Every finding on record at Wolf Creek Care Center

Based on interview and record review, the facility failed to obtain consent for the administration of a Covid Vaccine (vaccine designed to induce immunity against SARS-Co-V-2, virus responsible for coronavirus disease 2019) for one of two sampled residents (Resident 1) when Resident 1 was administered the vaccine after Resident 1's RP's (Responsible Party) declined the vaccine. This failure resulted in Resident 1 to receive a covid vaccine without consent and violated the resident's RP's right to make health care decisions.Findings: Resident 1 was admitted to facility 4/10/13 with diagnoses that included, TBI (Traumatic Brain Injury, a complex injury by sudden external trauma that damages brain tissue), and cognitive deficit (impairment in mental processes including memory, attention, and executive function-that affect ability to learn, reason and make decisions). During an interview on 1/27/26 at 5 p.m. with Resident 1's daughter (RP), the RP stated on 1/27/26 that Resident 1 was not supposed to receive a Covid Vaccination, the chart was marked in big red letters not to vaccinate. RP stated that resident was at a physician's appointment and stated he had been given a Covid vaccine, resident had a band aid on his arm where the resident stated the vaccine had been administered. The RP stated that a nurse (could not remember name) had told her that the resident did receive a Covid vaccine and they were apologetic. During a review of Resident 1's progress note, dated 4/30/21 at 6:33 p.m., the progress note indicated that licensed nurse (LN 3) spoke with Resident 1's RP who declined the vaccination. During a review of Resident 1's progress note, dated 5/4/21 at 7:32 p.m., the progress note indicated that Resident 1 had received a Covid-19 vaccine that morning. During an email correspondence received 2/5/26 from the current Administrator, (Admin) who had notes from the previous Administrator on 5/20/21 that the vaccine had been given without consent from the RP. The notes indicated that LN 4 stated she was responsible for the vaccine being administered without RP or resident consent. During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccine, dated (updated 1/26/22), the P&P indicated the facility recognizes the residents' right to accept or refuse the Covid-19 vaccine, and the right to change their mind from an earlier decision. Before receiving the Covid-19 vaccine, facility will provide the resident or legal representative and staff member information regarding the benefits and potential side effects of the Covid-19 vaccine. An informed consent will be obtained by the facility. If Resident refuses the Covid-19 vaccine, appropriate entries will be documented in each resident's medical record.

Based on interview and record review, the facility failed to ensure resident safety for two out of six sampled residents (Resident 1 and Resident 2) when:1. Resident 1 left the facility without staff knowledge and was found at a gas station without her Wander Guard (wearable monitoring device that alerts caregivers when a resident leaves a protected area); and2. Resident 2 had an avoidable fall (unintentional fall that happens because of identifiable and correctable factors) when she was not properly secured during transportation to an appointment.This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury and in Resident 2 sustaining a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that required surgery. Findings:1. During a review of Resident 1's admission Record, it indicated, Resident 1 was admitted to the facility November 2025, with multiple diagnoses which included dementia (impaired ability to remember, think, or make decisions), bipolar disorder (mental health condition that causes extreme mood swings) and generalized anxiety disorder (apprehension, tension, or uneasiness that stems from the anticipation of danger, which may be internal or external).A review of Minimum Data Set (MDS, an assessment tool), dated 10/1/25, the MDS indicated Resident 1 had moderate cognition impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Resident 1's family member was listed as the responsible party.During a review of Resident 1's Order Summary Report, order date 11/3/25, it indicated, Resident does not have the capacity to make her decisions related to: Dementia.During a review of Resident 1's Order Summary Report, order date 11/4/25, it indicated, Wander Guard [wearable monitoring device that alerts caregivers when a resident leaves a protected area] right wrist For exit seeking [attempting to leave a building or secured area] behaviors.During a review of Resident 1's care plan (CP), initiated on 11/4/25, the CP indicated, Elopement: [Resident 1] is at risk for elopement/exit seeking/wandering related to dementia or other cognitive impairment, unsafe wandering [going about from place to place] .Will not leave the facility without a responsible person.During a review of Resident 1's Progress Note, effective date 11/29/25, it indicated, .around 9:15am, Resident as noted with attempting to exit from the front door of the facility, redirection, provided multiple times, noted with no wander guard. Resident had taken off her wander guard, writer applied New wander guard, checkedplacement [sic] and functioning well. Resident was found off facility grounds approx. around 9:45am by a CNA [Certified Nursing Assistant] .Resident had taken off her wander guard second time prior to the incident.During an interview on 12/8/25 at 11:36 a.m., with CNA 2, CNA 2 confirmed Resident 1 had a history of taking off her Wander Guard and exiting the building. CNA stated on 11/29/25 at approximately 10:30 a.m., Resident 1 had left the building without staff knowledge and was found at a nearby gas station without her Wander Guard on. CNA 2 further stated Resident 1 could have gotten hurt while she was out of the building and was not sure how the Wander Guard was removed.During an interview on 12/8/25 at 11:46 a.m., with Licensed Nurse (LN) 2, LN 2 stated Resident 1 had removed her Wander Guard the morning of 11/29/25 and a new Wander Guard was put on. LN 2 confirmed Resident 1 later left the building without staff knowledge and was found down the street without her Wander Guard on. LN 2 further stated that contributing factors for Resident 1's elopement could have been not changing the Wander Guard location (to a place she could not reach on her body) and her poor safety awareness. During an interview on 12/8/25 at 12:29 p.m., with CNA 1, CNA 1 confirmed Resident 1 had left the building without staff knowledge on 11/29/25 and was found at a nearby gas station. CNA 1 stated Resident 1 did not have her Wander Guard when she returned to the facility and that Resident 1 could have potentially gotten hurt. CNA 1 confirmed the expectation for nursing staff was to keep residents safe and prevent elopement. During a review of the facility's policy and procedure (P&P) titled, Accident Prevention and Safety of Residents, revised 7/22, the P&P indicated, Resident safety and supervision are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring,.Employees shall be trained in potential accident hazards and try to prevent avoidable accidents.facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and adjust interventions accordingly .During a review of the facility's P&P titled, Wandering and Elopement, reviewed 10/24, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and provide interventions to decrease risk and keep residents safe.2. During a review of Resident 2's admission Record, it indicated, Resident 2 was originally admitted to the facility April 2024 with multiple diagnoses which included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), hemiplegia (severe loss of strength on one side of the body), and hemiparesis (partial loss of strength on one side of the body). During a review of Resident 2's MDS Section C, dated 11/4/25, it indicated, Resident 2 was cognitively intact (sufficient judgment, planning, organization, self-control, and memory). Resident 2's MDS Section GG, dated 11/4/25, the MDS indicated Resident 2 had impairment on both sides of her lower extremities (hip, knee, ankle, foot) and used a wheelchair as a mobility device. During an interview on 12/8/25 at 10:21 a.m., with the Administrator (ADM), ADM stated Resident 2 had a fall on 11/24/25 inside the transportation van while on her way to an appointment. ADM confirmed Resident 2 was sent to the hospital and returned to the facility on [DATE] with a confirmed injury of a broken femur that required surgery because of the fall in the van. ADM stated the driver of the van was terminated from employment on 12/1/25 because of the result of Resident 2 not being properly secured in the van using the required seat belt and four anchors as trained.During an interview on 12/8/25 at 1:41 p.m. with Resident 2, Resident 2 stated during the van ride to her appointment her wheelchair was not fastened correctly in the van. Resident 2 stated she had notified the Driver (DRI) 1 twice that she was not secured properly and that he stopped once to make adjustments. Resident 2 further stated when she notified DRI 1 a second time that she was not secured properly, DRI 1 did not stop but continued to the appointment. Resident 2 stated when the van stopped at the final destination and was being unbuckled, she fell out of her wheelchair while in the van and injured herself. Resident 2 confirmed she had broken her femur and had to have surgery because of the fall. During an interview on 12/8/25 at 2:01 p.m., with DRI 2, DRI 2 stated he was trained with DRI 1 when first hired at the facility. DRI 2 confirmed both he and DRI 1 were trained extensively on safety and how to properly secure wheelchairs in the transportation van using the seatbelt and four anchors. DRI 2 confirmed residents would not be able to fall out of their wheelchairs if they were secured properly as trained. DRI 2 stated residents could potentially fall and seriously injure themselves if not properly fastened in the van.During a review of Resident 1's Progress Note, effective date 11/24/25 13:01, it indicated, Resident left for apt. [appointment] via WCVAN [wheelchair van] at approximately 1300. All skin intact upon leaving. No c/o [complaint of] pain or discomfort.During a review of Resident 1's Progress Note, effective date 11/24/25 15:00, it indicated, .received a call from [hospital name] stating that upon arrival to scheduled apt., WC [wheelchair] driver entered the building and stated the resident had fallen on the floor during transport. Per [hospital name], they recommended resident be immediately brought to ER [emergency room] for further evaluation.A review of the facility's document titled, ED Physician Notes, dated 11/24/25 17:22:15, it indicated, FELL OUT OF WHEELCHAOR [wheelchair] IN WHEELCHAOR VAN TWISTING LEG. PAIN.She reports that she was being transported in a wheelchair van to an appointment in Sacramento earlier today, there was a mishap in her wheelchair, and she fell forward and struck her left leg on the ground. She has had continued pain just proximal [closer to center of body] to her left knee.imaging interpretation left distal [away from center of body] femur fracture.Discussed with orthopedic surgeon [medical doctors who specialize in bone, muscle, and joint surgery] [staff name] who recommended CT [medical imaging] for preop [prior to surgery] planning and admission to hospital.A review of the facility's document titled, EMPLOYEE COUNSELING FORM, dated 12/1/25, it indicated, Violation Date: 11/24/25.In Van.Failure to follow proper safety protocols while transporting patient .Patient was injured while being transported by [DRI 1] .Employee acknowledged on 11/26/25 that they were trained on proper safety protocols upon hiring and acknowledged on 11/26/25 that they did not follow all of them. Resulting consequence is termination.A review of the facility's document titled, Job Description: VAN DRIVER, dated 2/24, it indicated, Assists residents from loading and unloading from facility-approved vehicles.Ensure the safe transportation of residents to scheduled medical appointments.Properly securing WC [wheelchair] bound residents into bays in Vans.During a review of the facility's P&P titled, Accident Prevention and Safety of Residents, revised 7/22, the P&P indicated, Resident safety and supervision are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring,.Employees shall be trained in potential accident hazards and try to prevent avoidable accidents.facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and the adjust interventions accordingly.

Based on interview and record review, the facility failed to follow their Policy and Procedures (P&P) and ensure professional standards of practice were met for one of six sampled residents (Resident 3) when, Resident 3 was administered medications with possible drug interactions without clarification from the doctor.This failure had the potential to have caused adverse outcomes and worsen Resident 3's condition and decreased the potential to provide safe administration of medication.During a review of Resident 3's clinical record, Resident 3 was admitted [DATE] with diagnosis that included Nontraumatic Intracerebral Hemorrhage (ICH) (bleeding directly into the brain tissue from causes other than injury), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Transient Ischemic Attack (temporary blockage of blood flow to the brain), Cerebral Infarction (blood clot blocks an artery supplying the brain, leading to a lack of oxygen and nutrients, causing brain tissue death).During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/24/25, Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 00 out of 15 which indicated Resident 3 had severe cognitive impairment.During a review of Resident 3's physician orders dated 11/21/25, the order indicated Heparin Sodium (Porcine) Solution (blood thinner medication used to treat and prevent blood clots) 5000 Unit/Milliliter (ml) (the concentration of a substance within a liquid solution) subcutaneously (SQ) (under the skin) every 12 hours. Has triggered the following drug protocol alerts/warning(s) (a systems designed to prevent adverse drug events): Drug to Drug Interaction (when one drug changes the effect of another when taken together): The system identified a possible drug interaction with the following orders: Aspirin Oral Tablet (A drug taken by mouth that reduces pain, fever, inflammation, and blood clotting) 325 Milligrams (mg) (a unit of measurement) .Order: Aspirin Oral Tablet 325 mg. Give 1 tablet in the morning. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system identified a possible drug interaction with the following orders. Heparin Sodium (Porcine) Solution 5000 unit/ml . Both medications indicated the severity level as severe and the Interaction as Aspirin may enhance the anticoagulant effect of heparin. During a review of Resident 3's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for November 2025, the MAR indicated Aspirin 325 mg and Heparin 5000 units/ml SQ were given on 11/22/25. During an interview on 11/8/25 with Licensed Nurse (LN) 3 and LN 1 at 11:06 A.M. and 11:10 A.M., both stated they would call the doctor to clarify an order for Aspirin and Heparin for a resident with a diagnosis of ICH. Both stated they would obtain a new order if it was changed, and document in a progress note that the medication was clarified with the doctor. During a concurrent interview and record review on 11/8/25 at 11:14 a.m. with the Director of Nursing (DON), the DON confirmed Resident 3 had a diagnosis of ICH and had orders for Aspirin and Heparin. The DON confirmed Resident 3 was administered Aspirin and Heparin on 11/22/25. The DON confirmed the medications triggered a drug interaction warning. The DON stated the expectation for the nurse is if the doctors order it, give it. Providers review the medications on admission, and if they didn't want them to have it, they wouldn't have ordered it.During an interview on 11/8/25 at 2:09 a.m. with LN 4, LN 4 confirmed she medicated Resident 3 with Heparin and Aspirin despite the drug interaction warning. LN 4 was aware Resident 3 had a diagnosis of ICH but stated she only questioned what side effects to monitor. LN 4 stated the side effect of taking blood thinners with ICH are increased bleeding or possible death. LN 4 confirmed she did not call the doctor to clarify the order for Heparin and Aspirin as indicated on the warning and as per the P&P.During an interview on 12/15/25 at 12:04 p.m. with the Pharmacist, the Pharmacist stated that Aspirin and Heparin are a duplication (two or more identical medications or same therapeutic class) of anticoagulants (medications that stop your blood from clotting too easily) and could increase bleeding. The pharmacist stated that Aspirin and Heparin trigger warnings because they have a drug interaction and are contraindicated (not advised as a course of treatment). The Pharmacist confirmed the Aspirin and Heparin order for Resident 3 should have been clarified with the provider before being given because administering two anticoagulants with a diagnosis of ICH can cause increased bleeding and cause death. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications revised October 2024, the P&P indicated, If a dosage is believed to be inappropriate.or has been identified as having potential adverse consequences, . or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the resident 's Attending Physician/Nurse Practitioner or the facilities Medical Director to discuss the concerns.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for a census of 53 residents when the Registered Dietician (RD) and Dietetic Services Supervisor (DSS) were both hired as part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) employees. This failure had the potential for unsafe food handling and spread of food borne illnesses in a highly susceptible population. Findings: During an interview on 5/19/25 at 9:40 a.m. with the DSS, the DSS stated she was working as a part time employee for the facility and was also working at another facility. The DSS further stated that their RD was also working as part time employee and the Dietetic Services Supervisor in Training (DSSIT) who was not yet licensed, was working as full-time employee. A review of the DSS's employment document titled, New Hire Input Form, dated 9/7/24, indicated the DSS was hired as a part time employee of the facility on 9/7/24. During an interview on 5/20/25 at 10:52 a.m. with the DSSIT, the DSSIT stated she was working as a full-time employee for the facility. The DDSIT further stated she was currently doing online schooling and will take the Certified Dietary Manager (CDM) examination within four months. A review of the DSSIT's employment document titled, New Hire Input Form, dated 1/27/25, indicated the DSSIT was hired as a full-time employee of the facility on 1/27/25. During an interview on 5/21/25 at 10:01 a.m. with the RD, the RD stated she was working as a part time employee for the facility. A review of the RD's employment document titled, New Hire Input Form, dated 9/11/23, indicated the RD was hired as a part time employee of the facility on 9/11/23. During an interview on 5/21/25 at 11:08 a.m. with the administrator (ADM), the ADM stated that state regulations should be followed. A review of the facility's policies and procedures titled, PERSONNEL MANAGEMENT, undated, indicated, A qualified FNS [Food and Nutrition Services] Director is responsible for the total operation of the Food & Nutrition Services Department. All food & Nutrition service is performed under their direction. PROCEDURE: If a person is not a Registered Dietician, they must meet the Federal and State laws . A review of the California Health and Safety Code, section 1265.4, current as of dated 1/1/23, indicated, (a) A licensed health facility .shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations .(b) The dietetic services supervisor shall have completed at least one of the following educational requirements: .(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association . (https://codes.findlaw.com/ca/health-and-safety-code/hsc-sect-1265-4/)

Based on observation, interview, and record review the facility failed to ensure food storage and preparation, and maintenance of food contact surfaces were in accordance with professional standards for food safety for the 53 residents who ate facility prepared meals when: 1. Three out of three small cutting boards had stains, and two out of six large cutting boards had deep scratches; and, 2. A box of garlic bread, a box of fried eggs, and a box of bacon were found with ice crystals built-up, opened and were exposed to air in the freezer. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 5/19/25, within the initial kitchen tour beginning at 8:23 a.m., with the Dietetic Services Supervisor in Training (DSSIT), three out of three small cutting boards were found stained with brownish substance, and two out of six large cutting boards were found with deep scratches. The DSSIT confirmed the observation and stated cutting boards with stains and deep scratches could potentially harbor bacteria. During an interview on 5/21/25, at 10:01 a.m., with the Registered Dietician (RD), the DM stated bacteria might get into those uncleaned cutting board stains or in the groves of those cutting board scratches. The RD further stated cutting boards with stains and deep scratches are risk for bacterial overgrowth and possible foodborne illnesses. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-501.12, titled Cutting Surfaces, 1/18/23 version, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 2. During a concurrent observation on 5/19/25, within the initial kitchen tour beginning at 8:23 a.m., with the DSSIT, a box of garlic bread, a box of fried eggs, and a box of bacon were all found with ice crystals built-up, opened, and were exposed to air in the freezer. The DSSIT confirmed the observation. During an interview on 5/21/25, at 10:01 a.m., with the RD, the RD stated food items should be tightly sealed when placed in the freezer. The RD further stated the texture and taste of the food could get affected because of the ice crystals build-up. A review of facility's policies and procedures titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, indicated, 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn (a condition in which ice crystals form on frozen food as the result of air coming into contact with food). A review of the US FDA 2022 Food Code, section 3-302.11, titled Packaged and Unpackaged Food -Separation, Packaging, and Segregation, 1/18/23 version, indicated, (A) FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . A review of the US FDA article titled, Are You Storing Food Safely?, dated 1/18/23, indicated, .Freezer burn is a food-quality issue . (https://www.fda.gov/consumers/consumer-updates/are-you-storing-food-safely)

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of 16 sampled residents (Resident 17) when: 1. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days and was left uncovered when not in use; and, 2. Resident 17's oxygen nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure to germs, and may cause infection to Resident 17. Findings: 1. A review of Resident 17's clinical record indicated Resident 17 was admitted April of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), and shortness of breath A review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/30/25, indicated Resident 17 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 17 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 17's MDS Health Conditions, dated 4/30/24, indicated Resident 17 experienced shortness of breath or trouble breathing when lying flat. A review of Resident 17's physician's order, dated 4/28/25, indicated, Budesonide [a medication that reduces inflammation and swelling] Suspension [a mixture where solid particles are mixed with but not dissolved in a liquid] 0.5 MG [milligram- unit of measurement] /2ML [milliliters- unit of measurement] 2 ml inhale orally via nebulizer two times a day for COPD exacerbation [worsening]. During a concurrent observation and interview on 5/19/25 at 9:34 a.m. with Resident 17, in Resident 17's room, Resident 17's nebulizer face mask and tubing was labeled 5/6 and was placed on top of Resident 17's bedside drawer, uncovered. Resident 17 stated she last used her nebulizer last night. During a concurrent observation and interview on 5/19/25 at 10:15 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 17's room, CNA 1 confirmed that Resident 17's nebulizer face mask and tubing was labeled 5/6 which was 2 weeks ago and was placed on top of Resident 17's bedside drawer, uncovered. CNA 1 stated that nebulizer face mask and tubing should be changed every Sunday and should be placed in a black bag when it is not being used for infection control. 2. A review of Resident 17's physician's order, dated 4/29/25, indicated, Oxygen - @ 2 Liters/Min [liters per minute- unit of measurement for oxygen administration flow rate] Via Nasal Cannula Continuous Medical DX [diagnosis]: COPD . A review of Resident 17's physician's order, dated 4/29/25, indicated, Change Nasal Cannula. every night shift every Sun [Sunday] AND as needed. During a concurrent observation and interview on 5/19/25 at 9:34 a.m. with Resident 17, in Resident 17's room, Resident 17 was sitting on the side of her bed, awake, and was on oxygen set at 2 LPM via nasal cannula which was labeled 5/11. Resident 3 stated she uses oxygen all the time. During a concurrent observation and interview on 5/19/25 at 10:15 a.m. with CNA 1, in Resident 17's room, CNA 1 confirmed that Resident 17's oxygen nasal cannula was labeled 5/11. CNA 1 stated oxygen nasal cannula should be changed every Sunday. During an interview on 5/21/25 at 9:44 a.m. with the Infection Preventionist (IP), the IP stated that nebulizer face mask and tubing should always be placed in a bag when not being used and should be changed every Sunday. The IP also stated oxygen nasal cannula should also be changed every Sunday. The IP further stated there would be a risk of infection or possible exposure of the resident to bacteria if the nebulizer face mask is left uncovered and not being changed every week, and if the oxygen nasal cannula is not being changed every week. During an interview on 5/21/25 at 11:28 a.m. with the Director of Nursing (DON), the DON stated she would expect nebulizer face mask and oxygen nasal cannula to be changed every seven days for infection control. The DON further stated she would expect the nebulizer face mask to be clean and placed inside the black bag when not being used. A review of the facility's policy and procedures (P&P) titled, Respiratory Care and Oxygen Administration, revised 10/2024, indicated, Oxygen therapy is administered by way of .nasal cannula .c. The oxygen tubing is changed at least weekly, labeled with the date it was changed .Infection Control Considerations Related to Medication Nebulizers/Continuous .5. Store the nebulizer mask in the antimicrobial bag, marked with date and resident's first initial and last name. 6. Discard the nebulizer tubing and mask at least weekly.

Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with the facility's policy and procedures as well as professional standards of care for one out of 16 sampled residents (Resident 20), when Resident 20 did not receive insulin (hormone that controls the amount of sugar in the blood) medication within the parameters as ordered by the physician. This failure had the potential for Resident 20 to experience hypoglycemia (condition where the level of sugar in the blood drops below a healthy range) and for the resident to not achieve their highest practicable well-being. Findings: Resident 20 was originally admitted to the facility in September 2022 with multiple diagnoses which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin). A review of Resident 20's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated, Resident 20 was cognitively intact. During a review of Resident 20's Order Summary Report, dated 5/21/25, Resident 20 had an order for, Insulin Glargine [long-acting synthetic version of human insulin used to treat diabetes] Solution 100 UNIT/ML [unit of measure] Inject 18 unit subcutaneously [under the skin] at bedtime for DM [diabetes mellitus] Hold for FSBS [finger stick blood sugar- test that measures the level of sugar in a small drop of blood] less than 150, with a start date of 7/15/24. During a concurrent interview and record review on 5/20/25, at 2:48 p.m., with Licensed Nurse 1 (LN 1), Resident 20's Medication Administration Record (MAR, a legal document used to record medications given to the residents) for the month of May 2025 was reviewed. LN 1 confirmed Resident 20 had FSBS less than 150 on 5/2/25, 5/6/25, 5/10/25, and 5/13/25 but the MAR indicated insulin was given. LN 1 stated insulin should not have been given on those days because the order stated to hold insulin if FSBS was less than 150. LN 1 stated the expectation were for nurses to always follow the physician orders. LN 1 further stated that not following the physician orders could have potentially been dangerous for Resident 20 and result in them experiencing hypoglycemia. During an interview on 5/21/25, at 9:33 a.m., with the Director of Nursing (DON), DON stated it was the expectation of nursing staff to always follow physician orders including parameters when administrating medications. The DON confirmed that not following physician orders could potentially cause harm to the resident and result in a change of condition. A review of Resident 20's care plan initiated on 10/3/22, indicated, .Fluctuating blood sugars. At risk for ill effects such as: Hypoglycemia (Tremors, Confusion, and Diaphoresis [sweating]) .Medication as ordered . During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, revised 10/24, the P&P indicated, .The type of insulin, dosage requirements .are verified before administration to assure that it corresponds with the physician's order. During a review of the facility's P&P titled, Physician Orders, dated 10/24, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. During a review of the facility's P&P titled, Administering Medications, revised 10/24, the P&P indicated, Medications are administered in accordance with prescribers' orders, including any required time frame.

Based on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 2's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) drainage bag was not positioned below Resident 2's bladder during a wound care treatment. This failure had the potential for Resident 2 to develop infection and possible suprapubic catheter complications. Findings: A review of Resident 2's clinical record indicated Resident 2 was initially admitted September of 2024 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body), urinary tract infection (UTI- an infection in the bladder/urinary tract), and obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing properly causing backflow of urine from the bladder into the ureters). A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/9/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 2 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 2's MDS Bladder and Bowel conditions, dated 4/9/25, indicated Resident 2 has Indwelling catheter [a flexible tube inserted into the bladder and left in place to drain urine] (including suprapubic catheter .) A review of Resident 2's care plan, dated 4/8/25, indicated, [Resident 2] has a Suprapubic Catheter r/t [related to] OBSTRUCTIVE AND REFLUX UROPATHY. A review of Resident 2's care plan intervention, dated 4/8/24, indicated, CATHETER: .suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. During a concurrent observation and interview on 5/19/25 at 12:36 p.m. with Resident 2, in Resident 2's room, Resident 2 was observed connected to a urinary catheter tubing and bag draining yellowish liquid. The urinary bag was covered with privacy bag and hung on Resident 2's bedside. Resident 2 stated she recently got hospitalized because of UTI. During an observation on 5/20/25 at 10:04 a.m. with the Treatment Nurse (TN), in Resident 2's room, the TN was observed doing Resident 2's wound care treatment on Resident 2's back. The TN placed Resident 2's bed in a flat position, turned Resident 2 sideways, and placed Resident 2's suprapubic catheter drainage bag on the bed, next to her legs. Resident 2's drainage bag was not kept below Resident 2's bladder all throughout the wound care treatment. During a subsequent interview on 5/20/25 at 10:19 a.m. with the TN, in Resident 2's room, the TN confirmed that Resident 2's suprapubic catheter drainage bag was placed on Resident 2's bed and was not kept below Resident 2's bladder all throughout the wound care treatment. The TN stated the drainage bag should be always placed below Resident 2's bladder to prevent back flow of the urine. During an interview on 5/21/25 at 9:44 p.m. with the Infection Preventionist (IP), the IP stated that urinary catheter bag should have been placed below the resident's bladder because there would be a risk for the urine to flow back into the bladder causing possible UTI or other catheter complications. During an interview on 5/21/25 at 11:28 p.m. with the Director of Nursing (DON), the DON stated that the urinary catheter bag should always be placed below the resident's bladder. The DON further stated there would be a risk of infection or other complications if the catheter bag is not placed below the resident's bladder. A review of the facility's policies and procedures titled, Indwelling Catheters, revised 9/2021, indicated, Maintaining Unobstructed Urine Flow .3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 43) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 43's pain medication orders were not consistently followed. This failure had the potential for Resident 43 to experience over medication, not achieve pain relief, and not attain her highest practicable well-being. Findings: A review of Resident 43's clinical record indicated Resident 43 was admitted April of 2025 and had diagnoses that included infection following a surgical procedure, fracture (a break in the continuity of a bone) of left lower leg, osteomyelitis (a serious infection of the bone), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), and opioid dependence (reliance on a substance found in certain prescription pain medications). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/2/25, indicated Resident 43 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 43 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 43's MDS Health Conditions, dated 5/2/24, indicated Resident 43 occasionally experiences pain and received routine and as needed pain medications, and non-medication intervention for pain. A review of Resident 43's care plan, revised 5/1/25, indicated, Pain: [Resident 43] is at risk for acute pain or discomfort due to wounds, decreased mobility, Neuropathy. A review of Resident 43's care plan intervention, initiated 4/30/25, indicated, Administer medications as ordered . A review of Resident 43's physician's order, dated 4/30/25, indicated, Ibuprofen [a medication for pain] Oral Tablet 200 MG [milligrams- unit of measurement] .Give 2 tablet by mouth every 6 hours as needed for Mild Pain (1-3) [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain]. A review of Resident 43's physician's order, dated 4/30/25, indicated, oxyCODONE HCl [a controlled medication used to treat moderate to severe pain] Oral Tablet 10 MG .Give 1 tablet by mouth every 6 hours as needed for Moderate to Severe pain (7-10) for 7 Days. A review of Resident 43's physician's order, dated 5/13/25, indicated, oxyCODONE HCl Oral Tablet 10 MG .Give 1 tablet by mouth every 12 hours as needed for Moderate to Severe pain (7-10). During an interview on 5/19/25 at 9:40 a.m. with Resident 43, Resident 43 stated she was not getting her pain medications on time which causes her to experience severe pain at times. A review of Resident 43's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of May 2025 indicated Resident 43 received ibuprofen which was as needed for mild pain on the following occasions: 5/8/25 at 2:23 p.m.- pain level was 5 (moderate pain) 5/9/25 at 12:49 p.m.- pain level was 5 (moderate pain) 5/15/25 at 10:42 a.m.- pain level was 5 (moderate pain) 5/16/25 at 2:14 p.m.- pain level was 7 (severe pain) 5/17/25 at 11:49 a.m.- pain level was 5 (moderate pain) 5/19/25 at 11:58 a.m.- pain level was 10 (severe pain) 5/20/25 at 2:39 p.m.- pain level was 6 (moderate pain) A review of Resident 43's MAR for the month of May 2025 indicated Resident 43 received oxycodone which was as needed for moderate to severe pain on the following occasions: 5/6/25 at 6:15 a.m.- pain level was 0 (no pain) 5/8/25 at 4:31 a.m.- pain level was 3 (mild pain) 5/14/25 at 5:06 a.m.- pain level was 0 (no pain) 5/19/25 at 7:20 a.m.- pain level was 0 (no pain) 5/21/25 at 4:37 a.m.- pain level was 0 (no pain) During a concurrent interview and record review on 5/21/25 at 9:33 a.m. with Licensed Nurse (LN) 2, Resident 43's clinical records were reviewed. LN 2 confirmed that Resident 43's pain medication orders were not consistently followed. LN 2 stated the resident would either have an unrelieved pain or experience overmedication complications if the physician's order is not followed. LN 2 further stated that nurses should always follow the physician's order when administering pain medication. During an interview on 5/21/25 at 11:28 a.m. with the Director of Nursing (DON), the DON stated she would expect staff to assess the resident's pain level first and the pain level should accurately reflect the needed pain medication. The DON further stated the resident's pain would not be managed well or the resident would be overmedicated if the physician's order was not followed. A review of the facility's P&P titled, Pain Assessment and Management, revised 9/2024, indicated, Implementing Pain Management Strategies .3. Implement the medication regimen per Physician orders. A review of the facility's P&P titled, Administering Medications, revised 10/2024, indicated, 2. Medications are administered in accordance with prescriber orders .

Based on observation, interview and record review, the facility failed to provide a sanitary environment when one out of three sampled residents, (Resident 1), had oxygen tubing, suctioning tubing and yankhauer (hard tube-like plastic tool which is placed into a person ' s mouth to suction secretions) laying on Resident 1 ' s bedroom floor. This failure had the potential to transmit communicable diseases and infections to Resident 1. Findings: During a review of Resident 1 ' s record titled, Admission Record, dated 11/28/2023 indicated Resident 1 was admitted on [DATE]. Resident 1 was admitted with cancer of the major salivary glands (glands located in and around the mouth area), trouble swallowing, muscle weakness and a gastrostomy tube, (tube inserted directly into the stomach used for nutrition when a person cannot eat using their mouth). During a review of Resident 1 ' s record titled, Order Summary Report, indicated Resident 1 had an order for: 1. Oxygen 2 liters via nasal cannula (tube that is connected to oxygen on one end and the other end is placed in a person ' s nose to deliver the oxygen) as needed. 2. Change the nasal canula every night shift on Sundays and as needed. 3. Speech therapy to work with Resident 1 with trial diets to assess if Resident 1 could tolerate food and fluid via the mouth. During a review of Resident 1 ' s record titled, Care Plans, dated 12/1/2023 indicated Resident 1 had mouth care daily, and to ,cue Resident 1 to cough and clear secretions as able and suction as needed. During an interview on 12/6/2023 at 9:20 am, with Resident 1, Resident 1 appeared confused. Resident 1 attempted to respond but was only able to make sounds. During an observation on 12/6/2023 at 9:20 am, in Resident 1 ' s room, observed Resident 1 ' s bed against the wall with a portable oxygen tank next to his bed with oxygen tubing connected to it. The oxygen tubing did not have a date on it and it was laying on the floor under the portable oxygen tank. Resident 1 had a suction machine on a small dresser next to his bed with tubing and a yankhauer. The tubing and yankhauer were laying on the floor under his bedside table. During an interview with Licensed Vocational Nurse (LVN) 1, on 12/6/2023 at 9:25 am, stated she did not know when the oxygen tubing or suction tubing had been placed in Resident 1 ' s room. LVN 1 stated the oxygen tubing, should be changed weekly, dated, and stored in a black bag (an antimicrobial bag to decrease bacteria), hanging on Resident 1 ' s bed. LVN 1 was unsure how to store the suction tubing and yankhauer in Resident 1 ' s room. LVN 1 confirmed Resident 1 ' s oxygen tubing should have been dated. LVN 1 confirmed Resident 1 ' s oxygen tubing, suction tubing and yankhauer should not have been on the floor. During an interview on 12/6/2023 at 10:25 am, with Director of Nursing (DON), confirmed the oxygen tubing should have been dated. DON confirmed Resident 1 ' s oxygen tubing, suction tubing and yankhauer should not have been left on the floor. During an interview on 12/6/2023 at 11:00 am, with Assistant Director of Nursing (ADON), confirmed Resident 1 ' s oxygen tubing should be changed weekly, dated, and stored in an antimicrobial black bag at the resident ' s bedside and not on the floor.

Based on interview and record review, the facility failed to protect Resident 1 from abuse when Resident 1 was scratched on the face and her hair was pulled by Resident 2. This failure caused a scratch to the left cheek and mild scalp pain for Resident 1, potentially leading to adverse clinical outcomes. Findings: A review of Resident 1's (R1) Admission Record, indicated R1 was admitted to the facility on [DATE] with diagnoses including stroke, difficulty speaking and lack of coordination. A test for mental function referred to as a Brief Interview for Mental Status (BIMS) was scored as a12 on 8/03/23, indicating moderate cognitive (ability to think and reason) impairment. A review of Resident 2's (R2) Admission Record, indicated R2 was admitted on [DATE] with diagnoses including psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety disorder. R2 had a BIMS score of 2 on 7/26/23, indicating severe cognitive impairment. A review of R1's Nurse's Notes, documented by the Director of Nursing (DON) indicated, On 9/14/2023 at 17:10 (5:10 PM), staff responded to screaming from resident's (R1) room. [Staff] Entered to find roommate (R1) pointing to her hair and cheek which was bleeding. R2 was said to have grabbed her (R1) by the hair . After the incident, R1 was observed to have a scratch inflicted by R2 on the left side of her face. There were also tiny scratches on R2's hand caused by her ring being pulled off in the altercation. The ring was documented as being on the floor afterwards. R1 also indicated her hair was pulled by R2. A review of R1's Nurse's Notes, documented by the Director of Nursing (DON) on 9/15/23, indicated that, .she (R1) has mild pain where her hair was pulled. On 10/11/23 at 1:45 PM Certified Nursing Assistant (CNA1) was interviewed regarding the incident. CNA1 stated, I was working that day. She (R2) punched her (R1) and her (R2's) ring scuffed her (R1's) face. CNA1 went on to discuss prevention of future incidents by moving R2 to a different room. During a concurrent interview and record review on 10/12/23 at 9:00 AM , the DON confirmed the incident had taken place. The facility sought treatment for R2 so as to prevent future incidents. The DON related treatment for R2 was effective and no further incidents between R1 and R2 have occurred.

Based on interview and record review, the facility failed to follow their post-fall care interventions to ensure that one of two sampled residents (Resident 1) was monitored after a fall. The failed practice resulted in Resident 1 not having adequate clinical oversight for 72 hours after a fall with a head injury. Resident 1 was found deceased in his bed 41.5 hours after the fall. Findings: The facility policy and procedure titled, Wolf Creek Care Center Fall Program, revised 2022, directed facility staff to monitor the resident for 72 hours for potential injury related to the fall, and the IDT to meet post fall for evaluation of root cause and risk factors. Patient 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of first lumbar vertebra, collapsed vertebra, history of falling, dementia and anxiety disorder. Resident 1 had repeated history of falls and had a total of 2 falls in the 24 days of his stay in the facility. The record showed that on [DATE] at around 11:25 am, Resident 1 was noted with unwitnessed fall. Resident said he was attempting to get out of his bed. Resident stated he hit his head. Resident reported no pain post fall. Neuro checks initiated per protocol. The record had one additional Nursing Post-Fall Review written by the Director of Nurses on [DATE] at 3:57 pm. The next narrative nursing note was written on [DATE] at 7:15 am, which read, at approx. 0600 Staff doing room rounds found resident with no palpable pulse and no respirations. There were no further observations or assessments made in the record regarding Resident 1's fall on [DATE]. During a concurrent interview and record review on [DATE] at 2:10 pm, the Administrator and Nurse Consultant confirmed that the post-fall policy required that Resident 1 was supposed to have neuro signs and vital signs completed by staff every 15 minutes for 1 hour, every 30 minutes for 2 hours, every 1 hour for 4 hours, every 2 hours for 4 hours, every 4 hours for 4 hours and lastly, every 8 hours for 4 hours. They both verified that there was no evidence that this was done. They also verified that there was no follow-up by the IDT (Interdisciplinary Team-group of different disciplines that meet to discuss and review resident care needs) as required in the facility policy.

Based on observation, interview and record review, the facility failed to ensure that a care plan for one of two sampled residents (Resident 1) was revised and updated to reflect a change in condition for a left arm fracture and hospice services (end of life care) ordered. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status. Findings: A review of a policy revised February 2022, titled Comprehensive Care Plans, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change to include identified problem areas, and to incorporate risk factors and associated with identified problems. During a record review of a policy date January 2011, titled Safety and Supervision of Residents the Policy Statement indicated The staff shall use various sources to identify risk factors for residents, and communicate specific interventions to all relevant staff, assign responsibilities for carrying out interventions, provide training as necessary and document interventions. This policy also indicated Monitoring the effectiveness of the interventions shall include to ensure the interventions are implemented correctly and consistently, evaluate the effectiveness of the interventions, and modify or replace the interventions as needed. Resident 1 was admitted to the facility on [DATE] with diagnoses of fracture of left femur (broken upper leg), dementia (a cognitive disorder when a person can no longer be independent), and history of falling. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 01/03/23, indicated functional status for bed mobility, transfers, using toilet, and bathing, is extensive assistance with two assistants needed. Resident 1's Brief Interview for Mental Status (BIMS, an assessment of cognition) assessment score was 5, which indicated a severe cognitive impairment (unable to think and reason). A review of a record dated 1/24/23 titled Emergency Department Patient Discharge Instructions indicated diagnoses after an evaluation at a hospital included new closed fracture (a broken bone that does not go through the skin) of left proximal humerus, (upper arm bone), laceration (a cut) to the left eyebrow and was treated with adhesive glue to not be removed, and an abrasion to the left knee covered with a band aid. Use sling to left arm until follow up with an orthopedist (a doctor who specializes in the treatment of bones). A review of a record for Resident 1 dated 1/24/23 titled Nurse's Note indicated Resident 1 had a follow up appointment scheduled on 1/31/23 with an orthopedist appointment for hip and shoulder. A review of a record for Resident 1 dated 1/31/23 at 11:00 am, seven new orders were received from an orthopedist doctor as follows: 1- Left wrist brace, may remove for bathing, hand washing and skin checks. 2- NWB (non-weight bearing) to left upper extremity. 3-Start gentle range of motion to left shoulder pendulum (an exercise to relieve pain and preserve joint range of motion for shoulder injuries) and gentle range of motion to left elbow. 4-Sling to left upper extremity (LUE) for two more weeks, remove as needed (prn). 5-Weight bearing as tolerated (WBAT) to left lower extremity. 6-Left posterior hip precautions for two more months. 7-Follow up in four weeks. A review of Resident 1's record indicated there was no updated or revised plan of care to include new problems from a fall on 1/24/23 and seven new orders received from an orthopedist on 1/31/23 as of 2/9/23. During an interview on 2/9/23 at 2:29 pm, the Infection Prevention Nurse confirmed there were no instructions or information on the Simplified Plan of Care (a new process started to communicate needs to all staff), posted in Resident 1's room on the closet door for staff to read, no information was listed about the sling to the left arm, weight bearing status for left arm, and no update of hospice services started as of 2/9/23. During an interview on 2/9/23 at 2:50 pm, the Minimum Data Sheet (MDS) coordinator confirmed the plan of care for Resident 1 had not been updated or revised with the new problems for Resident 1 and was not communicated in writing to the staff providing direct care. MDS stated, I agree and confirm the care plan was not up to date or completed after the fracture and the hospice referral/admission. If I had it to do over, I would have just added it. The staff should have been updated in writing, not just a verbal update. During an interview on 2/9/23 at 2:55 pm, the Director of Nursing confirmed the care plan should have been revised for Resident 1 for the changes and new injury when she came back to the facility from the hospital with an injury to be transferred to the Kardex (a communication tool for all certified nursing assistants to use while providing care) for all the staff to be updated.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was treated with dignity and respect when the resident felt forced to take a shower. This failure had the potential for Resident 1 to feel devalued as an individual and not feel safe. Findings: A review of the facility ' s policy titled, Resident Rights dated 2011, indicated Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A review of Resident 1 ' s medical record revealed that Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was his own responsible party. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment) admission assessment dated [DATE], indicated Resident 1 required total dependence with bathing and it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment of cognition) assessment score was 14, indicating he was cognitively intact. During an interview on 11/17/22 at 12:05 pm, Resident 1 indicated he usually was given a bed bath because he did not like showers. Resident 1 stated they gave me a forceable shower, A big nurse wrapped her arm around me and plopped me into a shower chair. Resident 1 indicated he felt forced to do something he did not want to do; it was scary and very upsetting to him. During an interview on 11/17/22 at 12:18 pm, Certified Nursing Assistant (CNA) D indicated Resident 1 refused showers because he did not like to get out of bed. He preferred to have bed baths and stated, residents were supposed to get what they wanted. During an interview on 11/17/22 at 12:40 pm, Resident 1 indicated that the night he was given a shower he remembered saying to the CNA I get bed baths, and she (CNA) said no you ' re not, you ' re getting a shower. Resident 1 indicated that they gave him a shower, and he did not want one. Resident 1 stated he told the facility Administrator about it. During an interview on 11/17/22 at 12:45 pm, Resident 1 ' s roommate, Resident 2, indicated he remembered the incident because he had heard the conversation. He remembered Resident 1 telling the CNA he wanted a bed bath but the CNA telling him he was going to get a shower. Resident 2 recalled seeing Resident 1 being pushed out of their room in a shower chair. During an interview on 11/18/22 at 8:22 am, Resident 1 ' s family member (FM) indicated that during a visit to the facility on ,d+[DATE] and 11/13/22, Resident 1 mentioned to him that a staff member said, you ' re not getting any more bed baths you are getting a shower. During an interview on 11/21/22 at 8:58 am, CNA B recalled Resident 1 telling her that he was made to take a shower. During an interview on 11/21/22 at 10:06 am, CNA C confirmed that Resident 1 was known to refuse showers a lot. CNA C confirmed that a few weeks ago she had a conversation with Resident 1 about getting a shower when he had asked for a bed bath. She indicated it would be good for him to have at least one shower a week. She confirmed he was given a shower that day. During an interview on 11/22/22 at 12:05 pm, with the Activities Director (AD), the AD indicated she had interviewed Resident 1 concerning his likes and dislikes. AD confirmed that Resident 1 preferred to stay in bed that it was very important to him to choose between his bed bath or shower. AD indicated that if he wanted a bed bath then it was his choice, and he should get a bed bath. During an interview on 11/22/22 at 3:30 pm, the Administrator confirmed that if a resident wanted a bed bath, it was their right to have what they asked for.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was transferred with a full body lift (Hoyer), as his care plan indicated, when Resident 1 was manually transferred by two staff members from his bed to a shower chair then back to his bed again. This failure placed Resident 1 at risk for falling and being injured. Findings: A review of the facility ' s policy titled, Safety and Supervision of Residents dated January 2011, indicated Our facility strives to make the environment as free from accident hazards as possible. Implementing interventions to reduce accident risks and hazards shall include the following: e. ensuring that interventions are implemented. A review of resident 1 ' s medical record revealed that Resident 1 was admitted to this facility on 9/27/22 with the diagnoses of stoke ([CONDITION(S)]) with left sided weakness, muscle weakness, and a contracture of the left hand. He was his own responsible party. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment) admission assessment dated [DATE], revealed Resident 1 required total dependence with bathing and extensive assistance with bed mobility (there was no assessment of how he transferred). Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment of cognition) assessment score was 14, indicating he was cognitively intact. A review of Resident 1 ' s Activity of Daily Living Care Plan dated 9/27/22, revealed interventions indicating Resident 1 required a mechanical lift (Hoyer) for transfers. During an interview on 11/17/22, at 12:05 pm, Resident 1 stated. A nurse wrapped her arm around me and plopped me into a shower chair. He indicated they were supposed to use a lift on him, but they did not that day and it was painful for his already sore left shoulder. During an interview on 11/17/22, at 12:18 pm, with certified nursing assistant (CNA) A, CNA A confirmed that Resident 1 was a two person assist and they were supposed to use a Hoyer for transfers. During an interview on 11/17/22, at 12:45 pm, with Resident 2, Resident 2 was in the bed next to Resident 1. Resident 2 indicated he remembered the incident because he heard Resident 1 land in the shower chair and saw him be pushed out of their room. Resident 2 confirmed that the staff had not brought a lift into the room. During an interview on 11/17/22, at 3:30 pm, with the Director of Rehabilitation (DOR), the DOR confirmed Resident 1 required a Hoyer lift for transfers because of his left sided weakness. The DOR confirmed Resident 1 ' s care plan interventions included the use of a Hoyer for transfers. During an interview on 11/21/22, at 8:58 am, with CNA B, CNA B recalled Resident 1 telling her about a girl (cna) picking him up and putting him in a shower chair. CNA B stated, the staff did this a lot when they are supposed to use a Hoyer. She confirmed that Resident 1 required a Hoyer lift for transfer. During an interview on 11/21/22, at 10:06 am, with CNA C, CNA C confirmed that she and CNA D manually picked up Resident 1 and transferred him to a shower chair and did not use a Hoyer lift. We used a gait belt and a sheet under his legs (she called it a fireman ' s carry). CNA C stated Resident 1 was unable to stand on his feet due to his weakness. CNA C indicated she was unaware that Resident 1 was a Hoyer lift. During an interview on 11/22/22, at 3:30 pm, the Administrator confirmed that Resident 1 ' s care plan indicated he required a Hoyer lift when transferred and should not have been manually transferred by two staff members lifting him.

Based on observation, interview and record review, the facility failed to maintain clean, comfortable, and safe assistive devices needed for daily living for five of fourteen sampled residents (Resident 7, 8, 17, 19 and 45) when their assistive devices (wheelchair) were soiled with food debris and sticky substances. The failure to ensure a safe and sanitary condition of residents' assistive devices resulted in the potential to cause cross contamination between residents from micro-organisms present on the soiled wheelchairs and cushions. Findings: A review of a policy revised 2022, titled, Wheelchair Cleaning, indicated cleaning schedule as follows: All wheel chairs should be cleaned monthly on a weekly schedule when is use and as needed (prn). A cleaning log should be kept recording when wheelchairs are actually cleaned. Policy indicated cleaning method as follows: Remove all cushions from the wheelchair prior to cleaning. Ensure cushions are labeled appropriately. When cleaning, wheelchairs should be turned on their backs and hosed down with pressurized hot water. After being hosed down, the wheelchair should be sprayed with cleaning agent, then wiped down with a clean cloth. Spray cushion with cleaning agent, wipe down with a clean cloth. Return wheelchair to room or storage. 1. During a concurrent observation and interview on 11/2/22 at 9:08 am, Resident 17 and Certified Nursing Assistant, (CNA) A, Resident 17 was unable to communicate verbally except with yes and no answers. Resident 17 was totally dependent on a wheelchair and has left sided weakness. CNA A confirmed observation of the wheelchair was visibly soiled with food particles on the wheelchair cushion, and also confirmed the sides of the wheelchair and the arm rests had dried food particles and dried sticky substances. During a record review of the schedule for cleaning wheelchairs for October 2022 and November 2022, the last recorded date Resident 17's wheelchair was cleaned was on 10/10/22. 2. During a concurrent observation and interview on 11/2/22 at 8:42 am, Resident 7 was in bed and her wheelchair was observed beside the bed with a soiled cushion with sticky substances and food particles. CNA A confirmed the wheelchair cushion, and the outside of wheelchair including the arm rests, sides of the wheelchair had sticky substances and food particles. During a record review of the schedule for cleaning wheelchairs for October 2022 and November 2022, the last recorded date Resident 7's wheelchair was cleaned was on 10/10/22. 3. During a concurrent observation and interview on 11/2/22 at 8:35 am, Resident 45 was lying in bed and her wheelchair was sitting beside the bed. CNA A confirmed observed soiled cushion of reclining wheelchair with a white-color sticky substance, and the outside of her chair and footrest had both white and yellow-colored dried substances. During a record review of the schedule for cleaning wheelchairs for October 2022 and November 2022, the last recorded date Resident 45's wheelchair was cleaned was on 10/7/22. 4. During a concurrent observation and interview on 11/2/22 at 8:47 am, Resident 19's wheelchair was in a corner of room with linens and incontinent care supplies covering the bottom cushion. Linens and supplies were removed by CNA A and soiled cushion observed. CNA A confirmed the wheelchair cushion, arm rests, back support and leg rest had dried food, sticky substances, and food particles. The metal area under the cushion also had food particles and a sticky substance. CNA A stated, They always leave these things in her chair, and it is always dirty. During a record review of the schedule for cleaning wheelchairs for October 2022 and November 2022, the last recorded date Resident's 19's wheelchair was cleaned on 10/10/22. During an interview on 11/3/22 at 10:10 am, the Housekeeping Supervisor, (HS) stated, All wheelchairs are cleaned weekly and prn. We have not completed the 200 hall yet. If the staff tells us a specific wheelchair needs to be cleaned, we will clean it. I do not check after the staff cleans them, I will if I need to. 45757 5. During a concurrent observation and interview on 11/01/22 at 2:54 pm, Resident 8 was sitting in his wheelchair with a dried, yellow fluid and debris resembling food particles saturating the wheelchair frame and seat pad. CNA A and CNA F confirmed Resident 8's wheelchair was soiled and removed the seat pad to reveal large amounts of crusted, yellow fluid, with debris on the underneath seat frame. CNA A and CNA F stated the substance appeared very old and confirmed that a strong odor was coming from the seat frame. CNA A stated she will notify housekeeping that Resident 8's wheelchair needed to be cleaned. During an interview on 11/01/22 at 3:14 pm, DON stated that all resident devices are routinely sanitized monthly by housekeeping. DON further explained if a device needed additional cleaning, the staff that identified the soiled device was expected to clean the device with the necessary cleaning agents at the required dry times. If staff were untrained or unfamiliar with the cleaning processes then they were expected to notify housekeeping of the cleaning need. All device cleanings were to be logged on housekeeping audit sheets. Two days later,during a concurrent observation and interview on 11/03/22 at 11:50 am, Resident 8 was sitting in his wheelchair, hunched over, with a thick yellow substance hanging from his mouth to his leg. Resident 8's left pant leg, left arm, left wheelchair frame, and seat pad was saturated with a thick yellow/orange substance that had a strong odor. CNA G stated it appeared that Resident 8 had vomited on himself and his wheelchair. CNA G advised he was going to change Resident 8 and notify housekeeping that the wheelchair needed to be cleaned. During a record review of the facility's Wheelchair/Geri-Chair Cleaning Log for October 2022 and November 2022, the last recorded date Resident 8's wheelchair was cleaned was 10/17/22. During an interview on 11/04/22 at 11:36 am, DON, DSD, and MDS stated that both housekeeping and CNA's should properly clean devices to a sanitary and safe condition. DON reported she has only been employed with the facility for six weeks and has not had the opportunity to audit the facility's cleaning processes. DON stated she has attended Interdisciplinary Team (IDT-group of healthcare disciplines that meet to discuss residents care needs) meetings where the facility's equipment cleaning processes and back-up equipment inventory were discussed. DON stated to plan a future inservice to train staff on the correct cleaning and disinfection processes of resident equipment.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to reflect the care needs for four of 14 Residents (Residents 8, 14, 33, and 45) when: 1. A care plan problem and intervention for Hoyer lift (a mechanical lift used to safely transfer residents) use was not listed for Resident 45. This failure resulted in a dislocated right shoulder and pain. 2. A comprehensive care plan was not developed for antipsychotic (medication use to treat behaviors) use for Resident 33. This had the potential for staff to be unaware of potential adverse events, side effects or therapeutic effect. 3. Resident 8's skin assessment intervention was not implemented. This had the potential to result in skin injury going unnoticed and untreated. 4. Resident 14's weekly weight interventions were not implemented. This had the potential to result in delayed nutritional care for weight fluctuations. Findings: 1. A review of a facility policy titled, Care Plans, Comprehensive revised (February 2022), indicated a care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs must be developed and implemented. This included identifying problem areas, risk factors, and the professional services responsible for each element of care to aide in preventing or reducing decline in the resident's functional status. A review of a facility policy titled, Lifting Machine, Using a Mechanical, revised (July 2022), indicated the purpose is to establish the general principles of safe lifting using a mechanical lift. Number one indicated at least two nursing assistants are needed to safely move a resident with a mechanical lift. During a record review Resident 45 was admitted to the facility on [DATE] for diagnoses of Alzheimer's disease, history of falling and high blood pressure. The most recent Minimum Data Set (MDS- an assessment tool) dated 10/5/22 indicated, Resident 45 was totally dependent on staff for transfers, needed extensive assist with two assistant. Resident 45 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs and unable to recall events due to severe memory loss. During a record review titled, Care Plan, last revised on 10/12/22, the Hoyer lift was not listed as an identified problem and intervention for safe transfers for Resident 45. During a record review dated 10/28/22 at 10:29 am, titled, Progress Notes, indicated Restorative Nurse Assistant (RNA) was doing range of motion (ROM) with Resident 45 and found to have right shoulder pain. Physician notified and an x-ray ordered for the right shoulder. During a record review dated 10/31/22, titled, Discharge Summary, for Resident 45 from a hospital indicated on page five Diagnosis for this visit is shoulder injury-Major. Anterior dislocation of right shoulder, physician attempted reduction in the emergency department a few times without success, then an orthopedic surgeon was consulted, and patient deemed not a candidate for surgical intervention at this time. During an interview on 11/2/22 at 9:20 am, Certified Nursing Assistant (CNA) A stated with (DON) present, We were transferring Resident 45 using a side-to-side lift, we did not use the Hoyer lift. I was on the right side and CNA H was on the left. When I found out Resident 45 had a dislocated shoulder on Monday, I tried to tell the DON that CNA H was being rough during the transfer she helped me with. During an interview on 11/4/22 at 2 pm, MDS Coordinator stated, The Hoyer lift is not on the care plan dated 10/12/22, I will add the lift to the new one once I finish Resident 45's MDS for re-admission. 41567 2. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia, retinal detachment (layers of tissue in the back of the eye detach from the blood vessels that provide it nutrients and oxygen) and vision loss. A review of Resident 33's order audit report with an order by Medical Doctor (MD) A for quetiapine fumarate (an antipsychotic medication used to control certain mental disorders) 25 milligrams (mg), one tablet to be given at bedtime for the diagnosis of behavioral disturbances as evidenced by picking at eye. A review of resident 33's care plans revealed that there was no care plan in place for antipsychotic use. A concurrent interview and record review was conducted on 11/02/22 at 3:45 pm, with the Director of Nurses (DON). The DON stated that she had not reviewed Resident 33's care plans since starting in her position as DON. DON confirmed that there was no care plan addressing antipsychotic medication and stated that there should have been. 45757 3. A review of Resident 8's admission record indicated he was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses that included cervical vertebra fracture related to a fall, abnormal posture, and Parkinson's disease. (disorder of the central nervous system that affects movement including tremors) A review of medical orders dated 8/30/22, indicated that Resident 8 wears a trunk support harness at all times when up in a wheelchair and requires skin checks to the shoulders and trunk every other day to ensure there is no skin breakdown related to the trunk harness. A review of Resident 8's trunk postural support care plan dated 10/19/22, indicated that skin check interventions were to be implemented every other day to ensure skin integrity underneath the postural support remained intact. A review of Resident 8's treatment administration record dated 9/01/22 - 9/30/22, indicated that required skin checks were not completed on: 9/02, 9/04, 9/08, 9/10, 9/16, 9/20, 9/26, and 9/28. A review of Resident 8's treatment administration record dated 10/01/22 - 10/30/22, indicated that required skin checks were not completed on 10/06 and 10/14. During a concurrent observation and interview with CNA A on 11/02/22 at 8:03 am, Resident 8 was sitting in his wheelchair, wearing a trunk support harness secured to his torso with buckles that clasped behind each shoulder blade and waist. CNA A stated that Resident 8 repositions himself frequently in the wheelchair which can cause the harness to create pressure on Resident 8's shoulders and waist. During an interview on 11/03/22 at 1:19 pm, LN F confirmed that the facilities licensed nurses are responsible for implementing Resident 8's required skin checks every other day to ensure his postural harness is not causing injury to the skin. During a concurrent interview and record review on 11/04/22 at 12:29 pm, DON, MDS, and DSD verified that Resident 8's skin assessment interventions were not implemented in September or October. DON stated the facility did not have a process to audit treatment administration records for completeness of interventions. This will be a an action item at the next staff inservice. 4) A review of Resident 14's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included hip fracture, history of falls, and kidney failure. A review of Resident 14's nutritional problems care plan dated 10/18/22, indicated to refer to IDT for additional interventions. IDT meeting notes dated 10/18/22, indicated RD recommendations of weekly weights x 4 weeks to monitor Resident 14's weight variances. A review of Resident 14's weight and vitals summary dated 11/04/22, indicated Resident 14 was weighed once, on 10/19/22, since the RD recommended weekly weight interventions. Resident 14's weights on week two and week three were not measured. During a concurrent interview and record review on 11/04/22 at 12:29 pm, DON, MDS, and DSD verified that Resident 14's weekly weight interventions were not implemented in 10/22. DON stated the facility's RNAs or CNAs are expected to measure weights as ordered in the Residents' care plans. The facility did not have a process to audit Residents' weight and vitals summary for accuracy of interventions. This will be a an action item at the next staff inservice.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The blue plastic holder for the can opener and the base was unsanitary. 2. The chipped paint on white shelves in both three-door reach in refrigerators were not easily cleanable. 3. The rusting area of the shelf on the table had stored mixing bowls which had the potential to contaminate the clean metal bowls and containers. 4. A visible amount of water was observed in a kitchen drawer. 5. Four of the kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 6. The ventilator fans had black debris in both three-door reach in refrigerators. 7. The cooking utensils had dried food particles. 8. The metal dividers used for separating the food during tray line preparation had food particles. 9. The pipes under the cook preparation (prep) sink next to the stove were covered with black debris and cumulative dust. 10. There were sausage patties in a box unwrapped found exposed to air in the freezer. The food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food. The failures to ensure a safe and sanitary condition resulted in the potential for foodborne illness. Findings: 1. During a concurrent observation and interview on 11/1/22 at 10:20 am, the blue plastic piece of the can opener holder was filled with yellowish-brown slime, the metal base of the can opener was full of black debris. After Dietary Aide (DA) A removed the metal base of the can opener more black debris was observed under the base on the table. DA A stated, It looks like it has been a while since this part has been removed. The Dietary Supervisor (DS) confirmed the blue plastic piece of the can opener stand had not been cleaned per cleaning schedule and the base of the can opener needed to be completely removed. DS confirmed the table surface needed to be scrubbed to remove the black debris. DA A and DS confirmed this unclean can opener base could contaminate food and cause food-borne illness. During a record review of a policy dated 2018, titled, Can Opener and Base number three indicated to wash the base with a brush and cloth and a detergent solution following manufacturer's instructions. Make sure the shaft cavity is clean, rinse with fresh water and dry thoroughly with a clean cloth. Number five stated to clean the base at least once every three months, the underside of the base should be cleaned as well as the table where the base rested. 2. During a concurrent observation and interview on 11/1/22 at 9:45 am, both three-door reach-in refrigerators had chipped paint on the white shelves where residents' food was stored. The DS confirmed that cross contamination could potentially occur from the chipped white shelves in the three-door refrigerators that stored food for the residents and could cause food-borne illness. During an interview on 11/2/22 at 8:04 am, the Administrator (admin) stated he would replace all the shelves with chipped paint on both three-door refrigerators due to the potential for contamination to stored food. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 3. During a concurrent observation and interview on 11/1/22 at 10:22 am, a large rust-colored area was observed on the bottom shelve of the can opener table, cleaned storage mixing bowls were stored on this table over the rust-colored area. The DS confirmed this rust-colored area looked like rust and had the potential to contaminate the cleaned stored bowls and could potentially cause food-borne illness. During an interview on 11/2/22 at 8:10 am, the Admin stated I see the rust spots, I will replace this table. I will approve it now and the DS can order a new table. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 4. During a concurrent observation and interview on 11/1/22 at 10:28 am, a visible small amount of water was observed on the inside of a scoop (serving utensil) inside a kitchen drawer. DS confirmed all cooking and serving utensils should be kept clean and dry in the drawers to prevent cross contamination with food that could cause food-borne illness. The DS then removed all utensils out of the drawer to rewash and stated the utensils would all be air-dried for proper storage. Review of the Federal Food and Drug Administration (FDA) 2017 Food Code S4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. Cleaned equipment and utensils, shall be stored: (1) In a clean, dry location. 5. During a concurrent observation and interview on 11/1/22 at 10:30 am, four separate kitchen drawers had yellow-colored dried liquid substance on the inside of the drawers, both top and bottom of the drawers with the cooking utensils, spatulas, and scoop utensils. Black debris was also observed on the bottom of the drawers. The DS confirmed the drawers were not clean and removed all utensils from four separate drawers to rewash and stated the staff would clean the drawers before returning utensils to be stored in a clean and dry drawer. DS did confirm the yellow-colored substance and the black debris in the drawers could contaminate food and cause food-borne illness. According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. 6. During a concurrent observation and interview on 11/1/22 at 10:08 am, both three-door refrigerators had a large amount of black debris on the all the ventilators where prepared food is stored. The DS confirmed the ventilators were covered with black debris and would call maintenance to clean as soon as possible and she would move the prepared food to a clean area for safety until the ventilators were cleaned. The DS confirmed the dirty ventilators could cross contaminate food and cause food-borne illness. During a review of a policy dated 2018, titled, Sanitation indicated The maintenance department will assist Food and Nutrition services as necessary in maintaining equipment and doing janitorial duties which the kitchen staff cannot do. During a record review of a policy titled, Sanitation indicated, the kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures, and the hood over the stove to maintain a clean kitchen. 7. During a concurrent observation and interview on 11/1/22 at 10:15 am, cooking utensils with dried food particles in the kitchen drawer next to the refrigerator. DS confirmed the utensils for preparing food was dirty and had dried food particles. DS removed the utensils with dried food and confirmed dirty utensils could cause cross contamination and result in food-borne illness. During a record review of a policy dated 2018, titled, Sanitation indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. 8. During a concurrent observation and interview on 11/1/22 at 10:25 am, four metal serving dividers for meal preparation had orange-colored food particles present while stored in the drawer for use. The DS confirmed the serving dividers had orange- food particles and removed the dividers for cleaning. DS confirmed the dried food particles on the dividers used for tray line preparation could cross contaminate the cooked food and cause food -borne illness. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. 9. During a concurrent observation and interview on 11/1/22 at 10:35 am, the pipes under the prep sink on the left side of the stove were covered with black debris and cumulative dust. The DS confirmed this debris and dust had the potential to attract pests and harbor bacterial growth. During a record review of a policy titled, Sanitation indicated, the kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures and the hood over the stove to maintain a clean kitchen. Review of the Federal Food and Drug Administration (FDA) 2017 Food Code S4-601.11, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 10. During a concurrent observation and interview on 11/1/22 at 9:50 am, in the freezer, there was a box of opened sausage patties. Inside the box there were many pieces of sausage patties exposed to the air. The DS stated, We were short staffed this morning, and we forgot to seal the bag of frozen sausage. DS confirmed the opened food items need to be sealed to prevent freezer burn. During a record of a policy dated 2018, titled, Freezer Storage indicated to store foods in an airtight moisture-resistant wrapper such as a plastic bag or a freezer paper to prevent freezer burn.

Based on observation, interview and record review, the facility failed to ensure that a care plan for one of fourteen sampled residents (Residents 8) was revised and updated to reflect current fall risk interventions. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status. Findings: A review of a facility policy titled, Care Plan Revision, no date, indicated, Care plans shall be reviewed and revised to incorporate goals and objectives that lead to the resident's highest obtainable level of independence . These goals and objectives are revised when the desired outcome has not been achieved . A review of Resident 8's admission record indicated he was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses that included cervical vertebra fracture, abnormal posture, and Parkinson's disease (neurological involuntary movement which includes tremors) A review of the Minimum Data Set (MDS - a resident assessment) dated 8/19/22, indicated Resident 8 reentered the facility from an acute hospital. Resident 8 was screened as having severe cognitive impairment 9unable to think and reason) and required one-person physical assistance for bed mobility (turning side to side), transferring (moving from bed to chair to wheelchair), and locomotion in a wheelchair. A review of Resident 8's at-risk fall care plan dated 8/16/22, indicated that general fall risk interventions should be continued when an 'actual fall' care plan was developed. Interventions indicated the use of a wheelchair with a pad alarm and noted that a fall mat (a specially designed floor mat at the side of bed to protect from serious physical trauma resulting from falls). The fall mat should not be used due to the potential tripping hazard when Resident 8 transferred between bed and wheelchair. During a concurrent observation and interview with CNA E and CNA F on 11/01/22 at 2:54 pm, Resident 8 was in his room, sitting in a wheelchair positioned halfway on a fall mat. CNA E stated Resident 8 had a fall mat placed at the side of his bed for the past 1-2 months to protect him from serious injuries related to forward- leaning falls. CNA E stated that new care plan interventions were communicated to staff at the start of each shift. CNA E and CNA F had not been informed that Resident 8 should not have a fall mat. During a concurrent interview and record review on 11/04/22 at 12:24 pm, the Director of Nursing (DON), and DSD (Director of Staff Development) verified that Resident 8's at risk fall care plan had not been updated to reflect the current plan of care when Resident 8 was currently using a fall mat.

Based on interview and record review, the facility failed to transfer one of fourteen sampled residents, (Resident 45) safely using a Hoyer lift (a mechanical lift used to transfer residents safely) per resident's care plan when two Certified Nursing Assistants (CNA)transferred Resident 45 from the bed to the wheelchair without a lift. This failure resulted in an avoidable accident when Resident 45 sustained a dislocated right shoulder that caused pain. Findings: A review of a facility policy titled, Safety and Supervision of Residents, dated (January 2011), indicated Our facility strives to make the environment as free from accident hazards as possible. The policy instructed that The staff shall use various sources to identify risk factors for residents. It indicated Implementing interventions to reduce accident risks and hazards shall include the following: Communicate specific interventions to all relevant staff, assign responsibilities for carrying out interventions, provide training as necessary and document interventions. It further indicated Monitoring the effectiveness of the interventions shall include the following: Ensure the interventions are implemented correctly and consistently, evaluate the effectiveness of the interventions, and modify or replace the interventions as needed. During a record review of a policy revised (July 2022), titled, Lifting Machine, Using a Mechanical, indicated the purpose is to establish the general principles of safe lifting using a mechanical lift and at least two nursing assistants are needed to safely move a resident with a mechanical lift. During a record review Resident 45 was admitted to the facility on [DATE] for diagnoses of Alzheimer's disease, history of falling and high blood pressure. A review of the Minimum Data Set (MDS, a resident assessment) dated 10/5/22, indicated for functional ability Resident 45 was totally dependent on staff for transfers and needed two assistants. Resident 45 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 45's care plan last revised on 10/12/22, the Hoyer lift was not listed as an identified problem and intervention for safe transfers for Resident 45. A review of the Progress Notes dated 10/28/22 at 10:29 am, indicated, Restorative Nurse Assistant (RNA) was assisting with exercises with Resident 45 and found to have right shoulder pain. Physician was notified and an x-ray ordered for the right shoulder. A record review of the Discharge Summary dated 10/31/22, indicated Resident 45 had dislocated right shoulder. Physician attempted reduction in the emergency department a few times without success, then an orthopedic surgeon was consulted, and patient deemed not a candidate for surgical intervention at this time. During a record review dated 10/1/22, 10/8/22, 10/15/22, and 10/22/22 titled Weekly Summary Notes indicated Resident 45 had zero pain using a pain scale with faces that stated No hurt on all previous days of October 2022. During a review of the Medication Administration Record (MARs) on 11/2/22 at 12:40 pm, Tylenol 650 milligrams (mg, a unit of measure) was administered by mouth (PO) to Resident 45 for pain. A physician was notified requesting an order for break through pain at 1:47 pm by Licensed Nurse (LN) H. Physician ordered Motrin 600 mg PO three times daily as needed for breakthrough pain. During an interview on 11/2/22 at 9:10 am, the Director of Nursing, (DON) stated Resident 45 should have been transferred with a Hoyer lift and was unaware that CNAs were not using the lift. During an interview on 11/2/22 at 9:20 am, CNA A stated with DON present, We were transferring Resident 45 using a side-to-side lift, we did not use the Hoyer lift. I was on the right side and CNA H was on the left. When I found out Resident 45 had a dislocated shoulder on Monday, I tried to tell the DON that CNA H was being rough during the transfer when she helped me with the transfer. During a review of the fall care plan initiated on 11/1/22, indicated to continue to use Hoyer lift for transfers.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent an accident when Resident 1 was dropped out of a mechanical lift onto the floor. Resident 1 sustained a fractured right rib, and two vertebrae fractures of her spinal cord resulting in increased pain. This deficient practice resulted in a fall that caused Resident 1 to suffer increased pain from her injuries and a decline in overall health status. Findings: A review of Lifting Machine, Using a Mechanical policy, revised 7/2017, indicated that staff are to make sure the sling of the mechanical lift is securely attached to the clips before the resident is lifted. The policy additionally instructed staff to lift the resident two inches from the surface to check the stability of the attachments, and then gently support the resident as he or she is moved. Resident 1's record was reviewed and indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS, an assessment) dated 5/9/19, indicated Resident 1 had memory problems, was sometimes understood verbally, unable to ambulate, and required extensive assistance from two staff for transfers. A review of a nursing progress note dated 5/31/19 at 9:09 pm, Licensed Nurse (LN) C documented as she approached Resident 1's room she observed her fall to the floor in a fetal type of position resulting in a lump to the back of her head and redness and swelling to her right shoulder area. LN C documented that Resident 1 was transferred to a local emergency room (ER) the same day after the incident. A review of another nursing note dated 6/1/19 at 1:40 pm, indicated Resident 1 returned to the facility with a right rib fracture and compression fracture of [MEDICATION NAME] spine, (T) 1 and T 7 (base of the neck to the abdomen area) vertebras. The nurse documented, Resident 1 had a deformity of her right shoulder, bruising to her right side of her head, and would grimace when staff repositioned her. A review of an emergency room Physician's Progress Note dated 5/31/19 at 8:45 pm under history of present illness the physician documented Resident 1's presented after a fall out of a Hoyer lift onto the ground about 3 feet. Under X-RAY reports the physician documented Resident 1 had a right 8th rib fracture and a T1 and T7 fracture. During an interview, with Certified Nursing Assistant (CNA) A on 6/11/19 at 1:45 pm, she stated CNA B had asked for her assistance to transfer Resident 1 back to bed from her chair using a mechanical lift. CNA A stated the sling was already under Resident 1, and she pulled her chair backwards in to her room where Resident 1's back of her head was facing her roommates bed. CNA A stated she hooked up the left side of the sling (the top and the bottom) while CNA B hooked up the right side of the sling to the hoyer lift. CNA A stated she then observed CNA B go to the foot of the bed and chair and pulled out her cell phone. CNA A stated she started to operate the lift and CNA B was still looking at her phone. She stated the right upper strap came loose from the lift hook and then Resident 1 fell forward hitting her forehead on the floor. CNA A stated CNA B then ran and got LN C. CNA A stated CNA B is denying she was on her phone during the incident. On 6/11/19 at 2:30 pm, CNA B was interviewed. She stated the day of the incident they hooked the sling up to the hooks on the Hoyer lift. CNA B stated as soon as the Hoyer lift was pulled away from the chair one of the sling loops came loose and Resident 1 fell in a summersault motion hitting her head on the floor. CNA B stated she thought it was the right back hook that came loose. CNA B denied having her cell phone out of her pocket during the transfer. She stated, How is that possible when I am transferring someone? I had it in my pocket and showed her a picture on it prior. But it was in my pocket. On 6/11/19 at 3:10 pm, the mechanical lift and sling was observed. The sling contained four straps with loops that attached to four hooks tightly. Resident 1 was observed on 6/11/19 at 3:30 pm lying in her bed wearing a nasal cannula (tubing placed in the nose that delivers oxygen). Resident 1 did not respond when spoken to. During an interview on 6/13/19 at 10 am, LN C stated she was outside of the room and saw Resident 1 on the floor. She stated her feet were facing towards the head of her bead, and her head was towards her roommate. She stated CNA A was standing next to the lift while CNA B was observed standing next to Resident 1's chair. LN C stated she did not see any cell phones being used. On 6/13/19 at 11 am, the MDS Nurse was interviewed. She stated Resident 1 had a significant change and new pain caused by the fall and fractures. A review of a Cell Phone Policy dated 8/5/11, instructed employees phones are only to be used in the break areas or the parking lot. The policy additionally instructs that cell phones cannot be used in resident areas, rooms, the nursing station or in common halls. A review of 5/2019 physician's orders [REDACTED]. On 6/13/19 at 11:30 am, the Director of Nursing (DON) was interviewed while reviewing Resident 1's 5/11/19 to 6/11/19 physician's orders [REDACTED]. She stated when Resident 1 returned from the ER she was having increased pain. She stated the [MEDICATION NAME] ER 10 mg was increased to every eight hours on 6/1/19, and the [MEDICATION NAME] and Tylenol were prescribed prn. The DON acknowledged that on 6/10/19 the [MEDICATION NAME] 10 mg was changed to immediate release (IR) every 6 hours and the [MEDICATION NAME] was also increased to 100 mg due to increased pain. She acknowledged the fall was an .accidental mishap . that should have not happened if the CNA's were paying attention. She stated from the facility investigation of the incident it was her understanding that CNA B was observed to have her cell phone in Resident 1's room prior to the fall. On 6/18/19 at 11:15 am, CNA A was interviewed again. She stated again that the right upper sling came undone prior to Resident 1's fall. She stated both her and CNA B did not support or guide her during her transfer.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain resident well-being for one of four sampled residents (Resident 1) when: Licensed nursing staff failed to identify and promptly notify the physician of changes in condition, the need for alternative treatment, and abnormal laboratory test results that showed Resident 1 had an infection (UTI-urinary tract infection) from 12/30/13 through 1/7/14, per policy. A licensed Nurse Practitioner (NP) prescribed antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) for Resident 1 that had the potential to adversely effect the resident's well-being, due to the resident's known allergy to [MEDICATION NAME] (PCN). This went undetected by the facility until Resident 1's family alerted staff and refused to allow the medication to be administered. Prompt, effective treatment was not provided for Resident 1's urinary tract infection [MEDICAL CONDITION]. These failures delayed treatment for [REDACTED]. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Resident 1 had a known allergy to [MEDICATION NAME] (PCN). [MEDICATION NAME] is a member of a group of antibiotics which refers to a particular structure in their chemical makeup. The structure is also shared by semi-synthetic [MEDICATION NAME] (such as [MEDICATION NAME]), cephalosporins (such as [MEDICATION NAME]), and other antibiotics (such as Imipenem). Symptoms of an allergic reaction to PCN may be life-threatening and persons with a history of allergic reaction to PCN may suffer increased symptoms of allergic response, if given PCN again. Review of the facility's Risk for Chronic UTI's care plan, dated 12/22/13, for Resident 1, indicated that licensed staff were to administer medications as ordered, document urinary output, encourage fluids, report signs and symptoms of UTI such as acute confusion, back pain, malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), foul odor, and concentrated urine. The care plan goal was for Resident 1 to not exhibit signs of UTI. Review of nurses notes, dated 12/29/13 and timed 7:29 pm, indicated Resident 1 was having episodes of confusion and his urine was concentrated and had a foul odor. There was no evidence of notification to the physician of the abnormal urine characteristics on this day. On 4/8/14 at 12 pm, during an interview and concurrent review of Resident 1's record with Licensed Nurse (LN) G, the record disclosed that on 12/30/13, the physician was notified by faxed communication that Resident 1 had a decline in his cognition (mental status) and alertness. LN G confirmed that in response to this notification, a physician order, dated 12/30/13, was written for a urine test (UA) to determine the presence of a UTI. LN G confirmed that on 1/1/14 at 8:00 am, the UA results were abnormal indicating the presence of bacteria [MEDICAL CONDITION]. The UA results were not called to the physician and treatment orders were not obtained on this day. On 4/8/14 at 4:20 pm, during an interview with LN D, Resident 1's record disclosed that UA C&S (culture and sensitivity) laboratory report, indicating which antibiotics were effective in treating Resident 1's UTI, was reported to the facility on [DATE] at 8 am. A nurses narrative note, dated 1/3/14 at 10:52 am, written by LN D, indicated that the facility was "still awaiting" the lab test results (that had arrived at 8 am), however, a physician's orders [REDACTED]. LN D confirmed that the UA result was not reported timely to the physician. LN D explained that the facility practice required that a resident be put on "Alert Charting" (vital signs-temperature, heart rate, blood pressure, and effectiveness of oxygen saturation of the blood) and nursing narrative notes (a description of the residents current condition) which were to be written by the licensed nurse for each shift when a resident had a change in condition. LN D stated that residents receiving antibiotics, should be placed on Alert Charting for the duration of the antibiotic therapy, plus three days. LN D confirmed that the facility did not follow its policy to record information relative to changes in Resident 1's status. Review of the 1/2014 Medication Administration Record [REDACTED]. On 1/6/14 at 8:00 am, a nurse documented and circled their initials (indicating [MEDICATION NAME] had not been given). The nurse documented, "Initial dose from E-Kit." An E-Kit is an emergency drug supply kept at the facility for use when a medication needs to be administered as soon as possible, rather than waiting for a pharmacy to deliver the medication. Review of the 1/4/14 [MEDICATION NAME] Prescription Order indicated that on 1/6/14, a nurse documented directly on the 1/4/14 order, "family refusing this med due to PCN reaction. See UA/C&S. Please advise." The nurse had attempted to administer [MEDICATION NAME], however, Resident 1's family alerted the nurse that the resident had a PCN allergy and refused the [MEDICATION NAME] administration. In an interview on 4/9/14 at 10 am, the Nurse Practitioner (NP) stated that she had initiated the physician's orders [REDACTED]. NP confirmed that the facility did not promptly notify the physician regarding Resident 1's UA test results and delay in antibiotic treatment. A review of the facility's policy titled, "Administering Medications," last revised 4/2007, required, "...Medications must be administered in accordance with the orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns." On 4/3/14 at 12:15 pm, during an interview and record review, LN B stated that the facility's first attempt to administer the 1/4/14 [MEDICATION NAME] order was on 1/6/14 at 10:45 am, two days later. Resident 1's record also contained a new order, dated 1/6/14 (no time indicated), to discontinue [MEDICATION NAME] and start [MEDICATION NAME] for the treatment of [REDACTED]. LN B confirmed that [MEDICATION NAME] and [MEDICATION NAME] had not been given to Resident 1, from 1/4 through 1/6/14, and that the first [MEDICATION NAME] dose was not administered until 1/7/14 at 6:00 am, further stating that antibiotics are to be administered within 4 hours of the physician's orders [REDACTED]. LN B stated the system of communication between the nurse and NP or physician by fax or telephone failed to ensure timely response to Resident 1's changing/declining medical condition. During an interview and record review on 4/8/14 at 12:45 pm, LN G stated that she cared for Resident 1 on 1/5/14 during the evening shift. LN G stated that while the nursing narrative notes written by her on 1/5/14 at 10:35 pm indicated that Resident 1 remained "on ABT (antibiotic) for UTI (urinary tract infection)," there was no evidence that an antibiotic had been administered to Resident 1 from 1/4 through 1/6/14. LN G confirmed that Resident 1's physician was not notified of the progressive deterioration of his condition, the omission of medication, and the delay in treatment resulting in hospitalization . During an interview and record review on 4/8/14 at 3:55 pm, LN E stated that antibiotics were required to be administered within four hours of the written order. LN E confirmed that an ordered antibiotic was not administered to Resident 1 from 1/4 through 1/6/14. LN E confirmed that no documentation was found of [MEDICATION NAME] administration and the physician was not notified. LN E stated that [MEDICATION NAME] should not be administered to a resident with a PCN allergy and that the physician should have been notified of Resident 1's PCN allergy to request an alternate antibiotic, to ensure that Resident 1 received an antibiotic as soon as possible. LN E stated that antibiotics should be administered within four hours of receiving the physicians order, and documented in the nursing narrative note. LN E confirmed that no nursing narrative notes were found for her shift on 1/4/14. During an interview and concurrent record review on 4/8/14 at 4:20 pm, LN D confirmed that on 1/5/14 at 1:38 pm, the nursing narrative notes she had written indicated that orders had been received to "start [MEDICATION NAME] (and) ... orders (were) noted and carried out." LN D confirmed that no evidence was found that the [MEDICATION NAME] had been started and the order had been carried out (implemented). During an interview on 4/9/14 at 6:50 am, LN F stated that he was Resident 1's nurse from 10:30 pm on 1/6/14 through 7 am on 1/7/14. LN F stated that he noted the order for [MEDICATION NAME] during his shift, that antibiotics were required to be administered within four hours of the written order, and confirmed that the [MEDICATION NAME] was not administered within four hours of when it was ordered.

Based on interview and record review, the facility failed to ensure Licensed Nurse (LN) B examined Resident 1 after a fall on 3/9/12. Licensed nurses caring for Resident 1 on subsequent shifts, from 3/9/12 to 3/12/12, did not provided ongoing assessments and monitoring of Resident 1's physical condition for injuries or complications, in accordance with their clinical protocols for falls. As a result, Resident 1's [MEDICAL CONDITION] was not identified and treated for [REDACTED]. was crying and holding her left hip. Findings: On 3/12/12, the facility found that Resident 1 had redness, swelling and pain in her left hip area. An x-ray was obtained and showed that Resident 1 had a fractured left hip (proximal femur). The facility notified the Department of the incident, via fax, on 3/14/12. The facility's policy "Falls-Clinical Protocol," revised October 2010, identified four components used in their protocol to manage falls and fall risk. The first addressed physician and staff responsibilities in the assessment and recognition of residents at risk for fall and/or significant complications of falls. The protocol instructed staff to assess and identify risk factors, which included hypertension, cognitive impairment, and confusion. Physicians were to identify medical conditions such as the increased fracture risk in someone with [MEDICAL CONDITION]; the thinning of bone tissue and loss of bone density over time. Staff were instructed to consider and treat circumstances, such as sliding out of a chair, as a fall. The second component instructed staff to attempt to define possible causes within 24 hours of falls. The third component instructed staff to identify pertinent interventions to address the risk for, and causes of falls. The last component, monitoring and follow-up, instructed staff to monitor for consequences and/or delayed complications such as late fractures and major bruising that could occur hours or several days after a fall. The facility policy, Assessing Falls and Their Causes, revised October 2010, further specified that "Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record." In a written statement (no date), and interview on 3/22/12 at 3 pm, Certified Nurse Assistant (CNA) A described the event that occurred on 3/9/12 at approximately 7 pm. CNA A stated that she was getting Resident 1 ready for bed; the resident was in her nightgown sitting in her wheelchair next to the bed. CNA A was getting ready to put on her gait belt to transfer Resident 1 to bed when the resident scooted forward, her bottom was on the edge of the wheelchair seat and she was sliding out of her chair. CNA A stated that she was afraid Resident 1 was going to fall, so she helped the resident to the floor. CNA A statement read, "Resident 1 screamed out when I sat her down, but she screams out all the time, so it wasn't out of the ordinary." CNA A stated that she placed a pillow under Resident 1's head, and then left the room to tell Licensed Nurse (LN) B what happened. CNA A said that she asked LN B if she needed to take Resident 1's vital signs (recording body temperature, heart rate, blood pressure, and respiratory rate) and LN B told her "No." With the assistance of CNA C, CNA A transferred Resident 1 to bed. CNA A statement read, "Resident 1 screamed out again, but that wasn't out of the ordinary for her."... "Later that night, on last rounds, ...when we pulled her up (in bed) Resident 1 screamed out a little, but once we turned her, she was fine." During an interview on 3/22/12 at 3:45 pm, CNA C stated, during the evening of 3/9/12 she went into Resident 1 room and saw Resident 1 lying on the floor with a pillow under her head. CNA C stated, as she was assisting CNA A to transfer Resident 1 to bed the resident yelled out. CNA C stated, on 3/11/12 she noticed a palm size, blue and purple bruise on the back of Resident 1's left leg above the knee, and reported the finding to LN D. CNA C's written statement (no date) read, "On 3/11/12 CNA E and I noticed a bruise on Resident 1's leg. We reported it to the nurse before 5:30 pm. After dinner, around 7 pm, Resident 1 screamed in pain yelling, "It hurts!" "Anytime CNA E touched Resident 1's hip, she would scream in more pain." CNA E's written statement dated 3/12/12, read, on 3/11/12 Resident 1 was put to bed around 6:45 or 7 pm. "... She was screaming and whimpering. She usually vocalizes when we put her to bed but this was a little more intense. When I put my hand on her left hip/thigh area, Resident 1 said, "Oh, it hurts to touch." CNA E reported the incident to LN F. During her last rounds, around 9:45 pm, CNA E noted that "Resident 1 was asleep on her back ... she whimpered when I rolled her towards me. She seemed like she was in discomfort...it seemed like her pain was probably a two out of ten, if I had to guess." In LN F's written statement dated 3/12/12, LN F acknowledged that she was informed of Resident 1's leg pain. There was no documentation in Resident 1's record that LN F assessed Resident 1 verbalizations of pain after LN F was informed by CNA C and CNA E of a change in Resident 1's normal condition. During an interview on 3/22/12 at 3:55 pm, LN D confirmed that on 3/11/12, CNA C told her that Resident 1 had a bruise. LN D stated that she could not recall the size or location of the bruise on Resident 1's leg, and could not definitively say that she assessed the bruise. LN D stated that she did not document an assessment or monitoring of the bruise. LN D confirmed that the facility policy was to report, assess, document and monitor bruising. LN D also stated that she did not remember if she told the oncoming shift about the bruise. CNA G's written statement dated 3/12/12 read, "This morning I came in at 6:30 am, found Resident 1 up in wheel chair crying and holding her left hip. Her leg was turned outward and limp. Went straight to nurse (LN I) and reported it. Resident 1 cried in pain when touching the left hip and knee." On 3/22/12, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was unable to verbalize her needs, and was dependent on staff for eating, dressing and bathing. Resident 1 was unable to walk and had to be physically lifted in and out of bed by staff. Resident 1 was unable to maneuver her wheelchair and depended on staff to move her around the facility. There was no documentation entered into Resident 1's medical record on 3/9/12 regarding the resident being lowered to the floor or that she complained of left hip pain and that there was an increase in yelling out with care. There was no documentation of ongoing assessments, monitoring of the resident for injuries or complications following the incident on 3/9/12, and no documentation of a bruise being discovered behind her left knee on 3/11/12, in accordance with the facility's policies and nursing standard of care. An entry on Resident 1's 3/2012 medication flowsheet read, "Monitor for the presence of pain every shift using scale 0 -10. Zero equals no pain..." On the day, evening, and night shifts of 3/9, 3/10, and 3/11/12 Resident 1 was assessed as 0 (zero) no pain. Resident 1's PRN (as needed) Medication Flowsheet for 3/2012 showed that Resident 1 was able to receive two Tylenol tablets every four hours as needed (for pain). Despite Resident 1's yelling, screaming, crying, whimpering and complaints of pain in her left hip, there was no documentation that the cause of her discomfort was evaluated until 3/12/12 at 12:20 pm. The Resident Progress Note written at that time by LN H read, Resident complaining if increased pain with facial grimacing...left upper extremity red and swollen by hip, resident stated pain level 8 out of 10, two Tylenol tablets (650 milligrams) administered. LN H notified Resident 1's physician and obtained an order for [REDACTED]. The IDT (Interdisciplinary Team) noted dated 3/14/12 at 6:37 pm, contained the following information. On 3/12/12 at 4:50 am, CNAs got Resident 1 up and transferred her from her bed into her wheelchair. At approximately 7 am a CNA reported to a nurse that Resident 1's leg seemed to be hanging and crooked. The nurse examined the leg..., and moved the leg to the foot pedal. Resident was noted to be whimpering at that time. At approximately 12:00 pm, on the same day, the CNA brought the Resident to the nurse ' s station because she felt that something seemed wrong with the Resident. The nurse assessed the lower left proximal extremity by the hip and noticed that it was red, swollen and passive. Tylenol was administered, the physician was notified and an x-ray was ordered. The x-ray was obtained at 1 pm, and at 3:40 pm X-ray results showed left hip (proximal femur) fracture. At 3:50 pm, the MD responded with an order to transfer Resident 1 to hospital. During an interview on 6/21/12, the administrator stated that nursing staff did not provide post-fall care to Resident 1 in accordance with the facility's policies.