after breakfast and bed after lunch (initiated 07/24/15); -No shoes to left foot, pillow under left heel while in wheelchair, bed, and recliner (initiated 07/24/15); -Keep the left heel floated (initiated 07/24/15). Review of the comprehensive CNA shower review, dated 07/10/15, showed staff documented scratches to the resident's lower extremities and a sore that looked better on his/her buttock. Review showed the charge nurse and DON signed the form. Review of the comprehensive CNA shower review, dated 07/15/15, showed staff documented the resident with an open blister to the his/her left heel, red buttock, and a red right elbow. Review showed the charge nurse and the DON signed the form. Review of the comprehensive CNA shower review, dated 07/22/15, showed staff documented the resident's groin as very gaulded, a sore to the left buttock, and a treatment began. Review showed the charge nurse and DON signed the form. Further review showed staff did not document the open area to the resident's left heel. Review of the resident's wound assessment, dated 07/14/15, showed staff documented the resident had an open blister to his/her left heel. Staff documented the open area as a stage II, with dull, pale, dusky red tissue to the wound bed, and normal surrounding tissue. Review showed staff documented the wound measured 1.6 cm length by 2.0 cm width and no depth. The current treatment was [MEDICATION NAME] dressing, change every three days. Staff are to encourage the resident to not wear shoes and to place a pillow under his/her feet while in the bed and wheelchair. Review of the resident's wound assessment, dated 07/24/15, showed staff documented the resident had an open area to the left heel, measuring 0.8 cm length by 1.0 cm width by 0.2 cm depth. Review showed staff documented the wound bed with 80% non-adherent black eschar (a dark scab or area of dead skin) and 20% beefy red granulation tissue (new tissue). Documentation showed the resident reported a pain level of six out of 10 on the pain scale and a new protocol made for the resident. Review of the resident's wound assessment, dated 07/28/15, showed staff documented the resident with an open area to the left heel, measuring 1.5 cm length by 1.0 cm width by 0.2 cm depth. Review showed staff documented the wound bed with 80% non-adherent black eschar and 20% beefy red granulation tissue. Documentation showed staff are directed to keep the resident's left heel floated. Review of the resident's POS, dated 07/19/15-08/18/15, showed a physician's orders [REDACTED]. The resident's physician directed staff to use heel protectors on both heels. Further Review of the POS [REDACTED]. Review of the resident's TAR, dated 07/19/15-08/18/15, showed staff are directed to apply a [MEDICATION NAME] dressing to the left heel open blister until healed, change every three days (dated 07/14/15). Review showed the order changed on 07/28/15 to [MEDICATION NAME] dressing to the left heel, change two times weekly and apply heel protectors to both heels. Review of the resident's left heel wound culture, collected 07/28/15 final report 08/01/15, showed [DIAGNOSES REDACTED] Pneumonia (Gram-negative bacteria that can be caused by different types of healthcare associated infections such as pneumonia and wound or surgical site infection ), [MEDICAL CONDITION] (MRSA) (staphylococcus bacteria that is resistant to numerous antibiotics and is contagious ), and [MEDICATION NAME] Faecalis (gram-positive caused by a variety of healthcare associated infections). Further review showed staff documented on the wound culture report, the resident was on Bactrim DS two times daily with meals, for 10 days. Review showed [MEDICAL CONDITION] and [MEDICATION NAME] Faecalis are resistant to Bactrim DS. Review of the resident's nursing notes, dated 07/2/15-07/29/15, showed staff did not document information regarding the resident's wound to his/her left heel. Observation on 07/27/15 at 10:30 A.M. showed the resident up in his/her wheelchair with shoes on both feet. Observation showed the resident did not have heel protectors or a pillow under his/her heels as directed by the care plan. Observation on 07/27/15 at 2:00 P.M., showed the resident up in his/her wheelchair with a pillow folded under his/her left foot. During an interview on 07/27/15 at 2:00 PM., the resident said this is the first time staff placed a pillow under his/her foot. The resident said he/she always wears his/her shoes when out of bed. Observation on 07/28/15 at 08:08 A.M., showed the resident in the dining room in his/her wheelchair. The resident's feet rested on the the wheelchair foot rest. Further observation showed the resident did not have heel protectors or his/her feet floated. Observation on 07/28/15 at 10:15 A.M., showed the resident up in his/her wheelchair without heel protectors or his/her heels floated. Observation showed LPN G remove the resident's dressing from his/her left heel with a small amount of serosanguinous drainage on the dressing. Further observation showed an unstageable (full thickness tissue loss in which actual depth of the ulcer is obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer with raised edges around the wound with eschar in the center of the wound bed, a ring around the eschar with yellow slough (dead non viable tissue), and small ring of beefy red tissue to the outer wound bed. During an interview on 07/28/15 at 10:15, LPN G said the wound bed contained 80% black adherent eschar and 20% yellow slough and last week the wound was covered with 100% eschar. LPN G said the wound appeared as a pressure ulcer and he/she found the wound on the 07/14/15. When he/she found the wound, staff were instructed to float the resident's heels, and today the physician ordered heel protectors to both heels for the resident. He/She said the wound started as an opened blister and we followed the facility's wound protocol and applied a [MEDICATION NAME] dressing every three days. The LPN said when a wound is found, the wound protocol is started then the physician is notified and asked if the dressing per the protocol is ok. Observation on 07/28/15 at 04:50 P.M., showed the resident up in his/her wheelchair in the dining room. Observation showed the resident did not have his//her heels floated or heel protectors in place. Observation on 07/29/15 at 07:35 A.M., showed the resident in bed. The resident did not have his/her heels floated on a pillow or heel protectors in place. Observation on 07/30/15 at 01:00 P.M., showed the resident up in his/her wheelchair with his/her feet resting on the wheelchair foot rest. The resident did not have his/her heels floated on a pillow or heel protectors in place. 5. Review of Resident #6's MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required limited physical assistance with bed mobility and transfers; -Required extensive assistance with walking, toilet use, personal hygiene and bathing; -Used a walker or wheelchair for mobility; -Frequently incontinent of urine; -Occasionally incontinent of bowel; -At risk for pressure ulcers; -Did not have a pressure ulcer or suspected deep tissue injury; -Had a pressure reducing device for chair and bed. Review of the resident's comprehensive plan of care, revised on 02/26/14 and reviewed on 05/20/15, showed staff identified the resident with the potential for pressure ulcer development related to dehydration and documented the resident will have intact skin, free of redness, blisters or discoloration by/through the review date. Further review showed the resident's plan of care directs staff to: -Administer the resident's medications as ordered; -Educate the resident, family and caregivers as to the causes of skin breakdown, including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; -Follow facility policies/protocols for the prevention/treatment of [REDACTED].>-Inform the resident, family and care givers of any new area of skin breakdown; -Monitor, document and report to the physician as needed changes in in skin status including appearance; color; signs and symptoms of infection; wound healing; wound size and wound stage; -Observe skin for redness, open areas, scratches, cuts, bruises weekly and report changes to the nurse. Review of the resident's weekly comprehensive CNA shower review sheets, dated 06/15/15 through 07/28/15, showed staff are directed to perform a visual assessment of a resident's skin when giving the resident a shower, report any abnormal looking skin to the charge nurse immediately and forward any problems to the DON for review. Staff are instructed to use the form to show the exact location and description of the abnormality. Further review of the shower review sheets showed staff documented the residents skin condition as follows: -06/15/15 OK; -06/30/15 (15 days later) very dry flaky skin on the resident's legs and a not quite open decubitis on the resident's coccyx. Further review showed staff documented the area as being treated. The record was not signed by the charge nurse or DON; -07/13/15 (13 days later) bruising to bilateral lower extremities; -07/20/15 dry skin to bilateral lower extremities; -07/28/15 very dry skin to bilateral upper and lower extremities. Review showed staff did not document the wound on the resident's coccyx after 06/30/15. Review of the resident's nursing notes dated 07/11/15, showed staff documented the resident's open abrasions on his/her coccyx. Review showed staff documented they initiated the wound treatment per protocol. Further review showed staff did not document they notified the resident's physician for treatment orders. Review of the resident's TAR dated 06/19/15 through 08/18/15 showed a treatment, dated 07/11/15 (11 days after the wound discovery), directing staff to cleanse the resident's coccyx with wound cleanser and cover with a dressing every three days. Review of the licensed nurse weekly skin assessment, dated 07/14/15, showed staff documented a rash to the resident's coccyx. Review showed staff did not document the wound on the resident's coccyx. Review of a wound assessment, dated 07/17/15, showed staff documented the resident's stage II which measured 1 centimeter (cm) in length, 1.5 cm in width and 0.2 cm in depth. Review also showed staff documented the wound as 60 percent covered with white/gray non-viable tissue. Review of the resident's POS dated 06/19/15 through 08/18/15 showed a physician's orders [REDACTED]. Observation on 07/30/15 at 10:09 A.M., showed a 2.25 cm stage II pressure ulcer to the resident's coccyx. During an interview at the same date and time of the observation, Registered Nurse (RN) B described the wound as L shaped, with two open areas, approximately one cm apart. 6. Review of the

br>Based on observation, interviews and record review facility staff failed to utilize foot rests on wheelchairs when wheeling residents. The information gathered showed staff wheeled residents seated in wheelchairs without foot rests, causing residents to lift their feet off the floor and maintain them raised while staff wheeled them. Two (Residents #1 and 4) of eight reviewed residents (Residents #1, 2, 3, 4, 5, 6, 7 and 8) were unable to maintain their legs lifted off the floor. Resident#1 sustained a fractured leg while staff wheeled the resident without foot rests on his/her wheelchair. The facility's census was 53. 1. Review of Resident #1's most recent Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/25/15, showed staff assessed the resident as follows: - adequate hearing and vision; - able to understand and make self understood; - used a walker and/or wheelchair and required extensive assistance for locomotion; - shortness of breath with exertion; - on oxygen and anticoagulant medication. Review of the resident's Care Plan showed staff assessed the resident on 2/25/15 as at High risk for falls related to fatigue. The interventions staff planned to address this issue did not address the resident's use of a walker/wheelchair for locomotion. Review of the resident's nurse's notes dated 3/23/15 at 1:30 P.M. showed staff documented,resident had incident with right knee noted after lunch resident was propelling down hall and her right leg was pulled under wheelchair and skin below right knee opened up. Resident denies pain, swelling noted. Family at bedside. Resident family worried due to history with right knee. New order x-ray of right knee noted. Record review of an x-ray report signed by the Radiologist on 3/23/15 at 7:44 P.M. showed no acute fracture or dislocation is seen. Review of the resident's nurse's notes dated 3/24/15 at 5:50 A.M. showed staff documented Resident in much pain. PRN (as needed) Tylenol given. Review of the resident's nurse's notes dated 3/24/15 at 9:30 A.M. showed staff documented resident had complaint of pain. Resident refused to come out of room for breakfast due to pain in right knee. Resident given Tylenol 325 mg two tabs. Resident states pain medication does not help. Doctor called. this nurse was told to send a fax with resident's needs fax sent. Review of the resident's nurse's notes dated 3/24/15 at 10:50 A.M. showed staff documented resident states his/her pain was '0' when laying down on a scale of 1-10. Resident stated his/her pain was 10 with movement. Review of the resident's nurse's notes dated 3/24/15 11:30 A.M. showed staff documented the resident yelled out in pain and the family requesting a transfer to the hospital. Staff called the physician who authorized the transfer and they arranged transfer of the resident to the ER. Review of a fax dated 3/24/15 10:30 A.M. to the resident's physician showed staff documented On 3/23/15 resident's right knee was bent back when he/she was being propelled in resident's wheelchair. Resident right knee has had past history of surgery in past and has pins placed. After leg was bent open area was noted under right knee. The area was bleeding profusely. Pressure dressing was applied. Swelling noted in right knee and bruising noted. Family at bedside and request x-ray. X-ray done and shows no fracture or break. He/she had no pain on 3/23/15. Resident is now having pain in right knee on 3/24/15. Resident only has Tylenol 325 mg 2 tabs every 4 hrs for pain. He/She has taken it 2 times already today and has had no relief in pain. Can we have something stronger please? He/She is also still profusely bleed ?? with movement no stitches are needed. Review of the facility's internal investigation dated 3/23/15 showed staff documented the following: -On 3/23/15 at 2:15 P.M. the resident said, I asked the aide to take me the rest of the way to my room as I was tired and short of breath. My leg/foot went under the wheelchair. -On 3/23/15 (no time listed) Registered Nurse (RN) A documented the resident had propelled himself/herself part of the way down the hallway. Per therapy he/she was either supposed to be propelling himself/herself or ambulating with one assist. The resident asked the aide if he/she could take him/her the rest of the way as he/she was tired and short of breath. As he/she was pushing the resident, the resident's right leg went back under the wheelchair. The aide stopped and repositioned the resident's leg and continued on to his/her room. -Staff documented under the heading Steps taken by facility to prevent further incidents: Staff educated to remind resident to hold/elevate legs when being pushed in wheelchair. Review of the resident's emergency room Physician note, dated 3/24/15 1:05 P.M. showed the ER physician documented, the resident complained of pain just below his/her knee on the right side. The resident normally would hold his/her legs out as staff wheeled him/her in a wheelchair, but on 3/23/15 the resident had his/her leg down and as they pushed the wheelchair forward it brought the resident's leg up underneath the wheelchair. Staff pulled backwards to get the resident's leg out from under the wheelchair. The resident's right knee was stiff relative to some distant injuries and surgeries and the resident normally did not bend it. Observations on 4/3/15 at 10:45 A.M. to 11:05 A.M. showed staff wheeled four residents, (Residents #2, 5, 7, 8) into the dining room. A family member wheeled Resident #4 into the dining room. These five residents' wheelchairs were not equipped with foot rests and the residents held their feet up and off the floor. Observation on 4/3/15 at 12:05 P.M. showed Licensed Practical Nurse (LPN) B wheeled Resident #3 seated in a wheelchair without foot rests. When asked, LPN B said the resident did not have foot rests and he/she did not know why. The resident did not respond to questions. During an interview on 4/3/15 at 12:10 P.M. Certified Nurses Aide (CNA) E said, some residents want to self-propel. That is why some do not have foot rests as they could cause skin tears. During an interview on 4/3/15 at 12:20 P.M. CNA F said if a resident was ambulatory, staff could leave foot rests off. During an interview on 4/3/15 at 12:30 P.M. CNA D said if a resident could self propel the wheelchair, staff could leave foot rests off to prevent injuries. During an interview on 4/3/15 at 12:40 P.M. CNA C said if a resident was usually ambulatory staff did not use foot rests. During an interview on 4/3/15 at 1:00 P.M. Registered Nurse (RN) A said he/she is not aware of a facility policy regarding the use of foot rests on wheelchairs. Staff took off the foot rests if the resident was able to self propel and/or ambulate to prevent injuries related to the presence of the foot rests. There have not been problems with this until Resident #1's accident. During a telephone interview on 4/7/15 at 8:54 A.M. CNA H said, he/she was in the hall when the resident self-propelled his/her wheelchair. The resident asked him/her to push him/her back to his/her room because he/she was short of breath. The resident held up his/her legs, but must have gotten tired because he/she dropped his/her legs and one leg went under the wheelchair. During a telephone interview on 4/6/15 at 12:00 P.M. the resident's physician said, if the resident had not had the accident, he/she would not have ended up in the hospital. 2. Review of Resident #4's most recent Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/27/15, showed staff assessed the resident as follows: - minimally impaired hearing and adequate vision; - usually able to understand and make self understood; - impaired cognition; - required extensive assistance for any mobility and total dependence for locomotion. Review of the resident's Care Plan showed staff assessed the resident on 12/15/14 as at High risk for falls related to unaware of safety needs, hypotension, confusion, gait/balance problems. The interventions staff planned did not address the resident's use of a walker/wheelchair for locomotion. During an interview on 4/3/15 at 11:10 A.M. the resident's family member (FM) J said the resident had foot rests for the wheelchair. He/she said the resident usually could hold up his/her feet and usually walked to the dining room but was really sleepy that day. FM J said the resident's shoes acted like stoppers when the resident's feet drug on the floor and this was not safe. 3. Review of Resident #3's most recent Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/28/15, showed staff assessed the resident as follows: - minimal difficulty hearing and uses a hearing aid; - able to understand and make self understood; - impaired cognition; - required limited assistance for bed mobility and extensive assistance for walking and any locomotion. Record review of the resident's Care Plan showed on 12/16/14 staff assessed the resident at High risk for falls related to confusion. The interventions staff planned did not address the resident's use of a walker/wheelchair for locomotion. Observation on 4/3/15 at 12:05 P.M. showed the resident seated in a wheelchair without foot rests while Licensed Practical Nurse (LPN) B wheeled the wheelchair. The resident did not respond to questions. When asked, LPN B said the resident did not have foot rests and he/she did not know why. 4. Review of Resident #2's most recent Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/5/15, showed staff assessed the resident as follows: - adequate hearing; - usually understands and is understood; - impaired vision; - required extensive assistance for any mobility including locomotion. Review of the resident's Care Plan showed staff assessed the resident on 12/16/14 as at High risk for falls related to gait/balance. The interventions staff planned did not address the resident's use of a walker/wheelchair for locomotion. Observation on 4/3/15 at 9:40 A.M. showed the resident seated in his/her wheelchair without foot rests in place. During an interview on 4/3/15 at 9:40 A.M. the resident said he/she self-propelled the wheelchair with his/her feet, staff did not push his/her wheelchair. Observation on 4/3/15 at 10:45 A.M. showed the resident seated in his/her wheelchair, no foot rests attached, holding his/her feet a few inches above the floor, as staff wheeled the wheelchair into the dining room. Observation on 4/3/15 at 12:50 P.M. showed no wheelchair foot rests in plain view in the resident's room. 5. During an interview on 4/3/15 at 1:00 P.M. RN A said he/she is not aware of a facility policy regarding the use of foot rests on wheelchairs. Staff take the foot rests off if a resident is able to self-propel and/or ambulate, to prevent skin injuries related to the presence of foot rests. There have not been problems with this until Resident #1's accident. During an interview on 4/3/15 at 1:15 P.M. the administrator said he/she did not know of a facility policy specific to the use of wheelchair foot rests. MO 236

Based on interview and record review the facility's staff failed to notify the physician in a timely manner after a change in condition of one resident (Resident #1) out of a sample of three residents who experienced a change in their conditions. On 8/11/11 during the night shift the resident fell out of bed and experienced a change in his/her vital signs. Staff failed to notify the physician with the resident's change in vital signs after the fall. Additionally staff failed to notify the resident's physician of changes to the resident's left leg and increased complaints of left leg pain after staff found the resident on the floor. Results of an x-ray completed on 9/6/11 showed a [MEDICAL CONDITION]'s left tibia (the second longest bone of the skeleton located at the side of the leg) and the fibula (a smaller bone in the leg located beside the tibia) which resulted in admission to a local hospital. The facility census was 54. 1. Review of the Facility's Fall Prevention and Accident Reporting Policy, no date noted, showed the policy instructed staff to complete the following: -When an accident occurred, remain with the resident if possible and send help for the charge nurse; -The charge nurse should complete a full body assessment and provide emergency care as necessary; -The charge nurse should notify the physician immediately for further orders; -Complete an investigation report; -Notify the next of kin, legal guardian; -Document the notification of physician, family and condition of the resident; -Submit the investigation report to the Director of Nursing; -Amendment: If accident/fall happens on the night shift, reporting to physician and family may wait until A.M., unless injury/emergency 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/4/2010, showed staff assessed the resident as follows: -Required one staff member to assist with bed mobility; -Required one staff member to assist with transfers; -Did not ambulate; -Balance not steady but able to stand without human assistance; -Limitation in range of motion, impairment on both sides to upper and lower extremities; -fell in the last month prior to admission; -fell since admission or the prior assessment; -Required oxygen therapy. Review of the resident's care plan originally dated 11/05/10 showed staff planned the following interventions regarding resident safety from falls: -Use gait belt; -Encourage independence with minor assistance; -Assist of one for transfers and activities of daily living; -Teach resident proper use of assistive devices (walker, wheelchair). Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME]/Apap 5-500 ([MEDICATION NAME], narcotic pain medication) one tablet by mouth every 4-6 hours as needed for pain control (started 12/18/08); -Q-Pap (for Tylenol regular strength) 325 milligrams take one to two tablets by mouth every 4-6 hours as needed for pain or elevated temperature (started 12/18/11). Review of nurses' note dated 8/11/11 at 11:00 P.M. showed Registered Nurse (RN) A recorded, "resident has put his light on seven times in a 30 minute period." Review of the nurses' note dated 8/11/11 at 11:45 P.M. showed RN A recorded the resident was "yelling" and "hitting the wall." RN A recorded staff found the resident on the floor in his/her room between the bed and the wall incontinent of urine, with ashen skin color, "low" (no number given) oxygen saturation (normal 90 to 100 percent), pulse rate 34 (normal 60 to 100 beats per minute). RN A recorded staff lifted the resident back into bed and after 10 minutes of oxygen his/her saturation measured 95 percent and pulse rate increased from 34 to 64. RN A recorded, "no injury secondary to fall." Staff did not record they notified the resident's physician of the change in condition. Review of a nurses' note dated 8/12/11 6:00 A.M. showed RN A recorded the resident's "yelling" continued even after staff administered [MEDICATION NAME] for leg pain at 1:30 A.M. RN A recorded he/she faxed the resident's physician a report at 7:00 A.M. Review of the fax RN A sent to the physician on 8/12/11 showed RN A informed the physician the resident "slid off into the floor, no injury found." RN A did not report the changes he/she noted in the resident's vital signs and the continued complaints of pain after staff administered the pain medication. During an interview on 9/25/11 at 1:15 P.M. RN A said he/she did not call the resident's physician about the change in vital signs or to request an order for [REDACTED]. Review of the resident's POS dated 8/19/11 through 9/18/11 showed the resident's physician did not order oxygen for the resident until 8/25/11. During an interview on 9/26/11 at 3:00 P.M. the Director of Nursing (DON) said she was not aware of the incident on 8/11/11. The DON said she would expect staff to inform the physician "immediately." During an interview on 10/4/11 at 2:00 P.M. Physician F's nurse said if staff would have notified the physician at the time of the incident he/she would have sent the resident to the emergency room for evaluation. The nurse said staff faxed the physician on 8/12/11 but the fax did not include the assessment of the resident's change in condition. Record review of a nurses' note, dated 8/27/11 at 8:30 A.M. showed staff recorded they found the resident on the floor in his/her room at 6:15 A.M. The resident denied injury. Staff did not record they assessed the resident's range of motion before they moved the resident. Staff recorded two aides utilized the Hoyer lift (hydraulic lift used to transfer non-weight bearing residents) to lift the resident from the floor. Staff did not record they notified the resident's physician or family of the fall as directed by the facility's Accident Policy and Procedure. During an interview on 9/26/11 at 10:15 RN H said if staff found a resident on the floor they should complete neurological assessments, check range of motion of the resident's extremities, check vitals signs, and notify the physician and family. RN H said staff should transfer the resident to the emergency room if needed. During an interview on 9/19/11 at 1:40 P.M. Certified Nurse Assistant (CNA) C said he/she noticed the resident's foot looked "peculiar" on 8/28/11. CNA C said he/she first reported the foot to the nurse on 8/28/11. CNA C said he/she was off on 8/27/11 when it was reported the resident rolled out of bed, but was there the next day (8/28) and noticed the resident's foot. CNA C said he/she continued to report the resident's foot looked broken. CNA C said he/she reported it to the Director of Nursing (DON). CNA C said he/she last reported the resident's foot looked broken on 9/4/11 and was told the resident's foot had been assessed the day before. Record review of a nurses' note, dated 8/27/11 at 2:15 P.M. showed staff recorded the resident sat in his/her lift chair with it raised in the highest position. A Certified Nurse Assistant (CNA) observed the resident and assisted him/her to the floor before the resident slid out of the chair. Staff recorded they faxed a notification of the incident to the resident's physician. Review of the resident's plan of care showed on 08/27/11 staff added new interventions regarding resident safety. Staff added direction to apply a Personal Alarm device to alert staff of the resident's attempts to get out of bed unassisted. Staff recorded in the plan of care, "Keep alarm on at all times while in bed" and "answer call light as promptly as possible." Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 08/31/11, showed staff assessed the resident as follows: -Severely impaired cognitive skills; -Rejected care four to six day in the last week; -Required total assistance of two staff for transfers; -Did not ambulate; -Unable to balance and only able to stabilize with human assistance from seated position to standing; -Used a walker and wheelchair; -Limitation in Range of Motion with impairment on both sides of upper and lower extremities; -Experienced severe pain in the last five days frequently; -Staff administered pain medication when needed; -fell in the last month. Review of a nurses' note dated 8/29/11 at 6:00 A.M. showed staff recorded a CNA lowered the resident to the floor. Staff did not assess any injuries. Staff did not record why the CNA lowered the resident to the floor. Facility staff did not record they informed the physician and family of the incident as directed by the facility's Accident Policy and Procedure. Review of the resident's plan of care showed on 08/29/11 staff added new interventions regarding resident safety. Staff planned to utilize the Hoyer Lift (hydraulic lift used to transfer non-ambulatory residents) for all transfers and utilize two to three staff during the transfer. During an interview on 9/29/11 the DON said she was not aware staff lowered the resident to the floor at 6:00 A.M. on 8/29/11. Review of a nurses' note dated 8/30/11 from 11:00 P.M. - 6:30 A.M. showed staff recorded the resident slept "at intervals," pulled his/her oxygen off, experienced labored respirations at 1:30 A.M., and "cried out" his/her legs hurt. Staff recorded they administered pain medication that took one hour for relief. Staff recorded the resident's legs and feet appeared swollen and the resident's "general condition declining." Staff did not record they notified the resident's physician of the resident's change of condition. Review of a nurses' note dated 8/31/11, (no time noted) showed staff recorded, "left lower knee abrasion" (scraping or rubbing away of a surface by friction). Staff did not record they notified the resident's physician of the "left lower knee abrasion." Review of a nurses' note dated 8/31/11, (no time noted) showed staff recorded the resident had some bruises on the left shoulder, his/her appetite and fluid intake was poor, and he/she was in "constant pain." Staff recorded they administered pain medication. Staff did not record they notified the resident's physician of the changes in the resident's condition. Review of a nurses' note staff dated 8/31/11 10:00 P.M. - 1:00 A.M. showed he/she recorded the resident was uncomfortable and could not sleep. The resident's legs were "grossly [MEDICAL CONDITION]." Staff recorded the resident had not slept more than 30 minutes at a time due to leg pain. Staff recorded the resident received pain medication at 1:00 A.M., but persisted to "yell out" in pain at 5:30 A.M. Staff did not record they notified the resident's physician of the increased complaints of leg pain, swelling, and inability to sleep. Review of a nurses' note dated 9/3/11 6:00 A.M. - 2:00 P.M. showed staff recorded they assessed [MEDICAL CONDITION] in both of the resident's lower legs, the resident's legs were "very hard," and the resident "yells out in pain" when staff touched his/her legs. Staff recorded the resident's socks caused indentations in his/her legs. Staff did not record they notified the resident's physician of the resident's complaints of pain or the condition of the lower extremities. Review of a nurses' note dated 9/3/11 from 3:00 P.M. to 11:00 P.M. showed staff recorded the resident "yelled for help." Staff recorded when they entered the room the resident was "half way out of" his/her wheelchair. Staff recorded the resident threw items out into the hallway. Staff recorded they assisted the resident to bed to rest but he/she still complained of pain. Staff recorded they gave the resident's pain medication and would continue to monitor him/her. Staff did not record they notified the resident's physician of the resident's continued complaint of pain or agitation. Review of a nurses' note dated 9/5/11 at 1:45 P.M. showed staff recorded the resident complained of leg pain, but refused hospitalization . Staff recorded they assessed an "obvious deformity" of the resident's left lower extremity the resident's leg appeared "red, swollen, warm to touch." Staff did not record they notified the resident's physician of their assessment of the resident's change in condition. Review of a nurses note dated 9/6/11 at 5:30 A.M. showed staff recorded, "resident yelling out I hurt, I hurt." Staff recorded they assisted the resident to "adjust in bed," and would "continue to monitor" his/her pain. Staff did not record they notified the resident's physician of the resident's pain or change in condition. During an interview on 9/19/11 at 2:00 P.M. Licensed Practical Nurse (LPN) D said he/she assessed the resident's leg on Monday 9/5/11. He/she said the leg looked "deformed" but mobile x-ray was off due to the holiday. LPN D said he/she reported the leg deformity to the DON. During an interview on 9/29/11 at 10:48 A.M. CNA E said, "On Monday (9/5/11) you could look at the resident's foot and tell it was broken. It was turned inward." Review of the Facility's Investigation Report, (no date noted) showed staff recorded on 9/5/11 the CNA assigned to the resident reported something was wrong with the resident's left foot. Two nurses assessed the resident's leg and decided to elevate the leg and assess it again on 9/6/11. The report showed on 9/6/11 staff decided to notify the physician and to ask for x-ray. During an interview on 9/19/11 at 3:00 P.M. the DON said one CNA reported the resident's foot looked deformed. The DON said she and LPN D looked at the resident's leg but it did not look deformed. The DON said she assessed the resident's leg to have ongoing [MEDICAL CONDITION] (infection of the skin that can cause redness, pain,and swelling of an area). The DON said the resident continued to complain of pain. The DON said the resident's condition had declined in the last two months. The resident was less mobile and more confused. The DON said they notified the resident's physician for an x-ray order to "be on the safe side." Review of a nurses' note dated 9/6/11 at 1:55 P.M. showed staff recorded they notified the resident's physician of the resident's complaints of pain and left lower extremity deformity. The physician gave a new order to x-ray the resident's leg and administer an antibiotic. Staff further recorded the x-ray showed fractures of the resident's fibula and tibia, soft tissue deformity, angulation (rotation) of distal fracture fragments, and arthritic changes. Staff recorded they notified the resident's physician who directed staff to transfer the resident to the hospital. During a phone interview on 10/11/11 at 11:15 A.M., Physician G said he/she remembered he/she gave an order for [REDACTED]. Review of the Emergency Department Report dated 9/6/11 at 4:37 P.M. showed the following: "Patient received via ambulance from facility with reported left leg tib/fib fracture. Per nursing home the resident rolled out of bed last week. No complaints of pain until today more swollen. Patient normally nonambulatory." MO 2864 and MO 867