Every finding on record at Chateau Napoleon Caring, LLC

Based on record reviews and interviews, the facility failed to protect the resident's right to be free of verbal abuse by staff for 1 (Resident #1) of 3 sampled residents investigated for abuse.Findings: Review of the facility's Freedom from Abuse, Neglect and Exploitation policy and procedure, dated 11/2017 and revised on 03/2025, revealed, in part, the purpose was to keep residents free from abuse of any kind, by any person. Further review revealed the facility would provide a safe resident environment and protect residents from abuse. Further review of the policy revealed verbal abuse was verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2026 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact. Review of Resident #1's clinical record revealed a diagnosis of a left below the knee amputation.Review of Resident #1's documented Critical Incident Report (CIR) dated 07/27/2026 revealed, in part, Resident #1 alleged S3CertifiedNursingAssistant (CNA) told her, I still got legs you stank a!# b!#!#. Further review of Resident #1's CIR revealed, in part, the facility's investigation revealed Resident #1's allegation of verbal abuse by S3CNA was substantiated through interview with another resident who overheard S3CNA speak to Resident #1. Review of the facility's Statewide Incident Report dated 08/08/2026 revealed, in part, on 08/08/2026, Resident #1 alleged S4CNA and S5CNA were verbally abusive towards her during her shower. Further review revealed Resident #1 alleged S4CNA and S5CNA told her that if Resident #1 could get a penny for every time she hollered in pain, then Resident #1 could have $1.25 for a soft drink by the end of the week. Further review of the Statewide Incident Report revealed an investigation was completed and Resident #1's allegation of verbal abuse by S4CNA and S5CNA was substantiated through interview with staff and Resident #1. In an interview on 08/24/2026 at 2:54PM, Resident #1 indicated on 08/08/2026 S4CNA and S5CNA clowned and teased her during her shower. Resident #1 indicated S4CNA and S5CNA told her that if Resident #1 could get a penny for every time Resident #1 hollered in pain, then Resident #1 could have $1.25 for a soft drink by the end of the week. Resident #1 indicated one of the CNAs found a nickel on the floor and told her look how good God is; he already gave you a nickel towards your soft drink. Resident #1 indicated there was another incident which involved S3CNA who called her a stank a!# b!#!#. Resident #1 indicated she was upset about the situation. Resident #1 indicated she reported both of the above mentioned incidents to facility staff.In an interview on 08/25/2026 at 1:27PM, S1Administrator indicated Resident #1 reported allegations of verbal abuse on 07/27/2026 and 08/08/2026. S1Administrator further indicated the facility investigated Resident #1's allegations of verbal abuse and both allegations were substantiated. S1Administrator further indicated Resident #1 had the right to be free from abuse, and was not.

Based on interviews and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency through established procedures for 1 (Resident #1) of 3 sampled residents investigated for abuse.Findings:Review of the facility's Freedom from Abuse, Neglect and Exploitation policy and procedure, dated 11/2017 and revised on 03/2025, revealed, in part, when the facility had identified abuse, the facility would report the allegation to appropriate authorities within required timeframes.Review of the facility's undated Administrator's Job Description revealed, in part, the administrative functions included, in part, to maintain facility compliance with state and federal regulations.In an interview on 08/24/2026 at 2:54PM, Resident #1 indicated there was an incident where S3CertifiedNursingAssistant (CNA) called Resident #1 a stank ass b!#!#. Resident #1 indicated she reported the incident to the facility staff.Review of the facility's Statewide Incident Management System (SIMS) reports from June 2026 through August 2026 revealed, in part, a SIMS report was not completed for Resident #1's 07/27/2026 allegation of verbal abuse.Review of the facility's documentation revealed, in part, a Home and Community Based Service (HCBS) Critical Incident Report (CIR) form, dated 07/27/2026, was submitted by the facility to the State Survey Agency for Resident #1's 07/27/2026 allegation of verbal abuse made at 6:00PM.In a telephone interview on 08/25/2026 at 8:18AM, S6Former Interim Administrator indicated on 07/27/2026, when Resident #1 made an allegation of verbal abuse S6Former Interim Administrator did not have access to the SIMS program to enter the report as required. S6Former Interim Administrator further indicated S7Regional Director of Clinical Services provided S6Former Interim Administrator with the HCBS CIR form which S6Former Interim Administrator completed and faxed to the State Survey Agency on 07/27/2026 at 9:35PM.In an interview on 08/25/2026 at 12:02PM, S7Regional Director of Clinical Services indicated on 07/18/2026, S6Former Interim Administrator was assigned the role of Interim Administrator at the facility. S7Regional Director of Clinical Services further indicated when an allegation of abuse was received on 07/27/2026, no one in the facility had access to SIMS. S7Regional Director of Clinical Services indicated she was aware the allegation of abuse should have been reported to the State Survey Agency via SIMS as required, but it was not.In an interview on 08/25/2026 at 1:30PM, S1Adminstrator indicated Resident #1's allegation of verbal abuse on 07/27/2026 was not reported to the State Survey Agency via SIMS, and should have been.

Based on interview and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's elimination status for 1 (Resident #1) of 3 sampled residents investigated for activities of daily living. Findings: Review of Resident #1's Physician's Progress note dated 06/10/2026 revealed, in part, Resident #1 had a colostomy. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2026 revealed, in part, Resident #1 was coded for no bladder or bowel appliance. Further review revealed Resident #1's MDS reflected Resident #1 was frequently incontinent of bowels.In an interview on 08/25/2026 at 11:20AM, S2Director of Nursing (DON) indicated Resident #1's MDS with an ARD of 07/23/2026 was incorrectly coded. S2DON indicated Resident #1 had a colostomy, and the MDS failed to reflect Resident #1's bowel appliance. S2DON indicated Resident #1's bowel continence should have been coded as a 9 to reflect not rated due to presence of an ostomy.

Based on observations, interviews, and record reviews, the facility failed to ensure:1. Wound Care solutions were not accessible to residents (Resident #2);2. Cleaning solutions stored in housekeeping carts were not accessible to residents (Housekeeping Cart D, Housekeeping Cart E, Housekeeping Cart F); and, 3. Staff provided a resident with one-on-one supervision as ordered (Resident #3).This deficient practice was identified for 2 (Resident #2, Resident #3) of 3 sampled residents and 3 (Housekeeping Cart D, Housekeeping Cart E, Housekeeping Cart F) of 3 housekeeping carts investigated for accidents/hazards. Findings: Review of the facility's Accident Hazards/ Supervision/ Devices policy dated 03/2023 revealed, in part, in order to be considered hazardous, a potentially hazardous item or situation must be accessible to a vulnerable resident. Further review revealed the facility would strive to identify potential safety issues for residents who wander. Further review revealed potentially hazardous materials would have been contained, to the extent possible, to protect residents from exposure. Further review revealed potentially hazardous materials include, but are not limited to, chemicals used by facility staff in the course of their duties and drugs and therapeutic agents. 1. Resident #2 Review of Resident #2's nurse's note dated 08/02/2026 at 8:50PM revealed, in part, S4Agency Licensed Practical Nurse (LPN) documented Resident #2 was found seated in a wheelchair in front of Treatment Cart C and was holding an empty bottle of gentian violet (a medication solution used in wound care). Resident #2's face, teeth, hands, and mouth were visibly stained purple, which indicated possible exposure or ingestion. In a telephone interview on 08/17/2026 at 3:44PM, S4Agency LPN indicated on 08/02/2026 she was down the hall passing medications and S4Agency LPN heard someone yell Resident #2 was drinking something. S4Agency LPN further indicated Resident #2 was in a wheelchair near the nurse's station in front of Treatment Cart C, which was unlocked, and Resident #2's mouth was stained purple. S4Agency LPN further indicated Treatment Cart C was unlocked, and it should not have been. In a telephone interview on 08/18/2026 at 12:08PM, S12Weekend Registered Nurse (RN) Supervisor indicated when she left work on 08/02/2026, she left Treatment Cart C in the hall by the nurse's station unlocked. S12Weekend RN Supervisor further indicated she should not have left Treatment Cart C unlocked in an area accessible to residents. In an interview on 08/18/2026 at 11:27AM, S1Administrator indicated Treatment Cart C should not have been left unlocked. In an interview on 08/18/2026 at 11:36AM, S2Director of Nursing confirmed Treatment Cart C should not have been left unlocked in an area accessible to residents. 2. Review of the facility's tub and tile cleaner's safety data sheet (SDS) revealed, the tub and tile cleaner was harmful if swallowed. Further review revealed the tub and tile cleaner may cause burns to the mouth, throat, and stomach if ingested. Review of the facility's glass and hard surface cleaner's SDS revealed, in part, the glass and hard surface cleaner was harmful if swallowed. Further review revealed if the glass and hard surface cleaner was swallowed, to call poison control or a physician if feeling unwell. Review of the facility's disinfectant's SDS revealed, in part, the disinfectant may cause stomach distress, nausea, or vomiting after ingestion. Observation on 08/17/2026 at 10:03AM revealed Housekeeping Cart F was in Hall I and accessible to residents. Further observation revealed the top compartment of Housekeeping Cart F was unlocked. Further observation revealed the top compartment of Housekeeping Cart F contained a spray bottle of tub and tile cleaner and a spray bottle of glass and hard surface cleaner. Further observation revealed S9Housekeeper was in a resident's room and Housekeeping Cart F was out of his/her view/supervision. Observation on 08/17/026 at 10:20AM revealed Housekeeping Cart D was in Hall G and accessible to residents. Further observation revealed the top compartment of Housekeeping Cart D was opened and unlocked. Further observation revealed the top compartment of Housekeeping Cart D contained a spray bottle of tub and tile cleaner and a spray bottle of glass and hard surface cleaner. Further observation revealed S10Housekeeper was in a resident's room and Housekeeping Cart D was out of his/her view/supervision. Observation on 08/17/2026 at 12:58PM revealed Housekeeping Cart E was on Hall H and accessible to residents. Further observation revealed the top compartment of Housekeeping Cart E was unlocked. Further observation revealed the top compartment of Housekeeping Cart E contained a spray bottle of tub and tile cleaner, a spray bottle of glass and hard surface cleaner, and a bottle of an unknown liquid. Further observation revealed no staff was present to supervise Housekeeping Cart E. In an interview on 08/17/2026 at 12:59PM, S1Administrator indicated Housekeeping Cart E should not have been unlocked. In an interview on 08/17/2026 at 1:06PM, S1Administrator acknowledged the top compartments of Housekeeping Cart D, Housekeeping Cart E, and Housekeeping Cart F should not have been unlocked on Hall G, Hall H, and Hall I. In an interview on 08/17/2026 at 1:29PM, S11Vice President of Nutrition and Environmental Services indicated the unlabeled bottle in Housekeeping Cart E was a disinfectant. In an interview on 08/18/2026 at 8:25AM, S11Vice President of Nutrition and Environmental Services indicated the lock on the Housekeeping Cart E had not been functioning correctly. 3. Review of Resident #3's June 2026 physician's orders revealed, in part, an order dated 06/26/2026 to complete Alert Charting for 3 Days with one-on-one monitoring for Resident #3. Further review revealed the above order was to end on 06/29/2026 at 1:59PM. Review of Resident #3's Resident One-to-One Supervision Record revealed, in part, on 06/29/2026 at 6:00AM, S5CNA documented Resident #3 was going out the door. In a telephone interview on 08/18/2026 at 1:54PM, S5CNA indicated she was assigned to provide Resident #3 with one-on-one supervision on 06/29/2026. S5CNA further indicated on 06/29/2026 after 5:00AM, when she (S5CNA) was providing one-on-one upervision to Resident #3, she (S5CNA) walked down the hall to go and get her bag because it was almost time for her to leave, and Resident #3 was left alone in her room. S5CNA further indicated, when she was walking back from getting her bag, she noticed another CNA was bringing Resident #3 back to her room from down the hall. In an interview on 08/18/2026 at 2:13PM, S6Regional Director of Clinical Services indicated when staff were assigned to provide one-on-one supervision to a resident, the staff were not to let the resident out of their view. In an interview on 08/18/2026 at 2:20PM, S7CNA Supervisor indicated S5CNA should not have left Resident #3 unattended on 06/29/2026.

Based on observation, interviews, and record review, the facility failed to ensure medications were stored in a locked compartment for 1 (Medication Cart A) of 3 medication carts reviewed for storage requirements. Findings:Review of the facility's Medication Storage policy and procedure, last revised 03/2026 revealed, in part, all drugs and biologicals should be stored in locked compartments (medication carts, drawers, refrigerators, medication rooms). Further review revealed medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. Observation on 08/17/2026 at 8:26AM revealed Medication Cart A was unlocked and unattended outside the dining room in the hallway. In an interview on 08/17/2026 at 8:29AM, S8Licensed Practical Nurse (LPN) indicated she failed to lock Medication Cart A when she stepped away. S8LPN further indicated Medication Cart A should have been locked. In an interview on 08/17/2026 at 4:10PM, S2Director of Nursing confirmed S8LPN should not have left the medication cart unlocked and unattended.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (Resident #1, (Resident #3) of 3 residents investigated for call lights. Findings:Resident #1 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2026 revealed Resident #1 had a Brief Interview Mental Status (BIMS) Score of 14 which indicated Resident #1 was cognitively intact. Review of Resident #1's Care Plan, dated 05/08/2026, with a goal date of 08/09/2026, revealed, in part, Resident #1's call light was to be placed in Resident #1's reach. Observation on 06/01/2026 at 9:48AM, revealed Resident #1 was lying in his bed, in his room with the call light on the floor out of Resident #1's reach. Observation on 06/01/2026 at 1:42PM revealed S6Receptionist brought Resident #1 to his room in a Geri-chair. Observation further revealed Resident #1's call light was on the floor out of Resident #1's reach. In an interview on 06/01/2026 at 1:45PM, Resident #1 indicated he was able to use the call light and the call light was often out of his reach. Observation on 06/01/2026 at 4:04PM revealed Resident #1 was sitting in his room in a Geri-chair with his call light approximately 4 feet away wrapped around the positioning bar of Resident #1's bed. Observation on 06/01/2026 at 4:18PM with S7Certified Nursing Assistant (CNA) revealed Resident #1 was sitting in his room in a Geri-chair with his call light approximately 4 feet away wrapped around the bed's positioning bar. In an interview on 06/01/2026 at 4:20PM, S7CNA indicated Resident #1 could use the call light and the call light should've been within his reach. Observation on 06/02/2026 at 8:36AM revealed Resident #1 was lying in bed with the call light on the floor out of Resident #1's reach. Observation on 06/02/2026 at 8:48AM revealed S4CNA entered Resident #1's room. Further observation revealed S4CNA exited Resident #1's room without ensuring Resident #1's call light was within reach. Observation on 06/02/2026 at 9:10AM with S4CNA revealed Resident #1 was lying in bed in his room with the call light on the floor out of Resident #1's reach. In an interview on 06/02/2026 at 9:11AM, S4CNA indicated Resident #1's call light should have been placed within Resident #1's reach and not on the floor. Observation on 06/02/2026 at 1:40PM revealed S6Receptionist brought Resident #1 to his room in a Geri-chair and exited Resident #1's room without ensuring Resident #1's call light was within reach. Observation on 06/02/2026 2:07PM with S3CNA Supervisor revealed Resident #1 was sitting in a Geri-chair with his call light approximately 3 feet away wrapped around the bed's positioning bar. In an interview on 06/02/2026 at 2:08PM, S3CNA Supervisor confirmed Resident #1's call light was out of Resident #1's reach and it should not be. Resident #3Review of Resident #3's Care Plan, dated 03/17/2026, with a goal date of 06/18/2026, revealed, in part, Resident #1's call light was to be placed in Resident #1's reach.Observation on 06/01/2026 at 12:35PM revealed S8Licensed Practical Nurse entered Resident #3's room where Resident #3 was lying in bed with the call light located on the floor underneath the bed and was not within Resident #3's reach. Further observation revealed S8LPN exited Resident #3's room without ensuring Resident #3's call light was within reach. Observation on 06/01/2026 at 12:42PM revealed S5CNA entered Resident #3's room where Resident #3 was lying in bed with the call light located on the floor underneath the bed and was not within Resident #3's reach. Further observation revealed S5CNA exited Resident #3's room without ensuring Resident #3's call light was within reach. Observation on 06/01/2026 at 4:36PM revealed, Resident #3's call light was on the floor underneath Resident #3's bed, out of Resident #3's reach. Observation on 06/01/2026 at 4:48PM revealed S9CNA entered Resident #3's room where Resident #3 was lying in bed with the call light located on the floor underneath the bed and was not within Resident #3's reach. Further observation revealed S9CNA exited Resident #3's room without ensuring Resident #3's call light was within reach. In an interview on 06/01/2026 at 4:52PM, S9CNA indicated Resident #3 could use the call light, and Resident #3's call light should have been in the bed within reach. Observation on 06/01/2026 at 4:54 PM with S9CNA revealed Resident #3's call light was on the floor underneath the bed and was not within Resident #3's reach. In an interview on 06/01/2026 at 4:55PM, S9CNA indicated Resident #3's call light was out of Resident #3's reach. In an interview on 06/02/2026 at 2:10PM, S3Director of Nursing indicated a resident's call lights should be within a resident's reach.

Based on interviews and record reviews, the facility failed to ensure a resident with a mental disorder received appropriate behavioral health treatment for 1 (Resident #2) of 7 sampled residents reviewed for behavioral health services. Findings:Review of Resident #2's clinical record revealed, in part, Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/2026 revealed, in part, Resident #2 had diagnoses which included, in part, bipolar disorder (mental health disorder characterized by extreme mood swings), depression (mental health disorder characterized by sadness, anxiety, and irritable mood), anxiety (a mental health disorder characterized by excessive worry that causes behavioral changes), and unspecified mood disorder (a psychiatric diagnosis characterized by significant distress from mood symptoms that does not meet the criteria for a specific mood disorder). Review of Resident #2's care plan dated 03/26/2026 revealed, in part, Resident #2 had a mood problem related to bipolar disorder, and antipsychotic medications were to be administered as ordered. Review of Resident #2's clinical record revealed, in part, Resident #2 was transferred to a behavioral health hospital on [DATE], following a behavior incident. Review of Resident #2's Behavioral Health Hospital Discharge Orders dated 03/24/2026 revealed, in part, Resident #2 had discharge diagnoses which included reoccurring major depressive disorder with psychosis and impulse control disorder. Further review revealed Resident #2's had an order for Aripiprazole (an antipsychotic medication used to treat mental health disorders including bipolar disorder) 7.5 milligram (mg) at bedtime for treatment of bipolar disorder. Review of Resident #2's April 2026 Physician Orders revealed, in part, an active order for Aripiprazole 5 mg give one time a day related to bipolar dated 03/25/2026. Further review revealed there was no active order for Resident #2 to receive Aripiprazole 7.5 mg daily at bedtime as ordered on 03/24/2026. Review of Resident #2's March and April 2026 Electronic Medication Administration Records (EMAR) revealed, in part, Resident #2 received Aripiprazole 5 mg once daily on 03/26/2026, 03/28/2026, 03/29/2026, 03/31/2026, 04/01/2026, 04/02/2026, 04/03/2026, 04/05/2026, 04/06/2026, 04/07/2026, 04/08/2026, and 04/09/2026. Further review revealed an order for Aripiprazole 7.5 mg at bedtime for treatment of bipolar disorder with a start date of 03/24/2026 and a discontinue date of 03/25/2026. Further review revealed no documented evidence Resident #2 received Aripiprazole 7.5 mg daily at bedtime as ordered by the physician on 03/24/2025. In an interview on 04/09/2026 2:37PM, S9Unit Manager indicated she was responsible to review residents' medications on admission and/or following hospitalizations. S9Unit Manager confirmed Resident #2's Behavioral Health Hospital Discharge Orders indicated Resident #2 was to receive Aripiprazole 7.5 mg daily at bedtime. S9Unit Manager indicated Resident #2's order for Aripiprazole 7.5 mg one time daily was discontinued in error on 03/25/2026 and Resident #2's previous order for Aripiprazole 5 mg daily was reactivated, and should not have been. In an interview on 04/09/2026 at 3:33PM, S2Director of Nursing (DON) confirmed Resident #2's Behavioral Health Hospital Discharge Orders indicated Resident #2 was to receive Aripiprazole 7.5 mg daily at bedtime. S2DON confirmed Resident #2's March and April 2026 EMAR revealed no documented evidence Resident #2 received Aripiprazole 7.5 mg daily at bedtime as ordered by the physician, and Resident #2 should have.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, and comfortable environment for 5 (Room a, Room b, Room c, Room d, Room 'e) of 5 sampled rooms investigated for homelike environment. Findings:Review of the facility's Maintenance Request Binder revealed there were no documented entries for the time period of 10/01/2025 through 11/01/2025 regarding Room a, Room b, Room c, Room d, and/or Room e. Observation on 11/24/2025 at 10:40a.m., revealed Room a had black markings present on the right wall of Room a, behind the head of bed B. Further observation revealed the floor molding below the air conditioning unit was removed, which exposed the wood on the wall. Further observation revealed there was a hole in the right wall that had exposed insulation to the right side of bed A. Observation on 11/24/2025 at 12:59p.m., revealed Room b 's floor moldings on the right wall and the right back corner were peeling up from the wall. Further observation revealed the floor molding on the right wall of Room b 's bathroom near the sink was peeling up from the wall; a brown stain on the toilet and behind the seat of the toilet and dried paper towel products were stuck to the left wall, below the toilet paper dispenser. Observation on 11/24/2025 at 1:02p.m., revealed Room c had a hole in the bathroom door frame near the door knob; the floor molding was peeling up from the left wall and right back corner; peeling sheetrock partially covered by a piece of wood that had been secured to the right wall; the wallpaper was peeling above the air conditioner. Further observation revealed the wallpaper was peeling on the left wall of Room c 's bathroom, to the left side of the toilet; the wallpaper was peeling on the right wall, below the sink; an unknown brown residue present on the right wall, below the sink; an unknown black, white and brown discoloration on the floor to the left and front of the base of the toilet and a piece of flooring tile was missing in front of the back wall, to the right of the toilet. Observation on 11/24/2025 at 1:07p.m., revealed Room d had multiple black marks on the left wall, behind the head of bed A; the floor molding was peeling up on the left wall; the floor molding was peeling up to the bottom right of the air conditioner unit; there was a crack in the wall of the back left corner, behind the opened bathroom door, where the floor under the floor tile was exposed. Further observation revealed Rooms d 's bathroom had an unknown brown substance on the toilet seat and in the toilet of Room d 's bathroom. Observation on 11/25/2025 at 8:40p.m., revealed Room e 's bathroom had duct tape on the bathroom floor in the shape of an L. In an interview on 11/24/2025 at 3:12p.m., S1Administrator was shown the above findings and confirmed the presence of the above findings in Room a, Room b, Room c, and Room d. In an interview on 11/25/2025 at 8:53a.m., S1Administrator indicated the duct tape in Room e 's bathroom was on the floor to cover a tear in the linoleum flooring, and that it should have been repaired.

Based on interviews and record reviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 2 (Resident #10, Resident #106) of 22 (Resident #2, Resident #4, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #12, Resident #15, Resident #16, Resident #19, Resident #23, Resident #25, Resident #29, Resident #37, Resident #50, Resident #54, Resident #60, Resident #99, Resident #103, Resident #106, Resident #105) sampled residents reviewed for Advanced Directives. Findings:Review of the facility's policy, Resident Rights Advanced Directives dated 03/2023, revealed, in part, upon admission, the facility verifies the formulation of an advanced directive or the resident's wishes with regard to formulating an advanced directive. Further review revealed, in part, the facility will place the information about whether or not the resident has an Advanced Directive, and documents reflecting the decision regarding the Resident's Advanced Directive in the medical record, and are easily retrievable by the facility staff. Review of Resident #10's Clinical Record revealed Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's electronic Medical Chart (eChart) profile revealed, in part, Resident #10 did not have an advance directive in Resident #10's eChart profile.Review of Resident #106's Clinical Record revealed Resident #106 was admitted to the facility on [DATE]. Review of Resident #106's electronic Medical Chart (eChart) profile revealed, in part, Resident #106 did not have an advance directive in Resident #10's eChart profile. In an interview on 09/24/2025 at 12:04PM, S12Minimal Data Set Nurse stated indicated if the resident did not elect to have an advanced directive, then the resident was considered a full code. In a telephone interview on 09/22/2025 at 1:55pm, Resident #106's son indicated he and his father were over Resident #106's care, and Resident #106 was a full code.Review of Resident #10's 5 day Minimal Data Set with an Assessment Reference Date of 07/21/2025 revealed, in part, Resident #10 had a Brief Interview for Mental Status score of 15, which indicated Resident #10 was cognitively intact.In an interview on 09/23/2025 8:12AM Resident #10 indicated she would like to be a full code.In an interview on 09/22/2025 at 1:35PM, S2Director of Nursing, indicated all residents' advanced directives are located on the residents' eChart profile. S2Director of Nursing confirmed that Resident #10, and Resident #106 did not have an advanced directive; therefore, Resident #10 and Resident #106's wish to be a full code should have been documented in their eChart profile.

Review of Resident #37's electronic health record revealed, in part, Resident #37 had an admission date of 06/07/2024. Review of Resident #37's electronic health record revealed, in part, Resident #37 had a diagnosis of dysphagia, unspecified. Review of Resident #37's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2024 revealed, in part, Resident #37 had a Brief Interview Mental Score of 03, which indicated Resident #37 was severely cognitively impaired.Review of Resident #37's physician orders revealed, in part, Resident #37 had an order for a dental consult as needed with a start date of 06/10/2024. Observation on 09/23/2025 at 8:25AM revealed Resident #37 had missing and broken teeth on the upper jaw and lower jaw. On 09/23/2025 at 11:49AM S2Director of Nursing (DON) was asked for documentation of dental visits for Resident #37. In an interview on 09/23/2025 at 12:37PM, S2DON indicated she did not find any documentation that Resident #37 had received any dental services since admission. In an interview on 09/23/2025 at 2:23PM, S2DON indicated she called the facility's dental provider and the facility's dental provider indicated they never received a dental service referral from the facility for Resident #37. S2DON further indicated Resident #37 should have been seen by the facility's dental provider as ordered.On 08/01/2025 at 5:30PM during exit conference, S1Administrator was asked if he had any additional documentation to present. S1Administrator had nothing to add and did not provide any documentation as requested to dispute the above mentioned deficient practice.

Based on observations, interviews, and record reviews, the facility failed to:1. Implement the facility's Enhanced Barrier Precautions (EBP) policy and procedure for a resident with a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the abdominal wall and into the stomach) for 1 (Resident #6) of 1 (Resident #6) sampled residents observed for EBP in a total sample of 3 residents investigated for activities of daily living;2. Ensure reusable medical equipment was maintained in a sanitary manner for 2 (Resident #62, Resident #85) of 8 (Resident #6, Resident #24, Resident #31, Resident #42, Resident #62, Resident #80, Resident #81, Resident #85) sampled residents investigated for infection control; and,3. Ensure a laundry staff member properly sorted and washed dirty laundry on the proper wash cycles for 1 (S11Laundry Aide) of 1 (S11Laundry Aide) laundry staff observed for handling and processing dirty laundry. Findings:Review of the facility's Infection Prevention and Control Program: Enhanced Barrier Precautions Policy and Procedure dated 03/10/2025 revealed, in part, enhanced barrier precautions must be observed when providing direct care for residents with high-risk conditions, including indwelling medical devices such as feeding tubes. Further review revealed gowns and gloves should be worn for the following high-contact resident care area activities: maintenance or manipulation of devices (feeding tubes) and providing hygiene assistance (bathing and toileting). Signage will be placed outside the room. 1. Review of Resident #6's physician's orders, in part, revealed an order dated 02/21/2025 for enhanced barrier precautions. Further review revealed providers should put on a gown and gloves during high contact care activities which included providing hygiene such as changing bed linens, changing briefs or assisting with toileting. Review of Resident #6's Care plan dated 03/12/2025, in part, revealed Resident #6 had enhanced barrier precautions. Further review revealed gown and gloves were required for high-contact resident care such as bathing, incontinence care, toileting care, or devices. Observation on 09/23/2025 at 4:45PM, revealed a sign on Resident #6's door which read Enhanced Barrier Precautions. Observation further revealed gloves, gowns, and masks were available on the door. Review of the Enhanced Barrier Precautions sign on the outside of Resident #6's door revealed the following: Everyone must: clean their hands, including before entering and when leaving the room. Provider's and staff must also: wear gloves and a gown for the following high-contact resident care activities – dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Devices care or use: feeding tube. Observation on 09/23/2025 at 4:55PM revealed Resident #6 had a PEG tube. Further observation evealed S9Certified Nursing Assistant (CNA) and S10CNA provided Resident #6 incontinence care without using a gown. In an interview on 09/23/2025 at 5:21PM, S10CNA indicated she should have put on a gown when she provided incontinence care to Resident #6, and she confirmed she did not. In an interview on 09/23/2025 at 5:24PM, S9CNA indicated she should have put on a gown when she provided incontinence care to Resident #6, and she confirmed she did not. In an interview on 09/24/2025 at 9:19AM, S3Infection Preventionist indicated staff should put on a gown and gloves when changing a resident or providing any direct resident care when a resident was on enhanced barrier precautions. S3Infection Preventionist confirmed S9CNA and S10CNA should have put on gown when they performed incontinence care to Resident #6. In an interview on 09/24/2025 at 9:24AM, S2Director of Nursing (DON) confirmed a gown and gloves should have been worn when providing incontinence care to a resident on enhanced barrier precautions. Observation on 09/24/2025 at 10:00AM revealed, S8Licensed Practical Nurse (LPN) removed the enteral feeding tubing from Resident #6's PEG tube without putting on a gown. In an interview on 09/24/2025 at 10:02AM, S8LPN indicated she was unaware that she needed to put on a gown when she removed the enteral feeding tubing from Resident #6's PEG tube. In an interview on 09/24/2025 at 10:16AM, S12Unit Manager indicated a gown and gloves should have been worn when disconnecting enteral feeding tubes. In an interview on 09/24/2025 at 10:23AM, S2DON confirmed a gown should have been worn when disconnecting enteral feeding tubes. 2. Review of the Infection Prevention and Control Program policy, revision date 04/28/2025, revealed, in part, the facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Resident #62 Observation on 09/23/2025 at 11:03AM revealed an unidentifiable and uncontained toilet seat riser lying directly on Resident #62's bathroom floor. Observation on 09/24/2025 at 10:10AM with S13Certified Nursing Assistant (CNA) Supervisor present, revealed a toilet seat riser was unidentifiable uncontained, and lying directly on Resident #62's bathroom floor. In an interview on 09/24/2025 at 10:10AM, S13CNA Supervisor indicated the toilet seat riser had been used by Resident #62 and should not have been placed directly on the bathroom floor. S13Certified Nursing Assistant Supervisor further indicated the toilet seat riser should have been labeled and placed inside a bag for storage. In an interview on 09/24/2025 at 1:15PM, S2DON indicated the toilet seat riser for Resident #62 should not have been placed directly on the bathroom floor. S2DON further indicated the toilet seat riser should have been labeled and placed inside a bag for storage. Resident #85 Observation on 09/22/2025 at 9:22AM revealed an unidentifiable and uncontained bed pan was lying on Resident #85's bathroom floor. Observation on 09/23/2025 at 11:10AM revealed an unidentifiable and uncontained bed pan was lying directly on Resident #85's bathroom floor. Further observation revealed the bed pan had a brown unknown substance along the inside surface of the bed pan. Observation on 09/23/2025 at 3:53PM, with S13CNA Supervisor present, revealed an unidentifiable and uncontained bed pan was lying directly on Resident #85's bathroom floor. Further observation revealed the bed pan had a brown unknown substance along the surface of the bed pan. In an interview on 09/23/2025 at 3:54PM, S13CNA Supervisor confirmed there was an unidentifiable and uncontained bed pan lying directly on Resident #85's bathroom floor. S13CNA Supervisor indicated the bed pan had been used by a resident. S13CNA Supervisor further indicated the used bed pan was not stored in a sanitary manner, and should have been labeled and placed inside of a bag for storage. In an interview on 09/23/2025 at 3:57PM, S2DON confirmed the used bed pan observed in Resident #85's bathroom should not have been placed directly on the floor. S2DON further indicated the used bed pan was not stored in a sanitary manner, and should have been labeled and placed inside of a bag for storage. In an interview on 09/24/2025 at 10:20PM, S3Infection Preventionist confirmed a used bed pan should not have been place directly on Resident #85's bathroom floor. S3Infection Preventionist indicated the used bed pan was not stored in a sanitary manner, and should have been labeled and placed inside of bag for storage. 3. Review of the Clinical Services Policy and Guidelines of Linen, dated 04/28/2025, revealed in part, laundry and direct care staff should handle, and process linens to prevent the spread of infections. Review of the facility's laundry service agreement dated 01/28/2025, revealed in part, the provider would receive a wall chart as training for product/equipment use to be posted at the provider location. In an interview on 09/22/2025 at 8:56AM, S6Laundry/Housekeeping Supervisor indicated laundry staff was responsible for sorting dirty laundry and washing the dirty laundry on the wash cycle according to the wall chart instructions provided by the laundry service company. Observation on 09/22/2025 at 8:57AM revealed the provider's washers contained a mixture of dirty laundry including sheets, towels, bed pads, and resident clothing that were not sorted and separated before washing. In an interview on 09/22/2025 at 8:59AM, S11Laundry Aide confirmed she did not sort the dirty laundry before washing, and indicated she did not wash the dirty laundry on the correct wash cycle as required according to the chart provided by the laundry service company. Observation on 09/22/2025 at 9:00AM of the Linen Handling procedures chart posted on the wall in the laundry room revealed, in part, soiled linen was to be sorted before loading in the washer and the proper wash formula should be selected for each load. Observation on 09/22/2025 at 9:00AM of the Laundry System Processing Information chart posted on the wall in the laundry room revealed, in part, sheets should be washed on Wash Cycle 1, towels should be washed on Wash Cycle 2, blankets and residents' personal clothing should be washed on Wash Cycle 3, and bed pads should be washed on Wash Cycle 5. In an interview on 09/22/2025 at 9:01AM, S6Laundry/Housekeeping Supervisor confirmed the clothes in the washers were not sorted as required. S6Laundry/Housekeeping Supervisor indicated S11Laundry Aide should have sorted and washed the dirty laundry according to the Linen Handling procedure chart and Laundry System Processing Information chart provided by the laundry service company. In an interview on 09/23/2025 at 10:27AM, S1Administrator acknowledged S11Laundry Aide should have followed the wall charts provided by the laundry service company for sorting and washing dirty laundry.

Based on observation, interviews, and record reviews the facility failed to provide toenail care for 1 (Resident #99) of 3 (Resident #6, Resident #7, Resident #99) sampled residents investigated for activities of daily living. Findings:Review of Resident #99's electronic health record revealed, in part, Resident #99 had a diagnosis of diabetes mellitus due to underlying conditions with hyperglycemia and morbid (severe) obesity due to excessive calories. Review of Resident #99's quarterly Minimum Data Set with an Assessment Reference Date of 08/12/2025 revealed, in part, Resident #99 had a Brief Interview for Mental Status score of 15, which revealed Resident #99 was cognitively intact. Observation on 09/22/2025 at 8:51AM revealed Resident #99's toenails on his right foot extended one inch to one and a half inches past the toes. In an interview on 09/23/2025 at 9:09AM Resident #99 indicated his toenails had not been clipped by facility staff, and he wanted them clipped. In an interview on 09/24/2025 at 9:59AM Resident #99 indicated he did not have his toenails clipped since April of 2025. In an interview on 09/24/2025 at 1:15PM, S15Licensed Practical Nurse/Wound Care indicated she was responsible for providing toenail care of diabetic residents and she had not checked to see if Resident #99's toenails needed to be trimmed because he sometimes refused wound care. S15Licensed Practical Nurse/Wound Care further indicated Resident #99's toenails should have been clipped.

Based on observations, interviews, and record reviews, the facility failed to ensure a urinary catheter drainage bag (a medical device that collects urine from the bladder) was not placed directly on the floor for 1 (Resident #23) of 2 (Resident #9, Resident #23) sampled residents investigated for urinary catheter requirements. Findings:Review of Resident #23's electronic health record revealed, in part, Resident #23 had a diagnosis of chronic kidney failure stage 3 and acute kidney failure, unspecified. Review of the facility's contracted hospice nurse's progress note dated 09/16/2025 revealed, in part, Resident #23 had an indwelling catheter (a medical device inserted into the bladder that drains urine to a urinary catheter drainage bag). Observation on 09/22/2025 at 8:50AM revealed Resident #23 was lying in bed. Further observation revealed her urinary catheter drainage bag was lying on the floor with part of the urinary catheter tubing touching the floor. Observation on 09/22/2025 at 9:18AM revealed Resident #23 was lying in bed. Further observation revealed her urinary catheter drainage bag was lying on the floor with part of the urinary catheter tubing touching the floor. In an interview on 09/23/2025 at 1:34PM, Resident #23's contracted hospice nurse indicated a urinary catheter drainage bag and tubing should not have been on or touching the floor. In an interview on 09/23/2025 1:23PM, S16Certified Nursing Assistant indicated Resident #23's urinary catheter drainage bag and tubing should not have been on or touching the floor. In an interview on 09/24/2025 at 8:32AM, S17Certified Nursing Assistant indicated urinary catheter drainage bag and tubing should not have been be on or touching the floor. In an interview on 09/24/2025 at 9:21AM, S3Infection Preventionist indicated a urinary drainage bag and tubing should not have been on or touching the floor. S3Infection Preventionist further indicated it is standard infection control practice to ensure a resident's urinary catheter drainage bag and tubing should not be on or touching the floor. In an interview on 09/28/2025 at 9:27AM, S13Certified Nursing Assistant Supervisor indicated Resident #23's urinary catheter drainage bag and tubing should not have been on or touching the floor. In an interview on 09/24/2025 at 12:17PM, S1Administrator indicated a urinary catheter drainage bag and tubing should not have been on or touching the floor.

Based on observation, interviews, and record reviews, the facility failed to ensure the medication error was not greater than 5% for 1 (Resident #28) of 7 (Resident #15, Resident #16, Resident #28, Resident #42, Resident #59, Resident #72, Resident #79) sampled residents observed during the medication administration task. Findings:Review of the facility's undated Medication Pass Administration Policy and Procedure, last revised 12/01/2021, revealed, in part, medications shall be administered within 60 minutes prior to or after the scheduled time. Review of the facility's Nursing Recommendations/Manager Report dated 09/14/2025 revealed, in part, medications were not being administered as ordered (different time, etc. [other similar things]). Review of Resident #28's September 2025 physician's orders revealed, in part, Resident #16 had the following orders:Gabapentin (a medication used to treat seizures and neuropathy) 300 milligram (mg) oral capsule every morning scheduled at 8:00AM;Lyrica (a medication used to treat seizures and nerve pain) 75 mg oral capsule scheduled daily at 8:00AM;Culturelle capsule (a probiotic medication) scheduled daily at 8:00AM;Guaifenesin Extended-Release (ER) (a medication used to thin mucus) 600 mg tablet scheduled every 12 hours at 8:00AM and 8:00PM;B-12 (a vitamin) 500 mg tablet scheduled daily at 8:00AM;Plavix (an antiplatelet medication uses to prevent blood clots) 75 mg tablet scheduled daily at 8:00AM;Sertraline Hydrochloric acid (HCL) (a medication used to treat depression) 100 mg tablet every morning scheduled at 8:00AM; and,2 Acetaminophen 325 mg tablets scheduled daily at 8:00AM. There were 26 medication administration opportunities for error, with 8 observed errors for a medication administration error rate of 30.77%. Observation on 09/23/2025 at 9:17AM revealed S18Licensed Practical Nurse (LPN) administered the following medications by mouth to Resident #28: Gabapentin 300 mg oral capsule, Lyrica 75 mg oral capsule, Culturelle capsule, Guaifenesin ER 600 mg tablet, B-12 500 mg tablet, Plavix 75 mg tablet, Sertraline HCL 100 mg tablet, and 2 Acetaminophen 325mg tablets. In an interview on 09/23/2025 at 9:12AM, S18LPN indicated Resident #28's medications were given late this particular morning because of the care that her residents required. S18LPN further indicated the medications were scheduled for 8AM so they should have been given between 7:00AM and 9:00AM. In an interview on 09/23/2025 at 11:54AM, S2Director of Nursing indicated when medications are scheduled for 8:00AM they should be given an hour before an hour after the scheduled time, so between 7AM and 9AM. S2DON further indicated the facility's medication error rate should not be greater than 5%. In an interview on 09/23/2025 at 12:00 PM, S19Regional Director of Clinical Services confirmed if a medication was given more than 1 hour after the scheduled time it was considered a medication error.

Based on observation, interviews, and record reviews, the facility failed to ensure a medication were stored at the appropriate temperature for 1 (Medication Cart A) of 3 (Medication Cart A, Medication Cart B, Medication Cart C) medication carts observed for medication storage requirements. Findings:Review of the facility's Labeling and Storage of Drugs and Biologicals Policy and Procedure, last revised 03/2023, revealed drugs and biologicals were to be stored under proper temperature controls. Review of an email from the facility's pharmacy dated 09/24/2025 at 2:13PM revealed prior to initial use, Ozempic (medication used to treat diabetes) should be stored between 36 degrees Fahrenheit to 46 degrees Fahrenheit and should not be stored directly adjacent to the refrigerators cooling element. Observation of Medication Cart A on 09/24/2025 at 2:06PM, revealed an unopened Ozempic, a medication used to treat diabetes, stored on an unrefrigerated drawer on Medication Cart A. Observation further revealed the unopened Ozempic medication had a label which read to refrigerate until opened. In an interview on 09/24/2025 at 2:08PM, S12Unit Manager indicated the above mentioned Ozempic medication should have been refrigerated until opened. In an interview on 09/24/2025 at 2:10PM, S2Director of Nursing confirmed the above mentioned Ozempic medication should have been refrigerated until opened.

Based on interview and record review, the facility failed to ensure routine medication was available for administration for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for medication administration. Findings: Review of the facility's Medication Administration policy revised on 03/01/2023 revealed, in part, medications are administered by licensed nurses as ordered by the physician in accordance with professional standards or practice. Further review revealed to correct any discrepancies related to medication orders and report the discrepancies to the nurse manager. Review of Resident #2's Physician's Orders for May 2025 revealed, in part, an order for Brivaracetam oral tablet 75 milligram (mg) every 12 hours with a start date of 05/03/2025. Review of Resident #2's May 2025 Medication Administration Record (MAR) revealed the following was documented related to the administration of Resident #2's Brivaracetam 75mg oral tablet: -9 was documented at 8:00AM and 8:00PM doses on 05/03/2025, 05/04/2025, 05/05/2025, and 05/06/2025; -2 was documented at 8:00AM on 05/07/2025; -9 was documented at 8:00PM on 05/07/2025; -Nothing was documented at 8:00AM on 05/08/2025; -H was documented at 8:00PM on 05/08/2025; -H was documented at 8:00AM and 8:00PM on 05/09/2025; and, -H was documented at 8:00AM on 05/10/2025. In an interview on 06/17/2025 at 9:40AM, S1Director of Nursing (DON) indicated per Resident #2's medication Brivaracetam 75mg blister pack, the medication was issued to the facility by the pharmacist on 05/07/2025. In an interview on 06/17/2025 at 1:50PM, S1Director of Nursing (DON) indicated Brivaracetam 75mg was not administered to Resident #2 from 05/3/2025 to 05/07/2025. S2DON further indicated she could not explain why there were 9s and 2s documented on Resident #2's MAR and no documentation of administration on 05/08/2025. S1DON further indicated if the staff held Resident #2's medication for whatever reason, it should have been documented in the progress notes. S1DON confirmed there were no progress notes documented related to Resident #2's Brivaracetam administration. In an interview on 06/17/2025 at 2:00PM, S2Licensed Practical Nurse (LPN) indicated the 9 documented on Resident #2's MAR indicated other, such as the medication was not available. S2LPN further indicated H documented on Resident #2's MAR indicated Resident #2's Brivaracetam 75mg oral tablet was on hold, since it was not available to be administered. In an interview on 06/18/2025 at 4:52PM, S1DON indicated she was the nurse manger per the Medication Administration policy, and Resident #2's nurses did not report any discrepancies to her regarding Resident #2's Brivaracetam 75mg oral tablet not being available to administer, but should have.

Based on interviews and record reviews, the facility failed to ensure staff notified a physician regarding a change in a resident's skin condition for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for notification of change. Findings: Review of Resident #1's progress note dated 02/10/2025 at 9:30AM revealed, in part, the Certified Nursing Assistant (CNA) reported a red/purple discoloration to Resident #1's right neck/chest area. Further review revealed, upon assessment, Resident #1 presented with a small red/purple discoloration to Resident #1's right neck/chest area and Resident #1's physician was made aware. In an interview on 02/20/2025 at 2:10PM S6Former LPN indicated she attempted to notify Resident #1's physician's nurse of Resident #1's skin alteration, but the text message was not sent successfully. S6Former LPN further indicated she had not realized the text message did not send successfully until S5StaffDevelopement Nurse called her later in the day when she (S5Staff Development Nurse) was sending Resident #1 to the emergency room . In an interview on 02/20/2025 at 9:05AM, S5Staff Developement Nurse indicated S6Former LPN's text message to Resident #1's physician's nurse did not send successfully. S5Staff Development Nurse indicated Resident #1's physician was not notified of the bruise on Resident #1's right chest until around 7:00PM on 02/10/2024 when she sent Resident #1 to the emergency room . In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated S6Former LPN should have notified the Resident #1's physician on 02/10/2025 when she first noticed the rash/discoloration on Resident #1's chest.

Based on interviews and record review, the facility failed to ensure administrative staff (S2Director of Nursing [DON]) followed the facility's abuse prevention policy and did not indicate to a staff member (S6Former Licensed Practical Nurse) that she should not have admitted to seeing Resident #1's injury of unknown origin. Findings: Review of the facility's undated DON Job Description revealed, in part, the facility's DON was responsible for ensuring the facility's nursing service personnel understood and followed departmental policies and procedures. Review of the facility's Freedom from Abuse, Neglect, and Exploitation-Preventing and Prohibiting Abuse policy, last revised in 03/2023 revealed, in part, a sign of abuse was a suspicious injury. Further review revealed staff would immediately report allegations or suspicions of abuse to the Administrator, state agency, adult protective services, and other required agencies. In an interview on 02/20/2025 at 10:32AM, S4Former Admissions Nurse indicated S8LPN had sent her a recording of a conversation between S8LPN and S2DON in which S2DON told S8LPN she should have acted like she did not see the bruise on Resident #1's chest on 02/10/2025. In an interview on 02/20/2025 at 2:10PM, S6Former LPN indicated the recorded conversation between her (S6Former LPN) and S2DON and had taken place on 02/11/2025. S6Former LPN further acknowledged in the recorded conversation, S2DON told her she should have acted like she did not see the bruise/injury of unknown origin on Resident #1 that she had identified on 02/10/2025. Review of the above mentioned recorded conversation between S6Former LPN and S2DON regarding Resident #1's bruise/injury of unknown origin, revealed, in part, S2DON stated to S6Former LPN I would have just left it alone. I'm going to be honest with you, as an LPN on the hall, I would have swear to God I didn't see it, I wouldn't do nothing about it. I'm going to be straight up, and I'm not supposed to be telling you this. In an interview on 02/21/2025 at 11:59AM, S2DON confirmed that it was her (S2DON) speaking to S6Former LPN in the above mentioned conversation. When asked if she had any explanation to dispute the deficient practice at this time, S2DON declined to comment. In an interview on 02/21/2025 at 1:58PM, S1Administrator indicated S2DON should not have told S6Former LPN to not report a bruise/injury of unknown origin.

Based on interviews and record reviews, the facility failed to revise a plan of care with an intervention after a fall for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for resident centered care plans. Findings: Review of the facility's incident/accident log dated 11/2024 to 02/2025 revealed, in part, Resident #2 had unwitnessed falls on 11/24/2024 12/18/2024, and 02/13/2025. Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 12/10/2025 revealed, in part, Resident #2 had a Brief Interview for Mental Status assessment score of 9, which indicated moderate cognitive impairment. Further review revealed Resident #2 had one fall with no injury since Resident #2's last assessment. Review of Resident #2's nursing progress note dated 02/13/2025 at 9:10PM revealed, in part, a Certified Nursing Assistant (CNA) reported to the nurse Resident #2 was found lying on the floor near Resident #2's bed. Review of Resident #2's Plan of Care with a target date of 03/11/2025 revealed, in part, Resident #2 was at risk for falls related to gait/balance problems and had unwitnessed falls on 11/20/2024, 12/18/2024, and 02/13/2025. Further review of Resident #2's Plan of Care revealed no new intervention was implemented after Resident #2's fall on 02/13/2025. In an interview on 02/20/2025 at 10:08AM, S2DON confirmed a new intervention was not developed for Resident #2's Plan of Care following Resident #2's fall on 02/13/2025. S2DON indicated Resident #2's Plan of Care should have been updated with an intervention to decrease risk of falls on 02/13/2025.

Based on interviews and record reviews, the facility failed to ensure a licensed nurse (S7Licensed Practical Nurse [LPN]) did not leave the facility without ensuring another nurse assumed responsibility of her resident assignment. This deficient practice had the potential to affect all 28 residents (Resident #1, Resident #R4, Resident #R5, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R15, Resident #R16, Resident #R17, Resident #R18, Resident #R19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32) who resided on the facility's Hall y and Hall z on 02/09/2025. Findings: Review of the facility's LPN schedule dated 02/09/2025 revealed, in part, S7LPN was the scheduled nurse for Hall y and Hall z on the 6:00AM to 6:00PM shift and S18Agency LPN was the scheduled nurse for Hall y and Hall z on the 6:00PM to 6:00AM shift. Review of the facility's time sheets dated 02/09/2025 revealed, in part, S7LPN clocked out of her shift at 6:15PM on 02/09/2025. Further review revealed S18Agency LPN clocked in for her shift at 9:36PM on 02/09/2025. In an interview on 02/20/2025 at 9:05AM, S5Staff Development Nurse indicated on 02/09/2025 between 6:00PM and 10:00PM the residents on Hall y and Hall z did not have a scheduled nurse because S7LPN left without ensuring another nurse assumed her resident assignment. S5Staff Development Nurse further indicated she was notified that no nurse was taking care of the residents on Hall y and Hall z by S17Agency LPN and S18Agency LPN's nurse staffing agency. S5Staff Development further indicated she sent a text message to S7LPN to figure out why she had left without ensuring a nurse would be taking her assignment. S5Staff Development Nurse further indicated S7LPN had sent her a text message indicated that she had just left a written report sheet because she was not going to argue with S17Agency LPN. Review of the text exchange between S5Staff Development Nurse and S7LPN on 02/09/2025 at 8:18PM revealed, in part, S5Staff Development Nurse sent three text messages in a row that asked S7LPN to call her as soon as possible, asked S7LPN if she had left report for Hall y and Hall z and indicated to S7LPN, the nurses are at a standstill and ready to walk out due to you not giving a report! Further review revealed S7LPN replied back with a text message that indicated the other nurse did not want to get off of Hall w, so she left a written report sheet because she was not about to argue with her. In an interview on 02/21/2025 at 9:21AM, S3Former Assistant Director of Nursing (ADON) indicated on 02/09/2025, S7LPN left the keys to Medication Cart c on the counter and did not ensure S8LPN and/or S17Agency LPN accepted the Hall y and Hall z resident assignment before she left the facility. Review of the text exchange between S3Former Assistant Director and S7LPN on 02/09/2025 at 7:45PM revealed, in part, S3Former ADON sent a text message that asked S7CNA if she could call S8LPN and give her a report on Hall y and Hall z, as S8LPN was refusing to take the keys to Medication Cart c for Hall y and Hall z without report from S7LPN. Further review revealed S7LPN replied back with a text message that indicated the other nurse did not want to get off of Hall w, so she left a written report sheet because she was not about to argue with her In an interview on 02/20/2025 at 11:45AM, S17Agency LPN indicated she never took responsibility/report for the residents on Hall y and Hall z from S7LPN on 02/09/2025. In an interview on 02/21/2025 at 10:15AM, S8LPN indicated that she did not get report from S7LPN or take responsibility of the residents on Hall y and Hall z when S7LPN left the facility. S8LPN further indicated she did not accept the Hall y and Hall z resident assignment until after 8:00PM on 02/09/2025. In an interview on 02/24/2025 at 9:50AM, S7LPN confirmed she did not ensure another nurse took the Hall y and Hall z assignment before she left on 02/09/2025 because she did not want to deal with S17Agency LPN. There was no documented evidence, and the facility did not present any documented evidence, the resident's that resided on Hall y and Hall z had an assigned nurse between S7LPN's departure from the facility at 6:15PM on 02/09/2025 until 8:37PM on 02/09/2025 when S8LPN took Medication Cart c and accepted the Hall y and Hall z resident assignment. In an interview on 02/21/2025 at 11:59AM, S2Director of Nursing indicated S7LPN should not have left the facility without ensuring another nurse assumed the resident assignment for Hall y and Hall z. S2DON further indicated she would consider S7LPNs above actions as resident abandonment.

Based on record review, interviews and observations, the facility failed to protect 1 (#1) of 4 residents from resident to resident physical abuse. This deficient practice resulted in an actual harm for Resident #1 on 09/12/2022 when Resident #2, Resident #1's former roommate, hit Resident #1 on his head and leg with the foot rest from Resident #2's wheelchair which resulted in a laceration to the top of Resident #1's head, and bruising to Resident #1's right leg. Resident #1 was sent to the hospital on 09/12/2022, and presented to the hospital with a scalp laceration, soft tissue swelling to the scalp, right leg pain including soft tissue swelling of the right mid-thigh and right lower leg medial to the tibia (shin bone). Findings: Review of the facility's Abuse Policy and Procedure revealed, in part, the facility will not condone any form of resident abuse by anyone, including other residents. Resident #1 Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/2022 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 14 which indicated Resident #1 was cognitively intact. Review of the MDS revealed Resident #1 had feelings of being depressed, hopeless and had little interest in doing things for half or more of the days in the 7 day look back period. Review of the MDS revealed, in part, Resident #1 did not exhibit any verbal or physical behaviors directed towards others (e.g., hitting, kicking, scratching) in the 7 day look back period. Review of Resident #1's current care plan revealed, in part, Resident had a potential to be verbally aggressive related to mental emotional illness, poor impulse control with an intervention to monitor behaviors. Review of the care plan revealed, in part, Resident had a psychosocial well-being problem related to anxiety, and ineffective coping of incident with injury. Review of the facility's Incident Report dated 09/12/2022 revealed the certified nurse assistant made rounds, and Resident #2 complained about television being too loud. Resident #1 and Resident #2 started to argue about the volume of the television. Resident #2 attacked Resident #1 with the wheelchair's arm rest and hit Resident #1 in the leg and head with the wheelchair's arm rest. Review of Resident #1's hospital records revealed, in part, revealed Resident #1 reports that his roommate took the foot rest of a wheelchair and beat him several times with that. Review of hospital records revealed Resident #1 presented to the hospital with a scalp laceration, soft tissue swelling to the scalp, right leg pain including soft tissue swelling right mid-thigh and right lower leg medial to tibia. Further review of Resident #1's hospital records revealed the sheriff's department was contacted by nursing staff of the hospital. Review of Nurse's Notes for Resident #1 dated 09/12/2022 at 10:40pm revealed, in part, the Certified Nursing Assistant (CNA) reported Resident #1 and Resident #2 were quarrelling about the loudness of the television. The nurse and CNA went to their room and Resident #1 was bleeding from his head saying Resident #2 hit him. Resident #2 was in his wheelchair near his bed. Resident #2 was removed from the room. Resident #1 was hit with a foot pedal of a wheelchair. In an interview on 09/29/2022 at 1:45pm, Resident #1 stated that Resident #2 and he got into a verbal argument over the television's volume being too loud. Resident #1 stated that their argument escalated and he exchanged words with Resident #2. Resident #1 stated that Resident #2 then stood up from his wheelchair and grabbed the foot pedal from his wheelchair and started beating him in the head and towards the rest of body. Resident #1 stated that when Resident #2 was hitting him with the wheelchair's foot pedal that he was going to die. Resident #1 stated that he had a cut to the top of his head which required staples, a knot on his forehead, bruising to his right thigh and right lower leg. Resident #1 stated he lost a lot of blood from injuries. Observation on 09/29/2022 at 1:46pm revealed a black scab noted to the top of Resident #1's head with bruising noted under his eyes. Resident #2 Review of Resident #2's medical record revealed, in part, Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/2022 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 15 which indicated Resident #2 was cognitively intact. Review of the MDS revealed Resident #2 did not have any hallucinations or delusions in the seven day look back period. Resident #2 did not exhibit any behavioral or verbal symptoms towards others in the seven day look back period. Review of the MDS revealed, in part, Resident #2 had an active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's current care plan revealed, in part, Resident #2 had episodes of verbal and physical behavioral symptoms with poor impulse control related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #2 to not harm self or others through next review, decrease or eliminate episodes of behavioral symptoms, demonstrate effective coping skills and have decrease of verbal/physical aggression by administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, analyzing what triggers and what deescalates behaviors and document, listening to Resident #2 and discuss concerns as needed, observing for changes in behavior and altered mental status, consulting psychiatric services as indicated and Redirecting Resident #2 as indicated. Review of Resident #2's medical record, in part, revealed a nurse's note on 09/12/2022 at 10:40 pm revealed the CNA reported to her the Residents in the room were quarreling about the television volume and when she walked in Resident #1 was bleeding from the head. In an interview on 09/29/2022 at 10:10am, S2Director of Nursing (DON) stated Resident #2 was arrested and was not returning to the facility. In an interview on 09/29/2022 at 3:30pm, S3Certified Nursing Assistant (CNA) stated on 09/12/2022 Resident #1 and Resident #2's door was open and she heard them arguing about the television volume. S3CNA further stated Resident #2 came into the hallway saying someone better come to check on Resident #1. S3CNA stated she then left the room to find someone to come help, but was not able to find anyone so she went back into the room. S3CNA stated she then went into the room and she observed Resident #2 pick up the foot pedal of the wheelchair so she took the foot pedal from him and left the room to look for help again, and did not remove the other foot pedal from Resident #2's wheelchair. S3CNA confirmed when she and the nurse went back into the room Resident #2 had already hit Resident #1 with the remaining foot pedal, and Resident #1 was found lying in his bed with blood on his pillow. In an interview on 09/30/2022 at 12:40pm, S5Licensed Practical Nurse confirmed S3CNA came find her at the nurse's station shortly after change of shift report on 09/12/2022. S5LPN further added she did not recall the call bell ringing and did not hear S3CNA yelling for help. S5LPN stated on the night of 09/12/2022 when she walked into the room, Resident #1 was lying in his bed bleeding from the head, and Resident #2 was sitting in the wheelchair turned away from Resident #1. S5LPN then mentioned Resident #1 told her Resident #2 did this to him. S5LPN stated she the proceeded to check Resident #1 for injury and she noted a laceration to his head. In an interview on 09/30/2022 at 2:50pm S6LPN stated she worked from 2:00 pm to 10:00 pm Monday through Friday, and she had already left the facility prior to the incident. S6LPN stated she did not note the call bell to be ringing or heard yelling prior to her leaving work on the night of 09/12/2022. S6LPN confirmed Resident #1 and Resident #2 barely spoke to each other. S6 LPN additionally confirmed Resident #1 and Resident #2 complained about each other's television volumes. In an interview on 09/30/2022 at 11:10am, S7LPN stated when Resident #1 returned from the hospital he had 4 staples to the top of his head, an abrasion to his right cheek on his face, and a contusion to his right lower and right upper leg. In an interview on 09/30/2022 at 3:45pm, S1Administrator stated he did not call the police regarding the incident because he stated Resident #1 had already called the police. In an interview on 10/03/2022 at 1:45pm, S1Administrator and S2Director of Nursing (DON) stated that resident to resident abuse for the incident on 09/12/2022 between Resident #1 and Resident #2 did occur, it was substantiated, and it was the resident's right to be free from abuse. S2DON stated that the incident of physical abuse between Resident #1 and Resident #2 should not have happened.

Based on interview and record review the facility failed to ensure residents remained free from neglect for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents by failing to implement their abuse/neglect policy and procedures. The facility failed to: 1.) ensure a resident with a decline in their medical condition was reassessed to see if changes in Activities of Daily Living (ADL) assistance was warranted (Resident #1); 2.) ensure a plan of care was revised after a change in condition to ensure a resident's safety during transfers (Resident #1); and 3.) ensure staff reported that a resident fell on to the arm of a wheelchair while being transferred by staff from the bed to the wheelchair (Resident #1). This deficient practice resulted in an actual harm when a cognitively impaired resident who required staff assistance with her ADLs had a decline in her medical condition related to [MEDICAL CONDITION] and high blood sugars. Resident #1's ADL needs were not reassessed, and Resident #1's plan of care was not revised with new interventions as a result of this change in condition. Resident #1 sustained bilateral rib fractures, a left pneumothorax, a left clavicle fracture, a left scapula fracture, abnormal bruising to the skin with a large amount of bruising noted across the chest, anterior neck, bilateral arms, and right lower extremity which required hospitalization and prolonged rehabilitation resulting from a fall while being transferred manually by one staff member. Resident #1 did not receive immediate medical attention, since the staff member did not report the fall. This deficient practice had the potential to affect any of the 83 residents who reside in the facility as documented on the provider's Resident Census and Conditions of Residents. Findings: Review of the facility's policy and procedures for Abuse/Neglect Reporting revealed in part, that neglect was defined as a failure to provide goods and services necessary to avoid physical harm. Further review revealed conduct detrimental to resident care that results in neglect of any resident is strictly prohibited, and any employee who knows about resident neglect, including injuries of an unknown source, must be reported immediately to the Administrator. Review of Resident #1's Emergency Department hospital records dated 06/05/16 revealed in part, that Resident #1 arrived at the emergency department at 1:09pm with band like abnormally large bruising noted across the chest, on the front of the neck, both arms, and right lower leg. Further review revealed multiple pinpoint bruising was noted to the upper arms which were consistent with grip-like bruising from people grabbing her arms which warranted a high suspicion of elder abuse. Further review revealed Resident #1 sustained a left comminuted [MEDICAL CONDITION] of the left clavicle, a [MEDICAL CONDITION] tip of the scapula, a left third rib fracture, a right fourth rib fracture, a fifth rib fracture, and a left pneumothorax. Further review revealed Resident #1 also received four units of blood for severe [MEDICAL CONDITION], treatment for [REDACTED]. Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] and had the following [DIAGNOSES REDACTED]. Further review revealed she was assessed as being at high risk for falls. Review of Resident #1's Admission Minimum Data Set Assessment (MDS) with an assessment reference date of 06/09/16 revealed in part that Resident #1 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 6, was frequently incontinent of urine and always incontinent of bowels, required supervision and the assistance of one staff member for eating, required extensive assistance by one staff member for bed mobility, transfers, dressing, and toilet use, required total assistance by one staff member for bathing, had impairments on one side for her upper and lower extremity, and was not steady and only able to stabilize with staff assistance. Further review revealed she weighed 140 pounds. Review of the facility's Lifting Policy revealed in part, that blue color lifting code meant no mechanical lift required, hold hand or assist with one staff member. Review of Resident #1's Admission Care Plan revealed in part, that the lift type for Resident #1 was a blue dot transfer with the manual assistance of two staff members. Review of Resident #1's current Care Plan revealed in part, a problem of having the potential for falls due to personal history of falls, and having the potential for injury with one approach being blue assist with transfers. Further review revealed a self-care deficit problem with approaches to include blue assist for transfers, assist with pericare every two hours and as needed after each incontinent episode, and to notify the nurse of a decline in the ability to perform tasks. The above mentioned care plan also revealed in part, that smart charting was to be completed by CNA staff for handheld assist for transfer x 1-blue, turning and/or repositioning Resident #1 at least every two hours this shift, skin issue noted during care, and incontinence checks every two hours with pericare as needed. In a telephone interview on 06/14/16 at 1:07pm, S13/CNA indicated the blue dot transfer required a two person assist. In interview on 06/14/16 at 2:16pm, S14/CNA indicated she had cared for Resident #1 and when Resident #1 was initially admitted to the facility, she required a one person assistance with transfers, but in the past weeks Resident #1 required two person assistance with transfers, but the blue dot signified a one person assist with transfers. In telephone interview on 06/14/16 at 1:00pm, S15/Restorative CNA indicated a blue dot transfer was a two person assist. In telephone interview on 6/14/16 at 1:10pm, S16/CNA indicated she was occasionally assigned to care for Resident #1. S16/CNA further indicated a blue dot transfer was when a resident required two persons to assist with transfers and that she would get assistance when she took care of Resident #1 because of her size she felt she needed 2 staff members to transfer Resident #1. In interview on 6/14/16 at 10:15am S12/Medicare Skilled Nurse/Case Manager indicated Resident #1 was lethargic, and was taken to the hospital on Friday before the incident, and had a low Hematocrit and Hemoglobin. Review of Resident #1's lab results collected and reviewed by facility staff on 06/03/16, revealed in part, a Red Blood Cell (RBC) result of 2.22 (reference range: 3.8-5.3), Hemoglobin (HCB) result of 7.2 (reference range: 12.0-16.0), and a Hematocrit (HCT) result of 22.8 (reference range: 37.0-47.0). Further review revealed a Glucose level of 402 (reference range: 70-100) and a Blood Urea Nitrogen (BUN) level of 29 (reference range: 5-25). Review of Resident #1's clinical record revealed in part, that Resident #1's had changes in her medical condition beginning on 06/03/16 related to unstable high blood sugars and [MEDICAL CONDITION], and was scheduled to type and cross match 4 units of packed red blood cells on 06/06/16. Further review revealed S3/Physician was aware of the above and gave new orders for the high blood sugars and to call S3/Physician of blood glucose results. Review of WEB MD (Internet Resource Application) revealed in part, that [MEDICAL CONDITION] and/or [MEDICAL CONDITION] (high blood sugar) can cause fatigue, tiredness, weakness, and/or dizziness. Review of Resident #1's Functional Status-ADL assistance CNA charting for the time period of 06/01/16 - 06/05/16 revealed in part, that Resident #1 went from needing limited and extensive assistance with transfers to being totally dependent with transfers beginning 06/04/16. There was no documented evidence and the facility did not present any documented evidence that Resident #1 was reassessed to see if changes in ADL assistance was warranted which required additional staff and/or assisting devices. There was no documented evidence and the facility did not present any documented evidence that Resident #1's plan of care was revised after a decline in her medical condition was identified. Review of the facility's weekend staffing sheet for Saturday, 06/04/16 revealed in part that S6/CNA was the assigned CNA for Resident #1 for the 10:00pm-6:00am shift. Review of the facility's weekend staffing sheet for Sunday, 06/05/14 revealed in part that S6/CNA was the assigned CNA for Resident #1 for the 6:00am-2:00pm shift. Review of the facility's video surveillance log/notes completed by S1/Administrator and S2/Director of Nurses (DON) revealed in part that Resident #1 had not sustained any injuries in any of the common areas, and that S6/CNA was the only CNA that entered Resident #1's room during the 10pm-6am shift on 06/04/16 and on 06/05/16 from 6am till ambulance emergency staff arrived at 12:15pm. The above mentioned video surveillance log/notes revealed in part that on 06/04/16, S6/CNA spent 12 minutes in Resident #1's room from 10:09pm-10:21pm, then went in and out of Resident #1's room at 11:30pm. On 06/05/16, S10/LPN went in and out of Resident #1's room at 12:24am. S6/CNA went in and out of Resident #1's room on 06/05/16 at 12:38am. S10/LPN went in and out at 4:19am and again at 4:27am. S6/CNA going in and out of Resident #1's room [ROOM NUMBER]:20am, then was in Resident #1's room for 16 minutes from 6:43am-6:59am at which time Resident #1 was escorted to the dining room in her wheelchair by S6/CNA and at 7:32am. Resident #1 was observed putting her head down on the dining room table at 7:57am, and again at 8:04am with S6/CNA, S7/Assessment RN, and S11/LPN encouraging Resident #1 to eat while in the dining room then was put back to bed from 8:26am to 8:29am by S6/CNA. Review of Resident #1's Departmental Notes dated 06/05/16 at 12:45pm revealed in part that a late entry for 06/05/16 at 9:00am was made by S11/LPN that Resident #1 was leaning her head on the breakfast table, that Resident #1 indicated she was fine, and that she ate 50% of her breakfast then was assisted back to bed. Further review revealed S4/Physician was notified of Resident #1's weakness and declining oral intake with an order given to monitor lunch and fluid intake and send to the emergency room if Resident #1 doesn't eat or drink well. Review of Resident #1's Departmental Notes dated 06/05/16 at 12:50pm revealed in part, that Resident #1's family was at the facility and reported concerns of her current status and was going to be sent to the emergency room per family request. Review of Resident #1's Departmental Notes dated 06/08/16 at 10:56am revealed in part that a late entry for 06/05/16 at 12:04pm was made by S7/Assessment RN that she was approached by Resident #1's family about bruising. Further review revealed S7/Assessment RN then noted bruising to the right side of the neck and petechiae to the mid-upper chest area and left chest wall. Review of the facility's investigation from 06/05/16 - 06/14/16 revealed no staff member admitted that anything out of the ordinary happened to Resident #1 which could have caused the above mentioned injuries or that Resident #1 had sustained a fall or injury which could have caused the above mentioned injuries. In interview on 06/09/16 at 10:00am, S1/Administrator and S2/DON indicated they have no idea what happened to Resident #1 because no one had reported any fall or accident but they were still investigating. S1/Administrator and S2/DON further indicated that Resident #1 was showing a decline resulting from her medical condition because of [MEDICAL CONDITION] and high blood sugars and did not know if that contributed to the bruising because she was weak and began leaning on the tables in the dining room, but didn't know what was going on because they didn't have access to her hospital records. In interview on 06/10/16 at 8:05am, S9/Occupational Therapist indicated Resident #1 had poor trunk control. In interview on 06/14/16 at 2:00pm, S1/Administrator and S2/DON were informed that not all staff was aware of what the blue dot transfer meant, and that Resident #1's initial care plan indicated she required a blue dot two person manual assist, and her current care plan indicated blue dot was a one person manual assist. S1/Administrator and S2/DON indicated blue dot meant a one person assist, that staff should have known that, had no explanation as to why they did not or why Resident #1's initial care plan said blue dot meant a two person manual assist, but it was important for everyone to know what the lifting codes meant. In interview on 06/14/16 at 3:30pm, S1/Administrator and S2/DON were informed of and acknowledged that nursing staff was aware of Resident #1's decline, and that Resident #1 was not reassessed after her decline to see if she required an increase in staff assistance or required assistive devices with her ADLs and that her plan of care was not revised after Resident #1's above mentioned medical decline. S1/Administrator and S2/DON further indicated that the re-assessment of Resident #1's ADL needs and plan of care was not revised on paper, but were meeting her needs during the change in condition. In interview on 06/14/16 at 10:50am, S4/Physician indicated Resident #1 was in stable condition when she was admitted to the facility, and the Friday before the incident he was notified that she had a history of [REDACTED].#1 did not eat or drink well. S4/Physician was asked if he reviewed Resident #1's above mentioned hospital records. S4/Physician indicated he had and that Resident #1 had traumatic injuries that were consistent with a fall, and that it takes force to fracture a scapula. S4/Physician also indicated that bruising would show up quickly not long after those kinds of fractures. S4/Physician was then asked if Resident #1 fell on her own, was she capable of getting up without assistance and S4/Physician indicated that Resident #1 was not capable of getting up on her own in that condition without assistance from someone. In interview on 06/14/16 at 10:20am, S6/CNA indicated Resident #1 was a blue dot transfer, but couldn't move on her own anymore during transfers, so she was dead weight and was a big woman. S6/CNA further indicated she did not fall with her and didn't find her on the ground, but if she had, I (S6/CNA) would have reported it. S6/CNA was asked about Resident #1's bruising and S6/CNA indicated that she only had a small dark red spot on her left chest during her bed bath the morning of 06/05/16. S6/CNA further indicated Resident #1 wasn't her normal self for breakfast, and S7/Assessment RN asked me to put Resident #1 back to bed after breakfast, then family came and I had to make sure she was clean before she went to the hospital and that's when the family found the bruising, but Resident #1 did not have bruising on the neck at that time. In interview on 06/16/16 at 8:30am, the investigating Detective indicated S6/CNA was brought in for questioning on 06/15/16 for the above mentioned incident. S6/CNA had informed the Detective that on the morning of 06/05/16, she was attempting to transfer Resident #1 from the bed to her wheelchair and during that process Resident #1's knees buckled at which time Resident #1 fell against the arm of her wheelchair, but was grabbed under the arms before she hit the ground. S6/CNA then indicated she placed Resident #1 into the bed prior to again placing her into the wheelchair. The Detective further indicated that S6/CNA did not report the above incident to anyone because she considered it a slip and not a fall. S8/Detective also indicated that S6/CNA will be charged with cruelty to the infirmed which falls under criminal negligence because she failed to report the above incident which prevented Resident #1 from seeking immediate medical attention.