Every finding on record at Life Care Center of Longmont

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#34) of one resident out of 54 sample residents.Resident #34, was admitted on [DATE] with diagnoses that included Alzheimer's disease and dementia with behavioral disturbance. Resident #34 had a history of behavioral symptoms associated with dementia.On 2/9/26 at 4:30 a.m. certified nurse aide (CNA) #13 entered Resident #34's room to assist CNA #2 who was providing incontinence care. Resident #34 was yelling and striking out during care. CNA #2 said CNA #13 placed one hand over Resident #34's mouth and the other hand over the resident's arms while CNA #2 was providing care. CNA #13 said the facility did not pay her enough to get punched. Interviews completed with the resident's representative revealed Resident #34 would have been fearful if she was able to recall the incident. Specifically, the facility failed to ensure Resident #34 was not physically restrained by CNA #13.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, reviewed 5/6/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 12:18 p.m. It read in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any.Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as physically aggressive behavior and verbally aggressive behavior.II. Incident of physical abuse by CNA #13 towards Resident #34 on 2/9/26A. Facility investigationThe 2/10/26 facility investigation revealed an incident occurred on 2/9/26 at 4:30 a.m. when CNA #13 entered Resident #34's room to assist CNA #2, who was providing incontinence care. The investigation revealed Resident #34 was yelling and striking out during care. CNA #2 said CNA #13 placed one hand over Resident #34's mouth and the other hand over the resident's arms and said the facility did not pay her enough to get punched. The facility investigation included a written statement from registered nurse (RN) #10, dated 2/9/26, which documented that between 5:00 a.m. and 5:30 a.m., CNA #2 told RN #10 that CNA #13 was not being nice to the residents and said she would speak with RN #10 about it later.-However, CNA #2 did not inform a nurse (RN #9) of the details regarding the incident involving Resident #34 until the next day (on 2/10/26). The investigation included a written statement from RN #9 who had talked to CNA #2 after the incident. The statement said CNA #13 entered Resident #34's room to assist CNA #2 who was providing care. The statement documented Resident #34 was yelling during care. The statement documented CNA #13 approached the bed and placed her hand over Resident #34's mouth and held it there for approximately two minutes while the resident attempted to move and strike out. The statement documented CNA #13 grabbed Resident #34's hands and forcefully held them against the resident's chest and pushed the resident back onto the bed. The investigation included a statement from CNA #13 that said Resident #34 was combative, she held the resident's hands so the resident would not hit her, called the resident a gringa and denied putting her hand over Resident #34's mouth. The investigation revealed a skin and pain assessment was completed for Resident #34 on 2/10/26 and documented no new findings during the skin assessment and no signs or symptoms of pain were observed or reported during the interaction. The investigation revealed Resident #34 was at baseline on 2/11/26 and had no changes in mood or behavior. The investigation documented the facility was unable to substantiate or unsubstantiate abuse. -However, Resident #34 was physically restrained by CNA #13.B. Resident #34 1. Resident statusResident #34, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician's orders (CPO), diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 12/23/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required set-up assistance with eating, partial to moderate assistance with oral hygiene, dressing and substantial to maximal assistance with toileting hygiene and bathing.2. Resident #34's representative interviewResident #34's representative was interviewed on 3/12/26 at 2:46 p.m. The representative said this was the first time Resident #34 experienced an event like this in her life. The representative said the staff informed him a CNA placed her hand over Resident #34's mouth during care for about two minutes. The representative said the floor manager later spoke with Resident #34 and Resident #34 did not remember the incident. The representative said the event would have been frightening for Resident #34 and said he could see her being upset by someone covering her mouth.3. Record reviewThe comprehensive care plan, initiated 4/26/24 and revised 10/2/25, revealed Resident #34 had confusion and anxiety related to dementia. The care plan documented the resident frequently yelled that she was hungry and wanted something to eat. Pertinent interventions included providing snacks throughout the day and offering simple structured activities, such as word searches, crafts and small group activities.-The care plan did not include interventions to guide staff if the resident became physically aggressive during care.The 2/9/26 nursing progress note revealed Resident #34 had ongoing behaviors that included yelling, rejection of care and anxiety. The progress note documented staff attempted redirection and one-to-one interaction when the resident demonstrated these behaviors.The 2/10/26 nursing progress note revealed a skin and pain assessment was completed and documented no new findings and no signs or symptoms of pain were observed. The progress note documented Resident #34 remained at baseline.The 2/13/26 social services progress note documented the social services assistant (SSA) checked in with Resident #34. The note documented Resident #34 presented at baseline with a smile and eye contact and had no signs of stress or discomfort during the interaction. The note documented Resident #34 said her care was going well and nursing reported she slept well through the night and was eating 100% of her meals.III. Staff interviewsCNA #1 was interviewed on 3/10/26 at 2:41 p.m. CNA #1 said Resident #34 had a progressive disease and at times became agitated and could become physical during care. CNA #1 said when Resident #34 became anxious or panicky, staff approached the resident at eye level, reassured her she was not alone and attempted to calm her. CNA #1 said Resident #34's chart listed behaviors and interventions and staff should try to remove the resident from external stimuli when she became overwhelmed. CNA #1 said when a resident became combative during care, staff should step back, give the resident space and reapproach care after the resident de-escalated. CNA #2 was interviewed on 3/10/26 at 3:00 p.m. CNA #2 said she was providing care to Resident #34 (on 2/9/26) when the resident began yelling and became agitated. CNA #2 said CNA #13 entered the room and approached the resident. CNA #2 said CNA #13 placed her hand over Resident #34's mouth. CNA #2 said Resident #34 attempted to remove CNA #13's hand from her mouth. CNA #2 said she told CNA #13 to stop several times but CNA #13 did not stop. CNA #2 said CNA #13 then grabbed Resident #34's hands and pushed them back toward the resident's chest and yelled at the resident using a curse word. CNA #2 said after the incident, Resident #34 was scared and became more combative than before care had started. Licensed practical nurse (LPN) #1 was interviewed on 2/10/26 at 3:25 p.m. LPN #1 said the director of nursing (DON) informed her there was an allegation of abuse involving Resident #34. LPN #1 said CNA #2 told another staff member she observed CNA #13 do something to Resident #34 that she should not have done. LPN #1 said Resident #34 could become combative at times but usually de-escalated when staff calmly explained care. LPN #1 said she completed an assessment of Resident #34 after staff became aware of the allegation on 2/10/26. LPN #1 said Resident #34 said she had no pain and she did not observe injuries during the skin assessment. The DON was interviewed on 3/12/26 at 2:06 p.m. The DON said she had to be notified of all abuse and suspected abuse allegations and staff were expected to report incidents immediately to the NHA and to the DON.The DON said CNA #2 reported the incident one day after it occurred even though she was aware of the facility policy of reporting but she felt fearful of reporting and did not want her coworkers to view her as reporting on them or getting them in trouble. The DON said CNA #2 received education and was instructed that all allegations must be reported immediately and that delays in reporting would result in corrective action. The DON said there was a prior allegation involving CNA #13 and another resident. The DON said CNA #13 was terminated on 2/13/26.The DON said the facility could not substantiate or unsubstantiate the allegation regarding Resident #34 because the resident was not interviewable and the findings were based on CNA #2's account compared to CNA #13's account. The DON said interviews were conducted with residents and staff and no one said they observed staff treat or interact inappropriately with residents.The NHA was interviewed on 3/12/26 at 3:48 p.m. The NHA said the facility was unable to substantiate the allegation because CNA #2 said the incident occurred, CNA #13 said she did not place her hand over the resident's mouth, and the resident could not recall the event. The NHA said the facility assessed the resident for psychosocial harm by reviewing the Patient Health Questionnaire-9 (PHQ-9) (screening tool used to check for depression) to compare the resident's baseline mood and identify any changes and they did not find any changes. The NHA said the medical director completed an assessment, including evaluation for anxiety and provision of active listening and emotional support.The NHA said the unit manager followed up and continued to monitor Resident #34's behaviors, mood, and any changes from baseline. The NHA said staff monitored for nonverbal indicators of distress and observed no changes in appetite or baseline behaviors.

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature. Findings include:I. Facility policy and procedureThe Food Preparation policy, revised 4/29/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 10:53 a.m. It read in pertinent part, Food is prepared by methods that conserve nutritive value, flavor and appearance. The food that is served to the residents is palatable, attractive and served at the appropriate temperature. Food and drink that is palatable, attractive, and at a safe and appetizing temperature. It also revealed under Definitions, Food palatability refers to the taste and or flavor of the food, and Proper safe and appetizing temperature means both appetizing to the resident and minimizing the risk for scalding and burns. Under Procedure, the policy revealed, Food is seasoned appropriately and acceptable to the residents, Food has an appetizing aroma, and Food and drinks are palatable, attractive and served at a safe and appetizing temperature, while minimizing the risk for scalding and burns.II. Resident group interviewA group interview was conducted on 3/11/26 at 10:00 a.m. with five alert and oriented residents (#3, #9, #53, #84 and #118) who were deemed interviewable per the facility and assessment.The residents said the kitchen frequently ran out of certain food items, such as ice cream and Greek yogurt, usually close to the time of their delivery. The residents said they were offered an alternate option when items were unavailable and that the substitute usually met their needs. The residents said the quality of the food was inconsistent. They said the over-easy eggs were often overcooked, scorched, and hard. The residents said the facility had only one frying pan available for preparing fried eggs in the upstairs dining room. III. Additional resident interviewsResident #63 was interviewed on 3/9/26 at 1:45 p.m. He said breakfast should have been served when he was awake and in a timely manner. He said he had a sign on his door that said do not wake before 7:30 a.m., however the staff still came into his room and left the tray. He said the scrambled eggs served for breakfast were cold and he preferred hot food.Resident #137 was interviewed on 3/9/26 at 2:00 p.m. She said the food was sometimes served cold and she did not like cold food. She said the last time her meal was cold was two days prior.Resident #147 was interviewed on 3/9/26 at 2:57 p.m. She said she often did not receive milk with her cereal. She said the pancakes were often served hard and dry and the hamburgers were served cold.Resident #42 was interviewed on 3/9/26 at 4:31 p.m. She said the food was repetitive and the same foods were served every week. She said she would have liked more variety. She said she reported this concern during a resident council meeting the previous month and staff said they would look into it. She said the food was also served cold. She said food was very important to her and this made her feel ignored. She said staff usually heated the food, however the food became very hard because it was frozen food.Resident #8 was interviewed on 3/10/26 at 6:56 a.m. He said the food did not taste good, was sometimes cold, and he had experienced a few lunches that did not arrive.Resident #79 was interviewed on 3/10/26 at 7:09 a.m. He said the food was often cold, unappetizing, and missing requested items.Resident #46 was interviewed on 3/10/26 at 8:45 a.m. She said the food was inconsistent, was served cold, and was unpredictable. She said three weeks prior she was served green beans that were cold and appeared as if they had just come out of the refrigerator. She said on 3/9/26 her dinner order was not correct. She said she did not want broccoli and gelatin and instead wanted chocolate pudding, however she was still served broccoli and gelatin.Resident #118 was interviewed on 3/10/26 at 9:32 a.m. She said the food was often cold and trays had been forgotten and not delivered to her room.Resident #80 was interviewed on 3/10/26 at 9:58 a.m. She said the food was often cold.Resident #42 was interviewed again on 3/10/26 at 4:10 p.m. She said on 3/10/26 she received one third of a cup of coffee without creamer. She said she asked for oatmeal but did not receive it, then asked for Cheerios cereal and received cereal without milk. She said the staff said there was no milk that day. She said she felt like she was back in school. She said licensed practical nurse (LPN) #1 became aware of the concern and brought her coffee with creamer.Resident #147 was interviewed on 3/11/26 at 5:10 p.m. and said the eggs were cold that day. Resident #147 said the pot pie he was served for diner that day was not in the shape of a pot pie. The resident said the pot pie appeared as broken pieces of chicken and vegetables and did not look like a pot pie.IV. Test trayA test tray for a regular diet was evaluated by four surveyors immediately after the last resident was served their room tray for lunch on 3/11/26 at 12:35 p.m.The test tray consisted of meatloaf with gravy, mashed potatoes, seasoned spinach, cornbread, and fruit crisp.-The spinach lacked flavor;-The mashed potatoes had a pasty consistency and bland taste;-The meatloaf was bland in taste; and,-The cornbread was doughy, bland. V. Record reviewA review of the 2/21/26 concern and comment form documented that a resident voiced concerns related to food service regarding cold food. The follow-up response section documented that they completed a dietary audit for room trays. The findings section documented trays sat for 30 minutes before the last tray was delivered by nursing and the stew's temperature decreased from 175 degrees F to 130 degrees F. The test tray audit form dated 2/23/26 documented the cart left the department at 11:51 a.m., arrived on the floor at 11:52 a.m. and the last tray was served at 12:21 p.m. The response section documented staff were encouraged to have the resident dine in the dining room and to ensure trays were delivered quickly by nursing. -However, residents still had ongoing concerns of cold food (see resident interviews above).VII. Staff interviewsThe cook (CK) was interviewed on 3/11/26 at 3:23 p.m. She said she ensured food was palatable and not overcooked or dry by checking the temperature whenever she cooked items including food on the grill before placing the food on the plate. She said if a resident complained about the taste or quality of the food, she could remake the meal or provide the resident with something different.The CK said the recipes she followed had premade seasonings. She said sometimes residents preferred different flavors, so she individualized the seasoning based on the resident's preference.The dietary supervisor (DS) was interviewed on 3/11/26 at 3:35 p.m. The DS said the facility held a food committee meeting once a month. She said the DS and the dietitian attended the meeting and asked residents if they liked the food or wanted changes to the menu. She said residents provided suggestions during the meeting and they would implement those suggestions.She said the facility addressed resident complaints regarding food quality through the grievance process also. She said grievances were forwarded to her and she followed through with the concern.She said the acceptable hot holding temperature for food was around 140 degrees F and the kitchen staff attempted to keep food at 140 degrees and prevent the temperature from falling below that level. She said if a food item fell below the acceptable hot holding temperature, staff reheated the food to 165 degrees F for 15 seconds. She said staff checked food temperatures during the tray line right before service and again after service. She said the CK was responsible for verifying food temperatures before trays left the kitchen. She said she monitored the tray line process during meal times by assisting the CK, ensured temperatures were taken and helped to expedite meal service.

Based on observations, record review and interviews, the facility failed to provide sufficient nursing staff to ensure the resident received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and call lights were answered in a timely manner for residents dependent on staff for their care. Findings include:I. Facility policy and procedureThe Staffing policy and procedure, revised 3/9/21, was provided by the nursing home administrator (NHA) on 3/12/26 at 5:42 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet residents' needs. The facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met. II. Resident interviewsResident #129 was interviewed on 3/9/26 at 11:00 a.m. He said staffing seemed to be an issue. He said he felt like there were not enough certified nurse aides (CNAs). He said the night shift seemed to be the worst. He said there would be times when there was only one registered nurse (RN) for the entire unit and only one CNA for the entire unit. He said he has waited for over an hour for his call light to be answered. He said he did not always get consistent showers, he said some weeks he will get two, others only one and sometimes no shower at all. Resident #8 was interviewed on 3/9/26 at 11:15 a.m. He said he felt like the staff were not efficient. He said he used a sit-to-stand (mechanical lift) to get up and sometimes it takes a long time to get help. He said there have been times when he did not make it to the bathroom in time because there were no staff to help him. Resident #80 was interviewed on 3/9/26 at 12:55 She said she used the sit-to-stand to use the restroom and to go to bed. She said that there have been times when she did not get to bed until 11:00 p.m. because she was waiting for staff to finish with her roommate. She said she felt like the staff were always new. She said there have been times when she had to wait over an hour for her call light to be answered. She said she felt like there was not enough staff. Resident #93 was interviewed on 3/9/26 at 1:30 p.m. She said she had waited for over an hour to use the restroom multiple times. She said she never had incontinence issues and then ended up wetting herself once because she had to wait for staff to assist her, she said she did not like the feeling of wetting herself. Resident #11 was interviewed on 3/9/26 at 4:00 p.m. She said she was not receiving her showers as scheduled. She said she had not gotten a shower for at least a week. Resident #46 was interviewed on 3/10/26 at 8:45 a.m. She said she did not get her showers on her scheduled days. She said she had to initiate getting a shower and sometimes staff still did not come to get her for her shower. She said she has washed her own hair in the sink because she had not received a shower. Resident #3 and Resident #9 were interviewed together on 3/10/26 at 9:45 a.m. Resident #3 said that there were only two CNAs for the entire 300 hall which made it hard for the staff to get to everyone's needs in a timely fashion. Resident #9 said that he had pushed his call light before because he was having a hard time breathing and had to wait for over an hour. A group interview was conducted on 3/11/26 at 10:00 a.m. with five (#3, #9, #53, #84 and #118) oriented resident per facility and assessment. They said there had been times when they did not get their showers because there was not enough staff. Resident #118 said he did not get a shower because the staff ran out of time. They said for their call lights to be answered timely really depended on the staffing. They said there had been multiple times when they had to wait for 30 minutes or longer for their call light to be answered. They said this happened on all shifts. The group said they did not think there was enough staff to meet their needs. They said the turnover rate was very high. They said showers were not getting done and any task that can be delayed will be delayed because there was not enough staff. Cross-reference F677: failure to provide activities of daily living for dependent residents. III. ObservationsDuring a continuous observation on 3/11/26, beginning at 12:15 p.m. and ending at 12:45 p.m. the following was observed:At 12:15 p.m. Resident #33, pushed their call light. An unidentified staff member came out of their office and walked past Resident #33's room without checking on the resident. The same unidentified staff member walked down the hallway and past Resident #33's room again and did not check on the resident. There were no other staff members present at that time. Another unidentified staff member was walking down the hallway and appeared to be going to answer Resident #33's call light; however, the staff member stopped in the middle of the hallway and turned and went back the way they came and did not check on Resident #33. At 12:30 p.m. resident room [ROOM NUMBER] turned on their call light, which was down the hall from Resident #33. Multiple staff members exited an office and walked down the hallway without answering or checking on either residents. At 12:35 p.m. an unidentified CNA walked down the hallway passing Resident #33's call light and answered room [ROOM NUMBER]'s call light. At 12:40 p.m. another unidentified CNA entered the hallway and and went into Resident #33's room and answered the call light. -Resident #33's call light was not answered for 25 minutes. On 3/12/26 during a continuous observation, beginning at 10:37 a.m. and ending at 11:00 a.m., Resident #79 turned on her call light. CNA #4 entered Resident #79's room at approximately 10:41 a.m. and brought in a commode. CNA #4 told the resident she was waiting on a nurse to help her to get her out of bed and left the room. At 10:50 a.m. CNA #4 entered the room and told Resident #79 she was still waiting on the nurse. At 11:00 a.m. CNA #4 came back and told Resident #79 that she would have to complete her care in bed because she could not get another staff member to help get her up. IV. Facility assessmentThe facility assessment, revised 6/24/24, was provided by the NHA on 3/9/26 at 12:18 p.m. The assessment documented the average daily census as 116 residents and had the bed capacity of 187 residents. The assessment documented the desired staffing per day for the facility was 15 nurses and 28 CNAs.Review of the facility schedule from 1/1/26 to 3/11/26 revealed the facility did not have the correct amount of staff that was identified in the facility assessment on the following dates: On 1/1/26, the schedule indicated 21 CNAs were working at the facility. On 1/2/26, the schedule indicated 22 CNAs were working at the facility.On 1/3/26, the schedule indicated that 25 CNAs were working at the facility. On 1/5/26, the schedule indicated that 12 nurses were working at the facility.On 1/6/26, the schedule indicated that 13 nurses were working at the facility. On 1/7/26, the schedule indicated that 13 nurses were working at the facility. On 1/8/26, the schedule indicated that 12 nurses were working at the facility.On 1/9/26, the schedule indicated that 13 nurses were working at the facility. On 1/11/26, the schedule indicated that 22 CNAs were working at the facility. On 1/13/26, the schedule indicated that 25 CNAs were working at the facility. On 1/14/26, the schedule indicated that 14 nurses were working at the facility. On 1/15/26, the schedule indicated that 26 CNAs were working at the facility. On 1/16/26, the schedule indicated that 12 nurses and 21 CNAs were working at the facility. On 1/17/26, the schedule indicated that 25 CNAs were working at the facility. On 1/18/26, the schedule indicated that 23 CNAs were working at the facility.On 1/19/26, the schedule indicated that 14 nurses and 24 CNAs were working at the facility.On 1/21/26, the schedule indicated that 14 nurses were working at the facility.On 1/22/26, the schedule indicated that 11 nurses were working at the facility.On 1/23/26, the schedule indicated that 14 nurses were working at the facility.On 1/25/26, the schedule indicated that 20 CNAs were working at the facility.On 1/28/26, the schedule indicated that 14 nurses were working at the facility.On 1/30/26, the schedule indicated that 12 nurses were working at the facility.On 1/31/26, the schedule indicated that 14 nurses were working at the facility.On 2/1/26, the schedule indicated that 12 nurses and 27 CNAs were working at the facility.On 2/2/26, the schedule indicated that 13 nurses and 27 CNAs were working at the facility.On 2/3/26, the schedule indicated that 11 nurses were working at the facility.On 2/4/26, the schedule indicated that 13 nurses were working at the facility.On 2/5/26, the schedule indicated that 13 nurses were working at the facility.On 2/7/26, the schedule indicated that 13 nurses and 27 CNAs were working at the facility.On 2/8/26, the schedule indicated that 11 nurses and 26 CNAs were working at the facility.On 2/9/26, the schedule indicated that 14 nurses were working at the facility.On 2/10/26, the schedule indicated that 13 nurses were working at the facility.On 2/11/26, the schedule indicated that 14 nurses were working at the facility.On 2/12/26, the schedule indicated that 13 nurses were working at the facility.On 2/13/26, the schedule indicated that 13 nurses were working at the facility.On 2/14/26, the schedule indicated that 11 nurses and 25 CNAs were working at the facility.On 2/15/26, the schedule indicated that 12 nurses and 23 CNAs were working at the facility.On 2/16/26, the schedule indicated that 12 nurses and 27 CNAs were working at the facility.On 2/18/26, the schedule indicated that 14 nurses were working at the facility.On 2/19/26, the schedule indicated that 13 nurses were working at the facility.On 2/20/26, the schedule indicated that 13 nurses were working at the facility.On 2/21/26, the schedule indicated that 14 nurses were working at the facility.On 2/22/26, the schedule indicated that 26 CNAs were working at the facility.On 2/23/26, the schedule indicated that 14 nurses were working at the facility.On 2/24/26, the schedule indicated that 13 nurses were working at the facility.On 2/25/26, the schedule indicated that 11 nurses were working at the facility.On 2/26/26, the schedule indicated that 13 nurses were working at the facility.On 2/28/26, the schedule indicated that 14 nurses were working at the facility.On 3/1/26, the schedule indicated that 27 CNAs were working at the facility.=On 3/2/26, the schedule indicated that 14 nurses were working at the facility.On 3/5/26, the schedule indicated that 14 nurses were working at the facility.On 3/6/26, the schedule indicated that 14 nurses were working at the facility.On 3/7/26, the schedule indicated that 14 nurses were working at the facility.On 3/8/26, the schedule indicated that 13 nurses and 19 CNAs were working at the facility.V. GrievancesReview of the December 2025 to March 2026 grievances revealed the following: A grievance, dated 12/8/25, documented a resident had to take himself to the bathroom due to their call light not being answered between the times of 1:30 a.m. and 4:30 a.m. The resident documented that staff reported that they were under staffed. The CNA was spoken to and the CNA stated she answered his call light timely. The CNA stated they did not make the comment about staffing. The resident was assured that the call light will be answered timely and was apologized to. A grievance, dated 1/6/26, documented one plus hours for response time to call light and conditions were worse since admission. The facility reported they did an inservice with staff about walking to the end of the hall to make sure call lights were not on for extended times and that the resident's shower schedule was being followed as well as his up/down schedule. A grievance, dated 1/7/26, documented the call light wait times were up to 30 minutes, especially during meal times. The facility reported that they reviewed with nurses to be mindful of the all the call lights.A grievance, dated 1/12/26, documented a resident had to wait three hours to get help with the toilet and for pain medication. The facility reported they did a call light audit and the resident said her call light was being answered more timely. A grievance, dated 1/28/26, documented that the call light response times were extremely slow and that showers, especially during the evening shift got cancelled. The resident reported that staff had been telling him that the facility was short-staffed and he could not get a shower. The resident reported that he would prefer his scheduled showers to be in the morning or early afternoon. The facility reported education was given to CNAs about giving showers on time and a call light audit was done. The resident reported that he was satisfied with the results. VI. Staff interviewsCNA #6 was interviewed on 3/10/26 at 4:58 p.m. She said on most days the facility needed more help on all shifts. She said that particular day (3/10/26) there had been a lot of call-offs. She said the facility used agency staff for nurses but not for CNAs. She said they had 47 residents on the 300 hall and there were a lot of residents who required two-person transferred, She said the increased care needs of the residents made meeting the needs of every resident difficult when there is not enough staff. She said that there were currently two CNAs for the east 300 hall and two CNAs for the west 300 hall. She said they could benefit from a shower aide or a third CNA to assist. She said the previous week on Thursday she had 15 showers to give but was only able to get 12 of the 15 completed. The director of nursing (DON) and the NHA were interviewed together on 3/12/26 at 4:31 p.m. The DON said their goal was to have two nurses and four CNAs for each floor during the day shift and evening shift. She said for overnights they staffed one nurse and three CNAs. She said there were times that they were unable to meet their staffing goals. She said they most of the time they were able to get shifts covered. She said she was unsure of how many shifts that were not covered. She said often times they use the on-call nurse to come in and work the floor as a CNA if they were unable to get a CNA to cover the shift. The NHA said that staff have not voiced any concerns about staffing. She said that they did have resident care assistants who helped with a lot of the side work like answering call lights and making beds, so the CNAs could focus more on the residents' activities of daily living (ADL). She said she thought they had enough staff to meet the residents' needs.

Based on observations and interviews, the facility failed to maintain proper storage of medications for three out of three medication carts and two of three medication storage rooms.Specifically, the facility failed to:-Label insulin pens with the date they were opened;-Label inhalers with the date they were opened;-Discard medications that had expired;-Keep the cart free of personal items; and,-Ensure medications were labeled with residents' names. Findings include:I. Professional resourceAccording to the manufacturer, Viatris, How to Use a Wixela Inhub (inhaler used to treat asthma and lung disease), 2021, retrieved on [DATE] from https://www.wixelahcp.com/-/media/Project/Common/WixelahcpCom/PDF/[NAME]-2020-0047_V4_US_How-to-Use_PDF.pdf, Take Wixela Inhub out of the foil pouch just before you use it for the first time. Write the pouch opened and use by dates on the label. The use by date is one month from the date you opened the pouch for your first dose.According to the manufacturer Biocon Biologics, 2023, Patient Information-Storing the Insulin Glargine yfgn pen, retrieved on [DATE] from, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3ac85ebb-5594-59c8-77fd-df254329d151&type=display#section-18m, Only use your pen for up to 28 days after its first use. Throw away the Insulin Glargine yfgn pen you are using after 28 days, even if it still has insulin left in it.II. Facility policy and procedureThe LTC (long term care) Facility's Pharmacy Services and Procedures policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:30 p.m. It read in pertinent part, Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider.III. Observations and interviewsOn [DATE] at 2:55 p.m. the second floor west medication cart was observed with registered nurse (RN) #1. The following was observed:-An opened bottle of sublingual (under the tongue) Nitroglycerine (medication for chest pain) 0.4 milligram (mg) tablet, without a resident's name on it. Registered nurse (RN) #1 said the bottle should be labeled with the resident's name.-A used Wixela inhaler for Resident #138, which was not labeled with the date it was opened. RN #1 said she thought the inhaler could be used until the medication was empty. -An opened bottle of Docusate sodium 100 mg (a stool softener) with an expiration date of February 2026. RN #1 said the medication should have been discarded at the end of February.The second floor west medication storage room was observed with RN #1 on [DATE] at 3:10 p.m. The following medication was found:An opened bottle of Tuberculin Purified Protein 5 TU per 0.1 milliliter (ml), which was not labeled with the date it was opened. RN #1 did not know how long the medication was good for after opening.On [DATE] at 3:45 p.m. the third floor east medication cart was observed with licensed practical nurse (LPN) #2.A box of 5% lidocaine patches for a resident who was discharged . LPN #2 said the resident had been discharged from the facility. LPN #2 said the medication should have been removed from the cart as soon as the resident had been discharged from the facility.On [DATE] at 5:00 p.m. the first floor east medication cart was observed with LPN #3. The following observations were made.Three opened and undated insulin Glargine pens for Resident # 7, Resident #48 and Resident #15. LPN #3 said insulin pens must be used within 30 days of opening.A small, half-used bottle of normal saline, labeled opened 3/3.An opened, partially full water bottle, with a staff member's name written on it. LPN #3 said she did not know of any residents with the same name as written on the bottle.An opened bottle of chocolate syrup, partially open, with dried syrup around the lid. The bottle read refrigerate after opening. LPN #3 read the instructions and placed the bottle back in the cart.The first floor medication storage room was observed with LPN #3 around 5:20 p.m. The following was observed:An unopened respiratory syncytial virus (RSV) test with a physician's order to give one time only until [DATE]. LPN #3 said the test was unopened and could go back in the refrigerator despite the expired physician's order.An opened vial of tuberculin purified protein with an expiration date of [DATE]. LPN #3 said the tuberculosis test would be less accurate if staff used an expired vial to perform the test. IV. Staff interviewsThe director of nursing (DON) and the regional clinical resource were interviewed on [DATE] at 6:15 p.m. The DON said nitroglycerin vials were for individual resident use and should be labeled with a resident's name. The DON said insulin pens, Wixela inhalers, and tuberculin vials should all be labelled with the open date and discarded according to the manufacturer's instructions. The regional clinical resource said medications used beyond the manufacturer's recommendations could have reduced efficacy. The DON said the opened water bottle belonged to a staff member. The DON said the discharged resident with medications in the third floor east medication cart had been discharged on [DATE]. The DON said medications should be removed from the medication cart within 24 hours of their discharge.The DON was interviewed again on [DATE] at 9:40 a.m. The DON said the facility has discarded the undated tuberculin vials, inhalers, and insulin pens. The DON said any personal items that belonged to staff were also removed from the cart. The DON said she provided education to all staff about medication storage. The DON said LPN #2 was provided additional education on completing the narcotic log timely upon administration of narcotics.

Based on record review and interviews, the facility failed to protect three (#31, #71 and #96) of five residents reviewed for abuse out of 54 sample residents. Specifically, the facility failed to:-Protect Resident #31 from physical abuse by Resident #39; and, -Protect Resident #71 and Resident #96 from sexual abuse by Resident #149. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, reviewed 5/6/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 12:18 p.m. It read in pertinent part, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as physically aggressive behavior and verbally aggressive behavior. II. Failure to protect Resident #31 from physical abuse from Resident #39 on 2/20/26 A. Facility investigation The facility investigation was provided by the NHA on 3/11/26, the investigation revealed the following: On 2/20/26 a certified nurse aide (CNA) reported to the nurse that Resident #39 was found in Resident #31's room. Resident #31 told the CNA that Resident #39 had hit her chest. A second report was made to the same nurse from a different CNA at 11:30 a.m. The CNA reported that Resident #39 was in front of Resident #31's door at approximately 5:55 a.m., and Resident #39 was grabbing Resident #31's leg asking for her help to find his buddy. The CNA reported that she removed Resident #39's hand from Resident #31's leg and removed Resident #39 from the area. The investigation documented that Resident #31 stated Resident #39 crawled into her doorway and when she bent down to help him up, Resident #39 then hit her chest. The investigation documented that Resident #39 was removed from Resident #31's room. Resident #31 stated her chest hurt where she had been hit, but there were no visible signs of injury. Resident #39 was then provided with one-to-one supervision. The investigation documented the interdisciplinary team (IDT) did not feel the incident that occurred on 2/20/26 was a reportable incident. The investigation documented the IDT did not feel there was an allegation or intent. The facility interviewed Resident #31 she said she was trying to help Resident #39 to get up off of the floor and he did not want her help so he pushed her hand away to decline her assistance and then brushed her chest. The investigation documented that Resident #31 had always loved to help others when able to. -However, abuse occurred as Resident #39 hit Resident #31 in the chest, causing pain. -Cross-reference F609, reporting of alleged violations to the State Agency. B. Resident #31 (victim) 1. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale (multiple small blood clots in the pulmonary arteries), malnutrition, hyperlipidemia and hyperthyroidism. The 2/13/26 minimum data set (MDS) assessment revealed Resident #31 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #31 was independent or needed setup or clean-up assistance with her activities of daily living (ADL). The assessment revealed Resident #31 did not have any physical or verbal behaviors directed at others or other behavioral symptoms not directed towards others. 2. Resident interview Resident #31 was interviewed on 3/10/26 at 9:46 a.m. Resident #31 said there was a male resident (Resident #39) that had come into her room and she had tried to help him and he did not want her help and he had hit her chest. She said that when he hit her it had hurt. 3. Record review Resident #31's resistive to care care plan, initiated 2/13/25 and revised 9/30/25, identified Resident #31 had a behavior issue of declining her medications and had a history of being the victim of an altercation. Pertinent interventions included educating the resident and family of the possible outcomes of not complying with treatment or care, praising the resident when behavior was appropriate, providing the resident with opportunities for choice during care, separating immediately from the aggressor and behavior monitoring. Resident #31's potential for verbal aggression care plan, initiated 7/21/25 and revised 11/20/25, identified Resident #31 had the potential to become verbally aggressive due to ineffective coping skills. Pertinent interventions were giving the resident as many choices as possible about cares and activities, when the resident became agitated, intervening before agitation escalated, guiding the resident away from the source of distress, engaging the resident calmly in conversation, if response was aggressive, staff were to walk away calmly and approach later. -The care plan was not updated after the 2/20/26 abuse incident with Resident #39 to indicate that Resident #31 had a tendency to help others even when they might not want the help. A progress note, dated 2/20/26 at 12:10 p.m., revealed a nurse was notified by a CNA that Resident #39 was found inside Resident #31's room at approximately 6:00 a.m. and Resident #31 stated to the CNA that Resident #39 had hit her in the chest when she tried to help him. The progress note documented another CNA reported she had found Resident #39 in front of Resident #31's room at approximately 5:55 a.m. Resident #39 was grabbing Resident #31's leg, asking her to help him find his buddy. The CNA stated she removed Resident #39's hands from Resident #31's leg and moved Resident #39 away from Resident 31's room. The progress note documented skin and pain assessments were done. Resident #31 stated the area where she had been hit was sore and one-to-one supervision was provided for Resident #39. C. Resident #39 (assailant) 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included peripheral vascular disease (reduced blood flow to limbs or organs), dementia and acute kidney failure. The 12/17/25 MDS assessment revealed Resident #39 had short-term and long-term memory deficits and was severely impaired in his daily decision-making, per staff assessment. Resident #39 was dependent on staff for all of his ADLs. The assessment documented Resident #39 had physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. 2. Record review Resident #39's potential to be verbally aggressive care plan, initiated 6/24/24 and revised 9/24/24, documented Resident #39 had the potential to become verbally aggressive due to his dementia. Pertinent interventions included administering medications as ordered, analyzing key times, places, circumstances, triggers and what de-escalated his behavior and documenting, when the resident became agitated, intervening before agitation escalated, guiding the resident away from the source of distress, engaging the resident calmly in conversation, if response was aggressive, staff were to walk away calmly and approach later. Resident #39's dementia with behaviors care plan, initiated 6/24/24 and revised 2/19/26 documented Resident #39 had the potential to be physically and verbally aggressive with behaviors, such as throwing water on staff, hitting, swearing, kicking at staff, throwing chairs, moving furniture and yelling out. The care plan documented Resident #39 was an aggressor in a resident-to-resident altercation. Pertinent interventions included analyzing key times, places, circumstances, triggers and what de-escalated his behavior and documenting, checking to see if the resident needed to use the restroom every two hours, providing physical and verbal cues to alleviate anxiety, documenting observed behaviors and attempted interventions in the behavior log, increasing observation to line-of-sight monitoring due to physical aggression and providing one-to-one observation for increased safety measures. A progress note, dated 2/20/26 at 2:37 p.m., documented a CNA reported to the nurse that Resident #39 was agitated and was crawling on the floor and was found in Resident #31's doorway. Resident #31 reported that Resident #39 had hit her on the chest when she attempted to help him from the floor. The note further documented that Resident #39 was removed from Resident #31's room and was provided with one-to-one supervision. The note documented Resident #39 remained agitated and reassurance and redirection was unsuccessful. The note documented that at 11:30 a.m., another CNA reported to the nurse that at approximately 5:55 a.m., Resident #39 had crawled into Resident #31's room and grabbed Resident #31's leg and asked her to help him find his buddy. The CNA removed Resident #39's hands from Resident #31's leg and assisted Resident #39 to another location. D. Staff interviews The resident care assistant was interviewed on 3/11/26 at 9:29 a.m. The resident care assistant said when she was assigned as Resident #39's one-to-one caregiver. She said she tried to keep him entertained. She said the reason he was on a one-to-one was because he had certain behaviors, such as grabbing people. She said she received her information about behaviors in a verbal report or she would ask the nurse or unit manager. The resident care assistant said she had not heard of Resident #39 going into other residents' rooms and she had not heard of the incident between him and Resident #31. Registered nurse (RN) #4 was interviewed on 3/11/26 at 11:45 a.m. RN #4 said Resident #39 could become aggressive and grabby. She said he had struck her before. She said she had heard of the incident between him and Resident #31, but did not know all the details. She said she had not heard of Resident #39 making it into other residents' rooms. She said when a resident was having behaviors, she tried to witness them directly but, if she did not see the behavior in real time the CNAs would report to her or chart it in the CNA charting. She said she would pass off pertinent information to the CNAs or resident care assistants verbally. CNA #9 was interviewed on 3/12/26 at 9:44 a.m. CNA #9 said Resident #31 had reported the incident with Resident #39 to her. She said Resident #39 had grabbed Resident #31's leg in an attempt to pull himself up. She said she did not witness it herself but reported what Resident #31 had told her to the nurse. CNA #10 was interviewed on 3/12/26 at 9:59 a.m. CNA #10 said she was just coming on to her shift and she saw Resident #31 trying to get Resident #39 out of her room. She said Resident #31 reported to her that Resident #39 had punched her chest. She said Resident #31 was holding her chest when she told her about being punched. CNA #10 said she reported the incident to the nurse that was on duty and talked Resident #31 into making the report to the nurse and the unit manager. The social services assistant (SSA) was interviewed on 3/12/26 at 12:13 p.m. The SSA said he was aware of the situation between Resident #31 and Resident #39 on 2/20/26. He said Resident #39 was on the ground and he grabbed Resident #31's ankle as she was walking by and she did not like it. He said he spoke with Resident #31 about it and she had told him that she understood that Resident #39 had memory issues. He said Resident #39 was put on one-to-one supervision after the incident and had remained on the one-to-one monitoring since the incident. He said Resident #39 was not on a one-to-one prior to the 2/20/26 incident and staff would try to keep Resident #39 within their line-of-sight. He said staff would keep him close to the nurses' cart or nurses' station to monitor his behaviors. Licensed practical nurse (LPN) #1, who was the unit manager on the first floor, was interviewed on 3/12/26 at 12:49 p.m. LPN #1 said she was aware of the incident that happened between Resident #31 and Resident #39 on 2/20/26. She said she understood the situation as Resident #39 was on the floor and went into Resident #31's room and he then tapped or grabbed Resident #31's leg. She said she had not heard that Resident #31 had been hit in the chest. The director of nursing (DON) and the NHA were interviewed together on 3/12/26 at 3:41 p.m. The NHA said she was aware of the situation between Resident #31 and Resident #39 on 2/20/26. She said Resident #31 reached down to help Resident #39, and he appeared to not want help and then hit her in the chest with his hand. The NHA said the facility was on the fence about reporting it because of the interview with Resident #31. The NHA said Resident #31 had told them that she felt Resident #39 had not meant to hurt her. The NHA said Resident #39 had willfully hit Resident #31 and was then put on one-to-one supervision. III. Incident of sexual abuse of Resident #71 by Resident #149 on 1/3/26 A. Facility investigation The facility's investigation, dated 1/3/26, was provided by the NHA on 3/11/26 at 2:35 p.m. The investigation revealed the following: On 3/5/26 RN #5 witnessed Resident #71 sleeping on a couch in the common area. Resident #149 was sitting on the couch next to Resident #71 and placed his hand down inside Resident #71's pants. The residents were immediately separated. Resident #71 slept through the occurrence. Staff woke up Resident #71 and assisted her back to her room for a skin inspection and incontinence care. The assessment documented a skin assessment was completed and determined there were no changes with Resident #71. The investigation documented Resident #149 was assisted by staff back to his room for assistance with cleaning the feces off his hand. An investigation was initiated and all appropriate notifications were made. A one-to-one observation was initiated with Resident #149. Resident #71 was interviewed by the social services director (SSD). Due to the resident's cognitive impairment, she did not remember the incident. No behavioral changes were noted. Resident #149 was interviewed and due to cognitive impairment, the resident had no recollection and was unable to offer any insight to the situation. The root cause was secondary to dementia progression versus intent. Multiple residents and facility staff members were interviewed. Sample residents and staff member interviews indicated no other concerns during the investigation. The investigation documented the facility unsubstantiated the abuse. -However, abuse occurred due to Resident #149 placing his hand into Resident #71's brief without her consent. B. Resident #71 (victim) 1. Resident status Resident #71, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dementia with anxiety, chronic kidney disease, diabetes and dysphagia (difficulty swallowing). The 1/29/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. She required partial to moderate assistance with all ADLs. 2. Resident representative interview On 3/9/26 at 9:02 a.m. Resident #71's representative was interviewed. The resident's representative said there was an issue with another resident and the facility took care of it. The resident's representative said social services offered Resident #71 psychological services. The representative said the DON and the facility staff were very cooperative. She said Resident #71 did not recall the incident and the facility was good about placing Resident #149 on direct supervision. The representative said the facility notified the police and they decided not to press charges. 3. Record review The 1/3/26 nursing progress note, documented at 2:08 p.m., revealed the nurse was coming back from gathering supplies and noticed Resident #149 was sitting on the couch next to Resident #71 with his hand down the front of her pants. When Resident #149 noticed the nurse, he quickly withdrew his hand from Resident #71's pants. Resident #71 was incontinent of bowel during the incident and had bowel movement streaked from the front of the inside of her brief and outside of her sweater. The nurse had difficulty waking up Resident #71, but the resident did awaken once she was in bed. Resident #149 had bowel movement on his pointer and middle fingers. Staff assisted Resident #149 with cleaning his hands. The 1/4/26 nursing progress note, documented at 6:00 a.m., revealed Resident #71 slept most of the shift. The resident did not report any pain or anything that had happened during the prior incident. There was no interaction between Resident #71 and Resident #149. Staff maintained frequent checks and a safety net to Resident #71's room was up throughout the shift. C. Resident #149 (assailant) 1. Resident status Resident #149, age greater than 65, was admitted on [DATE] and discharged on 2/16/26. According to the March 2026 CPO, diagnoses included peripheral vascular disease, Alzheimer's disease, dementia and chronic obstructive pulmonary disease. The 2/16/26 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making daily decisions. He required supervision or touch assistance with all ADLs. 2. Record review The behavioral care plan, initiated on 12/16/25, revealed Resident #149 had a behavior problem which included grabbing others, public indecency and inappropriate sexual comments to women. The care plan documented the resident was hypersexual towards women. Pertinent interventions included assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express his feelings, if reasonable, discussing the resident's behavior and explaining/reinforcing why the behavior was inappropriate and/or unacceptable to the resident, intervening as necessary to protect the rights and safety of others, approaching/speaking to the resident in a calm manner, removing the resident from the situation and taking him to an alternate location as needed, minimizing potential for the resident's disruptive behaviors by offering him tasks which diverted his attention, such as walking in the hallway with a staff member for exercise and group activities, maintaining five feet between Resident #149 and other residents and allowing the resident access to porn and private time for masturbation. The 12/14/25 nursing progress note, documented at 1:15 p.m., revealed another resident's family member reported to staff Resident #149 was watching pornographic material and masturbating in the dining room. Resident #149 was in the common area near the nurses' station when a member of the therapy team and the nurse noticed the resident was again masturbating. In a low tone and as to not embarrass the resident, the nurse told Resident #149 that it was an inappropriate place to do that and his room would be a better place. The behaviors ceased and the resident was referred to social services. The 12/19/25 nursing progress note, documented at 12:03 p.m., revealed Resident #149 had asked his roommate twice to have sex with him. The roommate reported feeling unsafe with Resident #149 in the room. The nurse notified the unit manager and social services. The 1/1/26 nursing progress note, documented at 11:36 a.m., revealed the CNA found Resident #149 in another female resident's room. The CNA was unsure if the resident had done anything while in the female resident's room. The female resident was sleeping at the time of Resident #149 being in her room. The resident was removed from the female resident's room and taken to the dining room. The 1/1/26 social services progress note, documented at 3:25 p.m., revealed the SSA put interventions in place to close all female residents' doors and redirect Resident #149 down the hallway. The SSA was to educate staff as well. The 1/2/26 nursing progress note, documented at 11:53 a.m., revealed the resident was found three times in female residents' rooms. Resident #149 was removed from the rooms by staff and was told he was not supposed to be going into those people's rooms. Stop signs were added to every door of the rooms the resident had entered or tried to enter. Social services were made aware. The 1/3/26 nursing progress note, documented at 3:08 p.m., revealed Resident #149 was seen with his hand down Resident #71's brief. Resident #71 was asleep on the couch in the common area near the nurses' station. Resident #71 was removed from the area and taken to her room. Resident #149 was redirected and taken to his room. The 1/3/26 nursing progress note, documented at 7:25 p.m., revealed bedside staff were educated on the need for Resident #149 to be under direct one-to-one observation at all times. The staff were instructed to provide breaks to the family members at the resident's bedside as requested and to notify the DON or the unit manager immediately prior to family leaving if they expressed a need to leave the resident's bedside. Staff verbalized their understanding of the education provided. The resident's family agreed to notify staff prior to leaving the resident's bedside to allow planning for ongoing one-to-one observation by facility staff. IV. Incident of sexual abuse of Resident #96 by Resident #149 on 1/23/26 A. Facility investigation The facility's investigation, dated 1/23/26, was provided by the NHA on 3/11/26 at 2:35 p.m. The investigation revealed the following: Resident #149 was ambulating with a one-to-one caregiver when he reached down towards Resident #96, who was sitting in a wheelchair. Resident #149 touched Resident #96's breast on the outside of her clothing. The one-to-one caregiver intervened as the resident reached down. The investigation documented Resident #149 made contact with Resident #96. The staff member immediately removed Resident #149's hand and escorted him back to his room. He was placed in bed without any further incident and remained on a one-to-one caregiver. The investigation documented immediate education was provided to the one-to-one staff member regarding being in between Resident #149 and any other resident in the building. The investigation documented the police were notified, along with the family of both Resident #96 and Resident #149. The physician was notified and new physician's orders were received for new medications for Resident #149. A skin assessment was completed for Resident #96 and there was no bruising or abnormal findings noted. The investigation documented 10 out of 10 residents that were interviewed for the investigation had no concerns. The medical director (MD) completed a plan of care review on 1/24/26 for Resident #149 and recommended the primary care physician to implement medication management. The DON completed a chart review and updated Resident #149's care plan. On 1/26/26 the IDT and the MD reviewed standards of care and behaviors with medication changes. The investigation documented the facility substantiated the abuse. B. Resident #96 (victim) 1. Resident status Resident #96, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included encephalopathy (brain dysfunction, disease, or damage), dementia, morbid obesity and acute respiratory failure. The MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of four out of 15. She required moderate to maximal assistance with all ADLs. The assessment revealed the resident had a diagnosis of dementia unrelated to Alzheimer's. 2. Resident representative interview Resident #96's representative was interviewed on 3/12/26 at 9:13 a.m. The representative said the facility handled the incident regarding sexual abuse well. The representative said the facility raised the issue to the right level, and took it to the top by taking accountability. The representative said the facility was apologetic and put appropriate interventions in place to prevent the incident from happening again. The representative said the facility intervened immediately and had Resident #149 supervised 24/7 as well as maintaining specific distance. The representative said the facility notified him as soon as the incident happened. The representative said the facility notified the appropriate agencies and even found a new placement for Resident #149. The representative said due to Resident #96's cognitive impairment, she did not recall the incident. 3. Record review The dementia care plan, revised on 2/13/26, revealed Resident #96 was at risk for change in mood or behavior due to diagnoses of dementia and encephalopathy. Pertinent interventions included consulting with the resident on preferences regarding her customary routine, administering medications as ordered, offering group activities or active one-to-one listening when Resident #96 appeared to be tearful or confused and redirecting the resident safely as needed. Resident #96 could become confused and tearful thinking she was unsafe (bomb in the building, husband not being able to find her and missing her kids). The resident had difficulty being redirected at times. Additional interventions included providing the resident with redirection and reassurance as needed and notifying the physician of worsening mood. The 1/23/26 nursing progress noted, documented at 10:07 p.m., revealed Resident #96 was sitting at the nurses' station when Resident #149 walked by with his walker and a staff member next to him. Resident #149 reached down and touched Resident #96's breast. Staff witnessing the incident intervened by removing the resident's hand immediately. Resident #149 walked back to his room with the staff member. The nurse asked Resident #96 if she felt safe. Resident #96 said she was shaken up and wanted to talk with her son. The nurse called the resident's son and explained the situation to him. Resident #96's son said he would like a follow up next week with the plan explained to him. The nurse called and reported to the DON and executive director immediately following the incident. The 1/24/26 nursing progress note, documented at 6:30 a.m., revealed at the start of the night shift, Resident #96 was visibly upset from the prior incident with Resident #149. Resident #96 went to bed at approximately midnight, and was able to sleep most of the night. The 1/24/26 social service progress note, documented at 10:30 a.m., revealed the SSA was told by the weekend manager about the incident that occurred with Resident #149. The SSA did a check in with Resident #96 and she reported a female had stopped by to check out her blouse. Resident #96 said she did not have any fears or discomfort due to the incident. Resident #96 said she was happy with her care at the facility. The SSA conducted a BIMS and PHQ-9 assessment with the resident. Resident #96 scored a zero out of 27 on the PHQ-9 assessment, indicating the resident had no signs or symptoms of depression or sadness. Resident #96 scored a four out of 15 on the BIMS assessment, indicating the resident was cognitively impaired. The 1/24/26 nursing progress note, documented at 12:40 p.m., revealed a skin assessment was completed on Resident #96. No bruising or abnormal findings were noted. An interview was conducted related to the incident that happened on 1/23/26. Resident #96 said she was not fearful and had no concerns. The 1/24/26 executive director's progress note, documented at 1:55 p.m., revealed a meeting was held with the NHA, social services, the weekend supervisor, and the resident's son at approximately 1:00 p.m. to discuss the situation between Resident #96 and Resident #149. The facility's plan of correction and action steps were reviewed. The facility provided the resident's son with the contact information for the ombudsman and a business card for the NHA. The 1/24/26 nursing progress note, documented at 2:36 p.m., revealed Resident #96 was being monitored for any changes to her mood, eating patterns, sleeping patterns. Interviews with bedside staff were conducted and indicated no changes with the resident. Resident #96 appeared to be in good spirits as she was socializing throughout the unit as per her usual routine. The 1/24/26 social service progress note, documented at 3:32 p.m., revealed due to the resident's BIMS score four out of 15, Resident #96 would not be appropriate for therapy services at this time. C. Resident #149 (assailant) 1. Record review The 1/16/26 nursing progress note, documented at 2:22 p.m., revealed it was reported to the nurse by the one-to-one staff member that Resident #149 made an inappropriate comment to her at the end of her shift. The staff member said the resident asked her to have sex with him. The staff member wrote down the behavior in the one-to-one log. The 1/23/26 nursing progress note, documented at 10:00 p.m., revealed that while Resident #149 was ambulating with a staff member in the hallway, the resident reached down and touched another resident's breast over her clothing. Staff removed the resident's hand immediately and guided him to leave the area. The DON and the physician were notified immediately. The on-call nurse practitioner gave new physician's orders for medication changes. The nurse notified the resident's representative and reported the incident. An immediate intervention of having staff be in between Resident #149 and any other resident was initiated. 4. Staff interviews RN #6 was interviewed on 3/11/26 at 12:07 p.m. RN #6 said Resident #71 did not have any behaviors. RN #6 said the resident normally stayed in her room due to being on hospice care services. RN #6 said before admitting to hospice care services, Resident #71 would come out and sit on the couch in the main area. RN #6 said the DON educated all the staff about Resident #149's hypersexual behaviors. RN #6 said she documented any behavioral changes in a progress note. RN #6 said it was important to document behaviors so the physicians knew how long the behaviors had been going on and they could complete a medication review if necessary. RN #6 said documenting behaviors was also important if a facility needed to refer a resident to another facility. RN #7 was interviewed on 3/12/26 at 9:43 a.m. RN #7 said she was informed through report about the incident involving Resident #71 and Resident #149. RN #7 said Resident #71 was sitting out on the couch and the resident was known for sitting on the couch. RN #7 said Resident #71 fell asleep on the couch and Resident #149 approached her while she was sleeping. RN #7 said Resident #149 put his hand in Resident #71's pants. RN #7 said Resident #149 was ambulatory via his wheelchair. RN #7 said interventions were put in place for Resident #149. RN #7 said Resident #149 was placed on a one-to-one caregiver following the incident with Resident #71. RN #7 said if Resident #149 was walking in the hallway, h

Based on record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received necessary services to maintain proper personal hygiene for two (#11 and #46) of six residents reviewed for ADLs out of 54 sample residents.Specifically, the facility failed to ensure Resident #46 and Resident #11 received assistance with showers. Findings include: I. Facility policy and procedure The ADLs policy and procedure, issued 12/11/18 and reviewed 8/23/23, was received from the nursing home administrator (NHA) on 3/12/26 at 5:55 p.m. It read in pertinent part, The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. For all other ADLs, this facility will utilize the following Lippincott procedures Tub baths and showers. II. Resident #46 A. Resident status Resident #46, age [AGE], was admitted to the facility on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included displaced trimalleolar fracture of right lower leg (ankle injury), muscle weakness and history of falling. The 2/6/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She needed set-up assistance with eating, oral hygiene, toileting and partial to moderate assistance with showering/bathing, upper and lower body dressing. B. Resident interview Resident #46 was interviewed on 3/10/26 at 8:45 a.m. She said she had concerns regarding the showering system and said the process for assigning days to residents was broken. She said the facility did not ask about her preference for showers when she was admitted . She said the information the facility provided to her indicated shower days were Sundays and Wednesdays. She said she tried to schedule a shower on Sunday, however staff said the shower schedule was Wednesday and Saturday. She said she was on the list for a shower on Wednesday (3/4/26) and waited until 9:30 p.m. She said no one came to assist her and she did not receive a shower that day. She said when she asked staff they said they were supposed to get her for her shower. She said no one got her and she had to initiate it herself and still no one showed up. She said this made her feel angry. Resident #46 said she had to go to the front desk and ask. She said it still did not happen and she was not able to shower. She said she felt disgusted that she had not been able to shower. She said on 3/9/26 she washed her hair in the sink because staff did not come to give her a shower. She said on 3/7/26 she was supposed to receive a shower and did not receive one and she told staff and nothing happened. She said during the past five weeks she had been at the facility, she had only received four showers. C. Record review The ADL care plan, initiated 2/6/26, documented the resident had an ADL self-care performance deficit related to a tibia and fibula fracture. Interventions included providing supervision for bathing and showering and no tub baths until cleared by the surgeon. A review of the bathing documentation report for February 2026, revealed a preference for Wednesday and Saturday evenings showers. The documentation revealed a sponge bath was provided on 2/4/26 and showers on 2/7/26, 2/11/26, 2/18/26, and 2/25/26. -The facility failed to provide Resident #46 with two showers a week according to the shower schedule and preference. A review of the bathing documentation report for March 2026, revealed Resident #46 did not receive a shower on 3/4/26 and 3/7/26 as scheduled. -A review of Resident #46's electronic medical record (EMR) revealed no documentation to indicate why Resident #46 did not receive her showers as scheduled. A review of nursing progress notes, dated 3/4/26, documented the resident returned from an outside physician appointment with instructions she could shower over the incision but could not submerge it underwater. -A review of Resident #46's progress notes failed to reveal any refusals of showers by the resident. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/11/26 at 10:05 a.m. She said the staff member assigned to provide showers notified the resident on the day of their scheduled shower. CNA #3 said they brought residents to the shower room and residents were not expected to request the shower themselves. She said staff were expected to complete scheduled showers for dependent residents. She said if a shower could not be completed on the day shift, staff asked the evening shift to provide the shower. She said they notified the charge nurse and the nurse documented the information and relayed it to the next shift. She said CNAs could not document in point of care (POC). CNA #3 said Resident #46 had scheduled shower days on Wednesday and Saturday evenings. She said they asked the resident twice before notifying the nurse of a refusal. She said Resident #46 did not refuse showers. Registered nurse (RN) #2 was interviewed on 3/11/26 at 10:24 a.m. RN #2 said the shower schedule was created based on a baseline unit schedule. She said when a resident was admitted , staff placed the resident into the schedule unless the resident had a preference. She said staff accommodated resident preferences when possible. She said the admitting nurse informed residents of their assigned shower days. RN #2 said if a resident did not receive a scheduled shower, staff attempted to schedule the shower for the next day. She said staff communicated during shift report regarding missed showers. She said if a resident refused a shower, the CNA would notify the nurse and they would document the refusal. RN #2 said Resident #46 had scheduled shower days on Wednesday and Saturday evenings. She said documentation showed the resident received two showers on 3/3/26, and that she was out of the facility on 3/4/26. She said documentation for February showed the resident received showers once per week and no refusals were documented. The director of nursing (DON) was interviewed on 3/12/26 at 3:17 p.m. The DON said residents who required assistance with bathing received showers based on their preference and the facility offered showers but it was based on what the resident wanted. The DON said if a resident did not receive a scheduled shower, staff were to notify the charge nurse so the nurse could document and inform the next shift. She said missed showers were documented in POC and if the resident refused, the nurse documented the refusal in a progress note. The DON said the facility monitored whether residents received scheduled showers by reviewing the medical record and completing weekly shower audits. The DON said if records showed a resident only received one shower per week and there were no refusals documented, staff would follow up with the resident and staff and offer the shower. The DON said Resident #46 had scheduled shower days on Wednesday and Saturday evenings and from admission, should have received showers two times per week and there were no refusals documented. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included left humerus (upper arm) fracture, heart disease, urinary tract infection and diabetes. The 3/9/26 MDS assessment identified Resident #1 had a moderate cognitive impairment with aBIMS score of 12 out of 15. The MDS assessment revealed the resident required set-up assistance for eating and substantial assistance with hygiene, dressing and transferring. B. Resident interview and observation Resident #11 was interviewed on 3/9/26 at 4:00 p.m. Resident #11's hair was disheveled. Resident #11 said she was not getting her showers when they were scheduled. Resident #1 said she had requested to have a shower. She said she did not think the facility had enough staff to assist with showers. She said she had not had a shower in at least a week. C. Record review Resident #11's activities of daily living (ADL) care plan, revised 3/2/26, indicated she had a self-care performance deficit related to left upper extremity fracture and urinary tract infection, and she required substantial assistance for bathing. It revealed the need to check Resident #11's nail length and trim and clean Resident #11's nails on bath (shower) day and as necessary, and to avoid scrubbing and pat dry sensitive skin. Resident #11's shower record from 2/19/26 to 3/11/26 was provided by the NHA on 3/11/26 at 11:52 a.m. The record revealed Resident #11's last documented shower was on 3/1/26, 10 days earlier. The DON provided a document titled Follow Up Question Report on 3/12/26 at 3:40 p.m. The record revealed Resident #11's bathing preference was twice weekly, on Sundays and Thursdays, and the resident would accept showers on other days. The record documented Resident #1 had showered on 3/1/26 and the next documented shower was not until 3/10/26, nine days later. -Per Resident #11's documented shower preference, she did not receive a shower on Thursday (3/5/26) or Sunday (3/8/26). D. Staff interview The DON was interviewed on 3/12/26 at 3:40 p.m. She said Resident #11 should receive two showers per week. The DON said she did not know why there was a nine day gap between Resident #11's showers. The DON said she did not know why there was a discrepancy between the shower record provided by the NHA which did not reveal Resident #11's shower on 3/10/26. The DON said there was no documentation to indicate that Resident #11 had refused any showers.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#46) of four residents reviewed for quality of care out of 54 sample residents.Specifically, the facility failed to ensure physician's orders were obtained and entered for Resident #46's dressing changes following an orthopedic appointment.Findings include:I. Facility policy and procedureThe Physician Orders policy, revised 2/11/26, was received from the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. It read in pertinent part, The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. All physician/practitioner orders, including verbal/telephone orders, are recorded in the medical record for each resident.II. Resident #46A. Resident statusResident #46, age [AGE], was admitted to the facility on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included displaced trimalleolar fracture of right lower leg (ankle injury), muscle weakness and history of falling.The 2/6/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She needed set-up assistance with eating, oral hygiene, toileting and partial to moderate assistance with showering/bathing, upper and lower body dressing.B. Resident interviewResident #46 was interviewed on 3/10/26 at 8:45 a.m. Resident #46 said she had a right ankle fracture and had a wound on her right ankle following surgery. She said on 3/4/26 after the cast was removed, the orthopedic office ordered the dressing on her ankle to be changed every three days. She said the dressing was not changed until the morning of 3/9/26, after she brought it to the nurse's attention.C. Record reviewReview of the 3/4/26 orthopedic follow-up note revealed Resident #46's sutures were removed. The resident could shower over the incision but was not to submerge the incision under water, and dressing changes were to be completed daily or every other day.The 3/4/26 at 3:30 p.m. progress note revealed Resident #46 returned from an orthopedic appointment where her ankle cast and sutures were removed. The note documented the resident could shower over the incision but not submerge the incision under water, and dressing changes to her ankle were to be completed every other day or daily.Review of Resident #46's March 2026 physician's orders revealed no orders for dressing changes were entered following the 3/4/26 orthopedic appointment.-There was no documentation in the resident's electronic medical record (EMR) to indicate that the resident's ankle dressing had been changed as ordered.-A second review of Resident #46's March 2026 CPO revealed a physician's order for wound care to the resident's right lateral ankle, including cleansing and application of a dry dressing with securement using an ACE wrap every other day, was not initiated until 3/11/26 at 2:25 p.m., during the survey.III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 3/11/26 at 1:41 p.m. RN #2 said when physician's orders were received from an outside provider, the information would be reviewed by the facility's physician. She said if the facility's physician agreed with the outside provider's orders, the facility's physician entered the orders. She said if the facility's physician did not agree with the orders, the physician documented the information in a progress note and verbally notified the nurse. RN #2 said Resident #46 did not report to her or to other staff that the resident's ankle dressing had not been changed. She said the physician's orders for Resident #46's ankle dressing change were received from the orthopedic office on 3/4/26, and the dressing was to be changed daily or every other day. She said there was no documentation in the resident's EMR indicating the dressing was changed after the resident returned from the orthopedic appointment on 3/4/26. RN #3 was interviewed on 3/11/26 at 1:57 p.m. RN #3 said orthopedic provider notes would be reviewed by the nurse and the nurse was expected to write a progress note and enter the physician's orders in the residents' EMRs. She said she was not aware that Resident #46's ankle dressing had not been changed. She said the instructions received from the orthopedic office were for every other day or daily dressing changes. She said the instructions should have been entered into the resident's EMR as a physician's order. She said if dressing change orders were not entered and followed, the resident could be at risk for infection and the infection could lead to sepsis (severe infection response).The director of nursing (DON) was interviewed on 3/12/26 at 3:58 p.m. The DON said when Resident #46 returned from the orthopedic appointment on 3/4/26 with instructions for daily or every other day dressing changes, the nurse was responsible for reviewing the instructions and implementing the physician's orders. She said she did not know why the instructions were missed and said that she completed an audit (during the survey) going back to 3/1/26 to ensure outside appointment instructions were reviewed and entered into the residents' EMRs The DON said the unit managers would complete weekly audits to ensure physician's orders from outside providers were entered into the residents' EMRs and implemented. She said the facility would complete a look-back review and address the concern through the quality assurance and performance improvement (QAPI) process.

Based on observations, record review and interviews, the facility failed to ensure one (#33) of five residents reviewed for accidents out of 54 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to:-Ensure Resident #33's care plan was accurate and up to date with the resident's correct transfer status; and, -Ensure therapy timely assessed the resident after she sustained bruising related to a transfer. Findings include:I. Professional referenceAccording to the ARJO product guide, retrieved on 3/23/26 from https://www.arjo.com/en-us/products/patient-handling/floor-lifters/#product-list-tab-1, Sara Steady enables a single caregiver to assist patients or residents perform sit to stand transfers throughout the day. The pivoting seat can be moved out to enable the patient to stand, and provides an angled seated support during the transfer. According to the [NAME] Sit-to-Stand Lift product guide, retrieved on 3/23/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.hillrom.com/content/dam/hillrom-aem/emea/en/marketing/products/[NAME]-ii-sit-to-stand-lift/documents/7EN155106%20Rev%202%20-%20Sabina%20II.pdf, The [NAME] sit-to-stand lift is especially designed for people who have difficulty in standing up on their own from a seated position. There are two different sling bar options for [NAME] sit-to-stand lift, as well as many different sit-to-stand vests. The patient's overall mobility determines the choice of cling bar and sit-to-stand vest.II. Resident #33A. Resident statusResident #33, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), the diagnoses included Parkinson's disease, chronic respiratory failure, myocardial infarction (heart attack), and atrial fibrillation (heart arrhythmia). The minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required substantial/maximal assistance with all ADLs. The resident was dependent on staff for transfers.The MDS assessment revealed the resident was taking an anticoagulantB. Resident interviewsResident #33 was interviewed on 3/9/26 at 10:45 a.m. Resident #33 said she had a large bruise on her back from staff not using the sit to stand properly. The resident said she was on Eliquis for blood thinner and was aware that she bruised easily. Resident #33 said staff came in to assist her with a transfer using a lift. The resident said she was instructed to reach out with her hands and grab on to two bars in front of her. Resident #33 said a certified nurse aide (CNA) placed a belt around her back and did not put it on correctly. Resident #33 said as the resident began standing with the lift it started hurting her. Resident #33 yelled out for the CNA to stop because it was hurting. The resident said the CNA did not stop and continued lifting the resident from her wheelchair. C. Record reviewThe ADL care plan, revised on 1/13/26, revealed Resident #33 had an ADL self-care performance deficit related to her Parkinson's disease, chronic respiratory failure with hypoxia, myocardial infarction, hypertensive urgency, muscle weakness, and unsteadiness on feet. Pertinent interventions included the resident required maximum assistance of two people using the Sara Steady The Kardex (staff directive tool), dated 3/10/26, revealed Resident #33 was a two person maximum assist with a hoyer lift. -However, during an interview with CNA #6. CNA #6 said Resident #33 required a Sara Steady lift on Kardex (see interview below).The 3/1/26 social services note documented at 6:30 p.m. revealed the social services department met with Resident #33 to follow up on the nursing report regarding the bruise to her rib area. The resident said it happened with the lift and the lift continued to be uncomfortable. Social services met with the CNAs who reported struggling with space and layout of the resident's room. Resident #33 said the staff treated her well and no person has intentionally caused her discomfort or mistreated her in any way. The note documented the social service director (SSD) would review transfer concerns with the therapy team. -However, review of the resident's electronic medical record (EMR) did not reveal documentation that the therapy team was notified to review the transfer concerns of the resident. The 3/2/26 nursing progress note documented at 9:46 p.m. revealed Resident #33's Xray was cleared with no acute rib fracture. The 3/3/26 nursing progress note documented at 8:19 p.m. revealed Resident #33 had bruising across her back with bruising on her left side all the way to her breast. The nurse changed the resident from using a Sara Steady to the Hoyer lift for transfers. The nurse advised the CNAs to pad under the resident's shirt with pillows to cushion during the Hoyer transfer. Resident #33 was on Eliquis and bruised easily. D. Staff interviewsCNA #7 was interviewed on 3/10/26 at 2:35 p.m. CNA #7 said Resident #33 had bruising all across her back. CNA #7 said the bruise was black. CNA #7 said did not know how Resident #33 acquired the bruise. CNA #7 said it may have been from using a lift improperly. CNA #7 said she was only supposed to use a Hoyer lift with Resident #33, which required the assistance of two CNAs.CNA #6 was interviewed on 3/10/26 at 2:51 p.m. CNA #6 said she was made aware of Resident #33's bruising on her side, but had not visually seen the bruise herself. CNA #6 said initially she was informed Resident #33 used the Sara Steady lifts for transfers, but now the resident was a hoyer. CNA #6 said the incident occurred about two weeks ago. She said she was unsure of the root cause but thought it could have been due to pressure from a sling. CNA #6 said she did not know how the incident was documented in the electronic charting system but heard by word of mouth about the residents' bruising and to use the hoyer moving forward. CNA #6 said the resident's Kardex should also reflect the resident's transfer needs. CNA #6 said the Sara Steady lift was approved by therapy and only required the use of one CNA unless otherwise ordered by the rehabilitation department. CNA #6 said Resident #33 was not appropriate for the sit to stand because if a resident has a curved spine the sling for the sit stand was not appropriate. CNA #6 said the resident required a Sara Steady lift because it worked with her curved spine. CNA #6 said therapy had informed her about the curvature of the spine.CNA #6 said to her knowledge Resident #33 currently required a Hoyer lift. She said a couple months prior when she looked at the Kardex it said Resident #33 required a Sara Steady lift for transfers. CNA #6 said she the resident's Kardex currently said she required a Hoyer lift with the assistance of two people. CNA #6 said she observed two CNA's the other day attempting to go into Resident #33's room with a sit to stand and CNA #6 had to notify the RN on duty and the RN went and put a stop to the CNA's using the sit to stand on Resident #33. Registered nurse (RN) #5 was interviewed on 3/10/26 at 3:48 p.m. RN #5 said she was not working the specific day the incident occurred, however, days later RN #5 was on shift and was in Resident #33's room. RN #5 said the resident told RN #5 she was hurting on her side and in pain. RN #5 said she observed bruising to Resident #33's left side and immediately notified the physician, family, and arranged for an Xray. RN #5 said the bruising was caused during a transfer with a sling from the sit to stand. RN #5 said she could not recall what day the resident notified RN #5 but she believed it was over a weekend. RN #5 said the therapy team assessed the resident for the appropriate use of a lift. RN #5 said she reported any changes in the resident's mobility or transfer status to therapy so they could further evaluate the resident. RN #6 was interviewed on 3/11/26 at 12:02 p.m. RN #6 said she was unaware of any bruising to the resident's side. RN #6 said she reviewed Resident #33's chart and said a chest Xray was completed on 3/2/26 related to bruising. RN #6 said a risk management assessment and incident report were done on 3/1/26. RN #6 said Resident #33 did voice discomfort to arms, and the resident was evaluated for the sling for a proper fit. RN #6 said physical therapy was responsible for assessing a resident to determine the proper use of a sling and lift. The director of rehabilitation was interviewed on 3/11/26 at 10:07 a.m. The director of rehabilitation said Resident #33 had not been on the therapy caseload since 2/4/26 (prior to the bruising). The director of rehabilitation said facility staff had concerns with the Resident's transfer status. The director of rehabilitation was reviewing notes and said Resident #33 did not care for a gait belt because it hurts her ribs. The director of rehabilitation said a gait belt was always appropriate when transferring a resident. The director of rehabilitation said when staff are using the Sara Steady they should be putting a gait belt on the resident. The director of rehabilitation said any RN could always upgrade a resident, however if a Resident was a hoyer and the facility wanted to downgrade a resident to a sit to stand that resident would need to be assessed by therapy. The director of rehabilitation said if a resident isn't feeling well or needs more assistance then it was always best practice and safer for the resident to use a maximum assistance which could be the hoyer lift. The director of rehabilitation reviewed more notes and said Resident #33's bruising came from a sling and the progress note was dated 3/1/26. The director of rehabilitation said the RN's have degrees for a reason and are more than capable of assessing a resident to determine if the resident needs more assistance with a transfer. The director of rehabilitation said she suspected the Hoyer lift was accurate for Resident #33. The director of rehabilitation said therapy was not always involved with a resident. The director of rehabilitation said therapy tried to be involved as much as possible but it was not always necessary. The director of rehabilitation said Resident #33 was not making progress in therapy and she was dropped from the therapy caseload on 2/5/26.Physical therapist (PT) #1 was interviewed on 3/12/26 at 11:50 a.m. PT #1 said if a resident was deemed inappropriate for a sit stand lift if they were non weight bearing either to their upper or lower extremities. PT #1 said determining an appropriate lift is also individual based and dependent on the resident and their specific needs. PT #1 said a sit to stand lift would be inappropriate for a resident with a curved spine depending on if the belt was causing pain across the spine. PT #1 said the sit to stand would be inappropriate for anyone if it caused pain. The DON and the NHA were interviewed together on 3/12/26 at 3:00 p.m. The DON said as of 1/13/26 the resident required a sit to stand lift. The DON said therapy recommended Resident #33 used a sit to stand lift. The NHA said an audit was performed on therapies recommendation. The NHA said she thought the nurses on the floor are interchanging the words sit to stand and Sara Steady which was causing confusion. The NHA said the ideal process would be upon admission of a resident therapy was to assess them. The NHA said the therapy department was not always available and the facility was not going to wait until therapy had time. The NHA said an RN could make the initial assessment, however they also wanted the therapy departments input. The NHA said the RN's were always going to do what was quick and easier for the resident when it comes to transfers. The NHA said the RN might determine that a resident was a sit to stand but they wanted therapy to come in after and do a more thorough assessment to ensure the RN's determination was appropriate. The NHA said the facility would error on the side of caution for a level of higher assistance always to ensure the residents safety. The NHA said if a resident was a Hoyer lift then therapy would need to assess that resident to determine if the resident would be appropriate to step down to a sit stand because the RN's are not able to make that determination.

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#147) of two residents out of 54 sample residents. Specifically, the facility failed to ensure Resident #147's pain medication was administered as ordered and needed per the resident's condition. Findings include:I. Facility policy and procedureThe Pain Management policy was provided by the nursing home administrator (NHA) on 3/12/26 at 1:49 p.m. It read in pertinent part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.II. Resident #147A. Resident statusResident #147, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included explantation of knee joint prosthesis (surgical removal of the medical knee device), infection and inflammatory reaction due to internal left knee prosthesis, seizure disorder and neuropathy.Resident #147's minimum data set (MDS) assessment had not yet been completed as of 3/9/26. An MDS note on 3/6/26 at 2:40 p.m. documented Resident #147 had severe left knee pain.B. Resident observation and interviewResident #147 was interviewed on 3/9/26 at 3:05 p.m. Resident #147 was lying in bed with her left leg elevated on a pillow. A wound dressing was on Resident #147's left knee. Resident #147 said she had three knee surgeries prior to admission. Resident #147 said the most recent surgery had been the most extensive due to an infection and the resident said she experienced a lot of pain after this surgery. Resident #147 said when she arrived at the facility on 3/4/26, her pain was not significant because she had just received narcotic pain medication prior to leaving the hospital. Resident #147 said on 3/4/26 at 10:00 p.m. her left knee pain had increased to a level that was an 8 out of 10 on a pain scale and she requested narcotic pain medication. Resident #147 said the nurse gave her Tylenol for pain and then later told her that the narcotic medication was not available for administration. Resident #147 said by 3/5/26 at 5:00 a.m., she rated her pain a 10 out of 10 on the pain scale. Resident #147 said she did not receive the first dose of narcotic pain medication until mid-day on 3/5/26. Resident #147 said she managed to wait for the medication, however, she did not want other residents to have the same experience she had.C. Record reviewResident #147's pain care plan, initiated 3/5/26, revealed the resident expressed pain. The care plan interventions included evaluation of pain interventions and administration of pain medication as ordered. The pain care plan contained instructions to specify the pain type and what the pain was related to within the care plan. Resident #147's March 2026 CPO revealed the following physician's ordersNumeric Scale Pain Assessment every four hours for three days, ordered on 3/4/26 at 1:30 p.m.Hydromorphone Hydrochloride (HCL) oral tablet two milligrams (mg), one tablet by mouth every four hours as needed for pain, ordered on 3/4/26 at 1:30 p.m.-However, the first dose of Hydromorphone two mg was not administered until 3/5/26 at 11:30 a.m., 19.5 hours after Resident #147 began rating her pain at a seven level. -There were no physician orders for Tylenol or Tylenol administration documented until 3/10/26 (see Resident #147's interview above).-Resident #147's pain level intensity was documented as a seven on 3/4/26 at 4:00 p.m. and a seven on 3/4/26 at 8:00 p.m. on a numeric scale from zero to 10.-Resident #147's pain level was eight on 3/4/26 at 10:00 p.m, and ten on 3/5/26 at 5:00 a.m. (see interview above) and the resident's pain was not documented as ten until 3/5/26 at 11:30 a.m.A physician's progress note on 3/6/26 at 8:43 p.m. documented Resident #147 said the Hydromorphone helped her pain, however it took a while to get the medication after admission. D. Staff interviewsThe director of nursing (DON) was interviewed on 3/12/26 at 4:20 p.m. The DON said due to Resident #147's surgical pain, she should have pain medication available for administration upon the resident's admission. The DON said the facility had an automated medication dispensing system to retrieve medications if the medication was not yet available from the pharmacy at admission. The DON said if the nurse did not find the medication ordered in the automated medication dispensing machine, she should have contacted the physician on-call so the physician could order an alternative pain medication. The DON said she had not seen documentation from the nurse regarding any Tylenol administration. The DON said the facility would provide reeducation to nursing staff regarding pain medication assessment and administration.The DON was interviewed again on 3/12/26 at 5:30 p.m. The DON said she reviewed the inventory for the automated medication dispensing machine, and the Hydromorphone HCL two mg dose was available for administration on 3/4/26 and the nurses should have administered the medication when requested by Resident #147.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three (#2, #15, and #16) of five certified nurse aides (CNA).Specifically, the facility had not completed annual performance reviews for CNA #2, #15, and #16 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe Performance Evaluation policy and procedure, reviewed 12/4/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 6:02 p.m. It read in pertinent part, Ongoing performance feedback is strongly encouraged between associates and their supervisors throughout their employment. New associates should receive a formal 90-day evaluation, as should associates newly transferred or promoted to a new role. Annual performance reviews are given to all associates. II. Record reviewAnnual performance reviews were requested on 3/12/26 at approximately 11:33 a.m. Review of the employee files revealed CNA #2's last employee evaluation was done on 7/14/23, CNA #15's last employee evaluation was done on 6/5/24, and CNA #16's last employee evaluation was done on 7/14/23.III. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 3/12/26 at 4:31 p.m. The DON said the staffing development coordinator (SDC) tracked all the information for employee evaluations. The NHA said they do their all-staff training during their annual skills fair. The NHA said the SDC was unable to be interviewed due to being in the hospital.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 10.34%, which was three errors out of 29 opportunities for error. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Administration of Medications policy, revised 9/9/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 5:29 p.m. It read in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.III. Observations and record reviewOn 3/10/26 at 2:38 p.m. registered nurse (RN) #1 was observed during Resident #22's medication administration. The physician's order read:Give five milligrams (mg) of Oxycodone (an opioid pain medication) oral tablet every three hours for pain, ordered 3/7/26.RN #1 placed one tablet of Oxycodone in an administration cup and placed the medication cup on the bedside table in front of Resident #22. RN #1 then went out in the hall and performed hand hygiene. RN #1 then walked back into Resident #22's room and asked the resident if she had taken the medication. Resident #22 said she took the medication.-RN #1 did not watch Resident #22 take the medication and the resident did not have an order or assessment completed that allowed them to take their medication unsupervised.On 3/10/26 at 5:15 p.m. licensed practical nurse (LPN) #3 was preparing Resident #34's medications for administration.The physician's order read:Give 37.5 mg of Seroquel (an antipsychotic medication) two times a day for dementia with behaviors, ordered 1/24/26.LPN #3 pulled a medication card for propranolol (a blood pressure medication) out of the medication cart, pointed to the medication name, and incorrectly stated Seroquel. LPN #3 then placed the propranolol into the medication cup. She marked the Seroquel as given in the medication administration record (MAR). She then took the medication cup, which contained the propranolol, to administer the medication to Resident #34. Upon prompting, LPN #3 did not administer the medication after she was informed it was the incorrect medication.-Cross-reference F760: failure to ensure residents were free from a significant medication error.On 3/10/26 at approximately 5:17 p.m. LPN #3 was preparing Resident #34's medications. The physician's order read: Give 37.5 mg of Seroquel two times a day for dementia with behaviors, ordered 1/24/26.LPN #3 correctly identified the seroquel medication card and placed a 25 mg tablet into the medication cup. LPN #3 then administered the medication to Resident #34.-LPN #3 administered 25 mg of Seroquel. The correct dose for administration was 37.5 mg (1.5 tablets).IV. Staff interviewsLPN #3 was interviewed on 3/10/26 at 5:15 p.m. LPN #3 said she was not sure why she had attempted to administer propranolol instead of Seroquel. LPN #3 said it was two and a half hours before Resident #34 was due to receive propranolol. LPN #3 said she had charted the Seroquel had been given on the MAR, which indicated Resident #34 would have received the propranolol dose given in error in addition to her scheduled dose to be administered in the evening. LPN #3 said Resident #34 could have had adverse effects from receiving two doses of propranolol.LPN #1 verified the correct dose of Seroquel for Resident #34. LPN #1 said the correct dose of Seroquel was 37.5 mg, which was one and a half tablets. The director of nursing (DON) was interviewed on 3/10/26 at 6:15 p.m. The DON said Resident #34 could have suffered an adverse reaction to receiving propranolol instead of the prescribed medication. The DON said it could have resulted in Resident #34 receiving a second dose of the medication when it was scheduled to be given, which could have resulted in hypotension (low blood pressure).The DON was interviewed again on 3/12/26 at 1:55 p.m. The DON said the facility had given the remainder of the Seroquel dose to Resident #34 on 3/10/26. The DON said LPN #3 had been terminated in response to her medication errors. The DON said RN #1 should have observed Resident #22 taking their medications rather than leaving the room. The DON said she would provide education to RN #1 on medication administration.

Based on observations, record review and interviews, the facility failed to ensure one (#34) of 10 residents reviewed for medication administration was kept free from significant medication errors out of 54 sample residents.Specifically, the facility failed to ensure the correct medication was administered to Resident #34 based on the physician's orders. Findings include:I. Professional referenceAccording to the manufacturer, Amneal Pharmaceuticals NY LLC, 2025, Propranolol Hydrochloride (HCL) tablet Drug Label Information, retrieved 3/17/26 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=14d0c95d-418f-40a8-bad3-e20c82424960&audience=consumer, Adverse reactions - The following adverse events were observed and have been reported in patients using propranolol: Bradycardia (low heart rate); congestive heart failure (when the heart is unable to pump blood efficiently); hypotension (low blood pressure); paresthesia of hands (numbness and tingling); arterial insufficiency ( a lack of, or slow blood flow). Overdosage - Hypotension and bradycardia have been reported following propranolol overdose and should be treated appropriately.According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment . Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration . To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights : 1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Administration of Medications policy, revised 9/9/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 5:29 p.m. It read in pertinent part, Medication Error - This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; Significant medication error - This means one which causes the resident discomfort or jeopardizes his or her health and safety. Right Drug. Every drug administered must have an order from the provider. Compare the order with the medication administration record (eMAR) for accuracy. Compare the label on the drug to the information on the eMAR. three times: i. Before removing the container from the drawer ii. As the drug is removed from the container and iii. At the bedside before administering it to the resident\.III. Resident #34A. Resident statusResident #34, age [AGE], was admitted on [DATE]. According to the 3/11/26 computerized physician's orders (CPO), diagnoses included Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder.The 12/23/25 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15.B. Record reviewReview of Resident #34's March 2026 CPO revealed the following physician orders:Seroquel (an antipsychotic medication) 25 milligrams (mg) tablet, give 37.5 mg two times a day for dementia with behaviors, ordered 1/24/26.Propranolol HCL 20 mg, give one tablet by mouth twice a day. Hold (do not give) for heart rate less than 55 beats per minute, ordered 11/6/25.C. ObservationsOn 3/10/26 at 5:15 p.m. licensed practical nurse (LPN) #3 was preparing medications for administration to Resident #34. LPN #3 obtained a medication out of the medication cart, which read propranolol 20 mg. LPN #3 pointed to the medication name and stated, Seroquel. LPN #3 then placed the propranolol tablet into the medication cup. She marked the Seroquel as given on the medication administration record (MAR). LPN #3 took the medication cup to which contained the propranolol, to administer to Resident #34. - LPN #3 was prompted that there was a medication error, so the propranolol was not administered to the resident.-Cross-reference F759: failure to ensure residents were free from medication errors greater than five percent.D. Staff interviewsLPN #3 was interviewed on 3/10/26 at 5:15 p.m. LPN #3 said she was not sure why she had attempted to administer propranolol instead of Seroquel. LPN #3 said Resident #34 was not due for propranolol until later that evening. LPN #3 said she had documented the Seroquel had been administered on the MAR, which meant Resident #34 would have received propranolol twice within a few hours. LPN #3 said Resident #34 could have had adverse effects from receiving two doses of propranolol, such as a low heart rate.The director of nursing (DON) was interviewed on 3/10/26 at 6:15 p.m. The DON said Resident #34 could have suffered an adverse reaction from receiving propranolol instead of the prescribed medication. The DON said Resident #34could have experienced hypotension from receiving a second dose of the medication in the evening when it was scheduled to be given.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#62) of two residents reviewed for hospice services out of 54 sample residents.Specifically, the facility failed to implement a hospice care plan for Resident #62 when she was admitted to hospice. Findings include: I. Facility policy and procedureThe Hospice Coordination of Care policy and procedure, revised 9/3/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. it read in pertinent part, The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the resident; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.II. Resident #62A. Resident statusResident #62, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included senile degeneration of the brain (age-related loss of nerve cells causing cognitive decline), Alzheimer's disease, and dementia with psychotic disturbance. The 2/12/26 minimum data set (MDS) assessment revealed Resident #62 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The assessment revealed Resident #62 needed supervision or touching assistance with most of her activities of daily living. The assessment indicated Resicent #62 was receiving hospice care.B. Record reviewReview of the March 2026 CPO revealed Resident #62 was admitted to hospice on 2/3/26 with a diagnosis of senile degeneration of the brain. Review of Resident #62's comprehensive care plan, reviewed 2/24/26 did not reveal a hospice care plan with a delineation of cares. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/10/26 at 3:01 p.m. She said that there was not a hospice communication book. She said everything is uploaded into the electronic medical record (EMR). She said the EMR was their lifeline. The social services assistant (SSA) was interviewed on 3/12/26 at 12:13 p.m. He said he stayed in constant communication with the hospice social workers. He said they email and call back and forth and he will ensure everyone is aware of the care conferences.The SSA said he said he was not responsible for creating the hospice care plan. He said he thought that the unit manager or nursing was responsible for creating the hospice care plan. LPN #1 was interviewed a second time on 3/12/26 at 12:49 p.m. She said she did not initiate the hospice care plans. She said the MDS nurse initiated them. She said generally, the hospice care plans were generic and very general. The director of nursing (DON) was interviewed on 3/12/26 at 3:31 p.m. She said the MDS nurse primarily updated the care plans. She said hospice care plans should be initiated at the time of admission to hospice. She said the hospice care plan should include the delineation of care. She said the delineation of care was important because the facility and the hospice care company needed to be on the same page when caring for the resident. She said Resident #62 did not have a hospice care plan. She said she should have had a hospice care plan with a delineation of care implemented when she was admitted to hospice.

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for one (#31) of five residents reviewed for abuse out of 54 sample residents. Specifically, the facility failed to ensure an incident of alleged physical abuse for Resident #31 was reported to the State Survey Agency. Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, reviewed 5/6/25, was provided by the nursing home administrator (NHA) on 3/12/26 at 11:11 a.m. It read in pertinent part, Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any. II. Resident #31A. Resident statusResident #31, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale (multiple small blood clots in the pulmonary arteries), malnutrition, hyperlipidemia and hyperthyroidism. The 2/13/26 minimum data set (MDS) assessment revealed Resident #31 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #31 was independent or needed setup or clean-up assistance with her activities of daily living (ADL). The assessment revealed Resident #31 did not have any physical or verbal behaviors directed at others or other behavioral symptoms not directed towards others. B. Resident interviewResident #31 was interviewed on 3/10/26 at 9:46 a.m. Resident #31 said there was a male resident that had come into her room and she had tried to help him in February 2026. She said he did not want her help and he had hit her chest. She said that when he hit her, it had hurt. C. Record reviewA progress note, dated 2/20/26 at 12:10 p.m., revealed a nurse was notified by a certified nurse aide (CNA) that Resident #39 was found inside Resident #31's room at approximately 6:00 a.m. The note documented Resident #31 stated to the CNA that Resident #39 had hit her in the chest when she tried to help him. The progress note documented another CNA reported she had found Resident #39 in front of Resident #31's room at approximately 5:55 a.m. The note documented the CNA said Resident #39 was grabbing Resident #31's leg, asking her to help him find his buddy. The CNA stated she removed Resident #39's hands from Resident #31's leg and removed Resident #39 from Resident 31's room. The progress note documented a skin and pain assessment were completed. Resident #31 stated the area where she had been hit was sore and one-to-one supervision was provided for Resident #39. The facility's investigation was provided by the NHA on 3/11/26 and revealed the following:On 2/20/26 a CNA reported to the nurse that Resident #39 was found in Resident #31's room and Resident #31 told the CNA that Resident #39 had hit her chest. A second report was made to the same nurse from a different CNA at 11:30 a.m. that Resident #39 was in front of Resident #31's door at approximately 5:55 a.m. The second report documented Resident #39 was grabbing Resident #31's leg asking for her help to find his buddy. The CNA reported that she removed Resident #39's hand from Resident #31's leg and removed Resident #39 from the area. The investigation documented that Resident #31 stated Resident #39 crawled into her doorway and when she bent down to help him up, Resident #39 hit her chest. The investigation documented that Resident #39 was removed from Resident #31's room. Resident #31 stated her chest hurt where she had been hit, but there were no visible signs of injury. Resident #39 was provided with one-to-one supervision. The investigation further documented that the interdisciplinary team (IDT) did not feel the incident that occurred on 2/20/26 was a reportable incident. The investigation documented the IDT did not feel there was an allegation or intent. The facility interviewed Resident #31 and she said she was trying to help Resident #39 get up off the floor. Resident #31 said he (Resident #39) did not want her help, so he pushed her hand away to decline her assistance and then brushed her chest. Cross reference F600 for failure to protect residents from abuse. III. Staff interviewsCNA #9 was interviewed on 3/12/26 at 9:44 a.m. CNA #9 said Resident #31 had reported the incident with Resident #39 to her. She said that Resident #39 had grabbed Resident #31's leg in an attempt to pull himself up. She said she did not witness it herself but reported what Resident #31 had told her to the nurse. CNA #10 was interviewed on 3/12/26 at 9:59 a.m. CNA #10 said she was just coming on to her shift and she saw Resident #31 trying to get Resident #39 out of her room. She said Resident #31 reported to her that Resident #39 had punched her chest. She said that Resident #31 was holding her chest when she told her about being punched. CNA #10 said that she reported the incident to the nurse that was on duty and talked Resident #31 into making the report to the nurse and the unit manager. The social services assistant (SSA) was interviewed on 3/12/26 at 12:13 p.m. The SSA said when there were abuse allegations, he interviewed the residents who were involved in the incident and interviewed the other residents to see if they saw or heard anything. He said he was aware of the situation between Resident #31 and Resident #39 on 2/20/26. He said Resident #39 was on the ground and he grabbed Resident #31's ankle as she was walking by and she did not like it. He said he spoke with Resident #31 about it and she had told him that she understood that Resident #39 had memory issues. He said Resident #39 was put on one-to-one supervision after the incident and had remained on the one-to-one monitoring since the incident. Licensed practical nurse (LPN) #1, who was the unit manager of the first floor, was interviewed on 3/12/26 at 12:49 p.m. LPN #1 said her involvement with abuse allegations was to assess the residents, call the police, contact families and report the allegations to the director of nursing (DON). She said she was aware of the incident that happened between Resident #31 and Resident #39 on 2/20/26. She said she understood the situation as Resident #39 was on the floor and went into Resident #31's room and he then tapped or grabbed Resident #31's leg. She said she had not heard that Resident #31 had been hit on the chest. The DON and the NHA were interviewed together on 3/12/26 at 3:41 p.m. The DON said that staff would either notify herself or the NHA about an abuse allegation and then the facility would do an investigation. The NHA said she was aware of the situation between Resident #31 and Resident #39 on 2/20/26. She said Resident #31 reached down to help Resident #39, and he appeared to not want help and then hit her on the chest with his hand. The NHA said the facility was on the fence about reporting it because of the interview with Resident #31. The NHA Resident #31 had told them that she felt Resident #39 had not meant to hurt her. The NHA said that Resident #39 had willfully hit Resident #31 and was then put on one-to-one supervision. The NHA said after reviewing the incident, the facility should have reported it to the State Survey Agency.

Based on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the past three years. Specifically, the facility failed to ensure three years of survey and investigation findings were available for the public, and where individuals wishing to examine survey results did not have to ask to see them. Findings include: I. ObservationsOn 3/11/26 at 3:15 p.m. the facility's survey results binder was found in the front lobby of the facility. The binder was found to have the findings from the surveys on 9/28/22, 11/12/20, and 9/26/19 . The survey results binder failed to include the facility's most recent recertification survey from 1/23/24 and the last three years of complaint findings. II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 3/11/26 at 3:37 p.m. She said the most recent survey and the last three years of complaint findings should be in the binder. She said she had thought that they were in the binder.

Based on record review and interviews, the facility failed to notify the resident's representative when there was a significant change in the resident's condition for one (#3) of four residents out of four sample residents. Specifically, the facility failed to notify the designated representative for Resident #3 when he had a fall in the facility.Findings include:I. Facility policy and procedure The Change in Resident's Condition or Status policy and procedure, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 4:47 p.m. It read in pertinent part, A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is an accident or a significant change in the resident's physical, mental or psychosocial status.II. Resident #3A. Resident status Resident #3, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included transient ischemic attack (a mini stroke when there is a temporary interruption of blood flow to the brain), cerebral infarction (a stroke), acute respiratory failure, spinal stenosis (the spinal canal becomes narrow), bilateral osteoarthritis of the knee and a history of falling. According to the [DATE] minimum data set (MDS) assessment, the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. He required a walker. He required set up assistance for eating, supervision for oral hygiene and toileting, and partial assistance with personal hygiene. B. Resident representative interviewResident #3's representative was interviewed on [DATE] at 12:15 p.m. via telephone. The representative said the facility did not notify her when the resident fell on [DATE]. She said she was notified on [DATE] at around 8:30 a.m. that the resident needed to go to the hospital because he was unresponsive. She said no one at the facility could explain what happened to cause the resident to become unresponsive and need to go to the hospital. She said at the hospital, the resident was discovered to have a large hematoma (a localized collection of blood outside the circulatory system) on the right side of his head, and the doctors at the hospital said he was not a surgical candidate. She said he was placed on hospice care at the hospital and died four days later. Resident #3's representative said when the resident fell, the facility was supposed to call her because she was the resident's power of attorney (POA). She said it was really frustrating because the facility did not always call her and she had family members telling her what happened to the resident. She said the facility knew they could call her at any time, including in the middle of the night, when the resident fell or something else happened to him. She said although the resident's death happened three months ago ([DATE]), the death and experience with the facility was still fresh. The resident's representative was tearful throughout the phone call. C. Record reviewThe [DATE] at 12:38 a.m. nurse progress note revealed Resident #3 was found on the floor by a certified nurse aide (CNA). The resident was sitting on the floor with his back against his bed and his legs towards the closet. His legs were bent at the knees. He had grippy socks and slippers on his feet. His call light was within reach but not on. The resident's floor and clothes were wet. The resident denied hitting his head and said he hit his shoulder on the heater vent. The resident's four-wheeled walker was tipped over onto the heater. The registered nurse (RN) assessed the resident and no injuries were found. The physician was notified. The resident was encouraged to use the call light and wait for assistance. The call light was within reach.-There was no documentation to indicate the resident's representative was notified of the resident's fall. The [DATE] at 8:15 a.m. nurse progress note revealed Resident #3 remained on neurological checks and the checks were within normal limits. The CNA reported to the nurse that the resident was gasping when breathing. The nurse went to the resident's room, vital signs were obtained and the resident was noted to be unresponsive to verbal, physical or sternal rub stimuli. The resident was warm and moist to the touch and his breathing continued with gasps. The resident's right pupil was slightly smaller than the left pupil, which was a change for the resident as he was alert and was able to place his breakfast order this morning ([DATE]). Resident #3 had denied any pain earlier that same morning. The resident was incontinent. The unit manager was notified and emergency medical services (EMS) was called. The resident was a full code status. The unit manager placed phone calls to the resident's family and to the physician The resident was transferred to the emergency room to evaluate and treat. The [DATE] fall incident report revealed the POA was notified on [DATE] at 8:47 a.m. (eight hours after the resident's fall). The [DATE] history and physical trauma surgery report from the hospital revealed Resident #3 had a large left subdural hematoma (a collection of blood that accumulates between the tough outer layer of the brain and the middle layer of the brain). The report indicated the resident had experienced multiple falls over the last several weeks. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on [DATE] at 3:10 p.m. LPN #1 said if a resident fell, she contacted the resident's physician and the resident's representative by phone. She said if the resident fell in the middle of the night, she contacted the resident's representative in the middle of the night. She said if there were multiple family members listed on the resident's facesheet, she contacted the family member who was listed as emergency contact number one first. She said it was important to contact the family member because it was the protocol and because she did not want to have additional issues if there were any. She said she was familiar with Resident #3 but she did not know who the family members were and she was not familiar with any of his falls because he was only in her unit for a short period of time. Registered nurse (RN) #1 was interviewed on [DATE] at 3:18 p.m. RN #1 said if a resident fell, she contacted the resident's physician and the resident's representative by phone. She said if the resident fell in the middle of the night, she contacted the resident's representative in the middle of the night. She said if there were multiple family members listed on the facesheet, she contacted the family member who was listed as emergency contact number one first. She said it was important to contact the family member if a resident fell because if something happened after the fall and the facility contacted the family about the subsequent incident, she said she would imagine it could be a lot for a family member to digest. RN #1 said she was familiar with Resident #3. She said she was not working when he fell on [DATE]. She said she knew he was a frequent faller. She said she was familiar with his family and she said they wanted to be contacted any time something happened to him, including when he fell. She said his family wanted to be contacted in the middle of the night. The DON was interviewed on [DATE] at 3:47 p.m.The DON said if a resident fell, the nurse needed to notify the resident's physician and family by phone. She said if the resident fell in the middle of the night, the facility used to not contact the family until the morning. She said some of the residents who were long-term care residents had family members who did not want to be contacted in the middle of the night. She said the facility changed the process and now the staff was expected to call the family in the middle of the night unless the family said they did not want to be contacted. She said if the family did not want to be contacted in the middle of the night, it would be care planned to not contact the family. She said nurses knew which family member to contact based on who was the POA and/or who was listed as emergency contact number one on the resident's facesheet. She said it was important to contact the family because they deserved to know what was going on with their family member.The DON said she was familiar with Resident #3. She said the resident's representative was not contacted until the resident went to the emergency room on [DATE]. She said she did not know the representative would want to be contacted at any time, including in the middle of the night. She said she could imagine it would be a lot to hear he went to the emergency room and then to hear he had fallen in the middle of the night, prior to his transfer to the hospital.

Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity for one (#1) of three residents reviewed out of three sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to ensure dignity was maintained for Resident #1 by emptying urine from her external catheter canister in a timely manner. Findings include: I. Facility policy and procedure The Dignity policy and procedure, dated 9/25/23, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as honor and value their input. II. Resident #1 A. Resident status Resident #1, age 78, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included cellulites (infection of the skin) of the right lower leg, post-polio syndrome (affecting persons who had polio, causing weakness, pain and fatigue), chronic pain and muscle weakness. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required total assistance with transfers and substantial assistance with bed mobility. B. Resident interview and observations Resident #1 was interviewed on 9/9/24 at 2:00 p.m. Resident #1 said she used an external catheter at night because she had frequent urination. She said the staff did not always empty the urine from the canister in the morning when she got up. Resident #1 said she emptied it herself sometimes because it was embarrassing to have the urine sitting in her room all day and other people seeing it. At 2:05 p.m. the external catheter canister was in the lower drawer of Resident #1's night stand. The canister was about one-third full and the urine was visible from across the room. C. Resident #1's representative interview Resident #1's representative #1 was interviewed on 9/9/24 at 3:45 p.m. The resident's representative #1 said she visited Resident #1 several afternoons a week and the canister usually had urine in it. She said she had found Resident #1 trying to empty it herself on occasion. D. Record review The physician's order, dated 4/29/24 indicated Resident #1 was using an external catheter. The order indicated catheter care was scheduled for the night shift. The canister was scheduled to be inspected every night shift and emptied when the canister was three quarters full of urine. A grievance was filed by email on 8/29/24 by Resident #1's representative regarding care of the external catheter. In the email, Resident #1's representative requested that the staff empty and rinse the urine canister every morning. III. Staff interviews Registered nurse (RN) #1 was interviewed 9/9/24 at 3:45 p.m. RN #1 said the nurses emptied and rinsed the canister every morning after Resident #1 got up. She said they emptied it during the night if it was almost full. The director of nursing (DON) was interviewed on 9/9/24 at 4:43 p.m. The DON said she was not sure how often the external catheter canister should be emptied. The DON said she would check the policy. The DON said the user manual indicated the canister should be emptied before it reached 1,800 milliliters to prevent overflow. The DON said the staff should empty it for Resident #1 if she wanted it emptied in the morning and not leave urine sitting out in her room all day.

Based on record review and interviews, the facility failed to act promptly upon the grievances concerning the issues of resident care and life in the facility that were important to the resident, for one (#1) of three residents out of three sample residents. Specifically, the facility failed to respond timely to Resident #1's grievances regarding long call light wait times and maintain a systematic approach to ongoing resident grievances. Findings include: I. Facility policy and procedure The Grievance policy and procedure, dated 9/25/23, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. The resident has the right to, and the facility must make prompt efforts to resolve grievances the resident may have. Facilitate meetings and/or conversations with residents and families who have repeated concerns to better meet their needs. Follow up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction. II. Resident status Resident #1, age 78, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included cellulites (infection of the skin) of the right lower leg, post-polio syndrome (affecting persons who had polio, causing weakness, pain and fatigue), chronic pain and muscle weakness. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required total assistance from staff with transfers and substantial assistance with bed mobility. III. Resident and representative interviews Resident #1 was interviewed on 9/9/24 at 2:00 p.m. Resident #1 said she usually waits 30 to 50 minutes for her call light to be answered by staff. She said she did not use her call light at shift change because it took even longer for the staff to answer the call light at that time. Resident #1 said she complained to multiple staff members about the long waits but all she was told was they were working on it. Resident #1's representative #1 was interviewed on 9/9/24 at 3:45 p.m. She said she had expressed concerns about long call light times to staff but it had not improved. She said she visited the facility on 9/8/24 and Resident #1 waited 48 minutes for her call light to be answered for assistance in the bathroom. IV. Record review A grievance was filed on 8/29/24 by Resident #1's representative that stated Resident #1 had not been provided with a resident handbook and the grievance process was not explained to the resident. The resident's representative requested that a resident handbook be provided so she could understand the process for filing a formal grievance if necessary. Resident council minutes, dated 6/26/24, revealed a couple of residents in attendance who lived on different floors expressed concerns regarding long call light wait times of 45 minutes to get care assistance. The facility responded that they would continue to conduct call light audits for response times. V. Staff interviews The director of nursing (DON) was interviewed on 9/9/24 at 2:15 p.m. The DON said she had reviewed several complaints from the residents at the June 2024 resident council meeting. She said to address the complaints she talked to the nursing staff and none of the staff had any concerns about not being able to answer call lights timely. She said all of the staff believed that they were answering call lights timely. The DON said after talking with the staff, she and one of the receptionists conducted a few observations on 6/27/24 of the nursing staff answering call lights and found they were answering call lights within six minutes of a resident activating the call lights. The DON said she was unable to find any concerns. -The facility had not assessed any other factors of what was causing longer call light wait times, and no resident interviews were completed to assess how many residents had concerns over long call light wait time; how long call light wait time affected the resident population; or why the problem of long call light wait time existed.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (#1) of three residents reviewed out of three sample residents. Specifically, the facility failed to: -Arrange medical appointments with a dermatologist and urologist as requested by Resident #1 and ordered by the physician; and, -Arrange for a medical appointment with an infectious disease specialist for Resident #1 in a timely manner. Findings include: I. Facility policy and procedure The Transportation Coordination and Services policy and procedure, dated 6/12/24, was provided by the nursing home administrator (NHA) on 9/9/24 at 4:44 p.m. It read in pertinent part, The facility will assist residents in making necessary appointments for services not provided in the facility and arranging for transportation to and from such appointments. The facility will assist the resident and or resident representative in the making of necessary appointments, such as but not limited to, medical specialists (e.g., orthopedics, cardiology, neurology, surgical). II. Resident #1 A. Resident status Resident #1, age 78, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included cellulitis (infection of the skin) of the right lower leg, post-polio syndrome (affecting persons who had polio, causing weakness, pain and fatigue), chronic pain and muscle weakness. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required total assistance from staff with transfers and substantial assistance with bed mobility. B. Resident and representative interviews Resident #1 was interviewed on 9/9/24 at 2:00 p.m. Resident #1 said she had been waiting for an appointment with a dermatologist because of a rash on her back. She said she was also waiting for an appointment with a urologist. She said urine just poured out of her and that was why she used the external catheter at night. Resident #1's representative #2 was interviewed 9/9/24 at 3:15 p.m. The representative said that he had to call Resident #1's primary physician to request a referral to an infectious disease specialist for her chronic cellulitis, because the facility was not getting the appointment made. The representative said Resident #1 did have an appointment scheduled on 9/17/24. The representative said Resident #1 was still waiting for an appointment with urology and dermatology specialists. Resident #1's represntative #1 was interviewed on 9/9/24 at 3:45 p.m. She said the family requested an appointment with the infectious disease doctor on 2/1/24. She said the representative had to call the primary care provider himself for a referral because the facility had not taken action. B. Record review The May 2024 CPO revealed the following physician's orders: -Referrals to urology, dermatology and infectious disease, ordered on 5/2/24; and, -Referral to infectious disease, ordered on 8/16/24. -However, a review of the resident's EMR did not reveal documentation indicating the appointments had been made. -Review of the May 2024 medication administration record (MAR) indicated a nurse had signed off that the referral had been completed. III. Staff interviews The director of nursing (DON) was interviewed on 9/9/24 at 4:43 p.m. The DON said the unit managers received the referrals for specialists appointments and put the order into the EMR. She said the unit managers sent the referrals to the transportation manager and the transportation manager scheduled the appointments. The DON said if an order was written in May 2024, she would expect the appointments to have been made by now. The DON said the unit manager was not aware of the referrals for Resident #1. The DON said she did not attend the care conference meetings and had not met with the family of Resident #1, therefore she was not aware of the requests. The DON said she was working on scheduling the appointments today (9/9/24).

Based on observations, record review, and interviews the facility failed to ensure two (#47 and #73) of five residents out of 36 sample residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable and to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure timely interventions were put in place to prevent the development of a pressure ulcer to Resident #47's left ischium (curved bone at the base of the pelvis). Resident #47 was admitted to the facility on [DATE] and was at risk for the development of a pressure ulcer due to her having a left hip fracture with surgical repair. Despite Resident #47's decreased mobility due to the fracture, which made her a higher risk for developing a pressure ulcer, the facility failed to implement appropriate preventative interventions, such as an alternating pressure air mattress, upon the resident's admission. The resident developed a stage 3 pressure ulcer to the coccyx on 12/22/23, which was 11 days after her admission. The wound continued to be classified as a stage 3 and the classification should have been changed to an unstageable wound (see director of nursing interview below). The wound continued to be classified as stage 3 throughout the resident's clinical record. The facility implemented the use of an alternating pressure air mattress on 12/22/23 after the wound was identified, however, the facility failed to update the resident's care plan with the intervention. The facility failed to ensure timely interventions were put in place to prevent the development of a pressure ulcer to Resident #73's left ischium. Resident #73 was admitted to the facility on [DATE] and was at risk for the development of a pressure ulcer. The resident developed a stage 3 pressure ulcer to the left ischium on 12/5/23. The wound was observed to have 100% slough in the wound bed on 12/13/23. The wound continued to be classified as a stage 3 and the classification should have been changed to an unstageable wound. The wound continued to be classified as stage 3 throughout the resident's clinical record. The resident's care plan was not updated to include a stage 3 pressure ulcer to the left ischium and was not updated to include the use of an air mattress. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 1/25/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 1/17/24 at 3:41 p.m. The policy revealed in pertinent part, The facility associates and licensed nurses were provided with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment, care of skin and wounds utilizing professional standards of the National Pressure Injury Advisory Panel (NPIAP) and the Wound, Ostomy, Continent Nurses Society (WOCN). A comprehensive skin inspection/assessment would be performed on admission and re-admission to the facility so that the nursing staff might identify pre-existing signs of possible deep tissue damage already present. These signs included; purple or very dark areas surrounded by edema; profound redness, or induration (thick and.or hard soft tissue); bogginess (soft and watery); and/or discoloration. These signs possibly indicate an unavoidable Stage 3 or 4 with slough (nonviable yellow, tan, white, stingy tissue-byproduct of an inflammation process), drainage, or even eschar (dead tissue) within a few days. A skin assessment/inspection would occur on admission/readmission. Skin observations would also occur throughout points of care provided by certified nurse aides (CNAs) during activities of daily living (ADL) care (bathing, dressing, and incontinent care). Any changes or open areas were reported to a nurse. CNAs would also report to a nurse if a topical dressing was identified as soiled, saturated, or dislodged. A nurse would complete further inspection/assessment and provide treatment if needed. A risk assessment tool, Braden Scale or Norton Scale, determined the resident's risk for pressure injury development. The score was documented on the tool and placed in the resident's medical record using the appropriate form. A skin assessment/inspection should be performed weekly by a licensed nurse. Measures to maintain and improve the resident's tissue tolerance to pressure, were implemented in the resident's plan of care. All residents upon admission were considered to be at risk for pressure injury development due to medical issues requiring nursing care, related to disease process and illness or need for rehabilitation services. Upon admission and throughout the resident's stay, at a minimum, a pressure redistribution surface (Group 1 mattress) would be in use with turning/repositioning as needed with ADL care/assistance and incontinent care as needed. This included skin barrier application as needed, and a preventative wheelchair cushion if indicated. Staff were to facilitate skin inspections/assessments with particular attention to bony prominences; skin cleansed with the appropriate cleanser at the time of soiling and at routine intervals; treat dry skin with moisturizers; minimize skin exposure to incontinence using devices (briefs) and skin barriers; minimize injury due to shear/friction through proper positioning, transfers, and turning schedules (if indicated); encourage physician ordered food and fluid intake; and improve the resident's mobility and activity when the potential exists (restorative). Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear were implemented in the plan of care: reposition at least every 2-4 hours (per NPIAP standards) as consistent with overall patient goal and medical condition; utilize positioning devices to keep bony prominences from direct contact; ensure proper body alignment when side-lying; heel protection/suspension if indicated; maintain the resident's head of the bed at the lowest degree of elevation consistent with medical conditions; use lift devices to move resident in the bed; ensure a pressure redistribution mattress surface was placed under the resident; when positioned in a wheelchair, ensure the resident was placed on a pressure reduction device and repositioned (donut-type devices were not used); and when positioned in a wheelchair, consideration was given to postural alignment, distribution weight, balance, and stability. Residents and significant others involved in the resident's care were educated regarding the preventive skin care plan. When skin breakdown occurred, it required attention and a change in the plan of care might be indicated to treat the resident. III. Resident #47 A. Resident status Resident #47, age 93, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, chronic pain, obesity, diabetes mellitus type II, anemia, cognitive communication deficit and fracture with routine healing. The minimum date set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The resident had a functional limitation in her range of motion with an impairment to the lower extremity (hip, knee, ankle or foot) on one side of her. The resident was dependent on staff for toileting, lower body dressing and putting on/taking off footwear. The resident was dependent on staff for rolling left and right, lying to sitting on the side of the bed and chair/bed to chair transfer. The resident was at risk for the development of a pressure ulcer. The resident did not have any pressure ulcers. B. Resident interview The resident was interviewed on 1/17/24 at 12:26 p.m. She said she was not sure if she had a pressure ulcer on her bottom. C. Record review A care plan for a break in skin integrity related to left hip surgical repair and stage 3 to sacrum area was initiated on 12/12/23 and revised on 1/17/23 (during the survey). The pertinent interventions were for staff to perform weekly skin checks, clean and dry the skin after each incontinent episode. Staff were to apply an air mattress as ordered was dated 1/17/24 (during the survey). A care plan for the potential for pressure ulcer development related to decreased mobility, left hip surgical repair, diabetes mellitus type II, visual/cognitive deficits, muscle weakness and difficulty walking was initiated on 12/17/23. The pertinent interventions were to administer medications and treatment as ordered. Educate the resident/family/caregivers as to the causes of skin breakdown; transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Staff were to follow the facility policies/protocols for the prevention/treatment of skin breakdown. Staff were to inform the resident/family/caregivers of any new area of skin breakdown. Observe and report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length by width by depth), and stage the wound. The resident required a wheelchair cushion and pressure reduction mattress. Serve diet as ordered, monitor intake and record. -The care plan did not have the use of an air mattress as one of the interventions. The admission collection tool for skin dated 12/11/23 revealed the resident did not have a pressure ulcer. Braden Scale for predicting press sore risk dated 12/12/23 revealed a score of 13 or moderate risk. The weekly skin integrity data collection form dated 12/18/23 revealed the resident did not have a pressure ulcer. The Braden Scale for predicting press sore risk dated 12/20/23 revealed a score of 14 or moderate risk. The wound observation tool dated 12/22/23 revealed an air mattress ordered as requested. New wound to coccyx that started on 12/22/23. This stage 3 pressure ulcer of the coccyx measured 2.0 cm by 3.0 cm by 0.1 cm. The physician's assistant (PA) note dated 12/22/23 revealed the resident had a newly found stage 3 sacral pressure ulcer with no infection to the site. Ordered dressing changes per wound care team, will monitor for signs and symptoms of infection or worsening. The event note dated 12/22/23 revealed during peri-care a wound to the coccyx area was observed. The PA was notified and assessed the wound. New treatment orders were put in place. A skilled note dated 12/22/23 revealed a stage 3 wound to the buttock was observed and a dressing was applied. An air mattress was ordered and installed. A skilled note dated 12/23/23 revealed a pressure wound was observed on the coccyx with no signs or symptoms of infection. The weekly skin integrity data collection form dated 12/25/23 revealed an open area to the coccyx with treatment in place. The resident was added to the weekly wound rounds. The Braden Scale for predicting press sore risk dated 12/28/23 revealed a score of 16 or mild risk. -However, the resident's risk should have not been mild since the resident developed a pressure ulcer. The wound note dated 1/2/24 revealed a stage 3 pressure ulcer to the sacrum. Initial encounter measurements were 2.0 cm by 3.0 cm by 0.2 cm with an area of 6.0 square cm and a volume of 1.2 cubic cm. There was a moderate amount of sero-sanguineous drainage. The wound had 100% granulated tissue. The plan was to cleanse with a wound cleanser, apply a gel cover with foam and change the dressing daily. Preventative measures were to provide an alternating air mattress or low air loss mattress mattress and an offloading wheelchair cushion. Turn and reposition frequently while in bed and in a chair. Have the resident shift their weight frequently while in bed or in a chair. Have the resident utilize a low loss or alternative pressure mattress, if not contraindicated; check for proper placement and function each shift. Ensure the seat or wheelchair cushion was in place, if not contraindicated, check for proper placement and function every shift. If the resident utilized briefs and was incontinent; check briefs frequently. The Braden Scale for predicting press sore risk revealed a score of 16 or mild risk. -However, the resident's risk should have not been mild since the resident developed a pressure ulcer. The physician's order dated 1/9/24 revealed to administer Santyl Ointment 250 units/gram (Collagenase) to the coccyx topically every day shift for wound care. Before applying the ointment, clean the wound with normal saline. Cover the wound with foam and dressing to be changed daily. The wound note dated 1/9/24 revealed a stage 3 pressure ulcer to the sacrum. The measurements were 2.0 cm by 3.0 cm by 0.2 cm with an area of 6 square cm and a volume of 1.2 cubic cm. There was a moderate amount of sero-sanguineous drainage. The wound had 100% slough (unstageable wound per NPAIP) tissue. The plan was to debride (remove dead, contaminated or adherent tissue and/or material). A skin/subcutaneous tissue level surgical debridement with a total area of debridement of 6.0 square cm. Subcutaneous tissue was removed along with devitalized tissue (slough). The post debridement measurements were 2.0 cm by 3.0 cm by 0.3 cm with an area of 6.0 square cm and a volume of 1.8 cubic cm. The wound observation tool dated 1/10/24 by the wound nurse (WN) revealed a stage 3 sacral pressure wound with an onset date of 12/22/23. The measurements were 2.0 cm by 3.0 cm by 0.2 cm depth. The wound bed was 100% slough (unstageable wound per NPIAP). The Braden Scale for predicting press sore risk dated 1/11/24 at 9:51 a.m. revealed a score of 15 or mild risk. -However, the resident's risk should have not been mild since the resident developed a pressure ulcer. The wound observation tool dated 1/17/24 revealed a stage 3 sacral wound with an onset date of 12/22/23. The measurements were 2.7 cm by 3.0 cm by 0.2 cm. There was granulated (beefy, red) tissue present with 50% slough (yellow, tan, stringy) tissue in the wound bed. The wound observation on 1/23/24 by the wound physician (WP) and a nurse surveyor revealed a stage 3 coccyx wound measuring 2.5 cm by 2.0 cm by 0.6 cm. There was no sign or symptoms of infection. The wound was debrided on the last visit due to the slough in the wound. C. Interviews The director of nursing (DON), infection preventionist (IP) and the WN were interviewed on 1/22/24 at 10:20 a.m. They said the admission collection tool dated 12/11/23 and the weekly skin integrity data collection form dated 12/18/23 did not reveal the resident had a pressure ulcer. The DON said this was a facility acquired pressure ulcer. The DON said upon admission, the resident utilized a standard pressure reducing mattress. The DON said a treatment order of an air mattress was requested on 12/22/23 and placed on the resident's bed on 12/22/23 at 6:37 p.m. -However, this was after the resident had developed the stage 3 pressure ulcer. The DON said there was no physician's order or mattress settings for the air mattress. The DON said she used the manufacturer's specifications pamphlet to determine the comfort level and the alternating settings for the resident. The DON said the pressure ulcer should have been categorized as an unstageable wound on 1/9/24 with a wound bed of 100% slough. The DON was interviewed on 1/22/24 at 1:46 p.m. She said the resident's wound was debrided on 1/9/24 by the WP. She said she felt the resident's diagnoses of diabetes mellitus type II, polyneuropathy, cerebrovascular vascular disease and a system wide lack of oxygen were contributing factors to the acquisition of the pressure ulcer. The WN was interviewed on 1/23/24 at 9:00 a.m. She said when the resident arrived at the facility, a standard pressure reducing mattress was placed on her bed. She said the facility interventions that were implemented prior to the resident acquiring the stage 3 pressure ulcer were weekly skin assessments, therapy and frequent (every two hours) repositioning and/or turning. She said the resident was agreeable to be repositioned. She said the resident did get out of bed sometimes. She said this was a facility acquired pressure ulcer and she had no idea of how the pressure ulcer started. The DON was interviewed on 1/23/24 at 9:55 a.m. She said the facility knew the resident was at risk for the development of a pressure ulcer. She said the pressure wound was first observed on 12/22/23 and a request was made to the resident's primary care physician (PCP) to assess the wound on 12/22/23. A treatment order for an air mattress was received on 12/22/23 and was placed on the resident's bed on the same day. A request was made for the wound physician (WP) to see the resident. A nutritional supplement was added on 12/28/23 for poor meal intake on admission. -However, the resident was admitted on [DATE] so the supplement was added nearly two weeks after her admission. She said on 1/4/24 a protein supplement was added and ice cream was provided to the resident for additional calories. She said the resident had the ability to reposition herself, however she did not understand the necessity for repositioning. She said the resident needed staff cueing and/or assistance to reposition or offload the area. The DON said the pressure ulcer might have started by the use of a slide board (skin on wood) to transfer the resident from the bed to a wheelchair. The DON said on 12/21/23 the resident refused to participate in therapy services, was getting tired of living and had started to give up. The WP was interviewed on 1/23/24 at 12:19 p.m. He said the resident had no changes in her medical conditions that might have caused the pressure ulcer. He said the resident liked to stay in bed most of the time. He said there was nothing out of the ordinary about this resident; the pressure ulcer just occurred. Certified nurse aide (CNA) #1 was interviewed on 1/23/24 at 3:19 p.m. She said she had worked with the resident. She said the staff tried to reposition the resident every two hours. She said the resident liked to stay in bed and needed staff assistance to reposition. She said when she was repositioned in bed, the resident would stay in that position for about 30 minutes to an hour. After this amount of time, the resident wanted to be repositioned to one of her favorite positions in bed (on her back). She said the resident did get out of bed and sit in her wheelchair sometimes. CNA #2 was interviewed on 1/23/24 at 3:32 p.m. She said she did work with the resident. She said the staff tried to reposition the resident every two hours. During repositioning, they checked the resident for incontinence and changed the resident as needed. She said the resident had the ability to roll herself a little while in bed. She said the resident was okay with repositioning. She said the resident liked to stay in bed and was often on her back. She said the head of the resident's bed was often elevated while the resident was awake. IV. Resident #73 A. Resident status Resident #73, age greater than 65, was admitted on [DATE]. According to the January 2024 CPO, the resident had diagnoses of Alzheimer's disease, dementia, anxiety, mood disturbance, muscle weakness, pain in the left shoulder and COVID-19. The MDS assessment dated [DATE] revealed the resident had a BIMS score of zero out of 15. The resident had inattention as evidenced by difficulty focusing attention, such as being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present and did not fluctuate. The resident had disorganized or incoherent thinking as evidenced by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. This behavior was continuously present and did not fluctuate. The resident required extensive staff assistance with two plus staff for bed mobility, transfers, toileting and personal hygiene. The resident utilized a pressure reducing mattress and a pressure reducing chair seat cushion. The resident did not have any pressure ulcers. The MDS assessment dated [DATE] revealed the resident had short and long term memory problems. The resident had severely impaired cognitive skills for daily decision making. The resident had inattention as evidenced by difficulty focusing attention, such as being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present and did not fluctuate. The resident had disorganized or incoherent thinking as evidenced by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. This behavior was continuously present and did not fluctuate. The resident utilized a pressure reducing mattress and a pressure reducing chair seat cushion. The resident had one stage 3 pressure ulcer/injury. B. Record review A care plan for the presence of a pressure ulcer and the potential for pressure ulcer development related to impaired mobility, dementia, and cognitive/communication deficits was initiated on 5/18/23 and revised on 12/17/23. The plan revealed to provide protection to the resident's left and right heels. The interventions included administering medications and treatments as ordered. Assess wound healing and document the status of the wound healing progress. Report improvements and declines to a physician. Provide enhanced barrier precautions and follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/family/caregivers of any new area of skin breakdown. Observe and report as needed, any changes in skin status. Serve diet as ordered, monitor intake and record. The resident required extensive assistance to turn and reposition frequently as needed. The resident required a pressure reducing mattress, wheelchair cushions, and blue heel boots. The resident required supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. -The care plan did not have an intervention for the use of an air mattress. -The care plan did not mention the resident's left ischium stage 3 pressure ulcer. An additional care plan with no initiation date or revision date was provided by the NHA on 1/18/24 at 3:05 p.m; during the survey. The care plan and interventions were identical to the resident's care plan for pressure ulcers with the exception of the addition, for the staff to provide protection to the resident's left ischium wound. -The care plan did not have an intervention for the use of an air mattress. The Braden Scale for predicting pressure sore risk, dated 11/1/23, revealed a score of 15 or mild risk. -However, the resident was at risk due to being dependent on staff and utilizing pressure relieving measures according to the 9/20/23 MDS assessment. The wound care progress note dated 11/28/23 documented the resident had a skin tear to the right inner knee. -The progress note did not document an ischial pressure ulcer. The weekly skin data collection tool note dated 11/30/23 did not reveal the resident had an ischial pressure ulcer. The Braden Scale for predicting pressure sore risk dated 12/1/23 revealed a score of 14 or moderate risk. The wound care progress note dated 12/5/23 for the initial encounter for a left ischial pressure ulcer/injury measuring 2.5 centimeters (cm) in length by 1.5 cm in width by 0.2 cm in depth, with an area of 3.75 square cm and a volume of 0.75 cubic cm. There was a moderate amount of sero-sanguineous drainage (yellow with small amounts of blood) with a wound bed of 10% granulation (connective tissue) and 90% slough (nonviable yellow, tan, white, stingy tissue-byproduct of an inflammation process). The plan for this wound was to cleanse/protect the wound with a wound cleanser, apply a Santyl (an ointment that helps to remove dead skin tissue and aid in wound healing), cover with a foam and change the dressing daily. Turn or reposition the resident frequently while in bed and in a chair. Have the resident shift their weight frequently while in bed or in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated, check for proper placement and function every shift. Ensure seat or wheelchair cushion in place, if not contraindicated, check for proper placement and function every shift. If the resident wore briefs and was incontinent; check briefs frequently. The wound observation tool dated 12/6/23 by the facility the WN revealed a stage 3 left ischial wound started on 12/6/23 measuring 2.5 cm by 1.5 cm by 0.2 cm. This was the first observation and there was no previous reference. There was granulated (beefy red) tissue present and 90% slough tissue. There was moderate sero-sanguineous drainage. Staff were to apply Santyl to the wound bed and cover with foam dressing daily. The wound observation tool dated 12/13/23 by the facility WN revealed a stage 3 left ischial wound started on 12/6/23 measuring 3.0 cm by 3.0 cm by 0.2 cm. There was 100% slough (unstageable wound per NPIAP) tissue present with a moderate amount of sero-sanguineous drainage. Staff were to apply Santyl to the wound bed and cover with foam dressing daily. The physician's order dated 12/19/23 revealed to cleanse left ischium wound with normal saline, moisten a 4 inches by 4 inches (gauze pad) with Dakins (a solution of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water), pack in wound, and cover with foam dressings every day shift. The physician's order dated 1/11/24 revealed to continue antibiotics for the wound to the buttocks. The physician's order dated 1/23/24 revealed isolation and enhanced barrier precautions with a diagnosis of a wound. This order was received during the survey. The wound care progress note dated 12/18/23 revealed a stage 3 left ischial pressure ulcer/injury measuring 2.5 cm by 2.5 cm by 0.2 cm with an area of 6.25 square cm and a volume of 1.25 cubic cm. There was a moderate amount of sero-sanguineous drainage present. The wound bed was 100% slough (unstageable wound per NPIAP). There was no change in the wound's progression. The skin/subcutaneous tissue level was surgically debrided with a total area of 6.25 square cm of debridement. Subcutaneous tissue was removed along with devitalized slough. Post debridement measurements were 2.5 cm by 2.5 cm by 0.3 cm with an area of 6.25 square cm with a volume of 1.875 cubic cm. The plan was to cleanse with a wound cleanser, pack the wound with Dakins gauze packing and cover with a form dressing daily. Turn or reposition the resident frequently while in bed and in a chair. Have the resident shift their weight frequently while in bed or in a chair. Place the resident on a low air loss or alternating pressure mattress, if not contraindicated, check for proper placement and function every shift. Ensure seat or wheelchair cushion in place, if not contraindicated, check for proper placement and function every shift. If the resident wore briefs and was incontinent; check briefs frequently. The wound observation tool dated 12/20/23 by the WN revealed stage 3 left ischial wound starting on 12/6/23, measuring 2.5 cm by 2.5 cm by 0.2 cm. There was 100 % slough (unstageable wound per NPIAP) with a moderate amount of sero-sanguineous drainage present. The dressing was changed to Dakins soaked 4 inches by 4 inches (gauze pad) and covered with foam dressing daily. The wound care progress note dated 12/26/23 revealed a left ischial stage 3 pressure ulcer/injury measuring 2.5 cm by 2.5 cm by 1.0 cm with an area of 6.25 square cm and a volume of 6.25 cubic cm. There was a moderate amount of sero-sanguineous drainage present. The wound bed was 100% slough (unstageable wound per NPIAP). There was no change noted in the wound progression. The plan was to cleanse with a wound cleanser and apply a Dakins soaked gauze, cover with a foam and change the dressing daily or as needed. Turn or reposition the resident frequently while in bed a[TRUNCATED]

Based on record review, and interviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicated otherwise for one (#11) of eight out of 11 sample residents. Specifically, the facility failed to ensure the resident's care plan was revised to reflect her current nutritional status to include she required extensive one staff physical assistance for eating, the resident's current decrease in meal intakes, refusals of meals and supplements. Moreover, to notify the resident's family in a timely manner, regarding the resident's weight loss and recommendations for the resident's weight loss by the registered dietitian (RD) were implemented timely. Due to the facility's failures, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy The Nutritional Intake policy,effective date 8/21/19, was provided by the nursing home administrator (NHA) on 11/12/2020 at approximately 2:30 p.m. The policy revealed the purpose was to ensure documentation of nutritional consumption and to identify any residents at risk for compromised nutritional status. The policy also revealed food intake documentation would be part of the individual resident's permanent medical record. The Weights and Heights policy, reviewed on 5/5/2020, was provided by the NHA on 11/12/2020 at approximately 2:30 p.m. The policy revealed all residents would be weighted within 24-hours of admission, weekly for four weeks and as needed thereafter or more as determined by the resident at risk (RAR) committee and/or a physician order. II. Resident #11 A. Resident status Resident #11, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the November 2020 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/27/2020 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive staff assistance for eating with a one-person physical assist. The resident did not have any swallowing difficulties. The resident had a weight of 121 pounds. The resident was not on a physician prescribed weight loss program. B. Resident observations and interview On 11/12/2020 at 9:19 a.m., the resident was observed lying on her bed with covers pulled to her chin. She appeared well groomed and smiled often. She said she thought she ate breakfast this morning but was not sure. She said she could not remember if she received plenty of food to eat or that she received any supplements to drink. C. Record Review The resident's care plan, revised on 2/12/2020, revealed the resident was at risk for poor intakes related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Increased needs related to healing as evidenced by recent hip surgery - surgical incision. -The pertinent interventions revealed document, monitor weights, intakes and report to the interdisciplinary team as needed. Assist and encourage the resident with meals as needed. Provide the resident with a regular diet, regular texture and thin consistency of liquids. All of the interventions were dated 2/12/2020. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had the following weights: - 123 pounds on 10/22/2020 at 11:56 a.m., - 121 pounds on 10/23/2020 at 12:27 p.m., - 117 pounds on 10/24/2020 at 1:24 p.m., and - 111 pounds on 11/2/2020 at 11:59 a.m. The resident had a weight difference of -9.76% in 12 days, which was a weight loss of 12 pounds from 10/22/2020 to 11/2/2020. The nutrition dietary note dated 10/22/2020 at 1:47 p.m., the registered dietitian (RD) revealed the resident had a readmission weight of 123 pounds. The resident's weight had been stable. The resident remained on a regular diet, regular texture with thin liquids. The resident's meal intakes had been poor since readmission. The resident ate 0-25% of her meals. The resident did have increased intake needs related to a recent surgery. The RD ordered a supplement to support increased nutrition needs. The RD would continue to monitor the resident's weights, intakes and report to the interdisciplinary team (IDT) as needed. The resident's meal intake (consumption) records revealed, from 10/22/2020 through 10/31/2020 the resident had 30 opportunities for meal intakes. The resident ate 0 to 25% twelve times, 26% to 50% eleven times, 51% to 75 % seven times, and 75% to 100% zero times. The nutrition dietary note dated 10/23/2020 at 11:39 a.m., the RD revealed the resident had poor meal intakes since admission. The resident consumed 0 - 25% of most of her meals. The RD sat with the resident this morning. The resident took about five bites of the meal, with a lot of encouragement. The nursing staff reported to the RD this was the resident's pattern for meal intakes. The nursing staff reported after a few bites, the resident did not want to eat anymore. The RD ordered house shakes each day related to increased needs and poor intakes. The RD would continue to monitor the resident's weight, intakes and report to IDT as needed. This note was discussed in the resident at risk (RAR) meeting. An additional nutrition dietary note dated 10/23/2020 at 11:39 a.m., the RD revealed the resident was at risk for malnutrition related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had little interest in eating and would state she was not hungry or did not feel like eating. The RD left a note in the resident's physician mailbox, to consider an appetite stimulant for the resident's poor intakes and increased needs related to healing a recent surgery. Nursing staff continued to assist, monitor meals, encourage intakes, offer foods and fluids between meals. RD recommended increasing supplements to twice a day related to increased needs and continued poor intakes. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It revealed to provide four ounces of house shake once a day and document the percentage of consumption. The medication admiration record (MAR) for October 2020 revealed the resident received the supplement five times with a consumption rate of 80%. -However, the resident's supplement was not increased until 10/28/2020 to twice a day when the recommendation was made on 10/23/2020 (see nutrition dietary note above). The nurse practitioner (NP) note, dated 10/26/2020 at 9:43 a.m., revealed this was an acute visit related to a follow up for a fall with a hip fracture. The resident's abnormal weight loss was evaluated. The resident did not eat or drink well. The resident had advanced dementia. The note revealed to encourage nutrition and intakes. Provide the resident with shakes as well as a supplement. The resident needed help with all activities of daily living. The nutritional assessment, dated 10/28/2020 (not timed), by the RD revealed the resident had a regular diet, regular texture and regular size meal. The resident did not have any fortified foods. The resident was on a house supplement each day and was accepting 75-100%. The resident had a weight of 120.9 pounds on 10/26/2020 at 11:31 a.m. The resident had a usual body weight of between 117 to122 pounds. There was no significant weight change. The resident's meal intake for all three meals was between 0-25%. Most of the resident's meal intake was under 50%. The RD wrote to provide the resident with snacks between meals as needed. The resident had her own teeth and had no swallowing problems. The resident was independent with set up meal help and had no behaviors that would affect her nutritional status. The resident needed 1650 calories each day to provide 66 grams of protein. The resident's current intake was not meeting her needs. The resident had poor intakes with weight loss related to dementia. The resident was at risk for malnutrition related to dementia, variable intakes, and was considered slightly underweight for her age. The interventions revealed a liberalized diet and to encourage fluids between meals. The regular diet was appropriate for the resident's varied meal intakes. The care plan was reviewed/revised and implemented. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It revealed to provide house shakes two times a day for poor intake and document the percentage of consumption. -The October 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -The November 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's meal intake records from 11/1/2020 through 11/10/2020 revealed, the resident had 30 opportunities for meal intakes. The resident ate: 0 - 25% thirteen times, 26% - 50% eleven times, 51% - 75 % five times, and 75% - 100% one time. The nutrition dietary note dated 10/30/2020 at 3:12 p.m., the RD revealed the resident flagged on the high risk nutrition report. The resident was eating an average of 37% of meals. Her meal intakes continued to decline. The resident's current body weight was 121 pounds and was within normal limits for the resident. The resident remained on house shakes twice a day. The resident needed her meal set up for her and staff should supervise the resident at meals related to dementia and poor meal intakes. The staff were to encourage foods and fluids. At this time continue with the current plan of care. The RD would continue to monitor the resident's weight, meal intakes and report to IDT as needed. The nutrition dietary note dated 11/4/2020 at 1:29 p.m., the RD revealed the resident remained on a regular diet, regular texture and thin liquids. The resident's intake was overall poor. The resident consumed 50% or less for most of her meals. The resident continued on house shakes twice a day and was accepting them at this time. The house shakes were increased to three times a day, because twice a day was not adequate to stabilize her weight. Her current body weight was 111 pounds. This was a 7% significant weight loss. The RD notified the assistant director of nursing (ADON) and requested her to speak with the resident's physician to request the consideration for an appetite stimulate to promote meal intakes due to the resident's significant weight loss and poor meal intakes. The RD would continue to monitor the resident's weight, intakes and report to IDT as needed. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was provided the supplement 15 times. The documentation revealed the resident had zero consumption three times, 25% consumption three times, 50% consumption three times, 75% consumption zero times, 100% consumption three times and refusals three times. The average percentage of consumption was 35%. The nutrition dietary note dated 11/6/2020 at 2:01 p.m., the RD revealed she visited with the resident on 11/5/2020 during the lunch meal. The RD assisted the resident with the meal set up and the resident was able to eat by herself, once she started eating. The resident's meal intakes continued to vary, but have improved during the last two days. The resident continued on house shakes three times a day for poor intakes. The resident's acceptance of the house shakes varied and was overall poor. The RD educated staff to have the resident seated in her wheelchair during meals. At this time, continue with the plan of care. The RD would continue to monitor and report to IDT. This note was discussed with the unit manager. The resident's care plan revised after the survey started on 11/9/2020, included significant weight loss related to poor intakes as evidenced by a 0-50% intake for most meals. The interventions did not correlate with the MDS dated [DATE], which revealed the resident required extensive staff assistance for eating with a one-person physical assist. The nutrition dietary note dated 11/10/2020 at 1:36 p.m., the RD revealed the family was notified of the resident's weight loss and plan of care. The RD added a smoothie to the resident's lunch to prevent further weight loss as the resident continued with poor intake. The resident current body weight was 112 pounds. This was up slightly from last week. The RD would continue to monitor the resident's weights, intakes and report to IDT. The resident's meal card, dated 11/12/2020, was provided by the director of nursing (DON) at 2:15 p.m. The card revealed a smoothie at lunch. The meal care listed the resident's food preferences. The facility recognized the resident was losing weight. The resident's care plan was not revised prior to the survey, to reflect the resident required extensive one staff assistance for eating, the resident's reduction in meal intakes, and refusal of meals. The resident's family was not notified in a timely manner of the resident's weight loss. The request by the RD for an appetite stimulate on 10/23/2020 was not followed up until after the survey was completed on 11/12/2020. III. Staff Interviews The RD was interviewed on 11/12/2020 at 10:30 a.m., and 11:15 a.m. She said the resident was weighted weekly on Mondays and her weights were accurate. She agreed with the resident's weight loss numbers and percentages. She said the resident's weight was up a little this week. She said the resident had scheduled supplements and staff encouraged the resident to eat her meals. The RD said the resident could physically eat by herself, however with dementia she struggled at times. She said sometimes the resident was not interested in eating. She said staff sat with the resident and encouraged her with cueing to eat. She said the resident was capable of making her needs known and would put her hand up (stop) or tell the staff she did not want more to eat. The RD said the supplements had been increased from once a day to three times a day. She said she reviewed the residents' meals and supplement intakes. She said the resident's average meal intake lately was 0-50%. She said the resident was not on comfort care. She said the resident did not have an interest in food at this time. She said the smoothie was started on 11/10/2020 (after the survey started). She said she did discuss the resident's weights each week with the unit manager. She said she ordered the smoothie to be given with lunch to help with an increase of fluids and calories. She said she was unsure if the certified nurse aides were in-serviced on how to accurately document meal consumption. The RD said she requested the appetite stimulate on 10/28/2020 by placing a note in the mailbox of the resident's physician. She said she did not call the physician for an order and she did not know how often the physician visited the facility. She said she was not sure why the request for an appetite stimulate had not been received from the resident's physician. The RD said each Friday, the residents with weight concerns were discussed in the RAR meeting. She said this resident was discussed last Friday the 6th. She said the resident did at times refuse meals and supplements. CNA #4 was interviewed on 11/12/2020 at 12:02 p.m. She said she was in-serviced on how to document percentages of meal consumption. She said the resident did receive a smoothie with her lunch meal. She said if the resident ate the meal and did not drink the smoothie, she would document the intake between 76 to 100%. She said if the resident drank the smoothie and did not eat the meal, she would document the intake between 0 to 25%. She said the resident received assistance with meals and was able to eat herself. She said sometimes the resident ate her meals and drank her supplements. She said sometimes the resident refused. She said the resident had good days and bad days. On 11/12/2020 at 2:07 p.m. the NHA said there is no in service documentation on how CNAs know how to mark meal consumptions.

Based on observations, record review and interviews, the facility failed provide two (#1 and #10) of three residents an environment free from accident hazards out of 11 sample residents reviewed for falls The facility failed to consistently assist Resident #10 with transfers, who was a known fall risk due to her [DIAGNOSES REDACTED]. Contrary to these known risks, Resident #10 was left independent in her room and fell on [DATE] while she transferred herself to the bathroom. Moreover, the lack of supervision from staff, despite her known intermittent confusion and care plan for extensive assistance with transfers, resulted in Resident #10 sustaining a fractured right arm. Furthermore, the facility failed to follow her transfer status prior to and post falls. Furthermore, the facility failed to implement a toileting program for Resident #10 with dementia, falls, and occasional incontinence. The facility failed to identify and implement consistent assistance with transfers. Additionally, the facility failed to use two staff members to transfer Resident #1 as indicated in the care plan, resulting in a fall. Findings include: I.Facility policy and procedure The Resident Transfer policy and procedure, undated, was provided by the nursing home administrator (NHA) on 11/12/2020 at 1:12 p.m., documented in pertinent part: - Every resident has a care guide which has their transfer ability and needs on it. These can be accessed electronically on tablets. -Transfer status is determined by our therapy department as the safest way to transfer a resident . We are to follow the transfer levels and use the equipment as it is written on the care guide. -Every resident should have a transfer dot on their closet door which indicates their transfer status. This should match what is on the care guide. The Resident Transfer Status Dot System, undated, was provided by the director of nursing (DON) on 11/12/2020 at 2:30 p.m., and documented in pertinent part: -Red Circle = 2 person assist with H = hoyer, or S= sabina lift, or SPT = stand pivot transfer. -Yellow Circle = 1 person assist with SPT stand pivot transfer or, FWW = with walker. -Green Circle = modified independent with FWW = with walker, or SPC = with cane, or W/C = at wheelchair level. II. Resident #10 A. Resident status Resident #10, age 82, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 9/26/2020 minimum data set (MDS) assessment, revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #10 required extensive assistance of one person with bed mobility, transfers, dressing, hygiene, and toileting. She was totally dependent on staff for bathing. Resident #10 had a fall with major injury and had fallen since admission. The previous MDS dated [DATE], documented the resident had fallen prior to admission indicating the facility was aware she was a fall risk. B. Record review 1. Care plan The care plan, initiated 8/4/2020, documented in pertinent part, the resident was at risk for falls due to dementia, [MEDICAL CONDITION] arthritis, hypertension, [MEDICAL CONDITION], incontinence, [MEDICAL CONDITION] history of urinary tract infections, pain and history of falls. Interventions included, assist with activities of daily living (ADL's) as needed, back up brakes and bed assessed 9/11/2020, call light in reach, complete fall risk assessment, ensure environment is clutter free and well it, ensure shoes or non slip socks rar worn when up, orient to room. During the survey on 11/10/2020, two months after the resident fell , the care plan was updated to include, assist her to toilet in the morning upon rising, mid morning after breakfast, before and after lunch, mid afternoon, after dinner, prior to bedtime and as needed, check periodically throughout the night for toileting and incontinent care needs. The only intervention added after the fall on 9/10/2020 was back up brakes and bed assessed on 9/11/2020. The fall care plan did not address her occasional incontinence, extensive assistance needed to transfer, pain, dementia or other risk factors identified. Her ADL care plan, initiated 8/4/2020, documented extensive one person assist to transfer and toilet. 2. Fall details The fall risk assessment dated [DATE] documented the resident was at risk for falls due to mobility, multiple health conditions, and medications. The interdisciplinary note (IDT) dated 9/14/2020 was reviewed. The note documented, IDT meet to discuss fall that occurred, room evaluation done, back up brakes placed to wheelchair, bed brakes assessed. There was no documentation related to the root cause of the fall such as assistance with transfers, or toileting, as the resident fell getting up to go to the bathroom. There was no documentation addressing current transfer status. The nurses' notes dated 8/15/2020 at 1:36 p.m. documented the resident had intermittent confusion and required stand by assistance with transfers. However, the MDS dated [DATE] documented extensive assistance of one person with transfers. The nursing progress note dated 9/10/2020 at 10:40 p.m. documented, the resident was found on the floor on the left side, barefoot. States she was going to the bathroom and the wheelchair moved. Complained of right shoulder pain. -On 9/11/2020, the nurses notes documented the resident had an x-ray of the right shoulder and humerus. - On 9/12/2020 the nurses notes documented the resident had a [MEDICAL CONDITION] humerus (arm) and was sent to the hospital. 3. CNA Kardex The CNA Kardex (document for CNAs which documents care needs for residents) with instructions for how to care for Resident #10 was received from the nursing home administrator (NHA) on 11/12/2020 at 1:06 p.m. She said this was what the CNA should be following for care of Resident #10. The Kardex documented as of 11/12/2020 Transfer, extensive one person assistance, toileting assist her to toilet in the morning upon rising, mid morning after breakfast, before and after lunch, mid afternoon, after dinner, prior to bedtime and as needed: check periodically throughout the night for toileting and incontinent care needs. In addition, the NHA provided the resident's last functional assessment dated [DATE] which documented extensive one person assistance with transfers. 4. Physical therapy (PT) notes The PT notes dated 9/3/2020 were reviewed. The notes documented the patient present with reports of decreased ability to ambulate, increased feelings of unsteadiness, concerns of falling. and bed transfers. The PT notes dated 9/10/2020, prior to the fall with fracture of her right arm that night, documented the patient required 75 percent cues for locking brakes prior to standing. C. Interviews and observation Unit manager (UM) #1 was interviewed on 11/12/2020 at 10:58 a.m. She said she worked with the resident before she fell . She said before Resident #10 fell on [DATE], she was independent in her room. She said she could get out of bed by herself and go to the bathroom. UM #1 said the resident would have called for help if she needed assistance. However, the resident was documented as having a moderate cognitive loss on 8/3/2020. UM #1 said she could not explain why the MDS documented that the resident needed extensive assistance to transfer and toilet. UM #1 said, we do not toilet her, she calls us if she needs help. She said after her fall on 9/10/2020, the interdisciplinary team added anti rollback brakes to the wheelchair and checked the bed brakes to prevent her from falling when she transferred herself. Physical therapist (PT) #1 was interviewed on 11/12/2020 at 1:33 p.m. She said the resident was admitted in August 2020, but due to a problem with her insurance, therapy could not start until the beginning of September 2020. She said she evaluated the resident on 9/3/2020, prior to the fall 9/10/2020. She said the resident needed contact guard assistance for transfers at that time due to dementia and weakness. She said the nursing staff had told her the resident was independent in her room and did her own transfers. PT #1 said she educated the staff at that time she needed contact guard assistance from the staff to transfer. She said she educated the staff that the resident was forgetful and needed repetitive education to complete tasks. PT #1 said she initiated a yellow dot for the resident, and documented on the dot that hung on her closet door, contact guard assistance for transfers. The PT said the dot system told the staff how much assistance someone needed. She said the red dot meant a mechanical lift or two person assist, the yellow dot meant limited assistance, and the green dot meant independent. She said now the resident had to call for assistance because she is not able to get out of bed with the pain due the fracture of her right arm. She said she did have short term memory issues and the resident had said to her due to pain she did not want to work with her recently. The admissions coordinator (ADM) was interviewed on 11/12/2020 at 11:29 a.m. She said she was a certified nurse aide (CNA) and responsible for the care of Resident #10. She said she worked as a CNA frequently. She said the resident needed stand by assistance to transfer, no hands on or contact assistance. She said she had a dot on her door that told the staff how much help the resident needed. The resident had a yellow dot on her closet door that documented CGA which meant contact guard assistance. The ADM said the color of the dot did not matter, she said we just use a variety of colors. The ADM said the resident was not on a toileting program and could call using her call light when she needed to go to the bathroom. -However, the resident was on a toileting program as of 11/10/2020 as noted above and needed at least contact guard assistance per the DOT program and recommendation of physical therapy for fall prevention. CNA #2 was interviewed on 11/12/2020 at 11:26 a.m. She said the resident needed limited to extensive assistance with transfers depending on the day she was having. She said the resident was not on any scheduled toileting, and should have called the staff when she needed to use the bathroom. PT #2 was interviewed on 11/12/2020 at 1:49 p.m. She said the resident required contact guard assistance from the staff for transfers due to arthritis in her right hip and unsteadiness of that hip with pain. She said her pain could be moderate to severe. She said the resident was not stand by assistance, but required hands on contact guard. She said sometimes she was more tired and could require even more hands on assistance. She said she currently had no restrictions for her right arm. PT #2 confirmed the resident told her she took herself to the bathroom yesterday. The director of nursing (DON) was interviewed on 11/12/20 at 1:59 p.m. She said the interdisciplinary team had looked at the resident after the fall. She said they added anti roll back brakes to her wheelchair and checked the wheels on her bed. She said, in addition the resident did not have non-skid footwear on at the time of the fall. She said the resident was extensive assistance for transfers and on a toileting program. The DON could not explain why the staff interviewed did not know she was extensive assistance for transfers, and the yellow dot on her closet documented contact guard assist. In addition, the nursing staff did not know Resident #10 was on a toileting program. The DON confirmed toileting was only added to the fall care plan on 11/10/2020, during survey, two months after the fall. III. Resident #1 A. Resident status Resident #1, age 94, was admitted on [DATE]. According to the November 2020 CPOs, [DIAGNOSES REDACTED]. According to the 8/6/2020 MDS the resident had severe cognitive impairment with a BIMS of six out of 15. She required extensive two person assistance with transfers, dressing toilet use and personal hygiene. She required one person assistance with bed mobility and locomotion on and off the unit, and required set-up assistance with eating. B. Record review The fall care plan, last revised 11/10/2020, during the time of the survey, documented the resident was at risk for falls related to dementia, cognitive deficits, gait and balance problems, incontinence, restricted mobility, and decrease in balance, strength and endurance, arthritis pain, dementia, A-fib ([MEDICAL CONDITION]), incontinence and history of falls. The goal was for the resident to not sustain a serious injury requiring hospitalization through the review date. The pertinent approaches included: two person assists related to weakness and assist with ADLs (activities of daily living) as needed. The 9/22/2020 nursing alert note documented the following: When CNA (certified nurse aide) was putting (the) resident to bed the resident started to slip so (the) CNA lowered her to the floor onto her bottom. No injury found assessment. Family and MD (medical doctor) notified. 1. Review of 9/22/2020 fall investigation The 9/22/2020 Incident Follow-Up and Recommendation Form documented the following: Summary of the investigate facts: One person transfer and legs buckled and lowered her to the floor. Recommendations/Action taken: Reviewed transfer status. Follow-up: Zero new incidents changed to only lift. The nursing home administrator and director of nursing signed the form on 11/10/2020, during the time of the survey. The nursing home administrator and director of nursing signed the form on 11/10/2020, during the time of the survey. The 9/22/2020 Witness Interview Form documented the following: While helping the resident to bed I was given(a) false report of her and transfered (sic) her myself. She started slipping so I lowered her gently onto the floor and she landedon my ankle causing pain to it. The resident is fine, no fatal injuries she did not hit her head. The 9/23/2020 Education notice documented the following: Observation: Transfered (sic) a resident with 1 (one) person with a red transfer dot with 2 (two) person assist. C. Staff interviews The third floor unit manager (UM #2) was interviewed on 11/12/2020 at 9:45 a.m. She said she was part of the team who investigated the fall that occurred on 9/22/2020 with Resident #1. She said she had spoken with the CNA who had transferred the resident as part of the investigation. The UM said the CNA typically worked a different floor, and she had incorrectly written down Resident #1 transfer status when she was getting a report from the other CNAs. The UM said Resident #1 had been a two person transfer for quite a while, and the dot in her room at the time of the fall was a red dot indicating the resident was a two person transfer. The UM said Resident #1 was listed as a two person transfer on the Kardex, the CNA electronic care plan. The UM said she was the person responsible for providing the education to the CNA, who indicated she had never been trained on how to transfer residents or how to check their transfer status using the dot system. The UM said immediately following the education provided to the CNA, the CNA left the facility and never returned. The UM said she did not provide training to any additional staff to ensure they understood the dot system. The UM said she ensured that all of the residents in the facility had a dot in their room, and that they had the correct transfer status. The DON and director of nursing in training (DONIT) were interviewed on 11/12/2020 at 10:07 a.m. She said the CNA did not follow the recommendation that was listed on Resident #1 dot in her room. The DON said the resident had a red dot in her room, indicating she was a two person transfer. The DON said the resident's plan of care was also reviewed, and she was listed as a two person transfer at the time of the fall. The DON said the CNA also did not follow the resident plan of care. The DON said she did not provide any education to her staff to ensure they understood the dot transfer system. The DONIT stated she would immediately ensure all nurse staff understood each resident's transfer status. The DONIT was interviewed a second time on 11/12/2020 at 11:26 a.m. she said she had found training that had been completed with all of the CNAs regarding understanding transfers and transfer status. The DONIT stated she was not sure if the training had been completed as part of the fall investigation and follow-up for the 9/22/2020 fall. The staff development coordinator (SDC) was interviewed on 11/12/2020 at 12:15 p.m. She said she had completed the transfer training with the CNAs as part of their annual competencies. She said at the time of Resident #1 fall she had not provided any additional training to any of the staff to ensure they understood how to determine a resident's transfer status.