Every finding on record at Wildewood Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure a clean and homelike environment in resident restrooms for 3 (#4, 30, and #56) of 3 sampled residents reviewed for the environment. The administrator identified 77 residents resided in the facility. Findings: On 07/01/26 at 2:32 p.m., Resident #30's restroom connected to their room was observed. The restroom floor was observed to have black stains around the toilet extending approximately eighteen inches out from around the toilet. The restroom floor was wiped with a wet wipe. A black substance and debris were observed to have come up from the floor. On 07/01/26 at 2:34 p.m., Resident #4's restroom connected to their room was observed. The restroom floor was observed to have black stains around the toilet extending approximately eighteen inches out from around the toilet. The restroom floor was wiped with a wet wipe. A black substance and debris were observed to have come up from the floor. On 7/01/26 at 2:36 p.m., Resident #56's restroom connected to their room was observed. The restroom floor was observed to have black stains around the toilet extending approximately eighteen inches out from around the toilet. The restroom floor was wiped with a wet wipe. A black substance and debris were observed to have come up from the floor. An undated policy titled Bridges Health Basic Housekeeping Procedures, read in part, The administrator, housekeeping supervisor and the floor tech should all be aware of the condition of the floors throughout the facility. Burnishing the floor is accomplished using a highspeed burnisher and a white or combo gray pad on a clean floor. (A dirty floor will impede the shine and quickly deteriorate the floor surface.) An admission assessment for Resident #30, dated 06/01/26, showed the resident's cognition was intact with a BIMS score of 15. The assessment showed Resident #30 had diagnoses of malnutrition and other neurological condition. An annual assessment for Resident #4, dated 06/19/26, showed the resident's cognition was moderately impaired with a BIMS score of 12. The assessment showed Resident #4 had diagnoses of congestive heart failure and hypertension. A quarterly assessment for Resident #56, dated 06/30/26, showed the resident's cognition was severely impaired with a BIMS score of seven. The assessment showed Resident #56 had diagnoses of hypertension and non-Alzheimer's dementia. On 07/01/26 at 2:31 p.m., Resident #30 stated the restroom connected to their room always looked dirty. The resident stated staff cleaned the restroom, but the floor looked really bad, and they felt like they had to wear shoes while in there. On 07/01/26 at 2:35 p.m., Resident #4 stated they were not sure how often the restroom connected to their room was cleaned. The resident stated the appearance of the restroom floor bothered them because it always looked dirty. On 07/01/26 at 2:37 p.m., Resident #56 stated they tried to keep their restroom floor clean, but it looked really bad. Resident #56 stated the appearance of the floor bothered them. On 07/01/26 at 2:39 p.m., the administrator stated they have had talks of replacing the floors in the restrooms. The administrator stated the buffer machine will not fit around the toilets because the area is so small. The administrator stated the floors probably needed to be replaced.

Based on record review and interview, the facility failed to provide mail service to residents on Saturdays. The Administrator identified 80 residents resided in the facility. Findings: On 09/12/24 at 2:52 p.m. during a Resident Council group meeting with 18 residents in attendance, they stated they were not aware of any mail being delivered on Saturdays. On 09/13/24 at 2:00 p.m., the Social Services Director stated the BOM received the mail from the reception desk and sorts through it. They stated the residents personal mail went in to the Social Service Director's box. The Social Services Director stated they delivered personal mail to the residents. On 09/13/24 at 2:01 p.m., the DON stated the mail was not delivered on the weekends.

Based on record review and interview, the facility failed to administer medication as ordered for one (#30) of five sampled residents reviewed for unnecessary medications. The Administrator identified 80 residents resided in the facility. Regional Nurse Consultant #1 identified 15 residents who received insulin in the facility. Findings: A Specific Medication Administration Procedures policy, effective 01/22, read in part, .To administer medications via subcutaneous .routes in a safe, accurate, and effective manner .Check the order on the medication administration record to see that an injection is currently ordered and due .Document administration . Resident #30 had diagnoses which included type two diabetes mellitus with unspecified complications and for type 2 diabetes mellitus with diabetic chronic kidney disease. A Physician's order, dated 01/23/24, documented Humalog injection solution inject 5 units intramuscularly with meals related to type two diabetes mellitus with unspecified complications. A Physician's order, dated 01/23/24, documented Humalog injection solution inject as per sliding scale intramuscularly before meals and at bedtime related to type two diabetes mellitus with unspecified complications. A Physician's order, dated 05/16/24, documented insulin glargine subcutaneous solution 100 unit/ml inject 50 unit subcutaneously one time a day related to type two diabetes mellitus with unspecified complications. A Physician's order, dated 07/16/24, documented Lantus Solostar subcutaneous solution pen-injector 100 unit/ml inject 60 unit subcutaneously at bed time for type 2 diabetes mellitus with diabetic chronic kidney disease. The August MAR documented the following blanks: a. Humalog injection solution inject 5 units intramuscularly on the 3rd, 7th, 23rd, and the 26th at 1200 p.m., b. Humalog injection solution inject as per sliding scale intramuscularly on the 3rd and the 7th at 12:00 p.m., the 15th at 8:00 p.m., and the 30th at 8:00 p.m., and c. Lantus Solostar subcutaneous solution pen-injector 100 unit/ml inject 60 unit subcutaneously on the 30th at 8:00 p.m. The September MAR documented the following blanks: a. Humalog injection solution inject 5 units intramuscularly on the 5th at 8:00 a.m. and 12:00 p.m., b. Humalog injection solution inject as per sliding scale intramuscularly on the 5th at 8:00 a.m. and 12:00 p.m., and on the 6th at 8:00 p.m., and c. insulin galrgine subcutaneous solution pen-injector 100 unit/ml inject 60 unit subcutaneously on the 5th for the 7:00 a.m. to 11:00 a.m. medication administration. On 09/16/24 at 1:44 p.m., LPN #2 stated the policy for administering insulin to residents was to administer per physician's orders. LPN #2 reviewed the administration record for Resident #30. They stated the blanks on the insulin administration record meant it was not given. On 09/16/24 at 1:55 p.m., the DON stated the policy for insulin administration depended on the physician's orders. They stated the blanks on the insulin administration record could be a variety of things. The DON was informed of the blanks on the August and September MAR and was provided opportunity to provide documentation for the blanks. On 09/16/24 at 2:44 p.m., the DON provided documentation of resident being out of the facility on 09/15/24 during the 8:00 a.m. and 12:00 p.m. insulin administration times. They could not provide documentation for the above blanks.

Based on record reviewed and interview, the facility failed to ensure a dialysis resident had orders for monitoring for one (#78) of one sampled resident who were reviewed for dialysis. The Administrator identified 80 residents who resided in the facility. The DON identified five residents who received dialysis. Findings: Resident #78 had diagnoses which included hypertensive heart and chronic kidney disease without heart failure, with stage five chronic kidney disease, or end stage renal disease. Resident #78's renal care plan, initiated 01/24/24, documented the following interventions; a. check and change dressing daily at access site, b. check AVF for thrill and bruit every shift. If absent notify the physician, c. monitor AVF for S/S trauma and/or infection every shift, and d. remove AVF dressing four hours after dialysis treatment one time a day every Monday, Wednesday, and Friday. There were no orders or documentation for monitoring the above. On 09/16/24 at 1:25 p.m., LPN #2 stated dialysis residents were monitored by taking vital signs and checking the thrill and bruit upon return, and for bleeding. They stated they removed the dressing applied by the dialysis center four hours after the residents returned. They stated on non-dialysis days, the residents' labs, food and fluid intake were monitored. On 09/16/24 at 1:27 p.m., LPN #2 stated the thrill and bruit, signs/symptoms of trauma and/or infection, dressing changes are documented in the TAR. On 09/16/24 at 1:37 p.m., LPN #2 stated he must have gone out to the hospital, there are no orders. On 09/16/24 at 1:45 p.m., the DON stated they did not see any orders for Resident #39's dialysis monitoring, but they had just put in the orders.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered for one (#38) of two sampled residents reviewed for respiratory care. The DON identified eight residents who received continuous oxygen therapy in the facility. Findings: Resident #38 had diagnoses which included COPD and heart failure. A physician's order, dated 05/24/24, documented continuous oxygen at 2 liters per minute via nasal cannula related to COPD. On 09/10/24 at 3:34 p.m., Resident #38 was observed receiving oxygen. They stated they were on continuous oxygen at 2 liters. The concentrator was set at 3 liters per minute. On 09/10/24 at 3:46 p.m., LPN #1 reviewed Resident #38's orders. They stated the Resident was to receive 2 liters oxygen and there were no orders to increase as needed. On 09/10/24 at 3:49 p.m., LPN #1 observed Resident #38's concentrator. They stated it was set at 3 liters per minute. They stated it was wrong and adjusted the concentrator to 2 liters per minute. On 09/12/24 at 10:10 a.m., the DON stated oxygen should be administered as ordered.

Based on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received restorative services to prevent further decrease in range of motion for one (#4) of one sampled resident reviewed for restorative services. The Administrator identified 80 residents resided in the facility. MDS Coordinator #1 identified 10 residents on restorative services. Findings: A Restorative Nursing policy, revised 07/06/09, read in part, .It is the policy of this facility to provide restorative nursing services to promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on maintaining optimal physical, mental and psychosocial function. Skill practice in such activities as walking and mobility, dressing and grooming, eating and swallowing, transferring, amputation care, and communication can maintain function in physical abilities and ADLs and prevent further impairment .Interventions will be assigned to designated nursing assistants and they will initial the daily record of treatment .and document actual minutes to provide each time the resident participates in the activity. A licensed nurse will evaluate the restorative care plan and revise as indicated and complete the monthly assessment .includes active or passive-should maintain function .Focus on maintaining the resident's self performance. Resident #4 had diagnoses which included paraplegia and pain in left ankle and joints of left foot. A quarterly assessment, dated 06/17/24, documented Resident #4 had impairment with both lower extremities. A fall care plan, revised 11/19/19, documented PT, OT, and ST to screen, evaluate and treat prn. Restorative therapy as indicated. An ADL care plan, initiated on 04/20/17, read in part, .Resident #4 requires assist with ADL's .Restorative as needed . A Restorative Program/Nursing care plan Goals and Interventions form, dated 08/23/23, documented, long and short term goals: PROM to bilateral legs 3 sets of 15 repetitions 2 times a week times 4 weeks as tolerated. Facility Task History documented the following: a. Nursing Rehab: Active/Passive ROM to bilateral lower extremities, revision date 12/07/22, b. Nursing Rehab: Active/Passive ROM to bilateral lower extremities, revision date 12/10/22, c. Nursing Rehab: Passive ROM to bilateral lower extremities, revision date 08/23/23, d. Nursing Rehab: Passive ROM to bilateral lower extremities 3 set of 15 repetitions two times a week times four weeks as tolerated, revision date 08/23/23, and e. Nursing Rehab: Passive ROM to bilateral lower extremities 3 set of 15 repetitions two times a week times four weeks as tolerated, revision date 01/30/24. On 09/11/24 at 11:30 a.m., Resident #4 stated they had asked for restorative service due to their legs being stiff. Resident #4 stated they were told they were on a list and restorative just hadn't gotten around to Resident #4. They stated they just wanted some range of motion with their legs and the facility had just gotten a restorative aide in the past three or four months. Resident #4 stated they were able to move their legs a little bit. On 09/12/24 at 2:47 p.m., MDS Coordinator #1 provided a list of 10 residents who were currently receiving restorative services, Resident #4 was not on the list. They stated if the resident came off of therapy they would give her notification if the resident was determined appropriate for restorative therapy. They stated if a resident had a fall or a decline restorative interventions could get them back to where they were. They stated restorative therapy was done for 60 days and if no improvement services would be discontinued. On 09/12/24 at 3:30 p.m., MDS Coordinator #1 stated the facility did not have a restorative aide for two and a half years. There was an aide who was working the floor a lot. They stated they now had a restorative aide for three or four months. MDS Coordinator #1 stated their was no documentation of restorative services being provided to Resident #4 for the 08/23/23 restorative plan of care.

Based on observation, record review, and interview, the facility failed to ensure a resident's representative was informed about a fall intervention for one (#237) of two residents reviewed for falls. The Administrator identified 80 residents resided in the facility. Findings: The Fall Program policy, revised 05/24, read in part, Educate resident's family .regarding these interventions and encourage family assistance and support. Resident #237 was admitted on [DATE] and had diagnoses which included history of falling, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side. Resident #237's care plan for falls, revised 09/06/24, documented intervention for mattress on the floor. On 09/11/24 at 10:37 a.m., Resident #237 was observed laying on a floor mattress. There were two mattresses laid side by side. On 09/12/24 at 9:56 a.m., Resident #237 stated they did not like sleeping on the floor mattress. They stated staff told them it would stop them from falling. Resident #237 stated they fell because staff did not answer their call light in a timely manner. On 09/12/24 at 11:02 a.m., a fall incident report, dated 09/06/24, was reviewed. It did not document Resident Representative #1 was notified about putting the resident's mattress on the floor as a fall intervention. On 09/12/24 at 1:28 p.m., CMA #1 stated Resident #237's bed was taken away because they kept trying to get out of bed and they were a fall risk. They stated the Resident required two person assistance with transfers. They stated the bed was taken away about a week ago. On 09/12/24 at 1:35 p.m., LPN #3 stated Resident #237 kept falling so they took away the Resident's bed. On 09/12/24 at 1:39 p.m., the DON stated the mattress on the floor was implemented as a fall intervention on 09/06/24. On 09/12/24 at 1:42 p.m., the DON stated Resident #237 had two other falls prior to the fall on 09/06/24. The DON stated they spoke with Resident's Representative #1 about the fall and they both agreed on placing the mattress on the floor as a fall intervention. They stated the in person conversation was not documented. On 09/12/24 at 2:10 p.m., Resident Representative #1 stated they were not made aware of the Resident sleeping on a floor mattress. They stated they found out when they visited the Resident. On 09/12/24 at 2:13 p.m., Resident Representative #1 stated the facility did not educate them on any implemented fall interventions for Resident #237. On 09/12/24 at 2:36 p.m., the DON stated the facility did not have a system in place to determine what fall interventions to implement prior to taking away a resident's bed. On 09/12/24 at 3:00 p.m., the Infection Preventionist provided an incident report dated 09/06/24. The incident report documented Resident Representative #1 was verbally spoken to. It documented Resident #237 and Resident Representative #1 agreed on putting the mattress on the floor as a fall intervention. The above statement was not on the 09/06/24 incident report the surveyor reviewed prior to interviewing staff. On 09/12/24 at 3:03 p.m., the Infection Preventionist and the DON were asked why the 09/06/24 incident report was no longer on the historical list. They stated the 09/06/24 incident report was still active. They stated the surveyor would not be able to access any active incidents. On 09/12/24 at 3:04 p.m., the DON was asked how the surveyor was able to access the 09/06/24 incident report under the historical list. They stated they were not sure. On 09/12/24 at 3:05 p.m., the DON was asked when the statement about Resident Representative #1 was added to the incident report. They stated they were not sure but if an incident is active, they can add information to it.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#39) of one sampled resident reviewed for abuse. The Administrator identified 80 residents resided in the facility. Findings: A Resident Abuse, Neglect, and Misappropriation of Property policy, undated, read in part, .The resident has the right to be free from verbal, sexual, physical, and mental abuse .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology . Resident #39 had diagnosis which included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety. Resident #39's quarterly assessment, dated 08/04/24, documented Resident #39 had severe cognitive impairment and required substantial assistance with ADLs. An Initial State Reportable Incident form, dated 12/01/23, documented an allegation of Abuse/Mistreatment. It documented on 12/01/23 it was reported that there was a video with [Resident #39] and employee [name withheld]. Family doctor, police, and APS notified. An Notification of Nurse Aide/Nontechnical Service Worker form, dated 12/01/23, documented the allegation had been reported on 12/01/23, and dietary aide #1 had been terminated. A Follow up Information State Reportable Incident, form faxed to OSDH on 12/01/23 at 4:00 p.m., documented video was observed by the Administrator of employee [name withheld] displaying inappropriate content of language in the presence of [Resident #39]. No physical or sexual content was exhibited in the video. Employee was terminated immediately. A Follow up and Final Information State Reportable Incident, form faxed to OSDH on 12/04/23, documented, Facebook video observed by Administrator, shows employee [name withheld], waving their hand in front of resident [name withheld] asking them where their paper is at and stating you are goofy, at some point in the video employee [name withheld] also made a statement of [explicit remark]. Employee [name withheld] proceeded to state they can do whatever they wants and can go mess with another [explicit language]. Part C. The facility completed an initial investigation by interviewing involved resident [name withheld], resident does not recall anything regarding the video, involved employee [name withheld] interviewed and admitted to the video and stated resident [name withheld] was the only resident included in the video. Facility interviewed [13] residents and [eight] staff members and by completing a focused assessment on the resident [name withheld], a head to toe assessment, an evaluation of his medication, medical and history incident and chart and record review. The resident [name withheld] was seen by [name withheld] health services for emotional support. Facility will continue to monitor resident for any changes in behavior and will follow up with [name withheld] services to re-evaluate for any changes. Focus assessments performed on [13] residents with no complaints or signs of abuse and completed compliance rounds. Dr. [name withheld] notified, family notified, police department notified [case # withheld], APS and nurse aide registry notified. Employee [name withheld] was terminated immediately. Upon completion the facility substantiated the allegation of abuse. The facility has educated the family and all staff members on the residents updated plan of care, residents' preferences/choices for ADL care, the signs and symptoms on abuse, neglect, and misappropriation, residents' right to respect and protect resident privacy, HIPPA violation, media photography, and threatening behavior, and on the policy and procedure for reporting allegations of abuse, neglect, and misappropriation. The facility form titled Compliance Rounds documented compliance rounds were made on 12/01, 12/02, 12/03, 12/04, 12/05, 12/06, 12/07, 12/08, 12/09, and 12/10/23. In-services, dated 12/01/23, documented in-services on media, photographs, threatening behavior, abuse, neglect, and misappropriation. A suspension of a crime drill was held on 12/14/23. On 09/13/24 at 2:23 p.m., the Administrator stated as soon as they had come in on the day of the incident, Resident #39's [family member] had made her aware of the incident. On 09/13/24 at 2:24 p.m., the Administrator stated Resident #39's [family member] had shown them the video. On 09/13/24 at 2:25 p.m., the Administrator stated they had interviewed Resident #39 and other residents' of the facility to make sure there weren't video's of them. On 09/13/24 at 2:26 p.m., the Administrator stated they had interviewed residents, made sure Resident #39 was safe, asked facility therapist to see Resident #39, and a head to toe assessment with [name withheld] health services. They stated five day compliance rounds were completed and no residents or staff had any concerns. On 09/13/24 at 2:30 p.m., the Administrator stated the facility did a PIP each month to review abuse allegations. On 09/16/24 at 11:06 a.m., Resident #9 stated the facility would come ask every now and then if they felt safe in the facility. On 09/16/24 at 1:11 p.m., Resident #52 stated they could not remember but that did not mean they did not talk with them. On 09/16/24 at 2:11 p.m., CMA #2 stated we always talking about abuse and resident safety in our huddles. We monitor the residents for abuse. They stated that they did not witness the incident and they were sure the facility spoke with them because they talked with a lot of staff around that time. On 09/16/24 at 2:13 p.m., CMA #3 stated yes, they spoke to me about the abuse. They stated they had not witnessed the incident. CMA #3 stated the facility often came and spoke with them about abuse and resident safety. On 09/16/24 at 2:21 p.m., Resident #67 stated the facility did speak with them concerning abuse. I can't remember the specific time frame but they speak with us about safety and abuse.

Based on observation and interview, the facility failed to maintain a home like environment for one (#30) of two residents reviewed for homelike environment. The Administrator identified 80 residents resided in the facility. Findings: Resident #30 had diagnoses which included acute and chronic respiratory failure with hypercapnia. On 09/10/24 at 2:44 p.m., Resident #30's bed had an off white, dirty fitted sheet with a yellow spot and a torn pillow with no pillowcase. On 09/11/24 at 9:37 a.m., multiple brown spots were observed on Resident #30's fitted sheet. The yellow spot was still on the Resident's fitted sheet. Resident #30 stated their linens needed to be changed. On 09/11/24 at 10:16 a.m., CNA #1 stated they personally changed residents' linens every day. They stated the facility's process was Monday, Wednesday, and Friday. On 09/11/24 at 10:17 a.m., CNA #1 stated if a resident had dirty linens, they would change them. On 09/11/24 at 10:18 a.m., CNA #1 stated the use of torn pillows was not acceptable and they would replace them. On 09/11/24 at 10:19 a.m., CNA #1 stated the last time they were in Resident #30's room was this morning. On 09/11/24 at 10:21 a.m., CNA #1 made observation of the Resident's room. They stated the bed linens were dirty and needed to be changed. They stated the pillow needed to be replaced. On 09/12/24 at 11:18 a.m., the DON stated linens were to be changed as needed and at residents' request.

Based on record review and interview, the facility failed to provide a NOMNC to one (#239) of three residents reviewed for beneficiary notification. Regional Nurse Consultant #1 identified two residents who received skilled services in the facility. Findings: Resident #239 admitted to Part A skilled services on 02/12/24 and discharged from Part A services on 03/06/24. Resident #239 discharged home. There was no documentation a NOMNC was provided to Resident #239. On 09/12/24 at 1:39 p.m., the DON stated they could not locate a NOMNC for Resident #239.

Based on record review and interview, the facility failed to ensure a baseline care plan was completed in a timely manner for one (#84) of 18 sampled residents reviewed for baseline care plans. The Administrator identified 80 residents resided in the facility. Findings: Resident #84 admitted on [DATE] with diagnoses which included acute kidney failure and general anxiety disorder. There was no baseline care plan located in Resident #84's EHR or hard chart. On 09/12/24 at 12:40 p.m., MDS coordinator #1 stated the policy for initiating a baseline care plan was to access the baseline assessment on the EHR and it should be completed upon admission by the nurse admitting the resident. On 09/12/24 at 12:44 p.m., MDS Coordinator #1 stated Resident #84 did not have a baseline care plan in their records.

Based on record review and interview, the facility failed to ensure residents with a new diagnosis of mental illness was referred to OHCA for evaluation and determination of specialized services for two (#26 and #27) of three sampled residents reviewed for PASARR. The Resident Census and Conditions of Residents report, dated 08/01/23, documented 44 residents with psychiatric diagnoses. Findings: 1. Resident #27 was admitted to the facility on [DATE]. A Nurses Progress Note, dated 03/24/21, read in part, .focused charting r/t .PA .visited and evaluated resident .order to add diagnosis of schizophrenia d/t hallucinations and family report of diagnosis of schizophrenia . There was no documentation OHCA was notified of the new diagnosis. On 08/02/23 at 11:13 a.m., ADON #1 and BOM was asked to describe the process the facility complete when a resident had a newly evidence of serious mental disorder after the resident admited to the facility. ADON #1 stated they notified the BOM. The BOM stated they called OHCA and notified them. On 08/02/23 at 11:15 a.m., ADON #1 and BOM were asked if Resident #27 had been diagnosed with a mental disorder. ADON #1 stated Yes, schizophrenia. They were asked when the resident had been diagnosed . The BOM stated, 03/24/21. They were asked if OHCA had been notified. The BOM stated they didn't remember calling them. The BOM looked at their notes and stated they didn't have documentation OHCA had been notified. They were asked if OHCA should have been notified. The BOM stated, Yes, we usually do. 47827 2. Resident #26's admission record documented they were admitted on [DATE] with a diagnosis of dementia. A face sheet documented Resident #26's schizophrenia diagnosis was dated 12/21/22. On 08/02/23 at 12:35 p.m., ADON #1 was asked when Resident #26 was admitted . ADON # stated Resident #26 was admitted on [DATE]. When asked if Resident #26 had a PASARR II completed, ADON #1 stated, No. Corp. Nurse Consult #1 and #2 stated a PASARR II was not needed because Resident #26 had a diagnosis of dementia. On 08/02/23 at 1:20 p.m., Corp Nurse Consult. #1 was asked asked for the documentation of OHCA notification after Resident #26's schizophrenia diagnosis. No documentation was provided.

Based on observation and interview, the facility failed to ensure the kitchen, dishwashing area, and dry storage area was kept clean. The Corp Nurse Consult #1 identified 76 residents received meals from the kitchen. They identified one resident who received nutrition and hydration solely through a feeding tube. Findings: On 08/01/23 at 6:55 a.m., a tour of the kitchen was conducted. The following observations were made: a. one dead fly and fly swatter were on the table with containers of cereal, b. one dead roach was on the floor next to the table with cereal, c. one semi dead bug was on the floor in front of the table with cereal, d. food crumbs and debris were on the floor and along the wall under the table with the toaster, e. multiple dead roaches and brown debris were on the floor scattered under the dishwasher and sink areas, and f. mice feces, multiple dead roaches, chips, food wrappers, debris and crumbs were scattered under multiple shelves in the dry storage room and behind the door going into the dry storage room. On 08/01/23 at 7:22 a.m., DA #1 was asked when staff swept and mopped the floor in the kitchen, dry storage area, and dishwashing area. They stated they do it if they work evening shift and were scheduled to work the next morning. They stated they didn't sweep or mop last night. On 08/02/23 at 8:12 a.m., a follow up tour of the kitchen was conducted. The following observations were made: a. mice feces, multiple dead roaches, chips, food wrappers, debris and crumbs were scattered under multiple shelves in the dry storage room and behind the door going into the dry storage room, and b. one dead roach was on the floor under the shelf with pans, across from the stove in the kitchen. On 08/02/23 at 8:20 a.m., the ACDM was asked to describe the cleaning schedule in the kitchen, dry storage room, and dish washing area. They stated they do have forms but they were revising them currently. They stated the aides and cooks each have a list and they sign off on them every day. They stated they ensured to clean up, and leave no crumbs or debris. They stated they swept every night. On 08/02/23 at 8:25 a.m., the ACDM was asked for the cleaning sheets for this week they had signed off on. The ACDM was not able to locate them. The ACDM was asked if staff cleaned from 07/31/23 to 08/01/23. They stated when they arrived on 08/01/23, it didn't look like it.

Based on observation, record review and interview, the facility failed to ensure a resident used a smoking apron as ordered for one (#16) of one sampled resident reviewed for accident hazards. The Corp Nurse Consult #1 identified 30 residents who smoked. Findings: Resident #16 had diagnoses which included aphasia following cerebral infarction and dementia. A Annual Assessment, dated 12/04/22, documented the resident was severely impaired with daily decision making and currently used tobacco. A Behavior Note, dated 05/01/23, read in part, .res observed smoking in room. cigarettes and lighter surrendered and placed on nurses cart . A Behavior Note, dated 5/13/2023, read in part, .Res was noted by nurse .in [resident's] restroom smoking .Dr's on call was contacted and new order was given for res to have supervised smoking to prevent incidents . A Physician's Order, dated 06/04/23, read in part, .Ensure resident has smoking apron on when [the resident] is outside to smoke every shift . On 08/01/23 at 9:58 a.m., Resident #16's family member was asked if the resident could independently and safely smoke. They stated the resident had to be supervised. On 08/01/23 at 1:05 p.m., Resident #16 was observed outside with a cigarette. Another resident lit the cigarette for Resident #16. Resident #16 was not observed wearing an apron. Staff were not observed outside with residents. On 08/03/23 at 7:44 a.m., Resident #16 was observed with a unlit cigarette behind their ear wheeling towards the door to the outside smoking area. On 08/03/23 at 7:46 a.m., another resident let Resident #16 outside and lit Resident #16's cigarette. Resident #16 was observed smoking without a smoking apron and no staff were observed outside with resident. On 08/03/23 at 8:28 a.m., CNA #3 was asked how staff ensured residents safely smoked. They stated they make sure the residents can move their arms to their mouth. They stated some residents wore smoking aprons. They stated some residents were supervised and staff would monitor them. CNA #3 was asked who was supervised when they smoked. They stated Resident #16. CNA #3 was asked where residents smoked. They stated on the back patio. They stated a lot of the residents knew the code to go out. They stated if the resident couldn't go outside without assistance, the resident shouldn't be out there by themselves. CNA #3 was asked if Resident #16 was safe to smoke independently. They stated the residents looked out for each other. They stated they saw on the electronic health record Resident #16 was suppose to have a smoking apron. CNA #3 was asked who was responsible for ensuring interventions for smoking were followed. They stated the nurse or management. On 08/03/23 from 9:22 a.m., to 9:30 a.m., Resident #16 was observed to wheel themselves in their wheelchair to their room and back to the door to the outside smoking area. Resident #16 was observed to have a unlit cigarette behind their ear at the door to the outside smoking area. CMA #5 was observed to open the door to the outside smoking area for Resident #16 to go outside. Another resident was observed to light Resident #16's cigarette. Resident #16 was observed smoking without an apron and no staff were observed outside. On 08/03/23 at 9:34 a.m., LPN #3 was asked how staff ensure residents were safe to smoke independently. They stated when the residents went outside the staff kept an eye on them and some of the residents wore an apron. LPN #3 was asked what residents wore aprons. They stated Resident #16. LPN #3 was asked who ensured the residents wore the aprons. They stated the charge nurse or the staff who took the resident outside. On 08/03/23 at 9:36 a.m., LPN #3 was asked to observe Resident #16 currently outside. LPN #3 went outside to observe Resident #16. LPN #3 was asked if staff were present. They stated, No. LPN #3 was asked if the resident was wearing an apron. They stated, No. LPN #3 stated they were going to see where was the resident's apron. They stated the aprons were usually kept in the resident's room.

Based on record review and interview, the facility failed to ensure implemention of abuse policy and procedure for reporting and thorough investigation an allegation of abuse for one (#3) of three sampled residents reviewed for abuse. The facility census and conditions of residents dated 02/21/23 documented 74 residents resided in the facility. Findings: The facility policy, last up dated 12/28/17, titled Resident Abuse, Neglect and Misappropriation of Property, read in part, .page 6 .a member of the administrative staff will then conduct a through investigation of the incident/allegation to obtain information and complete ODH-283 .see policy related to reports to State and Federal agencies .facility will also file reports with agencies in accordance with regulations . Resident #3 had dementia, chronic obstructive pulmonary disease. An annual assessment dated [DATE], documented Resident #3's cognition was intact. A review of the clinical record for Resident #3 contained no documentation of any incidents of mishandled during repositioning at night. A review of the facility abuse investigations from 09/01/22 through 02/20/23 did not contain an incident with Resident #3 and a male aide. On 02/21/23 at 9:10 a.m., the director of nursing stated Resident #3 had complained to the ombudsman about an incident but did not provide any additional information. The director of nursing then stated they had spoken to Resident #3 and the resident stated she had been hurt when an aide walked into the room and repositioned her when telling the aide not to. The director of nursing then stated she moved the aide off the hall after doing some training with him. When asked if she completed any additional investigation and reporting the director of nursing stated, I did not do anything else. On 02/21/23 at 9:15 a.m., Resident #3 stated a male aide came in who was very strong and repositioned me when I did not want him moving me. The aide pulled me up by the arms roughly and hurt my arm. Resident #3 stated her arm did not hurt long but they were more surprised this happened. Resident #3 then stated she was not afraid of the aide but he had been moved to a different hall. I was shocked this had happened and told another aide what had happened. The resident then stated it happed about a week ago. 02/21/23 at 10:58 a.m., the director of nursing stated she did not interview other residents, report this to the state agency and did not document any staff interviews. The director of nursing stated she had talked with staff and all staff did not have any concerns with the aide. She then confirmed she had not fully followed the abuse policy.

Based on record review and interview, the facility failed to implement their abuse policy by not investigating an allegation of misappropriation of property for one (#40) of one sampled resident reviewed for abuse. The Census and Condition of Residents report, dated 06/28/2022, documented 59 residents resided in the facility. Findings: A Resident Abuse, Neglect and Misappropriation of Property policy, revised 12/28/17, read in parts, .misappropriation of property will not be tolerated .All employees of a nursing facility are mandated reporters of resident .misappropriation of property and must report any and all incidents . Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 11/23/21, documented the resident's cognition was intact and they required supervision with locomotion. It was documented the resident had impairment to both sides of their upper and lower extremities. On 06/29/22 at 11:00 a.m., Resident #40 was asked if their $420.00 voucher was still missing. They stated it was. They were asked if they reported the missing voucher to anyone besides LPN #1. They stated, No, they don't care. On 06/29/22 at 11:51 a.m., LPN #1 was asked if Resident #40 had reported missing a voucher on 12/04/21. They stated they had. They were asked if they reported it to administration. They stated had not. LPN #1 stated they looked for it, but couldn't find it. On 06/29/22 at 12:26 p.m., the administrator was asked if they were aware Resident #40 had been missing a $420.00 voucher from 12/04/21. They stated they were not. They were informed at that time of the missing $420.00 voucher. On 06/29/22 at 1:25 p.m., the administrator was asked if a resident reported missing property, such as $420. 00 voucher, should an investigation be conducted. They stated, Once I was notified. They were informed Resident #40 informed LPN #1 of the missing voucher. The administrator was asked if an investigation had been conducted. They stated there was not. They were asked what was staff instructed to do when informed of missing property. They stated staff were to follow their abuse policy which included neglect and misappropriation.

Based on observation and interview, the facility failed to ensure: a. food products were properly labeled/identified, and b. food service equipment and the building was maintained clean and in good repair. The Residents Census and Conditions of Residents report, dated 06/28/22, documented 59 residents resided in the facility, and two residents received tube feeding. The ADON identified one of the two residents received nutrition and hydration solely through a feeding tube. Findings: On 06/28/22 at 8:40 a.m., an initial tour of the kitchen was conducted. There were two bulk containers of white dry ingredients stored next to the cook line that were not labeled. On 06/29/22 at 7:58 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of black residue on the floor and the walls in the dish wash area, b. there were multiple dead roaches on the floor in the dry storage area, c. the lids on the two bulk containers of the white dry ingredients were cracked and in bad repair, d. there was an accumulation of food and grease on the fryer, fryer basket, and the side of the stove, e. the baseboard was loose and not secure to the wall behind the two compartment sink, f. there was trash and an accumulation of black residue on the floor under and behind the ice machine, g. there were holes in the walls behind the ice machine, h. there was plastic peeling off of the top section of the ice machine, the area was not smooth and easy to clean, i. there was an accumulation of black residue on the racks and the floor in the walk in cooler, j. paint was missing off of the floor in the walk in freezer, the floor was rusted, k. there was brown residue on the food storage racks in the walk in freezer, the racks were rusted, l. the outside area of the walk in cold hold units were rusted, m. there was an accumulation of grease and lint on the clean dish rack next to the two compartment sink, n. paint/material was peeling off of the wall behind the food preparation table near the ice machine and the can opener table, o. there were holes in the baseboards near the serve out window and the can opener table, p. there was an accumulation of black residue on the dried glue adhesive on the floor near the hand sink, and q. the white ceiling tiles throughout the kitchen were discolored with a yellow and red residue. On 06/29/22 at 10:40 a.m. , the CDM was asked what was the policy for cleaning and maintaining food service equipment and the physical environment. They stated staff cleaned daily and they had a schedule for deep cleaning. They stated they reported issues to maintenance and contacted outside companies for repairs as needed. They were asked what was the policy for labeling food products. They stated once a box was opened they labeled and dated the product. They were asked about dry food products. They stated they just knew what the products were. They were informed of the above findings.

Based on record reviewand interview, the facility failed to administer medications per physician orders for two (#40 and #44) of seven sampled residents who were reviewed for medications. The Resident Census and Conditions of Residents report, dated 06/28/22, documented 59 residents resided in the facility. Findings: 1. Resident #40 had diagnoses which included constipation. A quarterly assessment, dated 11/23/21, documented the resident's cognition was intact. A physician's order, dated 12/02/2021, documented dulcolax suppository (stool softener) insert 1 suppository rectally one time a day every Tuesday and Friday. The January 2022 TAR documented the resident had not been administered their dulcolax suppository on 01/25/22. There was a blank where it was to be documented the medication was to have been administered. On 06/29/22 at 1:15 p.m., LPN #1 was asked how they document a treatment had been provided on the TAR. They stated by clicking yes or no. They were asked a a blank indicated on the TAR. They stated either they did administer the treatment/medication or they did not chart on it. 2. Resident #44 had diagnoses which included pain, constipation, and [CONDITION(S)]. A physician's order, dated 07/06/21, documented to administer [MEDICATION(S)] Aerosol Solution 1.25 MCG/ACT (bronchodilator) 1 puff orally one time a day. The order was discontinued on 06/02/22. A physician's order, dated 07/30/21, documented to administer Senna-S ( stool softener/[MEDICATION(S)]) 50mg/8.6mg by mouth two times a day. A physician's order, dated 08/12/21, documented to administer [MEDICATION(S)] (anticonvulsant) 300mg three times a day. The May 2022 TAR was reviewed. It was documented the administration of [MEDICATION(S)] Aerosol Solution on 05/31/22 was coded as a 9. The chart code documented to see the nurses notes. An orders administration note, dated 05/31/22 at 3:45 p.m., documented [MEDICATION(S)] Aerosol Solution was on order. The June 2022 MARs and TARs were reviewed. The following medication administration times were coded as 9's. The chart code documented to see the nurses notes. a. 7a.m. - 11:00 a.m. dose of [MEDICATION(S)] Aerosol Solution on 06/01/22, b. 6:00 p.m. - 10:00 p.m. dose of [MEDICATION(S)] on 06/06/22, c. 3:00 p.m. doses of [MEDICATION(S)] on 06/07/22, d. 6:00 p.m. -10:00 p.m. doses of [MEDICATION(S)] and Senna-S on 06/07/22, e. 6:00 p.m. - 10:00 p.m. doses of [MEDICATION(S)] and Senna-S on 06/08/22 An orders administration note, dated 06/01/22, documented [MEDICATION(S)] Aerosol Solution was not available and the pharmacy was notified. Orders' administration notes, dated 06/06/22, 06/07/22, and 06/08/22, documented [MEDICATION(S)] and Senna-S had been ordered and/or was in route. On 06/29/22 at 12:44 p.m., the ADON was asked what determined when medications were to be ordered. They stated medications were to be ordered when they were low. They stated there should be a sticker on the medication card indicating for staff to order the medication. They were shown Resident #44's MARs, TARs and orders administation notes where the resident did not receive there medications.

Based on record review, observation, and interview the facility failed to maintain an environment free of roaches for two (#1 and #4) of four sampled residents whose environments were observed for pest control problems. Resident Census and Conditions of Residents report identified 61 residents resided in the facility. Findings: Pest Control Policy, effective 10/24/08, read in part, .It is the policy of this facility to maintain an effective pest control program so that the facility is free of pests . [Pest Control] Contract, effective 12/01/21, read in part, .Patient rooms will be treated as needed . Pest Sighting Log documented roaches were sighted in a residents' overbed table on 03/08/22, in a resident's drawer on 03/09/22, crawling up a residents' curtain on 05/17/22, and everywhere in the same residents' room on 05/23/22. There were no [Pest Control] Summary of Service records found that documented as needed treatment for roaches following these sightings. Resident #1 had diagnoses that included [CONDITION(S)] and muscle spasms. On 06/10/22 at 9:30 a.m., resident #1 was asked if they had noticed any type of pests around the facility. They stated, Yeah, they got plenty of roaches here. There was just one crawling up the wall. Resident #1 showed this surveyor two roaches crawling up the wall in their room and several others crawling about on their refrigerator and on the television. Resident #1 reported that frequently [LPN #1] comes in and has to knock two or three roaches out of their bed. On 06/13/22 at 9:13 a.m., LPN #1 was asked have you noticed a problem with roaches in resident #1's room. They replied, Roaches are always in there. I put the work order in. Roaches are everywhere in there. When asked if she has ever seen roaches in resident #1's bed, she stated, Yes. I just swat them out and kill them. Resident #4 had diagnoses that included malformation of upper and lower extremities and muscle spasms. On 06/09/22 at 4:00 p.m., resident #4 was asked if they had noticed any type of pests around the facility. They stated, Oh, yeah. They come out at night. When they scoot my bed out to change me they scatter. They'll be in my bed if there are crumbs in my bed. Two roaches were observed by this surveyor crawling on the floor beside resident #4's night table. On 06/10/22 at 10:30 a.m., Maintenance Supervisor was asked about the facility's pest control program. He stated, They come routinely once a month, between the 1st and the 8th. I can call them if we see roaches in resident rooms. They respond rapidly. Maintenance Supervisor was asked how he would know if they needed to have pest control come in for visits other than the routine visits. He stated, I check the log book every day. It is where anyone logs where they spot roaches. The date and time. Maintenance Supervisor was asked why the pest control company had not been called out for pest sightings on 03/08/22, 03/09/22, 05/17/22, and 05/23/22. He responded, I'm not sure. On 06/13/22 at 08:53 a.m., CNA #1 was asked if they see pests in the facility. They replied, Yes, mostly roaches in the rooms under the bedside tables when you move them. On 06/13/22 at 09:07 a.m., CNA #2 was asked if they see pests in the facility. They replied, Yes. I just started seeing ants, but roaches are around the concentrators, windows, and in the shower rooms. Very common. On 06/13/22 at 09:09 a.m., Housekeeping #1 was asked if they see pests in the facility. They replied, I see them every once in a while. Mostly in the rooms where the residents snack at night. On 06/13/22 at 11:58 a.m., the DON was asked if she was aware of any pest problems in the building. She responded, We had a real roach problem but now we have a new pest company. They come out once a month and as needed. We can call them to come earlier. The DON was asked under what circumstances the pest control company would be called out earlier. She explained that pest sightings between monthly pest control visits were documented in the pest control log book so that the pest control company could be called out early if needed. The DON was asked why the pest control company had not been called out for as needed visits for pest sightings on 03/08/22, 03/09/22, 05/17/22, and 05/23/22. She stated, I'm not sure, usually if there is an issue, [Maintenance Supervisor] would be the one to call them out. The DON was asked if she thought the current pest control program was effective in maintaining the facility free of roaches. She stated, It's better. On 06/13/22 at 12:15 p.m., the Administrator was asked if there were any pest problems in the building. She stated, Relatively, yes. We have pests like anywhere else. When asked how pest problems in the building were being handled, the Administrator replied, Right now we are getting things worked out with a new pest control company. The administrator was asked how often the facility was treated for roaches. She explained that the common areas, laundry, and kitchen were treated monthly and resident rooms were treated if there were sightings. The Administrator was asked why the pest control company had not been called out for as needed visits for pest sightings on 03/08/22, 03/09/22, 05/17/22, and 05/23/22. She stated, I am not sure. The Administrator was asked if she thought the current pest control program was effective in maintaining the facility free of roaches. She stated, Maybe it needs to be more frequently since the weather is warmer.

Based on observation, interview, and record review, the facility failed to provide adequate staff to meet the needs of residents for one (#1) of three residents reviewed for sufficient staffing. The Administrator reported 65 residents resided in the facility. Findings: Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment, dated 11/23/21, documented cognition fully intact, and required extensive assistance with 2+ person physical assist with transfers. The resident's Care Plan, dated 11/24/21, read in parts .Assist x 2 for transfers .Requires 2 staff participation with transfers using the Hoyer lift .Resident goes out of the facility in his motorized wheel chair several times a week to the community .Resident has been informed on choices of preferred bed time. An Incident Report, dated 01/24/22, read in parts .Resident #1 reported having his call light on for an undetermined amount of time .Resident changed the amount of time during each conversation .An investigation was conducted .The facility educated appropriate staff members on the resident's preference/choices for ADL care. On 02/07/22 at 10:07 p.m., Res # 1 reported he would leave the facility in the afternoons to go out and visit family using his motorized electric wheelchair, or to go and gamble. The resident reported on 01/21/22 around 8:00 p.m., he returned to the facility and asked an unnamed nurse aide to transfer him to bed. The resident reported the unnamed nurse aide told him she didn't know how to transfer him and there was no other aides to do it. He reported having to wait until 12:45 a.m. on 01/22/22 to be put in bed. The resident reported the facility had a lot of new nurse aides that were training and they didn't know how to transfer him or they didn't want to. He reported that on multiple occasions he had to wait for extended periods to get assistance and for nurses to answer his call light. On 02/08/22 at 11:45 a.m., the Administrator provided the quality of care staffing report, sent to the Oklahoma Healthcare Authority, which documented hours worked by direct care staff for the months of October, November, and December 2021. The reports documented the 24 hour staffing ratios for four days in October, eight days in November, and 12 days in December which were not adequately staffed for the reported census. The Administrator reported the January 2022 report had not been processed yet. On 02/08/22 at 3:06 p.m., the Ombudsman reported attending Res #1's care plan meeting with him on 10/19/21 because he was concerned about not getting adequate care and call lights taking too long to be answered. On 02/09/22 at 9:00 a.m., the Administrator provided documentation of Res #1's January 2022 MAR and TAR. The resident's MAR and TAR documented 11 days the resident had not received evening medications or treatments scheduled from 6:00 p.m. to 11:00 p.m., with no explanation of why the medication or treatment was not administered. On 2/09/22, the Administrator provided a staffing report and census report for January 2022. The report documented eight days which were not adequately staffed for the reported census. On 02/09/29 at 12:20 p.m., NA #1 reported Res #1 was a 2-person physical assist transfer and Hoyer lift. The NA reported she had worked at the facility for a couple of weeks and was in training. The NA reported on the second day of work, she had trained another new NA. On 02/09/22 at 12:22 p.m., CNA #1 reported the facility had been short-staffed a few times she had worked. CNA #1 reported one shift she worked as the only CNA because all the other CNA's had tested positive for Covid before the shift. CNA #1 reported Res #1 required two staff to transfer. On 2/09/22 at 12:39 p.m., CNA #2 reported Res #1 had to be transferred with two staff and if staffing was short, they had to wait for another nursing staff member to assist when available. On 02/09/22 at 2:10 p.m., the DON reported the facility had been having some staffing issues due to Covid, so each week the facility had a nurse on-call to cover shifts or get them covered by other staff. The DON reported the facility used nurse aides in training, agency staff, and corporate nurses to cover shifts. The DON reported Res #1 left the facility in the afternoons and usually didn't come back until late. The DON stated he may have missed his evening medications due to being out of the facility. The DON agreed the nurse should have documented a reason for the medication not being administered. She reported she had not been made aware the resident had missed any medications or treatments. On 02/09/22 at 2:20 p.m., the Administrator was made aware of the significantly low staffing ratio on 01/21/22 and 01/22/22 shift from 11:00 p.m. - 7:00 a.m. The Administrator stated she wanted to double check the staffing report because the facility used a 24 hour staffing ratio, not staff-to-resident ratio by shift. The Administrator confirmed that on 01/22/22 the facility had a census of 67 residents, with only a 1.93 direct care ratio when a 2.9 direct care ratio was required for a 24 hour period.

Based on record review, and interview, it was determined the facility failed to provide assistance of two staff during transfer with a mechanical lift for one (#31) of the four sampled residents reviewed for accidents/supervision. The resident experienced a fracture to the right tibia as a result of the inadequate assistance, resulting in actual harm. This had the potential to affect 17 of 71 residents identified by the facility on the 'Resident Census and Condition' report who were totally dependent with transfers. Findings: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had severely impaired cognition. The resident was totally dependent on two or more staff members for transfers. She had impairment in range of motion of one side upper extremity and bilateral lower extremities. A care plan, updated on 01/18/13, documented the resident had a potential for falls and was dependent with activities of daily living and transfers. Interventions included a mechanical lift was to be used for transfers with two person assistance. An incident report dated 03/27/13, and sent to the OSDH documented, "...Final...Description of Incident...Resident complain (sic) of pain to her right leg. Focused assessment completed. Resident complained of pain with palpation to right leg. Right shin edematous. Right ankle edematous and twisted...pain medication administered...Mobile x-ray ordered. Resident sent to ER, per physician orders, for further evaluation... summary of the investigation...the facility determined that the resident while being transferred by the CNA in the lift residents right leg was accidentally struck on the lift bar. Focused assessment completed. Resident complained of pain to right leg and ankle with palpation and ROM. Edema to right shin and right ankle noted...Resident sent to ER...X-ray reveal fracture to right leg...resident admitted to hospital..." A nurse's note dated 03/27/13 at 6:10 p.m. documented, "...in bed c/o pain to right leg unable to rate D/T mental status...examination revealed resident's right leg edemic, twisted @ ankel. Ankel edemic c/o pain to touch. Notified (name deleted physician) orders to x-ray right leg and ankel...Will continue to monitor..." A nurse's note dated 03/27/13 at 11:50 p.m. documented, "...Reevaluated residents right leg and ankel. Resident continues to c/o pain. Edema still present. Notified (name deleted physician). New orders to transfer resident to (name deleted hospital) for Evaluation." On 05/17/13 at 11:20 a.m., CNAs #3 and #4 were asked about the use of the mechanical lift. They stated a mechanical lift was used by all residents who required total assistance with transfers, and two staff were to be utilized to assist with the use of the mechanical lift. An interview was conducted on 05/17/13 at 1:52 p.m., with the DON. She stated it was determined the resident had been transferred via mechanical lift by one CNA. The DON concluded that only one CNA had transferred the resident and caused the fracture to her right leg. This resulted in actual harm. A facility policy for the use of a hydraulic lift documented, "It is Grace Living Centers policy to have two staff members present during transfer to stabilize and support the resident."