Every finding on record at Will-O-Bell

Based on observation, interview and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #39) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #39. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.The findings include: Record review of Resident #39's face sheet, dated 05/14/26, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles). Record review of Resident #39's Quarterly MDS assessment dated [DATE], reflected that resident had no impairment to upper extremity (shoulder, elbow, wrist, hand). MDS assessment reflected Resident #39 was at risk of developing pressure ulcers/injuries. Resident #39's Quarterly MDS assessment reflected that Resident #39 had a BIMS score of 00 indicating she was severely cognitively impaired. Record review of Resident #39's Physician's Orders, dated 06/26/25, reflected resident had and an order for gauze roll to left hand for prophylactic treatment. Monitor every day shift for prophylactic treatment. Record review of Resident #39's care plan dated 03/09/26 and revised 04/01/26 reflected Resident #39 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to Immobility, physical limitations. Care plan dated 05/18/22 reflected Resident #39 had an ADL self-care performance deficit r/t fatigue, impaired balance, limited mobility, musculoskeletal impairment. Goal: resident will maintain current level of function in all ADLs through the review date. Interventions included: Dressing: The resident requires extensive assistance by 1 staff to dress. Gauze roll to left hand for prophylactic TX. monitor Q day. During an observation on 05/13/26 at 2:29 PM, Resident #39 was observed lying in bed with her left hand laying over her chest area. Resident's left hand appeared impaired and closed. Resident was not able to demonstrate if she could have opened her left hand. During an interview on 05/14/26 at 11:10 AM, LVN A stated she was responsible for completing the MDS assessments. She stated she had been trained on completing the MDS assessments accurately. She stated anytime a resident had a physical limitation to their extremities including their hands, it should have been coded on the MDS assessment. She stated she was aware that Resident #39 had a physical limitation to her left hand. She stated she was not sure why Resident #39's left hand limitation was not coded on her MDS assessment but it should have been. She stated if the MDS assessment had not reflected Resident #39's physical limitations in her left hand it could have caused the care plan to not be completed correctly. She stated the physicians' orders were still in place and she did not feel like it would have affected the resident's care. During an interview on 05/14/26 at 11:16 AM, the DON stated LVN A was responsible for completing the MDS assessments. She stated the MDS nurse had been trained on completing MDS assessments correctly. She stated if a resident had a limitation in their extremities such as their hands it should have been coded on the resident's MDS assessment and it should have been coded on Resident #39's MDS assessment. She stated she did not feel like the resident's MDS assessment being coded incorrectly would have directly affected the resident's care but it could have affected the resident's care plan. During an interview on 05/14/26 at 11:33 AM, the ADM stated LVN A was responsible for completing the MDS assessments. She stated LVN A had been trained on completing MDS assessments correctly. She stated if a resident had a limitation in their extremities such as their hands it should have been coded on the resident's MDS assessment and it should have been coded on Resident #39's MDS assessment. She stated if a resident's MDS assessment had not been completed correctly, it could have caused the facility to not get paid properly and it would not have represented the proper care that was required for the resident. Record review of the facility's policy dated 2001 and revised October 2023, titled Quarterly Assessments, reflected Policy Statement: Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Record review of the facility's policy dated 2001 and revised March 2022, titled Resident Assessments, reflected Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. Policy Interpretation and Implementation: 9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #3) reviewed for infection control. Resident #3 had a Stage 3 Pressure Ulcer to the Left buttock and the facility failed to place him on Enhanced Barrier Precautions.This deficient practice could increase the risk of the spread of infection to other residents.Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year-old male admitted on [DATE] with Encephalopathy, (any disease or damage that alters the brain's structure or function), Muscle wasting and atrophy (the shrinking and loss of muscle mass) and Polyosteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage and bone in five or more joints simultaneously. It causes chronic pain, stiffness and reduced mobility, often affective weight-bearing joints).Record review of Resident #3's Quarterly MDS assessment, dated 04/13/2026, reflected Resident #3 had a BIMS score of 14, no impairments in cognitive function, orientation to time and place, and short-term memory. Section M-Skin Conditions revealed Resident #3 had a pressure ulcer/injury. The MDS listed the following treatments: Pressure reducing device for chair, Pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, Pressure ulcer/injury care, applications of ointment/medications other than to feet.Review of Resident #3s comprehensive care plan revealed a care plan focus problem of a stage 3 pressure injury related to a history of ulcers, limited mobility, dated 02/11/2026 and revised on 04/10/2026. There was no notation of Enhanced Barrier Precautions on the Care Plan.Review of Resident #3s orders revealed wound care orders dated 04/11/2026 and discontinued 04/20/2026 read, Cleanse wound to L buttock with ns, pat dry, apply honey then calcium alginate, cover with gauze island dressing. Wound care orders for 04/21/2026 and discontinued on 04/29/2026 read, Cleanse wound to L buttock with NS, pate dry, apply honey then calcium alginate, cover with gauze island dressing. Wound care orders beginning 04/30/2026 and discontinued on 05/08/2026 read Cleanse wound to L buttock with ns, pat dry, soak with gauze squares in Dakins solutions wring out most of the way, Pack into wound and cover with gauze island dressing. Wound care orders started 05/09/2026 and still in place at the time of the survey read, Cleanse wound to L buttock with wound cleanser spray to wound bed, pat dry, soak 1 gauze square in Dakins solutions wring out most of the way, pack into wound and cover with gauze island dressing. There were no orders for Enhanced Barrier Precautions.During an observation on 05/13/2026 at 11:18AM, Resident #3's room did not have any posting indicating Resident #3 was on Enhanced Barrier Precautions.During an interview with LVN B, 05/13/2026 at 11:20AM, LVN B stated the need for EBPs would include those residents with chronic wounds, catheters, colostomy, and wound care. LVN B stated EBPs are only required if the wound is considered chronic. LVN B stated the DON and LVN B train staff on EBPs upon new hire and every in-service huddle. LVN B stated the training occurs mostly weekly but definitely monthly. LVN B stated the training is verbal but is also written as in-service material. LVN B stated a possible outcome of not using EBPs would be infection. LVN B stated wounds that are considered acute do not require EBP.During an interview with the DON on 05/14/2026 at 2:03PM she stated it is her expectation that EBPs would be implemented for residents who had ostomies, catheters, chronic wounds (if the wound has been there 4-6 weeks with no or minimal improvement). The DON stated a non-chronic wound does not require EBPs. The DON stated a possible outcome of not using EBPs could be that the care partner and the elder could be placed at risk of infection.During an interview with the Administrator on 05/14/2026 at 2:08PM she stated her expectations for use of EBPs are dependent upon the residents' needs such as wounds and any kind of opening like an ostomy or catheter. The Administrator stated she expected the staff to follow those precautions. The Administrator stated a risk of not following the precautions could be that infection could be spread to another resident.Record review of the Enhanced Barrier Precautions policy in the Nursing Services Policy and Procedure Manual reviewed and approved on 12/10/2025 stated: EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #39) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #39 had her gauze roll placed inside her left hand on 05/13/26 as directed by physician orders. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, and hospitalization.Findings included: Record review of Resident #39's face sheet, dated 05/14/26, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles). Record review of Resident #39's Quarterly MDS assessment dated [DATE], reflected that resident had no impairment to upper extremity (shoulder, elbow, wrist, hand). MDS assessment reflected Resident #39 was at risk of developing pressure ulcers/injuries. Resident #39's Quarterly MDS assessment reflected that Resident #39 had a BIMS score of 00 indicating she was severely cognitively impaired. Record review of Resident #39's Physician's Orders, dated 06/26/25, reflected resident had and an order for gauze roll to left hand for prophylactic treatment. Monitor every day shift for prophylactic treatment. Record review of Resident #39's care plan dated 03/09/26 and revised 04/01/26 reflected Resident #39 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to Immobility, physical limitations. Care plan dated 05/18/22 reflected Resident #39 had an ADL self-care performance deficit r/t fatigue, impaired balance, limited mobility, musculoskeletal impairment. Goal: resident will maintain current level of function in all ADLs through the review date. Interventions included: Dressing: The resident requires extensive assistance by 1 staff to dress. Gauze roll to left hand for prophylactic Tx. monitor q day. Record review of Resident #39's TAR dated May 2026 reflected gauze roll to left hand for prophylactic Tx. Monitor q day shift for prophylactic Tx. It had been signed as completed for 05/13/26 by LVN B. During an observation on 05/13/26 at 2:29 PM, Resident #39 was observed lying in bed with her left hand laying over her chest area. Resident's left hand appeared impaired and closed. Resident was not able to demonstrate if she could have opened her left hand and there was no ordered gauze roll present in her hand. No gauze hand roll was seen in the area where Resident #39's left hand was laying. During an interview on 05/13/26 at 1:59 PM, LVN C stated he was the nurse that took care of Resident #39 on his shift and he knew resident's left hand was contracted. He stated he was not sure if Resident #39 should have had a gauze roll to her hand, but he was going to go check the physician's order. He stated residents with hand contractures should always have had a gauze roll or something in place to prevent the hand from closing more. He stated he had been trained on ADL care and placing gauze in the hands of those with contractures. He stated if a resident had a hand contracture and the gauze roll was not in place as ordered it could have caused the resident's nails to cut into their hand which could have caused a wound or it could have caused bacteria to grow inside the closed the hand. During an observation on 05/13/26 at 2:00 PM, observed Resident #39's left hand being opened slightly by LVN C. Resident #39's left hand was clean and without skin impairment. Resident #39's left hand did not have ordered hand roll in place. During an interview on 05/13/26 at 2:03 PM, CNA D stated she took care of Resident #39 on her shift. She stated she had not noticed Resident #39's left hand being contracted and she was not aware that resident needed a gauze hand roll to her hand. She stated if a resident's hand was contracted and closing and there was no gauze roll in place to the resident's hand it could have caused sores or open wounds to the resident's hand. She stated she was trained on ADL care and placing gauze rolls in the hands of residents that had hand contractures. During an interview on 05/14/26 at 11:16 AM, the DON stated staff had been trained on quality of care and if a resident had an ordered gauze hand roll, the hand roll should have been put in place. She stated she was aware Resident #39 had a physical impairment and limitations to her left hand. She stated Resident #39's ordered gauze hand roll should have been in place in her left hand as much as possible. She stated resident was able to open her left hand some and the gauze roll could have fallen out. She stated if an ordered gauze hand roll had not been in place, it could have caused the resident's hand to become more contracted and skin breakdown could have occurred. During an interview on 05/14/26 at 11:33 AM, the ADM stated staff had been trained on quality of care and if a resident had an ordered gauze hand roll, the hand roll should have been put in place. She stated she knew Resident #39 had a physical impairment and limitations to her left hand because she saw resident daily. She stated Resident 39's gauze hand roll should have been in place in her left hand as ordered. She stated if an ordered gauze hand roll had not been in place, it could have caused the resident's hand to become more contracted. During an interview on 05/14/26 at 2:14 PM, LVN B stated she was the nurse that signed the TAR which reflected Resident #39's gauze roll had been placed in her left hand. She stated she knew the hand roll had been placed in Resident #39's left hand on 05/13/26 because she made sure of it and she saw it there. She stated she ensured Resident #39's gauze roll was placed in her left hand daily. She stated Resident #39 moved her arms and hands a lot and sometimes the gauze roll would fall out. She stated if Resident #39's gauze roll was not in resident's hand it could have caused residents hand closure to worsen or it could have caused skin issues. Review of facility policy dated 2001 and revised March 2018 and titled Activities of Daily Living (ADL), Supporting reflected Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); d. dining (meals and snacks); 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control.CNA A failed to properly dispose of Resident #1's soiled brief after incontinent are. CNA A failed to change gloves and perform hand hygiene after handling soiled brief.This failure could place residents at risk for infection and hospitalization. Findings include: Record review of Resident #1’s, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, severe, with psychotic disturbance and agitation, muscle weakness, major depressive disorder (is a mental health condition that significantly affects how you feel, think, and behave). Record review of Resident #1’s quarterly MDS assessment, dated 06/17/2025, reflected a BIMS score of 7, which indicated severe cognitive impairment. It reflected he required maximum assistance with toileting hygiene. Record review of Resident #1’s care plan, initiated 01/03/2025, reflected the following: [Resident #1] has ADL Self Care Performance Deficit relating to dementia, impaired balance and limited mobility. Interventions included: The resident requires extensive assistance by 1 staff for toileting. Observation on 07/03/2025 at 11:23 AM, revealed CNA A walked with Resident #1 with gloved hands. CNA A turned around after the State Surveyors passed her and hurriedly ran to pick up a soiled brief that was left on the floor on the hall. CNA A used gloved hands, picked up the soiled brief and put in the barrel that was about 3 feet away. CNA A then went back to continue walking Resident #1 with the same gloved hands. During an interview on 07/03/2025 at 12:27 PM, CNA A stated when she was seen on the hall, she had just changed Resident #1’s soiled brief and was trying to get Resident #1 back to the day room quickly so she put the soiled brief on the floor to get back to it. CNA A stated she knew she was not supposed to put the soiled brief on the floor because it was not sanitary, she should have put the soiled brief in a bag and transported it to the barrel. CNA A stated she was not supposed to wear gloves while walking down the hall, but usually wore gloves to hold residents’ hands. CNA A stated holding Resident #1 with the same soiled gloved hands could cause infection. CNA A stated, “I was in a rush, I messed up.” During an interview on 07/03/2025 at 1:19 PM, the Infection Control Preventionist stated soiled briefs were supposed to be placed in a bag and the bag placed in the soiled brief barrel in a room on each hall. The Infection Control Preventionist stated it was not okay to put soiled briefs on the floor, because it could spread germs (microorganism that causes disease) . The Infection Control Preventionist stated it was not okay to walk around with gloves on, because they did not know where those gloves came from. The Infection Control Preventionist stated staff were educated to take the gloves off after care and while on the halls. The Infection Control Preventionist stated it was not okay to touch the resident with a soiled gloved hand, because it could spread of germs, the resident might touch their eyes, and their eye could get infected. During an interview on 07/03/2025 at 2:53 PM, the DON stated it was not okay to put the soiled brief on the floor due to infection control. The DON stated CNA A was not supposed to walk around with gloves on while in the hall. The DON stated if CNA A touched the soiled brief, CNA A was supposed to remove the soiled gloves, wash her hands before touching Resident #1. Record review of the facility's policy titled Infection Briefs/Underpads, revised January 2024, reflected: “Purpose The purpose of this procedure is to provide guidelines for changing a soiled brief and underpad… 13. Remove underpad from resident by rolling the underpad toward the inside soiled area. Place the underpad in the nearby receptacle/container. Steps in the Procedure 14. Remove gloves, sanitize hands and replace with clean gloves… 19. Discard disposable equipment and supplies in designated containers. 20. Remove gloves and perform hand hygiene.” Record review of the facility's policy titled infection Standard Precautions, revised September 2022, reflected: “Policy Statement Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situation. Standard precautions include the following practices: 1. Hand Hygiene b. Hand hygiene is performed with ABHR or soap and water: (1) before and after contact with the resident. (4) after contact with items in the resident's room; and (5) after removing gloves. 2. Gloves Gloves are not to be reused. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.” Record review of the facility's policy titled Handwashing / Hand Hygiene, revised October 2023, reflected: Policy: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitor. Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident. b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces. d. after touching a resident. e. after touching the resident's environment. f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.”

Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biological's were stored under proper temperature in the Front Medication Room and the Back Medication Room reviewed for medication storage. The facility's failures could place residents receiving medication at risk for lack of drug efficacy. Findings included: During an observation on 03/26/2025 at 09:55 AM of the back medication room revealed that the refrigerator temperature log for the medications was out of range 25 of 26 days of March 2025. The log reflected the temperatures ranged from 28 degrees Fahrenheit to 32 degrees Fahrenheit. On 03/26/2025 the temperature was observed in the fridge at 28 degrees when visually checked. At the time of the observation, the fridge contained insulin pens. During an observation on 03/26/2025 at 11:55 AM of the front medication room revealed that the refrigerator temperature log for the medications was out of range 24 of 24 days of March 2025. The log reflected the temperatures ranged from 28 degrees Fahrenheit to 31 degrees Fahrenheit. On 03/26/2025 the temperature was observed in the refrigerator at 28 degrees when visually checked. At the time of the observation, the refrigerator contained insulin pens. During an interview on 03/26/25 at 11:55 AM DON stated that it was the night nurse's responsibility to check the carts and the temperatures of the medication refrigerators. She also stated they had recently implemented a Performance Improvement Project to ensure the refrigerators' temperatures were consistently monitored. The DON stated that the negative outcome for having medications stored below their recommended storage temps could lead to the medications being compromised and losing their efficacy. During an interview with the Pharmacist on 03/26/2025 at 4:30 PM he stated the refrigerator/freezer combos tended to be harder to control and tended to run colder. When the refrigerators were thawed, they tend to get colder. He had not ever seen anything in there frozen during his monthly inspections. He stated his first recommendation would be to replace the thermometers to ensure accurate readings. Additionally, he stated he believed the med's in the refrigerators were still safe and the integrity of med's was intact. Record review of the facility policy titled, Storage and Expiration Dating of Medications and Biological's revealed the following: 16. Facility should ensure medications and biological are stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges and manufacturer guidance. 16.2 Refrigeration: 36-46 [degrees] F or 2-8 [degrees] C.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. - Moldy and rotten food was present during inspection of the walk-in refrigerator. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on [DATE] at 9:15 am of the walk-in refrigerator reflected the following: - Potatoes that were dated [DATE] had green sprouts growing from the potato. - The lunch meat dated [DATE] was expired. - Diced chicken was dated [DATE] with no discard date. - 15 Sandwiches dated [DATE] had no discard date. - Ranch dressing was not in the original container, dated [DATE], with no discard date. - Grated cheese was not in the original container, dated [DATE], with no discard date. - Grated cheese was not in the original container, dated [DATE], with no discard date. - Tomato soup was not in the original container, dated [DATE], with no discard date. - Was an unknown drink in the refrigerator with a name and no date. An observation of the pantry on [DATE] at 9:25 am reflected the following: - A loaf of bread on the shelf that had no open date or discard date on the bag. During an interview on [DATE] at 10:25 AM, the KC said a sheet in the kitchen told them how long an item could be kept in the refrigerator before it must be thrown out. The KC said prepared food should not be kept in the fridge for more than 7 days and should have an expiration date. The KC said the refrigerator was checked regularly for moldy food. The KC said that if expired food was used, residents could get sick. Interview on [DATE] at 10:35 AM, KC said that when food is received, it will have an expiration date on the package. The KC said that outdated food should be thrown away immediately. Prepared food cannot stay in the fridge for more than ,d+[DATE] days before it must be thrown out. The KC said that if residents were to eat expired food, they could get sick. Interview on [DATE] at 10:45 AM, the DM said that prepared food in the fridge should have an open date and an expiration date on the container. The DM said out-of-date food should be thrown out. The DM said all the food in the kitchen should be dated. The DM said that food in the refrigerator should be checked daily for out-of-date products. The DM said that residents can get sick if outdated food is used to feed the residents. Interview on [DATE] at 1:15 PM the ADM said that all food in the kitchen should be dated. The ADM said that prepared food in the refrigerator should be labeled with an expiration date. Food that has expired should be thrown in the trash. If the residents are served outdated or moldy food, they could get sick. Record Review Will O Bell Policy & Procedure Manual on [DATE] at 2:20 PM. Will O Bell Food Storage Policy Statement: Storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free of contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. 13 f. All foods should be covered, labeled, dated, and routinely monitored to assure that foods, including leftovers, will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on interview and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for one of one resident reviewed. The facility failed to submit a NFSS form request by the specific deadline for Resident #2 for a pressure reducing mattress and a motorized wheelchair. This failure could place residents at risk of not receiving or benefiting from specialized equipment they may require. Findings included: Record review of Resident #2's Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Muscle weakness (generalized), Muscle wasting and Atrophy, and Unsteadiness on feet. Record review of the MDS dated [DATE] revealed that Resident #2 was PASARR positive, and her Cognitive status was rated with a BIMS of 2. The MDS also revealed recommendation for the resident to be provided with a pressure reducing device for the bed due to her risk for developing pressure ulcers. Record review of Resident #2's Baseline Care Plan of 07/01/2024 revealed she needed assistance with mobility and had the risk for the development of pressure ulcers. In an interview with the ADM on 03/26/2025 at 3:08PM she confirmed that the request for the medical equipment should be submitted by the 20th day after the Interdisciplinary Team meeting in which the resident's needs were identified. In an interview with the MDS Coordinator on 03/27/2025 at 11:27AM, the MDS Coordinator stated the process for implementing the recommendations from the IDT was as follows: once a determination of need was made, the DOTS was to contact the DME. The DME was then responsible for getting any measurements needed and estimating a price. Once the information was received, the DOTS was to enter the information in the PASARR portal. She stated failure to enter the information in a timely manner could result in the resident not receiving the approved medical equipment. In an interview with the DOTS on 03/27/2025 at 11:45 AM he stated he did notify the DME of the recommended medical equipment; however, he did not keep any written documentation of the contacts. He also stated he was aware that he did not enter the required request for the equipment in a timely manner. He stated the failure could result in the resident not receiving the optimal equipment in a timely manner.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #38) reviewed for PASARR Level 1 screenings. The facility failed to notify the local authority of the PASARR I screen for Residents #38. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a Face Sheet dated 03/25/25 for Resident #38 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy); anoxic brain damage non else classified (a catastrophic and potentially fatal injury characterized by the brain's complete deprivation of oxygen. It distinguishes from hypoxic brain injuries, where oxygen flow to the brain is reduced); other psychoactive substance abuse with psychoactive substance induced psychoactive disorder unspecified (is characterized by hallucinations and/or delusions due to the direct effects of substance or withdrawal from substance in the absence or delirium); type 1 diabetes mellitus with ketoacidosis without coma (a serious complication of diabetes that occurs when the body can't produce enough insulin). Record review of Resident #38's diagnosis report revealed that he was diagnosed with alcohol abuse, in remission on 3/28/18 and psychoactive substance abuse with psychoactive substance induced psychoactive disorder unspecified on 04/19/18. Record review of Resident #38's Quarterly MDS dated [DATE] revealed a BIMS score of 00 which indicated a severe impairment in section C. Record review of Resident 38's care plan dated 03/01/2023 revealed a focus that Resident #38 had a behavior problem if kicking and shouting r/t brain damage: anxiety disorder, depression and psychotic disorder (with a goal to have fewer episodes of kicking and shouting by the review date. Interventions in place were to anticipate and meet the resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Record review of Resident #38's PASARR Level 1 Screening dated 06/19/21 indicated the resident did have a Mental Illness, Intellectual Disability, or Developmental Disability in section C. During an interview with the MDS Coordinator on 03/27/2025 at 11:27AM, she stated failure to enter the PASARR request in a timely manner could result in the resident not receiving the services needed to have a productive life. During an interview with the DOTS on 03/27/2025 at 11:45 AM he stated not submitting the PASARR in a timely manner to the local authorities, this failure could result in the resident not receiving services. During an interview with the Administrator on 03/26/2025 at 3:08 PM she confirmed that the request should be submitted by the 20th day after the Interdisciplinary Team meeting in which the resident needs were identified. If the request is not submitted, it can cause the resident not to receive the services they need. The facility stated they did not have a PASARR policy as they follow the policy and procedure per Health and Human Services Commissioner website.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of four residents reviewed for quality of care. The facility failed to: - Ensure Resident #1 was not sitting in his bed with linens covered in feces and his pants saturated with urine. The staff failed to complete accurate skin assessments to be able to provide appropriate treatment to MASD on his buttocks. - Ensure Resident #2 was getting barrier cream applied to a rash on her buttocks and failed to complete accurate skin assessments. These failures placed residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and a decreased quality of life. Findings included: Resident #1 Review of resident #1's face sheet dated 08/01/24 reflected an [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE], and readmitted on [DATE] with a with diagnoses that included chronic kidney disease stage 3, cognitive communication deficit, and hereditary and idiopathic neuropathy (when the causes of the nerve damage interferes with the functioning of the peripheral nervous system can't be determined) Review of Resident #1's most recent MDS assessment, dated 07/16/2024 for add new record, reflected a BIMS score of 05, indicating he was severally cognitively impaired. Section GG (Functional Abilities and Goals) were left blank. Section M (Skin Conditions) reflected he was at risk of developing pressure ulcers/injuries and had a pressure reducing device for his bed and chair. Review of Resident #1's care plan focus dated 02/24/21, reflected Resident #1 had an ADL self-care performance deficit r/t impaired balance, weakness, hypotension, debility, spinal stenosis (the space inside the backbone is too small with interventions dated 02/24/21 that resident required extensive assistance by 1 staff for toileting, encouraged the resident to use bell to call for assistance, monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Review of care plan focus dated 06/22/23 reflected the resident has had a fall (unintentional change in plane) with minor injury r/t poor balance and unsteady gait with interventions dated 02/24/21. That resident required extensive assistance by 1 staff with personal hygiene, the resident required skin inspection Q shower day, and PRN to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The resident required extensive assistance by 1 staff for toileting, the resident required extensive assist by 1 staff with bathing/showering Q Mon, Wed, Fri 2p-10p, and as necessary. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected he required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of Resident #1's Skin Observation Tool dated 07/11/24 reflected skin warm, dry, and intact. No skin issues noted. Review of Resident #1's Skin Observation Tool dated 07/17/24 reflected skin warm, dry, and intact. No skin issues noted. Review of Resident #1's Skin Observation Tool dated 7/31/24 reflected skin warm, dry, and intact. No skin issues noted. Review of Resident #1's shower sheets dated 07/03/24 reflected no skin concerns, clean linens, and shaved, 07/05/24 reflected clean shaved, changed linen, no skin comment, 07/10/24 reflected no comments, 07/12/24 reflected showered, hair washed, resident shaved, linen changed, no skin issues, 07/15/24 reflected shower, no comments, 07/17/24 reflected showered no skin issues, sheets changed, 07/24/2024 reflected showered, no skin comment, 07/26/24 reflected showered no additional comments, and 07/31/24 reflected showered no additional comments. Review of Resident #1's shower sheets dated 07/16/24 reflected showered, no skin comment, 07/18/24 reflected showered, no skin comment, 07/23/24 reflected, everything look good, 07/25/24 reflected showered everything look good, and 08/01/24 reflected showered, no skin issues. Review of Braden Scale for Predicting Pressure Sore Risk, dated 07/09/24, revealed a score of 21 indicating Resident #1 was a very high risk for pressure sores. Observation on 08/01/24 at 1:18 pm of Resident #1 revealed he was in his room seated on his bed close to the end of the bed. Observed sheets unmade and bunched around Resident #1. Bottom sheet towards the middle of the bed revealed a brown colored circular stain approximately 6 inches in diameter. Resident #1 was Spanish speaking, limited in his English but able to communicate with basic English and gestures. The State Surveyor pointed at his sheets and asked, can I look and Resident #1 nodded. Upon lifting the bunched top flat sheet from the bottom fitted sheet the state surveyor observed, on the bottom fitted sheet, a square shaped brown stain approximately 6 inches in length and 4 inches in width. The flat top sheet was lifted from the fitted lower sheet and revealed a square shaped brown stain approximately 4 inches in length and 2 inches wide. The State Surveyor, with no objection from Resident #1, separated the bunched top flat sheet from the lower fitted sheet to reveal a lump of feces on the lower flat sheet, firm with a stain that secreted around the upper top flat sheet, and the lower fitted sheet. The State Surveyor observed the sweatpants worn by Resident #1 were saturated with urine. Observation on 08/01/24 of a photograph provided by a family member of Resident #1's posterior taken 07/14/24 revealed Resident #1s buttock to be red approximately 6 inches from the bottom of his buttock to the top of his buttock to 3 inches below his buttock on his thighs. The State Nurse investigator traveled to the facility on [DATE] and 08/03/24 for Resident #1's skin assessment but he was on leave with his family and an observation was not conducted but the redness appeared to be MASD. Interview on 08/02/24 at 2:29 pm with LVN revealed Resident #1 needed to be rounded on every hour or every two hours because he needed bathroom assistance. He needed to be constantly looked on because his sheets would be dirty. LVN revealed he could not use the call light and he needed to be checked on to see if he needed help. Attempted interview on 08/01/24 at 2:00 pm with Resident #1, Spanish speaking, through interpreter service was unsuccessful. Resident #1 revealed he could not hear or understand the interpreter, although the resident was on the speaker and the interpreter was asked to speak loudly because of resident hearing issues. Resident #2 Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified urinary incontinence, need for assistance with personal care, obesity, and unspecified dementia. Review of Resident #2's quarterly MDS assessment, dated 05/01/24, reflected a BIMS score of 8, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent for toileting hygiene. Section M (Skin Conditions) reflected she was at risk of developing pressure ulcers/injuries and had a pressure reducing device for her bed. Review of Resident #2's quarterly care plan, dated 01/05/24, reflected she had potential for pressure ulcer development related to limited mobility and weakness with an intervention of educating the resident/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements, importance of taking care during ambulating/mobility, and good nutrition and frequent repositioning. It further reflected she had an ADL self-care performance deficit related to dementia with an intervention of requiring limited assistance by 1 staff for toileting an Q 2-hour checks. Review of Resident #2's Skin Observation Tool, dated 07/25/24, reflected her skin was warm, dry, and intact. No issues noted. Review of Resident #2's Skin Observation Tool, dated 07/31/24, reflected her skin was warm, dry, and intact. No issues noted. Interview on 08/01/24 at 4:08 PM, Resident #2 stated she was often left for long periods of time in a soiled, wet brief. Observation and assessment on 08/02/24 at 10:28 am by the State Nurse Investigator revealed Resident #2 gave her permission to observe her skin while CNA A turned her, lifted her clothing, and unfastened her brief. Resident #2's skin was observed head to toe. Observed Resident's skin was clear except for slight rash under bilateral breasts and red area across buttocks which appeared to be irritation from sitting in urine, possibly even the start of Moisture Associated Skin Damage (MASD). Observed Resident #2 was sitting in a urine-soaked brief. No evidence of cream on Resident #2's buttock area. CNA A stated there should have been cream applied to her buttock area. Interview on 08/02/24 at 10:28 am by the State Nurse Investigator with CNA A revealed when they find skin issues, they go tell the nurse, and if the nurse says to, they will put cream on the skin area. Interview on 08/05/24 at 12:51 pm with the DON, when shown the photos of the stains and feces in Resident #1's bed she said it looked like the feces had been there a bit, but she could not tell how long. It was unacceptable. She stated that the Administrator has had conversations with Resident #1's family members about Resident #1 being found with feces on him and in his bed. If residents have feces in their bed or on their bodies, it was a dignity issue, it was an infection control issue, and residents could get sick. She stated that if residents were left in soiled or wet briefs and clothing, they could have skin breakdown. She said she did not know what the issue was with her staff that they did not check on him. When shown the photograph provided by a family member of Resident #1's posterior taken 07/14/24 that revealed Resident #1s buttock, she said that there should have been treatment in place for is skin issues on 07/14/24. Review of facility policy routine resident checks dated 07/2013 reflected staff shall make routine resident checks to maintain resident safety and well-being. Routine resident checks involve entering the residents' room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, and needs toileting assistance, etcetera. Review of facility bath/tub policy dated 02/2018 reflected the purpose of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for medications. The facility failed to ensure Resident #1 was discharged home without two of Resident #2's medications (Trazadone and Tegretol). This deficiency put residents at risk of consuming unprescribed medications, harm, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic myelomonocytic leukemia (cancer of the blood-forming cells of the bone marrow), acute pulmonary edema (buildup of fluid in the lungs), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected a BIMS of 9, indicating a moderate cognitive impairment. Section N (Medications) reflected he was taking an antidepressant. Review of Resident #1's quarterly care plan, dated 01/25/24, reflected he had impaired immunity related to cancer with an intervention of monitoring/documenting/reporting PRN any s/sx of infection. Review of Resident #1's physician orders, on 04/23/24, reflected he did not have an order for Tegretol or Trazodone. Review of Resident #1's Discharge Summary, dated 03/07/24 and completed by RN B, reflected his admission diagnoses, disposition (where he went), condition on discharge, discharge diagnoses, and prognosis. No medications were documented. Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, insomnia (trouble sleeping), stroke, vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain), and unspecified convulsions. Review of Resident #2's quarterly MDS assessment, dated 04/15/24, reflected a BIMS of 7, indicate a moderate cognitive impairment. Section N (Medications) reflected he was taking an antidepressant. Review of Resident #2's quarterly care plan, dated 02/08/24, reflected he used antidepressant medication related to depression and insomnia and had a seizure disorder related to a stroke with interventions of giving medications as ordered. Review of Resident #2's physician order, dated 11/04/21, reflected Tegretol 200 MG - give 1 tablet by mouth two times a day related to unspecified convulsions. Review of Resident #2's physician order, dated 09/13/23, reflected Trazodone HCl Oral Tablet - give 75 mg by mouth at bedtime related to major depressive disorder. During a telephone interview on 04/23/24 at 10:58 AM, Resident #1's FM A stated he was discharged home on 03/07/24 in the late afternoon. She stated when they were leaving, RN B handed her a plastic bag of his medication. She stated once she got home, she realized she knew nothing about the medications or when he was supposed to be administered them, so she went back to the facility. She stated RN B wrote either AM or PM on the blister packs and verbally told her what the medications were. She stated she did not write anything down for her. She stated while going through the medications at home, FR C noticed that Resident #2's name was on two of the medications. She stated she was appalled she had been given someone else's medication and was happy she had not given any to Resident #1. She stated she immediately called the facility and RN B came and picked up the two blister packs. Observation of pictures provided by FM A, on 04/23/24 at 11:15 AM, revealed two blister packs of medication, Trazadone and Tegretol, with Resident #2's name on the top. During an interview on 04/23/24 at 11:34 AM, the DON stated her expectation of nurses upon a resident discharge was they reviewed their medications with them and their RP. She stated the nurses should hand-write all medications and when they were to be administered. She stated the resident and/or RP and the nurse should sign the medication list and a copy should be given to the resident and/or RP. The DON was asked if she was aware of the incident that occurred on 03/07/24 with Resident #1 regarding medications. She stated she had not. Once informed she stated she was extremely shocked and stated she would have expected RN B to have notified her immediately. She stated a resident receiving/administering medication that was not prescribed to them could lead to some very serious outcomes. She stated she was going to start in-servicing nursing staff right away. During an interview on 04/23/24 at 11:48 AM, RN B stated she remember it being a very chaotic evening on 03/07/24. She stated she remembered going over with Resident #1's FM A the medications, doses, and times, but must have missed verifying the name on the medications. She stated not long after they left the facility, FM A came back and wanted her to explain the medications for her, in which she did. She stated she provided her with a list of the medications. She stated about 30 minutes later, FM A called and told her there were two medications that did not belong to Resident #1 mixed in with his medications. She stated she could not believe it, but when she got to Resident #1's home, there were two medication cards that belonged to Resident #2. She stated she should have notified the DON but she just forgot. She stated she felt awful because someone could take the wrong medications, somebody could go without their prescribed medications, or someone could have been hurt. During an interview on 04/23/24 at 1:29 PM, the NP stated she expected nurses to reconcile medications with their orders before sending them home with residents. She stated it was only common sense to verify what was on their MAR versus what was in your hand. She stated negative outcomes of receiving/taking the wrong mediation could be altered mental status, passing out, falling, sedation, or death. Review of the facility's in-service, dated 04/23/24 and conducted by the DON, reflected nursing staff were in-serviced on the facility's policy for discharge mediations. Review of the facility's Discharge Medications Policy, revised March of 2022, reflected the following: Unless otherwise specified by facility policy, or contrary to current law or regulation, medications shall be sent with the resident upon discharge. Controlled substances may not be released to the resident upon discharge. . 5. The nurse shall review medication instructions with the resident, family member or representative before the resident leaves the facility. 6. The nurse shall complete the medication disposition record, including: a. the resident's name .

Based on interview and record review, the facility failed to include effective communications as mandatory training for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to provide CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA M's personnel record had a hire date of 07/15/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA P's personnel record had a hire date of 01/01/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of FSS's personnel record had a hire date of 05/21/07, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated she was not aware of all the required inservice topics but the facility would ensure these were completed in the future.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 5 residents (Resident #7, #46, and #13) reviewed for indwelling urinary catheter care, in that: 1. Resident #7's indwelling urinary catheter drainage bag was on the floor. 2. Resident #46's indwelling urinary catheter drainage bag was on the floor. 3. Resident #13's indwelling urinary catheter drainage bag was on the floor. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #7's face sheet, dated 2/9/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included urinary tract infection, abnormalities of gait and mobility, hydronephrosis (condition characterized by excess fluid in a kidney due to a backup of urine), and retention of urine. Record review of Resident #7's most recent quarterly MDS assessment, dated 1/1/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and required an indwelling urinary catheter. Record review of Resident #7's comprehensive care plan, revision date 8/30/23 revealed the resident had an indwelling urinary catheter related to urinary retention with a goal for the resident to remain free from catheter-related trauma and interventions that included to provide catheter care as ordered. Record review of Resident #7's Order Summary Report, dated 2/9/24 revealed the following orders: -replace foley (indwelling urinary) bag every night shift every Sunday for infection control with order date 7/22/21 and no end date. -foley care every shift for foley catheter with order date 7/4/21 and no end date. -Insert 16 French foley catheter, 10 cc balloon by aseptic technique into urethral meatus as needed related to retention of urine with order date 7/22/21 and no end date. Observation on 2/9/24 at 8:00 a.m. revealed Resident #7's indwelling urinary catheter drainage bag was on the floor on the left side of the bed in full view of the hallway. 2. Record review of Resident #46's face sheet, dated 2/9/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in consciousness caused by diffuse or global brain dysfunction), gastrointestinal hemorrhage (bleeding of the digestive tract), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #46's most recent quarterly MDS assessment, dated 1/21/24 revealed the resident was severely cognitively impaired for daily decision-making skills and required an indwelling urinary catheter. Record review of Resident #46's comprehensive care plan, revision date 3/6/23 revealed the resident had an indwelling urinary catheter related to urinary retention with a goal the resident would be free from catheter related trauma and interventions that included to monitor and document for pain/discomfort due to catheter and provide catheter care as ordered. Record review of Resident #46's Order Summary Report, dated 2/9/24 revealed the following order: -Change foley bag every Sunday for infection control every night shift with order date 2/27/23 and no end date. -Change foley catheter, 16 French every month, every day shift for urinary retention with order date 2/27/23 and no end date. Observation on 2/9/24 at 8:00 a.m. revealed Resident #46 in bed and the indwelling urinary catheter drainage bag was on the floor on the right side of the bed in full view of the hallway. 3. Record review of Resident #13's face sheet, dated 02/09/24 revealed a [AGE] year old female admitted to the facility 03/20/23 with diagnoses that included urinary tract infection, acute cystitis with hematuria (bladder inflammation with bleeding), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problem), major depressive disorder (mood disorder), Type 2 Diabetes Mellitus (chronic health condition that affects how body turns food into energy) without complications and multiple sclerosis (a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything). Record review of Resident #13's Care Plan with date initiated on 03/28/23, revealed resident has a suprapubic catheter due to neurogenic bladder. The interventions included change suprapubic catheter as ordered, measure output q (every) shift, and monitor for s/sx (signs/symptoms) of discomfort on urination and frequency. Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. On 02/06/24 at 11:22 am, Resident #13 was observed from the hallway asleep in her bed. Her catheter bag was observed to be hooked on her low bed and touching the floor. The catheter bag was not in a privacy bag. An observation and interview on 02/07/24 at 11:30 AM revealed Resident #13's catheter bag on the floor with a privacy bag. LVN D, who was working just outside Resident #13's room, was asked to observe the catheter on the floor and was interviewed. LVN D said the catheter should not be touching the floor due to the potential for an infection control issue. LVN D was asked what could be done to prevent the catheter bag from touching the floor since the bed needed to be in the low position. LVN D then obtained a small plastic basin and placed the catheter bag in it to prevent it from coming in contact with the floor. During an observation an interview on 2/9/24 at 8:02 a.m., CNA A stated Resident #7 and Resident #46's indwelling urinary catheter drainage bag should not have been on the floor due to a sanitary issue. CNA A further stated the indwelling urinary catheter drainage bag could result in the bag being snagged on something or leak and again stated it was just not sanitary. CNA A revealed the CNA staff were responsible for ensuring the indwelling urinary catheter drainage bag was placed in a dignity bag, off the floor and draining by gravity. During an interview on 2/9/24 at 8:34 a.m., the DON revealed it was the expectation of the facility to ensure the indwelling urinary catheter drainage bags should not be on the floor, even when placed in a dignity bag, because the resident could get a urinary tract infection and if the indwelling urinary catheter drainage bag was on the floor it was also an infection control issue. The DON stated it was everybody's responsibility to ensure the indwelling urinary catheter drainage bags were kept off the floor. Record review of the facility policy and procedure titled, Catheter Care, Urinary, revision date August 2022 revealed in part, .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . 41095

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 5 of the food and nutrition service staff reviewed for competency training in that: The facility did not ensure the DM, Cook W, Cook X, DA Y or DA Z had current food handlers training. The DM's food handler's certificate had an expiration date of [DATE] with a start date of [DATE]. Cook W's food handler's certificate had an expiration date of [DATE] with at start date of [DATE]. Cook X's food handler's certificate had an expiration date of [DATE] with a start date of [DATE]. DA Z's food handler's certificate had an expiration date of [DATE] with a date of [DATE]. The deficient practice could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. The finding included: Interview on [DATE] at 12:05 p.m. with the DM, the DM stated all of the kitchen's staff training was expired, their training should have already been completed but it was not and mine is expired too. No other state inspector looks at the stuff you look at, I have been here for years and no one has ever asked me for these certificates. DM also stated there are other staff in the kitchen that only wash dishes and are not required to have the food handlers course, I only gave you the ones that should have the training. Interview on [DATE] at 4:27 p.m. the ADMN stated, I am aware of all but one of the kitchen staff's food handler's certificate was expired. The ADMN went on to say the expectation was for all kitchen staff to have the required trainings and it should have been up to date, each individual should keep up with when their training was due and make sure it was done. Then the ADMN explained there should be a system, the individual should first make sure their training was current, the DM should be checking, HR should be reviewing that and the facility pays a dietician and consultant that was supposed to be monitoring that as well. Interview with HR on [DATE] at 6:02 p.m. said, I was not taking care of making sure that the Dietary Department was up to date with their training, the DM usually does those, but I will probably be keeping up with that from now on after all of this happened. We do not have a policy and procedure for how to monitor dietary staff training. Record review of USDA Food Code 2022, Chapter 8 Compliance and enforcement reflected the following: By the time of the preoperational inspection, operating procedures for training should include definitive practices and expectations of how the management of the proposed food establishment plans to comply with paragraph ,d+[DATE].11(N) of this Code which requires the person in charge to assure that food employees are properly trained in food safety as it relates to their assigned duties.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen areas in that: There were items in the kitchen that were not dated, not labeled with a date, not labeled with a name, ingredients or contents of packaging, and damaged kitchen spatulas. In addition there were only unpasteurized eggs in the kitchen that had been reportedly served with runny middles to residents. A cook failed to ensure eggs served soft fried with runny middle were pasteurized for 2 residents. These failures could place residents at risk for foodborne illness. The findings included: Observation in the kitchen on 02/06/2024 at 9:26 a.m. revealed: One large bag of cheese cubes opened exposing the contents of the bag to other odors in the refrigerator. One large approximately 5-gallon container of a white substance identified by Cook X as thickener with no label or date and opened, in the kitchen under a preparation table. One large bag of a substance later identified as processed chicken in the freezer with no label or date of any type anywhere on the clear manufacture's bag. During an interview with Cook X on 02/06/2024 at approximately 10:00 a.m, Cook X said she should not have served unpasteurized eggs with runny middles to any of the residents and she knew this, but she did not want the residents to get upset and wanted them to have the eggs the way they wanted them. Cook X said she did know if eggs were going to be served with runny middles she was supposed to use pasteurized eggs, but the facility didn't have any and it would probably be several days before they got anymore. Cook X said all the items observed should have been labeled and dated, she did not know why they were not and explained the training says they are supposed to be labeled. Cook X said the rubber spatulas should not be used because they could get bad stuff in the cracks and make someone sick, and then took them down from the hanging area. During a follow up interview with the DM on 02/06/2024 at 11:15 a.m., the DM said all items in the kitchen should be labeled and dated in some way and damaged tools (the rubber spatulas) shouldn't be used if they have cracks in them because stuff can get stuck in the cracks or bacteria can grow in them and that would not be good. When asked about the use of unpasteurized versus pasteurized eggs when serving eggs not cooked until solid, the DM stated Cook X knows better and she said she told you that, I have no idea why she did that we can go to the store and get some if we need them, there is just no excuse for that at all. Policy provided prior to facility exit titled, Food Storage chapter 3 not dated revealed the following: Sufficient storage facilities will be provided to keep foods safe, wholesome and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 8. Plastic containers with tight -fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk food or opened packages. All containers or storage bags must be legible and accurately labeled and dated.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #3, #30 and #57) reviewed for infection control practices, in that: 1. LVN D did not utilize appropriate hand hygiene during the medication pass to Resident #3 2. Med Aide T did not sanitize the blood pressure cuff used between Resident #30 and Resident #57 These failures could place residents at risk of infection, transmission of communicable diseases and a decline in health. The findings included: 1. Record review of Resident #3's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease state 3 (kidneys are damaged and can't filter blood the way they should), peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #3's most recent annual MDS assessment, dated 12/15/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #3's comprehensive care plan, revision date 1/8/24 revealed the resident had diabetes with interventions that included to monitor for hyperglycemia (increased blood sugar levels) and hypoglycemia (low blood sugar levels). Observation on 2/7/24 at 11:05 a.m., during the medication pass, revealed LVN D grabbed Resident #3's wheelchair and assisted the resident from the dining room to the resident's bedroom. LVN D then returned to the medication cart and obtained the glucometer (a test device used to obtain a rapid assessment of blood glucose concentration results) to prepare to take a blood sample. LVN D took a sanitizing wipe and cleaned the glucometer. LVN D then put on a pair of gloves, did not utilize appropriate hand hygiene and obtained a small blood sample from Resident #3's second finger with a small lancet. LVN D was not successful in obtaining a blood sample from Resident #3 and returned to the medication cart for another test strip. LVN D continued to wear the same gloves, returned to the bedside and obtained a second blood sample from Resident #3. During an interview on 2/7/24 at 11:27 a.m., LVN D revealed he was nervous and realized he did not utilize appropriate hand hygiene prior to obtaining the small blood sample from Resident #3. LVN D stated he should have been washing or sanitizing his hands before putting on gloves because it was considered cross contamination and the resident could get sick. During an interview on 2/8/24 at 11:37 a.m., the DON stated, after Resident #3 was assisted to her room, LVN D should have been sanitizing his hands prior to getting the supplies and should have been sanitizing his hands prior to putting on gloves. The DON stated the reason for washing or sanitizing the hands before putting on gloves was to stop the spread of infection and was considered an infection control issue. The DON stated, not utilizing proper hand hygiene could result in the resident getting an infection. 2.a. Record review of Resident #30's face sheet, dated 2/8/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, heart failure, shortness of breath and hyperlipidemia (high cholesterol). Record review of Resident #30's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #30's comprehensive care plan, revision date 9/16/23 revealed the resident had coronary artery disease with interventions that included to monitor blood pressure and notify the physician of any abnormal readings. b. Record review of Resident #57's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Record review of Resident #57's most recent quarterly MDS assessment, dated 1/12/24 revealed the resident was moderately cognitively intact for daily decision-making skills. Record review of Resident #57's comprehensive care plan, revision date 4/25/23 revealed the resident had coronary artery disease with interventions that included to give medications for hypertension and document response to medication and any side effects. Observation on 2/8/24 at 8:49 a.m., during the medication pass revealed Med Aide T took the wrist blood pressure cuff from the medication cart and obtained Resident #30's blood pressure but did not sanitize the blood pressure cuff prior to use. Med Aide T, after obtaining Resident #30's blood pressure, returned to the medication cart and placed the wrist blood pressure cuff on the medication counter without sanitizing it. Med Aide T then used the same wrist blood pressure cuff used on Resident #30 and obtained Resident #57's blood pressure. During an interview on 2/8/24 at 9:15 a.m., Med Aide T revealed the wrist blood pressure cuff used on Resident #30 and Resident #57 was not provided by the facility and was her own personal equipment. Med Aide T confirmed she had not sanitized the wrist blood pressure cuff prior to using it on Resident #30 or before using it on Resident #57. Med Aide T stated the wrist blood pressure cuff should have been sanitized/disinfected prior to use on a resident because it would mean potentially spreading germs from one resident to the other and was cross contamination. Med Aide T further stated an example of cross contamination would be using the wrist blood pressure cuff on a resident with COVID-19 and if not sanitized could spread COVID-19 (a severe acute respiratory syndrome also known as SARS-COV-2) to another resident. During an interview on 2/8/24 at 11:37 a.m., the DON revealed it was her expectation when a blood pressure cuff was used on a resident it should be sanitized prior to use to prevent the spread of infection. The DON further revealed, cross contamination could result in a resident getting sick or getting an infection. Record review of the facility policy and procedure titled, Handwashing/Hand Hygiene, revision date April 2012 revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infection .When to use Alcohol-Based Hand Rub .before donning sterile gloves .before preparing or handling medications .after contact with objects in the immediate vicinity of the resident and after removing gloves . Record review of the facility policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revision date September 2022 revealed in part, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Non-critical items are those that come in contact with intact skin but not mucous membranes .include .blood pressure cuffs .Reusable resident care equipment is decontaminated and/or sterilized between residents .

Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 4 Halls (Hall #2 and Hall #3) reviewed for environment in that: 1. The bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and had several pieces of wood missing and the bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and was partially covered in black duct tape. 2. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: During a joint observation and interview on 2/9/24 at 4:07 p.m. with the MD (Maintenance Director) and the Administrator revealed Resident room [ROOM NUMBER] on Hall #2 could have resulted in the bedroom door having splintered edges and several pieces of wood missing from the resident's bed having been moved a couple of weeks ago. The MD stated the facility was built in 1963 and the bedroom door seen in Resident room [ROOM NUMBER] was the same door. The MD and the Administrator acknowledged the splinters could cause injury to a resident if their body came in contact with the splinters. The MD stated the purpose of the duct tape seen on Resident room [ROOM NUMBER]'s door on Hall #2, Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] on Hall #3 was to keep splinters from sticking out and if the splinters were sticking out they could poke a resident. The door on room [ROOM NUMBER] had been repaired with a metal strip along the side of the door where it had been frayed. The MD further stated, the doors needed to be fixed and had been addressed but then we got COVID, and it went on the wayside. The Administrator stated, I feel we need to do something, it's not a decent environment. The Administrator further stated the facility used an electronic notification maintenance system, but staff were not reporting the situation anymore because the doors had been that way for a while. The Administrator acknowledged the doors were not conducive to a homelike environment. 41095

Based on interview and record review, the facility failed to provide required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 7 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD). The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated she was not aware of all the required inservice topics but the facility would ensure these were completed in the future.

Based on interview, and record review, the facility failed to provide resident abuse prevention training to 4 of 18 staff reviewed including CNA K, CNA L, CNA O, and CNA Q. The facility failed to ensure that 4 of 18 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated that abuse prevention training was included in the initial orientation training for new staff as well as during the year.

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to ensure that quality assurance and performance improvement training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately informed staff regarding goals for care as identified by the QAPI committee and could result in a decline in health and well-being. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA M's personnel record had a hire date of 07/15/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA P's personnel record had a hire date of 01/01/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN R's personnel record had a hire date of 20/20/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of FSS's personnel record had a hire date of 05/21/07, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. The list did not include QAPI training.

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 14 staff (CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD. This failure could place residents at risk of illness due to lack of staff training. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of MA N's personnel record had a hire date of 02/07/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN S's personnel record had a hire date of 08/22/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of AD's personnel record had a hire date of 04/28/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. The list included 2 opportunities for training for infection prevention and control but the staff listed above did not attend either one.

Based on interview and record review, the facility nursing staff failed to immediately notify the physician of a significant change in the resident's physical status for 1 of 2 residents reviewed for an unknown injury (Resident #2) LVN B and RN A failed to immediately notify Residents' Physician when a large bruise was discovered on his ankle, which was discovered to be a fracture. This failure may have resulted in Resident #2 experiencing pain from a fracture for 4-5 days. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT x-ray was ordered by nurse. Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source. Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record.

Based on interview and record review, the facility staff failed to report to the administrator and/or designee, physician, and failed to investigate an injury of unknown source for 1 of 2 (Resident #2) reviewed for incident reporting. LVN B and RN A failed to reported an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT x-ray was ordered by nurse. Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source. Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. #2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4.) the incident of injuries over time. # 3. Documentation shall include information relevant to the risk factors and conditions that could cause or predispose someone to similar signs and symptoms (e.g., receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement, etc ) Any descriptions in the medical record shall be objective and sufficiently detailed (e.g., size and location of bruises), and should not speculate about causes. #4 The nursing staff shall discuss the situation with the attending Physician or Medical Director to consider whether medical conditions or other risks factors could account for the findings . Continued review revealed a section titled Reporting Abuse to Facility Management, which includes; it is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source and theft or misappropriation of resident property to facility management.

Based on interview and record review, facility staff failed to immediately, or within 2 hours, report injuries of unknown source to the administrator and/or designee and to other officials for 1 of 2 residents reviewed for an injury of unknown origins (Resident #2) LVN B and RN A did not report an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on 04/27/2023. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated 6/8/2019, revealed the following focus: The resident has a Hx (history) of bone fracture to lower end of R (right) femur and has an old Fx (fracture) to R tibia (lower leg bone) r/t (related to) Osteoporosis. The focus was last updated on 10/07/2020. The interventions listed for the focus area include monitoring, documenting, and reporting as needed for edema, bruising/discoloration of skin, skin temperature changes and loss of sensation below fracture. Review of a Skin Observation Tools for Resident #2 dated 9/30/23, revealed the treatment nurse (RN A) documented a bruise to the right ankle. Continued review of the tool revealed the sections designated to size measurement were blank. Review of the Facility Incident Reports from 7/1/2023 through 10/7/2023 revealed on 10/4/23 a report written by LVN A indicated that Resident #2 had approached the nurse after breakfast at 0800, pointing to his right lower extremity (RLE) (Resident is nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When asked if he was experiencing pain? Resident #2 shook his head no. When asked by LVN A if he had fallen? Patient shook his head no. Resident #2's RP and NP were notified. STAT x-ray was ordered by nurse. Review of a Radiology Report dated 10/4/23. Reason for exam Contusion of right ankle, initial encounter, contusion of right lower leg. Results: There is diffused bone demineralization. There is an impacted fracture deformity involving the medial malleolus (ankle) without callus (healing tissue around fracture). Distal fibula ( 2nd lower leg bone) appears grossly intact as visualized on this limited positioned exam. Review of Resident #2's Nursing Notes from 9/29/23 thru 10/7/23 revealed no mention of a bruise to Resident #2's ankle until 10/4/23. LVN A documented at 9:57 am the following: Resident approached nurse after breakfast at 0800, pointing at his RLE (Resident nonverbal). Upon inspection, nurse noticed bruise to Tib/Fib area. When patient was asked if he was experiencing pain? Patient shook his head no. When asked by nurse if he had fallen? Patient shook his head no. V/S 128/54, 62, 17, 97.2. RP, NP notified. STAT x-ray was ordered by nurse. Review of Resident #2's hospital records revealed an Attestation by MD on 10/6/2023 at 7:12am. Impression Right minimally displaced distal tibia/fibula fracture in non-ambulator. Plan: No surgery indicated. The fracture will be treated in a closed manner. X ray imaging results noted a evaluation is significantly limited due to severe osteopenia (reduced bone mass). Review of Resident #2's Treatment Administration Record for the month of September 2023 revealed there is no mention of bruise to ankle. Continued review of October 2023 TAR revealed an order dated 9/30/2023 to, Monitor bruising to right ankle for any changes until resolved every day shift. On 10/1 through 10/4 there are initials of RN A indicating monitoring took place. Interview on 10/7/23 at 12:46pm Resident #2's Responsible Party (RP) stated he was informed by the facility of the injury. He did not know how it happened but realized that the day before he had been notified of the fracture, he had visited Resident #2 to feed him lunch. The RP stated during that visit Resident #2 kept pointing to his right leg. The RP stated Resident #2 does do pointing frequently, so that does not always indicate an injury, but he wonders how long the injury was there before they found it. The RP stated that Resident #2 did not act like he was in pain during his visit, but he usually does not indicate pain. The RP stated there is a history of fractures as Resident #2 has weak bones. Interview on 10/7/23 at 11:07 am with LVN A revealed that on 10/4/23 he noticed that Resident #2 pointed to his right leg while he was talking to him. LVN A stated he lifted Resident #2's pant leg and noticed a bruise that he had not been aware of. LVN A stated he is aware that Resident #2 has a history of brittle bones and fractures, so he notified the NP got orders for a STAT X-ray and notified Resident #2's RP. LVN A stated the bruise was purple and reddish, so it was not an old bruise. The X-rays showed a fracture and Resident #2 had sent to the hospital and is still there. Interview on 10/7/23 at 4:20pm with LVN B revealed she was the Charge Nurse on 9/30/23 when a CNA asked her if she knew about a bruise on Resident #2 . LVN B stated at the same time she was walking in Resident #2's room RN A, who is the Treatment Nurse was coming into the same room. LVN B stated that RN A told her she would assess the bruise. LVN B stated she asked Resident #2 if he was in pain, and he said no. She noticed an approximately one-inch bruise on the side of Resident #2's foot but was not able to remember all the details about it because she left it to RN A to assess. LVN B stated RN A told her she had added monitoring to the Treatment Administration Record to occur daily . LVN B stated she had not asked RN A if she notified the doctor of the injury. Interview on 10/9/23 at 9:30am with RN A Treatment Facility Nurse, revealed on 9/30 she had put in a standing order to monitor Resident #2's bruise. RN A stated she saw the bruise on Friday the 29th of September. RN A stated on that Friday, the charge nurse (LVN B) called me over and asked if I had seen the bruise on Resident #2's ankle. RN A stated she had not seen the bruise before LVN B pointed it out. RN A stated she did not measure the bruise but did make a Skin Tool note on 9/30/23, the day after seeing the bruise and put an order in to monitor. RN A confirmed she did not know the cause of the bruise . RN A confirmed she had not notified the Nurse Practitioner (NP) or Doctor of the bruise. RN A stated she had received counseling from the DON and realizes she should have measured and described the bruise, made an IR, called the doctor and RP. RN A stated she had assumed at the time that LVN B was notifying the doctor and documenting in the progress notes. She stated she should not have made that assumption. When asked if she could estimate the size or show with her hands, RN A placed her hands fingertip to fingertip and held her hands apart to make a circular shape. She stated it was right over Resident #2's right ankle. When asked if the area she was making with her hands was about 4-5 inches she confirmed it was. RN A stated it was a significant injury. She stated she does not know if the bruise was related to the fracture but at the time she saw it, she asked Resident #2 if he was in pain, and he indicated he was not. RN A stated the area was not swollen. Interview on 10/7/23 at 10:58 am CNA C revealed she has worked at the facility for 4 years. She stated she works with Resident #2 frequently. CNA C revealed he is a two person transfer but there are times that he will get out of his low bed by himself because he wants to play by with his toys. CNA C stated Resident #2 is nonverbal, but he can make is needs known with pointing and grunting. She stated she became aware of the fracture on 10/4/23, when x-rays were taken and that prior to that Resident #2 had not complained of pain. Interview on 10/7/23 at 11:55 am with CNA D, she stated she has worked with Resident #2 for a little over a year. CNA D stated that she has not worked on Resident #2's hall in a while but she does still see him in the halls. CNA D stated the day before the fracture was found Resident #2 had passed her as he was going to an activity. CNA D stated Resident #2 was pointing to his right leg area, so she touched his foot and said here? Resident #2 shook his head yes and she thought he wanted her to scratch him because of itching like he usually does she stated she scratched his foot and asked him all better and he said yes. CNA D stated he did not indicate he was in pain; she did not see a bruise and that in the past he has indicated pain by making an ow ow sound, but he had not done that. Interview on 10/7/23 at 3:40 pm, the Facility DON revealed she had thought Resident #2's injury was first recognized on 10/4/23 when the LVN A discovered it and got orders for an x-ray. She stated she asked several staff to write out statements for an investigation into the injury of unknown origins. RN A who is the Facility Treatment Nurse, wrote that she had seen a bruise on 9/29/23 after the Charge Nurse (LVN B) had pointed it out to her. The DON stated that neither RN A or LVN B reported the injury to her, the Doctor or the NP as was expected. The DON confirmed that there also was no size of the bruise documented as it should have been on 9/29/23 . The DON stated that the statement by RN A was written on 10/6/23 and that is when she found out it was either the same bruise where the fracture is or another. On 10/9/23 at 9:15am the DON reported that she had written disciplinary actions for LVN B and RN A due to their failure to report the bruise to the NP or Doctor. She stated that she had spoken to both and the verbal descriptions, although described in different but similar areas on Resident #2, by the two different nurses, indicate a significant injury which is supposed to be reported. Interview on 10/9/23 at 11:08am with the Facility NP revealed she had been notified for the first time of Resident #2's injury/bruise on 10/4/23 when LVN A reported the need for x-rays. The NP stated that she should have been notified of the bruise that was found on 9/29/23 or 9/30 but was not. She stated Resident #2 has osteoporosis, so his bones are dry. Review of the Facilities Policies and Procedures revealed a policy titled Change in Resident's Condition or Status, revised 2/2021, includes on pg 1, #1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of unknown source. Continued review revealed an Abuse policy, revised 12/2009, contained a section titled Investigating Unexplained Injuries, which includes a policy statement: An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation, #1. includes the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record.

Based on interview, and record review, the facility failed to ensure a resident's environment remained as free of accident hazards for (Resident #1) one resident reviewed for transfers. The staff failed to ensure Resident #1 was transferred without a Hoyer lift, resulting in an anterior right shoulder dislocation with associated comminuted fracture. This failure put the residents at risk for falls and injury. Review of Resident #1's face sheet, dated 07/10/2023, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses of hypertension, anemia, kidney disease, and dementia. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 04 indicating a severe cognitive impairment. Further review of the MDS revealed a bed mobility of extensive assistance with two plus person set up, and a transfer of total dependence with two plus persons set up. Review of Resident #1's care plan, undated, revealed a focus Resident #1 has an ADL self-care performance deficit, with a goal to maintain current level of function in ADLS, and intervention for transfers revealing Resident #1 required total dependence by 2 staff using Hoyer lift for all CNA transfers to move between surfaces as necessary. Review of Resident #1's ADL plan of care in the ADL flowsheet, dated 06/08/2023, revealed transfers: total dependence x 2 person assist (using Hoyer lift). Review of Resident #1's progress notes, dated 06/23/2023, revealed Resident #1 noted her arm was hurting a little bit on 23:15 (11:15 p.m.) staff assessed and treated Resident #1. Further review revealed a stat order for mobile x-ray to be performed. The progress notes revealed the x-ray report indicated Resident #1 has a dislocation of right anterior shoulder, the doctor was notified, and orders were obtained to give Resident #1 Tramadol 100 mg. Resident #1 was sent to the hospital for further treatment. Review of Resident #1's medical records, dated 06/28/2023, revealed an x-ray to the shoulder, result 1. Acute anterior right shoulder dislocation with associated comminuted fracture through the surgical neck and greater tuberosity. Review of the facility reported incident investigation's interviews, dated 06/26/2023, revealed CNA A's statement in that she was working with CNA B on Resident #1, CNA B arrived to assist CNA A to get Resident #1 out of the chair, CNA B did not state she needed a Hoyer lift. CNA A stated this was her first time working at the facility, and she was following CNA B's lead as CNA B stated she was working there for a while. Review of the facility reported incident investigation's interviews, dated 06/26/2023, revealed CNA B's statement, on 06/23/2023 CNA B and CNA A assisted Resident #1 to her bed, stating they slid her on the bed. CNA B revealed that she did not know Resident #1 required a Hoyer lift. CNA B stated, I hate this happened to Resident #1 we were only trying to help transfer her back into bed. Interview on 07/10/2023 at 09:40 a.m., the DON revealed CNA A and CNA B were agency staff. The DON revealed during the facility's investigation CNA B admitted she transferred Resident #1 without a Hoyer lift. The DON revealed all agency staff are oriented to the facility with an agency staff checklist. The DON revealed agency staff are oriented by the off going CNA including a tour of the facility and are walked to assigned hall and briefly review any concerns or appointments with residents. The DON stated the outgoing CNA was to orient the agency CNA to the ADL flowsheet. DON added there is more than likely a chance that the injury occurred during the transfer, as the CNA admitted that they did not use a Hoyer lift and the resident afterwards complained of pain. DON added that CNA A and CNA B were called to the facility to complete in-services after the incident, they did not show, this is one of the reasons why they were listed as DNR (do not return) to the agency company. Interview on 07/10/2023 at 10:11 a.m., the ADM revealed CNA B did a transfer without a Hoyer lift, the ADM revealed that during the investigation the Hoyer lift was in Resident #1's room, ADL flowsheets instructing Resident #1 was a 2 plus person assist with a Hoyer lift, and CNA A and CNA B have both been oriented to the facility. The ADM revealed CNA A and CNA B are in do not return DNR to the facility status. Interview on 07/10/2023 at 10:37 a.m., CNA C stated that there is an agency book that is located at the nurse's station for agency staff to sign, this is used to familiarize the agency staff to our residents and their needs, all agency staff must sign and the CNA that is that is informing the agency staff must report and acknowledge agency staff have been informed. CNA C stated she is aware that Hoyer transfer are always needing 2 or more staff members and should never be done alone. CNA C stated that the ADL books for residents are located at every hallway, it is in a binder on the wall. Interview on 07/10/2023 at 10:43 a.m., LVN A stated Resident #1 needs a Hoyer lift requiring 2 plus persons. LVN A stated she was not here at the time of the incident with Resident #1. LVN A stated that agency staff are to check in and sign the agency checklist, the outgoing CNA will do a standard walkaround with incoming CNAs to give information on residents that staff are assigned to, they are to discuss continuation of care, whether it would be showers, check and change, meals, and how residents are to be transferred. LVN A stated that all staff, including agency, are informed to ask any and all questions about residents. LVN A stated that all staff should be aware to not do transfers alone, LVN A states she always tells her staff to call whenever needed, and she will always be available if there is need for assistance, and to always use a Hoyer lift for all residents. Observation on 07/10/2023 at 10:57 a.m., revealed location of agency staff checklist for facility at nurses station, and further observations on each hallway revealed ADL flowseet binder for residents in all hallways. Further observation reveled Resident #1's ADL plan of care in the ADL flowsheet, dated 06/08/2023, revealed transfers: total dependence x 2 person assist (using Hoyer lift). Observation on 07/10/2023 at 11:28 a.m., was made on CNA D and CNA E for a resident transfer using a Hoyer lift. The Hoyer lift was in good working condition. CNA D and CNA E followed procedure for a two person assist for using a Hoyer lift. Observations confirmed a successful transfer. Interview on 07/10/2023 at 11:39 a.m., CNA D and CNA E stated that they are familiar with which residents require a Hoyer lift but they always have to confirm with the ADL sheet for residents, if staff are not aware, or if they are new, there is an ADL flowsheet folder located in every hallway for all residents. CNA D and CNA E displayed knowledge of location, and identified area for ADL Flowsheet, staff added that Hoyer transfers are always completed with 2 plus persons, no matter what, CNA D stated that there are many risks, such as dropping a resident or hurting a resident during a transfer. CNA E added that if a Hoyer lift is not used, this can hurt the resident and even hurt the employee, such as hurting their back by lifting. CNA D and CNA E both stated that all agency staff are to acknowledge and sign the agency staff checklist, and the outgoing CNA is required to orient the incoming CNA with resident rounds on the hallway. CNA D added that this is how we communicate to staff what needs to be done and how procedures are to be done. Observation on 07/10/2023 at 01:38 p.m., was made on CNA F and CNA G for a resident transfer using a Hoyer lift. The Hoyer lift was in good working condition. CNA D and CNA E followed procedure for a two person assist for using a Hoyer lift. Observations confirmed a successful transfer. Interview on 07/10/2023 at 2:07 p.m., CNA F stated that all Hoyer transfer are done by two staff, CNA F added there are no exceptions, and If you are alone do no attempt a transfer by yourself and to always ask for help, CNA F stated you can ask another CNA or a nurse to help. CNA F stated that regular staff are familiar with residents and their needs, but we must always check the ADL sheet for residents which is located in a binder on every hallway for our residents. CNA F added that the sheet has all the information for a resident, such as how to transfer, feeding information, showers days, and any preference of the residents. CNA F stated she recalls informing CNA A on how to transfer Resident #1 as she was the staff leaving, CNA F added she informed CNA A of where the Hoyer lift was located at, and did a demonstration how to use it, she added that she informed CNA A on all the residents in the hallway, informing CNA A on the details needed to care for the residents. Attempted interview on 07/10/2023 at 2:33 p.m. to CNA B, the line was answered, after introduction there was no response from the receiving end, the call then ended in the receiver's side. At 2:35 p.m. a second attempt was made to call CNA B, there was no answer, an option was given to leave a voice message and a message was left for a return phone call. Attempted interview on 07/10/2023 at 2:37 p.m. to CNA A, there was no answer, an option was given to leave a voice message and a message was left for a return phone call. At 2:40 p.m. a second attempt was made to call CNA A, there was no answer, an option was given to leave a voice message and a second message was left for a return phone call. Review of the facility reported incident investigations correspondence with agency, dated 06/28/2023, revealed CNA A status was do not return, description failure to follow plan of care/ADL flowsheet for elder. Review of the facility reported incident investigations correspondence with agency, dated 06/28/2023, revealed CNA B status was do not return, description failure to follow plan of care/ADL flowsheet for elder. Review of the facility's agency staff checklist, dated 05/18/2022, revealed CNA B signed and acknowledge to: screen at kiosk at front door, sign in at front nurses station and report to front charge nurse, PCC (point click care) log in info, front charge nurse will escort to assigned call and introduce to offgoing CNA, off going CNA will orient agency CNA to facility including a brief tour of facility (show agency location of both nurses stations, activity room, dining room, bathrooms, supply rooms, linen carts and linen room break room), offgoing CNA is to walk assigned hall with agency and briefly review any concerns or appointments with elders, offgoing CNA is to orient agency CNA to ADL flowsheet and activity calendar. Further verbiage states to turn in the form to charge nurse at end of shift. Review of facility's policy lifting machine, using a mechanical, revised July 2017, revealed general guidance 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 resident (Resident #1) reviewed for accidents and supervision. The facility failed to ensure the resident was assessed upon admission to the facility to determine if he was safe to smoke independently. The resident started a fire in his room. The facility failed to follow interventions to keep resident staff by supervising resident while he was smoking. An Immediate Jeopardy (IJ) situation was identified on 06/07/2023. While the IJ was removed on 06/12/2023 at 11:30 AM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk of smoke inhalation, burns, loss of property and could affect residents by placing them at risk of serious injury when residents were not supervised when smoking. The findings were: Record review of Resident #1's face sheet, dated 06/07/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, mood disorder due to known physiological condition with depressive features, and persistent mood [affective] disorder, unspecified. Record review of the admission MDS for Resident #1, dated 04/26/2023, reflected a BIMS score of 8 which indicated moderate cognitive impairment. Record review of the care plan for Resident #1, dated 03/01/2023, reflected the following: The resident was a smoker. Resident #1 started a fire in his room r/t violating the smoking policy. Resident #1's care plan goal was resident would not suffer injury from unsafe smoking practices. Resident was informed that supervised smoking was now mandatory and to notify the charge nurse if unsafe smoking techniques were present. Observation on 06/07/2023 at 11:00 AM of Resident #1 outside of the facility alone, with no residents or staff member, smoking and in possession of a lighter. Observation on 06/07/2023 at 11:00 AM revealed HA approached Resident #1 in the company of the State Surveyor and HA took the lighter from Resident #1 and returned it to the building leaving the State Surveyor with the resident who was smoking alone with no facility staff supervision. In an interview on 6/12/2023 at 9:59 AM with CNA A revealed on 03/01/2023 she was alerted by a housekeeper, who looked anxious and said fuego (fire) and pointed to Resident #1's room. When CNA A got to Resident #1's room, Resident #1 was holding a pillow that was ignited. CNA A revealed she grabbed the pillow and threw it to the floor, grabbed a cup that contained water from the bedside table and threw the water on the pillow, ran to get the fire extinguisher from the wall in the hallway and when she returned, the fire had smoldered out. A lighter was found on Resident #1's bed. CNA A stated she was absolutely sure Resident #1 lit the pillow on fire and he was the only one in the room. CNA A revealed Resident #1 did not have a roommate. In an interview on 06/12/2023 at 11:00 AM with Resident #1, he revealed he did not light a pillow on fire and the incident did not happen. When asked if he was alone outside smoking, he said there was a staff member with him, but the staff member went inside and had not come out yet and did not know if she was going to come back out. Resident #1 said it was not unusual for him to be outside smoking without a staff member. Resident #1 stated he lit his cigarette with his lighter. An interview on 06/12/2023 at 2:25 PM with the ADM revealed the facility had not had any fire drills for the year 2023 and on 06/07/2023 LSC issued the facility a citation for not having fire drills. Record review of Resident#1's care plan reflected no smoking safety assessment completed for Resident #1 upon admission. Record review of Resident #1's Smoking - Safety Screen, dated 03/01/2023, revealed Resident #1 started a fire in his room on 03/01/2023 due to cognition issues. Resident #1 was noted to have had cigarettes and ashes in his room on two different occasions. Record review of Resident #1's Smoking - Safety Screen, dated 06/01/2023, revealed Resident #1 was not safe to smoke independently at this time. Record review of the facility's, undated, policy Record of Drills revealed the facility shall maintain a record of all drills that it conducts. Record review of the facility Smoking Policy, dated 08/2022, revealed any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. This was determined to be an Immediate Jeopardy (IJ) on 06/07/2023 at 11:46 AM and the ADM and DON were provided notified and provided the IJ Template. The following Plan of Removal submitted by the facility was accepted on 06/09/2023 at 11:46 AM: Statement F689 The facility failed to have adequate supervision to prevent potential accidents. The notification of the immediate jeopardy states as follows: On June 7, 2023, around 8am, an abbreviated survey was initiated at (facility). On June 7, 2023, at 7:45pm the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to have adequate supervision to prevent potential accidents. Action: Root Cause Analysis: Elder does not remember, Family and Friends bring in cigarettes and lighters, Elder is from this town and has extended family and friends that might not be informed of rules. The investigation revealed that the Elder reported that his nephew brought the cigarettes, and his sister left the lighter the last time she visited. At a careplan meeting on June 8, 2023, the Responsible Party who is the Elder's son, stated he has informed the nephew and the sisters, and known visitors to NOT bring any smoking materials at all to the Elder. The facility policy of no smoking materials in the Elders' room is part of the Admission Packet and a notice of this policy is placed on the front door and front nurses' station for Elder, Visitors and Carepartners to view. Start Date: 06/07/2023 Completion Date: 06/08/2023 Responsible: Administrator Action: To prevent the Elder from smoking alone or having smoking material on his person, we notified the Elder and family and friends and Inserviced carepartners of the smoking policy. Informing all that Elder is now a scheduled supervised smoker. Elder should not be outside smoking without supervision of staff. Elder is not allowed to have smoking materials in his room per policy. To prevent Elder from smoking alone or in his room, all smoking materials are kept in the locked medication room. Start Date: 06/07/2023 Completion Date: 06/08/2023 Responsible: Director of Nursing Action: When we first learned that Elder was smoking outside unsupervised, we checked with the Nurses and Medaides who had access to his cigarettes to identify who gave him smoking materials and allowed him to go out and smoke unsupervised. No staff provided any smoking materials. So, then the Social Worker Assistant called the Ombudsman to get them involved to protect the Elder's rights and left two messages on 6/7/2023 and another on 6/8/2023. Since the Ombudsman did not return our call, we sent a copy of the Discharge Notice to the Ombudsman via fax on 6/8/2023. Next, we called the son and informed him that the Elder was currently outside smoking with smoking materials that were not checked out at the nurse's station and that we needed to search the Elder's side of the room to see if there were any smoking materials. The son who is the responsible party gave permission. When the Elder returned from smoking, we asked if we could search his room and he gave verbal approval. The roommate and the Elder then went to lunch while the room was cleaned. The smoking material found in the room was confiscated and will be returned to the responsible party per the smoking policy. The social worker visited with the Elder and the roommate to inform both that the room will be checked on a daily basis to look for smoking materials and obtained written permission from both. Start Date: 06/07/2023. Completion Date: 06/08/2023 Responsible: Activity Assistant and Housekeeping Supervisor Action: Fire Drills were performed on all shifts, 2p-10p, 6a-2p, and 10p-6a starting on 6/7/23 thru 6/8/23. Fire Drills will be repeated again next week on all 3 shifts, then monthly on all 3 shifts until the QA committee reviews in September of 2023. The Fire Drills are recorded on HHSC Form #4719. Start Date: 06/07/2023 Completion Date: 06/08/2023 Responsible: Administrator and Maintenance Supervisor Action: Visual safety checks of the Elder will be performed by nursing staff and documented every 15 minutes to ensure the Elder is safe and not violating the smoking policy. The Charge Nurse is responsible for checking the room daily until resolved. This plan will be reviewed weekly to determine if anything needs to be adjusted. All carepartners have been inserviced on the visual safety checks and the daily room checks. Start Date: 06/07/2023 Completion Date: 06/09/2023 Responsible: Nursing Action: Careplan with Family and Elder to discuss concerns and safety and discharge: Note Text: Care plan meeting held at this time, elder attended and son, via phone conference), DON, Administrator, SW, SWA, and this nurse attended, concerns addressed r/t elder smoking against policy guidelines, elder is supervised smoker- now is scheduled supervised smoking from 9am to 9pm, approximately every 2 hours to be supervised by the Charge Nurse or the person he/she designates. Elder states that he chooses not to follow a smoking schedule- Elder asked to discharge to another facility. And the social worker will assist Elder in finding safe placement, son is in agreement on elder discharging due to elder not agreeing to follow a safe smoking schedule, elder is to be on supervised smoking schedule which is posted in his room and at the nurse's station from 9am to 9pm, approximately every 2 hours, to be supervised by the charge nurse or his/her designee until discharge to another facility and all smoking apparatuses to be kept at nurses station and son is informed not to bring elder any smoking supplies and son states that he will inform friends and family to do the same, continues with Q 15 min visual safety checks, SW to refer elder to another facility. The Supervised Smoking schedule is posted in the Elders room. The smoking schedule is approximately every 2 hours between 9am and 9pm. The Carepartners, Elder, family, and friends have been educated on the policy. Staff were inserviced on paper by the Director of Nursing and electronically by the Administrator of the supervised smoking schedule. The charge nurse or his/her designee is responsible for making sure it gets done. Resident #1 discharged on [DATE] at his request. Start Date: 06/07/2023 Completion Date: 06/08/2023 Responsible: MDS Nurse, DON, Administrator, SW and Assistant, Elder and Responsible Party Action: Because the Elder refused to comply with the safety plan, the QAPI Team agreed to issue a 30-day discharge notice to the Elder, with copies to the medical director, Texas Department of Aging Ombudsman, and Regional Director of Operations. A 30-Day Discharge Notice has been provided to the Elder, Responsible Party, and Ombudsman. The Social Worker is working with the Elder to discharge to the place of his choice or to the home of the responsible party within 30 days. His Right to Appeal is included in the Discharge Notice. Elder is planning to move on 6/9/2023. Start Date: 06/08/2023 Completion Date: 06/09/2023 Responsible: Administrator Monitoring of the Plan of Removal from 06/07/2023 - 06/12/2023 included the following: Interview on 06/08/2023 at 12:50 PM with Resident #1 who revealed he wanted to leave the facility because they would not allow him to smoke as much as he would like to. Interview on 06/09/2023 11:38 am with Resident #1's son and responsible party who revealed his father wanted to go another facility. In interviews from 06/09/2023 through 06/12/2023 with one HA, one medication nurse, one CMA, one LVN, one housekeeper, and two CNAs stated they participated in in-service fire drills, felt comfortable that they understood the fire drill procedures and the different responsibilities assigned to staff in different areas and were able to describe what action should be taken during the event of a fire to protect the residents. Record review of discharge notice, dated 06/08/2023, to Resident #1 notified him of his right to appeal, included ombudsman contact information, and a carbon copy sent to resident's physician, resident's responsible party, and the ombudsman. Record review of the in-service dated 06/07/2023, for all personnel revealed Resident #1 was a supervised smoker and should not be outside smoking without supervision and to report to the charge nurse if staff saw Resident #1 outside smoking or found Resident #1 with cigarettes or lighter. Record review of the in-service dated 06/08/2023, for all personnel revealed Resident #1's lighter was to be kept locked in the medication room at the nurse's station and cigarettes and lighters were to be returned to charge nurse at front nurses' station. Record review of 15-minute lighter check for Resident #1, dated 07/07/2023, beginning at 7:45 PM and ending at 11:45 PM. Record review of 15-minute lighter check for Resident #1, dated 06/08/2023, beginning at 6:15 AM and ending at 11:45 PM. Record review of 15-minute lighter check for Resident #1, dated 06/09/2023, beginning at 12:00 AM and ending at 1:15 PM. Record review of the Fire Drill Report dated 06/07/2023 at 8:15 PM, for shift 2:00 PM - 10:00 PM. Record review of the Fire Drill Report dated 06/08/2023 at 9:08 AM, for shift 6:00 AM - 2:00 PM. Record review of the Fire Drill Report dated 06/08/2023 at 10:45 PM, for shift 10:00 PM - 6:00 AM. Record review of the Fire Drill Report dated 06/10/2023 at 10:37 AM, for shift 6:00 AM - 2:00 PM. Record review of the Fire Drill Report dated 06/10/2023 at 2:33 PM, for shift 2:00 PM - 10:00 PM. Record review of the in-service training dated 06/09/2023 for all personnel revealed if time did not allow for a Hoyer lift transfer, all beds in facility fit through the residents' doors and resident should be moved out of room in bed. Record review of the in-service training, dated 06/09/2023 for all personnel, written in Spanish and English, revealed if time did not allow for a Hoyer lift transfer, all beds in facility fit through the residents' doors and resident should be moved out of room in bed. The ADM and DON were informed the Immediate Jeopardy was removed on 06/12/2023 at 11:30 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for one (1) of two (2) residents reviewed for pain management (Resident #5) during wound care. Resident #5 expressed pain by grimacing, tensing up, and shaking her head during wound care for a Stage III pressure ulcer on her sacrum and left buttocks, a Stage II pressure ulcer to her left heel, a diabetic ulcer to her left ankle, and a suspected deep tissue injury to her right ankle. The resident had not been assessed for pain prior to treatment. Resident #5 received wound care on four ( 4) days without receiving narcotic pain medication prior to the wound care as ordered by the physician. This deficient practice contributed to ineffective pain control for Resident # 5 and had the potential to place the 4 other residents identified with pressure ulcers at risk for inadequate/ineffective pain management during wound treatment. Findings included: Review of Face Sheet dated 7/22/13 reflected Resident # 5 is a [AGE] year-old women admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident # 5 is not interviewable and does not have family involvement in her care. Review of the Nursing Admission Screening/History dated 9/26/13 reflected that the resident was readmitted to the facility from the hospital. admitting [DIAGNOSES REDACTED]. Resident was noted to have skin breakdown to buttocks, right outer ankle, left heel has fluid filled blister, and old wound to left outer ankle. Review of Resident # 5's handwritten physician orders [REDACTED]. Review of Resident # 5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident # 5 also received [MEDICATION NAME] 325 mg two (2) tablets every 4 hours as needed for pain or fever. Review of Resident # 5's physician's orders [REDACTED]. Observation on 10/01/13 at 11:10 am revealed wound care provided for Resident #5 by Registered Nurse (RN) A for the Diabetic ulcer of the left ankle measuring 0.8 centimeters (cm) x 1.3 cm x 0.1 cm, a pressure sore on the right ankle measuring 3.5 cm x3.5 cm x 0 cm, a Stage II pressure sore on the left heel measuring 3.4 cm x 2 cm x 0 cm, a Stage III pressure sore on her sacrum measuring 8.5 cm x 3.4 cm x 0.1 cm, and a Stage III pressure sore to the left buttocks measuring 1.1 cm x 1 cm x 0.1 cm. RN A did not ask the resident if she was having any pain. The resident was tensed up and grimaced each time RNA touched her sores. Resident # 5 also shook her head when the pressure sores on her sacrum and buttock were cleaned. During an interview on 10/01/13 at 11:20 am when asked by this surveyor if the resident had been pre-medicated prior to the wound care RN A replied that she is on scheduled pain medications and always grimaces and tenses up during treatment. RN A continued that when she " sees tears, she knows she (Resident # 5) is hurting.. " Review of Resident # 5 ' s pain assessment dated [DATE] reflected that E. Indicators of Pain or Possible Pain 5. None of these signs observed or documented F. Frequency of Indicator of Pain or Possible Pain Left blank G. Pain Management 1. Received scheduled pain medication regimen? 1a. [MEDICATION NAME] (a opioid [MEDICATION NAME] that is a scheduled III narcotic used for severe pain) 10/325 milligrams (mg) po (by mouth) QID (four times a day) 4. Comments: Resident has pressure ulcer to Lt (left) ankle and drsg (dressing)to rt (right) lateral foot-Dressings changed daily and PRN (as needed). CNA (Certified Nurse Aide) to change dressing 30 minutes after administration of pain meds-bilateral booties intact. Review of Resident #5 ' s Minimum Data Set ((MDS) dated [DATE] reflected Staff Assessment for Pain included Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) and Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement. MDS also reflected resident at risk for developing pressure ulcers. Review of Resident #5 ' s Care Plan most recently revised on 10/01/13 did not include pain management as one of the resident problems. The Resident ' s Care Plan did include the diabetic ulcer on the left ankle, but pain was not addressed in the plan. The Care Plan did not include the other Pressure Sores that were acquired at the hospital. Review of Resident # 5 ' s MAR indicated [REDACTED]. [MEDICATION NAME] was restarted on 10/1/13 at midnight. Review of Resident # 5 ' s MAR indicated [REDACTED]. This order was initialed as given on 9/30/13 at 4:50 pm and 8:21 pm, and 10/1/13 at 9:18 am, and 10/2/13 at 12:12 am (midnight). Review of Resident # 5's MAR indicated [REDACTED] 1. Santyl Ointment [MEDICATION NAME] Clostridiun Hist (Histolyticum) Cleanse left outer Ankle with Normal Saline (NS) pat dry, apply Santyl to slough in wound bed, apply Collagen to wound (don't overlap Collagen outside of woundbed) activate with NS, cover with gauze, secure with [MEDICATION NAME]. This order was initialed as complete on 9/27/13, 9/29/13, 9/30/13, and 10/1/13. 2. Cleanse right buttock with NS pat dry apply collagen and duodern change q 72 hours. This order was initialed as complete on 9/30/13. 3. [MEDICATION NAME]-iodine Cleanse Left heel with NS, pat dry, paint blister with bedadine , cover with foam dressing QD (every day). This order was initialed as complete on 9/27/13, 9/29/13, 9/30/13, and 10/1/13. 4. Clense Right lat (lateral) ankle with NS, pat dry, cover with foam dressing QD. This order was initialed as complete on 9/27/13, 9/29/13, 9/30/13, and 10/1/13. 5. Santyl Ointment [MEDICATION NAME] Clostridiun Hist (Histolyticum). Cleanse sacrum/buttocks with NS, pat dry, apply santyl to wound bed, cover with collegen and [MEDICATION NAME] Q72H (every 72 hours) This order was initialed as complete on 9/27/13 and 9/30/13. During an interview on 10/01/13 at 11:50 am Licensed Vocational Nurse (LVN) A stated that since Resident # 5 came back from the hospital on Thursday she has only been getting Tylenol for pain. LVN A continued that she just caught the missing order today. During an interview on 10/01/13 at 12:50 pm LVN A stated that she usually goes through their (resident ' s) orders when they are being readmitted and verify the orders with the Doctor I was not here the day she came back. LVN A continued that Resident # 5 has pain when you touch her wound. When asked by this surveyor what she would think if the resident was shaking her head and grimacing LVN A stated she is in pain. During an interview on 10/01/13 at 1:45 pm LVN A stated that she found a medication order dated 9/27/13 to resume the [MEDICATION NAME] 10/325 mg. The order was never transcribed or sent to the pharmacy. During an interview on 10/01/13 at 1:50 pm Assistant Director of Nurses (ADON) A stated that she would stop doing the treatment and assess for pain if the resident was shaking her head and grimacing. During an interview on 10/01/13 at 1:55 pm the Director of Nurses stated that she would expect her nurses to stop the treatment and assess for pain if the resident was grimacing and shaking her head. Review of facility policy " Pain-Clinical Protocol " dated April 2013 reflects 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. b. The staff will observe the resident (during rest and movement) for evidence or pain; for example, grimacing while being repositioned or having a dressing changed. Review of CMS 672 provided by facility reflected 4 residents with pressure ulcers. Resident #5 was not included in the list.

Based on interview and record review the facility failed to provide pharmaceutical services including not administering medications or accurately following the correct procedures for transcribing of all drugs to meet the needs of one (1) of 9 residents reviewed for medications. Resident #5 A. Licensed Vocational Nurse (LVN) A failed to administer physician ordered Hydrocodone-Acetaminophen 10-325 milligrams (mg) gel cap by mouth (po) four times a day (QID) for pain prior to wound care for Resident #5. B. The facility failed to transcribe Resident #5 ' s physician ordered Hydrocodone-Acetaminophen 10-325 mg gel cap po QID written on 9/27/13 to the pharmacy, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. These deficient practices contibuted to uncontolled pain for Resident #5 and had the potential to affect four (4) additional residents with pressure ulcers at risk for inadquate ineffective pain managerment during wound care. Findings include: Review of Resident # 5 ' s facesheet reflected a [AGE] year old woman admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident # 5 is not interviewable and does not have family involvement in her care. Review of the Nursing Admission Screening/History dated 9/26/13 reflected that the resident was readmitted to the facility from the hospital. admitting [DIAGNOSES REDACTED]. Resident was noted to have skin breakdown to buttocks, right outer ankle, left heel has fluid filled blister, and old wound to left outer ankle. Review of Resident # 5's handwritten orders reflected an order dated 9/27/13 for Hydrocodone-APAP 10-325 mg QID. Review of Resident # 5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Hydrocodone was restarted on 10/01/13 at midnight. Observation on 10/01/13 at 11:10 am revealed wound care provided for Resident #5 by Registered Nurse (RN) A for the Diabetic ulcer of the left ankle measuring 0.8 centimeters (cm) x 1.3 cm x 0.1 cm, a pressure sore on the right ankle measuring 3.5 cm x3.5 cm x 0 cm, a Stage II pressure sore on the left heel measuring 3.4 cm x 2 cm x 0 cm, a Stage III pressure sore on her sacrum measuring 8.5 cm x 3.4 cm x 0.1 cm, and a Stage III pressure sore to the left buttocks measuring 1.1 cm x 1 cm x 0.1 cm. RN A did not ask the resident if she was having any pain. The resident was tensed up and grimaced each time RN A touched her sores. Resident # 5 also shook her head when the pressure sores on her sacrum and buttock were cleaned. During an interview on 10/01/13 at 11:20 am when asked by this surveyor if the resident had been pre-medicated prior to the wound care RN A replied that she is on scheduled pain medications and always grimaces and tenses up during treatment. RN A continued that when she " sees tears, she knows she (Resident # 5) is hurting." Review of Resident # 5's physician's orders [REDACTED]. During an interview on 10/10/13 at 11:50 am LVN A stated that Since Resident # 5 came back from the hospital on Thursday she has only been getting Tylenol for pain. LVN A continued that she just caught the missing order today. During an interview on 10/01/13 at 12:50 pm LVN A stated that she usually goes through their (resident ' s) orders when they are being readmitted and verify the orders with the Doctor I was not here the day she came back. LVN A continued that Resident # 5 has pain when you touch her wound. When asked by this surveyor what she would think if the resident was shaking her head and grimacing LVN A stated she is in pain. During an interview on 10/01/13 at 1: 45 pm LVN A stated that she found a medication order dated 9/27/13 to resume the Hydrocodone 10/325 mg. The order was never transcribed or sent to the pharmacy. Review of the CMS form 672 reflected 4 residents with pressure ulcer Resident #5 was not listed.

Based on interview and record review, the facility failed to maintain accurate clinical records for one (1) of 9 residents reviewed for pain assessment documentation (Resident #5) when; Resident # 5's pain assessment dated [DATE] reflected that she was receiving [MEDICATION NAME] (a opioid [MEDICATION NAME] that is a scheduled III narcotic used for severe pain) 10/325 mg four times a day. Review of Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This deficient practice contributed to uncontrolled pain for Resident # 5 and had the potential to place the additional four (4) residents at risk for inadequate and ineffective treatment. Findings include: Review of Face Sheet dated 7/22/13 reflected Resident # 5 is a [AGE] year-old women admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident # 5 is not interviewable and does not have family involvement in her care. Review of the Nursing Admission Screening/History dated 9/26/13 reflected that the resident was readmitted to the facility from the hospital. admitting [DIAGNOSES REDACTED]. Resident was noted to have skin breakdown to buttocks, right outer ankle, left heel has fluid filled blister, and old wound to left outer ankle. Review of Resident # 5's handwritten physician orders [REDACTED]. Review of Resident # 5's MAR indicated [REDACTED]. Review of Resident # 5's physician's orders [REDACTED]. Observation on 10/01/13 at 11:10 am revealed wound care provided for Resident #5 by Registered Nurse (RN) A for the Diabetic ulcer of the left ankle measuring 0.8 centimeters (cm) x 1.3 cm x 0.1 cm, a pressure sore on the right ankle measuring 3.5 cm x3.5 cm x 0 cm, a Stage II pressure sore on the left heel measuring 3.4 cm x 2 cm x 0 cm, a Stage III pressure sore on her sacrum measuring 8.5 cm x 3.4 cm x 0.1 cm, and a Stage III pressure sore to the left buttocks measuring 1.1 cm x 1 cm x 0.1 cm. RN A did not ask the resident if she was having any pain. The resident was tensed up and grimaced each time RN A touched her sores. Resident # 5 also shook her head when the pressure sores on her sacrum and buttock were cleaned. During an interview on 10/01/13 at 11:20 am when asked by this surveyor if the resident had been pre-medicated prior to the wound care RN A replied that she is on scheduled pain medications and always grimaces and tenses up during treatment. RN A continued that when she "sees tears, she knows she (Resident # 5) is hurting." During an interview on 10/01/13 at 11:50 am Licensed Vocational Nurse (LVN) A stated that since Resident # 5 came back from the hospital on Thursday she has only been getting Tylenol for pain. LVN A continued that she just caught the missing order for [MEDICATION NAME]-APAP 10-325 mg today. During an interview on 10/01/13 at 12:50 pm LVN A stated that she usually goes through their (resident ' s) orders when they are being readmitted and verify the orders with the Doctor I was not here the day she came back. LVN A continued that Resident # 5 has pain when you touch her wound. When asked by this surveyor what she would think if the resident was shaking her head and grimacing LVN A stated she is in pain. During an interview on 10/01/13 at 1:45 pm LVN A stated that she found a medication order dated 9/27/13 to resume the [MEDICATION NAME] 10/325 mg. The order was never transcribed or sent to the pharmacy. Review of the Facility's CMS Form 672 reflected 4 residents with pressure ulcers resident #5 was not listed.

Based on observation, interview and record review, the facility failed to thoroughly assess for injury and pain in a timely manner in order to provide care and services to maintain the highest practicable physical, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 Residents reviewed for falls/fractures (Resident #16) when: Resident #16 fell in his room on 5/21/2011(Saturday) causing injury and pain to his right knee and leg. Nursing staff failed to assess Resident #16 when he continued to complain of pain that required the use of PRN (as needed) pain medication following the incident. Resident #16 was found to have a fractured Tibia and Fibula on 5/24/11. He was evaluated and treated at a local hospital on [DATE]. This deficient practice caused one (1) resident (Resident #16) un-necessary pain and suffering and could have contributed to complications associated with bone fractures such as Fat Embolism and Osteo[DIAGNOSES REDACTED] (an infection in the bone) 12 additional residents with a history of falls could be affected by this deficient practice. Findings Include: Review of the face sheet dated 3/18/11 reflected Resident #16 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. In an interview on 6/29/11 at 2:28 PM, Resident #16 stated he fell in his room on Saturday (5/21/11) and he was hollering for help and it must have been 15 to 20 minutes before anyone came to help. He stated that a whole bunch of people came into his room after that. He stated that he told them his right leg was hurting and someone looked at it. He stated that he was still complaining of pain on Tuesday (5/24/11). (Resident #16 complained of pain Saturday 5/21/11, Sunday 5/22, Monday 5/23, Tuesday 5/24 and Wednesday 5/25/11). He stated that they finally did an X-ray of his leg on Tuesday (5/24/11) and his leg was broken in two (2) places. He further stated that his leg was placed in a cast for three weeks. Review of a Fax to Resident #16 ' s Primary Care Physician dated 5/21/11 at 1:00 PM reflected Resident #16 became dizzy and fell on the floor. He complained of right knee pain. He was able to flex his knee and stand bearing weight. He states that he has been having dizzy spells but this is the first time he has fallen. Physician ' s reply (dated 5/24/11): Recheck Basil Metabolic Profile (BMP-Laboratory blood work). Review of Incident Report dated 5/21/11 (Saturday) reflected Resident #16 was ambulating with permission. He reported feeling dizzy and falling while ambulating in his room. He complained of pain in his right knee. The facility ' s measure to prevent re-occurrence was to instruct Resident #16 to use a walker for ambulating. The facility ' s fall investigation reflected Resident #16 had a history of [REDACTED]. Observation on 6/29/11 at 2:28 PM revealed Resident #16 was emotional and became anxious and tearful when explaining the incident to the surveyor. He stated there ' s not enough staff and they don ' t help you as soon as you need help. In a second Interview on 7/1/11 at 9:30 AM, Resident #16 was again tearful. He stated that the only time a nurse came in to assess his pain or his leg was when he initially fell on [DATE]." He stated that he went to visit his mother on 5/22/11 and had to return to the facility early to get pain medication. He stated that he couldn ' t enjoy his visit because his leg was hurting. Review of the Nurses ' Note dated 5/21/11(Saturday) at 11:45 AM reflected Resident #16 called staff to his room. He was lying on the floor by the bathroom door. He reported that he was using the restroom and was returning to his bed when he became dizzy and his legs " gave out " . He denied hitting his head or loosing consciousness. He complained of pain to his right knee but was able to bend it without difficulty. He was assisted to a standing position by two staff members and was able to ambulate but showed favor to his right leg. He requested a muscle relaxer for complaints of tight muscles in his right leg. Nurses ' Notes dated 5/21/11 at 5:00 PM reflected Resident #16 received two Tylenol 500 milligrams (mg) by the Medication Aide for complaints of " all over pain " . On 5/22/11 at 9:00 PM Resident #16 was [MEDICATION NAME](a muscle relaxant also used for muscular-skeletal pain) for complaints of leg pain. (This is a medication ordered prior to the incident for Diabetic [MEDICAL CONDITION] daily as needed). On 5/23/11 at 8:54 AM Resident #16 received two Tylenol 500 mg by the Medication Aide for complaints of right leg pain at a six on a scale of 1-10. On 5/24/11 at 8:44 AM Resident #16 was [MEDICATION NAME] mg by the Medication Aide for complaints of right leg pain. On the documented date of 5/25/11 at 4:30 PM (probable date of 5/24/11 based on the date of the X-ray) an order was obtained to X-ray Resident #16 ' s right knee and lower leg. At 8:30 PM (after business hours) the X-ray results were faxed to Resident #16 ' s Primary Physician. On 5/25/11 at 9:38 AM Resident #16 was [MEDICATION NAME] the Medication Aide for complaints of right lower leg pain. On 5/25/11 at 12:45 PM orders were received to transport Resident #16 to the local hospital for evaluation and treatment of [REDACTED]. Resident #16 was notified and agreed stating, " It has been hurting when I walk. " On 5/26/11 at 9:00 AM Resident #16 returned with an ace bandage on his right knee and a new order for [MEDICATION NAME] 50 mg every six hours as needed for pain. Nurses ' There was no documented nurses ' assessment of Resident #16 ' s right leg or his complaint of right leg pain from 5/21/11 (the date of his fall) through 5/25/11 (the date he was sent to the hospital for evaluation) in spite of his increased use of Tylenol [MEDICATION NAME] complaints of right leg pain. In an interview on 7/1/11 at 8:15AM LVN O (Charge Nurse on 5/21/11) stated that when Resident #16 fell he was in no distress and there was no swelling to his right leg. He was complaining of pain to his right knee but was able to bear weight and flex the joints in his right leg. She stated that there were no urgent issues at that time. She stated that when there is no injury to the resident she just faxes the fall report to the Physician. She stated that they telephone the Physician and the family if the resident bumps their head. She further stated that this was the first place that she had worked where they fax incidents to notify the Physician. She stated that she Faxed the report to Resident #16 ' s Physician on 5/21/11 but got no response that day. LVN O stated that the fax came back on 5/24/11 with a physician's order [REDACTED].#16 ' s Primary Physician was difficult to get a hold of. She stated that she did not know how to get a hold of Resident #16 ' s Primary Physician on the weekends. LVN O stated that she did not re-assess Resident #16 following the initial dose [MEDICATION NAME] he received following the incident. In a telephone interview on 7/1/11 at 9:10 AM LVN C stated that Resident #16 told her that he fell when he was coming out of the toilet and he said his knee and below his knee hurt. She stated that she checked his leg on 5/23/11 at 8:54 AM when the Medication Aide first administered medication for pain. She stated that there was no bruising or swelling and he was able to move his toes. She stated that she did not assess Resident #16 after that time. She stated that she was not sure if she documented her assessment of Resident #16 on 5/23/11. In an interview on 7/1/11 at 9:55 AM, LVN B stated that she came to work on 5/24/11 at approximately 2:00 PM and received report from LVN C. LVN C told her to order an X-ray of Resident #16 ' s right leg. LVN B confirmed that there was no documented nursing assessment done on Resident #16 between his fall on 5/21/11 and 5/25/11 when he was transported to the hospital for evaluation and treatment of [REDACTED]. Review of the portable x-ray report dated 5/24/11 at 6:09 PM reflected a compression [MEDICAL CONDITION] fibula, age unknown, possibly acute/sub acute on chronic, and lateral tibia plateau. Review of a written physician's order [REDACTED].#16 to local hospital for compression fracture "age unknown". Review of the emergency room discharge instructions dated 5/25/11 reflected Resident #16 had ' right proximal fibula head fracture'. He was to be medicated with [MEDICATION NAME] 50 mg ( every six hours as needed for pain. The facility ' s CMS form 802 reflected 12 residents with a history of falls.

Based on interview and record review the facility failed provide necessary care and services to to attain or maintain the highest practicable physical, mental, and psychosocial well-being when they failed to thoroughly assess Resident #2 following a fall. On [DATE] Resident #2 rolled off of her bed onto the floor during a transfer when Certified Nurses Aide (CNA) A turned away from the resident leaving her unsupervised. Resident #2 sustained visible injury to her head. Two days after the fall Resident #2 was diagnosed through an X-ray with a fractured left Femur. Resident #2 expired at the facility on [DATE]. This deficient practice could cause un-necessary and prolonged pain and suffering for Resident #2 and could contribute to complications associated with bone fractures such as Fat Embolism and [DIAGNOSES REDACTED] (an infection in the bone). This deficient practice could affect 59 additional residents who depend on facility staff for assistance with transfers. Findings include: Review of the face sheet for Resident #2 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the consolidated physician's order [REDACTED]. Review of an admission assessment dated [DATE] (completed by LVN D) reflected Resident #2 returned from the hospital with [DIAGNOSES REDACTED]. The assessment reflected Resident #2 had swelling in her left upper leg. She had no signs or symptoms of pain. Review of the Minimum Data Set ((MDS) dated [DATE] and [DATE] reflected Resident #2 required extensive assistance of two staff members for transfers. Review of the Care Plan dated [DATE] reflected Resident #2 was a fall risk, required extensive assistance of one or two staff for transfers and was always confused. All of her needs were anticipated. Review of an Incident Report dated [DATE] at 7:20 AM reflected Certified Nurses Aide (CNA) A was going for a chair with Resident #2 lying on the side of the bed. Resident #2 rolled out of the bed onto the floor onto her right side, hit her head on the floor and received a four centimeter (cm) knot on the right side of her forehead. Measures Taken to Prevent Reoccurrences reflected ' two assist with all transfers and do not leave alone at the side of the bed ' . The report further reflected that the Regulatory Agency was not notified. Documented under the heading of " For Employee Injuries Only " was a section titled " Investigation " which reflected "Spoke with CNA-who described incident. Leg was less swollen on Sat (Saturday [DATE]) per family member. Last night was worse. Spoke to family member [DATE]-Nurse and staff said head to toe assessment completed. Ask to document on NN (Nurses ' Notes) or Incident report". A follow up section at the bottom of the Incident Report was blank. Review of the Fall Investigation report dated [DATE] reflected Resident #2 was left unattended inappropriately. Conclusion: Resident not to be left unattended during transfer and mandatory two assist. The section marked Supervisor Report was blank. Review of Nurses ' Notes dated [DATE] reflected Resident #2 ' was being transferred to her Geri chair by the CNA. The CNA turned to reach for the chair when resident rolled out of bed onto the floor on her right side. She had a knot on her right side of forehead neuro (neurological) checks were with in normal limits. She was alert with no signs or symptoms of pain or discomfort ' . Review of Nurses ' Notes dated [DATE] reflected Resident #2 ' s left knee and femur was more swollen than the right. An X-ray of the left knee, hip and femur were ordered to rule out fracture after fall. No bruising or redness noted. Resident #2 ' s responsible party was contacted and stated that the day before Resident #2 left the hospital ([DATE]) her left leg was swollen three times bigger than the right leg. X-rays revealed a left Femur fracture. Orders were received to transfer Resident #2 to the hospital for treatment. Resident #2 returned to the facility with a fiberglass splint on her left leg. In an interview on [DATE] at 11:30 AM CNA A stated that on [DATE] she was getting Resident #2 dressed and out of bed. She stated that she was dressing Resident #2 while CNA C was dressing Resident #2 ' s roommate. CNA A stated that after dressing Resident #2, Resident #2 was lying on her back near the edge of the bed. She stated that she placed her left leg over her right and turned to reach for Resident #2 ' s Geri chair. She stated that when she turned, Resident #2 rolled out of bed onto the floor. She stated that Resident #2 landed on the floor on her right side. She stated that she heard Resident #2 ' s head hit the floor. CNA A stated that she knew she should not have turned her back on the resident and that she left Resident #2 too close to the side of the bed. She stated that she went and got the nurse (Licensed Vocational Nurse, LVN D) who assessed Resident #2 by getting her vital signs and checking her head and her eyes. LVN D then said we could transfer her to her Geri chair. CNA A stated that she and CNA C used a gait belt to assist Resident #2 off of the floor into her chair. She stated that Resident #2 was able to stand on both legs and did not appear to be in pain. She stated that the only visible injury Resident #2 had was a knot on the right side of her forehead. She stated that later in the day, approximately 2:00 PM, she noticed that Resident #2 ' s left knee looked extremely swollen. She stated that she went and informed LVN D who informed her that Resident #2 had recently been diagnosed with [REDACTED]. CNA A stated that LVN D did not go down to Resident #2's room and assess the Resident's knee at that time as far as she knew. CNA A stated that LVN D told her (regarding the swelling) "I promise it is from the blood clot and was already swollen." CNA A stated that she did not work the next few days and when she returned to work everyone was telling her that Resident #2 ' s left leg was broken. CNA A also stated that Resident #2 had a history of [REDACTED].#2 was placed in a Geri chair after she fell out of her wheelchair in the television room approximately three weeks prior. CNA A stated that she was in-serviced on transfers and that when a resident is a two person transfer there needs to be two people right there to transfer that resident. She stated that the other person cannot just be in the room and that she should never leave the side of a resident's bed. In an interview on [DATE] at 12:15 PM CNA C stated that on the morning of [DATE] she and CNA A were in Resident #2 ' s room getting both residents ready to get out of bed. She stated that CNA A had been getting Resident #2 ready and she had been getting Resident #2's roommate ready when she heard CNA A say, " Oh, shoot! " CNA C stated that she turned to see Resident #2 roll off of her bed and land on her right side on the floor. She stated that only Resident #2 ' s right side came in contact with the floor. She stated that CNA A went and got LVN D who assessed Resident #2 while she was on the floor. LVN D then told us that we could get her up and place her in her chair. She stated that she and CNA A used a gait belt to assist Resident #2 from the floor to her chair and Resident #2 was able to stand on both legs and did not appear to be in any pain. She stated that at the end of her shift, approximately 2:00 PM when putting Resident #2 back to bed, her left knee was kind of swollen. She stated that they informed LVN D at that time and LVN D informed them that Resident #2 ' s left knee was swollen before the fall because she returned from the hospital like that. In an interview on [DATE] at 4:50 PM LVN D stated that on the morning of [DATE] she was at the nurses ' station when CNA A came and reported that Resident #2 had fallen out of bed. She stated that when she entered the room, Resident #2 was lying on her right side on the floor next to her bed. She stated that CNA A reported to her that she was getting ready to get Resident #2 out of bed. She had left Resident #2 lying on the side of the bed with her left leg crossed over her right and turned around to get the Geri chair when Resident #2 rolled out of bed. LVN D stated that Resident #2 had a knot on the right side of her forehead. She stated that she checked Resident #2's skin and the only injury she saw was the knot on her head. When asked if she did a head to toe assessment, LVN D stated, "Yes, she documented in the nurses' notes." She stated that Resident #2's left leg was swollen from the previous day when Resident #2 returned from the hospital with a [DIAGNOSES REDACTED]. She stated she and the two CNAs assisted Resident #2 to her chair and Resident #2 did not appear to be in any pain. LVN D stated that she filled out an incident report and notified Resident #2's physician of the fall and head injury. In an interview on [DATE] at 2:10 PM LVN E stated that on [DATE] (two days after Resident #2 ' s fall) she was informed by a CNA that Resident #2 ' s left leg was extremely swollen. LVN E stated that she noted that Resident #2 ' s left leg was two to three times larger than her right leg. There was no redness or bruising to the knee, just swelling. She stated that she notified the physician and ordered a portable X-ray. LVN E stated that she also spoke with Resident #2 ' s responsible party who informed her that Resident #2 ' s left leg was much more swollen while she was in the hospital and diagnosed with [REDACTED]. LVN E stated that Resident #2 ' s left leg had always been bigger than her right leg but when she saw it on [DATE] it was " huge " . She stated that she may not have thought of getting an X-ray of Resident #2 ' s left leg because she was diagnosed with [REDACTED]. She stated that the X-ray revealed a left Femur (large bone of the leg) fracture and she sent Resident #2 to the hospital for treatment. In an interview on [DATE] at 11:45 AM LVN F stated that Resident #2 normally had a very small upper body and very large legs. At first the size of her legs was thought to be [MEDICAL CONDITION] but later determined to be her normal anatomy. LVN F stated that even on her initial admission, Resident #2 was noted to have large legs and her left leg was always a little larger than the right. In an interview on [DATE] at 12:55 PM the Director of Nurses (DON) stated that she was made aware of Resident #2 ' s fall resulting in a knot on her head on Monday [DATE]. She stated that once she learned of the fall with injury she went to see Resident #2 and made her own head to toe assessment. She stated that Resident #2 had a purple knot on the right side of her forehead. She stated that Resident #2 ' s left leg was swollen above the knee to the groin area greater than the right, which she attributed to the [MEDICAL CONDITION]. She stated that Resident #2 did not appear to be in any pain as she palpated her left leg. She stated that there was no bruising, redness or warmth to the left leg. She stated that she was satisfied at that point that the only injury from Resident #2 ' s fall was the knot on the right side of her forehead. The DON stated that an X-ray obtained on [DATE] revealed that Resident #2 had a fracture of her left Femur. She stated that the fracture was discovered two days after Resident #2 ' s fall and she did not know how or when the fracture occurred. She stated that the section on the Fall Investigation report for Supervisor Report was only filled out when further investigation into the fall was indicated. Review of the current clinical record for Resident #2 reflected no documentation of a facility investigation into the cause or contributing factors that resulted in Resident #2 ' s left Femur fracture. In an interview on [DATE] at 12:40 PM the Assistant Director of Nurses (ADON) stated that they did not do an investigation into Resident #2 ' s Femur fracture. She stated that the fracture was discovered a couple of days after Resident #2 ' s fall but they just assumed that it was a result of Resident #2 falling out of bed. She stated that she really did not know how or when the fracture occurred. In an interview on [DATE] at 12:45 PM LVN B stated that there was a period of two days after the fall and the X-ray results of a fracture and it is possible that something may have occurred within that period of time that may have resulted in the fracture to Resident #2 ' s left leg. In an interview on [DATE] at 1:20 PM the Administrator stated that she really did not consider the fracture an injury of unknown origin. She stated that she just thought Resident #2 ' s fracture must have been from the fall that she had on [DATE]. She stated that an investigation was not done and the injury was not reported to the State Agency. She stated that her main concern was making sure that the resident was being taken care of. Review of the X-ray dated [DATE] reflected Resident #2 had a likely acute comminuted (one in which the bone is splintered or crushed), impacted (one in which one fragment is driven into the other) distal Femur fracture. Review of Nurses ' Notes dated [DATE] through [DATE] reflected Resident #2 began having increased coughing and congestion with thick secretions requiring oral suctioning. On [DATE] Hospice (end of life care) assessed Resident #2 and she was placed on Hospice services. In an interview on [DATE] at 10:45 AM LVN B stated that Resident #2 expired on [DATE]. Review of an in-service dated [DATE] reflected Subject covered: Assessing Falls and their causes; Policy. Problems, Comments, Suggestions: *Add head to toe assessment documentation in the nurses' notes with each fall. Review of the policy and procedure titled Assessing Falls and Their Causes dated ,[DATE] reflected the following: DOCUMENTATION: When a resident falls, the following information should be recorded in the resident's medical record: 2. Assessment data, including vital signs and any obvious injuries. (Handwritten to the side 'Always document head to toe assessment in nurses' notes') Review of the facility ' s CMS 672 reflected a census of 67 and 60 of those residents required assistance with transfers.