Every finding on record at Boulder Park Terrace

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of existing pressure injuries and prevent the development of two additional pressure injuries for one Resident (#60) of two residents reviewed for wounds. This deficient practice resulted in harm when R60 developed two stage II pressure injuries to bilateral heels.Findings include:Resident #60 (R60)Review of R60's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/8/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (a stroke causing partial or complete paralysis on the right side of the body), chronic kidney disease, diabetes mellitus, and bilateral cataracts (cloudy areas that form on the lens of the eye resulting in vision impairments). Review of R60's most recent Minimum Data Set (MDS) assessment, submitted 4/29/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.Review of R60's Braden Score Assessment [a standardized assessment tool used by healthcare providers to predict a patient's risk of developing pressure injuries], completed 4/14/26, revealed a score of, 18 - AT RISK [of developing pressure injuries] - if other major risk factors are present e.g. advanced age, fever, poor dietary intake of protein.On 7/9/26 at 1:20 PM, an interview was conducted with Infection Preventionist/Registered Nurse (IP/RN) C regarding skin condition monitoring expectations for early pressure injury identification. IP/RN C indicated when Certified Nursing Assistants (CNAs) complete a weekly shower they evaluate for new skin conditions or developments and document it on the designated shower sheet. The sheet is then given to the floor nurse to review, sign, and further investigate any skin impairments, ensuring skin inspections are completed at least weekly. Review of the CNA/RA [Resident Assistant] Bath and Shower Documentation Sheet directions read: During bath or shower, check the resident's head (including ears), body and feet for any skin condition including skin tear, bruise, blister, reddened area, etc.After bathing/showering resident, indicate the skin conditions on the diagrams below by placing an X on the appropriate location(s) and complete the information below. If no skin conditions are noted, check 'No Skin Conditions Noted.'If resident refuses bath/shower, note the reason below and report refusal to the nurse. Sign, date and give the completed sheet to the nurse.Review of R60's shower sheet for the previous 3 months revealed the following:4/1/26 - Bath/Shower Refused, Reason: was indicated with a check. No reason was provided for the refusal. The Skin Conditions portion of the document was not completed, and the form contained no nurse's name or signature.4/5/26 - Bath/Shower Refused, Reason: Parcal [sic] bed bath. The Skin Conditions portion of the document was not completed.4/8/26 - Bath/Shower Refused, Reason: given the items for bathing @ [at] bed side. No reason was provided for the refusal. The Skin Conditions portion of the document was not completed, and the form contained no nurse's name or signature.4/16/26 - Skin Conditions: Reddened Area, Location: Buttox [sic]. 4/19/26: No shower/skin assessment was completed during the week of 4/19/26.4/30/26 - the form contained no nurse's name or signature.5/6/26 - Skin condition: sore on bottom, very yeastey [sic]. Foul order present? 'Yes' was indicated with a checkmark. The form contained no nurse's name or signature.5/7/26 - No Skin Conditions Noted was indicated with a checkmark. Location: Already noted/cream applied. The documentation did not specify the location of the impairment, where the cream was applied, or what type of cream which was applied.5/10/26: No shower/skin assessment was completed during the week of 5/10/26.5/20/26 - Skin Condition: discolored heels.5/28/26 - Skin Condition: discolored heels.5/31/26 - No Skin Conditions Noted was indicated with a checkmark. Written on the side of paper read, R [right] heel scabbed, L [left] heel breakdown6/5/26 - The Skin Conditions portion of the document was not completed, and the form contained no nurse's name or signature.Review of the facility census revealed R60 was hospitalized from [DATE] - 6/29/26.No shower/skin assessment were completed since R60's re-admission from the hospital until the time of survey exit (6/29/26 - 7/9/26).On 7/9/26 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding expectations surrounding weekly skin inspections. When asked how the facility ensures they are conducted weekly if a resident refuses a shower, a shower is not given, a form is not adequately completed, or a nurse does not sign off, the NHA stated, We know our staff. We know we have accountability. We know we're able to catch everything at this moment. We don't have a skin sweep concern in the building.Review of R60's plan of care revealed the following Problem, with a start date of 1/8/26: Resident is at high risk of developing pressure ulcers AEB [as evidenced by] less than 13 on Braden scale.The following approaches were initiated on 1/8/26:Complete Braden assessment per protocolElevate resident's heels while in bed as toleratedEnsure resident has a pressure-reducing cushion for the wheelchairObserve skin while providing care. Notify nurse of any changes.Offer resident adequate hydration throughout shift.Perform skin assessment as ordered.Perform weekly skin assessment per protocol.Provide padding to at risk bony prominences.Reposition resident frequently to prevent skin breakdown.Review of R60's EMR reviewed the development of the following wound: Date/Time Identified 5/20/26 at 4:48 PM. Wound type: Pressure Ulcer, Wound Location: Right heel, Present on admission: No.Review of R60's Wound Assessments revealed the progression of the wound:Date/Time Observed Pressure Ulcer: 5/26/26 at 3:51 PM, length (centimeters): 2.5, width (centimeters): 2.1, tissue type: stable.Date/Time Observed Pressure Ulcer: 6/5/26 at 7:00 PM, length (centimeters): 2.3, width (centimeters): 2.5, tissue type: necrotic tissue.Date/Time Observed Pressure Ulcer: 6/8/26 at 4:42 PM, length (centimeters): 2.5, width (centimeters): 2, tissue type: necrotic tissue.Review of R60's EMR reviewed the development of the following wound: Date/Time Identified 5/20/26 at 4:47 PM. Wound type: Pressure Ulcer, Wound Location: Left heel, Present on admission: No.Review of R60's Wound Assessments revealed the progression of the wound:Date/Time Observed Pressure Ulcer: 5/26/26 at 3:52 PM, length (centimeters): 3, width (centimeters): 2, wound healing status: stable.Date/Time Observed Pressure Ulcer: 6/1/26 at 3:30 PM, length (centimeters): 3, width (centimeters): 2, wound healing status: declining.Date/Time Observed Pressure Ulcer: 6/4/26 at 1:37 PM, length (centimeters): 2.5, width (centimeters): 2, tissue type: necrotic tissue, skin surrounding wound: dark purple or rusty discoloration.Date/Time Observed Pressure Ulcer: 6/5/26 at 7:00 PM, length (centimeters): 2.5, width (centimeters): 1.5, wound healing status: declining, comments: heel is boggy with fluid filled ulcer.Review of R60's EMR revealed the following provider notes which did not indicate the notification of the development or declination of wounds:5/24/26 at 1:25 PM (Date of Service [DOS] 5/18/26).5/26/26 at 10:41 PM (DOS 5/24/26).6/10/26 at 9:30 PM (DOS 6/2/26).6/13/26 at 3:53 PM (DOS 6/8/26).6/10/26 at 12:39 PM (DOS 6/9/26).6/10/26 at 8:23 PM (DOS 6/10/26).Review of R60's plan of care revealed the addition of the following approaches on 6/16/26, 27 days after the initial identification of the pressure injuries on 5/20/26:Labs as orderedMonitor for s/sx [signs/symptoms] of infectionTreatment/meds [medications] orderedWeekly rounds assessment per protocolReview of a Hospitalist Progress note on 6/25/26 at 15:07 [3:07 PM] at a local acute care hospital read, in part: . [R60] transferred from [City name] for possible heel ulcerations/worsening infection, initial adequate coverage; due to worsening leukocytosis, AKI [acute kidney injury], and foot wounds, transferred to [larger acute care hospital] for ID [infectious diseases] consultation, podiatry eval [evaluation] and MRI [Magnetic Resonance Imaging] of feet for possible infected foot wounds.Review of an Infectious Disease progress note on 6/2/26 at 14:13 [2:13 PM] at an acute care hospital read, in part: .[R60] is a 63yo [year-old] man transferred to [larger acute care hospital] for further workup of bilateral heel ulcers. He was noted to have bilateral heel ulcers with concern for possible underlying infection. These ulcers/wounds have developed since his hospitalization in January. ID consulted. Continue wound care, pressure offloading. [R60] is s/p [status post] right posterior tibial angioplasty w/balloon [with] followed by right heel ulcer debridement + bone biopsy. Heel biopsy negative for OM. Continue [antibiotics] through 6/29/26 for right heel ulcer infection.Review of a Podiatry Progress Note at a local acute care hospital on 6/25/26 at 14:03 [2:03 PM] read, in part: .Continue with offloading Podus boots. He [R60] can follow-up with [podiatrist name], his surgeon, in 7 to 10 days.On 7/9/26 at approximately 9:25 AM, an interview was conducted with Transporter/Staff L who verified she was responsible for scheduling appointments outside the facility. Staff N stated a follow-up appointment had not been scheduled with R60's podiatrist, currently 14 days after his surgery.Review of a progress note written by Nurse Practitioner (NP) D on 6/30/26 at 1:02 PM, read, in part: [R60] seen today for readmit to facility, status post orthopedic surgery on bilateral feet. Patient returns with hospital records, indicating ulcer on right inferior ankle, ulcer on right heel that requires Dakin solution and Metahoney dressing, left heel ulcer with dressing to be changed every five days per ortho [orthopedic] instructions. It is also noted that a patient has a sacral ulcer on or near the coccyx, NP was unable to visualize this today .Review of R60's Braden Score Assessment completed 6/29/26 revealed a score of, 12 - HIGH RISK [of developing pressure injuries].Review of R60's plan of care revealed the following approach with a start date of 7/2/26, 3 days after re-admission to the facility: Res. [resident] To wear PRAFO boots at all times while in bed.On 7/9/26 at 2:20 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding the lack of follow-up with R60's surgeon. The NHA stated most surgeons' suggested follow-up appointments without realizing the patient is a resident of a long-term facility that can be seen by the in-house provider. The NHA stated, It [the follow-up appointment] could be to take the stitch out. I wouldn't put him [R60] in an ambulance to do that when we can do it here. When asked if that's what the follow-up appointment was for, the NHA stated, I don't know.Review of patient education forms provided with the acute care hospital discharge summary read, in part: .Preventing pressure injuries. change positions often. In bed: change positions at least every two hours, more if possible.check your skin twice a day.Review of R60's EMR reviewed the development of the following wounds: Date/Time Identified 6/29/26 at 6:06 PM. Wound type: Pressure Ulcer. Wound Location: Coccyx. length (centimeters): 1.5, width (centimeters): 0.5. Date/Time Identified 6/29/26 at 6:07 PM. Wound type: Pressure Ulcer. Wound Location: Right buttock. length (centimeters): 0.5, width (centimeters): 0.5. Stage: Stage II. Date/Time Identified 6/29/26 at 6:08 PM. Wound type: Pressure Ulcer. Wound Location: Right buttock. length (centimeters): 1.5, width (centimeters): . Stage: Stage II.On 7/7/26 at 9:16 AM, R60 was again observed in bed on his back with the head of bed elevated, leaning significantly to the left. A wheelchair was noted in the corner of R60's room. When asked the last time he was out of bed, R60 stated, Before I went to the hospital. I guess they don't have the time [to transfer R60 to the wheelchair].On 7/7/26 at 2:58 PM, R60 was again observed in bed, positioned on his back. R60 confirmed open wounds on his backside. When asked about changing positions, R60 stated, They're supposed to reposition me. It doesn't get done; I practically have to beg.Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, revised June 2023, read, in part: .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living).Reposition resident as indicated on the care plan. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences.Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.Review of the facility policy titled, Change in a Resident's Condition or Status, revised November 2015, read, in part: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent significant weight loss in one Resident (#28) of two residents reviewed for nutrition. This deficient practice resulted in a weight loss of 45.8 pounds (21.8%) over a six-month period.Findings include:Resident #60 (R60)Review of R60's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/8/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (a stroke causing partial or complete paralysis on the right side of the body), chronic kidney disease, diabetes mellitus, and bilateral cataracts (cloudy areas that form on the lens of the eye resulting in vision impairments). Review of R60's most recent Minimum Data Set (MDS) assessment, submitted 4/29/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 7/6/26 at 9:41 AM, R60 was observed in bed with the head of bed elevated, leaning significantly to the left, with a breakfast tray resting on a bedside table which was positioned over the top of him. The breakfast tray contained a virtually untouched meal of pancakes, mixed berries, a plastic fruit cup, and frosted flakes. When asked how he was enjoying breakfast, R60 stated, I'm still hungry . I had a stroke; I can't chew these pancakes. I need things that can slide down my throat easily, like a fruit cup. This Surveyor informed R60 of the fruit cup sitting on his breakfast tray. R60 stated, I didn't see them. I can't see, I have cataracts. I have eye surgery tomorrow. When asked if he received assistance with eating, R60 stated, Nobody helps me.On 7/7/2026 at 9:16 AM, R60 was again observed in bed with the head of bed elevated, leaning significantly to the left, with a breakfast tray resting on a bedside table which was positioned over the top of him. When asked how his day was going, R60 stated, Terrible. My eye surgery was cancelled. R60 continued, It's so hard to eat in bed. They're supposed to be bringing me down to the dining room starting back in April . I've been down there once or twice. It's just so hard to eat lying down. I can't reach the tray, I can't see, it's hard to digest like this [semi-reclined] . A wheelchair was noted in the corner of R60's room. When asked the last time he was out of bed, R60 stated, Before I went to the hospital. I guess they don't have the time [to transfer R60 to the wheelchair]. No feeding assistance was offered by staff.Review of a facility census report revealed R60 was hospitalized from [DATE] - 6/29/26.Review of R60's plan of care revealed the following intervention, initiated 4/13/26: Offer to take resident to Long term dining room for all meals.On 7/8/2026 8:48 AM, R60 was again observed in bed with the head of bed elevated and a breakfast tray resting on a bedside table which was positioned over the top of him. R60 stated, I can't see this stuff [food]. R60 indicated staff had not offered to take him down to the dining room. When R60 was asked if he would have went to the dining room had he been asked, he responded, Yes. I can't see this stuff. It's hard to see. I just can't see what this is. I used to weigh 210 pounds. No feeding assistance was offered by staff.Review of R60's weights revealed he weighed 210 lbs on 1/12/26 and 164.2 lbs on 7/9/26, equating a 45.8 lbs (21.8%) weight loss over the previous approximate 60 days.On 7/9/2026 at 8:55 AM, this Surveyor greeted R60 from the right side of his bed (the side affected by a previous stroke), approximately three feet away. R60 stated, Who is it? and was unable to physically locate this Surveyor. After directing R60's attention to his right side, it was observed he had spilled cranberry juice down the front of his shirt and over the bed linens. R60 indicated he must have, missed the tray.Review of R60's EMR revealed the following progress notes:6/29/26 at 5:59 PM: Resident arrived at facility via EMS [emergency medical services] . Resident stating that he needs assistance with feeding. Also, that 'he can't see'.6/30/26 at 1:02 PM by Nurse Practitioner (NP) D: .Per nurse's report a [sic] patient is acting like he's having difficulty performing the basic ADLs [activities of daily living] that he was doing before he left our facility. Patient does act confused and is mostly concerned about lunch and that he can only see very little.7/4/26 at 10:25 AM by Registered Nurse (RN) O: .[R60] noted to have spilled both his hot and cold drinks on his right arm and side of his body, no redness, pain, or skin alterations noted. resident is struggling with weaker arm and trunk strength, than previously demonstrated.On 7/9/2026 at 9:13 AM, an interview was conducted with RN O regarding R60's change in functional status. RN O confirmed R60 came back from the hospital, much weaker than before, demonstrating a hard time sitting up straight and feeding himself. RN O stated, He couldn't even bring a cup to his mouth. When asked about visual deficits, RN O stated R60 has difficulty attending to the right half of his body due to deficits from his stroke. RN O revealed if you want to engage with R60 You can't even stand there [on the right side of his body].Review of R60's EMR revealed the following physician's note written by MD K on 3/16/26 at 10:33 AM: .[R60] is concerned about losing strength. Weight decreased - monitor PO [oral] intake, encourage strength exercises.On 7/8/2026 at 8:48 AM, an interview was conducted with Director of Rehabilitation (DOR) P regarding R60's functional decline. DOR P stated R60 had not been on skilled therapy services since his discharge on [DATE]. When asked if therapy had been asked to screen R60 per Medical Director (MD) K recommendations or recent reports of increased difficulty eating, DOR P stated he was told by management to not pick him back up [on therapy services] for insurance reasons. When asked if R60 would benefit from skilled therapy, DOR P stated, Yes.Review of a Physical Therapy (PT) Discharge summary, dated [DATE], read, in part: .Discharge Recommendations: Med [Medicare] B [Part B] OT [Occupational Therapy]/PT.Review of an OT Discharge summary, dated [DATE], read, in part: .Eating = supervision/touching assistance [Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently] .Discharge Recommendations: Med B OT/PT.On 7/8/2026 at 10:28 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding MD K and previous skilled therapy recommendations. The NHA confirmed R60 was eligible to receive skilled therapy services. Why asked why R60 hadn't been evaluated despite a recent decline, the NHA replied, We are waiting to pick him up on Med B services for therapy until after his ophthalmologist appointment. He isn't functional because he can't see. But I guess it got cancelled [the ophthalmologist appointment]. When asked if R60's visual deficits were impacting the ability to see his meal tray and therefore feed himself, the NHA replied, I think he's playing it up. He's used to being fed in the hospital. For example, he will say 'Help me take a sip of water' versus 'Where is my water?'On 7/9/26 at approximately 9:22 AM, an interview was conducted with Transporter/Staff L who confirmed R60's ophthalmology appointment had been cancelled.Review of an Infectious Disease Progress Note, dated 6/29/26, from R60's recent hospitalization, read, in part: .Baseline cataracts. He reports baseline visual changes for the last 4 years with increased vision changes over the last month. - Ophthalmology consulted and eye examination performed. Hypermature cataract OS>OD [an advanced, late-stage cataract where the eye's natural lens becomes extremely dense or liquefies, left eye worse than right eye]. Discussed he is legally blind secondary to this treatable condition.On 7/8/2026 at 8:48 AM, an interview was conducted with CNA J regarding R60's functional status and ability to perform activities of daily living (ADLs). CNA J stated, He [R60] reports a lot he can't see. When I report it to the nurse a lot of them say, 'He's telling stories again.' CNA J stated she had not been notified R60 required assistance with feeding.On 7/9/2026 at 9:24 AM, an interview was conducted with CNA N regarding R60's difficulties with self-feeding. CNA N stated, He doesn't attend [the lack of awareness on the recovering side of the body post stroke] to his right side. He has trouble eating if you don't set his tray up using the clock method [a primary orientation method used to help individuals with visual impairments navigate their surroundings, locate items, or identify food placement] or if you don't put the tray on the left side of his body. I tried to tell the other aides this but not everybody listens.Review of a progress note written by NP D on 5/24/26 at 1:25 PM read, in part:[R60] seen today for a refusal of magic cup nutritional supplementation. Pt [patient] is on this medication due to his lack of intake and weight loss. Will encourage patient to eat more of his food, and reevaluate if necessary.Review of R60's weights revealed he weighed 200.5 pounds (lbs) on 2/5/26, 185.4 lbs on 3/14/26, 185 lbs on 4/6/26, and 178.6 lbs on 5/8/26 equating a 10.9% weight loss over 3 months. R60's weight loss reflected a 7.73% weight loss over one month (March - April), a 7.73% weight loss over 3 months (February - April), and a 10.92% weight loss over 4 months (February - May). No nutritional interventions were added after the evaluation by NP D on 5/24/26.Review of a progress note written by NP D on 6/13/26 at 3:53 PM read, in part: .[R60's] wait [sic] and vital signs have essentially been within normal limits and stable over the last 60 days. he does eat very slowly, and has not been eating very much due to poor appetite. Will continue to monitor patient's weights and food intake to identify any further concerns.Review of R60's weights revealed he weighed 185 lbs on 4/6/26 and 173.9 lbs on 6/2/26, an 11.1 weight loss (6.0%) over the previous 60 days. No nutritional interventions were added after the evaluation by NP D on 6/13/26.Review of R60's Food Acceptance (FA) Records (breakfast, lunch, and dinner) from 4/7/26 - 7/7/26 (excluding R60's hospitalization from 6/10/26 - 6/29/26), revealed 216 meal opportunities. FA were charted on 105 out of 216 opportunities (48.6%). Of the 105 FA opportunities, 30 (28.6%) were charted as, 0%, 1-25%, or not taken.On 7/09/26 at 10:17 AM, a telephone interview was conducted with Registered Dietitian (RD) Q who confirmed R10 was not currently prescribed any dietary interventions despite over a 45-pound undesired weight loss since admission which is classified as severe weight loss. RD Q stated the Nutritional Preference Assessment and Nutritional Assessments should be completed on admission, quarterly, and with any significant change.Review of R60's EMR revealed the most recent Nutritional Preference Assessment was completed on 1/28/26.Review of R60's revealed the most recent Nutritional Assessment was completed on 1/14/26 which read, in part: .at risk for malnutrition.On 7/9/26 at 2:12 PM, during a follow-up interview with the NHA, R60's significant weight loss and lack of interventions were brought up as a concern. The NHA again stated R60 did not have visual deficient impacting his ability to eat stating, He had no problem findings his oatmeal last time I was in there [R60's room].Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, read, in part: .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions.Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, read, in part: .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the highest possible level of physical, mental, and psychological well-being for all 49 residents of the facility.Findings include:A confidential resident council meeting was held on 7/7/26 at 1:00 PM. During the meeting, the facility staff levels and resident care were discussed with the following statements: one Confidential Resident (CR) stated, No, there is not enough staff during the day or night. There is one CNA and one nurse. It takes 35-40 minutes to answer a call. It happens daily. I have soiled, urinated and fallen because they don't answer my light. I get one shower a week if I beg and I am lucky. Another CR stated, Not enough staff during the day, but it is unreal at night. I can't believe they can get away with what they are doing. I was freezing last night and pushed the buzzer, 45 minutes later to ask for a blanket and another 45 minutes later to get it. I have to get up at 5 AM every morning if I want care. My catheter bag leaked a day and a half ago because they hadn't change it. I got my last shower a week ago and would like more. A third CR stated, There is not enough staff. I get a shower every 10 days to 2 weeks. I got a bed bath last Thursday. I have a wound and it needs to be changed (wound care dressing) during the day with the nurse, if I don't get my shower in the morning and my wound dressing is changed, I don't get a shower that day. A fourth CR stated, They are very understaffed and I have had to wait a long time. I feel bad for the girls (staff). Lights are on and they don't know which ones to go to first. One nurse and one CNA for a lot of night shifts. I maybe shower once a week, sometimes it's eight days. A fifth CR stated, I maybe get a shower every week and they have bad attitudes each time they have to give me one. Findings include: On 7/6/26 at 5:45 AM, this Surveyor entered the facility and observed two Registered Nurses (RNs) and one Certified Nursing Assistant (CNA) working the night shift (6:30 PM – 6:30 AM) with a census of 49 residents. On 7/6/26 at 6:10 AM, an interview was conducted with CNA M who confirmed she was the only CNA working the night shift. When asked how the night went, CNA M replied, Where do I even start? Do you want me to include all my mental breakdowns? When queried further, CNA M stated she could not provide timely care for all 49 residents. CNA M indicated there were around 20 residents who require incontinence, check and changes every two hours, but she couldn't possibly get to all of them timely. CNA M confirmed this resulted in residents laying in excrement for longer than necessary. When asked about current staffing trends and needs, CNA M stated for a census a 49, three CNAs would be considered fully staff. CNA M continued, There has been terrible staffing. the last three nights there has only been one CNA on duty for the whole facility. On 7/6/26 at 8:33 AM, Resident #36 (R36) was asked about staffing levels in the building. R36 indicated he waits up to two hours after night for a brief change as there is often only one CNA on duty. Review of Section H: Bladder and Bowel in R36's most recent Minimum Data Set (MDS) Assessment, submitted 6/8/26, revealed R36 was always incontinent of urine. Further review of Section GG: Abilities and Goals, revealed R36 was dependent [helper does ALL of the effort; resident does none of the effort to complete the activity] for toileting hygiene. On 7/6/26 at 8:46 AM, Resident #1 (R1) voiced his concerns regarding the facility staffing levels. R1 indicated he frequently waits for up to an hour or more for assistance on night shift after activating his call light. On 7/7/26 at 9:16 AM, Resident #60 (R60) was observed in bed with a breakfast tray stationed over him on a bedside table. R60 stated, It's so hard to eat in bed. They're supposed to be bringing me down to the dining room starting in April . I've been down there once or twice. It's just so hard to eat lying down. I can't reach the tray, I can't see, it's hard to digest like this . When asked why facility staff didn't offer to take R60 to the dining room he replied, I guess they don't have the time. Review of R60's Electronic Medical Record (EMR) revealed the following order, initiated 4/13/26: Offer to take resident to Long term dining room for all meals. Once A Day; 06:30 AM - 06:30 PM. R10 was observed eating all breakfast and lunch meals in bed from 7/6/26 – 7/9/26. On 7/7/2026 at 2:58 PM, a follow-up interview was conducted with R60 who voiced concerns regarding receiving assistance with regular showers and facial grooming. R60 stated, I got shaved last night for the first time since I got back from the hospital. A brown substance was observed surrounding the fingernails on R60's left hand. Review of a facility census report revealed R60 was hospitalized from [DATE] – 6/29/26. Review of R60's shower sheets since 4/1/26 indicated a lapse in showers from 4/16/26 – 4/30/26 (14 days), 5/7/26 – 5/20/26 (20 days), 5/20/26-5/28/26 (8 days), and 6/29/26 – time of survey exit, 7/9/26 (10 days). There were no documented refusals during these timeframes. On 7/9/26 at 9:24 AM, an interview was conducted with CNA N regarding the frequency of resident showers. CNA N stated residents were supposed to get 1-2 showers per week, at a minimum. CNA N confirmed that because of staffing issues, shower aides frequently get pulled to work the floor which results in missed showers. CNA N also indicated some residents are getting bed baths instead of their preferred showers to save time due to the lack of staff.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, including food and food-use utensil storage, cleaning and sanitizing of soiled food preparation equipment, cleaning of non-food contact surfaces such as ceiling and air duct covers, and storage of food utensils resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include: On 7/6/2026 at 5:55 AM a cart with pans of food and soiled dishes from resident rooms was noted outside of the dirty dish room. On 7/6/2026 at 6:02 AM open boxes of single serve items were found on the floor of the dry storage room, including disposable lids for 8-ounce bowls, an open bag of large foam to-go containers stored in a cardboard box originally for luncheon napkins. On 7/6/2026 at 6:04 AM an open box of bagged corn flakes was noted on the floor in the dry storage room. On 7/6/2026 at 6:12 AM the base of the garbage grinder was noted soiled, and soiled rags were observed wrapped around the airgap of the drain line coming from the vegetable prep sink. When asked what that sink was used for, Dietary Aide (DA) 'S' said the sink was used for washing vegetables. On 7/6/2026 at 6:14 AM the can opener blade was observed to be soiled with food debris. When asked when the can opener was used last, DA 'S' stated it would have been yesterday. On 7/6/2026 at 6:16 AM observed the sides of the oven were soiled with grease and the floor below the oven had grease and food debris built up, as well as the floor below the ovens. On 7/6/2026 at 6:16 AM observed the handle of the utensil drawer containing food scoops was soiled. On 7/6/2026 at 6:19 AM observed the single serve knives, forks and spoons were stored in a utensil storage tray with the handles mixed in both directions. On 7/6/2026 at 6:19 AM observed several air duct vents with covers that were soiled, in the ceiling of the kitchen. On 7/6/2026 at 6:26 AM the ice machine was noted with heavy buildup of minerals around the dispenser and down the backsplash into the drain tray. On 7/6/2026 at 6:28 AM the dish machine was observed with heavy debris build up on top of the unit. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of equipment and furnishing in the building, resulting in an increased potential for contamination and a possible decrease in the satisfaction of living affecting residents throughout the building. Findings include:On 7/6/2026 at 6:48 AM observed the ceiling air conditioning unit dripping from the ceiling of the Rehab room located in the C Hall nurses station into trash cans. Nurse 'T' who is the team leader stated she had noticed the problem and asked at the nurse's station to have maintenance notified. When Nurse 'T' asked at the C Hall nurses station, if someone had been notified about the situation yet, they said nobody had sent it through yet. On 7/6/2026 10:33 AM observed the ceiling air duct vent covers in the B Hall and the ceiling around them were soiled with dust. On 7/6/2026 at 10:36 AM observed the couch in the hall at the intersection of B and C wings with candy wrappers and debris under the cushions.

Based on observation, interview and record review, the facility failed to provide Activity of Daily Living (ADL) care (showers hygiene, and eating) to two Resident (#36 & #60) and five of seven confidential residents from a total 14 residents reviewed for ADL care. This deficient practice resulted in extended periods of not providing ADL care and created frustration amongst the residents. Findings include: Resident #36 (R36 On 7/6/26 at 8:33 AM, R36 was asked about the quality of care he received at the facility. R36 indicated he waits up to two hours during the night for a brief change as there is often only one CNA on duty. Review of Section H: Bladder and Bowel in R36's most recent Minimum Data Set (MDS) Assessment, submitted 6/8/26, revealed R36 was always incontinent of urine. Further review of Section GG: Abilities and Goals, revealed R36 was dependent [helper does ALL of the effort; resident does none of the effort to complete the activity] for toileting hygiene. Resident #60 (R60) Review of R60's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/8/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (a stroke causing partial or complete paralysis on the right side of the body), chronic kidney disease, diabetes mellitus, and bilateral cataracts (cloudy areas that form on the lens of the eye resulting in vision impairments). Review of R60's most recent MDS assessment, submitted 4/29/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 7/6/26 at 9:41 AM, R60 was observed in bed with the head of bed elevated, leaning significantly to the left, with a breakfast tray resting on a bedside table which was positioned over the top of him. The breakfast tray contained a virtually untouched meal of pancakes, mixed berries, a plastic fruit cup, and frosted flakes. When asked how he was enjoying breakfast, R60 stated, I'm still hungry . I had a stroke; I can't chew these pancakes. I need things that can slide down my throat easily, like a fruit cup. This Surveyor informed R60 of the fruit cup sitting on his breakfast tray. R60 stated, I didn't see them. I can't see, I have cataracts. I have eye surgery tomorrow. When asked if he received assistance with eating, R60 stated, Nobody helps me. On 7/7/2026 at 9:16 AM, R60 was again observed in bed with the head of bed elevated, leaning significantly to the left, with a breakfast tray resting on a bedside table which was positioned over the top of him. When asked how his day was going, R60 stated, Terrible. My eye surgery was cancelled. R60 continued, It's so hard to eat in bed. They're supposed to be bringing me down to the dining room starting back in April . I've been down there once or twice. It's just so hard to eat lying down. I can't reach the tray, I can't see, it's hard to digest like this [semi-reclined] . A wheelchair was noted in the corner of R60's room. When asked the last time he was out of bed, R60 stated, Before I went to the hospital. I guess they don't have the time [to transfer R60 to the wheelchair]. No feeding assistance was offered by staff. Review of a facility census report revealed R60 was hospitalized from [DATE] - 6/29/26. Review of R60's plan of care revealed the following intervention, initiated 4/13/26: Offer to take resident to Long term dining room for all meals. On 7/8/2026 8:48 AM, R60 was again observed in bed with the head of bed elevated and a breakfast tray resting on a bedside table which was positioned over the top of him. R60 stated, I can't see this stuff [food]. R60 indicated staff had not offered to take him down to the dining room. When R60 was asked if he would have went to the dining room had he been asked, he responded, Yes. I can't see this stuff. It's hard to see. I just can't see what this is. I used to weigh 210 pounds. No feeding assistance was offered by staff. Review of an OT Discharge summary, dated [DATE], read, in part: .Eating = supervision/touching assistance [Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently] . On 7/7/2026 at 2:58 PM, a follow-up interview was conducted with R60 who voiced concerns regarding receiving assistance with regular showers and facial grooming. R60 stated, I got shaved last night for the first time since I got back from the hospital. A brown substance was observed surrounding the fingernails on R60's left hand. Review of R60's shower sheets since 4/1/26 indicated a lapse in showers from 4/16/26 – 4/30/26 (14 days), 5/7/26 – 5/20/26 (20 days), 5/20/26-5/28/26 (8 days), and 6/29/26 – time of survey exit, 7/9/26 (10 days). There were no documented refusals during these timeframes. On 7/9/26 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding her expectations with resident shower frequency. The NHA stated, We aim for once a week. two [per week] in a perfect world. A confidential resident council meeting was held on 7/7/26 at 1:00 PM. During the meeting resident care was discussed with the following statements: One Confidential Resident CR stated, I get one shower a week if I beg and I am lucky. Another CR stated, I got my last shower a week ago and would like more. A third CR stated, There is not enough staff. I get a shower every 10 days to 2 weeks. I got a bed bath last Thursday. I have a wound and it needs to be changed (wound care dressing) during the day with the nurse, if I don't get my shower in the morning and my wound dressing is changed, I don't get a shower that day. A fourth CR stated, I maybe shower once a week, sometimes it's eight days. A fifth CR stated, I maybe get a shower every week and they have bad attitudes each time they have to give me one. Review of the following residents 'Shower Sheets' revealed the following: One of the seven CR's had three showers in the month of April 2026 (4/8, 4/19, 4/29); five showers in the month of May 2026(5/6, 5/13, 5/17, 5/23, 5/30); five showers in the month of June 2026 (6/2, 6/10, 6/14, 6/18, 6/23) and one shower in July 2026 before exit date (7/1). Another of the CR's had two showers in the month of April 2026 (4/16, 4/30); four showers in the month of May 2026 (5/6, 5/13, 5/20, 5/28); four showers in the month of June 2026 (6/6, 6/11, 6/18, 6/21) and one shower in July 2026 before exit date (7/1). The third CR reviewed had five showers in the month of April 2026 (4/2, 4/9, 4/16, 4/24, 4/30); four showers in May 2026 (5/6, 5/14, 5/21, 5/29); four showers in the month of June 2026 (6/5, 6/11, 6/18, 6/24) and one shower in July 2026 before exit date (7/2). The fourth CR reviewed had three showers in the month of April 2026 (4/9, 4/15, 4/26); five showers in May 2026 (5/6, 5/13, 5/20, 5/23, 5/29); five showers in June 2026 (6/2, 6/12, 6/19, 6/21, 6/24) and one shower in July 2026 before exit date (7/3). The fifth CR reviewed had two showers in April 2026 (4/14, 4/23); four showers in May 2026 (5/4, 5/12, 5/17, 5/26); four showers in June 2026 (6/5, 6/13, 6/18, 6/21) and one shower in July 2026 before exit date (7/1). Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, read, in part: Residents will[sic] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems).

Based on observation, interview, and record review, the facility failed to ensure bedside urinals were cleaned and stored per standards of care for two Residents (#3 and #1) of 14 residents reviewed for infection control.Findings include: On 7/6/2026 at 11:21 AM, Resident #3 (R3) was observed laying in bed in his private room. A bedside table was observed located on R3's right side, with a urinal containing urine sitting on the bedside table. A Styrofoam drinking cup with an exposed straw was observed sitting next to the urinal on the bedside table. On 7/7/2026 at 8:36 AM, Resident #1 (R1) was observed sitting on the edge of his bed, eating breakfast. A urinal with no top was observed hanging from a nightstand drawer handle containing visible dried urine in bottom. An incentive spirometer (a hand-held device that helps people to take slow, deep breaths) and nebulizer with attached oxygen tubing and a mouthpiece were observed placed next to the contaminated urinal. On 7/8/26 at 3:05 PM, a nearly full urinal (approximately 900 milliliters [mL]) was observed on R3's beside table, located next to a Styrofoam drinking cup with an exposed straw and an open sports drink. An interview was conducted with Infection Preventionist/Registered Nurse (IP/RN) C on 7/9/26 at 9:51 AM. IP/RN C confirmed that urinal storage when not in use should not be sitting on residents bedside tables, and if facility staff see a urinal sitting on a bedside table, especially if filled with urine, staff should empty the urinal, rinse, and place on the residents garbage can. Ongoing education to residents on proper urinal placement should continue, as well as monitoring from facility staff. IP/RN C stated that all urinals should have a lid and be changed out weekly by the night staff.

Based on observation and interview, the facility failed to ensure the right to personal privacy during toileting and performance of perineal care for 2 of 2 Residents (#2, #3) reviewed for privacy.Findings include: Resident #2 (R2)During an observation on 7/8/2026 at approximately 11:00 AM, R2 was observed receiving perineal and catheter care in a semi-private room by Certified Nursing Assistant (CNA) J. R2 was located in the bed closest to the window. CNA J did not ensure adequate privacy, as the window blind was raised and allowed a clear view into the courtyard. CNA J acknowledged the blind had not been lowered when she asked R2 to turn so she could cleanse the posterior perineal area. Although CNA J paused care to walk around the bed and pull the blind down, she did not close or angle the slats, leaving visibility into the room and failed to provide full visual privacy. Resident #3 (R3) On 7/8/26 at 3:05 PM, a nearly full urinal (approximately 900 milliliters [mL]) was observed on R3's beside table, located next to a Styrofoam cup with an exposed straw as well as an open sports drink. On 7/8/26 at 3:18 PM, R3 engaged his call light and notified Certified Nursing Assistant (CNA) B he needed to use his urinal and therefore first required assistance emptying it. CNA B was observed entering the room, emptying the urinal, and handing it back to R3 before leaving the room without closing the door or privacy curtain. R3 was then observed utilizing the urinal from the hallway. On 7/9/26 at 1:17 PM, an interview was conducted with Infection Preventionist/Registered Nurse (IP/RN) C regarding her expectations with resident privacy during personal cares. IP/RN C stated privacy curtains should be utilized and/or room doors should be shut during all personal care tasks to ensure a dignified care experience.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one Resident (#35) out of two residents reviewed for abuse reporting.Findings include:Resident #35 (R35) Review of R35's Electronic Medical Record (EMR) revealed admission to the facility on 7/22/24 with diagnosis including Alzheimer's disease, dementia with anxiety and depression. R35's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment.On 7/6/2026 at 12:23 PM, R35 was observed sitting in a chair near the front entrance with a large bruise surrounding her right eye and down the side of her face. At attempted interview was conducted with R35, who could not recollect what happened to cause the bruise on her face.On 7/6/2026 at 9:20 AM, R35 was observed walking down the hallway. R35 was observed to have a large brise surrounding her right eye and down the side of her face. Review of R35's EMR revealed the following progress notes: 6/30/2026 7:46 AM Writer called into res. (resident) room by staff, upon entering res. room, res laying on bed with a baseball size hematoma on left forehead. Res, face, shirt, bed, floor, and left hand covered in smears of blood. Left hand and left fingers swollen. Res. calm and c/o (complaint of) headache and left-hand pain .Order to send to ER (emergency room) for eval (evaluation) and treat received . 7/3/2026 2:00 PM (35), a [AGE] year-old female patient seen today status post fall this a.m. in which the patient was sent to the emergency room for evaluation and treatment. This was an unwitnessed fall. Patient was found in her room on the floor with blood on the floor. She had a large hematoma on her forehead, as well as blood on the left middle fingertip coming from the nail area. She was sent to the emergency room for evaluation and treatment and came back to us a few hours later. ER diagnosis includes hematoma with head trauma, fractured, left middle finger fingertip, which was splinted, as well as UTI (Urinary Tract Infection) . Witness Statements from Certified Nurse Aide (CNA) N read, in part, (CNA U) called me into (R35's) room at breakfast said she looks like someone beat her up. Upon entering I noticed her laying in her bed with a baseball size goose egg on her head and a bloody finger on her left hand. I asked her what happened and she stated she didn't know. An interview was conducted with the NHA on 7/9/2026 at 1:00 PM. The NHA stated that they did not report this injury of unknown origin to the SA because they felt this was the resident's normal behavior. The NHA confirmed that this injury was unwitnessed and happened in the resident's room with R35 last being checked over two hours before being found with the large hematoma and blood. The NHA also stated that they did not review camera footage to ensure that there was no abuse or neglect.

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin for one Resident (#35) out of two residents reviewed for abuse.Findings include:Resident #35 (R35) Review of R35's EMR revealed admission to the facility on 7/22/24 with diagnoses including Alzheimer's disease and dementia. Review of R35's EMR revealed the following progress notes: 6/30/2026 7:46 AM Writer called into res. (resident) room by staff, upon entering res. room, res laying on bed with a baseball size hematoma on left forehead. Res, face, shirt, bed, floor, and left hand covered in smears of blood. Left hand and left fingers swollen. Res. calm and c/o (complaint of) headache and left-hand pain .Order to send to ER (emergency room) for eval (evaluation) and treat received . 7/3/2026 2:00 PM (35), a [AGE] year-old female patient seen today status post fall this a.m. in which the patient was sent to the emergency room for evaluation and treatment. This was an unwitnessed fall. Patient was found in her room on the floor with blood on the floor. She had a large hematoma on her forehead, as well as blood on the left middle fingertip coming from the nail area. She was sent to the emergency room for evaluation and treatment and came back to us a few hours later. ER diagnosis includes hematoma with head trauma, fractured, left middle finger fingertip, which was splinted, as well as UTI (Urinary Tract Infection) . An interview was conducted with the NHA on 7/9/2026 at 1:00 PM. The NHA stated that they did not report this injury of unknown origin to the SA because they felt this was the resident's normal behavior. The NHA confirmed that this injury was unwitnessed and happened in the resident's room. The NHA also stated that they did not review camera footage to ensure that there was no abuse or neglect.

Based on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a resident transfer or discharge for three Residents (#51, #55, & #58) of three residents reviewed for discharge processes. Findings include:Resident #51 (R51) A review of R51's Electronic Medical Record (EMR) indicated she was transferred to the hospital emergency department on 1/14/26. Review of the documentation provided to the Long-Term Care Ombudsman in January, indicated they were not notified of the resident's discharge from the facility. Resident #55 Review of R55's EMR indicated he was transferred to the hospital on 4/14/26. Review of the documentation provided to the Long-Term Care Ombudsman in April, indicated they were not notified of the resident's discharge from the facility. Resident #58 (R58) Review of R58's Electronic Medical Record (EMR) revealed initial admission to the facility on 7/24/25. Review of a progress note dated 12/18/25 at 3:08 PM read, in part: VISIT TYPE: Discharge. lateral transfer to [facility name] . Review of a facility census report confirmed a discharge date of 12/18/25. Review of the December 2025 Ombudsman notification record revealed R58 was not included. On 7/7/2026 at 3:10 PM, an interview was conducted with Coordinator of Social Services I, who stated she was in charge of notifying the Ombudsman while the facility did not have a medical records person. Coordinator of Social Services I stated she would just run the report on matrix to ask for admit/discharge report. Coordinator of Social Services I stated she didn't know that all discharges were to be sent to the Ombudsman. At 3:18 PM on 7/7/2026 and Nursing Home Administrator (NHA) stated the Medical Records person left on 2/24/26. The NHA stated the Coordinator of Social Services was asked to take over the notification of the Ombudsman at that time. Review of the facility's policy titled Discharging the Resident revised in December of 2016, did not indicate that an Ombudsman should be notified for any of the described discharges.

Based on interview and record review, the facility failed to monitor, report and act upon a change in condition; and transcribe a medication order into the Electronic Medical Record (EMR) for two Residents (#36 and #2) out of 14 residents reviewed for quality of care.Findings include:Resident #36 (R36)Review of R36's EMR revealed initial admission to the facility on [DATE] with diagnoses including peripheral vascular disease, chronic pain syndrome, and rash and other nonspecific skin eruptions. Review of R36's most recent Minimum Data Set (MDS) assessment, submitted 6/8/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 7/6/2026 at 8:33 AM, an interview was conducted with R36 who stated he had an ongoing rash on his back which was painful and itchy that he believed was caused by the facility laundry detergent. R36 stated, I think they need to use a better-quality laundry detergent.Review of R36's EMR revealed the following progress notes:6/11/26 at 9:06 AM by Licensed Practical Nurse (LPN) F: pt [patient] complaining of back rash r/t [related to] laundry detergent, back is red and some small scratches, ointment applied put on Dr. rounds.6/16/26 at 9:40 AM by Nurse Practitioner (NP) D: [R36] seen today for rash on his back. He does have a rash on his back that has been itching him. NP will order some hydrocortisone cream to be put on his back three times a day PRN [as needed] .Review of R36's physician orders did not reveal an order for hydrocortisone cream.On 7/3/26 an order was initiated, which read: Offer resident cream applied to itchy areas on back until healed.On 7/7/2026 at 10:58 AM, an interview was conducted with Registered Nurse (RN) E who confirmed R38 was currently under her care. RN E stated R38 did have a rash on his back but was unsure if it had resolved. RN E was uncertain whether hydrocortisone cream was ordered for R38.On 7/7/2026 at 11:56 AM, a follow-up interview was conducted with RN E who stated she was unable to locate an order for hydrocortisone cream in R36's EMR. RN E stated she found an order to offer cream but she did not know which cream to offer.Review of R36's Wound Observation Record revealed the following entry created on 7/7/26: Wound Type: Rash. Wound Location: Right lower back. Date/Time Identified: 7/7/26 at 11:43 AM. Rash distribution: Distributed. Rash color: Pink. Rash texture: Raised/Bumpy. Rash details: Itchy.Review of progress note written by Infection Preventionist/Registered Nurse (IP/RN) C on 7/7/26 at 12:00 PM read, in part: This nurse was informed of a rash to [R36's] lower back this shift. Myself and [RN E] assessed area. rash located to lower portion of back with obvious scratch marks throughout the rash.Order placed to trial dye free laundry soap and also apply hydrocortisone cream.On 7/7/2026 at 12:47 PM, a follow-up interview was conducted with R36 who stated two nurses had just been in his room to assess his back. R36 confirmed he had never been offered a cream to address his itching prior to that day, 7/7/26.On 7/7/2026 at 12:04 PM, an interview was conducted with IP/RN C regarding R36's back rash. IP/RN C stated, I don't feel like it was addressed. IP/RN C stated upon initial identification of the rash on 6/11/26, LPN F should have created a Wound Observation Record which would have then prompted nursing staff on subsequent shifts for further monitoring. IP/RN C stated NP D is responsible for creating her own medications orders in the EMR system and confirmed the hydrocortisone cream was never ordered as prescribed on 6/16/26. IP/RN C confirmed she had just finished assessing the rash stating, .he's [R36] scratching it, there are apparent scratch marks. It's definitely irritating him.Resident #2 (R2)Review of R2's EMR revealed initial admission to the facility on 7/15/25 with diagnoses including congestive heart failure, ischemic cardiomyopathy (ineffective blood pumping by the heart as a result of muscle damage), urinary tract infection (UTI), and chronic kidney disease. Review of R2's MDS assessment, submitted 5/6/26, revealed a BIMS score of 15, indicative of intact cognition.On 1/11/26 at 8:04 PM, a blood pressure reading of 84/46 was taken by Certified Nursing Assistant (CNA) G according to R2's vital charting. Further review of the EMR did not reveal if R2's blood pressure was re-checked, if R2 was experiencing symptoms, or if a nurse or physician was notified of the low blood pressure reading. The next blood pressure was taken on 1/12/26 at 12:48 AM, over 4 hours later.Review of a progress note written by Licensed Practical Nurse (LPN) F on 1/12/26 at 11:07 PM read: pt [patient] woke to take meds[.] b/p [blood pressure] low at start of shift. encouraged fluids. [blood pressure] up to 96/46. pt is sleeping at this time.Further review of the EMR did not reveal if R2's blood pressure was re-checked, if R2 was experiencing symptoms, or if a nurse or physician was notified of the low blood pressure reading.Review of R2's EMR revealed the following progress notes:1/13/26 at 12:00 PM - Resident sent tp [sic] [local emergency department] via ambulance. vitals were 92/38, spo2 98 [oxygen saturation percentage], pulse 73. Instructed he was being sent for hyponatremia, hypotensive, and acute mental status change.1/15/26 at 2:58 PM - Patient arrived via EMS [emergency medical services] from the hospital today. ER [emergency room] reports sepsis upon admission, blood transfused, UTI treated.On 7/9/26 at 12:27 PM, a telephone interview was conducted with Medical Director (MD) K regarding his clinical expectations with blood pressure changes and other changes in conditions. MD K stated he would expect to be notified when a resident's blood pressure had a deviation from their norm, especially if the resident was symptomatic (experiencing dizziness or lightheadedness, fainting, blurred vision, fatigue, confusion, altered mental status, nausea, and cold, clammy, or pale skin).On 7/9/26 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) who preferred to answer all clinical questions as the interim Director of Nursing (DON) was not on site. The NHA stated the blood pressures on 1/11/26 and 1/12/26 should have been re-checked and acknowledged low blood pressure combined with altered mental status and personal history of UTI could be signs and symptoms of urosepsis.Review of the facility policy titled, Change in a Resident's Condition or Status, revised November 2015, read, in part: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition.

Based on observation, interview, and record review, the facility failed to follow the standards of care for urinary catheters for two Residents (#2 and #8) of two residents reviewed for catheter care.Findings include: Resident #2 (R2) Review of R2's Electronic (EMR) revealed initial admission to the facility on 7/15/25 with diagnoses including congestive heart failure, urinary tract infection (UTI), and chronic kidney disease. Review of R2's most recent Minimum Data Set (MDS) assessment, submitted 5/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 7/7/2026 at 8:54 AM, R2 was observed sitting in his wheelchair in the dining room. R2's catheter tubing was observed to be in direct contact with the dining room floor. On 7/9/26 at approximately 9:20 AM, R2 was observed returning from an appointment in a facility transport vehicle. Transporter/Staff L was observed assisting R2 down the vehicle wheelchair ramp, across the sidewalk, into the entrance vestibule, and down the length of the entire hallway to his private room while R2's catheter tubing was dragging on the floor. Review of R2's EMR revealed hospitalizations from 1/13/26 - 1/15/26 and 4/19/26 - 4/22/26 for diagnoses including UTIs. Resident #8 (R8) Review of R8's EMR revealed admission to the facility on 3/5/26 with diagnoses including Down syndrome, UTI, and retention of urine. R8 was deemed not able to make medical or financial decisions due to severely impaired cognition. On 7/6/2026 at 9:52 AM, R8 was observed sitting in his wheelchair in his room. R8's catheter bag and catheter tubing was observed to be in direct contact with the floor. On 7/7/2026 at 1:40 PM, R8 was observed sitting in his wheelchair in the hallway near the dining room. R8's catheter bag and tubing were observed to be in direct contact with the floor. R8 was unable to answer questions appropriately during an attempted interview. On 7/8/2026 at 9:32 AM, R8 was observed in his wheelchair, self-propelling himself to the front office. R8's catheter bag and tubing were observed dragging on the floor underneath his wheelchair as he moved himself towards the front office. Review of R8's EMR revealed an emergency room visit and diagnoses including UTI on 6/13/26. On 7/9/2026 at 9:51 AM, an interview was conducted with the facility's Infection Preventionist/Registered Nurse (IP/RN) C in regard to proper catheter placement and care. IP/RN C stated that catheter bags and tubing should not be touching the floor. Review of the facility's Catheter Care, Urinary policy read, in part, Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor.

This deficient practice pertains to Intake 2805315.Based on observation, interview and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. Review of a complaint submitted to the State Agency (SA) on 3/17/26 read, in part: .There are 2 nurses in the building, and there should be a minimum of 3. The DON [Director of Nursing], Infection Control Nurse, and Administrator are all out of the building.We are drowning here with no staff. Send help!On 3/24/26 at 1:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) L regarding staffing levels in the facility. CNA L stated the facility is constantly understaffed, often running with just two CNAs for a census of 50 or more. CNA L stated the unit she typically works on has many incontinent residents and although she tries to get to everybody as fast as she can for incontinence care, residents sit in excrement for longer than they should.On 3/24/26 at 2:19 PM, an interview was conducted with Resident #7 (R7) who requested to speak with this Surveyor. R7 stated he was concerned about the staffing levels in the building as there are often just one or two CNAs working the entire building. R7 stated residents are not getting the care they deserve because they are waiting extended periods for call light responses, sitting extended times in soiled briefs, and going over a week without bathing. On 3/25/26 at 10:58 AM, an interview was conducted with Resident #6 (R6) regarding her care at the facility. R6 asserted, They're understaffed. it's unsafe here. R6 stated she is incontinent of urine and there have been several nights with only one CNA on duty. R6 estimated she had to wait an hour or more for assistance after activation of her call light.On 3/24/26 at 3:35 PM, a phone interview was conducted with CNA H who stated, Staffing has been strangely low. CNA H stated when he comes in for his night shift, residents will already be sleeping for the night and dirty dinner trays will still be placed in front of them because the day shift CNAs didn't have time to pick them up. CNA H stated there is usually two CNAs on duty at night, which is not enough as it stands, and sometimes there will even be one. Many times, CNA H indicated, travel CNAs will come in to help, find out they are the only CNA on duty, and walk-out. CNA H stated, There's just no back-up.On 3/25/26 at 12:20 PM, an interview was conducted with CNA E regarding her perception of staffing levels. When asked if showers get missed due to low staff, CNA E stated, All the time. CNA E explained sometimes there is a shower aide on duty and sometimes there is not. CNA E stated, Like today.there was supposed to be three CNAs on [working] but one called in (sick) so there's only two of us. It's nearly impossible to help anybody shower with only two CNAs on duty. CNA E indicated showers for all residents are recorded in a binder located in the shower room. Review of the shower binder on 3/25/26 at 12:25PM revealed the dates of the latest showers for the following residents:Resident #12 (R12): 3/14/26 (11 days prior).Resident #13 (R13): 3/14/26 (11 days prior).Resident #14 (R14): 3/10/26 (15 days prior). Resident #4 (R4): one shower recorded in the month of March, 3/18/26 (7 days prior).On 3/25/26 at 2:53 PM, R13 was observed sitting on the edge of his bed with an approximate six-inch beard and hair extending passed his earlobes. An interview was conducted with R13 regarding the quality of care he was receiving at the facility. R13 estimated he hadn't received a shower in two weeks and indicated he would like to shower at least once a week. When asked if it was due to low staffing, R13 replied, That's what they tell me. When asked if he preferred the current length of his beard, R13 stated, No, some help me shave, some don't. They don't have the time.Review of daily nursing staff assignment sheets from November 1st, 2026 - March 25, 2026, revealed 46 occasions where two CNAs were on duty and seven occasions when only one CNA was on duty. The facility census ranged from 42-58 during this timeframe.Review of the current resident population revealed 11 out of 42 residents (26%) required a two-person transfer.Review of the Facility Assessment, reviewed 1/19/26, read, in part: .Staffing Plan: The table below describes the number of staff available to meet residents' needs.# [number of staff needed when census at or under 50 in 24 hr [hour] period:# [number of staff needed when census 63-68 in 24 hr period.No data was available for a census between 51-62 nor specific staffing needs by shift.On 3/25/26 at 3:18 PM, an interview was conducted with the Nursing Home Administrator (NHA) regarding staffing level concerns. The NHA indicated ideal staffing nurses would be three nurses and three CNAs at the bare minimum. The NHA pointed out, What we want and what we can obtain are two different things. The NHA acknowledged the concerns related to lacking specific staffing needs according to shift and census in the facility assessment. When asked about call-ins, the NHA stated there is no specific staff contingency policy, but personnel can come early or stay late and lead nurses or management and help fill in on the floor.Review of the facility policy titled, Staffing, revised October 2017, read, in part: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans the facility assessment.

Based on interview and record review, the facility failed to maintain a comprehensive facility assessment which included specific staffing needs by shift and census, a plan to maximize recruitment and retention of direct care staff, and a contingency staffing plan.Findings include:Review of the Facility Assessment, reviewed 1/19/26, read, in part: .Staffing Plan: The table below describes the number of staff available to meet residents' needs.# [number of staff needed when census at or under 50 in 24 hr [hour] period:# [number of staff needed when census 63-68 in 24 hr period.No data was available for a census between 51-62 nor specific staffing needs by shift.Further review of the Facility Assessment failed to outline a plan to maximize recruitment and retention of direct care staff or establish a contingency staffing plan for events that do not require activation of the facility's emergency plan but do have the potential to affect resident care.On 3/25/26 at 3:18 PM, an interview was conducted with the Nursing Home Administrator (NHA) who acknowledged the concerns related to lacking specific staffing needs according to shift and census. The NHA stated there is no specific contingent staff policy, but personnel can come early or stay late and lead nurses or management and help fill in on the floor.

This deficient practice pertains to Intake 2805315.Based on observation, interview, and record review the facility failed to ensure a sufficient supply of:Incontinence products for Residents #6, #9, #10, and #11.Urinary catheter components for Residents #2 and #15.Custodial products for routine trash removal.Findings include:Review of a complaint submitted to the State Agency (SA) on 3/17/26 read, in part: .There are limited supplies of briefs, wipes, and chucks (disposable under pads used to protect surfaces like mattresses, chairs, and wheelchairs from fluid leakage and incontinence). No [panty] liners. No trash bags. We are drowning here with no staff. Send help!On 3/24/26 at 1:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) L regarding the availability of incontinence supplies. CNA L stated, When aren't we out of supplies? We are constantly out of liners, chucks, the correct sized briefs. CNA L indicated there were currently four residents who were heavy wetters on her unit who preferred either a liner or chuck in addition to a brief to prevent leaks and frequent bed linen changes. CNA L stated the facility was currently out of both liners and chucks therefore Residents #6, #9, #10, and #11 were all wearing two briefs in an attempt to prevent urine leaks onto the bedding. Resident #6 (R6)Review of R6's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/29/26 with diagnoses including urinary incontinence and acquired absence (amputation) of the right leg below the knee. Review of R6's most recent Minimum Data Set (MDS) assessment, dated 2/10/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition. Further review of MDS Section H, Bladder and Bowel, revealed R6 was frequently incontinent of urine.On 3/25/26 at 10:58 AM, an interview was conducted with R6 regarding her care at the facility. R6 stated she was currently wearing two briefs because the facility had run out of liners which she preferred to wear in addition to a brief. R6 indicated, I don't want to soak through [onto the bed]. When asked about the comfort of wearing two briefs at once, R6 replied, It's not ideal.On 3/24/26 at 1:28 PM, an interview was conducted with CNA I regarding facility supplies. CNA I stated the facility is constantly out of the correctly sized briefs, liners, chucks, washcloths. CNA I indicated aides were directed to use washcloths instead of disposable wipes for perineal care due to plumbing issues which led to an extreme shortage of washcloths. CNA I reported the night staff had completely run out of washcloths and were cutting up towels to utilize as a last resort. On 3/24/26 at 3:35 PM, a phone interview was conducted with CNA H who verified he primarily worked the night shift. CNA H stated an inadequate supply of correctly sized briefs and liners were also a problem during night shift. CNA H indicated he often must attach two small briefs together and lay it under the resident if the bigger sizes run out. CNA H stated in terms of washcloths there have been very few or none. CNA H stated he has witnessed other nurse aides cutting up towels or using paper towels for perineal care due to the shortage of washcloths. CNA H stated the shortages are conveyed to management and is unsure why it remains an ongoing problem.On 3/25/26 at 9:56 AM, an interview was conducted with Housekeeper M regarding linen supplies and storage. A tour of the facility was conducted with Housekeeper M to inventory washcloths which revealed 13 washcloths stocked on C-Hall, no washcloths stocked on A hall, no washcloths stocked on B hall, and no clean washcloths in laundry which were ready to distribute. When the Director of Nursing (DON) was made aware of the low inventory, he stated there was an unopened box of washcloths on the third shelf in the laundry room (requiring a ladder to access). When asked if the CNAs working on A and B hall were expected to retrieve the box when in need of a washcloth, the DON indicated that would be the responsibility of laundry personnel. The box was unmoved at the time of this Surveyor's exit on 3/25/26 at 3:18 PM.Resident #2 (R2)On 3/24/26 at 3:16 PM, an interview was conducted with CNA F regarding facility supplies. CNA F endorsed frequently running out of briefs, liners, chucks, as well as colostomy supplies and the correct urinary catheter components. CNA F indicated R2 was receiving end-of-life care in January 2026 and recalled a travel nurse having to piecemeal a foley catheter together because the facility was out of catheter kits.Review of a progress note written on 1/23/26 at 11:51 AM read, in part: [R2] self-removed foley during the night shift. Facility out of foley bags. I was able to use 18F [French] foley and a leg bag to reinsert for now.Resident #15 (R15)Review of R15's EMR revealed initial admission to the facility on 7/15/25 with diagnoses including obstructive and reflux uropathy (a condition where urine flow is blocked and flows backward into the kidneys), chronic kidney disease, and benign prostatic hyperplasia. Review of R15's most recent MDS assessment, dated 2/17/26, revealed a Brief BIMS score of 15, indicative of intact cognition. Further review of MDS Section H, Bladder and Bowel, revealed presence of an indwelling urinary catheter.On 3/25/26 at 1:47 PM, an interview was conducted with R15 regarding quality of care at the facility. R15 stated the there have been times the facility had ran out of catheter supplies and he was unable to get his scheduled monthly catheter change. R15 indicated the elastic catheter leg strap was causing discomfort and irritation to his skin and he had requested leg anchor bandages instead, but the facility indicated they did not have those in stock.Review of R15's EMR revealed a Progress Note written on 1/16/26 at 9:31 PM which read: Unable to change cath[eter] at this time R/t [related to] unable to find new drainage bags.On 3/25/26 at 9:57 AM, an interview was conducted with Housekeeper A regarding custodial supply needs. Housekeeper A stated during the previous week, the facility had completely run out of trash can liners forcing her to empty all the room trashes into a large trash without changing the liners. Housekeeper A indicated the rooms that contained used briefs or wipes remained odorous due to the soiled materials leaking or contacting the trash liners that were not changed. Housekeeper A stated, It was gross.On 3/25/26 at 10:03 AM, an interview was conducted with the DON who verified he was responsible for ordering supplies. The DON stated the facility had recently changed vendors and some order numbers didn't transfer over which could have caused problems. The DON confirmed the facility did run out of a supplies on a few occasions, but he had stopped by the main campus and picked up the necessary items immediately after he was notified. The DON confirmed availability of liners are hit or miss.On 3/25/26 at 3:18 PM, an interview was conducted with the Nursing Home Administrator (NHA) who understood the concerns related to inadequate supplies.Review of the Facility Assessment, reviewed 1/19/26, read, in part: .The facility has a designee who oversees the procurement and maintenance of par levels for resident equipment and supplies based on resident population needs. Weekly inventory and ordering take place. Items that are including in the weekly order are various sizes of pulls [pull-ups] and briefs.

This deficient practice pertains to Intake 2805315.Based on observation, interview, and record review the facility failed to ensure the appropriate colostomy supplies were provided for one Resident (#5) of one Resident reviewed for colostomy care. This deficient practice resulted in feelings of extreme embarrassment and social withdrawal due to noxious odors from fecal leakage.Findings include:Resident #5 (R5)Review of R5's Electronic Medical Record (EMR) revealed initial admission to the facility on 7/2/25 with diagnoses including malignant neoplasm (cancer) of the colon, colostomy (a surgical procedure which bypasses part the intestine and redirects feces to exit through an opening [stoma] in the abdominal wall and into a pouch), and parastomal hernia (a type of incisional hernia allowing abdominal contents to protrude through an abdominal wall defect). Review of R5's most recent Minimum Data Set (MDS) assessment, dated 1/7/26, revealed a Brief Interview of Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. On 3/24/26 at 3:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) F regarding availability of medical supplies at the facility. CNA F indicated facility staff had been using urostomy bags [a pouch designed to collect urine rather than feces from a stoma] on R5's colostomy site for months because the proper sized colostomy bags were not in stock at the facility. CNA F stated supply shortages, including colostomy bags, had been communicated to management multiple times with no response. CNA F indicated due to the size of R5's stoma, he required a colostomy bag with a flange (opening) size of 38mm [millimeters] and the only available bags were not compatible for R5, measuring 28mm.On 3/25/26 at 10:03 AM, an interview was conducted with the Director of Nursing (DON) who confirmed he was responsible for ordering medical supplies, including colostomy bags. The DON indicated that the clear pouches R5 was currently using were colostomy, not urostomy, bags, but the facility was working on obtaining opaque bags per the resident's preference. This Surveyor and the DON inventoried the colostomy supplies in the storage closet and were only able to locate a partial box of 28mm colostomy pouches. On 3/25/26 at 10:49 AM, CNA F was observed performing R5's colostomy care. R5's ostomy bag was transparent and nearly completely full of feces. Fecal matter was observed leaking from the upper right portion of R5's stoma resulting in a strong, noxious odor throughout the room. CNA F obtained a new urostomy bag from R5's nightstand supply drawer and demonstrated how the plastic had to be slightly ripped to accommodate the size of R5's stoma. CNA F also pointed out an anti-reflux valve designed exclusively for urine to prevent black flow into the stoma. CNA F explained when the urostomy bags are inappropriately used on R5, stool becomes clogged in the valve eventually leading to back-ups causing fecal leakage. This Surveyor asked the DON to oversee the colostomy care provided by CNA F who at that time confirmed R5's pouch was a urostomy bag. The DON stated the stated potential consequences of using a urostomy bag instead of a colostomy bag could be restricting the flow of feces which could result in a backup leading to a potential leak or infection. The DON stated he would immediately obtain the correct pouches.On 3/25/26 at 10:55 AM, an interview was conducted with R5 regarding his feelings surrounding his colostomy care at the facility. R5 stated the current pouches bring him great embarrassment due to the transparency of the bag and the noxious odors that are often associated with the leakage. R5 explained attending church is very important to him, and he resorts to sitting in the back of the church away from other patrons instead of socializing due to fear of the look and smell of his colostomy. R5 stated he had a colostomy for quite some time and never had issues with leaking or offensive odors. R5 said he has asked for a different type of pouch stating, The smell comes through this one too easily.Review of R5's EMR revealed the following progress note written on 3/19/26 at 2:16 PM: .[R5] does not like the colostomy supplies we are using at this time as they are clear and he get[s] embarrassed that people can see the stool in the bag and he feels that they are thinner and do not stop the smell as well.Review of R5's MDS Section F, Preferences for Customary Routine and Activities, dated 11/12/25, asked how important is it to you to participate in religious services or practices? R5 selected very important.Review of R5's Plan of Care revealed the following problem with the start date 10/27/25: Resident has an ostomy. A goal, with the start date of 10/27/25, read: Ostomy care will be managed appropriately.stool will not leak.On 3/25/26 at 3:18 PM, an interview was conducted with the Nursing Home Administrator (NHA) who endorsed concerns related to colostomy care. The NHA stated the facility was actively obtaining the correct supplies.

Findings include: Resident #7 (R7)Review of R7's face sheet revealed an admission to the facility on 7/30/24, with diagnoses including constipation, heart failure, diabetes mellitus, and hypertension (elevated blood pressure). Review of R7's quarterly Minimum Data Set (MDS) assessment, dated 10/17/25, revealed R7 required substantial maximal assistance from staff for activities of daily living cares including toileting, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. R7's brief interview for mental status (BIMS) revealed moderate cognitive impairment. Section M Skin revealed R7 had a facility acquired stage II pressure ulcer (an open sore on the skin that involves partial-thickness loss of dermis) that was unhealed, and indicated R7 was at risk for developing additional pressure ulcers.On 11/20/25 at 10:30 AM, an interview was conducted with R7 in his room. R7 was lying in bed and resting. R7 was asked about having a pressure ulcer on his buttock and replied, Yes, I do. R7 was observed lying on his left side with a wedge placed under the right side of his back. R7 was observed laying on a regular pressure reduction mattress and no air mattress overlay was observed. During the interview with R7, his roommate (Resident #3) stated staff were not in at all the previous night (referring to 11/19/25) to turn and reposition R7, and stated R7 never had an air mattress on the bed. Resident #3's BIMS was obtained from a current MDS and indicated intact cognition. On 11/20/25 at 11:15 AM, an observation was made of R7 during a wound dressing change for his sacral area and surrounding buttocks. R7 was observed displaying signs and symptoms of excruciating pain during the dressing change procedure including hyperventilating and moaning. R7 called out, I just want it to be done. Ouch! Oh God! and repeated this during much of the dressing change. During the wound dressing change, Registered Nurse (RN) D was assisted by Certified Nurse Aide (CNA) J who helped position R7 up on his left side and held him there. RN D who was performing the dressing change stated, He's (R7) in pain. Poor guy is in pain. RN D was asked to measure the wounds and classify them and stated there was one large unstageable pressure ulcer (a full thickness tissue loss where the damage is obscured by slough - yellow, tan, gray, green, or brown dead tissue or eschar) and three other smaller stage II pressure ulcers that were facility acquired. RN D was asked to measure R7's current wounds which were found to be as follows:a. Pressure ulcer unstageable to the coccyx, facility acquired, and measured 10 centimeters (cm) in length x 7 cm in width x 0.6 cm (depth),b. Pressure ulcer stage II to the right buttock, facility acquired, and measured 3 cm in length x 1.5 cm in width, no depth,c. Pressure ulcer stage II to the upper left buttock, facility acquired and measured 1.2 cm in length x 1.0 cm in width. No depth,d. Pressure ulcer stage II to the lower left buttock, facility acquired and measured 3 cm in length x 3.5 cm. in width. No depth. R7's progress note, dated 11/20/25 at 12:22 PM, read in part, New order for resident to go to ED to have his ulcerations on his buttocks looked per [local surgeons group name] . R7's progress note, dated 11/20/25 at 12:44 PM, read in part, Resident left the facility via EMS [emergency medical services] approximately 1240 (12:40 PM) . Review of R7's hospital records, dated 11/20/25 through 11/24/25, revealed the following:a. History and physical 11/20/25, chief complaint: decubitus ulcer [pressure ulcer]. Assessment and plan: 1. Infected decubitus ulcer - large unstageable chronic decubitus ulcer at the coccyx, surrounding erythema [redness], drainage, appears infected. 2. Sepsis. 3. Elevated lactic acid level [a build-up of lactic acid in the bloodstream commonly caused by sepsis]. 4. Hyponatremia [decreased sodium in the bloodstream]. 5. Hyperglycemia [elevated blood glucose]. 6. Urinary retention. 7. Diastolic heart failure (ineffective pumping of blood from the heart to the body to meet its needs).b. Consultation report 11/22/25, reason for consultation: bacteremia (infection in the blood stream by bacteria). Assessment and plan: Gram positive bacteremia, MSSA [methicillin susceptible staphylococcus aureus] infection, decub [decubitus] ulcer, leukocytosis [elevated white blood cells], transient bacteremia likely related to his wound which had not been debrided (removed damaged tissue) at that point. Wound is deep with exposed bone. Minimum 2 week IV [intravenous] course though may extend longer depending on the appearance of wound. Discussed with hospitalist, in order to heal the wound patient would need IV antibiotic in addition to off-loading, aggressive wound care, enteral feeding, potential diverting ostomy [a surgical created opening on the abdomen, called a stoma, that allows waste products like stool to exit the body]. c. Hospital course 11/20/25 through 11/24/25 and ongoing: positive blood culture, positive wound infection culture, two different antibiotics, wound debridement, and two different IV strong opioid (drug derived from opium and strong pain reliever) pain medications.d. Wound description and measurements post-surgical debridement 11/21/25: Assessment and plan 1. Decubitus ulcer, sepsis with staph aureus bacteremia. Status post incision and drainage - Surgical findings: The black eschar [a layer of dead, dry, and dark tissue that forms over a wound] that was visible measured initially 4.0 x 4/2 cm with surrounding stage II decubitus for a total size of 10.5 x 10.5 cm. The initial black eschar was lifted and debrided resulting in the wound being 5.2 x 4/2 cm. Unfortunately, it then tunnels 5 cm cephalad [toward the head] (4 cm wide) under viable skin. The total amount of the cavity debrided measured approximately 5.2 cm wide extending a total of 10 cm between the open tunneled area. This was debrieded [sic] with sharp dissection, cautery [a hot instrument to burn and seal blood vessels], pulse lavage [washing out], and then deampened (sic) gauze with quarter percent Dakin's (diluted bleach solution used as an antiseptic to clean and disinfect ulcers). During an interview on 11/20/25 at 1:15 PM, RN D was asked how long R7 had the pressure ulcers and replied, It has been over a couple months, but I am not exactly sure when it developed. RN D stated R7 was being sent to the local hospital for a general surgery consult for the pressure ulcer today after dressing change and working on the wound clinic this week. On 11/20/25 at 1:30 PM, an interview was conducted with RN B who was asked if R7 had an infection in their pressure ulcer and how often wounds were to be measured and replied, I do not recall him being on the line listing [prescribed antibiotics/monitoring infection]. Wounds are to be measured every Sunday.On 11/20/25 at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked about interventions for R7 and their pressure ulcer and replied, Air mattress and turning and repositioning every two hours. The DON was asked why R7 did not have an air mattress prior to today on his bed and replied, I am not sure, but he should have had one.On 11/21/25 at 2:45 PM, an interview was conducted with CNA H who was asked if R7 had an air mattress on their bed prior to today and replied, No, I don't think so. It just came over the walkie talkie to go ahead and put it on a little while ago. Review of R7's wound management detail report, dated 5/3/25 through 11/20/25, revealed the following:a. Date identified 5/3/25 Wound type: Other, Stage I, wound location: coccyx, measurement 23 cm x 30 cm, wound healing status: stable, comments: Cleaned left buttock wounds and coccyx wound with Saf-Clens. Dried and covered wounds with Sacral Mepilex. (4x4 Mepilex unavailable).b. Date observation 7/26/25 Wound type: Other, Stage I, wound location: coccyx, measurement 23 cm x 30 cm, wound healing status: stable, comments: Removed Mepilex, petroleum jelly dressing and cleaned the area with wound cleanser. Applied petroleum jelly dressing and covered with Mepilex.c. Date observation 11/17/25 Wound type: Other, Stage I, wound location: coccyx, measurement 4 cm x 4 cm, wound healing status: declining, comments: Unstageable with black eschar and foul odor noted. Review of R7's wound management detail report, dated 6/8/25 through 11/20/25, revealed the following:a. Date identified 6/8/25 Wound type: Pressure ulcer, wound location: left buttock, measurement 1cm x 1.75 cm, can depth be measured: yes, 0.2 cm, exudate amount: light, exudate color and consistency: serous (clear, amber, thin and watery), wound odor present: no, stage: stage II, tissue type: granulation, skin surrounding wound: dark purple or rusty discoloration, comments: Medi-honey with Mepilex ordered.b. Date observation 7/26/25 Wound type: Pressure ulcer, wound location: left buttock, measurement 1cm x 1.75 cm, can depth be measured: no, exudate amount: light, exudate color and consistency: bloody (bright red, thin), tissue type: granulation tissue, wound healing status: improving, comments: Removed Mepilex, petroleum jelly dressing and cleaned the area with wound cleanser. Applied petroleum jelly dressing and covered with Mepilex.No weekly wound measurements were found in R7's electronic medical record. Review of R7's quarterly Braden scale (residents at risk for developing pressure ulcers), dated 5/15/25, revealed R7 was at risk for developing pressure ulcers. No other quarterly Braden scale was found for the next quarter month of September 2025. On 11/21/25 at 11:00 AM, an interview was conducted with the DON, who was asked how R7 was doing and if there were any updates from the local hospital and replied, [R7] was having some debridement today. The DON was asked why R7's wounds were not measured weekly and replied, They should have been completed weekly.Review of R7's care plan, dated 10/23/25, read in part, Problem: Category: Pressure Ulcer/Injury; Alteration in skin integrity R/T (related to) areas of pressure on buttocks.Potential for further pressure ulcer development.Unstageable pressure injury to coccyx. Goal: Unstageable pressure injury to coccyx will heal without complications by target date. Approach: Treatments as ordered 11/20/25. Enhanced barrier precautions. Treatments per order. See MAR.Encourage food and fluid intake at mealtimes.Low air loss pressure mattress to bed 11/12/24. The low air loss pressure mattress was implemented and was not in use at the time of the first observation of R7. The facility implemented the low air loss pressure mattress during the survey after R7 had already went to the hospital. The wounds progressed from stage II pressure injuries to unstageable pressure injuries which subsequently had to be debrided at the hospital. There was marked deterioration of the wounds observed in the documentation from 11/17/25 to 11/20/25 as described below:R7's progress notes revealed the following:5/6/25 at 4:43 PM, read in part Skin on coccyx is noted to be intact but red.6/8/25 at 4:32 PM, read in part Called into resident's room by CNA. Noted to have an open area on the middle of the L buttock that measures 1.0 cm x 1.75 cm x 0.2 cm. Noted to have a pink base and noted to have irregular wound edge.7/13/25, read in part Resident was found to have two open areas on left buttock. The medial sore measured 0.5cmx0.5cm and the lateral sore measured 0.75cmx0.5cm.7/20/25 at 12:58 PM, read two open areas to left natal cleft the medial one is 0.4cm x 0.4cm x <0.1 the 2nd is lateral to the first and is 0.5cm x 0.5cm x <0.1, wound bases are pink wound edges are not adhered and surrounding skin is normal for skin color.9/22/25 at 6:52 PM, read in part Resident's continues to have bilat (bilateral) upper buttocks wounds that are beefy red and tender when cleaned/palpated.11/17/25 at 2:18 PM, read in part This writer was notified by the assigned nurse that [R7's] decubitus wounds over his coccyx has progressed. This writer noted two unstageable decubitus with eschar and a foul odor.11/17/25 at 2:40 PM, read in part .After discussing.it was determined to contact surgical services for recommendaiton (sic) and likely planned ED visit.11/19/25 at 2:13 PM, read in part .Completed dressing change- base of the wound is noted to be black and does have a foul odor.11/20/25 at 12:00 PM, read in part Completed dressing change on his buttock- Removed old dressing, noted to have an odorus (sic) smell, and base of the wound is noted to be dark in color on the sacral area. Does (sic) have two small open areas on the upper and lower portion of the wound. Does have an irregular shape. The middle open area measures 10 cm x 8 cm x 1.2 cm. The open area on the R (right) lower portion of the wound measures 3 cm x 4 cm x <0.1 cm. There is an open area on the L (left) upper portion of the wound that measures 2 cm x 3 cm x <0.1 cm. Applied crushed Flagyl to the wound bed, packed the large wound in the middle, covered with Hydrogel soaked 4x4 guaze (sic), and covered with an abdominal pad.11/20/25 at 4:21 PM, read in part Update recieved [sic] from.local ER [emergency room].admitted d/t (due to) decubitus ulcer on his buttock. Surgery is seeing him tomorrow. Will probably mostly end up with a wound vac and IV (intravenous) anx (antibiotic) therapy.Noted to have hyperglycemia, increased lactic acid, and hyponatremia (low sodium). WBC (white blood cell count) 16.8 [elevated].Review of policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated June 2023, read in part, Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces.

Based on observation, interview, and record review, the facility failed to ensure adequate pain control was achieved for one Resident (Resident #7) of three residents reviewed for pain management. This deficient practice resulted in Resident #7 experiencing excruciating uncontrolled pain during pressure ulcer dressing changes.Findings include: Resident #7 (R7)Review of R7's face sheet revealed an admission to the facility on 7/30/24 with diagnoses including constipation, heart failure, diabetes mellitus, and hypertension. Review of R7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R7 required substantial maximal assistance from staff for activities of daily living cares including toileting, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. R7's Brief Interview for Mental Status (BIMS) revealed moderate cognitive impairment. section M of the MDS revealed R7 had a stage II describe stage 2 pressure ulcer. A review of the Physician's Orders for R7 on 11/20/25, revealed no pain medication was provided to R7 until 11/17/25. The first dose of Tramadol 50 mg (milligrams) was provided at approximately 2:00 PM, and continued to be scheduled every six hours at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM. R7's medication administration record dated 11/1/25 through 11/20/25 revealed on 11/17/25 at 8:00 PM the drug was not administered because it was documented unavailable.Review of R7's pain assessments, dated 5/1/25 through 11/20/25, revealed no documented pain assessments after 10/17/25 by nursing. Review of R7's progress note, dated 9/22/25 at 6:52 PM, read in part, Resident's (sic) continues to have bilat (bilateral) upper buttocks wounds that are beefy red and tender when cleaned/palpated.NP (nurse practitioner) stated she is to do orders after assessing wounds with his nurse.According to the facilities MDS matrix (form 802 census and conditions), dated 11/20/25, R7 had a facility acquired pressure ulcer that was describe as an unstageable pressure injury. Review of R7's care plan, dated 11/20/25, revealed no care plan with interventions related to pain management. On 11/20/25 at 10:30 AM, an interview was conducted with R7 in his room. R7 was lying in bed and resting. R7 was asked about having a pressure ulcer on his buttock and replied, Yes, I do. R7 was noted to be lying on his left side with a wedge placed under his right back, and a regular bed mattress and not an air mattress.On 11/20/25 at 11:15 AM, an observation was made of R7 during a wound dressing change on his sacral area and surrounding buttocks. R7 was observed in excruciating pain and was visualized hyperventilating and moaning. R7 called out, I just want it to be done. Ouch! Oh God! and repeated this during much of the dressing change. During the wound dressing change Registered Nurse (RN) D was assisted by Certified Nurse Aide (CNA) J who helped position R7 up on his left side and held him there. RN D did not offer R7 any additional analgesia for the pain. During the wound dressing change, Registered Nurse (RN) D stated, He's (R7) in pain. Poor guy is in pain. RN D was asked to measure the wounds and classify them and stated that there was one large unstageable and three other smaller stage II pressure ulcers that were facility acquired.During an interview on 11/20/25 at 11:35 AM, an interview was conducted with CNA J who was asked how long R7 was having increased pain with dressing changes and replied, Over the last month he (R7) has been having a lot more pain. I told several staff that his pain was worse, and nothing was done. He has been having a lot more pain because of his bottom. This past week has been extremely hard on him. Review of facility standing orders, dated 12/17/2024, revealed standing orders for pain/discomfort included administration of acetaminophen either oral or rectal q (every) 4 hours prn (as needed). The standing orders also stated if pain is persistent or not completely relieved, notify Dr (doctor) on rounds sheet, and if the pain is severe with little or no relief, nursing was to perform a head-to-toe assessment and notify Dr. None of this was documented completed for R7. On 11/21/25 at 12:30 PM, an interview was conducted with RN F who was asked how long R7 was experiencing pain during wound dressing changes and replied, For a month and it has become worse in the last week or two. During an interview on 11/21/25 at 12:45 PM with the Director of Nursing (DON) who was asked about pain assessments for R7 and why nursing was not completing the pain assessments over the last month when staff verbalized that R7's pain was present during wound dressing changes and increased extensively over the last week. The DON stated, Pain assessments should be completed each shift. There should be an order in place for nursing to complete a pain assessment. I am not sure why there is not an order to do so. If he (R7) was having pain, then nursing should have at least been giving acetaminophen from the standing orders and if that did not help then the provider should have been contacted related to pain during dressing changes. The DON agreed that a premedication prior to dressing changes would be beneficial for R7.Review of policy titled, Pain Assessment and Management, date revised March 2015, read in part, Purpose: Support consistent pain assessment and documentation and promote safe treatment and follow up. General Guidelines.2. Complete a pain assessment each shift for any resident with pain.3. Use the o to 10 subjective pain scale for residents who self-report.6. Document all findings.Responsibilities: Nurse 1. Complete all pain assessments.6. Notify the provider of uncontrolled pain.8. Reassess after interventions. 9. Update the care plan when needed.

Based on interview and record review, the facility failed to protect the residents right to be free of misappropriation of property by staff. This deficient practice resulted in psychosocial harm based on the reasonable person perspective. Findings include: This citation pertains to intake: 2615537Resident #5 (R5)Review of R5's Electronic Medical Record (EMR) revealed admission to the facility on 7/2/25 and discharge on [DATE]. Review of R5's medical diagnosis included metabolic encephalopathy (brain dysfunction caused by chemical imbalance).On 8/30/25, Family Member N was visiting R5 who was actively dying at the facility and stayed until approximately 3:30 a.m. Family Member N noted during the visit, R5 had her gold wedding band and solitaire diamond band on her fingers. Family Member N returned to the facility at approximately 12:00 p.m. on 8/30/25 and continued to sit with R5 until her death at 12:45 p.m. Family Member N requested R5's rings be given to him before she was taken to the funeral home. It was at this time Family Member N and staff noted the rings were missing from R5's fingers. Family Member N reported this to the floor nurse and Nursing Home Administrator (NHA) and a search was conducted. Local police were contacted and had begun an investigation into whether R5's missing wedding rings were misappropriated.On 8/31/25, Licensed Practical Nurse (LPN) O spoke to Family Member N and stated one of R5's wedding rings had been recovered when Certified Nurse Aide (CNA) I returned the ring after being questioned by police in connection to the investigation.An interview was conducted with Registered Nurse (RN) P on 11/21/25 at 12:00 p.m. RN P confirmed one missing ring was returned by CNA I after being questioned by police. RN P stated CNA I was only in R5's room for approximately a minute before exiting with one ring. CNA I stated she found the ring stuck in the wheel of R5's bed. RN P stated only one ring was retrieved of two that were missing.An interview with Detective Q on 11/21/25 at 10:50 a.m. confirmed local police were involved in the alleged misappropriation of R5's wedding rings. Detective Q stated, upon investigation, CNA I admitted to the misappropriation of the wedding rings and was arrested on the morning of 8/30/25.An interview was conducted with CNA I who confirmed she did steal R5's rings on 8/30/25 after Family Member N had left the facility. CNA I confirmed she did try and plant one of R5's rings in her room after an investigation had begun.An interview was conducted with the NHA on 11/21/25 at 2:00 p.m. The NHA stated that Family Member N requested R5's wedding rings continue to stay on her finger while staying at the facility. NHA stated that Family Member N recognized that R5 would be devastated if her wedding rings were not there. Review of the facility's 'Abuse Prevention Program' policy read, in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for one Resident (#6) of three residents reviewed for abuse. Findings include: This citation pertains to intake: 2667693Resident #6 (R6)Review of the Electronic Medical Record (EMR) for R6 revealed admission to the facility on 9/1/25 with diagnosis of cerebral infarction. R6 scored an 8/15 on a Brief Interview for Mental Status (BIMS) score dated 9/5/25, indicating moderate cognitive impairment. However, the medical record indicated R6 was responsible for their own medical and financial decisions.An interview was conducted with Social Services Director (SSD) M on 11/20/25 at 1:30 p.m. SSD M stated she was walking down the B hall when Registered Nurse (RN) G stated, Do I prevent a fall or let someone get the [explicit word] beat out of them. SSD M then proceeded down the hallway to grab RN B to assist. SSD M stated she started to hear loud and aggressive shouting and when coming through the doors in the B hall, witnessed RN G in close proximity of R6 stating Because your CNA (Certified Nurse Aide) was busy getting the [explicit word] beat out of her. SSD M stated RN B attempted to diffuse the situation between RN G and R6, but indicated RN G continued to be aggressive in the hallway. SSD M stated they separated RN G and R6 and proceeded to call the Nursing Home Administrator (NHA).An interview was conducted with RN B on 11/20/25 at 1:46 p.m. RN B stated she was assisting a resident with behaviors approximately four rooms down from the incident with R6 and RN G. RN B stated she heard loud voices coming from the hallway and when stepping out to see what was happening, saw RN G inches from the face of R6 and was yelling It's because your CNA was busy getting the [explicit word] beat out of her, that's why! RN B stated RN G's voice was aggressive and angry. RN B stated she went toward R6 to comfort her and R6 stated, I have a hard time hearing and then she yelled at me. When RN B tried to diffuse the situation and separate R6 and RN G away from each other, RN G stated, It's not ok, no one really understands it's really not ok. RN B confirmed she helped report the incident to the NHA.Camera footage was reviewed with the NHA on 11/20/25 at 2:20 p.m. Registered Nurse (RN) G and R6 were observed on camera, in the hallway and RN G was with R6 crouching down, with her finger pointed at R6 and coming within inches of R6's face. RN G was observed standing up and turning around, before quickly turning back to R6 still sitting in the hallway and getting very close to R6's face again. Two staff members come into the hallway with one approaching R6 while RN G goes off camera.An interview was conducted with R6 on 11/20/25 at 2:45 p.m. R6 stated she has a very difficult time hearing but does not need staff to yell at her for her to understand.Review of the facility's Abuse Prevention Program read, in part, Our residents have the right to be free from abuse.as part of the resident abuse prevention, the administration will: Implement measures to address factors that may lead to abusive situations.

Intake: MI00144784 Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R601) of three residents reviewed for falls. This deficient practice resulted in actual harm with R601 sustaining a fall with a right hip fracture requiring surgical interventions. Findings include: A review of R601's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including symptoms and signs involving cognitive functions and awareness, unsteadiness on feet, and pain. R601 scored a 10/15 on the 2/27/24 Brief Interview for Mental Status (BIMS) score indicative of moderate cognitive impairment. R601 was noted to have one fall with no injury and one fall with major injury in section J of the 2/27/24 Minimum Data Set (MDS) assessment. R601's Fall Risk Assessment Tool dated 9/1/23 revealed a fall risk score of 22 points, indicative of a high fall risk. Review of the Facility Reported Incident submitted to the State Agency on 5/23/24 read, in part, .Resident (R601) had a fall on 5/20/24 at approximately 2:30 p.m. Resident initially thought to be without injury .Xray was ordered at 3:30 a.m. the morning of 5/22/24. Pain and BP (blood pressure) increased, so resident was sent to ER (emergency room ) for x-ray and treatment at approximately 1 p.m. Resident was found positive for fracture that afternoon. Resident had hip displacement corrected by surgery that same afternoon . Review of the History and Physical from [Hospital Name] emergency room revealed R601 sustained an acute angulated intertrochanteric right hip fracture. Review of R601's Progress Notes read, in part, 5/20/24 4:47 p.m. Resident was in her room sitting in her recliner with feet on the floor with grippy socks on her feet. Resident has been yelling wanting to drive a car. CNA (Certified Nurse Aide) and nurse in resident's room several times but resident didn't need anything. CNA called writer to residents' room, found resident lying on her left side of the floor. Resident denies hitting her head, states, she just fell . Resident is complaining of right hip pain, Medical Director (MD) D notified, hip Xray ordered. Resident was assisted to her bed with mechanical full lift and 2 CNA's. Full skin assessment resulted in no injuries or bruising noted at this present time but will continue to monitor as needed. Resident is currently lying in her bed, supine position, napping on and off, resident denies having any pain or discomfort at this time .Licensed Practical Nurse (LPN) A. Review of R601's Physician Note, dated 5/20/24 read, in part, .I was then urgently requested to see her later in the day after she attempted to self-ambulate from her reclining chair to her bed and fell on her left side .As I was leaning over her to examine her left side, she told me that it was the right side that hurts .Assessment .Cognitive impairment .Post fall I have ordered x-ray of the right hip/pelvis/knee and ankle to be done as soon as possible. I have instructed both resident and staff that she is to stay in bed until x-ray results are known . An interview was conducted with CNA B on 6/20/24 at 3:00 p.m. CNA B stated she heard an alarm going off and entered R601's room and found her on the floor. She then radioed for LPN A to come in and look at R601. CNA B stated LPN A never completed a full head to toe assessment on R601 and requested that two CNA's put her back into bed, which CNA B did and confirmed they did not use a mechanical lift but rather a gait belt and slid R601 onto the bed. CNA B confirmed MD D did exam R601 and ordered an x-ray be done as soon as possible, and R601 was to stay in bed until completed. When CNA B returned to work on 6/21/24, she was instructed to keep R601 in bed as the x-ray had not been completed. CNA B stated R601's blood pressure continued to increase but was instructed to let LPN A complete all vitals. An interview was conducted with LPN A on 6/20/24 at 3:08 p.m. LPN A stated R601 was restless all day long on 5/20/24 and wanted to spend as much time with the staff as possible. LPN A stated it was a CNA who placed R601 in her recliner chair and placed the recliner chair in an upright position, not allowing her feet to touch the floor and closed the door. LPN A stated she instructed the CNA to lay R601 in her bed as this was a restraint to have R601 in her chair unable to get out. LPN ' A stated she received a page over the radio to R601's room as she had fallen and upon entering the room did complete a full assessment. LPN A instructed two CNAs to lay R601 back in her bed and notified MD D. LPN A stated MD D took R601's chart after the assessment was completed. LPN A stated she did not receive the chart back prior to her leaving for the day but passed the information to her relief nurse. An interview was conducted with CNA C on 6/20/24 at 3:23 p.m. CNA C stated she was not R601's aide that day but did respond to the radio for assistance in R601's room. CNA C stated, when she got to R601's room, LPN A and CNA B were observing R601 who was lying on her left side facing the door into the hallway. CNA C stated she did not observe LPN A complete any post fall assessments and requested CNA B and CNA C place R601 back into her bed. CNA C confirmed they did place R601 back in bed with a gait belt, lifting and sliding her to the bed and hoisting her back. CNA C confirmed they should have used a mechanical lift to place R601 back into bed and did not receive further education on how to transfer a resident post fall. An interview was conducted with the Director of Nursing (DON) on 6/20/24 at 4:12 p.m. The DON confirmed she was working as a floor nurse on 5/20/24 along with LPN A. The DON stated it was LPN A who placed R601 into her wheelchair and placed the footrest in an elevated position because she was annoyed with the requests R601 was making. The DON stated she instructed LPN A to complete a bladder scan on R601, but LPN A refused. When the DON saw R601 after her fall, she confirmed R601 had to have attempted to stand from her recliner and her elevated footrest launched her onto the floor. The DON stated, according to witness statements, LPN A instructed the two CNAs to put R601 in bed and did not complete a post fall assessment and did not order for an x-ray per the physician order. An interview was conducted with R601 on 6/20/24 at 4:30 p.m. R601 was observed sitting in a recliner geri chair. R601 stated she fell a while back and continued to have pain from the fall. R601 could not explain further how she fell . Review of the termination record for LPN A read, in part, Termination 5/31/24; Violation Information; 5/20/24 Gross negligence and/or gross misconduct in the performance of duties. Violation of accepted professional standards pertaining to patient care and technical practices or ethics. Details of what occurred: On 5/20/24 you were assigned to perform a bladder scan and assist (R601) into bed due to her discomfort and restlessness. You were also asked to reach out to the doctor for a PRN (as needed) medication for anxiety as you said you had already given the resident something for anxiety that did not work. Upon investigation it was noted she did not have any PRN anxiolytic medications. Regrettably, it has come to our attention that you did not lay the resident down, which may have contributed to her falling. Furthermore, your decision to restrain the patient by putting her feet up potentially led to a distressing incident where the patient fell and sustained a hip injury. Despite the gravity of the situation, your failure to promptly follow through with the necessary verbal and written X-ray orders to rule out hip, knee, and pelvis fractures on the day of is deeply concerning. This lapse in providing essential medical care has led to a breach of our duty to ensure patient safety and well-being. Your initial explanation, citing a lack of awareness regarding the order for the X-ray, followed by a claim of incompetence in executing orders, reflects a pattern of inadequate communication and competency.

This citation refers to intake(s): MI00139977 Based on interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R2) of three residents reviewed for falls. This deficient practice resulted in R2 sustaining a fall with subsequent injuries requiring staples. Findings include: R2 A review of R2's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including repeated falls, weakness, osteoarthritis, pain, and dementia with behaviors. R2 scored a 7/15 on the 9/25/23 Brief Interview for Mental Status (BIMS) score indicating he was severely cognitively impaired. In Section J on R2's 9/25/23 Minimum Data Set (MDS) assessment he was marked 'yes' as having a fall in the last month prior to admission/entry into facility. R2's Fall Risk Assessment Tool dated 9/18/23 revealed he scored an 18, indicative that he was a high fall risk. Review of R2's Care Plans revealed the following: Problem Start Date 9/18/23, Category: Falls: At risk for falls related to impaired cognition, weakness, and fall history while at home .Approach Start Date: 9/18/23 Ensure (R2) has a floormat in place next to his bed at all times when in bed. When in wheelchair the floor mat may be stored in the closet .Approach Start Date: 9/18/23 Ensure (R2) has grippy socks or footwear with grippy soles for safe ambulation and transfers .Approach Start Date: 9/18/23 Ensure call light is within reach at all times when (R2) is in the room .Approach Start Date: 9/18/23 Ensure walkway is well lit and free from clutter and spills .Approach Start Date: 9/18/23 Keep bed at lowest height when not providing cares .Approach Start Date: 9/18/23 Pad alarm to bed, wheelchair, & bedside chair (if applicable). Check alarm placement, low battery indicator, and functionality of both pad & alarm box, prior to leaving (R2) unattended . A review of R2's Fall Investigation Summary dated 9/29/23 read, in part, At approx. (approximately) 9:50 a.m. resident fell . (Certified Nurse Aide [CNA] I) found him on the floor (resident was attempting to get up) and called the nurse. Nurse (Registered Nurse [RN] F) entered the room and found resident sitting on the floor .Resident told the aide and nurse his feet got tangled in the sheet and he fell . Shortly after (RN D) entered the room and resident was in bed .At the time of the fall resident stated his scalp hurt but denied all other pain. EMS (Emergency Medical Services) was called per physician order to send to the ER (emergency room ) for treatment. Per report from the hospital resident received 4 staples to the injury which was noted by the nurse 2 cm (centimeters) x 3 cm. Resident was difficult upon return from ER yelling out. CAT (Computerized Axial Tomography) scan completed no findings .The Admin (Administrator) and DON (Director of Nursing) found that resident had been moved earlier in the day. (RN D) had noted she had checked his bed and chair alarms, low bed, and mat in place on the clinical chart however she stated in her progress note that certain items were not in place .The nurses are tasked with a check off system in the electronic chart to ensure that all interventions are in place. The nurse stated she had ensured all was in place at 7:30 p.m., but at the time the fall happen [six] she stated these interventions were not in place . Review of R2's Emergency Department - Final Note dated 9/29/23 read, in part, .Physical Exam, Head: 5 cm scalp laceration on the occiput .Patient does appear to have a scalp laceration which will require repair .After copious cleaning with sterile saline four skin staples were applied . Review of CNA I's witness statement dated 9/29/23 read, in part, Did you witness the fall? No .Was the alarm going off and if so what type of alarm, bed/chair? No alarms were on bed, Resident was moved to this room when alarms should have been placed .Had the resident or could the resident tell you what happened? Yes, resident said his feet got tangled up in his sheet. Review of RN D's witness statement dated 9/29/23 read, in part, .Resident was transferred 9/29/23 from room [ROOM NUMBER]-2 to room [ROOM NUMBER]-1. Resident was in w/c (wheelchair) @ (at) shift change with active w/c pad alarm. There was no bed alarm or mat in the room . An interview was conducted with the Administrator on 1/31/24 at 3:00 p.m. The Administrator confirmed that the fall mat and bed alarm were not in place at the time of R2's fall on 9/29/23. The Administrator stated that the resident had been moved earlier that day, and that the nurse checked that all interventions were in place when they in fact were not. Review of the facility's Falls-Clinical Protocol policy revised in March 2018 read, in part, .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .

This citation pertains to intake number: MI00144208 Based on interview and record review, the facility failed to follow the physicians order for PT/INR (prothrombin time/international normalized ration) laboratory testing for one Resident (R4) of three residents reviewed for physician orders. This deficient practice resulted in a delay in treatment in response to R4's blood work which subsequently resulted in R4's hospitalization . Findings include: R4 Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including cerebral infarction, and paroxysmal atrial fibrillation. R4's 11/2/23 Brief Interview for Mental Status (BIMS) score was 3/15 indicative of severe cognitive impairment. Review of R4's Minimum Data Set (MDS) assessment dated [DATE], revealed in Section N0415, High Risk Drug Classes, R4 was marked as taking anticoagulant medications. Review of R4's Baseline Care Plan dated 10/26/23 read, in part, .Medications: Anticoagulant: Coumadin .Lab monitoring: yes . Review of R4's Physician Note dated 10/26/23 and written by Medical Doctor (MD) J read, in part, .History of Present Illness: .present to [facility name] hospital September 27, 2023 being discharged home on October 2, 2023 post treatment for an acute urinary tract infection, atrial fibrillation with RVR (rapid ventricular response[bottom heart chambers beating too fast]) and a subacute right sided subacute infarction with left-sided weakness and dysphagia .medications were adjusted during hospitalization and she was discharged home .and resumed Coumadin therapy .It is unclear when her last pro time INR was completed .discharge from hospital pro time 14.5 INR 1.12 .Diagnosis, Assessment and Plan: Paroxysmal atrial fibrillation: .She has been placed back on Coumadin 5 mg (milligrams) daily. I have ordered a pro time, INR, and CBC (complete blood count) to be drawn next lab day. Currently there is no evidence of concern with anticoagulation. Cerebrovascular accident (CVA): Pro Time INR along with CBC (complete blood count) has been written for and I have requested results of her hemoglobin A1c (blood sugar average 90 days) and lipid panel. Medical non-compliance: education provided to her during this visit about the need to be compliant with medications and follow-up both for blood work being on Coumadin and her primary care provider appointments. Multiple bruises: monitor closely. I suspect this is a combination from blood work and IV sites during hospitalization and falls while at home along with anticoagulation on Coumadin. I have ordered blood work including a pro time INR and CBC along with TSH (thyroid stimulating hormone), B12 and folic acid and will adjust medications and treatment depending on results. Review of R4's Physician Telephone Orders dated 10/26/23 and signed by MD J read, in part, Tues (10/31/23): PT/INR, CBC. BMP, Mag, Vit (vitamin) D, TSH, B12, Folate, HA1C, Lipid Panel. This was also signed by two facility nurses, indicating they received and entered the order into the computer system. The two nurses were confirmed to be Licensed Practical Nurse (LPN) G and Registered Nurse (RN) D. Review of R4's Physician Noted dated 10/27/23 and written by Physician Assistant (PA) C read, in part, .(R4) has a history of atrial fibrillation and was on warfarin (also known as Coumadin) .she was lost to INR follow-up since March 2021 on the date of her last visit .Diagnosis and Assessment: Paroxysmal atrial fibrillation; patient is to be on Coumadin. She will need her INR . Review of R4's EMR Medication Administration Record (MAR) revealed that MD J's order for labs was entered into the computer to be drawn on Tuesday October 31st, 2023. It was noted that RN K wrote on 10/31/23 at 2:07 p.m. in R4's MAR Not Taken .Late Administration: Charted late . Review of R4's Physician Note dated 11/1/23 and written by PA C read, in part, .I was asked to urgently evaluate patient by staff. Staff attempted to perform a phlebotomy and patient abruptly became extremely pale and quite unresponsive .Patient is extremely pale and cool. Some clamminess has. Patient had a recent passage of large amounts of blood clots in urine. Patient has been here since the 27th and we have no PT INRs. Patients' family was contacted, and we will send to the hospital for further evaluation .Patient has not had PT/INR since admission . Review of R4's Progress Notes dated 11/1/23 and written by Licensed Practical Nurse (LPN) L read, in part, Resident returned to facility via EMS, lab work at hospital showed PT 116.9 INR 15.32 [Critical] (Normal Range INR: 2.0-3.0) she was treated with vit K and IV fluids. She was seen at her PCP (primary care provider) office on 10/12/23 for admission to [facility name] her admission orders from that visit called for 5 mg of coumadin daily, however her son said that the PCP office had called them 'a couple days later' and changed her to 2.5 mg daily however that was not communicated to us by her PCP office prior to her admit her on 10/26/23 . Review of R4's Physician Noted dated 11/2/23 and written by PA C read, in part, .Family noted that she had a progressive weakness and has a large amount of blood in the urine this morning discovered by [facility name] employees .patient had PT/INR which showed INR greater than 15.32 which was critical. Patient then had 1 L (liter) of normal saline IV (intravenous) along with vitamin K 10 mg (milligrams) IV piggyback. Patient is to hold Coumadin x (times) 3 days and then have a recheck of PT/INR .Diagnosis and Assessment: Poisoning by anticoagulant antagonists, vitamin K and other coagulants, accidental (unintentional), initial encounter . An interview was conducted with PA C on 1/31/24 at 11:15 a.m. PA C confirmed that a physician order was written for R4 to have a PT/INR drawn on 10/31/23, and that the order was not completed by staff on 10/31/23. PA C then stated, had the PT/INR been drawn on the correct date, staff would have had time to respond and adjust R4's medications as needed. During a follow up interview on 1/31/24 at 1:50 p.m. PA C was asked about how physician orders are written and communicated to the facility staff. PA C stated that orders are written on a tri-colored sheet and then entered the EMR system for each specific resident by the facility nursing staff. An interview was conducted with the Director of Nursing (DON) on 1/31/24 at 2:15 p.m. The DON stated that physician orders are reviewed and entered into the facility's EMR system and then left open for a second nurse to verify and close out each physician order. When asked why R4 did not receive a lab draw on 10/31/23 per physician order, the DON stated that it was verified and entered by two nurses per the facility protocol and could not explain why it was not drawn on 10/31/23. An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/24 at 3:00 p.m. The NHA confirmed that there was a system failure for R4, related to her lab draws that were to be completed on 10/31/23. The NHA stated that R4's labs were not completed on that day when they should have been.

Based on observation, interview, and record review, the facility failed to ensure adequate safety and supervision to prevent a fall with major injury for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted in actual harm to Resident #1, who sustained cervical (neck) fractures, a functional decline, and increased pain. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 10/18/22, showed Resident #1 was admitted to the facility on [DATE], with diagnoses including anemia, kidney disease, diabetes, and hyponatremia (low sodium/electrolyte imbalance). Resident #1 required one-person assistance for dressing, transfers, and toileting, and supervision for walking in their room and for wheelchair mobility. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed Resident #1 had normal cognitive impairment. The assessment showed Resident #1 wore glasses, and there was no sensory impairment (vision, hearing, speech, understanding), and no behaviors. Review of the facility's 5-day Investigation report, dated 12/14/22, revealed on 12/06/22: Resident #1 returned from the Emergency Department (ED) with Acute C5, C6, and C7 (Cervical/neck vertebrae) spinous fractures, acute posterior head contusion (bruise), and acute thoracolumbar (mid-back muscle) strain . The report reflected Resident #1 was not admitted due to reasonable pain control and stable C-spine fractures. A rigid neck collar was placed at time of fracture, to use as needed, with a soft roll neck collar to be worn after. Additionally, on 12/07/22, Resident #1 was admitted to the hospital with a GI (gastrointestinal) bleed, with no additional intervention recommended, and it was noted the neck fracture remained stable, with soft collar again recommended. Per this report, the neck fractures occurred when Resident #1 fell off the wheelchair lift on the facility transport van, which had parked at a community restaurant during a facility outing. This occurred when the Van Driver, Staff A, was pushing [Resident #1]'s wheelchair backwards out of the van onto the lift, when [Staff A] realized the lift was not in the 'up' position, and despite her attempts, [Staff A] was unable to stop [Resident #1's] wheelchair, and unfortunately, they [Resident #1 and Staff A] both fell out of the van, and were taken to ER via ambulance .[Resident #1] obtained C-spine fractures, and [the] driver obtained [sic] hand fractures . The report showed there were three residents in the van, and when the Activity Coordinator (Staff B) had taken Resident #2 off the lift, they left the lift on the ground, and had not raised it to the 'up' position and the accident ensured . The report revealed, .[Resident #1] experienced some pain due to the trauma of the fall .Corrective actions taken: When two staff are present during transports it has been common procedure to have one staff member handle the resident(s), and the other staff member handle the lift controller. We believe this may have contributed to the fall. Therefore, we have determined to ensure this accident does not recur, the procedure will be going forward only the van driver [chauffeur] will move the patients on and off the lift and utilize the lift controller to raise and lower the lifts . Abuse and neglect were ruled out by the facility, and nothing intentional was found on the part of staff. During an interview on 12/28/22 at 10:30 a.m., the Nursing Home Administrator (NHA) was asked about the incident. The NHA confirmed the incident occurred as described above. The NHA was asked about a facility process describing the steps to transporting and securing a resident in the facility transport van with lift, and confirmed there was no process delineating each step, as the steps were right on the van posted adjacent to the lift. The NHA reported Staff A's vision had been checked, and there were no vision or health concerns. The NHA reported upon investigating there had been some distractions, as Staff A had been discussing the resident's lunch order (for the restaurant) during the process. The NHA explained Staff B was not a chauffeur, and had pushed the button (lift controller) to lower the lift, and had stated, I was trying to help. The NHA confirmed both Staff A and Staff B were involved in a process failure related to human error, verses any concerns with the van or lift apparatus, and the van had just been in for service the month prior with no concerns. When asked about Resident #1, the NHA confirmed Resident #1 had cervical fractures after the fall, and her glasses were broken, and clarified Resident #1 was not fearful after the incident or since. The NHA confirmed this was an accident, not neglect or abuse, and reported Staff A was taken off transport that day, had not worked in transportation since, and was wearing a cast due to an arm fracture, which Surveyor observed. The NHA reported the four transporters had received an immediate education that they were the only staff responsible for taking residents in and out of the transport van and operating the wheelchair lift/ramp. The NHA confirmed Staff A and Staff B made the decision to take three residents with two attendants, as the residents were independent in wheelchair mobility at the facility, and there was no process or policy that said there had to be one attendant per chauffeur, yet this was typically done. The NHA reported it was up to activities coordinator and chauffeur to make the decision of how many residents to take on outings, given available staff and needs of the residents, and confirmed they supervised the transportation supervisor (Staff A) and staff, including the chauffeurs. Review of Resident #1's ED Final Report, dated 12/06/22, revealed, This [AGE] year old female [Resident #1] presents with her aide [Staff A] .The aide was getting [Resident #1] out of wheelchair van and was pushing [the] wheelchair from the front .[Staff A] thought the ramp was down but apparently it was not, and she [Staff A] pushed the wheelchair backwards and obviously the patient [Resident #1] then fell back and the aide went with her .[Resident #1] hit the back of her head, and presents with pain in the head but also throughout her spine. She did not lose consciousness .CT head: no intracranial hemorrhage .CT-spine: Impression: Acute fractures through the spinous process of C5, spinous process and left lamina of C6, and spinous process and bilateral lamina of C7 . Compression fractures and stenosis of the thoracic [mid] spine were noted, This [AGE] year old female suffered an accident when getting pushed out of her transport van. [Resident #1] ended up falling backwards, hitting the back of her head and suffering what I would assume is a hyperflexion injury of the C-spine .X-ray did not show any traumatic changes in the thoracal lumbar spine [sic] did not show anything acute but she [Resident #1] does have some old severe compression fractures of the thoracic spine .CT spine was reviewed .these are basically advanced spinous process fractures [sic] .they are felt to be stable and even C-spine immobilization is based on patient's preference and comfort. Patient was given IV [intravenous] [name brand over the counter pain medication] along with a single dose of [a name brand prescription pain relieving medication] .There is no indication for admission at this time based on reasonable pain control and her stable C-spine fractures. We will send her home with [Brand name of rigid fixed neck] collar to use as needed. I also recommend getting a true soft roll [neck] collar .Diagnosis: 1. Acute C5 spinous process fracture. 2. Acute C6 spinous process and left lamina fracture. 3. Acute #7 spinous process and bilateral lamina fractures. 4. Acute posterior head contusion [bruise], 5. Acute thoracolumbar [thoracic spine] strain .Disposition: Discharge home [to nursing facility] . Review of Resident #1's [hospital] Patient Education Material, titled, Spinous Process Fracture, revealed, a fracture of a spinous process is a break of a part of one of the bones in the spine. This part extends out from the back of the main body of the bone (called the vertebral body) .In the elderly, these injuries can also occur in the lower neck area .It takes a lot of force to cause this type of fracture .Most of these injuries occur as a result of a variety of accidents such as: Falls .Patients with process fractures have severe pain even if the actual break is small or limited .Medication for pain control, special back bracing, and limitations in activity are done first followed by physical therapy later . Review of Staff A's witness statement, dated 12/06/22, revealed, Tuesday, December 6th at 12:30 p.m., [Staff B], Activities Coordinator, 3 residents, and myself went on a resident outing to lunch and Christmas shopping at [local retail store]. I loaded the three residents, one of which was [Resident #1], into the facility lift van. Upon arrival at the lunch destination, I removed the safety straps on the first resident and rolled resident [#2] onto the exit lift from the inside of the van. [Staff B] was on the outside of van and lowered the lift to the ground and assisted the resident into the restaurant. Meanwhile, I [The Admissions Coordinator, Staff A] removed the safety straps from [Resident #1]'s wheelchair and [sic] pushing her to the exit lift with her back to the exit. I thought the lift was raised and was in place. At the last second, I realized the lift was not raised and despite my attempts I [Staff A] was not able to stop [Resident #1]'s wheelchair and unfortunately both [Resident #1] and I [Staff A] fell out of the van. [Resident #1] landed on her back and I landed on top of her side and pavement. 911 arrived. We were both taken to ER [name of the local emergency room of nearby hospital] .I have been working at [Facility] for [AGE] years and am responsible for scheduling and transporting the residents to appointments and outings. We have never had an accident while transporting our residents. The NHA confirmed this as accurate. Review of Staff B's Witness Statement, dated 12/07/22, revealed, On 12/06/22, [Staff A] and myself planned an outing for three of our residents. [Staff A] loaded and secured the three residents in the transport van for lunch and shopping .I [Staff B] lowered the lift and assisted the first resident off [Resident #2]. [Resident #2] is able to self-propel in her wheelchair but was having difficulty on the slight incline [pavement]. Trying to be helpful, I [Staff B] left the back of the van to assist the resident [Resident #2] into the restaurant .We were inside when I heard [Staff A] yell .I went back outside to find [Resident #1] laying on her left side on the lift. [Staff A] was sitting beside her also on the lift. A bystander was already on the phone with 911 . Review of Resident #1's Witness Statement revealed, .Describes in detail how [Staff A] pushed her from in front of her to lift that evidently wasn't there. 'All of a sudden I was falling backwards and [Staff A] fell with me .The doctor said I had neck fractures' . Review of Resident #2's witness statement revealed, [Staff B] helped me down on the lift. When [Staff B] was wheeling me away, she turned to [Staff A] and said, 'I'll be right back to help you with [Resident #1] .[Staff B] went back out to get [Resident #1] and came running back in for help. [Staff B] told me, 'There's been an emergency.' [Staff B] went back outside but came back in to check on me . During an observation on 12/28/22 at 1:10 p.m., Resident #1 was observed in their room, and agreed to be interviewed. Resident #1 was wearing her soft neck collar, and propelled her wheelchair to the doorway approximately 5', and then asked for staff assistance to wheel her out of room down the hallway to be interviewed in a private area in the facility per her preference. Resident #1 reported she experienced moderate neck and back pain when pushing her wheelchair. During an interview on 12/28/22 at 1:20 p.m., Resident #1 reported the incident occurred on a Tuesday this month, before Christmas, and described how she and two other residents were in the wheelchair van with lift for an outing, and they took a bigger van to fit the three residents. Resident #1 stated, [Staff A] thought [Staff B] raised the ramp up, and [Staff B] didn't, and it was still on the ground, and she [Staff A] started to push me out, and I [Resident #1] went head over heels out of the van, and [Staff A] fell on top of me. Resident #1 described how she went out backwards, and Staff A came out frontwards, and Staff A broke her arm, and added, My back was hurting like crazy, all the way through my back. Resident #1 reported they were both taken to the hospital, and she was told she had two broken bones in her neck, and was given a hard neck collar to wear two days and then the soft collar which she was currently still wearing, and had to wear it for six weeks. Resident #1 reported she felt scared when the incident happened, and stated, I feel ok now. I tell [Staff A] not to worry as it was an accident . Resident #1 confirmed nothing was intentional and there was no abuse, and [Staff A] was distressed the incident had occurred. Resident #1 reported her family (responsible party) believed Staff A should have looked (before pushing Resident #1 out of the van), and it should not have happened. During further interview, Resident #1 was asked about the subsequent hospital stays for a GI bleed and low blood pressure related to medications. Resident #1 reported she had incidents of blood in her stool prior, and did not believe this hospital visit was related to the fall on 12/06/22. When asked about pain, Resident #1 reported she did not have neck or back pain prior to her fall, and described the pain initially as all over my back, and stated, I am starting to get better. When asked about her prior functional level for self-care and mobility, Resident #1 reported she used her walker to go to the bathroom, and go to bed, and used the wheelchair in her room prior, and said, I'm using the wheelchair now, and reported it was physically difficult to propel the wheelchair (herself) at times since the accident. Resident #1 described her mood as happy and she felt safe at the facility and was receiving good care. Regarding pain, Resident #1 denied neck pain during the interview, and reported constant pain in her back ranging from 5/10 (with 10 the highest pain level) to 9/10. Resident #1 reported she did not believe the pain medications were adequately controlling her pain, and would like additional pain medication (which was shared after the interview with nursing management, the physician, and the NHA). When asked to show Surveyor where pain was occurring, Resident #1 reached back to the lower left side of her back (thoracic/lumbar region -mid to low back). Resident #1 expressed frustration she was not able to do more for herself, and explained prior to the fall she used to dress herself when staff obtained her clothing, and she would get herself to the bathroom and onto the toilet, and staff assisted her off of the toilet. Resident #1 stated, I have told my friends it is frustrating they [staff] have to wait on me. Resident #1 asked how long she needed to wear the neck brace, and described how it was very irritating (the soft neck collar), as she had to sleep and eat with it. When asked about activities, Resident #1 reported while she was participating, she needed additional assistance, and was upset her gingerbread house [holiday project] fell apart, which she could have completed prior to the incident. Resident #1 added while the social worker did see her once after the incident (which record review confirmed), she recognized she needed additional psychosocial support, as she was feeling frustrated by the neck brace and the functional decline and needing assistance with some activities. Surveyor notified nursing management and the NHA of Resident #1's request for additional psychosocial supportive visits. During the interview, Resident #1 was fully oriented and demonstrated good cognition including sequential recall of the incident, subsequent hospital visits, and described medical interventions. A phone call was made to Resident #1's family member/responsible party on 1/03/22 at 11:07 a.m , which identified them as the recipient of the voicemail. No call was returned by the end of the survey. During an interview on 12/28/22 at 2:37 p.m., the Activity Coordinator, Staff B confirmed the incident on 12/06/22 occurred, and they left the facility van lift (platform) on the ground, when Resident #2 needed assistance to propel herself into the restaurant. Staff B reported they were newer to their position as activity coordinator (since April, 2022), and had not been trained in the use of the facility van with lift. Staff B acknowledged this was only their third outing with residents (in the community), and said the other two times, The driver (chauffeur) did everything. Staff B reported they stepped in to help Staff A assist residents leave the van, but had not been asked. Staff B reported when they returned to the van they witnessed Resident #1 laying on her side, and Staff A sitting up next to her, both were on the lift platform, and a bystander called 911. Staff B acknowledged they did not have a chauffeur's license, and called the facility for assistance. Staff B reported they made sure the residents were safe, and called facility, who sent Staff F, another van driver, to assist with transport back to the facility. Staff B reported the prior activity director had not trained them on the use of the facility van and lift, and they had only participated and observed community outings when they used community transportation services. Staff B reported they had received an education after the accident with the chauffeurs regarding only the chauffeurs would secure residents in the wheelchair vans, apparatus, and lifts, and operate the lift themselves. During an interview on 12/28/22 at approximately 3:15 p.m., Health Care Coordinator, Chauffeur/Van Driver, Staff F, was asked about the process for operating the facility van with lift, and who was responsible for raising the lift up and down. Staff F reported the driver/chauffeur was responsible for the entire process of securing the residents in the vehicle, buckling seat belts, addressing tie downs, and raising and lowering the lift (platform). When asked how the accident occurred, Staff F reported both Staff A and Staff B were responsible, and Staff A would have been responsible for raising and lowering the lift. Staff F confirmed they were called to assist on 12/06/22 when the accident occurred, and they ensured Resident #2 and Resident #3 were returned safely to the facility, after they had received lunch, and brought Resident #1 lunch at the hospital. When asked about the number of residents (3) and the number of staff (2) on this outing, Staff B responded it is to the discretion of the chauffeur and activity coordinator to decide how many attendants were needed, and confirmed Resident #2 and Resident #3 had demonstrated independence with wheelchair mobility at the facility, and they would not have anticipated a concern. Staff F reported they would have independently done the whole process themselves as they always did, i.e. removing residents from the van, taking them to the restaurant, etc Staff F reported they received adequate training from Staff A and Staff C, had watched training video on the lift, and had return demonstrated use of the lift as part of their training. Staff F showed Surveyor their Chauffeur's license, which was current. Staff F reported both Staff A and Staff B were proficient at their jobs, and were valued employees at the facility, with no prior performance concerns related to transport or outings. During an interview on 12/28/22 at 3:48 p.m., Staff A was asked about the accident with Resident #1 on 12/06/22, related to the facility wheelchair van. Staff A confirmed the incident occurred, and indicated Resident #1 fell off the lift after Staff B had unloaded Resident #2, and Staff A was talking to Resident #1, and unfastened the clips securing the wheelchair to the van, and pushed Resident #1 'out', and thought the lift was there (in the 'up' position). As soon as Staff A noticed (the lift platform was still on the ground), they were both already on the ramp outside the vehicle, on the platform. Staff A placed the wheelchair pad under Resident #1's head, and an observer called 911. Staff A reported Resident #1 did not lose consciousness, and stated, I just hurt. Staff A reported their face was bleeding. Staff A described they observed Resident #1 laying on the metal lift platform on the side over the edge, and was located between the ground and the lift, and was positioned on her side. Resident #1 reportedly denied hitting her head at the time. When asked how this accident could have been prevented, Staff A stated, I should have taken full responsibility for the lift. Staff A reported they and chauffeur staff had been reeducated only the driver will control the lift. Staff A reported they had been using the van and lift and acting as a Chauffeur for over 5 years, and had never had an accident or incident using the van or lift, nor had any of the van drivers/chauffeur's, which the NHA earlier confirmed. Staff A reported the prior activities coordinator and herself had both used loaded and unloaded residents from the van (in the past), and they were not aware Staff B had not been trained in this process. Staff A reported both they and Staff C trained the chauffeurs, and the activity coordinator (former) would have trained Staff B in their job duties. Staff A denied any personal factors contributing to the fall, such as vision, health, being under the influence of substances, or other concerns. Staff A reported there was no intent, and they felt very bad about the accident. Staff A acknowledged they were distracted both by talking to Resident #1 as they were unbuckling them, and by Staff B assisting with the lift process. Staff A confirmed they had received adequate training on the use of the facility van with lift, and trained staff in its use, along with the Van Driver, Staff C. Surveyor attempted to interview Residents #2 on 12/28/22 at approximately 2:00 p.m., and on 1/03/23 at 10:10 a.m Resident #2 declined to be interviewed due to upcoming activities, and was out of the facility at a doctor appointment, respectively. During an interview on 1/03/23 at 10:27 a.m., Certified Nurse Aide (CNA) K was asked about Resident #1's functional status prior and post the accident (fall off van lift on 12/06/22). CNA K explained prior to the accident Resident #1 would walk to the bathroom herself, mainly toileted herself, dressed herself overall, but needed minimal assistance for lower extremity dressing, required stand by assistance for transfers, and propelled her own wheelchair in her room. CNA K clarified at present Resident #1 frequently declined to push her own wheelchair due to pain. CNA K stated Resident #1 was attending activities regularly, however, was sleeping more, often sleeping in until noon, when prior she was up earlier in the morning. CNA K reported no change in Resident #1's affect, reporting she was generally happy, was not fearful or anxious, and had no falls since the occurrence. Review of the Risk Management Occurrence Reporting Worksheet, for Resident #1, received from the Nursing Home Administrator (NHA), dated 12/06/22, revealed, Resident [#1] fell out of the wheelchair van backwards, hitting head. Transporter [Staff A] fell on top of her. Transporter has been pulled from transporting/lift operating until proper investigation can be completed. Resident [#1] went to ER for evaluation. This form showed notification of physician, family member, and NHA. Review of Resident #1's nursing progress note, dated 12/06/22 at 10:19 p.m., revealed Resident #1 returned to the facility at approximately 8:15 p.m., wearing a neck collar for stabilization and comfort, and she could remove or wear as needed. A prescription for Naproxen [a pain medication with anti-inflammatory properties] was included, with diagnosis Stable cervical spine fractures [C5 - C7] .Resident had small abrasions on left elbow and left knee. Resident [#1] in pleasant mood but stated she was sore . Review of Resident #1's nursing progress note, dated 12/07/22 at 11:02 p.m., revealed, Called [hospital] ED to get an update on [Resident #1] .Admitting diagnosis of GI bleed, not suspected due to 12/06/22 event [fall with cervical fractures] . Review of Resident #1's Medication Administration Record (MAR) for December, 2022, revealed Resident #1 had [an OTC - Over the Counter pain medication ordered in the dose 500 mg every 6 hours PRN (as needed). Resident #1 received one dose on 12/06/22, prior to being hospitalized with a GI bleed on 12/07/22. She did not utilize any of the Naproxen ordered after the fall. Review of Resident #1's Physician Visit note, dated 12/20/22, revealed, [AGE] year-old female [Resident #1] with multiple comorbid conditions was initially admitted to [Name of] Hospital. She apparently fell while getting out of a transport vehicle. There was obvious head and neck injury .Imaging studies .were remarkable for acute C5, 6, and 7 spinous process fractures, chronic [ongoing/past] T6 and T9 compression fractures, and diffuse degenerative changes throughout patient's spine. The patient was placed in a C-collar [Cervical Collar]. Neurosurgery was consulted. It was felt the patient's fractures were stable and conservative management was recommended. [Resident #1] was subsequently discharged back to [facility]. On 12/07/22, the patient had gross blood in her stool. She was transferred back to the emergency room .Admitting hemoglobin was stable. She was subsequently admitted for a GI bleed. Given the patient's stable hemoglobin, outpatient evaluation was recommended . A third hospitalization was described on 12/14/22, for an apparent medication reaction, and two of Resident #1's pain medications were discontinued (Norco and a muscle relaxant). Resident #1 continued to report neck pain upon readmission, and inadequate pain control was noted. It was recommended to continue Neurontin (a medication which addressed nerve pain), increase Tylenol and Ibuprofen coverage (dosing), and add Tramadol (a controlled pain medication) as needed. The report showed Resident #1 had a long history of GI concerns; labs were ordered and an outpatient GI follow up was scheduled. Review of Resident #1's Physician Visit note, dated 12/29/22, revealed, Reevaluation of this [AGE] year-old female with multiple comorbid conditions who was placed on tizanidine and Norco for both muscle spasms and pain control on follow-up visit, December 12th (2022). On the morning of December 14 (2022), she had been provided with both her first dose of tizanidine 4g along, with Norco 5/325 mg, and subsequently was found unresponsive with low blood pressure . The report showed resident became responsive prior to leaving the facility, and had elevated troponins (a possible indication of heart damage) at the hospital however there were no acute EKG (heart monitor) changes and echocardiogram (heart ultrasound) was done and showed no changes as well. Thus Resident #1 was deemed stable and returned to the facility. During another physician visit on 12/20/22, Resident #1 had increased pain in her cervical region and low back. A history of chronic pain was noted with diabetic polyneuropathy (nerve pain throughout body) and chronic low back pain. She had been sent back from the hospital with Tylenol only and as needed use of cervical collar. Physician ordered Ibuprofen and tramadol at that time, which Resident #1 reported was causing her nausea and increasing her acid reflux. During Physician Is evaluation on this visit date (12/29/22), Resident #1 reported her pain was not in her neck but in her low back. Physician I added a prescription pain medication patch and a medication to help the bone healing, as well as warm blankets, and a second OTC (over the counter) pain patch, and keeping the Tylenol and gabapentin in place as needed. During this same physician visit, Resident #1 expressed not wanting to wear the cervical collar, as it was restricting her activities. Resident #1 agreed to wear 4 to 6 more weeks per Physician I recommendation, only if she could remove for meals and sleeping; Physician I respected resident wishes per her strong insistence. This report noted Resident #1 reported her social activities had significantly deteriorated since the time of her fall. Physician I noted and observed Resident #1's activity and activities of daily living participation had significantly improved since the time of her fall, including pushing her wheelchair in her room, feeding herself, brushing her teeth and hair, with no pain or grimacing, stable range of motion, sleeping well, and reportedly was ambulating in her room with assistance. Physician I noted the majority of Resident #1's pain was coming from her thoracic spine related to the (prior/old) compression fractures, and neurosurgical follow up was recommended for these concerns, and neurosurgery had not recommended follow up for the cervical spine, unless she was symptomatic. Resident #1 agreed to this appointment for back pain management. During a phone interview on 12/28/22 at approximately 4:25 p.m., Physician I was asked about Resident #1's medical status post the 12/06/22 incident (fall from van wheelchair lift). Physician I confirmed they were the primary physician overseeing Resident #1's care, and indicated the second hospitalization for the GI bleed was not related to the fall, as Resident #1 had GI concerns prior to the fall which were longstanding. Physician I reported Resident #1's cervical fractures showed no displacement, and they expected Resident #1 to make a full functional recovery, and added Resident #1 had old thoracic compression fractures, which were found with no change post the fall. Physician I indicated there had been pain medication changes for Resident #1 when they had been off work and there was coverage by another physician, and the reason Resident #1 was still experiencing pain was likely due to during her recent hospitalization she was taken off most of her pain medications, and was mainly receiving Tylenol, and had Tramadol (a pain medication) available, as she did not medically tolerate Norco (an opioid pain medication) and tizanidine (a muscle relaxant). Physician I had a visit planned 12/29/22 to follow up and address ongoing pain concerns for Resident #1. When asked about their conclusion regarding the cause of Resident #1's accident/fall off the faciltiy wheelchair van lift, Physician I reported they understood this occurred from a miscommunication related to unintentional human error, and no similar incident had occurred at the facility. Review of Resident #1's, Physical Therapy (PT) Discharge Summary, dated 03/21/22, revealed, .Pt [patient] is able to ambulate 50' using 2 ww [Two- wheeled walker], SBA [stand by assistance - no physical assistance] for walker management and safety . Bed mobility was noted as independent and functional transfers were SBA. Wheelchair mobility was marked as not applicable. Pain assessment revealed pain was not present on the 2/23/22 evaluation for this therapy episode. This was confirmed as the last physical therapy episode prior to Resident #1's fall with major injury. Review of Resident #1's, Physical Therapy (PT) Evaluation and Plan of Care, dated 12/16/22, revealed, .Pt to perform transfers safety with mod [moderate] A [assistance] of 1 person. Baseline: [12/16/22] 2 person dependent transfer. Pt to ambulate using 2 ww, Ind [independent]: Baseline: [12/16/22] Unable. Reason for referral: Pt [Resident #1] fell backward while in w/c and hit or head, sustaining fractures t[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide safe bed mobility for four Residents ( #121, #128, #129 & #130) of 10 residents reviewed for accidents/hazards. This deficient practice resulted in a hospitalization and discovery of multiple fractures sustained from a fall, and had the potential to affect other residents who are at high risk for falls. Findings include: Resident #121 A review of the face sheet for Resident #121 revealed admission to the facility on [DATE] with diagnoses including other fracture of right lower leg, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing, other chronic pain, [CONDITION(S)], and weakness. A review of Resident #121's Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment of 10, indicating moderate cognitive impairment. Section G of the MDS assessment indicated Resident #121 required extensive assistance of two staff for bed mobility. On [DATE] at 2:36 p.m., during an interview, MDS Nurse/ Registered Nurse (RN) I indicated she had completed the MDS assessment dated [DATE]. When asked about section G-0110 Activities of Daily Living under A. Bed Mobility being assessed at extensive assist of two staff, RN I stated even if it was one time where two staff were utilized then the assessment automatically goes to maximum assist of two persons for areas like bed mobility. RN I then stated the interventions in place at the time were based off of the 7-day look back report for Resident #121. RN I was asked to show the seven day look back period report for this care area used for the MDS assessment dated [DATE] for Resident #121. The Point of Care ADL (Activities of Daily Living) Report indicated Resident #121 required extensive assist of two staff for bed mobility a total of five times out of 13 documentation entries during the look back period from [DATE]-[DATE]. A review of the Resident Profile dated [DATE] read in part: .[DATE] Bed Mobility: ,d+[DATE] person EA (Extensive Assist) to turn and re-position in bed every ,d+[DATE] hours as she allows. Air Mattress . A review of the Activities of Daily Living (ADL) care plan for Resident #121 revealed an intervention which read: 2 person EA (extensive assist) to turn and re-position in bed every ,d+[DATE] hours as (Resident #121) allows . Edited: [DATE] Edited by: (Director of Nursing [in training] {DON}) A review of the Event Report, dated [DATE], revealed Resident #121 had Rolled out of bed approx(imately) (4:00 p.m.) Possible RLE (right lower extremity) injury, and states hit back of head. The report indicated the event was witnessed and happened in Resident #121's room while getting cleaned up. Resident #121 was experiencing 7 - Severe Pain-Horrible, Intense following the event. Under .injury to the head, extremities, or trunk, Abnormal Alignment, Bruising, Swelling were checked. Under Range of Motion (ROM), ROM Painful/Limited in Lower Extremity - BLE (bilateral lower extremities) was checked. A review of the Hospital #1 Final Note dated [DATE], revealed Resident #121 was admitted to the local hospital on [DATE] and .c/o (complaint of) bilateral knee pain . and was found to have .bilateral distal femur fractures . Resident #121 also complained of .tingling in her toes . Resident #121 was also presumed to have Urinary Tract Infection ([CONDITION(S)]) [CONDITION(S)] based on the appearance of urine and white blood cell count. Resident #121 was ultimately transferred to Hospital #2 to better treat these concurrent medical issues. A review of the Hospital #2 Discharge Documents revealed admission to Hospital #2 on [DATE] at 11:31 p.m. and Resident #121 was discharged on [DATE] deceased . Diagnoses this visit included fall out of bed with multiple resultant fractures, fracture of distal (furthest away from head) end of left femur (thigh bone), fractue of distal end of right femur, T9 (9th [MEDICATION(S)] [mid back]) vertebral (spine bone) fracture, abdominal pain, acute, generalized, fecal impaction, [CONDITION(S)], lactic acidosis, [CONDITION(S)], leukocytosis, acute blood loss [CONDITION(S)], acute kidney injury, and Troponin (cardiac enzyme indicating heart damage) level elevated.In addition to her traumatic injuries, she was found to be septic and thought to be related to a [CONDITION(S)] . A review of the x-ray report for the left knee, dated [DATE], revealed an oblique (fracture is on an angle) displaced (out of alignment) distal fracture of the femur along the diaphysis (shaft). A review of the x-ray report for the right knee, dated [DATE], revealed a displaced and mildly impacted (broken ends jammed together) and angulated (broken bones at an angle to each other) periprosthetic (above artificial joint hardware) distal femur fracture. A review of the Emergency Documentation, dated [DATE] from Hospital #1 read in part: CNA (Certified Nurse Aide) who was cleaning (Resident #121) on her right side stated that (Resident #121) went to roll over and rolled too far and rolled out of bed landing on her knees. On [DATE] at 11:23 a.m., during an interview, Physician B stated Resident #121 was complaining of hip and knee pain when the incident happened. Physician B stated she was the one who assessed Resident #121 immediately after the incident and suspected some rotation in one of Resident #121's lower extremities. On [DATE] at 11:37 a.m., during an interview, CNA D stated she went to check on Resident #121 and discovered she required incontinence care. When asked to identify which side of the bed CNA D was on, CNA 'D stated she was on the left side of the bed. CNA D stated Resident #121 rolled to the right, away from CNA D and grabbed onto the bed rail. CNA D stated the bed height was at waist level for working height (approximately 30'-36). CNA D demonstrated she turned to reach for wipes and brief located at the end of the bed using her right hand. When asked if CNA D was holding onto Resident #121 when attempting to reach for these items, CNA D stated No. CNA D stated Resident #121 rolled off out of the bed on her right side. When asked how Resident #121 rolled out of bed, CNA D stated she saw out of the corner of her eye, Resident #121 move her left leg further over her right leg, which CNA D thought shifted the weight of Resident #121. CNA D stated this caused Resident #121 to have forward momentum away from CNA D and toward the edge of the bed, which CNA D felt ultimately caused Resident #121 to fall out of the bed. CNA D stated Resident #121 landed on her bottom. When asked why she turned Resident #121 away from her to provide care, CNA D stated it was the only way to clean her up because Resident #121 was obese. CNA D verbalized understanding of the concern regarding turning the Resident away from her on the bed while providing care. On [DATE] at 12:18 p.m., during an interview, RN E stated she had come into the room to see Resident #121 was already on the floor and in a semi-sitting position with her legs out in front of her. RN E stated Resident #121's skin color was white/pallor and had observed Resident #121's right leg looked shorter than the other and the left leg looked a little bent. RN E stated Physician B came in to assess Resident #121 and agreed the right leg appeared shorter than the other and gave an order to send Resident #121 to the emergency room . On [DATE] at 12:41 p.m., during an interview, RN F and RN (Director of Nursing in Training) C were asked how the facility assessed competency for CNAs and stated initial skills were checked off within 90 days of hire and the CNA Trainer usually tries to touch base in all the areas. RN F and RN C explained the CNAs then have to go through annual competency review, which was performed by RN F, RN M and RN C. When asked what the expectation was when turning a resident while providing care when there is only one CNA, RN F and RN C stated a single CNA should be on the same side of the bed the resident is being turned towards. When asked where items necessary for the care being provided should be, RN F and RN C stated items needed should be within reach. When asked when the last competency was performed for CNA D, RN F and RN C stated CNA D was assessed at the end of September (2021) or the beginning of October (2021) with everyone else. A review of the progress notes section for Resident #121 revealed the following: [DATE] 01:25 a.m. Resident (#121) alert and oriented times 3ish. (Resident #121) is able to make her needs known .Requires max assist with changing brief. Incontinent of bowel and bladder. (Resident #121) is able to turn side to side, and to make small movements in bed [DATE] 11:47 p.m. Resident (#121) alert with confusion .(Resident #121) stays in bed and requires moderate to max assistance .(Resident #121) is able to make small movements in bed . On [DATE] at 2:48 p.m., during an interview, RN C stated there was an air mattress was in place and a Bari (bariatric)-Bed was being utilized for Resident #121. On [DATE] at 9:25 a.m., during an interview, CNA H was asked how she would roll a resident while providing incontinence care with only one staff. CNA H stated she would roll the resident toward her. When asked why, CNA H stated to prevent a resident from accidentally rolling out of bed onto the floor. Resident #128 A review of the face sheet for Resident #128, revealed admission to the facility on [DATE] with diagnoses including dementia, muscle spasm, obesity, and [CONDITION(S)]. A review of an Occurrence Reporting Worksheet dated [DATE], revealed Resident #128 was being provided care when Resident #128 was turned toward the wall by CNA K and Resident #128 slid between the mattress and the wall. A review of the witness statement provided by CNA K, dated [DATE], revealed she had to call for assistance and staff had to lower Resident #128 to the floor before using a lift to return Resident #128 back into bed. Resident #128 sustained a right knee abrasion. On [DATE] at 11:40 a.m., during an interview, RN C stated CNA K had to be educated because it was determined during the course of the investigation CNA K rolled Resident #128 away from her during the incontinence care she was attempting to provide at the time of the incident. RN C stated, given the recent incidents involving Resident #121 and Resident #128, it was time to re-educate the staff on making sure residents are rolled toward the caregiver when a single staff provides resident care. Resident #129 A review of the face sheet for Resident #129 revealed the latest admission to the facility with diagnoses including muscle weakness, chronic pain, and fracture of right femur. On [DATE] at 10:40 a.m., CNA J was observed providing incontinence care for Resident #129. CNA J rolled Resident #129 away from her and towards the wall to provide incontinence care. The left side of the bed was positioned against the wall. Resident #130 On [DATE] at 10:15 a.m., CNA D was observed providing incontinence care, dressing, transfer assistance for Resident #130. CNA D approached the left side of the bed and rolled Resident #130 away from her. CNA D was observed turning away from the resident toward her right, removing both hands from the resident to retrieve additional wipes sitting on the bedside stand ,d+[DATE] times. CNA D performed this action by holding the wipe container with one hand and pulling them from the container with the other hand. At this time Resident #130 was holding onto a bed mobility bar on the right hand side of the bed with her body positioned at the edge of the bed with approximately one inch of bed surface space remaining. Resident #130's left leg was over her right leg. Resident #130 was at risk of falling out of bed if there was any shifting of weight or movement of left leg further towards the right side. CNA D completed the incontinence care for Resident #130 and asked Resident #130 to stay in the side lying position as previously described. CNA D then removed her gloves and left Resident #130's bedside with the bed in an elevated position and Resident #130 still on her right side at a 90 degree angle. CNA D then proceeded to Resident #130's bathroom and washed her hands. At this time, Resident #130 was not in the line of sight for CNA D. Resident #130 was at high risk for injury and safety could not be assured while no staff were present at the bedside. CNA D then returned to the bedside to complete Resident #130's care. CNA D then rolled Resident #130 away from CNA D while dressing Resident #130 with slacks. On [DATE] at 1:47 p.m., during the exit conference, the DON and Nursing Home Administrator (NHA) were informed of the observations involving CNA D and CNA J rolling residents away from them during care being provided with only one staff. The NHA and RN C stated they would make sure the concern was taken care of. RN C stated she had reeducated CNA D on proper bed mobility performance with one staff member after the incident with Resident #121. A review of the website: https://medlineplus.gov/ency/patientinstructions/ 6.htm, accessed on [DATE] read in part: .The following steps should be followed when turning a patient from their back to their side or stomach: Explain to the patient what you are planning to do so the person knows what to expect. Encourage the person to help you if possible. Stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. The patient's bottom arm should be stretched towards you. Place the person's top arm across the chest. Cross the patient's upper ankle over the bottom ankle . If you can, raise the bed to a level that reduces back strain for you. Make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you .