Every finding on record at Bakersfield Post Acute

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 2, Resident 3, and Resident 4) were treated with dignity and respect when urinary catheter bags were left uncovered for Resident 2, Resident 3, and Resident 4. These failures had the potential to impact Resident 2, Resident 3, and Resident 4's privacy, confidentiality, and dignity.Findings:During a concurrent observation and interview, on 8/26/26 at 1:08 p.m. with Licensed Vocational Nurse (LVN) 1, outside of Resident 2's room. Resident 2's catheter bag was uncovered and contained yellow fluid. LVN 1 stated Resident 2's catheter bag has not been drained, and it had no dignity bag cover.During a concurrent observation and interview, on 8/26/26 at 1:10 p.m. with LVN 1, outside of Resident 3's room. Resident 3's catheter bag was uncovered and contained yellow fluid. LVN 1 stated Resident 3's catheter bag has not been drained, and it had no dignity bag cover.During a concurrent observation and interview, on 8/26/26 at 1:107 p.m. with LVN 1, outside of Resident 4's room. Resident 4's catheter bag was uncovered and contained yellow fluid. LVN 1 stated Resident 4's catheter bag has not been drained, and it had no dignity bag cover.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised August 2009, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . d. Privacy and confidentiality

Based on interview and record review, the facility failed to ensure medications were administered per physicians' order for two of four sampled residents (Resident 1 and Resident 5). This failure had the potential for adverse outcome including heart attack for Resident 1 and potential for ineffective medication regimen for Resident 5.Findings:During a concurrent interview and record review on 8/28/26 at 2:01 p.m. with Director of Nursing (DON), Resident 1's Medication Administration Record. (MAR) for May 2026, June 2026, July 2026, and August 2026 were reviewed. The MAR had multiple ordered medication with missing initials on multiple dates. These medications included: Amlodipine (medication used to treat high blood pressure [hypertension-high blood pressure)] . Oral Tablet 10 mg (milligram- unit of measure) . Give by mouth one time a day.On 5/10/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/7/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/8/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/17/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/19/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/20/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/22/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 6/25/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 7/9/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 7/16/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 7/21/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 7/27/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 8/7/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank).On 8/19/26 at 9 a.m. Resident 1's Amlodipine was not documented as administered (blank). Heparin (medication used to prevent and treat harmful blood clots in the blood vessels, heart, and lungs) . 5000 unit/ML (milliliter-unit of measure) . Inject (force a fluid into a body or tissue) 1 application subcutaneously (the fatty layer of tissue just below the skin and above the muscle) two times a day for DVT (Deep vein thrombosis- a medical condition where a blood clot forms in a deep vein, usually in the lower leg and thighs)On 5/10/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 5/21/26 at 9 p.m. Resident 1's Heparin was not documented as administered (blank).On 6/7/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 6/8/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 6/19/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 6/20/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 6/25/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 7/9/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 7/16/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 7/21/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 7/27/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 8/7/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank).On 8/18/26 at 9 p.m. Resident 1's Heparin was not documented as administered (blank).On 8/19/26 at 9 a.m. Resident 1's Heparin was not documented as administered (blank). Gabapentin (prescription medication used to treat nerve pain) Oral Capsule 100 mg .Give 1 capsule by mouth three times a day for Neuropathy (general term for damage or disease affecting the nerves) BLE (Bilateral Lower Extremities-both legs) painOn 5/8/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 5/10/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 5/10/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 5/22/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/4/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/7/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/7/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/8/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/8/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/17/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/19/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/19/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/20/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/20/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 6/25/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/8/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/9/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/9/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/13/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/16/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/16/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/20/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/21/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/21/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/22/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/27/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/27/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 7/28/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/7/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/7/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/18/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/19/26 at 9 a.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/19/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/24/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank).On 8/25/26 at 1 p.m. Resident 1's Gabapentin was not documented as administered (blank). Pro-Stat Liquid (read-to-drink concentrated liquid protein) . Give 30 ml by mouth two times a day for Supplement.On 5/8/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 5/10/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 5/10/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 5/22/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/4/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/7/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/7/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/8/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/8/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/17/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/19/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/19/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/20/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/20/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 6/25/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/8/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/9/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/9/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/13/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/16/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/16/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/20/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/21/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/21/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).8On 7/22/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/27/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/27/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 7/28/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/7/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/7/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/18/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/19/26 at 9 a.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/19/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/24/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).On 8/25/26 at 1 p.m. Resident 1's Pro-Stat was not documented as administered (blank).During a concurrent interview and record review on 8/28/2 at 2:01 p.m. with DON, DON confirmed Resident 1 had multiple dates with blank, (missing initials) on Resident 1's MAR for the month of May 2026, June 2026, July 2026, and August 2026.During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 6/20/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (a score of 13 to 15 points indicated the resident was cognitively intact).During an interview on 8/28/26 at 12:45 p.m. with Resident 1, Resident 1 stated, sometimes the facility runs out of Pro-Stat and Heparin.During a concurrent interview and record review on 9/11/26 at 3:53 p.m. with Quality Assurance Nurse (QAN), Resident 1's MAR for May 2026, June 2026, July 2026, and August 2026 were reviewed. QAN stated the medications were not available. QAN stated we should have the medication supply on hand all the time.Resident 5's Medication Administration Record, was reviewed with QAN. On 9/10/26 Resident 5's Ozempic (medication used for weight loss) 1 mg one time a day every Thursday for weight loss, was not administered. Resident 5's corresponding Medication Administration Note, indicated the medication was not available. QAN stated the Ozempic should have been ordered after the fourth dose was administered.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 3. Medications are administered in accordance with prescribed orders, including any required time frame. 4. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example, before and after meal orders) . 11. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 12. As required or indicated for a medication, the individual administering the medication records in the resident medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable) e. the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to provide documentation of competency and skills performance for three of five sampled Certified Nursing Assistants (CNA 8, CNA 10, and CNA 11). This failure had the potential to result in lack of competent and skilled staff and residents needs not being met.Findings:During a concurrent interview and record review on 5/12/26 at 2:11 p.m. with Director of Staff Development (DSD), CNA 8's Personnel File (PF) was reviewed. The PF indicated the last competency was completed on 3/1/25. DSD stated the next competency was due on 3/1/26 and it was not completed. DSD stated the competency was completed to ensure staff were competent to take care of residents and meet their needs.During a concurrent interview and record review on 5/12/26 at 2:22 p.m. with DSD, CNA 10's PF was reviewed. The PF indicated the last competency was completed on 3/23/25. DSD stated the next competency was due on 3/23/26 and it was not completed.During a concurrent interview and record review on 5/12/26 at 2:24 p.m. with DSD, CNA 11's PF was reviewed. The PF indicated the last competency was completed on 3/1/25. DSD stated the next competency was due on 3/1/26 and it was not completed.Policy was requested and the facility provided policy and procedure (P&P) titled Competency Evaluations dated 12/2026 but the P&P did not address how often the competencies should be completed.

Based on interview and record review, the facility failed to complete annual performance evaluations for five of five sampled Certified Nursing Assistants (CNA 7, CNA 8, CNA 9, CNA 10, and CNA 11). This failure had the potential for CNAs not being aware of their need for improvement in a certain area which could affect all the residents' care.Findings:During a concurrent interview and record review on 5/12/26 at 1:59 p.m. with Director of Staff Development (DSD), CNA 7's Personnel File (PF) was reviewed. The PF indicated CNA 7 was hired on 4/12/23 and there was no performance evaluation found in PF. DSD stated there was no performance evaluation completed for CNA 7.During a concurrent interview and record review on 5/12/26 at 2:11 p.m. with DSD, CNA 8's PF was reviewed. The PF indicated CNA 8 was hired on 3/1/23 and there was no performance evaluation. DSD stated there was no performance evaluation completed for CNA 8. DSD stated performance evaluation was completed to ensure how staff can grow.During a concurrent interview and record review on 5/12/26 at 2:17 p.m. with DSD, CNA 9's PF was reviewed. The PF indicated CNA 9 was hired on 3/1/23 and there was no performance evaluation. DSD stated there was no performance evaluation completed for CNA 9.During a concurrent interview and record review on 5/12/26 at 2:22 p.m. with DSD, CNA 10's PF was reviewed. The PF indicated CNA 10 was hired on 3/1/23 and there was no performance evaluation. DSD stated there was no performance evaluation completed for CNA 10.During a concurrent interview and record review on 5/12/26 at 2:24 p.m. with DSD, CNA 11's PF was reviewed. The PF indicated CNA 11 was hired on 3/1/23 and there was no performance evaluation. DSD stated there was no performance evaluation completed for CNA 11.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 9/2020, the P&P indicated, 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

Based on interview and record review, the facility failed to follow their Facility Assessment (a document that indicates the facility's resources to meet resident needs), when Certified Nursing Assistant (CNAs) had more residents than it was planned. This failure had the potential for all residents not receiving sufficient nursing care.Findings:During a review of Nursing Staffing Assignment (NSA), dated 12/3/25, the NSA indicated there were 92 residents in the facility and there were total of nine CNAs scheduled in the morning shift [a ratio of 10 residents per CNA] and seven CNAs scheduled in the evening shift [a ratio of 13 residents per CNA].During a review of NSA, dated 12/10/25, the NSA indicated there were 99 residents in the facility and there were a total of seven CNAs scheduled in the morning shift [a ratio of 14-15 residents per CNA] and eight CNAs scheduled in the evening shift [a ratio of 12-13 residents per CNA].During a review of NSA, dated 12/24/26, the NSA indicated there were 94 residents in the facility and there were a total of seven CNAs scheduled in the morning shift [a ratio of 13-14 residents per CNA] and six CNAs scheduled in the evening shift [a ratio of 12-13 residents per CNA].During an interview on 5/13/26 at 9:22 a.m. with CNA 16, CNA 16 stated she has been working in the facility for over six months. CNA 16 stated she normally works in the morning shift and today, she had 11 residents. CNA 16 stated she normally has 11-13 residents. CNA 16 stated when the facility was short staff, she had up to 15 residents and sometimes showers or repositioning of residents gets missed.During an interview on 5/13/26 at 1:10 p.m. with CNA 17, CNA 17 stated she has been working at the facility for two years and she has been working the morning shift. CNA 17 stated she has 11 residents today.During an interview on 5/13/26 at 1:46 p.m. with CNA 18, CNA 18 stated she has been working the morning shift. CNA 17 stated she has 11 residents today. CNA 18 stated when facility was short staff, they had up to 18 residents. CNA 18 stated when they were short staff it takes longer to answer the call light and sometimes showers were being missed.During a concurrent interview and record review on 5/13/26 at 3:52 p.m. with Director of Staff Development (DSD), DSD stated she took over this position because the previous DSD was not scheduling enough CNAs to meet resident needs and she did not ensure the showers were being completed. DSD reviewed the shower sheets and stated there were no shower sheets on 12/3/25, 12/10/25 and 12/24/25.During a concurrent interview and record review on 5/13/26 at 4:19 p.m. with DSD, Facility Assessment (FA), dated 12/18/25 was reviewed. The FA indicated CNA/RNA [Restorative Nursing Assistant] has 1 to 8-9 residents' ratio for day shift, 1 CNA/RNA to 11 residents' ratio during evenings, and 1 CNA to 16 resident ratios during nights. DSD stated the facility did not meet the staffing requirements in the facility assessment.During a review of facility's policy and procedure (P&P) titled, Bath, Shower, dated 2/2018, the P&P indicated, Documentation 1. The date and time the shower was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data.During a review of facility's P&P, titled, Staffing, Sufficient and Competent Nursing, dated 8/2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation and interview, the facility failed to maintain a safe environment when cardboard boxes containing detergents, bleach and soap, were being stored behind the washing machine. This failure had the potential for increasing the fire hazard affecting all residents, staff, and visitors in the facility. Findings:During an observation on 5/13/26 at 8:03 a.m., in the laundry room, there were multiple cardboard boxes containing commercial detergents, bleach, and soap solutions stored behind the washing machine. The cardboard boxes were stored behind the washing machine approximately one to two inches from the back of the washing machine. The back of the washing machine had electrical wiring, tubing, water hoses, and a heat emitting motor. During an interview on 5/13/26 at 8:12 a.m. with the Housekeeping and Laundry Supervisor (HLS), in the laundry room, HLS stated, They [cardboard boxes] should not be there.During an interview on 5/13/26 at 8:55 a.m. with the Housekeeping and Laundry Manager (HLM), HLM stated there was no policy for safely storing supplies.

Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for four of 53 sampled residents (Resident 107, Resident 76, Resident 14, and Resident 85). This failure had the potential for residents not being assisted with their activities of daily living and have a delay in care. Findings:During an interview on [DATE] at 8:49 a.m. with Resident 107, Resident 107 stated call light was not answered timely. Resident 107 stated, That's [waiting for a long time for call light to be answered] punishment I don't deserve.During a review of Resident 107's Nursing - Admission/readmission Evaluation/Assessment (NAREA), dated [DATE], the NAREA indicated, Resident 107 was alert and oriented.During a review of Resident 107's Care Plan Report (CPR), dated [DATE], the CPR indicated under Interventions/Tasks, Transfer: Assist of (substantial) (Resident 107 requires substantial assistance with activities of daily living).During an interview on [DATE] at 8:50 a.m. with Resident 76, Resident 76 stated, Takes [staff] long to answer call light.During a review of Resident 76's Brief Interview For Mental Status (BIMS-cognitive screening), dated [DATE], BIMS indicated Resident 76 had a score of 15 (score of 13-15 means cognitively intact). Resident 76 Functional Abilities (FA), dated [DATE], the FA indicated Resident 76 was dependent with activities of daily living.During an interview on [DATE] at 10:01 a.m. with Resident 85, Resident 85 stated, I waited over an hour for a pain pill, because they took tool long to answer the call light.During a review of Resident 85's BIMS dated [DATE], BIMS indicated Resident 85 had a score of 15. Resident 85 FA, dated [DATE], the FA indicated Resident 85 was required substantial/maximal assistance (Helper does more than the effort) with activities of daily living.During an interview on [DATE] at 10:03 a.m. with Resident 14, Resident 14 stated the call light was not answered timely.During a review of Resident 14's Minimum Data Set (MDS comprehensive assessment tool), dated [DATE], the MDS indicated Section C - Cognitive Patterns BIMS summary score of 15. Resident 14's Section GG - Functional Abilities dated [DATE], the Section GG indicated Resident 14 was dependent with activities of daily living.During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated [DATE], the P&P indicated, 7. Answer the resident's call as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure:1) Floor mats were implemented bilaterally for one of six sampled residents (Resident 51).2) Falling star was implemented for one of six sampled residents (Resident 70).3) Certified Nursing Assistants (CNAs) were knowledgeable on falling star program.4) One of three sampled residents (Resident 51) was safely transferred when utilizing a Hoyer lift (a mechanical assistive device designed to safely transfer residents with limited mobility between a bed, wheelchair, or bathroom).These failures had the potential to result in injury for Resident 51, Resident 70 and other fall risk residents.5) To prevent accidents for one of six residents (Resident 51) when the facility failed to evaluate Resident 51's personal shower chair for safety before allowing its use, failed to train staff on the use and operation of Resident 51's personal shower chair, and allowed Resident 51 to use his personal shower chair when the facility knew it was unsafe. These failures resulted in Resident 51's falling from his personal shower chair during a shower causing Resident 51 to hit his head on the wall and his face on the floor of the shower stall. As a result of the impact on the wall and floor from the fall, Resident 51 suffered a nosebleed, experienced severe pain, and was sent to the hospital for evaluation and treatment of his injuries. Findings: 1) During a review of Resident 51's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on Falls: [Resident 51] is at risk for falls, initiated [DATE]. The care plan indicated a few of the interventions were Floor mat to left and right side, initiated [DATE]. During a concurrent observation and interview on [DATE] at 9:43 a.m. with Certified Nursing Assistant (CNA) 3, inside Resident 51's room, Resident 51 was sleeping in bed. During a concurrent observation and interview on [DATE] at 10:27 a.m. with CNA 3 outside of Resident 51's room, CNA 3 stated Resident 51 did not have fall mats at bedside. 2) During a concurrent observation, interview, and record review, on [DATE] at 10:33 a.m. with Director of Staff Development (DSD) outside of Resident 70's room, Resident 70's care plan with the focus on Falls: Resident had an unwitnessed fall on [DATE] initiated [DATE] was reviewed. The care plan indicated, Falling Star fall prevention program (place Falling Star identifier on the outside of room door and on assistive devices as applicable). DSD stated no falling star on Resident 70's name plate. 3) During an interview on [DATE] at 9:48 a.m. with CNA 14, CNA 14 stated the happy face sticker indicated fall risk. During an interview on [DATE] at 10:53 a.m. with CNA 6, CNA 6 stated the happy face sticker indicated the resident was a fall risk. During an interview on [DATE] at 3:54 p.m. with the Director of Nursing (DON), DON stated that the happy face sticker indicated the resident was on enhanced barrier precautions and the gold star on a resident name plate indicated the resident was part of the falling star program. 4) During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated [DATE], the MDS indicated Resident 51's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). During a review of Resident 51's Change in Condition Evaluation (CICE), dated [DATE], the CICE indicated, [Resident 51] stated that when he was getting transferred by two CNAs to the [NAME] chair [specialized padded medical chairs on wheels designed for resident with limited mobility] he hit his neck, and shoulder on the corner of the bed. (Resident 51) c/o (complained of) neck and back pain 8/10 [numeric pain scale - allow residents to rate their pain. Zero is considered no pain; 1 to 3 is mild pain; 4 to 6 is moderate pain and 7 to 10 is severe pain]. During a review of the facility provided Incident Report, dated [DATE], written by CNA 14, the statement indicated, When lifting [Resident 51] from bed, I tried not to have [Resident 51] all the way up as we had to adjust [Resident 51]. When turned to the side w/out [without] moving Hoyer the weight of the (Resident 51) caused bed to tilt. During an interview on [DATE] at 1:58 p.m. with Resident 51, Resident 51 stated he was dropped by a CNA 14 on Monday ([DATE]). Resident 51 stated he was supposed to be transferred with the use of a Hoyer lift and there should always be two CNAs but on Monday CNA 14 came in and transferred him alone. Resident 51 stated the Hoyer lift tipped over and he hit the back of his head and neck on the foot board of the bed. Resident 51 stated the CNA 14 left the room and returned with a female CNA 15 who assisted him back to bed. Resident 51 stated he asked to be transferred back to the Geri-chair so he could go and talk to the nurse and tell her what happened. Resident 51 stated when he spoke to the nurse, the CNAs had already told her a whole different story. During an interview on [DATE] at 9:48 a.m. with CNA 14, CNA 14 stated on [DATE] there was an incident happened when he and CNA 15 were transferring Resident 51 from bed to Geri chair. CNA 14 stated Resident 51 was ready for transfer he and CNA 15 started hooking Resident 51 up and raised Resident 51 up just a little. CNA 14 stated, when the bed shift, I saw [Resident 51] lean down because of the weight CNA 14 and CNA 15 decide to lift the Hoyer higher to prevent the bed form shifting. CNA 14 stated the bed shifted due to Resident 51's weight. CNA 14 stated Resident 51's left side was still touching the bed. During an interview on [DATE] at 11:52 a.m. with CNA 15, CNA 15 stated on Monday ([DATE]) she assisted CNA 14 with Resident 51's transfer. She stated, When I went in, [Resident 51] was dressed and in the sling when we [CNA 14 and CNA 15] went to turn [Resident 51] the foot of his bed went down and the head went up it was weird so we had already had him turned so we just lifted the Hoyer a little more and placed [Resident 51] in the chair. During a concurrent interview and record review on [DATE] at 4:06 p.m. with DON, DON stated Resident 51 hit his head during a Hoyer lift transfer. DON stated with Resident 51's condition it may have been a nerve sensation but both CNAs said he did not touch the bed or anything. DON stated CNA 14 and CNA 15 had consistent stories and there were no other witnesses, DON stated CNA 14 and CNA 15 stated Resident 51 did not touch the bed. CNA 14's Incident report, dated [DATE] was reviewed. DON stated CNA 14's statement indicated Resident 51 was in contact with the mattress when the transfer took place. During a review of the Facility's Competency Evaluation (CE) titled, Transferring with a Mechanical Lift (2 Person Assist), undated, the CE indicated, Transferring from Bed to Chair . 22. On the count of three raise the lift using the lift control until the resident and the sling are elevated and clear of the bed. Transferring from Chair to Bed . 47. On the count of three raise the lift using the lift control until the resident and the sling are elevated and clear of the wheelchair/geri-chair (sic). During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 1/2025, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide priorities. 4. Employees Shall be trained and inserviced (sic) on potential accident hazards and how to identify and report accident hazards, (sic) and try to prevent avoidable accidents. 4. Employees Shall be trained and inserviced (sic). 4 Implementing interventions to reduce accident risk and hazards shall include the following: . c. providing training, as necessary; . d. ensuring that interventions are implemented; and . 5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently. 5) During a review of Resident 51's admission Record (AR), undated, the AR indicated Resident 51 was admitted to the facility on [DATE] with a primary diagnoses of complete quadriplegia (total paralysis of both arms and legs). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had a BIMS score of 15 and was completely dependent (helper does all the effort/resident does none of the effort to complete the activity) for bathing and showers. During a review of Resident 51's Care Plan Report (CPR), [DATE], the CPR indicated Resident 51 had a shower chair brought from home for his use in the facility. The CPR indicated, [Resident 51] prefers to use his own shower chair from home. The CPR indicated [Resident 51's] preference will be honored. The CPR indicated the following interventions initiated on [DATE]: (1) maintenance to eval[uate] chair for safety, okay'ed for use, (2) explain risk v benefits of using his own chair, (3)honor resident's preferences, (4) therapy to educate resident on safety. During a review of Resident 51's clinical record, the clinical record indicated document titled [Facility] Resident Personal Equipment Acknowledgement & Liability Waiver (Liability Waiver), dated and signed by Resident 51 on [DATE]. The Liability Waiver indicated Resident 51 agreed to bring and use his own personal shower chair at the facility; agreed that the facility was not responsible for maintenance, storage, condition, or safety of the shower chair; and agreed that the facility assumed no liability for injury related to the use of the shower chair. During an observation on [DATE] at 11:45 a.m. in front of the shower room in the 400 hall, Resident 51 was taken out of the shower room on a stretcher by Emergency Medical Personnel (EMS) and CNA 5. Resident 51 had gauze on his right nostril. During a concurrent observation and interview on [DATE] at 11:47 a.m. with CNA 5 in the 400 hall shower room, CNA 5 stated Resident 51 was being taken to hospital because he had fallen in the shower, hit his head on the floor, and was bleeding from his nose. An observation of the shower room indicated a pool of blood on the upper left corner of the shower stall. CNA 5 stated Resident 51 was on his personal shower chair in the shower stall when his personal shower chair rolled towards the center of the stall, flipped over, and threw Resident 51 on the floor. CNA 5 stated he did not witness the fall but the above was reported to him by CNA 6, who was with Resident 51 in the shower room when Resident 51 fell. During an interview on [DATE] at 12:12 p.m. with CNA 6, CNA 6 stated she was showering Resident 51 when he fell. CNA 6 stated Resident 51 was on his personal shower chair in the shower room. CNA 6 stated when she turned around to close the shower curtain, Resident 51's personal shower chair flipped on its side and threw Resident 51 on the floor. CNA 6 stated Resident 51 hit his head and face on the floor and started bleeding from his nose. CNA 6 stated Resident 51 was too heavy for his personal shower chair, which caused the chair to flip over. CNA 6 stated before showering Resident 51, she offered and advised Resident 51 to use the facility's shower bed for safety reasons, but Resident 51 requested to use his personal shower chair. CNA 6 stated Resident 51 personal shower chair was unsafe for him to use. During an observation [DATE] at 3:35 p.m. in the 300 hall, Resident 51 returned from the hospital to the facility, brought back by EMS on a stretcher. During a concurrent observation and interview on [DATE] at 3:37 p.m. in Resident 51's room with the Director of Maintenance (DM), DM inspected and measured Resident 51's shower chair. The shower chair was composed of a metal frame with a slanted/tilted back seat, a plastic back support, both footrests, both armrests, and four wheels. The two back wheels had foot-operated locks. DM stated the shower chair had a seat height of 20 inches. During a review of Resident 51's Rehab[ilitation] – Status Post-Fall Screen[ing] (RSPFS), dated [DATE] at 4:18 p.m., the RSPFS indicated, Resident [51] is quadriplegic with inability to use his B[ilateral] (both sides) UE [Upper Extremities] (arms) and B LE [Lower Extremities] (legs), and has no sitting balance. Recommended to use shower gurney for showers. to decrease the risk for falls. During a review of Resident 51's Interdisciplinary Team (IDT a group of health care professionals with various of expertise who work together to improve residents safety and outcome) Note dated [DATE] at 6:50 p.m., the IDT Note indicated Resident 51 had a witnessed fall on [DATE] at 11:46 a.m. The IDT Note indicated, [Resident 51] had a witnessed fall in the 400 hall shower room .IDT determined fall was due to inability to maintain safe seated posture during bathing related to impaired trunk control, combined with use of a personal shower chair per preference. During an interview on [DATE] at 9:05 a.m. with Resident 51 in his room, Resident 51 stated he fell from his personal shower chair because CNA 6 did not lock its wheels allowing his personal shower chair to roll inside the shower stall, causing his weight to shift to the right side and his personal shower to chair to flip over on its side, launching him towards the floor. Resident 51 stated when he fell he first hit his head on the side wall and then hit his face on the floor of the shower stall, causing pain and a nosebleed. Resident 51 stated he experienced pain 10/10 (on a scale of zero – 10 were zero is no pain and 10 the worst pain possible) on his face and head because of the fall. During an interview on [DATE] at 8:10 a.m. with DM, DM stated Resident 51 had brought a personal shower chair to the facility. DM stated the facility did not have or used that type of shower chair. DM stated he was first informed Resident 51 had a personal shower chair on [DATE] after Resident 51 fell, at which time he inspected the shower chair and found it to have no mechanical defects. DM stated he only inspected the shower chair for mechanical defects. DM stated he was not qualified to evaluate the shower chair for safety. During interviews with the Director of Rehabilitation (DOR) on [DATE] at 11:40 a.m. and at 11:53 a.m., DOR stated Resident 51's personal shower chair was only evaluated for safety on [DATE] after Resident 51's fall. DOR stated Resident 51's personal shower chair was unsafe because the seat was off balance, meaning when Resident 51 shifted his weight the weight could cause the shower chair to flip over. DOR stated the facility did not use those shower chairs and it was the first time she had seen one. During an interview on [DATE] at 1:40 p.m. with CNA 6, CNA 6 stated Resident 51's personal shower chair was not a model the facility used and no other resident in the facility had it. CNA 6 stated when she took Resident 51 to the shower on [DATE], it was the first time she had operated that type of shower chair. CNA 6 stated she had not been trained on the use or operation of Resident 51's personal shower chair. During an interview on [DATE] at 8:08 a.m. with the Director of Staff Development (DSD), DSD stated CNAs were trained in the use of resident shower chairs. DSD stated Resident 51's personal shower chair was not a model the facility used. DSD stated the facility's CNAs had not been trained in the use of Resident 51's personal shower chair. During an interview on [DATE] at 10:27 a.m. with DON, DON stated Resident 51 brought his personal shower chair to the facility on [DATE] and requested it to be used for his showers. DON stated his personal shower chair was unsafe and for this reason Resident 51 signed a liability waiver assuming responsibility for its use and releasing the facility of responsibility for any injuries resulting from its use, which Resident 51 signed on [DATE]. During an interview on [DATE] at 1:45 p.m. with DON, DON stated the facility's process for residents who bring their own personal equipment to the facility, such as shower chairs, was for residents to sign a liability waiver assuming all responsibility for the use of the equipment and releasing the facility of responsibility for any injuries. DON stated Resident 51 had the right to keep and use personal property in the facility, including his personal shower chair. DON stated it was a resident rights issue and provided the facility's policy and procedure (P&P) on resident rights. During a review of the facility's P&P titled, Resident Rights, revised [DATE], the P&P indicated, Federal and state laws guarantee certain rights to all residents in the facility. These rights include the resident's right to: (k) Retain and use personal possessions to the maximum extent that space and safety permit. During a review of the facility's P&P titled, Job Description: Certified Nursing Assistant, undated, the P&P indicated, Perform only those nursing care procedures that you have been trained to do. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised [DATE], the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes and try to prevent the resident from falling.

Based on observation, interview, and record review, the facility failed to notify physician and responsible party of abuse allegation and change of condition for three of five sampled residents (Resident 81, Resident 83, Resident 4). This failure had the potential for Resident's not to receive care and services and for physician and responsible party not to be made aware of the alleged abuse and change of condition. Findings: During a review of Resident 81's Minimum Data Set (MDS - an assessment tool), dated 2/1/26, the MDS indicated, Resident 81's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). During a concurrent observation and interview on 4/9/26 at 2:17 p.m. with Resident 81, outside of Resident 81's room. Resident 81 stated that his roommate hit him last week (4/3/26). Resident 81 stated he blocked the hit from Resident 109 with his right forearm and he sustained a bruise to his right forearm; several bruises observed on right forearm of various stages of healing. During an interview on 4/9/26 at 4:38 p.m. with CNA 1, CNA 1 stated Resident 81 told him that Resident 109 had struck Resident 81 on his right forearm (4/3/26). CNA 1 stated there was what looked like a fresh mark on Resident 81's right forearm on that (4/3/26) day he stated Resident 81 always has red or purple marks on his arm but these marks looked fresh. During an interview on 4/15/26 at 4:21 p.m. with Director of Nursing (DON), DON stated the alleged abuse occurred on 4/3/26. DON stated the abuse allegations were not reported to the facility until 4/9/26, when this State Surveyor notified her of the allegations. DON stated there was no assessment completed until 4/9/26 (six days after the alleged abuse was reported to facility's staff). DON confirmed no physician or responsible party notification was made until 4/9/26 (six days after the alleged abuse was reported to facility's staff). During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician on call when there has been a (an) : a. accident or incident involving the resident. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR [Situation, Background, Assessment, and Recommendation] Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. During a review of Resident 83's BIMS, dated 3/27/26, the BIMS indicated, Resident 83's score was 10 (8-12 means moderate cognitive impairment). During a concurrent interview and record review on 5/13/26 at 10:15 a.m. with Quality Assurance (QA) Nurse, Change in Condition Evaluation (COC), dated 5/9/26 was reviewed. The COC indicated Resident 83 had an open wound to left foot and redness with swelling to the right lower leg. COC indicated under Resident Representative (RP) Notification stated self. QA Nurse stated there was no RP notified. QA Nurse stated only the resident was notified and not RP. During a concurrent interview and record review on 5/13/26 at 10:17 a.m. with QA Nurse, Change in Condition Evaluation (COC), dated 5/11/26 was reviewed. The COC indicated, Resident 83 had a skin tear on left forearm. The COC indicated under Resident Representative Notification indicated self. QA nurse stated there was no RP notified. QA Nurse stated only the resident was notified and not RP. During a review of Resident 4's BIMS dated 2/17/26, the BIMS indicated, Resident 4's score is 3 (Severe cognitive impairment). During a concurrent interview and record review on 5/13/26 at 10:40 a.m. with QA nurse, COC, dated 5/8/26 was reviewed. The COC indicated Resident 4 had weight loss. The COC indicated under Resident Representative Notification indicated self. QA Nurse stated there was no RP notified. QA Nurse stated only the resident was notified and not RP. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician on call when there has been a (an) : a. accident or incident involving the resident. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR [Situation, Background, Assessment, and Recommendation] Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to implement infection control practices when:The residents' clean personal laundry was not stored in a designated space to reduce the risk of contamination.The portable air conditioner (AC) in the laundry room had thick grey colored debris in the front and side vent grills.Two of two Certified Nursing Assistants (CNA 12 and CNA 13), did not follow their policy and procedure (P&P) on Enhanced Based Precaution (EBP - an infection control intervention designed to reduce the spread of multidrug-resistant organisms [MDROs - These are germs-primarily bacteria-that have evolved to resist multiple classes of antimicrobial drugs, making the infections they cause highly difficult, and sometimes impossible, to treat with standard medications in nursing homes and long-term care facilities]).These failures had the potential to spread infections and diseases to residents, staff, and visitors.Findings:1.During a concurrent observation and interview on [DATE] at 8:03 a.m. with Housekeeping/Laundry Supervisor (HLS) in the laundry room, the residents' clean personal laundry was stored in the HLS office. There were chemicals, cleaning materials, office desk, microwave, filing cabinets, and personal belongings approximately two feet from the residents' clean personal laundry. HLS stated, We have nowhere else to store them.During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated [DATE], the P&P indicated, Storage: 3. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.2. During a concurrent observation and interview on [DATE] at 8:12 a.m. with HLS, in the laundry room, there was a portable AC in the clean area. The portable AC had thick grey colored debris in the front and side vent grills. HLS stated, For me, it's [portable AC] not clean.During the review of the facility's P&P titled, Cleaning and Disinfecting Resident's Rooms, dated [DATE], the P&P indicated, 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.3. During an observation on [DATE] at 2:42 p.m. in Resident 108's room, Resident 108's door had a sign for EBP. CNA 12 and CNA 13 entered Resident 108's room without wearing gowns. CNA 12 and CNA 13 went to change Resident 108's brief, clothing, and linens.During a review of Resident 108's Care Plan Report (CPR) dated [DATE], the CPR indicated, Resident [108] requires Enhanced Barrier Precautions during high contact resident care activities due to the presence of: -Chronic [long-lasting, persistent, or recurring frequently] Wound: arterial ulcer to left 2nd toe. Utilize PPE (gown and gloves, face shield as indicated) during high-contact resident care activities (e.g. dressing, bathing/showering transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care).During an interview on [DATE] at 2:49 p.m. with CNA 12 and CNA 13, CNA 12 stated they were doing patient care, and not wearing a gown. CNA 13 stated they should have worn a gown. CNA 13 stated they changed Resident 108's brief, linen, and gown.During an interview on [DATE] at 11:05 a.m. with Infection Preventionist (IP), IP stated residents on EBP, staff should wear a gown and gloves during high contact care including transferring, bathing, brief changes, turning, and bed baths.During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated February 2025, the P&P indicated, 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing).

Based on interview and record review, the facility failed to ensure resident Hemodialysis Communication Observation/Assessment (HCOA) forms were accurately completed for three of three sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 5, Resident 7, and Resident 83). This failure had the potential for Resident 5, Resident 7, and Resident 83 not to receive necessary care during and after dialysis, and for any adverse event to be addressed. Findings: During a review of Resident 7's admission Record (AR), undated, the AR indicated Resident 7 was admitted to the facility on [DATE] with a diagnoses of Diabetes Mellitus (uncontrolled sugar levels in the blood) due to underlying condition with hyperglycemia. During a review of Resident 7's Minimum Data Set (MDS a comprehensive assessment tool) dated 3/28/26, the MDS indicated Resident 7 had a Brief Interview for Mental Status (BIMS) (a cognitive assessment tool) score of 15 (scores of 13-15 indicate intact cognition). During a review of Resident 7's Order Summary Report (OSR). dated May 2026, the OSR indicated, Resident to receive Dialysis.The Dialysis schedule is 3 times per week on Monday, Wednesday, and Friday. During a concurrent interview and record review on 5/13/26 at 9:02 a.m. with Minimum Data Set Nurse (MDSN), Resident 7s HCOA dated APRIL and May 2026 was reviewed. The HCOA indicated the following: On 5/11/26 Resident 7's HCOA form was missing Resident 7's Arrival Time Post Dialysis, Licensed Nurse Signature, and date. On 5/8/26 Section to be completed by Licensed Nurse post dialysis was blank. On 5/4/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/29/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/27/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/22/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/17/26 Section to be completed by Licensed Nurse post dialysis was blank. MDSN stated Resident 7 should have had been assessed after dialysis and the HCOA form should have been fully completed. During a review of Resident 5's admission Record (AR), undated, the AR indicated Resident 5 was admitted to the facility on [DATE] with a diagnoses Type 2 Diabetes Mellitus and end stage renal disease (the finale, irreversible stage of chronic kidney disease. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had a BIMS score of 15. During a review of Resident 5's OSR, dated May 2026, the OSR indicated, Hemodialysis 3x a week every Tuesday, Thursday and Saturday. During a concurrent interview and record review on 5/13/26 at 9:28 a.m. with MDSN Resident 5s HCOA, dated APRIL and May 2026 were reviewed. The HCOA indicated the following: On 5/9/26 Resident 5's HCOA form was missing Licensed Nurse Signature and date. On 4/28/26 Section to be completed by Licensed Nurse post dialysis was blank. MDSN stated Resident 5's HCOA was missing the post dialysis treatment portion to be completed by the nurse and stated all residents returning from dialysis should be assessed for bleeding. During a concurrent interview and record review on 5/13/26 at 9:53 a.m. with Quality Assurance (QA Nurse), Resident 83's HCOA, dated April 2026 and May 2026 were reviewed. The HCOA indicated the following: On 5/9/26 Section to be completed by the Dialysis Center and Section to be completed by Licensed Nurse post dialysis were blank. On 4/29/26 Section to be completed by the Dialysis Center was blank. On 4/25/26 Section to be completed by the Dialysis Center and Section to be completed by Licensed Nurse post dialysis were blank. On 4/23/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/21/26 Section to be completed by Licensed Nurse post dialysis was blank. On 4/18/26 Section to be completed by the Dialysis Center and Section to be completed by Licensed Nurse post dialysis were blank. QA Nurse stated the HCOA's were blank and should be completed. QA Nurse stated the HCOA were blank and should have been completed. During a review of the facility's policy and procedure (P&P) titled, Dialysis Communication, dated 5/2025, the P&P indicated, The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. Use of Dialysis Communication Form helps ensure the coordination of safe and effective care of residents who need dialysis treatments.If the Dialysis Center fails to send the at-dialysis communication form back to the facility, the receiving nurse may complete the form by taking a verbal report from the dialysis facility nurse.Post-Dialysis Communication: This observation/Assessment is auto scheduled to be completed once the pre-dialysis communication form has been saved, signed and locked. Electronically completed by the receiving nurse upon return to the facility following a Dialysis Treatment.

Based on observation, interview, and record review, the facility failed to ensure:1. One of 53 sampled resident's (Resident 51) call light was within reach. This failure had the potential for Resident 51's care needs, health and safety concern not to be addressed timely.2. One of 53 sampled residents (Resident 49) had access to a working call light. This failure prevented Resident 49 from calling staff to bring him water. 3. Three of four resident shower rooms (shower rooms in halls 200, 400 and 500) had call lights inaccessible to residents. This failure had the potential to prevent residents from calling for assistance. Findings: 1.During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated 3/27/26, the MDS indicated, Resident 51's Brief Interview for Mental Status (BIMS - standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). During an interview on 4/15/26 at 1:58 p.m. with Resident 51, Resident 51 stated that sometimes the staff do not give him his call light. During a concurrent observation and interview on 4/16/26 at 9:43 a.m. with Certified Nursing Assistant (CNA) 3, inside Resident 51's room, Resident 51 was sleeping in bed. Resident 51's call light was on his nightstand approximately three feet from the bed. CNA 3 stated the call light was on the night stand and Resident 51 could not reach his call light. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised September 2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. During a concurrent observation and interview on 5/11/26 at 11:52 a.m. with Resident 49 in his room, Resident 49 was lying in his bed and stated his water jug was empty. Resident 49 pressed his call light to request his water jug refilled. Resident 49's call light did not activate. Resident 49 stated his call light was not working. During a concurrent observation and interview on 5/11/26 at 11:55 a.m. with the Director of Maintenance (DM) in Resident 49's room, DM inspected Resident 49's call light system and stated it was not operational. DM stated Resident 49's call light cable needed to be replaced. 3. During a concurrent observation and interview on 5/13/26 at 8:15 a.m. with DM, the resident call light systems in shower rooms in hall 200, hall 400 and hall 500 were inspected. The shower room in hall 200 had two shower stalls and the call lights in both stalls did not have a string to activate it, making the call lights inaccessible to residents on the floor. The shower room in hall 400 had two shower stalls. The call light in the stall closest to the door did not have a string, making the call light inaccessible to residents on the floor. In the stall farthest from the door, the call light was placed outside the shower stall and was inaccessible to residents on the floor in the shower stall. The shower room in hall 500 had two shower stalls. The call light in the stall closest to the door did not have a string, making the call light inaccessible to residents on the floor. In the stall farthest from the door the call light was placed outside the shower stall and was inaccessible to residents on the floor in the shower stall. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised September 2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure three of 53 sampled residents (Resident 79, Resident 23, and Resident 81) were treated with respect and dignity when facility staff converse in a language other than the resident's primary language while providing care. This failure had the potential to negatively affect Resident 79, Resident 23, and Resident 81's psychosocial well-being.Findings:During a review of Resident 79's Minimum Data Set, (MDS - an assessment tool), dated 12/18/25, the MDS indicated Resident 79's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During a review of Resident 79's admission Record, (AR), the AR indicated, Resident 79's primary language was English.During an interview on 4/9/26 at 2:34 p.m. with Resident 79, Resident 79 stated Certified Nursing Assistants (CNAs) will speak other languages in his room. Resident 79 stated, It makes me feel disrespected and isolated because I am singled out. Resident 79 stated he believes the staff are talking about him based on the looks they give each other while providing care. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's BIMS score was 15.During a review of Resident 23's AR, the AR indicated, Resident 23's primary language was English.During an interview on 4/9/26 at 3:57 p.m. with Resident 23, Resident 23 stated, I don't like when they [CNAs] come in here [Resident 23's room] and speak their own language to each other. Resident 23 stated, I am not stupid I know they are talking about me. Resident 23 stated they have their clicks the Hispanic and Filipino CNAs.During an interview on 4/9/26 at 4:38 p.m. with CNA 1, CNA 1 stated it is not ok to speak other languages in front of residents because they may think you are talking about them.During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's BIMS score was 15.During a review of Resident 81's AR, the AR indicated, Resident 81's primary language was English.During an interview on 4/15/26 at 12:32 p.m. with Resident 81, Resident 81 stated the CNAs speak Spanish while providing care. Resident 81 stated, I don't like it [speaking another language] because I think they are talking about me sometimes.During an interview on 4/15/26 at 2:46 p.m. with CNA 2, CNA 2 stated the facility staff should not speak languages the resident does not speak, the resident can take it wrong and think they are talking about them.During a review of the facility's policy and procedure (P&P) titled, Residents Rights, revised August 2009, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.During a review of the facility policy and procedure (P&P) untitled and undated, the policy indicated, It is the facility's policy to affirm the residents' and employees' rights to be free of discrimination. At the same time, all employees have the right to communicate in their primary language when not engaged in direct communication with or caring for a resident. Staff are required to comply with the following guidelines. Procedure: 1. Speak clearly to residents in a language they can understand. 3. Staff should not appear to be distracted when they are interacting with or providing care to residents. 4. There should never be a social conversation between staff members while staff members are providing services to residents. 5. Staff members may converse with each other in their native tongue when they are not in residents' area such as the employees [sic] lounge. English must be spoken at all times when in resident areas.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, when allegations of abuse were not investigated timely for one of 53 sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being investigated timely.Findings:During a review of the facility provided document titled, Resident to Resident Altercation Investigation for [Resident 81] (RRAI), dated 4/9/26, the RRAI indicated, Interview with [Certified Nursing Assistant (CNA) 1] PM Shift. [CNA 1] stated that on 04/03/2026, [Resident 81] informed him that his roommate had hit him. During an interview on 4/15/26 at 4:21 p.m. with Director of Nursing (DON), DON stated the alleged abuse occurred on 4/3/26. DON stated the abuse allegations were not reported to the facility until 4/9/26. DON stated the investigation did not start until 4/9/26 (6 days after the alleged abuse was reported to facility's staff).During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, the P&P indicated, All reports of resident abuse. Investigating Allegations 1. All allegations are thoroughly investigated. 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. Follow-up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview, and record review, the facility failed to ensure allegations of abuse were reported timely for one of three sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being reported timely and delaying the investigation.Findings:During a review of Resident 81's Minimum Data Set, (MDS - an assessment tool) dated 2/1/26, the MDS indicated, Resident 81's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During a concurrent observation and interview on 4/9/26 at 2:17 p.m. with Resident 81, outside of Resident 81's room, Resident 81 stated that his roommate hit him last week. Resident 81 stated he blocked the hit from Resident 109 with his right forearm and he sustained a bruise to his right forearm; several bruises were observed on right forearm of various stages of healing. Resident 81 stated he informed his Certified Nursing Assistant (CNA) 1 on the day of the altercation (4/3/26).During an interview on 4/9/26 at 4:38 p.m. with CNA 1, CNA 1 stated on that day (4/3/26) Resident 81 told him that Resident 81 had a physical altercation with Resident 109. CNA 1 stated Resident 81 told him they had fought a little, that Resident 109 struck Resident 81 on his right forearm. CNA 1 stated there was what looked like a fresh mark on Resident 81's right forearm on that day.During a review of Resident 109's Notice of Room Change, (NRC) dated 4/3/26, the NRC indicated Resident 109 was moved to another room.During an interview on 4/15/26 at 4:21 p.m. with Director of Nursing (DON), DON stated the abuse allegations (4/3/26) were not reported to the facility until 4/9/26. DON stated CNA 1 assumed the nurse was aware of the abuse allegations and did not report Resident 81's allegations of abuse to the nurse.During an interview on 4/15/26 at 4:34 p.m. with DON, DON stated abuse allegations with injuries should be reported within 2 hours and no injuries within 24 hours to the state (licensing agency), Long Term Care (LTC) Ombudsman (a trained advocate who investigates complaints, protects the rights, and promotes the safety, health, and welfare of residents in nursing homes), and the local law enforcement. DON stated the alleged abuse occurred on 4/3/26 was not reported to state, LTC Ombudsman, and local law enforcement until 4/9/26 (6 days after the alleged abuse was reported to facility's staff).During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, the P&P indicated, All reports of resident abuse. are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting Allegations to the Administrator and Authorities 1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. 2.The administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; . e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of the allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or results in serious bodily injury.

Based on interview, and record review, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting), for one of two sampled residents (Resident 4). This failure had the potential for Resident 4 to be placed in an inappropriate setting and not receive required services.Findings:During a review of Resident 4's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/20/24, the PASRR indicated, Level I- Positive.During a concurrent interview and record review on 5/13/26 at 10:34 a.m. with Quality Assurance (QA) Nurse, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/20/24 was reviewed. QA Nurse stated Resident 4's PASRR was positive for mental health evaluation but there was no Level II PASRR completed for Resident 4.During a review of Resident 4's admission Record (AR), dated 5/14/25, the AR indicated Resident 4 had diagnosis of Bipolar disorder (a mental condition characterized by extreme, cyclical shifts in mood, energy, and activity level), psychosis (a collection of symptoms that indicate a loss of contact with reality), dementia (a decline in mental abilities severe enough to interfere with daily life), and adjustment disorder with mixed anxiety (an emotion characterized by feeling of tension, worried thoughts) and depressed mood (persistent feeling of sadness and loss of interest).During a review of Resident 4's Order Summary Report (OSR), dated 4/24/26, the OSR indicated Resident 4 was on Divalproex Sodium (to treat bipolar disorder) 125 milligram, give 8 capsules by mouth one time a day.During a concurrent interview and record review on 5/13/26 at 10:36 a.m. with QA Nurse, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/14/25 was reviewed. The PASRR indicated on question 9. Diagnosed Serious mental Illness. Does the individual have a serious diagnosed mental disorder? Answer was marked No. QA Nurse stated Resident 4's PASRR was filled incorrectly because Resident 4 had diagnosis of mental illness and Resident 4 was taking medication for mental illness.During a review of facility's policy and procedure (P&P) titled, admission Criteria PASARR, dated 3/2019, the P&P indicated, 9. All new admissions and readmissions are screened for mental disorder (MD), intellectual disabilities (ID) or related disorders (RD).b. If the level I screen indicated that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on observation, interview, and record review, the facility failed to implement care plans for two of 53 sampled residents (Resident 51 and Resident 70). This failure had the potential for Resident 51 and Resident 70's safety to be at risk.Findings:During a review of Resident 51's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on Falls: (Resident 51) is at risk for falls, initiated 3/23/26. The care plan indicated a few of the interventions were Floor mat to left and right side, initiated 4/2/26 and Keep call light within reach. initiated 3/23/26. During a concurrent observation and interview on 4/16/26 at 9:43 a.m. with Certified Nursing Assistant (CNA) 3, inside Resident 51's room. Resident 51 was sleeping in bed. CNA 3 located Resident 51's call light pad on his nightstand approximately three feet from the bed. CNA 3 stated Resident 51 would not been able to reach his call light.During a concurrent observation and interview on 4/16/26 at 10:27 a.m. with CNA 3, outside of Resident 51's room, CNA 3 stated Resident 51 did not have fall mats at bedside.During a concurrent observation, interview, and record review, on 5/11/26 at 10:33 a.m. with Director of Staff Development (DSD) outside of Resident 70's room. Resident 70's care plan with the focus on Falls: Resident had an unwitnessed fall on 4/20/26 initiated 4/20/26. The care plan indicated, Falling Star fall prevention program (place Falling Star identifier on the outside of room door and on assistive devices as applicable). DSD stated no falling star on Resident 70's name plate. During a review of the facility's policy and procedure (P&P) titled, Care plans, Comprehensive Person-Centered, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: .g. receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to administer medication according to the physician order for one of six sampled residents (Resident 23) when Resident 23 had an order for the administration of one inhalation (drawing the medication into the lungs) of Trelegy Ellita inhalation Aerosol Powder (a medication to treat inflammation of the lungs) 100-62.5-25 MCG (micrograms-unit of measurement)/ACT (actuation - refers to a single spray, puff, or activation of an inhaler) and Resident 23 did not receive the medication. This failure had the potential for Resident 23 to experience negative health outcomes due to breathing problems.Findings:During a review of Resident 23's Order Summary Report (OSR), dated 3/25/26, the OSR indicated, Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT I inhalation inhale orally one time a day.During a review of Resident 23's Communication Result Report (CRR), dated 5/12/26 at 2:47 p.m., the CRR indicated Trelegy was reordered from the pharmacy on 5/12/26.During a concurrent observation and interview on 5/13/26 at 8:20 a.m. with Registered Nurse (RN) 1 in 400 hall, RN 1 prepared the medications for administration to Resident 23, but no inhaler to administer. RN 1 stated there was no Trelegy inhaler available to administer.During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 3/2026, the P&P indicated, i. Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand.

Based on interview and record review, the facility failed to ensure one of 53 sampled residents (Resident 51) was turned and repositioned every two hours. This failure had the potential for delayed wound healing and worsening of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, from pressure, or pressure in combination with shear and/or friction) for Resident 51.Findings:During an interview on 4/23/26 at 1:27 p.m. with Treatment Nurse (TN), TN stated turning and repositioning every two hours was the facility's standard for residents with pressure injuries. TN stated everyone with a pressure injury should have a care plan for turning and repositioning every two hours. During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated 3/27/26, the MDS indicated, Resident 51 was dependent (helper does all the effort) for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). The MDS indicated Resident 51 had a stage four pressure injury (a severe, full-thickness skin and tissue loss where underlying muscles, tendons [flexible tissue, like a rope], ligaments [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones are exposed) upon admission. During a review of Resident 51's Order Summary Report (OSR), dated 4/28/26, the OSR indicated, Q [every] 2hr [2 hours] repositioning while in bed during day time with wedge [foam or bead-filled support devices designed for people with limited mobility, providing critical support to reduce pressure sores, improve circulation, and maintain proper body position] every day shift . Start Date 04/08/2026 and Q 2hr repositioning while in bed during day time with wedge every evening shift . Start Date 04/08/2026.During a review of Resident 51's care plan with the focus on Skin: [Resident 51] has Impaired skin integrity present on admission as evidenced by . Stage 4 Pressure ulcer to coccyx, initiated 3/23/26. The care plan indicated a few of the interventions were to Administer treatments as ordered and monitor for effectiveness, and Low air loss mattress. (turn and repositioning were not included in care plan).During a concurrent interview and record review, on 4/30/26 at 12:30 p.m. with QA Nurse and MDSN. Resident 51's care plan was reviewed. QA Nurse and MDSN stated Resident 51's care plan did not indicate turn and reposition. Resident 51's Documentation Survey Report (DSR), dated February, March, and April of 2026, the DSR indicated for the task of Turn and Reposition, were reviewed. The DSR indicated the following:On 2/12/26, the DSR indicated Resident 51 was not turned or repositioned (T&R) at 6 a.m., 8 a.m., 10 a.m., and 12 p.m. (total of 10 hours). The DRS indicated Resident 51 self-repositioned at 6 p.m. (total four hours, Resident 51 was not T&R for a total 14 out of a 24 hour period).On 2/18/26, the DSR indicated Resident 51 was not turned and repositioned at 2 p.m., 4 p.m., 6 p.m. and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 2/20/26, the DSR indicated Resident 51 self -repositioned at 2 p.m., 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 2/21/26, the DSR indicated Resident 51 self -repositioned at 2 p.m., 4 p.m., and 6 p.m. (Resident 51 was not T&R for eight hours out of a 24 hour period). On 2/22/26, the DSR indicated Resident 51 self -repositioned at 2 p.m., 4 p.m., and 6 p.m. (Resident 51 was not T&R for eight hours out of a 24 hour period).On 2/23/26, the DSR indicated Resident 51 self -repositioned at 10 p.m. (Resident 51 was not T&R for four hours out of a 24 hour period).On 2/24/26, the DSR indicated Resident 51 self -repositioned at 12 a.m. and 2 a.m. (Resident 51 was not T&R for six hours). The DSR indicated Resident 51 self-repositioned at 6 a.m. and 8 a.m., 10 a.m., and 12 p.m. (Resident 51 was not T&R for eight hours for a total of 14 hours out of a 24 hour period). On 2/26/26, the DSR indicated Resident 51 was not turned and repositioned at 6 a.m., 8 a.m., 10 a.m., and 12 p.m. (Resident 51 was not T&R for eight hours). the DSR indicated Resident 51 self -repositioned at 2 p.m., 4 p.m., and 6 p.m. and 8 p.m. (Resident 51 was not T&R for 10 hours for a total of 18 hours out of a 24 hour period).On 2/27/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 3/24/26, the DSR indicated Resident 51 was not turned or repositioned at 6 a.m., 8 a.m., 10 a.m., and 12 p.m. (total of 10 hours). The DSR indicated Resident 51 self-repositioned at 2 p.m., 4 p.m., 6 p.m., 8 p.m., and 10 p.m. (Resident 51 was T&R for 12 hours, for a total of 22 hours out of a 24 hour period).On 3/25/26, the DSR indicated Resident 51 was not turned or repositioned at 12 a.m., 2 a.m., and 4 a.m. (Resident 51 was not T&R for eight hours). The DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours for a total of 18 hours out of a 24 hour period).On 3/26/26, the DSR indicated Resident 51 self-repositioned at 6 a.m. (Resident 51 was not T&R for four hours out of a 24 hour period).On 3/27/26, the DSR indicated Resident 51 was not turned and repositioned at 8 p.m. (Resident 51 was not T&R for four hours out of a 24 hour period).On 3/28/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 3/29/26, the DSR indicated Resident 51 was not turned and repositioned at 8 p.m. (Resident 51 was not T&R for four hours out of a 24 hour period).On 3/29/26, the DSR indicated Resident 51 was not turned or repositioned at 12 a.m., 2 a.m., and 4 a.m. (Resident 51 was not T&R for eight hours out of a 24 hour period). On 4/7/26, the DSR indicated Resident 51 self-repositioned at 12 a.m. and 8 p.m. (Resident 51 was not T&R for eight hours out of a 24 hour period).On 4/9/26, the DSR indicated Resident 51 self-repositioned at 2 p.m., 4 p.m., and refused to T&R 6 p.m. then self-repositioned at 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/14/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/15/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/16/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/17/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/18/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/22/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/23/26, the DSR indicated Resident 51 self-repositioned at 2 p.m. and 4 p.m., 6 p.m., and 8 p.m. (Resident 51 was not T&R for 10 hours out of a 24 hour period).On 4/25/26, the DSR indicated Resident 51 self-repositioned at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 8 a.m., 10 a.m., and 12 p.m. (Resident 51 was not T&R for 16 hours out of a 24 hour period).During a concurrent interview and record review, on 4/30/26 at 12:30 p.m. with QA Nurse and MDSN, QA Nurse and MDSN stated Resident 51 would not be able to turn and reposition himself.During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised April 2020, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. f. Reposition resident as indicated on the care plan. Mobility/repositioning 11. Reposition all residents or at risk of pressure injuries on an individualized schedule, as determined by MD order. Monitoring 13. Evaluate, report and document potential changes in the skin.

Based on observation, interview, and record review, the facility failed to ensure nutritional assessment was accurate for one of two sampled residents (Resident 11). This failure had the potential for Resident 11 to not meeting her nutritional needs.Findings:During an observation on 5/11/26 at 8:50 a.m. in Resident 11's room, Resident 11 was lying in bed with a feeding tube (a soft, flexible, medical device used to deliver liquid nutrition, fluids, and medications directly into the stomach or small intestine) attached to a pole. Resident 11's feeding tube was connected to a bottle with a label of Jevity 1.5 (liquid nutrition formula).During a review of Resident 11's Dietitian Note (DN), dated 4/9/26, the DN indicated, Enteral [the administration of food, fluids, or medication directly into the stomach, typically through the mouth via a feeding tube]: Jevity 1.2 @ [at] 72 ml [milliliter]/hr [hour] x [times] 20 hrs [hours] provides 1440 ml/day, 1728 kcal [kilocalorie]/day, 80 gm [gram] protein/day, 1152 ml FW [free water]/day.During a review of Resident 11's Medication Administration Record (MAR), dated March, April, and May 2026, the MAR indicated Resident 11 received Jevity 1.5 from 3/3/26 to 5/12/26. During a review of Resident 11's Order Summary Report (OSR), dated 3/3/26, the OSR indicated, Enteral Feed Order every shift TUBE FEEDING FORMULA: Jevity 1.5 @72 ML/HR x 20hrs. continuous VIA g-tube [medical device inserted through the abdomen directly into the stomach] =1440ml/1728 kcals per 24hrs, on at 1800 [6 p.m.], off at 0400 [a.m.]; on at 0600 [a.m.], off at 1600 [6 p.m.] am shift=432cc [cubic centimeter], pm shift=432cc, noc [night] shift=576cc.During a concurrent interview and record review on 5/13/26 at 3:32 p.m. with Registered Dietitian (RD), RD reviewed Resident 11's OSR. RD stated she recommended Jevity 1.2. RD stated she was not aware the Jevity 1.2 was changed to Jevity 1.5. RD stated, I did not look at my notes, we need a better system and self-audit myself. RD stated Jevity 1.5 has more calories than Jevity 1.2. During an interview on 5/14/26 at 8:46 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, There was a time we had no supply of Jevity 1.2, the doctor was called and okayed for Jevity 1.5. LVN 2 stated there was no documentation notifying the RD of the change in formula.During the review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated January 2025, the P&P indicated, 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: d. Dietitian: (1) An estimate of calorie, protein, nutrient and fluid needs; (2) Whether the resident's current intake is adequate to meet his or her nutritional needs; and (3) Special food formulations.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence), for one of three sampled residents (Resident 79) when staff did not evaluate, report and document potential changes in the skin. This failure resulted in Resident 79 developing a facility acquired right heel injury which progressed to a pressure ulcer (open sore caused by poor blood flow or pressure) causing pain to Resident 79. Findings: During a review of Resident 79's Admission Record (AR), dated 9/17/24, the AR indicated, Resident 79 was admitted on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalance in the brain), type 2 diabetes mellitus (high blood sugar), end stage renal disease, (kidneys lose the inability to remove waste), dependence on renal dialysis (process of removing water, and toxins when kidneys no longer perform this function), neuromuscular dysfunction of bladder (when nerves and muscles don't work together properly), and hypertension (high blood pressure). During a review of Resident 79's Minimum Data Assessment (MDS - standardized resident screening tool), dated 10/10/24, the MDS, Section M - Skin Conditions indicated, Is the resident at risk for developing pressure ulcers - 1. Yes. During a review of Resident 79's Brief Interview for Mental Status (BIMS - assessment score of cognitive functioning), dated 10/3/24, the BIMS indicated, Resident 79's BIMS (score 0-7 means severe cognitive impairment, 8-12 means moderate cognitive impairment and 13-15 means cognition intact) was coded as severe cognitive impairment with a score of 7. During a review of Resident 79's Nursing/Readmission Evaluation/Assessment (NREA), dated 10/2/24, the NREA indicated, 1.c. Resident has wounds or skin integrity concerns present on admission. a. yes - . 1.e. Description: L/R [Left/Right] heel blisters. During a review of Resident 79's Treatment Administration Records (TAR) dated, 10/1/24 -10/30/24, and 11/1/24 - 11/30/24, the TAR indicated, the last date of treatment to Resident 79's bilateral feet blisters was 10/17/24 (35 days ago). During a review of Resident 79's Plan of Care (POC), dated 9/17/24, the POC indicated, Skin: Resident is at risk for skin breakdown related to fragile skin, old age, diabetes . Check skin during daily provisions. Notify physician of abnormal findings. During a concurrent observation and interview on 11/18/24 at 10:52 a.m. in the activities room, with Resident 79 and Infection Preventionist Nurse (IPN), Resident 79 was sitting in her wheelchair. Resident 79 had dressings on both feet with a date of 10/27. Resident 79 stated she has had problems with her feet for a while. During an interview on 11/21/24 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated treatment nurses take care of residents' wounds/dressings. During a concurrent observation and interview on 11/21/24 at 10:08 a.m. in Resident 79's room, with Resident 79 and Treatment Nurse (TN) 1, TN 1 stated, There are no current orders for dressing changes to [Resident 79's] feet. Resident 79's dressings on bilateral (both sides) heels were removed by TN 1. Resident 79 stated, Duele [Spanish word for 'hurt'] while dressing was being removed. TN 1 stated the dressing had a date of 10/27 taped on the dressing which indicated her feet had not been assessed since 10/27. TN 1 stated Resident 79 had a possible UTD [unstageable deep tissue injury] on her right heel. During a concurrent observation and interview on 11/21/24 at 10:22 a.m. with Director of Nursing (DON) and TN 1, in Resident 79's room, DON stated Resident 79's feet had not been treated or assessed since 10/27/24. During a review of Resident 79's Medication Administration Record (MAR) dated 11/1/24 -11/30/24, the MAR indicated, Resident 79 had pain and Norco Oral Tablet (pain medication) was administered for pain level of 5 on a scale of 1-10 (score of 0 means no pain, score of 1-3 mild pain, score of 4-5 means moderately strong pain and a 6-9 means severe pain, 10 is the worst pain you have experienced) on 11/5/24 at 12 a.m., 11/18/24 at 10:39 a.m., 11/20/24 at 6:49 a.m. and on 11/21/24 at 10:28 a.m. During an interview on 11/21/24 at 12:30 p.m. with TN 2, TN 2 stated she is the weekend treatment nurse. TN 2 stated TN 1 is responsible for taking pictures of wounds and documenting progression of wound healing. TN 2 stated she recalled changing the dressing for Resident 79's feet on 10/27/24 (25 days ago). TN 2 stated she did not check the physician's order before changing the dressing or document the dressing change to Resident 79. TN 2 stated she should have called the doctor and documented Resident 79's dressing change. During a concurrent interview and record review on 11/21/24 at 12:35 p.m. with TN 2, a photo of Resident 79's right heel wound dated 10/21/24 was reviewed. TN 2 stated, It looks like an unstageable pressure injury [type of bed sore that cannot be staged due to damaged tissue covering wound]. During a concurrent interview and record review on 11/21/24 at 12:38 p.m. with Certified Nursing Assistant (CNA) 1, Resident 79's Resident Shower Log (RSL), dated 11/13/24, was reviewed. The RSL indicated no skin issues. CNA 1 stated the process was to note skin issues during bathing of the residents and to document. CNA 1 stated she remembered giving Resident 79 a bed bath and did not recall any skin issues. During a concurrent interview and record review on 11/21/24 at 2:10 p.m. with TN 1, Resident 79's medical record (MR) was reviewed. The MR did not indicate a phone call to the doctor or any documentation of skin wounds. TN 1 stated there was no documentation of a phone call to the doctor or of the wounds and both should have been done. During a concurrent interview and record review on 11/21/24 at 3:22 p.m. with DON, Resident 79's Nursing - Weekly Summary (NWS), dated 11/2/24, 11/9/24, 11/16/24, and 11/18/24 were reviewed. The NWSs indicated, C. Skin 4. No new skin issues this week. 5. Skin clear and intact. DON stated the expectation was for the nurse to do a complete head to toe skin assessment and for these assessments to be accurate and complete. During a review of Resident 79's SBAR [Situation, Background, Assessment, Recommendation - written communication tool helps provide concise information], dated 11/21/24 at 11 a.m., the SBAR indicated, pt [patient] with skin issue to right heel 2.6x2.5x0, 1 cm (centimeter) surrounded by 1 cm callus, site previously had dried blister upon admission. contacted wound provider dr. [sic] who gave an initial order md ordered treatment. During a review of Resident 79's Skin & Wound Evaluation (SWE), dated 11/21/24 at 10:09 p.m., the SWE indicated the pressure injury was acquired in house on 11/21/24. During a review of Resident 79's Progress Note Details (PND), dated 11/24/24, the PND indicated, Associated Signs and Symptoms: complaints of increased Pain 11/21/24 . initial exam- pt [patient] wound consulted and tx [treatment] in place . 11/24/24 pt with stable wound with arterial doppler study with significant findings consult for vascular eval [evaluation] placed. During a review of the facility's P&P titled, Prevention of Pressure Injuries dated April 2020, the P&P indicated, Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition . Skin Assessment. 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non blanchable erythema). B. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); d. Moisturize dry skin daily. Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. During a review of the facility's P&P titled, Pressure Injury Risk assessment dated [DATE], the P&P indicated, Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment (s) conducted. 2. The date and time of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternative. Document family and physician notification of refusal. 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration noted with change of plan of care, if indicated. 12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care (helps nurses and other care team members organize aspects of resident care according to a timeline) to address risk for falls for one of two sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall with fracture (break in the bone) to the anterior (near the front of the body or nearer to the head) column of the left acetabulum (the socket portion of the ball-and-socket hip joint) with extension of the fracture into the left superior (higher in position) and left inferior (lower in position) pubic rami (pubic rami are a group of bones that make up part of the pelvis (basin-shaped complex of bones that connects the trunk [central part of the body] and the legs), unnecessary hospitalization , and pain. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), abnormalities of gait and mobility (when a person is unable to walk or move normally due to injuries, underlying conditions), and hypotension (low blood pressure - which can cause fainting or dizziness because the brain does not receive enough blood). During a review of Resident 1's Fall Risk Observation/Assessment (FROA), dated 6/28/23, the FROA indicated, Resident 1's score was 20 (score of 16-42 indicated resident is at high risk for falls) high risk. During a review of Resident 1's Baseline Care Plan Person-Centered Care Planning (BCP), dated 6/29/23, the BCP indicated, there was no care plan developed to address Resident 1's risk for falls. During a review of Resident 1's Admission Minimum Data Set (MDS - an assessment tool), dated 7/3/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 11 (a score of 8 to 12 suggests the resident has moderately impaired cognition). The MDS indicated, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for transfer (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) with two plus person assist, Resident 1 needed extensive assistance with locomotion on and off unit (how resident moves between locations in his/her room and adjacent corridor on same floor) with one person assist, and Resident 1 needed extensive assistance with toilet use (how resident uses the toilet, commode, bedpan, or urinal; transfers on/off toilet: cleanses self after elimination) with one person assist. During a review of Resident 1's SBAR (situation, background, appearance, and review) Communication Form (SBAR), dated 8/27/23, the SBAR indicated, Resident 1 had a fall incident while trying to go to the restroom without assistance. During a review of Resident 1's IDT [Interdisciplinary Team- a group of health care professionals with various areas of expertise who work together toward the goals of their residents] - Fall, dated 8/28/23, the IDT - Fall indicated, (Resident 1) requires extensive assist with ADLs (activities of daily living-activities related to personal care, which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a review of Resident 1's ED (Acute hospital-emergency department) Physicians Notes (EDPN), dated 9/6/23, the EDPN indicated, CT (computerized tomography - scan combines a series of X - ray images taken from different angles around your body and uses computer processing to create cross - sectional images [slices] of the bones, blood vessels and soft tissues inside your body) Pelvis. Indications: left hip pain, possible pelvic fracture. Conclusion: 1. Acute fracture of the anterior column of the left acetabulum with extension of the fracture into the left superior pubic ramus. 2. Acute fracture of left inferior pubic ramus. recommends no weightbearing [sic] for at least 2 weeks. During a concurrent observation and interview on 9/15/23, at 12:38 p.m. in Resident 1's room, Resident 1 was in bed and stated he went to the restroom in the middle of the night and fell (8/27/23). Resident 1 stated he was not able to get out of bed until 9/26/23 (28 days). Resident 1 stated he was experiencing 10 out of 10 (7 - 10 = severe) pain since the fall incident. During an interview on 9/15/23, at 3:37 p.m. with Certified Nursing Assistant (CNA 1) CNA 1 stated she worked with Resident 1 on the day of the fall incident (8/27/23). CNA 1 stated Resident 1 went to the restroom without assistance [Resident 1 needed extensive assistance with toilet use with one person assist]. CNA 1 stated she was never given verbal report Resident 1 was at risk for falls. CNA 1 stated Resident 1 did not have pain before the fall but he (Resident 1) complains of pain a lot now (after the fall incident on 8/27/23). During an interview on 9/27/23, at 11:38 a.m. with Admission Nurse (AN), AN stated she completes a fall risk assessment on admission and if the score is high, resident is at risk for fall; a fall risk care plan should be developed. AN stated, We (nurses) give verbal report to CNA and inform of all interventions that need to be put into place. During a concurrent interview and record review on 9/27/23, at 11:38 p.m. with AN, the facility protocol titled, New Admission Nursing Check List, undated, was reviewed. The New Admission Nursing Check List indicated, . 3rd Shift LN (Licensed Nurse). Initiate Care Plans. AN stated the protocol (Initiate Care Plans for fall risk) should be used during admissions process. During an interview on 9/27/23, at 3:18 p.m. with Director of Nursing (DON), DON confirmed there was no care plan developed to address Resident 1's risk for falls [6/28/23 to 8/28/23]. DON stated the expectation was for the nurses to develop and implement care plan to address Resident 1's risk for falls and to ensure interventions were effective. During a concurrent interview and record review on 10/17/23 at 10:51 p.m. with DON, the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, was reviewed. The P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident -Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. DON provided no further information. During a concurrent interview and record review on 10/17/23 at 10:51 p.m. with DON, facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, was reviewed. The P&P indicated, 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. 2. The Comprehensive person-centered care plan should be developed within the seven (&) days of the completion of the required MDS assessment. 6. The comprehensive, person-centered care plan should. b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for he above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). DON provided no further information.

Based on interview and record review, the facility failed to provide a safe environment for one of nine sampled residents (Resident 1) when the facility failed to: 1. Ensure an air mattress was appropriately deflated prior to provision of care for Resident 1. 2. Ensure one staff (Certified Nursing Assistant [CNA] 1) was competent to perform a task prior to providing that task for Resident 1. These failures resulted in Resident 1 falling off her bed onto the floor and sustaining a right arm skin tear, laceration to the scalp and a collarbone fracture, which required the resident to be transferred to the acute care hospital. Findings: During an interview on 11/17/21, at 12:15 PM, with CNA 1, CNA 1 stated, she was providing care to Resident 1 when she fell on [DATE]. CNA 1 stated Resident 1 was on an air mattress when she was changing her soiled brief. CNA 1 stated during care Resident 1 slid off the bed and fell to the floor. CNA 1 stated Resident 1 had bleeding to the back right side of her head. During a review of Resident 1's facility document titled Investigation of [Resident 1] fall with right clavicle [collarbone] fracture (IRCF), dated 11/11/21, the IRCF indicated, [Resident 1] is a [AGE] year old female long-term care resident that admitted to [facility] on 11/10/2019. On 11/10/2021 @ [at] approximately 7:00 AM, a staff member was performing incontinence care on [Resident 1] . When the staff member turned [Resident 1], she began to slide off the bed. The staff member then ran to the right side of the bed in an attempt to assist her [Resident 1] down to the floor, but she was too late resulting in [Resident 1] sliding to the ground unassisted. [Resident 1] is on an airflow mattress due to her history of skin breakdown. [Resident 1] sustained a 4.5 x 2.5 cm [centimeter - a unit of measurement] skin tear to her right upper arm and a 3.2 x 1.4 [sic] laceration to her scalp. [Resident 1] returned from the ER [emergency department] at approximately 1300 [1 PM] with orders for wound care to her scalp and skin tear . The admission nurse went to evaluate [Resident 1] and found that she has swelling to her right shoulder and was complaining of pain MD [medical doctor] was notified and ordered [immediate] x-ray. The x-ray showed: an acute clavicle fracture . The MD was notified and ordered to send [Resident 1] to [acute hospital] for evaluation and treatment of fracture. During a review of Resident 1's acute hospital document titled ED [emergency department] Physician Notes (EDPN), dated 11/10/2021, the EDPN indicated, [AGE] year-old female sustained a sudden onset constant moderate fall out of bed striking her head onto the ground while staff at her skilled nursing facility were trying to change out her adult diaper. [Resident 1] also has a skin tear to the right elbow. Resident 1 required staples to her right scalp to close the laceration. Resident 1 also had a scan of her head done which resulted in a diagnosis of right sided scalp swelling. During an interview on 11/17/21, at 1:15 PM, with CNA 1, CNA 1 stated, she did not deflate the air mattress Resident 1 was on during provision of care. CNA 1 stated the air mattress remained inflated. CNA 1 stated she had not received any type of training for providing care to residents on air mattresses. During a concurrent interview and record review, on 11/17/21, at 1:30 PM, with Director of Staff Development (DSD), CNA 1's Nursing Assistant Orientation (NAO) competencies (documented evidence a staff is competent to perform a task by demonstration of appropriate knowledge and skills in a clinical setting) dated 8/24/21 were reviewed. The NAO indicated every section of CNA 1's competencies including the section that involves providing resident care, did not have a return demonstration conducted as indicated on the form in order to appropriately assess if CNA 1 was competent. DSD stated staff competencies are done upon hire and yearly. DSD stated return demonstrations are done so that employees are able to show what they were taught back to the educator and the educator could then be certain that the employee was proficient or needed more training. DSD stated return demonstrations should have been checked off for CNA 1 to show she had completed training and was competent. DSD stated she was not sure if staff were trained on how to care for a resident on an air mattress. During an interview on 11/17/21, at 1:55 PM, with Director of Nursing (DON), DON stated, he was not sure how, or if staff received training on how to care for a resident on an air mattress. DON stated DSD should know if staff receive air mattress training. DON stated residents on air mattresses should have their mattresses deflated when being provided care in bed because the mattress is slippery and elevated. DON stated competencies for staff should have return demonstrations to show that they are competent in performing their task. DON stated, competency shows they [staff] are safe. During a review of the facility's policy and procedure (P&P) titled, Knowledge and Skills Competency Evaluation, undated, the P&P indicated, In an effort to provide optimal clinical care, direct care nursing staff are required to meet minimum standards before caring for residents. Knowledge and skill competencies are evaluated upon hire, annually thereafter and as needed, as indicated by job performance, newly introduced procedures, specific techniques required for an individual resident or new products and equipment. Purpose . Provide a method to measure employee's performance based on objective data. To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skill to fulfill their assigned responsibilities in a safe and professional manner. During a review of the facility's policy and procedure (P&P) titled, BEDS, SPECIAL - LOW AIR LOSS THERAPY, dated 11/2012, the P&P indicated, It is the policy of this facility to utilize low air loss therapy under the direction of a physician's order. Facility staff working directly with the low air loss therapy unit will have training in its use by company representative or a trained facility staff member . Procedure . To place and remove bedpans, turn resident away from you, deflate seat section, depress bedpan into seat position and turn resident back into pan. When finished, remove bedpan, render hygiene and return inflation of sear section to preset level.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (2) from sexual abuse when another resident (1), who had a history of [REDACTED]. This resulted in violating Resident 2's right to be free from sexual abuse, causing abrasions to her genital area and fearful of being touched by caregivers. Findings: The clinical record for Resident 1 was reviewed. The Nurses' Notes, dated 9/26/16, at 1:20 AM, indicated Resident 1 was found next to Resident 2's bed with his left hand touching her vagina. The History and Physical Record for Resident 1, dated 5/29/16, indicated, Resident 1 had the capacity to understand and make his own decisions. The Minimum Data Set (MDS-a comprehensive assessment tool) for cognitive function, dated 8/4/16, indicated Resident 1 received a score of 14 (score of 13-15 means cognitively intact). The Functional Status section of the MDS indicated Resident 1 could independently perform dressing, transfer, walking, and moving between locations. Resident 1 also has had history of inappropriate behaviors such as making inappropriate sexual comments to staff, sitting outside his room naked in his wheelchair, and going outside the facility naked. A care plan, titled The Behavioral Disturbance Care Plan, was initiated for Resident 1 on 6/26/16. The interventions the facility had planned to address Resident 1's inappropriate behaviors included psychiatric evaluation, encourage wearing clothes at all times especially around others, and ensuring safety of other Resident, if necessary removing them to another area. The clinical record of Resident 2 was reviewed. The MDS for Resident 2, dated 9/2/16, indicated she received a score of 3 (score of 0-7 means severe cognitive impairment). The Functional Status section of this MDS indicated Resident 2 was dependent on staff to perform activities of daily living, such as dressing, transfer, and changing position in bed. The History and Physical Record, dated 9/1/16, indicated, Resident 2 did not have capacity to understand and make her own decisions. The Cognitive Pattern(s) Care Plan for Resident 2, dated 9/21/16, was reviewed. The concern the facility had was Resident (2) removes clothes. The approaches the facility planned to address the behavior included: Provide resident with privacy in room and Close curtains of room if resident removes clothes in room. The SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 9/26/16, at 4 AM, indicated Resident (2) was possibly abused, (Resident 1) was found with his fingers in (Resident 2's) vagina. This SBAR indicated Resident 2 had redness and a scratch to the skin outside her vagina, upon assessment following the incident. During an observation on 9/26/16, at 2:02 PM, in Resident 2's room, Resident 2 was in bed crying with grimacing face. Certified Nursing Assistant (CNA) 1 asked Resident 2 why she was crying. Resident 2 stated, Please don't touch me. During a concurrent observation and interview with Resident 1, on 9/26/16, at 2:45 PM, he recalled the incident and stated, I am tired of the same questions over and over. I can't talk right now. Resident 1 stood up from his wheelchair, transferred himself to the bed, lay down, and closed his eyes. During an interview with Licensed Vocational Nurse (LVN) 1, on 9/28/16, at 8:32 AM, she stated, (CNA 2) reported to me, she saw (Resident 1) in (Resident 2's) room inappropriately touching (Resident 2)'s vagina and (Resident 1) had his pants down. (Resident 2) was masturbating and his middle finger was in her (Resident 2) vagina. LVN 1 stated, (Resident 2) had scratch marks and little bumps in different places on her body and redness, scratches, and marks on the left side of her labia (the fleshy area outside the vagina). LVN 1 stated when she made her rounds at the beginning of her shift, Resident 2 was wearing a diaper. After the incident, when she assessed Resident 2, Resident 2 was on her left side naked with a sheet over her. During an interview with CNA 2, on 9/28/16, at 9:21 AM, she stated she was making her rounds when she saw Resident 1 in Resident 2's room leaning over his chair with his left fingers inside Resident 2's vagina. CNA 2 was asked if prior to the incident, Resident 2's curtain was pulled or her door was closed, she stated, No, the curtain was open. During an interview with LVN 2, on 9/28/16, at 10:13 AM, she stated she saw Resident 1 come out of his room at around 12 midnight and LVN 2 walked passed Resident 1 while giving medications to another resident prior to the abuse incident. After the abuse incident, LVN 2 stated she asked Resident 1 what he was doing in Resident 2's room, Resident 1 responded, She (Resident 2) was showing me something. The facility staff on duty at the time of the sexual assault failed to monitor Resident 1 to ensure safety of other residents while he was seen in the hallway; and failed to close Resident 2's curtains or door when she exposed herself. These failures provided the opportunity for Resident 1 to sexually assault Resident 2. The facility policy and procedure titled, Policy: Abuse, Neglect, and Misappropriation of Resident Property Prohibition, dated 11/2003, indicated, Policy Statement: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. Sexual Abuse: Any form of non-consensual contact, including but not limited to, unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing, and sexual harassment. Remember that sexual contact may also include interactions that do NOT involve touching. In instances of abuse of resident who is unable to express or demonstrate physical harm, pain or mental anguish, the abuse is presumed to cause physical harm, pain, or mental anguish. Prevention: Center supervisors immediately intervene and correct reported or identified situations which abuse, neglect or misappropriation of resident property is at risk for occurring.

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for four of four sampled residents (1, 2, 3, and 4). This failure resulted in mental anguish for three residents (1, 3, and 4) and a fall for one resident (2). Findings: During an interview with Resident 1, on 7/16/15, at 9:15 AM, she stated when she has to use the bathroom, she activates her call light and sometimes has to wait an hour for staff to answer the call light. Resident 1 stated, When they come, it's too late. I hate it when it happens and they have to clean me up. I hate wearing diapers, but what can I do? Resident 1 began to cry and stated I felt so embarrassed. During a review of the clinical record for Resident 1, the current Minimum Data Set (MDS-standardized primary assessment tool) indicated she was totally dependant on staff and required two person assistance for toilet use. During an interview with Resident 2, on 7/16/15, at 9:50 AM, she stated she usually has to wait a long time for staff to answer her activated call light, sometimes an hour or more. Resident 2 stated on 7/8/15, she needed to use the bathroom; she activated her call light, but no one answered the call light. She stated, I tried to get out of bed by myself (to go to the bathroom) and fell . I got up and fell again. the call light was still on. I had to yell for help. I was screaming. They had to send me to the hospital. I felt neglected and forgotten. I'm still very sore and beaten up. During a review of the clinical record for Resident 2, the Patient Transfer Form, dated 7/9/15, indicated Resident 2 was transferred to the hospital for evaluation after a fall. The Discharge Summary from the acute care hospital, dated 7/9/15, indicated Resident 2 sustained a closed head injury, lower back pain and a skin tear to her elbow from the fall. The current MDS indicated she required extensive assistance with one staff person for toilet use. During an interview with Resident 3, on 7/16/15, at 10:15 AM, she stated when she uses the call light, she frequently has to wait 45 minutes to an hour to get help to the bathroom; sometimes she has to go to the bathroom by herself. and I pee my pants when she can not make it to the bathroom in time. Resident 3 stated, Sometimes they forget about me, they say they are busy. During a review of the clinical record for Resident 3, the current MDS indicated she required extensive assistance with one staff person for toilet use. During an interview with Resident 4 on 7/16/15, at 10:15 AM, she stated call lights (response times) are a problem on the night shift. I almost always have to wait at least 30 minutes for someone to come help me. During a review of the clinical record, the current MDS for Resident 4 indicated she required extensive assistance from two staff for toilet use. During an interview with the Executive Director (ED), on 7/21/15, at 11:40 AM, she stated the expectation for call light response time, is three minutes for an emergency bathroom call light, and 15 minutes for a regular call light. The ED verified the facility did not have a policy related to call lights.

Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (3), under hospice care (care designed to assist the terminally ill person to be comfortable through the phases of dying) received medications as ordered by the physician for pain control which resulted in the resident having unrelieved pain. Findings: During an observation on 11/12/13, at 9:08 AM, Resident 3 was in bed with closed eyes while turning her head from side to side. During an interview with Family Member (FM) 1, on 11/12/13, at 9:09 AM, she stated Resident 3 was in pain after admission to the facility since 4 PM on 11/9/13. FM 1 also stated Resident 3's medications were not delivered on time and the pain medication and the medication to reduce inflammation (swelling) of the brain were given late. FM 1 stated Resident 3 is not interviewable, she would hold her head and chest and say the word "hurt" when in pain or discomfort. During an interview with Registered Nurse (RN) 2, on 11/15/13, at 9:10 AM, she stated Resident 3 was admitted to the facility on [DATE], at 3:35 PM. RN 2 stated she had called the pharmacy multiple times between 5 PM to 9 PM on the day of admission to get Resident 3's medications delivered to the facility. RN 2 stated she called the physician at 9 PM because the medications had not been delivered and he ordered [MEDICATION NAME] 5/325 (an oral pain medication used to treat pain) to be given once while waiting for the [MEDICATION NAME] sulfate (a narcotic [MEDICATION NAME] that acts on the central nervous system that has therapeutic effect to relieve moderate to severe pain) to be delivered. RN 2 stated she administered [MEDICATION NAME] 5/325 on 11/9/13, at 9:05 PM. RN 2 stated the pain assessment was completed at 5 PM with a score of 8 as very painful (Pain Scale 0-10: 0=No Pain, 1-3=Discomfort, 4-6=Painful, 7-9=Very Painful and 10=Worst Possible). RN 2 assessed Resident 3's pain 15-30 minutes after administering [MEDICATION NAME] but the pain remained at score of 8. During an interview and record review with Licensed Vocational Nurse (LVN) 2, on 11/15/13, at 9:30 AM, she stated after receiving the [MEDICATION NAME] sulfate on 11/9/13, at 10 PM from a local pharmacy, LVN 2 administered the first dose at 10:30 PM. LVN 2 verified there was no documentation in the Medication Administration Record (MAR) that [MEDICATION NAME] sulfate was administered and she stated she forgot to sign the MAR. During an interview with LVN 4, on 11/15/13, at 10:20 AM, she stated she did not administer [MEDICATION NAME] (a long acting medication used in the treatment of [REDACTED]. LVN 4 stated she did not notify the physician. During an interview with FM 2 on 11/15/13, at 1:05 PM, he stated a few hours after admission on 11/9/13, Resident 3 was holding her head and chest and told family members her head hurts. FM 2 also stated Resident 3's [MEDICATION NAME] and the [MEDICATION NAME] were administered late. FM 2 was aware of the [MEDICATION NAME] medication that was administered on 11/9/13, but stated it gave very little relief to Resident 3's pain. During a review of the clinical record for Resident 3, the admission history and physical, dated 11/9/13, indicated that Resident 3 had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. According to the MAR, LVN 8 administered the first dose of [MEDICATION NAME] sulfate sublingually (under the tongue) on 11/10/13, at 12 AM, (Midnight), which was eight hours after admission. The physician orders, dated 11/9/13, also indicated [MEDICATION NAME] 4 milligrams was to be administered by mouth 2 times a day to reduce the swelling of the brain. The MAR, dated 11/2013, indicated the [MEDICATION NAME] was not administered as scheduled on 11/10/13 at 8 AM and 4 PM or on 11/11/13 at 8 AM. The MAR indicated the first dose of [MEDICATION NAME] was administered on 11/11/13, at 4 PM, two days after admission. The Pain assessment dated [DATE], at 5 PM indicated a pain scale of 8 as very painful (Pain Scale 0-10 and 10 as worst possible). The pain assessment from 11/9/13 to 11/12/13 remained at a score between 7-9 both morning and the evening shift. The night shift had zero score of pain from 11/10/13 to 11/12/13. The pain assessment is to be done three times a day on every shift. There was no documentation in Resident 3's clinical record that a pain assessment was done each time the medication for pain was administered. The Emergency Kit listing was reviewed 11/15/13, at 1:15 PM and indicated no [MEDICATION NAME] sulfate both in the oral and intramuscular list of medications. There was no documentation seen in the clinical record for the physician notification when the pain score of 7-9 was noted for 11/10/13 to 11/12/13. During an interview with the Director of Nursing (DON), on 11/15/13, at 1:30 PM, she reviewed the clinical record and she was unable to find documentation the [MEDICATION NAME] sulfate was administered by LVN 2 on 11/9/13 at 10:30 PM. The DON verified the [MEDICATION NAME] was delivered from a local pharmacy on 11/11/13, at 1:45 PM. The DON also could not find documentation the physician was notified when the [MEDICATION NAME] medication was not administered for two days after Resident 3's admission.

Based on observation, interview, and record review, the facility failed to protect one resident (1) from a fall with injury when left alone in the shower. This failure resulted in Resident 1 slipping on the wet floor and sustaining a fracture to her knee. Findings: During an observation on 9/6/12 at 12 Noon, Resident 1 was lying on her left side in bed with the covers pulled up to her chin sleeping. Pillows were propped behind Resident 1's back and one between her knees. Resident 1 had a splint on her right leg. Resident 1 did not wake up when her name was called. During an interview with the Administrator on, 9/6/12, at 11:40 AM, she stated the investigation revealed that on 8/22/12, Certified Nursing Assistant (CNA) 1 left Resident 1 in the shower alone. CNA 1 said she had forgotten the body wash and went back to Resident 1's room. Resident 1 told the Administrator she was reaching for the shower head to rinse off and slipped on the floor when she stood up and fell . The Administrator stated residents are not to be left alone for any reason in the shower room. During an interview with CNA 1 on 9/12/12 at 11:50 AM she described she took Resident 1 into the shower room and while the resident was washing with soap she left the room to get the shampoo and to pull the sheets from the resident's bed. CNA 1 stated Resident 1 liked to take a long time in the shower and it was common for her to be left in the shower while the CNAs did other chores. The clinical record for Resident 1 was reviewed on, 9/6/12, at 9 AM. The "Physical Therapy Evaluation, Plan of Care", dated 8/2/12, indicated Resident 1 presented with "functional regression secondary to decreased strength, decreased balance, decrease activity tolerance, and pain on right hip and knee." The report indicated Resident 1 required moderate assistance with scooting, going from bed to wheelchair, going from lying to sitting, sitting to lying and sitting to standing. Resident 1's care plan for "Self-care Deficit", dated 5/31/12, indicated she had limited range of motion, impaired balance, and inability to transfer and bathe herself. The care plan indicated staff were to assist Resident 1 with her ADL's (activities of daily living such as grooming). The "Fall Evaluation" dated 8/1/12, indicated Resident 1 had had 1-2 falls within the past three months. It also indicated she was chair bound and needed safety reminders. The Care Plan for "ADL Impairment" 4/3/12 related to impaired physical function, and generalized weakness indicated the resident was unable to complete her ADLs without physical assistance. The "Nurses Notes" dated 8/22/12 at 9:30 AM indicated "She was in shower and went to stand up, aide not in room and her right knee went out from under her." The "Interdisciplinary Progress' Notes dated 9/5/12 indicated "This A & O (alert and oriented) resident fell while unattended in shower and sustained knee fracture."

Based on observation, interview, and record review, the facility failed to medically justify the use of urinary catheter for one of seven sampled residents (29) who was continent of bladder. This had resulted in Resident 29 having a urinary catheter inserted unnecessarily. Findings: On 6/27/11, at 8:05 AM, during an initial tour, observed Resident 29 was lying on a specialty mattress used specifically to relief pressure and promote healing. Resident 29 had a urinary catheter to a bag. The Supervising Nurse (Registered Nurse (RN) 1), when asked about pressure ulcers, stated Resident 29 had three pressure ulcers on her buttocks. RN 1 stated Resident 29 was alert and oriented and able to interview. On 6/29/11, Resident 29 ' s clinical record was reviewed. On 6/9/11, Resident 29 developed two Stage II pressure ulcers (a shallow open ulcer with a red pink wound bed as a result of pressure). The one on her coccyx (commonly referred to as the tailbone) measured 2 x 1.5 cm. The second Stage II pressure ulcer was on her left buttock which measured 1 x 1 cm. On 6/28/11, Resident 29's pressure ulcers were evaluated by RN 2. The pressure ulcer to the resident's coccyx had advanced to Stage III and the size had increased to 0.8 x 1.2 x 0.2 cm (length/width/depth) with yellow slough. The ulcer to her left buttock had improved in size which was 0.2 x 0.2 cm. A physician's orders [REDACTED].? (change) prn (as needed) for leakage or displacement ? bag & tubing Q (every) month wound healing)." The catheter order was obtained at 10 PM on 6/28/11 after RN 2 assessed Resident 29's pressure ulcers. On 6/29/11, at 9:40 AM, during an interview, Resident 29 stated she was not aware how she developed the pressure ulcers. She added she has been able to control her bowel and bladder but required assistance from staff to use the bathroom. The resident was asked if staff obtained her permission to place a urinary catheter prior to insertion, Resident 29 responded, "No" and added "They just said I need it." When asked the resident if the facility explained to her the risk and benefits of having a catheter, she replied, "No." Resident 29 was asked if she wanted the catheter, she said, "No." At 9:45 AM, during an interview with certified nursing assistant (CNA) 3 who had been taking care of Resident 29 for two years on regular basis, she stated the resident "is continent and may not be able to make it to the bathroom once every two weeks, and she is rarely incontinent of bowels." She explained Resident 29 also required one person to assist her to use bathroom. On 6/29/11, Resident 29's "MULTI-DISCIPLINARY PROGRESS NOTES" was reviewed. There was no documentation entered by nursing staff, prior to the catheter insertion, to indicate the risk and benefits of having a urinary catheter was explained to the resident for her to make informed choice or the consideration that the resident had been continent of bladder. Resident 29's clinical record was further reviewed. A hand written summary on a "Bowel and Bladder Evaluation" form completed on 6/9/11, read, "Able to voice/determine the need to void/move bowels. Requires assistance (with) toileting." The interdisciplinary team recommended not to proceed to bowel and bladder screening because the resident was "Cont(inent) of B & B (bowel and bladder)." On 6/29/11, at 3:45 PM, the Administrator, Senior Nurse Consultant (RN 2), Nurse Consultant (IDON), and Wound Nurse were informed of the above findings. IDON could not provide supportive documentation that the resident had been given the necessary information of the catheter in order for her to make an informed choice. The IDON proceeded to interview Resident 29 and informed the surveyors during the exit conference that the urinary catheter would be discontinued as request by the resident.

Based on observation, interview and record review, the facility failed to identify a pressure ulcer on admission which resulted in a pressure ulcer (pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight) going untreated. Findings: On 4/11/11 at 9:50 AM, during the initial tour of the residents, a charge nurse (LN A) stated, "Resident 5 has a pressure ulcer on her coccyx." The clinical record for Resident 5 was reviewed on 4/12/11. The resident's admission skin assessment, dated 3/1/11, indicated Resident 5 had no pressure ulcers upon admission. Nurses notes dated 4/4/11 read, "late entry for 4/1/11 Resident has new pressure wound to coccyx." The Wound/Skin Evaluation and Documentation form, dated 4/1/11, indicated the coccyx wound was a Stage II measuring 0.3 cm wide and long. Further review of the record indicated that up until 4/1/11 staff had not identified the pressure ulcer. Resident 5's Minimum Data Set (MDS), a resident assessment instrument, dated 3/17/11, indicated no pressure ulcers were present upon admission. However, the MDS dated [DATE] indicated there was one pressure ulcer present upon admission. During an interview and concurrent record review with the MDS Nurse on 4/12/11, at 11:55 AM, when asked about the discrepancies on the MDS, she stated the MDS assessment dated [DATE] was incorrect as Resident 5 had a pressure ulcer when she was admitted . She stated "I marked it (the MDS) wrong." She stated the MDS dated [DATE] was correct. During an interview with the Treatment Nurse, on 4/13/11 at 4:15 PM, she indicated she had began treating the opened area on Resident 5's coccyx on 4/1/11 (1 month after the resident was admitted ). When asked about the improvement of the wound she stated "It has actually gotten bigger." The facility form "Admission Nursing Assessment" signed and dated on 3/1/11, had instructions for Skin Condition that indicated "Using the diagrams provided, indicate all body marks such as old/recent scars, bruises, ...pressure ulcers, or questionable markings. Indicate size, depth (in cms), color and drainage." There was no documentation on the diagram. During an observation on 4/11/11 at 10:15 AM, 12:35 PM and 2:55 PM Resident 5 was seen in her room, laying in bed on her back. Again, on 4/12/11 at 8:55 AM, 10:35 AM, 10:45 AM, and 3:55 PM Resident 5 was observed to be in the same position. On 4/13/11 at 8:35 AM, 10:20 AM, and 12:52 PM, Resident 5 continued laying in bed on her back.