Every finding on record at Northbrook Healthcare and Rehabilitation Center

Based on clinical record review, staff interviews, urologist interview, hospital record review, death certificate and policy/procedure review, the facility failed to provide accurate measurements of urinary output, and failed to implement fluid intake and assessments/interventions for 4 out of 4 resident with a an indwelling catheter (Resident #9, #4, #7 and #12) and 3 out of 4 resident that were diagnosed with a urinary tract infection (Resident #9, #7 and #12) which resulted in Resident #9 who showed no urinary output for 32 hours and had a fluid intake of 150 cc over a 48 hour period from 1/9/26-1/12/26. Resident #9 displayed symptoms of confusion, abdominal distention, and discomfort during cares on 1/12/26. The facility was notified by the ARNP (Advanced Registered Nurse Practitioner) at 12:00 PM that the labs that were drawn earlier that morning on 1/12/26 showed a high potassium level of 6.6 (3.5-5.0), BUN (a waste product from protein breakdown in the liver) of 134 (7-20) and Creatinine (waste product from normal muscle activity) of 4.44 (.4-1.3). Orders were received to transport Resident #9 to the local emergency department. Resident #9 was admitted to the hospital on [DATE] and transferred to the Intensive Care Unit with diagnosis of hyperkalemia (high potassium) secondary to acute kidney injury, sepsis (the body's extreme, life threatening response to an infection), E-Coli (a bacteria commonly found in the intestines of humans) and Proteus mirabilis bacteremia (a bacteria known for causing complicated urinary tract infections) and placed on Hospice 1/14/26. Resident #9 was discharged back to the facility on 1/26/26 and passed away on 2/5/26. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility census was 67 residents.On July 9th, 2026 at 11:30 AM, the Iowa Department of Inspection, Appeals and Licensing (DIAL) staff contacted the facility to notify them the Department staff determined and Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy after the facility staff completed the following:*All Certified Nursing Assistants must collect, and chart catheter output, report to charge nurse and chart in point of care charting.*All urinary catheter output must be documented every shift*Must chart all catheter outputs effective immediately*Every staff member must watch catheter care video1. Identification of Residents Affected or Likely to be Affected:*Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Completion Date: July 9, 2026)*Affected resident no longer resides in the facility. Nine current residents have urinary catheters.*Residents with urinary catheters were evaluated for signs/symptoms of urinary tract infections, intake/output records and recent lab values reviewed. Physician/provider notified of current status (if applicable).2. Actions to Prevent Occurrence/Recurrence:*Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. (Completion Date: July 9, 2026)*The policies related to documentation of intake/output from urinary catheters and reporting of signs/symptoms of urinary tract infections being reviewed.*Education provided to licensed nursing staff regarding assessment of intake and output, signs/symptoms of urinary tract infections, and provider notification expectations when changes in conditions occur for residents with urinary catheters. All licensed nursing staff currently present in the building (including contracted staff) have been educated. All remaining staff were verbally educated, with education material being sent to them. These staff will be given in-house education on their next scheduled shift. Education provided to unlicensed direct care staff regarding documentation of intake of fluids/output from urinary catheters, reporting changes/abnormal findings to the licensed nurse, and signs/symptoms of urinary tract infections. All unlicensed direct care staff (including contracted staff) currently present in the building have been educated. All remaining staff were verbally educated, with education material being sent to them. These staff will be given in-house education on their next scheduled shift.*Consultation with the Medical Director regarding notification expectations for residents with poor fluid intake and output.*The DON will audit the I/O documentation, including documentation of signs and symptoms of urinary tract infections. The documentation review may include, but is not limited to vital signs, nurse notes, nursing assessments, and other relevant clinical documentation. Follow up measures will be taken as indicated.Date Facility Asserts Likelihood for Serious Harm No Longer Exists: July 9, 2026The facility implemented their plan of correction and removed the immediacy on 7/9/26 and the scope was lowered from a K to a E.Findings include:1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 for which indicated severe impaired cognition with decisions, has adequate hearing and vision, clear speech, makes self understood and is usually able to understand others, and no rejection of cares present. The MDS addressed the resident required dependence of staff for toileting hygiene, and upper and lower body dressing plus repositioning and an indwelling catheter is in place. The MDS included diagnoses of Benign Prostatic Hyperplasia (BPH)(enlarged prostate), obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing freely), urinary tract infection (in the last 30 days), urethritis (inflammation of the urethra, the tube that carries urine from the bladder out of the body), dysuria (pain, burning, or discomfort during or immediately after urination), retention of urine (the inability to completely empty your bladder) and an antibiotic was used in the last 7 days of the MDS look back period.The Plan of Care with an initiated date 1/10/25, documented the resident has an indwelling foley catheter with a goal the resident will be free from catheter related trauma. Interventions include: Monitor and document intake and output as per facility policy, monitor for signs/symptoms of discomfort on urination and frequency, monitor for pain/discomfort due to catheter, and to report to the Medical Doctor signs and symptoms of a UTI to include pain, burning, blood tinged urine, cloudiness, no output, foul smelling urine, altered mental status, change in eating patterns and record urine output.The Documentation Survey Report dated January 2026, revealed that Resident #9 had no record of urinary output on 1/10/26 night shift, 1/11/26, day, evening and night shift.The Documentation Survey Report dated January 2026, revealed that Resident #9 had oral fluid intake of 150 cc from 1/9/26-1/12/26.The Progress Notes for Resident #9 documented the following: On 1/11/26 at 8:17 PM the resident has had no urinary output today. Foley catheter irrigated without difficulty. Will have CNAs assist resident with increasing fluid intake. On 1/12/26 at 7:49 AM secure message sent to ARNP with update. Per CNA report that worked last night, the resident had no urinary output. Bag assessed and empty. Per other nurse the resident has had decreased oral intake. On 1/12/26 at 9:08 AM Foley catheter 18 french, 10 cc balloon changed per order for occlusion or leakage. On 1/12/26 at 12:19 PM area ambulance arrived. The Progress Notes lacked any other documentation of intake or output or urinary assessment. The Emergency Department Provider notes dated 1/12/26 at 1:00 PM, documented that resident presented to the emergency department from the care facility for concerns of a potassium of 6.6 (3.5 to 5.0) and new acute kidney injury with creatinine of 4.4. The patient has an indwelling foley catheter which has not produced urine in the last 24 hours. The urine in the bag is dark brown. The patient is typically confused but is now alert and only oriented to self. The patient is painful throughout the abdomen on palpation but is unable to participate further in history or physical exam. The patient's last oral intake was at 8:00 AM. Foley catheter had been in place for 1 month which was removed earlier today after 24 hours of no urine output. Upon deflating the balloon there was a large [NAME] of blood from patients urethra. Patient has been increasingly confused per facility staff over the last 24 hours with decreased oral intake over the last week.The Emergency Department notes dated 1/12/26 at 1:08 PM, documented that a patient was brought in by emergency medical services for abnormal potassium, BUN (blood urea nitrogen) Creatinine (a waste product produced by muscles from the breakdown of a compound called creatine). Reports no urinary output in patients catheter for 24 hours which prompted them to change it. Upon changing the catheter nurse reported dark brown/red urine. Patient is mildly confused at baseline, but more confused today. Upon arrival to emergency department residents initial diagnosis included hyperkalemia, foley catheter complications, and sepsis.The History and Physical dated 1/12/26 at 4:23 PM, documented that a [AGE] year old with history of urinary retention with indwelling foley catheter and Alzheimer's dementia noted to the emergency department due to concerns of not producing urine for the last 24 hours. History from chart review and son revealed the patient underwent foley exchange at the facility after they noted approximately 24 hours of no urine output. Reportedly there is a large amount of blood expelled from the urethra during the exchange. Repeat foley catheter was quickly placed and the patient was subsequently brought to the emergency department. In the emergency department the patient appears slightly more confused than baseline. admission labs notable for potassium of 6.9 (3.5 to 5.0) creatinine of 4.04 (0.7 to 1.3) anion gap(a blood test calculation that measures the difference between positive and negative charged electrolytes in your body) of 22 (3 to 12) and white blood cell count (measure the number of infection cells in your body) of 25,430 (4,500 to 11,000). Computed Topography (CT) scan abdominal pelvis was obtained noting concern for malposition Foley catheter in the prostate with evidence of ruptured urethra. Also noted diffuse bladder wall thickening and bilateral hydroureteronephrosis. ED provider discussed with urology who recommended taking to the operating room (OR) for cystoscopy and relieving of obstruction. Emergency department provider started 2 liters of fluid and started the patient on intravenous antibiotics. Did discuss a plan to admit to intensive care unit for monitoring of urine output. Problems include urinary retention, due to benign prostatic hyperplasia with urinary retention, acute kidney injury, acute cystitis with hematuria (blood in urine), sepsis (the body extreme, life-threatening response to an infection) and acute metabolic encephalopathy (a sudden global alteration in brain function caused by systemic issues like organ failure).The Urology Consult dated 1/12/26 at 5:02 PM, documented a [AGE] year old man with history of Alzheimer's dementia who resides at a facility and was brought to the emergency department due to hyperkalemia (a medical condition characterized by higher than normal levels of potassium in the blood) as well as acute kidney injury in the context of a foley catheter that is not draining. He has a chronic indwelling foley catheter for history of urine retention. The catheter had not been draining for 24 hours and therefore it was removed today. There was blood per urethra noted after catheter removal and he subsequently had a new foley catheter replaced. He is brought to the hospital by emergency medical services. He is baseline confused and vocalizes he has abdominal pain but is unable to provide much more history than this. The patient is chronically ill-appearing.The urine in the foley catheter bag appears grossly purulent and brown tinged. The Hospital Course dated 1/26/26 at 12:01 PM, documented Patient has multiple comorbidities including stroke with residual deficits, Alzheimer's dementia and patient is overall not a good candidate for dialysis. Palliative care was consulted on 1/14/26 for further discussion and the decision was for Hospice.The Patient Care Order (verbal order) dated 1/26/26, had an order for indwelling foley catheter placed on 1/12/26 in operating room per urology, irrigate/flush catheter with 60 cc of normal saline every evening shift and as needed to keep patent. CALL HOSPICE IF UNABLE TO CLEAR OR WITH ANY OTHER ACUTE CHANGES IN OUTPUT. DO NOT REMOVE FOLEY CATHETER unless directed by Hospice. On 7/7/26 at 2:10 PM, Staff E, Certified Nursing Assistant (CNA) stated that she worked on 1/11/26 from 10:00 PM to 6:00 AM and on 1/12/26 from 6:00 AM to 2:00 PM. Staff E, stated that during shift report on 1/11/26 around 9:45 PM, staff explained that Resident #9 had no urine output in the catheter bag. Staff E, stated that Resident #9 was repositioned routinely throughout the night with no incidents. On 1/12/26, Staff E, stated that she went to get Resident #9 ready for breakfast around 7:30 AM, and Resident #9 did not want to eat or drink, and just kept his eyes closed. Staff E, stated that when she went to reposition him, you could tell he was uncomfortable, that he would grimace like he was in pain but was not able to explain where he was having the discomfort. Staff E, acknowledged that Resident #9 had no urinary output during the overnight hours. On 7/7/26 at 3:00 PM, Staff F, Licensed Practical Nurse (LPN), confirmed and verified that on 1/12/26, Resident #9 had no urinary output in the catheter bag. Staff F, explained that when the bulb on the catheter bag was deflated, blood, urine and a white milky substance came gushing out the end of the penis. Staff F, stated that after a new foley catheter was placed, urine was flowing into the catheter bag and Resident #9 appeared to be more alert and oriented and ate a peanut butter sandwich and drank fluids.On 7/8/26 at 1:00 PM, the residents Urologist stated that the expectation of the staff are to empty Resident #9 catheter bag every shift and document/record the amount of urine in the bag and if no urinary output then an assessment/intervention is needed. The medical provider stated that the main concern with Resident #9 was that no urinary output for over 24 hours and that the urine was sitting in the bladder, for which caused sepsis, acute kidney injury and the need for dialysis. The Certificate of Death dated 2/6/26, documented the immediate cause of death is acute renal failure with consequences of bacteremia (presence of viable bacteria in the bloodstream), cystitis (inflammation of the bladder) and underlying cause of prostate hypertrophy (non-cancerous enlargement of the prostate gland).2. Resident #4's MDS assessment dated [DATE], documented the resident had a BIMS score of 5 for which indicated severe impaired cognitive with decisions, has adequate hearing and vision, clear speech, makes self understood and is able to understand others, and no rejection of cares present. The MDS addressed the resident required substantial to maximal staff assistance for all aspects of activities of daily living (toileting and personal hygiene), and upper and lower body dressing and an indwelling catheter is in place. The MDS included diagnoses of obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing freely), anemia, diabetes mellitus and Alzheimer's disease.The Plan of Care with an initiated date 9/12/25, had a focus area of the resident has an indwelling foley catheter. Interventions include: Check tubing for kinks each shift, monitor and document intake and output as per facility policy, Monitor/document for pain/discomfort due to catheter, Monitor/record/report to Medical Doctor for signs/symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Review of the Point of Care (POC) History dated 6/11/26-7/9/26, revealed output was recorded on these dates and times:*6/11/26 at 5:51 AM*6/13/26 at 1:59 PM and 9:59 PM*6/14/26 at 5:43 AM and 1:30 PM*6/15/26 at 3:52 AM and 9:46 PM*6/20/26 at 5:59 AM and 1:37 PM*6/21/26 at 3:00 AM*6/23/26 at 1:59 PM and 11:34 PM*6/24/26 at 11:47 AM*6/25/26 at 4:32AM and 9:37 PM*6/26/26 at 12:07 PM*6/27/26 at 5:55 AM*6/28/26 at 1:38 PM and 8:27 PM*6/30/26 at 1:59 PM*7/1/26 at 1:59 PM*7/4/26 at 4:56 AM and 1:59 PM*7/5/26 at 5:59 AM and 1:59 PM *7/6/26 at 9:44 AM*7/7/26 at 9:54 PM Further review revealed no documentation/record of emptying of urinary catheter bag output on these dates: 6/12/26, 6/16/26, 6/18/26, 6/22/26, 7/2/26, 7/3/26 and 7/8/26.3. Resident #7's MDS assessment dated [DATE], documented the resident had a BIMS score of 14 for which intact cognitively with decision making, has adequate hearing and vision, clear speech, makes self understood and is able to understand others, and no rejection of cares present. The MDS addressed the resident required substantial to maximal staff for toileting hygiene and lower body dressing and set up help with personal hygiene with an indwelling catheter in place. The MDS included diagnoses of Benign Prostatic Hyperplasia (BPH)(enlarged prostate) with lower urinary tract symptoms and multiple sclerosis.The Plan of Care with an initiated date 12/22/25, had a focus area of the resident has an indwelling foley catheter, atonal bladder (a medical condition where the bladder muscles lose the ability to contract) and neurogenic bladder. Interventions include: Check tubing for kinks each shift, monitor and document urinary outputs, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter, Monitor/record/report to Medical Doctor for signs/symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.The Orders Administration Note dated 5/16/26 at 11:35 PM, documented that resident states pressure and urine leakage around catheter. Catheter full of thick white sediment, unable to flush. Catheter changed out and immediate return of 200 cc of clear yellow urine return noted. Resident educated on not pushing or pulling on the catheter to reduce risk of infection and displacement. The Nurses Notes dated 5/21/26 at 6:26 AM, documented that the resident reported generalized feelings of being unwell to CNA at shift change. Temperature 101.9 degrees Fahrenheit. The resident verbalized wanting to go to hospital. The Nurses Notes dated 5/21/26 at 2:03 PM, documented the resident being admitted for pyelonephritis (a serious kidney infection caused by bacteria moving up from the bladder, leading to high fever, back pain and chills.The History and Physical dated 5/21/26 at 10:00 AM, documented that the patient experienced fever and chills on the night of 5/20/26 and reported neck stiffness and soreness. Has significant evidence of urinary tract infection with bacteriuria (bacteria in the blood stream) and pyuria (presence of 10 or more white blood cells per cubic millimeter in a urine sample). Presumably urinary tract infection is due to underlying chronic indwelling foley catheter. Catheter has been changed in the emergency department. Initial urine culture has been planted and patient has been started on antibiotic therapy. He had previously had a long hospitalization for complicated urinary tract infection and has required chronic indwelling foley ever since that time. Urine analysis reveals greater than 100 red cells greater than 100 white cells and moderate bacteria. I have arranged patient admission.The admission Note dated 5/26/26 at 3:45 PM, documented resident readmitted to facility from hospital after a 5 day hospital stay for a complicated UTI according to discharge after visit summary. Review of the Point of Care (POC) History dated 6/11/26-7/9/26, revealed output/emptying of the catheter bag was recorded on these dates and times:*6/11/26 at 5:49 AM*6/15/26 at 9:06 PM and 9:23 PM*6/17/26 at 5:47 AM and 1:54 PM*6/18/26 at 1:59 PM*6/20/26 at 5:59 AM*6/22/26 at 1:59 PM and 7:30 PM*6/23/26 at 9:39 PM*6/24/26 at 1:32 PM and 8:09 PM*6/25/26 at 1:31 PM and 8:45 PM*6/28/26 at 1:39 PM *6/29/26 at 1:33 PM*6/30/26 at 1:45 PM and 9:12 PM*7/1/26 at 1:50 PM*7/2/26 at 2:00 PM and 9:15 PM*7/3/26 at 1:36 PM*7/6/26 at 1:39 PM*7/7/26 at 9:59 PM*7/8/26 at 1:46 PM*7/9/26 at 3:24 AM and 1:46 PM*7/10/26 at 5:29 AM Further review revealed no documentation/record of urinary output or emptying the catheter bag on these dates: 6/12/26, 6/13/26, 6/14/26, 6/16/26, 6/19/26, 6/21/26, 6/26/26, 6/27/26, 7/4/26.4. Resident #12's MDS assessment dated [DATE], documented the resident had a BIMS score of 14 which indicated intact cognition, has adequate hearing and vision, clear speech, makes self understood and is able to understand others, and no rejection of cares present. The MDS addressed the resident required dependence on staff for toilet hygiene and lower body dressing and partial to moderate assistance with personal hygiene with an indwelling catheter in place. The MDS included diagnoses of renal failure, neurogenic bladder and cerebrovascular accident (CVA).The Plan of Care with an initiated date 10/11/2019, had a focus area for urinary retention and acute cystitis and is followed by the urology clinic. Interventions include: position catheter bag and tubing below the level of the bladder and away from entrance door, record urine output and report complaints of bladder spasms to the nurse.The Nurses Notes dated 5/20/26 at 12:42 PM, documented that the resident is having an increase in complaints/confusion. She has been complaining of bladder spasms for a couple of days on and off today she is claiming that the wheelchair is in is not hers. Possible urinary tract infection?The Nurses Notes dated 5/23/25 at 00:41 AM, documented a new order for urine analysis with culture and sensitivity. Urine sample collected at 4:24 AM from catheter.The Encounter dated 6/1/26 at 9:32 PM, acute/follow up documented that chief complaint today is that resident is seen for positive urine analysis and increased confusion. Nurse Practitioner had positive UA results back and antibiotic started twice daily for 7 days and is now starting today. Acute UTI with starting antibiotic for 7 days.Review of the Point of Care (POC) History dated 6/12/26-7/10/26, revealed output/emptying catheter bag was recorded on these dates and times:*6/14/26 at 8:18 PM*6/15/26 at 9:53 AM*6/16/26 at 12:29 PM and 9:59 PM*6/17/26 at 1:47 PM and 9:19 PM*6/18/26 at 10:35 AM*6/19/26 at 5:31 AM and 9:19 PM*6/20/26 at 8:53 AM*6/21/26 at 3:44 AM and 8:57 PM*6/22/26 at 1:05 AM and 8:57 PM*6/24/26 at 12:22 PM *6/25/26 at 5:42 AM and 10:40 AM*6/27/26 at 1:18 PM *6/29/26 at 11:03 AM and 5:34 PM*6/30/26 at 1:44 PM and 9:35 PM*7/1/26 at 1:59 PM*7/3/26 at 1:59 PM and 9:59 PM*7/4/26 at 12:24 PM and 7:29 PM*7/5/26 at 1:59 PM and 9:59 PM*7/6/26 at 1:34 PM*7/7/26 at 9:59 PM*7/8/26 at 1:40 PM and 9:59 PMOn 7/7/26 at 4:15 PM, Staff G, Registered Nurse (RN) stated that the expectation of the staff are to inform the nurse if no urine output is in a resident catheter bag and to document the amount of urine at the end of each shift or per facility policy/procedure.On 7/8/26 at 3:42 PM, the facility Director of Nursing (DON) stated that the expectation of the staff is to empty the catheter bag every shift and more frequently if needed and to document in the clinical record the output. The DON did not think that the facility had a policy/procedure on how often to empty the resident catheter bag.On 7/8/26 at 4:45 PM, Staff H, LPN, stated that the expectation of the staff are to empty the resident catheter bag every shift and document/record the output in the resident clinical record.On 7/8/26 at 5:00 PM, Staff I, RN stated that the expectation of the staff are to empty resident catheter bags every shift and to record/document the output in the clinical record.On 7/9/26 at 4:45 PM, Staff J, CNA, stated that it is common practice to empty a resident catheter every shift and record/document the output in the clinical record and that the expectation of the staff are to follow that standard of practice. On 7/9/26 at 4:55 PM, Staff K, CNA, stated that the expectation of the staff are to empty resident catheter bags every shift and more often if needed and to record/document the output in the clinical record.The Catheter Care Policy dated 6/13/25, stated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use: Catheter care will be performed every shift and as needed by nursing personnel. Empty drainage bags when bag is half-full or every 3 to 6 hours. Document care and report any concerns noted to the nurse on duty. The Change in Condition Protocol, undated, documented the purpose of the protocol is to provide care to resident through nursing assessments, interventions and appropriate follow up. When a change in condition or change from baseline is observed and reported, the charge nurse is responsible to evaluate the residents condition. The charge nurse completes a full assessment and documents in point click care (PCC) and notifies the physician as appropriate. Every shift is required to perform and document vitals and a focused assessment. Continue to monitor resident for response. There are no exceptions to this requirement. The protocol included charting guidance that included to chart until the concerns are resolved for change in urinary status ie: decreased urinary output.

Based on clinical record review, policy/procedure review, facility investigation review, resident and staff interviews the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 6 residents reviewed. (Resident #6 and Resident #10). The facility identified a census of 67 residents.Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 for which indicated intact cognitive decisions, is usually able to be understood and understand others, and no behaviors present. The MDS addressed the resident with limited range of motion in the upper and lower extremities on one side of the body and required set up assistance of staff for toileting hygiene, upper and lower body dressing. The MDS included diagnoses of cerebrovascular accident (CVA), hemiplegia (severe or total paralysis of one side of the body, caused by brain damage, often from strokes) hemiparesis (one side muscle weakness, caused by central nervous system damage such as a stroke) hypertension and depression.The Plan of Care with an initiated date 6/5/24, had a focus area of, the resident has a communication problem. Interventions include; anticipate and meet needs, allow adequate time to respond, repeat as necessary, do not rush, use simple, brief, consistent words/cues, use alternative communication tools as needed. On 7/1/26 at 3:15 PM, Resident #6 acknowledged that there are times that staff seem to be rude, and in a hurry and feels that staff needed to treat all residents with dignity and respect. 2. Resident #10's MDS assessment dated [DATE], documented the resident had a BIMS score of 15 for which indicated intact cognitive decision making, is understood and able to understand others with adequate vision and hearing. The MDS addressed the resident required staff dependence with toilet hygiene and showers/bathing. The MDS included diagnoses of hypertension, diabetes mellitus, anxiety, depression and will have vocal complaints of pain.The Plan of Care with an initiated date 3/6/26 with a focus area of resident has a trauma history with interventions include: staff will provide supportive counseling for resident and speak with a slow calm voice when resident is feeling anxious, social worker will help resident establish mental health support services to improve overall well being. The resident requires assistance by 2 staff to turn and reposition in bed.The undated Summary Report received from the Administrator documented the following for Resident #10:a. The resident was admitted to the facility on [DATE], has a BIMS score of 15, diagnosis of hypertension, chronic kidney disease with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease, morbid (severe) obesity due to excess calories, other specified diabetes mellitus with diabetic chronic kidney disease. b. The Administrator checked in with Resident #10 on the morning of 6/19/26, and Resident #10 made no mention of the incident. The Administrator spoke with Resident #10 in the afternoon at 12:09 PM, Resident #10 stated that she lays in bed and watches people go by and go about their day and is not doing anything to work toward getting out of the facility. Resident #10 stated that therapy does not even look at her. Administration discussed therapy services with Resident #10, and she stated that she wanted therapy services. Therapy authorization was approved on 6/22/26.c. Resident #10 further stated that during assistance with repositioning in bed on 6/19/26 at approximately 3:00 AM, two staff members informed her that she had been moved as high in the bed as possible. Resident #10 stated that staff were rough while attempting to reposition her. Resident #10 reported that one staff member moved her right arm upward toward the headboard while explaining how far she had been moved in the bed. Resident #10 informed staff that she had a bad shoulder and experienced discomfort. Resident #10 reported that she was holding the call light and stated to staff that she was going to request for someone else to help her. Resident #10 states that a staff member took hold of the call light while she was also holding it and informed her that there was no one else to help.d. The Administrator asked Resident #10 if the call light was removed from her at any point, and she stated that it was not. Resident #10 declined physician assessment and denied a need to be seen by a physician related to the reported incident. A head-to-toe assessment was completed. Family and the physician were notified. Resident #10 declined to have a police report made.e. The facility initiated an investigation, including interviews with the staff members involved, other staff members, and residents as well as a review of the circumstances surrounding the allegation. [NAME] investigation determined that the Registered Nurse was assigned to the hall and available during the time of the reported incident. Staff members interviewed who were not involved in the reported incident stated they had no concerns regarding the conduct, care practices, or interactions of the staff members naked in the allegation. Residents interviewed similarly reported no concerns regarding the staff members involved. f. During the investigation, Resident #10's mother reported concerns that briefs had been taken from the resident room. This concern was reviewed with the resident, who stated that briefs had not been stolen or removed from her room and did not identify this as a concern. Interviews with the involved staff members revealed different statements regarding whether briefs may have been borrowed from another resident room. This information was reviewed as part of the investigation. g. Both aides involved were suspended pending the outcome of the investigation.h. During the investigation, concerns were raised regard staff identification. The DON provided education to staff regarding facility uniform requirements and reinforced that wearing a visible name tag is mandatory and considered part of the required staff uniform. i. At the time of reporting, information obtained indicates differing accounts regarding the repositioning assistance provided and the interaction involving the call light.On 7/1/26 at 10:50 AM, Staff C, Certified Nursing Assistant (CNA), confirmed and verified that the expectation of staff are to treat all residents with dignity and respect at all times.On 7/2/26 at 11:10 AM, Staff D, CNA, confirmed and verified that the expectation of all staff are to treat residents with dignity and respect at all times. On 7/2/26 at 1:02 PM, the facility Director of Nursing acknowledged that staff are expected to treat all residents with dignity and respect at all times.The Resident Right Policy dated 11/5/25, stated that the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her right and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The resident has the right to be treated with respect and dignity. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide professional standards of quality by not following physician orders for coumadin (a blood thinner) to be started and not give for 3 days for 1 resident (Resident #2) and failed to follow the physicians order for Occupational Therapy to be given 2 times a week for 1 resident (Resident #3) out of 4 residents reviewed. The facility reported a census of 67 residents.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 for which indicated moderate impaired cognitive memory, is usually able to be understood and understand others. The resident required substantial to maximal assistance with all aspects of activities of daily living (toileting, transfers, dressing, and personal hygiene). The MDS included diagnoses of cancer, anemia (lack of healthy red blood cells, prevents your body from getting enough oxygen), hypertension (force of blood pushing against artery walls is consistently too high), renal failure (kidneys lose the ability to filter waste and excess fluids from your blood), diabetes mellitus, cerebrovascular accident (blood flow to the part of the brain is interrupted or reduced, depriving brain tissues of oxygen and nutrients) and depression. The Care Plan with a revision dated 9/17/24, indicated Resident #2 is on anticoagulant therapy. Interventions include: administer anticoagulant medications as ordered by the physician, monitor for side effects and effectiveness, daily skin inspection, and report abnormalities to the nurse, avoid use of aspirin and use Vitamin K for bleeding emergencies. Vitamin K is located in the emergency kit.The New Order dated 6/29/26 at 1:59 PM, note text, verbal order to restart Warfarin (coumadin) 2 milligrams daily. Resident notified of new order and pharmacy notified.The Orders Administration Note dated 6/30/26 at 5:18 PM, documented Warfarin Sodium oral tablet 2 milligrams by mouth in the evening related to cerebral infarction, medication is unavailable at this time, still waiting for pharmacy to deliver.The Orders Administration Note dated 7/1/26 at 8:31 PM, documented Warfarin Sodium oral tablet 2 milligrams give 1 tablet by mouth in the evening related to cerebral infarction, medication is unavailable.The Medication Administration Record (MAR) dated 6/1/26-6/30/26, instructed staff to give Warfarin Sodium (coumadin) 2 milligrams by mouth in the evening. The June MAR identified that the coumadin was not given on 6/29 and 6/30/26. The MAR dated 7/1/26-7/31/26, instructed staff to give Warfarin Sodium (coumadin) 2 milligrams by mouth on the evening shift. The July MAR identified that the coumadin was not given on 7/1/26.On 7/8/26 at 2:33 PM, the facility Director of Nursing (DON) stated the expectation of the staff are to follow the physicians orders as written and facility policy/procedure and that the emergency kit has coumadin and that staff were aware that the coumadin was in the kit so Resident #2 should not have missed 3 days of coumadin.2. Resident #3's MDS assessment dated [DATE] documented the resident had a BIMS score of 15 for which indicated intact cognitive memory, is able to be understood and understand others. The resident required dependence with assistance with all aspects of activities of daily living (toileting, transfers, dressing, and personal hygiene) and had functional limitations in range of motion to upper and lower extremities on both sides of the body. The MDS included diagnoses of anemia (lack of healthy red blood cells, prevents your body from getting enough oxygen), depression, anxiety, joint contractures, abnormal posture and weakness. The Care Plan with a revision dated 4/17/26, restorative passive range of motion, to bilateral knees, right ankle, hip, fingers, wrists and shoulders. Interventions include: Passive range of motion lower extremity 10 repetitions, notify nurse if decline or significant change in performance. The Consultant Report dated 6/2/26, documented the recommendations/orders are to please start outpatient hand therapy twice weekly.The Therapy Part B Screen/Insurance dated 6/3/26, instructed to have hand therapy two days per week, for stiffness in all hand joints on the right hand.The Occupational Therapy Evaluation and Plan of Treatment dated 6/11/26, stated that the frequency is 1-3 times per week.The Occupation Therapy Treatment Encounter Notes revealed that Resident #3 had passive range of motion to right hand and digits to address contracture management and maintain joint mobility on 6/19/26, record review revealed only 1 day of services for that week.On 7/9/26 at 2:02 PM, the facility Occupational Therapist confirmed and verified that Resident #3 only received one day of therapy the week of 6/15/26-6/19/26 and that the orders were to be twice per week.The Consulting Physicians/Practitioner Orders Policy dated 4/3/25, follow facility procedures for verbal or telephone orders including, noting the order, submitting to pharmacy, and transcribing to medication administration record.

Based on observation, staff interview, and policy review the facility failed to provide complete incontinent cares for 1 of 3 resident (Resident #13) reviewed. The facility reported a census of 67 residents. Findings include:Resident #13's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 6 for which indicated severely impaired cognitive memory, usually able to be understood and understand others. The resident required dependence on staff for activities of daily living (toileting, transfers, dressing, and personal hygiene) and was frequently incontinent of bladder and always incontinent of bowel. The MDS included diagnoses of hypertension (force of blood pushing against artery walls is consistently too high), diabetes mellitus, and non-alzheimer's dementia. The Care Plan initiated date 1/19/24, documented the resident has a history of urinary tract infections and has activities of daily living self-care deficits. Interventions include: resident requires assistance by 2 staff for toileting, check and change or bedpan, good hygiene practices, females to wipe and cleanse from front to back, clean per area well after each bowel movement in order to help prevent bacteria in urinary tract. Wear clean underwear daily.Observation on 7/1/26 at 11:15 AM, revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, provided incontinence cares for Resident #13. Staff A and Staff B positioned Resident #13 on their left side and while on their left side the resident started to urinate and have a bowel movement. Staff B cleansed the residents right buttock, hip and thigh area. Staff A and Staff B proceed to roll Resident #13 onto their back and place a clean brief and nap pad underneath. Staff B failed to cleanse the left buttock, hip and thigh area where the urine had dribbled.On 7/1/26 at 11:22 AM, the facility Director of Nursing acknowledged that Staff B failed to cleanse the left hip, thigh and buttock area on Resident #13 and that the expectation is to cleanse all the areas where urine had touched.The Incontinence Care Policy and Procedure with no date, stated that the policy established guidelines are to be followed that will aid the caregiver in caring for the incontinent resident. Each resident who experiences an episode of incontinence will be appropriately cleaned. Wash the residents' perineal area front to back with soap and water.

Based on clinical record review, staff interview, and policy/procedure review at the time of the investigation, the facility failed to assess a resident with a change in condition for 1 of 6 residents reviewed. (Resident #8). The facility identified a census of 67 residents. Findings include:Resident #8's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognitive decisions. Resident #8 is able to make self understood and usually understands others, has adequate vision and moderately difficulty with hearing. Resident #8 was dependent with toileting hygiene, and lower body dressing and substantial to maximal assistance with showers/bathing and partial to moderate assistance with personal hygiene, and shortness of breath with exertion (walking, bathing and transferring) and whey lying flat. The MDS included diagnoses of hypertension, (a chronic condition where blood force against artery walls is consistently too high), cerebrovascular accident (when blood flow to a part of the brain is interrupted and depriving brain tissue of oxygen and nutrients) hemiplegia (complete paralysis of one entire side of the body caused by brain or spinal cord damage) anxiety and depression.The Care Plan Focus area dated 7/24/25, indicated Resident #8 has altered cardiovascular status and complications for cardiac problems, and shortness of breath. Interventions include: maintain a clear airway be encouraging resident to clear own secretions with effective coughing, and suction as needed, monitor/document breathing patterns such as respiratory depth changes, altered chest excursion, use of accessory muscles, pursued lip breathing or prolonged expiratory phase, increased chest diameter, position resident with proper body alignment for optimal breathing patterns, report any changes in lung sounds, edema and changes in weight.The Health Status Note documented on these dates and times:On 6/3/26 at 7:23 PM, Guaifenesin (over the counter medicine used to treat chest congestion and cough), give 10 milliliters by mouth every 4 hours as needed for cough.On 6/4/26 at 7:44 AM Guaifenesin ER tablet, (used to thin and loosen mucus in the chest, making coughs more productive) extended release 12 hour 600 milligram, give 1 tablet by mouth every 12 hours as needed for chest congestion.On 6/5/26 at 8:21 PM, Guaifenesin ER tablet, extended release, 12 hour 600 milligram, give 1 tablet by mouth every 12 hours as needed for chest congestion.On 6/8/26 at 4:37 PM, Guaifenesin liquid 10 milliliters, give 10 milliliters by mouth every 4 hours as needed for cough.On 6/11/26 at 10:39 AM, resident stated that a pill is stuck in the throat from this morning medications, post all intervention resident continues to complain of discomfort, physician was notified and requested to give resident apple sauce and more fluids. The resident continues to complain of discomfort, and the physician agrees to have the resident sent out to the Emergency Room. The clinical record lacked documentation of any further assessment on the resident with a change in condition.The Emergency Medical Record Report dated 6/11/26 at 1:30 PM, documented resident positive for congestion and positive for wheezing.On 7/2/26 at 12:28 PM, the facility Director of Nursing (DON) confirmed and verified that the clinical record lacked documentation of lung sounds being completed after the resident requested medication for congestion and cough and it is the expectation of the nursing staff to follow the facility policy/procedure for changes in resident condition.The Change of Condition Protocol with no date, the purpose is to provide care to residents through nursing assessments, interventions and appropriate follow up. Condition change is an alteration (improvement/decline) in a person's mental physical status from normal status or baseline. Could include changes in vital signs, signs/symptoms of dehydration, or decline in resident condition. When a change of condition or change from baseline is observed and reported, the charge nurse is responsible to evaluate the resident condition.Every shift is required to perform and document vitals and a focused assessment, continue to monitor residents response, there are no exceptions to this requirement.

Based on clinical record review, facility policy review and staff interview the facility failed to administer the restorative program as recommended by the therapy department for one of three residents reviewed (Resident #2). The facility reported a census of 71 residents.Findings include:The MDS (Minimum Data Set) assessment tool dated 2/19/2026 revealed Resident #2 had intact cognition, required partial to moderate assistance with dressing and hygiene, and was dependent on staff to ambulate and transfer from one surface to another. The MDS reported the resident's nutritional approaches included a feeding tube and altered diet, and received no therapy services including restorative service during the prior seven days.The resident's Care Plan revealed the resident had an ADL (Activities of Daily Living) self-care performance deficit focus area initiated on 8/22/25, and a risk for falls focus area initiated on 8/28/2025. The Intervention dated 8/28/25 directed staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility.The resident's physician orders included orders for occupational and physical therapy evaluation and treatment on 8/20/2025, 10/7/2025, 10/13/2025, 12/11/2025, 2/25/2026. An order dated 3/1/2026 instructed staff to send the resident to the hospital for an evaluation. The resident failed to return to the facility. A Therapy Recommendation dated 12/19/2025 advised the facility restorative staff to administer active range of motion exercises to the bilateral lower extremities: march, knee extension, and ankle dorsiflexion and plantar flexion 1-5 times a week.In a progress note dated 12/4/2025 at 7:49 a.m., Staff A, LPN (Licensed Practical Nurse) documented therapy recommendation received for restorative exercise program, copy provided to rehab aid to schedule.In a progress note dated 12/6/2025 at 1:07 p.m., Staff B, C.N.A., documented, continues with restorative program this week. No concerns at this time.In a progress note dated 12/12/2025 at 1:45 p.m., Staff C, former Administrator and Regional Consultant documented the facility received new therapy orders. Insurance verified and resident aware. Communicated to therapy.In a progress note dated 12/23/2025 at 7:30 a.m., Staff A documented the facility received therapy recommendation for restorative exercise program, copy provided to rehab aide for scheduling.In a progress note dated 12/26/2025 at 11:41 p.m., Staff B documented the resident continues with restorative program. No changes or concerns at this time.In a progress note dated 2/25/2026 at 5:50 a.m., Staff A documented orders submitted for PT (Physical Therapy), OT (Occupational Therapy) evaluation and treatment for insurance approval. Resident also had PT/OT at discharge planned for 3/1/2026.On 4/28/2026 at 8:37 a.m., Staff E, DON (Director of Nursing) reported Resident #2 discharged to the hospital and believed she went home from there with home health services. The resident had foot pedal machine that she independently used in her room when she allowed staff to get her up into the wheelchair. According to Staff B, C.N.A., the resident did her own program. Therapy typically writes up a restorative program and the facility follows it. It appeared from her notes that the resident had not been on the therapy caseload from sometime in December to February.On 4/29/2026 at 10:00 a.m., Staff E reported the facility owned the failure to administer the resident's therapy from 12/15/2025 - 2/2026.On 4/28/2026 at approximately 2:00 p.m., Staff D, Occupational Therapy Aide reported Resident #2 received OT until 12/3/2025, PT until 12/2/2025, and ST (Speech Therapy) until 1/12/2026. On 12/4/2025 therapy made a referral to the restorative program for a home program and received education. The resident had a portable pedal machine in her room. On 12/19/2025 the resident had another order for a PT evaluation. The evaluation determined the resident was not appropriate for further physical therapy, the resident remained at baseline. The resident admitted to not using the portable pedal machine. Therefore, PT made a restorative recommendation for exercises of the lower extremities on 12/19/2025.On 4/27/2026 at 9:45 a.m. Staff B, C.N.A., Restorative Aide reported he had a list of residents on the restorative program. At 3:00 p.m., Staff B reported Resident #2 failed to receive restorative. The resident received therapy and then discharged from the facility. The resident had a pedal machine from home that she used in her room when she agreed to get out of bed. Staff B had no referral from PT to the restorative program.On 4/29/2026 at 8:00 a.m., Staff A, LPN indicated she did oversee resident's therapy. She reviewed the restorative recommendation for Resident #2 on 4/28/2026, and her progress note dated 12/4/2025. Staff B denied received a copy of the recommendation. A question remained regarding the resident's ability to exercise on her own. Either way, there should have been documentation as to whether or not the resident actually did it. The resident went to a physician's appointment and returned with a therapy evaluation order on 12/19/2025. In a progress note dated 12/23/2025, Staff A documented the facility received the referral for the restorative program.The facility Restorative Nursing Program Policy copyright 2025 included, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.Definition: Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.Policy Explanation and Compliance Guidelines: .2. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences.

Based on record review and resident interviews the facility failed to consistently answer call lights in a timely manner for 3 of 3 residents reviewed, (Residents #4, #5 and #6). The facility reported a census of 77 residents. Findings include:1.The MDS (Minimum Data Set) dated 2/3/2026 revealed Resident #4 had an intact cognitive status. Observation on 3/10/2026 at 2:35 p.m. revealed the resident seated at the dining room table with her walker nearby. During an interview, the resident reported call light response times takes awhile, greater than fifteen minutes. The resident also puts her call light on for her roommate who is not capable of calling for assistance. 2.The MDS dated [DATE] revealed Resident #5 had intact cognitive status.Observation on 3/10/2026 at 2:40 p.m. revealed the resident in bed, alert and watching television. The resident reported he required assistance of two staff to transfer in and out of bed and use the bathroom. He stated staff failed to answer his call light in a timely manner at least once a day, on any shift. The resident has timed the response time and it has taken up to an hour. This delay has caused him to have incontinence.3.The MDS dated [DATE] revealed Resident #6 had intact cognitive status.Observation on 3/10/2026 at 2:45 p.m. revealed the resident in his recliner with oxygen on per nasal canula and his walker nearby. The resident reported staff are slow to respond to his call light. Response time can take over a half hour, and he has timed it to take up to an hour. At times staff respond to his call light, turn it off, leave his room without assisting him, and fail to return. The resident required assistance of staff to ambulate when he is feeling unsteady. The Resident Council Meeting notes dated 3/3/26 included under Old Business - call lights too long.On 3/10/2026 at 3:25 p.m., the DON (Director of Nursing) and Administrator reported when Resident Council reports reveal a call light concern, the facility follows up with audits and staff education. The concern is reviewed at the next resident council meeting.

Based on observations, interviews, and record review, the facility failed to administer medications as ordered for 2 of 3 residents reviewed (Resident #1 and Resident #4) when Resident #1 received Resident #2's insulin injection and was transferred to the emergency room (ER) for close observation, and Resident #4 received Resident #8's morning medications and required monitoring of his blood pressure (BP) every shift for the following 72 hours. The facility reported a census of 77 residents. Findings include: 1.A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included acute kidney failure, Type 2 diabetes and schizophrenia. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15 which revealed intact cognition.A Medication Error Wrong Medication Incident Report dated 12/5/25 at 8:25 a.m., revealed Staff B, Licensed Practical Nurse (LPN) (Agency nurse) documented the following:While administering morning insulins, Resident #1 received the wrong insulin. (Staff A) Certified Nurse Aide (CNA) was questioned as to Resident #1's identity. When (Staff A) was questioned as to whether she was sure of (Resident #1's) identity, Staff A stated 'yes, she is the one with the red blanket right there.' When (Staff B) called the resident's name, the resident responded to the incorrect name with yes. While completing Vital Signs (VS) on the unit, (Staff B) noticed Resident #1 in her room with a different name tag on the door. Staff B notified administration immediately. Resident #1 stated she was feeling fine. There were no signs or symptoms (s/s) of hypoglycemia at this time as of yet. Blood Sugar (BS) check was 177. Administration notified immediately of medication error. Primary care physician notified of incident. Resident Blood Sugar taken (177). Order to send resident to the emergency room (ER) for evaluation and treatment. Resident was fed house supplement milk for protein and blood sugar support. 911 was called, and a report was given to the hospital. (Resident #1) was aware of the incident and new order to evaluate at the ER. (Resident #1) was sent to the hospital. Resident #1 was alert and oriented X 3 (oriented to person, place, and time), had no distress at the time of transfer. Recent Blood Sugar was 177, no acute distress noted. Sent to ER for observation due to risk. An ED (Emergency Department) Provider Notes dated 12/5/25, documented the following. Chief Complaint: [Facility Name] accidentally gave patient the incorrect insulin dosing. Resident #1 came to the ER via EMS (Emergency Medical Services). Episode onset 8:30 a.m .Context: Erroneous medication by staff. The incident was reported. The incident was witnessed/reported by a caregiver .Patient stated they (the facility) gave her a sugar drink . Patient is an [AGE] year old female with past medical history of insulin-dependent type 2 diabetes who usually takes 13 units of long-acting insulin at night and 10 units regular insulin with meals. EMS reports [Facility Name] accidentally gave patient the incorrect insulin dosing in addition to her 10 units regular insulin with her breakfast this morning they also gave her 40 units of long-acting Lantus, she usually takes 13 units of Lantus in the evening only. She had this medication given to her while eating breakfast, and the patient states that they gave her a sugar drink after the medication error was noticed. EMS reports this sugar drink was Ensure. Patient is otherwise asymptomatic. Physical Exam revealed patient in no acute distress, vital signs stable, with benign exam. Will check Accu-checks (blood sugars), labs.Patient is resting comfortably in bed on reexam, would like to be discharged back to [Facility Name]. Her sugars have stabilized. (this provider) recommended that they do Accu-Checks every hour to ensure no hypoglycemic episodes, and recommended that the patient snack frequently throughout the day to try to maintain sugars. She is given strict ER return precautions.Final diagnoses: Insulin overdose, accidental or unintentional, initial encounter. Resident #1 arrived to the ER at 9:21 a.m. and discharged at 2:34 p.m. Resident #2's December 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) directed staff to inject:a. Insulin Glargine (long acting insulin(24 hours)) 40 units subcutaneously twice a day. On 12/5/25 at 7:00 a.m., Staff B entered her initials as administering this insulin. b. Humalog (short acting insulin) 10 units subcutaneously before meals. On 12/5/25 at 7:30 a.m., Staff B entered her initials as administering this insulin.Resident #1 received both of Resident #2's insulins the morning of 12/5/25. Resident #1's December MAR/TAR directed staff to inject Insulin Glargine 13 units in the evening. This is the only insulin Resident #1 receives. It was administered on 12/4/25 evening. A Nurses Progress Note dated 12/5/25 at 8:40 a.m., documented that a phone call was placed to 911 requesting a resident transfer to the ER for potential hypoglycemia and observation per verbal order from a facility provider, Resident #1 is her own responsible party and aware of the transfer. Current blood sugar is 177. REsident #1 is alert and oriented X 3 and drinking 120 mls (milliliters) house supplement.A Nurses Progress Note dated 12/5/25 at 8:45 a.m., documented a phone call was placed to the ER and the facility nurse spoke with the ER nurse. The facility nurse reported incorrect insulin doses, current blood sugar, intervention of house supplement, and that Resident #1 was alert and oriented X3 and she is her own responsible party. A Nurses Progress Note dated 12/5/25 at 2:44 p.m., documented that Resident #1 returned from the ER at 2:36 p.m. New orders to monitor blood sugar every hour and give small frequent snacks. Will continue the plan of care. A doctor's order dated 12/5/25 at 2:51 p.m., directed staff to monitor BS (blood sugar) every hour for 24 hours to make sure BS does not drop below 60. Give frequent snacks as needed.A Blood Sugar Summary documented:12/5/25 at 4:44 a.m. 139.0 mg/dL (milligram/deciliter)12/5/25 at 8:48 a.m. 177.0 mg/dL12/5/25 at 2:59 p.m. 300.0 mg/dL12/5/25 at 3:04 p.m. 289.0 mg/dL12/5/25 at 4:10 p.m. 349.0 mg/dL12/5/25 at 4:45 p.m. 380.0 mg/dL12/5/25 at 5:48 p.m. 307.0 mg/dL12/5/25 at 7:49 p.m. 289.0 mg/dL12/6/25 at 1:44 a.m. 87.0 mg/dL12/6/25 at 4:44 a.m. 205.0 mg/dL12/6/25 at 6:59 a.m. 119.0 mg/dLBlood sugars were not checked at 12:00 a.m., 1:00 a.m., 3:00 a.m., 4:00 a.m., .and 6:00 a.m. on the morning of 12/6/25. 'SL' was documented by these times. Review of the Chart Codes key indicated SL=sleeping. On 12/17/25 at 1:40 p.m., the Administrator stated the blood sugar check hourly was a suggestion from the hospital provider but the provider didn't say how long. She acknowledged the facility obtained a doctor's order for Resident #1 directing staff to do hourly blood sugars for 24 hours. She acknowledged that SL would have stood for sleeping. On 12/11/25 at 2:52 p.m., Staff A stated she was making coffee in the dining area on that morning as a resident wanted a cup of coffee. The nurse (Staff B) asked Staff A which resident was Resident #1's first name. I heard her say Resident #1's first name. Later on I found out that she was asking for Resident #2's first name. Staff B had never met Staff B before. Staff A stated she was a couple of tables away from Staff A in the dining room when Staff A asked Staff B. Staff A said she was occupied making a coffee for a resident and it needed thickener in it, so she was putting the thickener in the coffee and stirring it up. Staff A stated she just heard later about Resident #1 receiving the wrong insulin. They sent Resident #1 out to the hospital right away and she did not get back from the hospital before Staff A left at the end of her shift, so Staff A did not see Resident #1 again on that day after Resident #1 received Resident #2's insulin. Staff B could not be reached for an interview. On 12/9/25 at 2:35 p.m., Resident #1,when asked if she knew about and /or had concerns about receiving the wrong insulin, she said yes. She stated there are so many residents with similar first names. Resident #1 could not remember if the nurse asked Resident #1 what her last name was prior to administering the insulin. 2. A MDS dated [DATE], documented that diagnoses for Resident #4 included hypertension (high blood pressure), septicemia (serious bloodstream infection), aphasia (difficulty with language) and CVA (Cerebrovascular Accident)(stroke). A BIMS documented a score of 9 out of 15, which indicated moderately impaired cognition. A Medication Error Wrong Medication Incident Report dated 10/27/25 at 6:40 a.m., documented that Staff C, OMT (Oral Medication Technician), administered another resident's scheduled a.m. medications to Resident #4, which included folic acid (vitamin B supplement), nadolol (BP lowering agent), spironolactone (diuretic and BP lowering), carafate(anti ulcer medication), multivitamin, lasix (diuretic) and protonix(decreases stomach acid). Allergies were checked, doctor was notified, baseline VS assessed- provider instructed to monitor BP every shift X 72 hours and notify of changes, order received to hold Metoprolol (BP lowering agent) today. The medication aide confused Resident #4 with another new resident that name also started with a [letter redacted]. A Blood Pressure Summary documented the following:10/27/2025 at 7:00 a.m. 97/59 mmHg (Sitting r/arm) Diastolic Low of 60 exceeded10/27/2025 at 8:50 a.m. 101/60 mmHg (Sitting r/arm)10/27/2025 at 12:59 p.m. 94/57 mmHg (Sitting r/arm) Diastolic Low of 60 exceeded10/27/2025 at 1:19 p.m. 95/51 mmHg (Sitting l/arm) Diastolic Low of 60 exceeded10/27/2025 at 8:03 p.m. 98/63 mmHg (Lying l/arm)10/28/2025 at 3:55 a.m. 100/60 mmHg (Lying l/arm)10/28/2025 at 10:53 a.m. 92/58 mmHg (Sitting l/arm) Diastolic Low of 60 exceeded10/28/2025 at 1:21 p.m. 94/58 mmHg (Sitting r/arm) Diastolic Low of 60 exceeded10/28/2025 at 5:31 p.m. 98/58 mmHg (Sitting l/arm) Diastolic Low of 60 exceeded10/29/2025 at 12:31 a.m. 94/54 mmHg (Lying l/arm) Diastolic Low of 60 exceeded10/29/2025 at 7:57 p.m. 113/64 mmHg (Lying r/arm)10/29/2025 at 9:24 p.m. 114/51 mmHg (Lying l/arm) Diastolic Low of 60 exceeded10/30/2025 at 5:12 a.m. 84/58 mmHg (Lying l/arm) Resident #8's October 2025 MAR/TAR directed staff to administer the following medications at 7:00 a.m.:Folic Acid 1 mg (milligram) by mouthFurosemide 40 mg by mouthMultivitamin give 1 tablet by mouthNadolol 40 mg by mouth Spironolactone 100 mg by mouthArtificial Tears 1 drop in each eye for dry eyesProtonix 40 mg by mouthSulcrafate suspension 10 ml (milliliters) by mouthThese medications were administered to Resident #4. Staff C initialed she administered these medications. On 12/10/25 at 3:50 p.m., Staff C stated that both Resident #4 and Resident #8 were new to the facility and she hadn't met them yet. She said that both residents' names started with a [letter redacted]. She said that they lived either right beside each other or directly across the hall from each other because she knew when she came out of the room after giving the meds to Resident #4 she saw the Resident #8's name outside of his door and knew that she had given that Resident #8's medications to Resident #4. She said Resident #4 was hard of hearing. She didn't know that he was hard of hearing at the time, but Resident #4 answered to Resident #8's name when she asked if that's who he was. Staff C stated she reported it right away. Staff C stated that Resident #4 didn't have any side effects that she saw from receiving the wrong medications.On 12/11/25 at 3:05 p.m., Staff D, Registered Nurse (RN), stated she was the nurse working the morning Staff C gave Resident #4 the wrong medications. She said she called the physician and they held Resident #4's blood pressure medications and then monitored his blood sugars for 3 days. She said from what she remembers this resident did okay while she was there. He didn't complain of dizziness to her. She was not sure if she worked either of the following 2 days so doesn't know or remember if he had any hypotension or experienced any signs or symptoms of hypotension. On 12/11/25 at 4:30 p.m., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the concerns with Resident #1 and Resident #4 receiving other residents' medications. They acknowledged that both residents were ordered follow up for monitoring of by their provider related to the medications they received. An Administration of Drugs and Biologicals Policy dated 6/2025, directed the following:It is the policy of this facility that residents receive their medications on a timely basis and in accordance with our established policies.PROCEDURE1. Must be administered by personnel who are certified to perform such services.2. Must be administered by the person preparing the doses.3. May may not be prepared in advance.4. Must be charted in EHR (electronic health record) by the person administering the drugs.5. Should there be any doubt as to the correct identification of a resident, medication may not be administered to that resident until positive identification has been made.6. Should there be any doubt concerning the administering of medication(s), the physician's order must be verified before the medication is administered.7. Current drug reference is available at all nurses' stations via computer or handbook.8. Self-administration is permitted when reviewed and approved by the IDT (interdisciplinary team).9. Medication administration will be individualized and addressed as needed through the physician orders and the care planning process.Six Rights Of Drugs And Biologicals Followed By Staff1. Right Patient - Confirm identity using two identifiers (e.g., name & date of birth ).2. Right Medication - Verify the exact drug ordered.3. Right Dose - Check that the dosage is correct for the patient.4. Right Route - Administer using the correct method (oral, IV (intravenous), IM (intramuscular), etc.).5. Right Time - Give the medication at the correct time and frequency.6. Right Document - Document medication accurately after it is administered.

Based on observation, clinical record review, manufacturer's product manuals, resident and staff interviews, the facility failed to ensure staff utilized the correct full body mechanical lift sling size, resulting in 1 of 3 residents utilizing a mechanical lift to slide in the sling, and be lowered to the floor (Resident #3). The facility identified a census of 79 residents.Findings include:Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 15/15 indicating intact cognition. Resident #3 exhibited upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) functional impairments on both sides of the body and utilized a wheelchair.Resident #3 was not able to do sit to stand (ability to come to a standing position from a sitting in a chair, wheelchair or on the side of the bed) due to medical condition/safety concerns and was dependent upon staff for chair/bed to chair transfers. The MDS listed diagnoses of arthritis, narcolepsy with cataplexy (a chronic neurological disorder characterized by excessive sleepiness and sudden, uncontrolled muscle weakness called cataplexy. Other symptoms include sleep paralysis, hallucinations and disturbed nighttime sleep) and chronic gout. Per the MDS, Resident #3's height was 64 inches (5 foot 3 inches), and resident's weight was 182 pounds.Resident #3's 9/4/25 Nursing admission Screening/History documented, in part, the resident exhibited an unsteady gait and poor balance for motor control, and had a history of falling/recent fall.The 9/5/25 Care Plan listed Resident #3 had an Activities of Daily Living (ADL) Self-Care Performance Deficit related to limited mobility, limited range of motion, and bilateral leg contractures. The Care Plan directed Resident #3 required the use of a full body mechanical (Hoyer style) lift with two staff assistance for transfer and to move resident between surfaces with the full body mechanical lift. The Care Plan lacked direction to the staff on the size or style of sling to utilize with the full body mechanical lift. A Nurses Note dated 10/22/25 at 11:40 AM written by Staff A, Licensed Practical Nurse (LPN) documented the certified nursing assistants (CNA's) were preparing to transfer Resident #3 using a full body lift. The resident slid backwards in the sling and was lowered to the floor with the full body mechanical lift .No injuries were noted. She denied pain or discomfort . Provider notified with no new orders received. An Incident Report dated 10/22/25 at 11:40 AM prepared by Staff A documented a witnessed fall, the CNA's reported that while preparing to transfer the resident using a full body mechanical lift, Resident #3 slid backward in the sling and was lowered to the floor with the full body mechanical lift. The Resident stated, I slid down. The Immediate Action Take Resident #3 was repositioned in the sling on the floor and transferred using the full body mechanical lift to be changed, then was transferred to the wheelchair. The Incident Report lacked documentation of any witnesses or witness statements.An Incident/Interdisciplinary Team (IDT) Note dated 10/23/25 at 6:16 AM, with attendees Staff B, MDS Coordinator, Director of Nursing (DON), Assistant DON and Administrator, documented resident was getting ready for a full body mechanical lift transfer to bed when resident's body began to slid through the middle hole in the sling. The resident was not positioned safely to complete the transfer to the bed and due to the resident's poor position in the sling safe transfer back into the wheelchair was not an option. The resident was lowered to the floor with the assist of the full body mechanical lift and two staff. The sling was repositioned and transfer was completed. The Root Cause of the incident was poor positioning in the full body mechanical lift sling. The IDT note failed to identify Resident #3 was placed in the wrong size sling for the full body mechanical lift.Interview completed on 11/13/25 at 9:39 AM revealed Resident #3 verbalized she had told the staff she wasn't in the lift sling right, but they wouldn't listen to her. They went ahead and transferred her anyway and she slid in the sling and ended up on the floor. Review of Resident #3's EHR Weight Summary record revealed resident's weight was 187 pounds on 11/9/25. On 11/17/25 at 12:05 PM, observation revealed Staff C and D, CNA's positioned a blue purple trimmed full body mechanical lift sling (brand specific sling for a different manufacturer full body mechanical lift #2) under Resident #3. Staff C and D placed the bottom sling straps through Resident #3 legs, crossed the straps between the inner thighs and hooked the sling up the (brand specific #1) full body mechanical lift. Resident #3 leaned to the right once upon in a sitting position in the sling. Staff C and D transferred Resident #3 to the wheelchair. On 11/18/25, review of Resident #3's ADL Self-Care Performance Deficit Care Plan, under Transfers, directed Resident #3 required a full body mechanical lift with two staff assist for transfers, cross lift sling between legs for transfer, revised 11/17/25. On 11/18/25 at 8:06 AM, the ADON explained the CNA staff received education after Resident #3's incident. When the ADON and DON were queried on which full body mechanical lift was utilized for Resident #3's transfer on 10/22/25, neither could answer what actual full body mechanical lift was used that day, but stated they would check with the staff. When queried on which staff members had been involved in the incident, both stated it had been a while ago and they would have to go back and look to see which staff were involved in the incident. The ADON further explained they identified staff had used the type of sling that could have the lower straps crossed between the legs, but the staff had not crossed the bottom straps of the sling between the resident's legs and she started to slide out of the sling. During an interview on 11/18/25 at 8:13 AM the Administrator voiced staff knew the size of sling to use for residents as there was a guide that hung on the lift that indicated the size of sling for the residents to use. When queried when the guides were placed on the lifts, the Administrator did not state a date, but indicated it was after Resident #3's incident. On 11/18/25 at 8:16 AM, Staff B explained each incident report had an IDT note summary in the resident's progress notes where they reviewed falls. The root of the problem was the full body mechanical lift sling when placed did not have the bottom straps of the sling crossed between the resident's legs, which is why she slid in the sling. Staff B didn't know if they had specifically looked at the actual full body mechanical lift as it wasn't a mechanical issue. That was ruled out right away. Staff B didn't know which full body mechanical lift had been used during Resident #3's incident. On 11/18/25 at 8:28 AM, observation of the full body mechanical lift, identified by the DON as the lift that had been used for Resident #3 on the day of the incident, revealed a laminated sling size guide, undated. On 11/18/25 at 9:50 AM, the ADON voiced she had misspoke earlier. The issue with the full body mechanical lift was not crossing the sling under the resident's legs. It was the wrong size sling. When queried on the size used, she stated she couldn't speak to that, but Staff E, Restorative Aide would be the one to talk to about that. Staff E had put out size charts on the lifts after the incident.Interview completed on 11/18/25 at 9:56 AM Staff E, reported he was not present during Resident #3's incident. Through the investigation they concluded the sling was too large for the resident. He thought the blue trimmed sling had been used for Resident #3. Staff E commented the blue trimmed sling was way too big for Resident #3 and the bigger the sling, the bigger the hole in the sling to fall through. Resident #3 was short and she tended to lean forward and roll into a ball in the sling. He voiced he wasn't present during the incident, and didn't know if the sling was crossed between Resident #3's legs. The sling was a toileting sling that was used on her that day. He explained he did the in-service after the incident, demonstrated how to pick the size of the sling, and how to properly place the sling under a resident. The sizing charts went on the lifts after the incident, but he couldn't give an actual date of when he did it. Staff E explained CNAs could determine the size of sling after they got a weight on a resident. They could tell if the sling was too big for a resident. Staff E voiced he didn't know if the facility had anything in place to communicate size of slings for the staff prior to the incident. They had a 5 Minute Communication Book at each nurse station they looked at every morning that had change of transfer status. He had placed updated sling and full body mechanical lift information in the communication book at each nurses' station (Front A/B Hallways, Back C/D Hallways and CR Hallway). Staff E stated he felt Resident #3 would have been safe even if staff had not crossed the sling straps under the resident's legs if she would have been in the correct size sling. Staff E showed the posted education in the CR unit 5 Minute Meeting Book for Nursing Department Communication Book. He thought he placed the information in the book on 11/10/25, but acknowledged none of the education items were dated when posted in the communication book. During an interview on 11/18/25 at 10:11 AM Staff D explained prior to the incident, there were no guides or tools to follow to determine sling size for the full body mechanical lift. She just eye balled if the sling looked right for the resident. On 11/18/25 at 10:12 AM, Staff F, CNA voiced she just looked at the resident to see if the sling looked right. She didn't know if there were any tools or communication prior to the chart being on the lift. On 11/18/25, review of the 5 Minute Meeting Book for Nursing Department Communication on the Front (Hallway A/B) nurses station revealed an undated posting to use two staff for a full body mechanical lift and standing lift to prevent potential staff and resident injuries and to report any incidents regardless of injury to management as soon as possible. An MDS/Care Plan Communication dated 11/17/25 posted by Staff B regarding the full body mechanical lift and standing lift for nursing directed it was required that two staff assisted with all full body mechanical lift and standing lift transfers. No exceptions. The 5 Minute Meeting Book for Nursing Department Communication (B Hallway) lacked any guide to the staff on the use of the (brand specific) full body mechanical lift. Interview on 11/18/25 at 10:40 AM Staff G, Registered Nurse (RN) reported she was not sure how the staff knew what size of sling to use for the lifts. She wasn't aware of any tools or communication for the aides to determine what to use. During an interview on 11/18/25 at 10:44 AM, the Administrator queried on dates of the undated staff education regarding the lift slings, and stated the education was posted in the books right after the incident, but couldn't give an actual date. On 11/18/25 the DON provided a note that listed Staff H and I were the CNA's involved in Resident #3's incident. Interview completed on 11/18/25 at 12:36 PM Staff A reported the CNA's notified her Resident #3 had slid back in the lift sling and they lowered her to the floor. When she entered the room Resident #3 was laying on the floor to the right of the door of the room. She placed a pillow under Resident #3's head. Resident #3 said she slid backward in the sling, but denied hitting her head, having pain or being injured. She completed vital signs and an assessment on the resident. Staff A explained they transferred Resident #3 from the floor to the bed using the same sling the resident had been lowered to the floor with. She thought the sling did have a hole in the middle of the sling, but didn't remember anything else about the sling. On 11/18/25 at 12:55 PM, Staff H, CNA explained she was not in the room when the incident occurred. It was Staff I and an CNA that Staff I was training. Resident #3 was already on the floor when she entered the room. They positioned Resident #3 back on the same sling she had slid in and lifted her from the floor to the bed with the full body mechanical lift.On 11/18/25 at 1:00 PM, Staff I explained they were lifting Resident #3 with the full body mechanical lift. The issue was the sling was just way too big for her. Part of the issue was the resident refused to have the lift sling left under her in the wheelchair and it was very hard to place the sling under her in the wheelchair with her trunk control and muscle spasms that she had. As soon as she was lifted within 2 inches of coming out of the wheelchair, she was sliding in the lift sling. They couldn't get her safely back to the wheelchair with the way she was positioned in the sling, so they lowered her to the floor for safety. She was assisted by an agency CNA but couldn't recall her name. Staff I voiced prior to the incident they just used the lift slings that were available in the closet. They just picked one and it stayed with the resident until it was soiled or they needed another one. Management didn't direct which type of sling should be used for each resident, but they only had a basic sling and a shower sling they used. She didn't think there was guide on the full body mechanical lift regarding the size of the slings, but there may have been something in the communication book, but she wasn't sure. During an interview on 11/18/25 at 1:54 PM the DON reported she expected during full body mechanical transfer for two staff to ensure the resident is positioned well and hooked up to the lift correctly. If the staff noticed anything or the resident stated something was not right, she expected staff to acknowledge that as soon as they could. She expected staff to use the guide on the lifts to ensure the residents are in the correct sling size. On 11/19/25 at 9:01 AM, Staff E reported he had put the sling guides on the full body mechanical lifts. The facility has three full body mechanical lifts, two newer ones and an older one. He stated he used the product information from the (brand specific #1) regarding the sling size guide and posted it on each full body mechanical lift. There was a table that stated the size of slings. He stated if looked at brand specific #1 slings and brand specific #2 slings were the same, and one couldn't tell a different unless looked at the label. The slings were interchangeable. The Use of Mechanical Lift Transfers Policy and Procedure, undated, provided by the facility lacked documentation to direct staff on full body mechanical lift sling size or which sling could be used with appropriate lifts. The (brand specific #1) Patient Sling Reference Guide under Patient Sling Guide stated it was very important to use the correct sized sling and make sure it was fitted properly prior to lifting. The Size and Weight Range Guide stated a full risk assessment must be done prior to any sling being selected to ensure the safety for the patient and caregiver. The Brand Specific Full Body Mechanical Lift weight/Height Sling Chart documented a blue large sling for patients weighing 250 to 300 pounds. The (brand specific #2) Patient Sling Reference Guide showed a blue extra-large sling appropriate for patients weighing over 200 pounds to 400 pounds. The (brand specific #2) Battery Powered Patient Lift User Manual under 2.2.6 Lifting the Patient, Warning brand specific #2 sling are made specifically for use with brand specific #2 lifts. For the safety of the patient, do not intermix slings and patient lifts of different manufacturers. The (brand specific #1) Owner's Manual 600 Power Patient Lift provided by the facility on page 6, Warning! Brand Specific #1 medical slings are specifically designed to be used in conjunction with Brand Specific #1 lifts. Do not use slings manufactured by other companies with any Brand Specific #1 medical equipment. Using other manufacturer's slings on equipment is unsafe and may result in serious injury to users and caregivers. Page 19 Transfer from Wheelchair directed to draw the legs sections of the sling to the front along the length of the user's thigh and feed the legs sections under the thighs. From between the legs, gently pull the leg section up the inner thigh. Feed as much material as possible under and between the thighs. Ensure the leg sections are positioned midway under the thighs to provide good support and greater comfort. Attach loops to the lift. Lift patient above the wheelchair. Pull the lift away from the wheelchair and position the patient over the bed and lower patient onto it.

Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to respond in a respectful manner to a resident (Resident #7) who requested help to find a bathroom for 1 of 3 residents reviewed for dignity. The facility also failed to protect residents' right to privacy when electronic health information was left visible and unattended on a computer in 2 of the 4 hallways observed. The facility reported a census of 87 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Resident #7's MDS had the following diagnoses listed, in part: Alzheimer's disease, Cerebral Vascular Accident (CVA or stroke), and cancer. The MDS identified that Resident #7 had a history of falling within the past month and required a partial to moderate amount of staff assistance for toilet transferring and toileting hygiene.Review of the Care Plan, initiated 9/18/25, revealed Resident #7 had a self-care deficit of Activities of Daily Living (ADL) related to impaired balance and limited mobility, and the intervention dated 9/18/25 revealed Resident #7 required one staff assistance for toileting. The Care Plan identified Resident #7 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. Interventions directed, in part:a. Anticipate and meet the resident's needs. Date initiated 10/16/25.b.be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date initiated 10/16/25. During an observation on 10/20/25 at 12:08 PM Resident #7 self propelled wheelchair from her room into the hallway near Staff A, Registered Nurse (RN) who stood at the treatment cart. Resident #7 asked Staff A where the bathroom was located. Staff A responded that the bathroom was in her room and asked Resident #7 what she was doing out here (in the hallway). Staff A then asked an ancillary staff who passed by if there were any aides around here. The ancillary staff informed Staff A that she did not work at facility, Staff A stated I can't, I'm trying to get my treatments done (while referring to Resident #7). Staff A then walked away from Resident #7 and went into the dining room. During an observation on 10/20/25 at 12:16 PM, Resident #7 in her room unattended and in the process of self transferring from the wheelchair to the bed. Resident #7's pants and incontinence underwear were pulled up only part way, exposing Resident #7's upper buttocks. Resident #7's bathroom door was open and the light was on.During an interview on 10/21/25 at 3:20 PM, the Director of Nursing (DON) revealed the expectation of all staff was to treat residents with respect and dignity and to help residents when they asked for assistance. 2. During an observation on 10/20/25 at 9:35 AM, an unattended treatment cart was left unlocked in the middle of residential hallway B-wing. On top of the treatment cart was a laptop computer with a resident's picture and confidential health care information displayed on the screen. During an observation on 10/20/25 at 12:25 PM, Staff A, RN, walked away from the treatment cart, left in the middle of a residential hallway A-wing, to enter the dining room, out of sight from the treatment cart. On top of the treatment cart was a laptop computer with a resident's picture and confidential health care information displayed on the screen. Various residents and staff passed by the treatment cart on the way to the dining room for the noon meal. During an interview on 10/21/25 at 2:20 PM, Staff C, RN, stated that nurses were expected to lock computer screens when walking away to protect residents' privacy and confidentiality. During an interview on 10/21/25 at 3:00 PM, Staff D, RN, stated that nurses were expected to lock computer screens when walking away to protect residents' privacy and confidentiality. During an interview on 10/21/25 at 3:20 PM, the DON revealed the expectation of staff to protect residents' right to privacy by locking computer screens when not in use. Review of the facility policy, titled Resident Rights dated 8/10/03, revealed that the facility will protect and promote each residents' rights, including the right to a dignified existence, self-determination, and communication with and access to persons and services, both inside and outside the facility.

Based on observation, resident interviews, staff interviews, and policy review the facility failed to answer call lights within 15 minutes to meet resident needs for 7 of 9 residents reviewed (Residents #13, #28, #53, #55, #58, #60, #81). The facility reported a census of 85 residents.Findings include: 1.The Minimum Data Set (MDS) for Resident #53 dated 7/28/25 listed diagnoses of hemiplegia and hemiparesis (weakness/loss of movement on one side of the body), urinary tract infection in the past 30 days, and cerebral infarction (stroke). The Brief Interview for Mental Status (BIMS) indicated intact cognition with a score of 13/15. Section GG indicated the resident required assistance with self care due to functional limitations that interfered with daily function on one side of his upper body and both sides of his lower body. The Care Plan (CP) for Resident #53 with an admission date of 7/22/25 documented activities of daily living self care deficits and directed staff to encourage the resident to use the bell to call for assistance. A section that documented a risk for falls directed staff to ensure the call light was in reach and to encourage the resident to use it. The resident needed prompt response to all requests for assistance. During an interview on 8/11/2025 at 8:54 AM the resident reported the some days call lights were longer than they should be. He thought they should be answered in 10-15 minutes and stated he knew others needed help too. During an observation on 8/11/25 the surveyor noticed the call light on at 12:46 PM for the resident's room. At 12:50 a staff member walked by without answering the light. At 12:53 PM the surveyor stood by the resident's room. Resident #53's roommate (Resident #55, MDS dated [DATE] BIMS 5/15 which indicated severe cognitive impairment) was sitting in bed with a tray in front of him on the bedside table. He waved the surveyor in. He stated his call light was on because he needed his table higher so he could eat better. At 12:59 PM 2 staff walked by headed toward the dining room and offices at the end of the hall. Neither staff member addressed the light. At 1:02 PM the surveyor observed staff at the medication cart in view of the call light. She did not respond. At 1:03 PM the Director of Nursing (DON) came out of her office directly across the hall and did not address the light. At 1:03 PM the same 2 staff who walked by at 12:59 returned to the hallway. Neither addressed the light. At 1:04 PM a nurse walked by and did not address the light. At 1:04 PM a dietary staff member walked by and did not address the light. At 1:05 PM a CNA answered the light and assisted the resident with adjusting the table. She left without asking if the resident needed his food warmed. During a follow up interview with Resident #53 and his roommate Resident #55, Resident #55 was unable to answer call light questions. When asked if there were other days or specific times call lights were over 15 minutes, Resident #53 stated his roommate couldn't remember but he could. He stated call lights were often as long as 30 minutes. He knew because he watched a lot of television shows that were 30 and 60 minutes long. On 8/14/2025 at 9:23 AM Staff I, Certified Nurses Aide (CNA) stated all staff are responsible for answering call lights. On 8/14/2025 at 9:33 AM Staff H, Registered Nurse (RN) stated answering call lights was a collaborative effort. On 8/14/2025 at 9:54 AM the Assistant Director of Nursing stated all staff were expected to answer call lights. The facility policy Call Lights: Accessibility and Timely Response, dated 3/27/25, directed staff to respond to call lights and if they could not meet the resident's request, to remain with them until help arrived. 2. The MDS assessment tool, dated 7/7/25, listed diagnoses for Resident #13 which included diabetes, depression, and respiratory failure. The MDS stated the resident required substantial/maximal assistance for toilet transfers and listed his BIMS score as 15 out of 15, indicating intact cognition. On 8/11/25 at 11:00 a.m., Resident #13 stated he did not get care in a timely manner. He stated he needed to use the bathroom and sat helpless three feet from the toilet waiting for staff for 20 to 30 minutes. He stated he had an incontinence accident that was preventable if staff had been there in time. 3. The MDS assessment tool, dated 8/4/25, listed diagnoses for Resident #28 which included muscle weakness, lack of coordination , and abnormal posture. The MDS stated the resident was dependent on staff for toilet transfers and listed the resident's BIMS score as 13 out of 15, indicating intact cognition. On 8/11/25 at approximately 2:00 p.m., Resident #28's spouse stated the resident had to go to the bathroom and staff said they would be right back but never returned. He stated they had to wait until shift change three hours later and by that time the resident had an incontinence accident. Resident #28 stated this made her feel terrible. 4. The MDS assessment tool, listed diagnoses for Resident #60 which included weakness, lack of coordination, and diabetes, and listed his BIMS score as 11 out of 15, indicating moderately impaired cognition. On 8/11/25 at 4:16 p.m., via phone, Resident #60's spouse stated on 8/1/25, the resident reported to her that staff took too long to assist him to the bathroom so he had an incontinence accident. The resident stated staff kept coming in and stating they would be back but not return for an hour. An 8/1/25 Care Plan entry stated the resident required the assistance of two staff for toileting. On 8/13/25 at 11:22 a.m., via phone, Staff O Certified Nursing Assistant(CNA) stated she took care of Resident #60 on 8/1/25. She stated that day was very chaotic and there were many residents which required the assistance of two staff. She stated there were not enough staff to answer call lights in a timely manner and there was never enough staff for them to take care of everyone. 5. The MDS assessment tool, dated 7/17/25, listed diagnoses for Resident #81 which included anxiety, depression, and weakness and stated the resident required substantial/maximal assistance for toileting hygiene. The MDS listed the resident's BIMS score is 14 out of 15, indicating intact cognition. On 8/12/25 at 9:25 a.m., Resident #81 stated that she was supposed to have help to go to the bathroom but because she had to wait an hour, she just went by herself. On 8/13/25 at 4:38 p.m., the Director of Nursing (DON) stated she expected staff to answer call lights within 10 minutes or at least enter the room to touch base with the resident and tell them they would be back. She stated they had a lot of residents which required the assistance of two staff so it could take a minute. On 8/13/25 at 5:05 p.m., the Administrator stated staff should answer call lights in a timely manner and they added more staff. 6. The MDS assessment for Resident #58, dated 7/11/25, identified the resident had diagnoses of heart failure, repeated falls and difficulty in walking. The MDS assessment revealed a BIMS score of 5 (indicative of severe cognitive impairment) and assessed the resident was dependent on staff for toileting, lower body dressing, mobility and transfers. The Care Plan, last revised 8/12/25, revealed Resident #58 required assistance by staff with a walker for toileting, ambulation, and transfers. The resident required assistance of staff for dressing and personal hygiene. On 8/12/2025 at 8:05 AM, during an interview, Resident #58 reported he had to wait to get up for up to hour in the mornings, because he was waiting on help from staff. Resident #58 reported it (waiting to get up in the morning) happened frequently; he explained waiting to get up happened a couple times a week. Resident #58 reported going to the bathroom was the main issue. The resident reported he had a couple falls back to back last week, one at night and one in the morning. Resident #58 reported he had to go to the bathroom and used his call light prior to each of the falls. Resident #58 explained staff did not respond for about one hour, he got tired of waiting, got up and fell. Review of Progress Notes, titled Nurses Note Narrative, dated 8/5/25 at 5:58 AM and 8/5/25 at 4:05 PM, Resident #58 had falls in relation to trying to use the bathroom in his room. A Nurses Note Narrative, dated 8/9/25, included documentation the resident was found sitting on the floor in front of the toilet in his room. Resident #58 was noted to be continent and reported he lost his footing while entering the bathroom. On 8/13/25 at 11:05 AM, Staff B, CNA, explained the morning time was the busiest time at the nursing home. Staff B reported she had one other CNA working the hall she was on. Staff B reported there were a few times residents had to wait longer than 30 minutes for their call light to be answered. On 8/13/2025 at 11:13 AM, Staff N, CNA, reported Resident #58 did not like to wait when he needed to use the bathroom. Staff N reported the residents usually did not have to wait longer than minutes. Staff N reported the morning time was busiest with trying to get resident's up for the day.

Based on observation, interviews, Food and Drug Administration (FDA) Food Code, and policy review dietary staff failed to properly wear hair restraints while preparing and serving food during 3 of 3 observations. The facility reported a census of 85 residents.Findings include: During lunch observations on 8/11/2025 at 12:44 PM dietary staff were serving food from the steam table parked outside of the kitchen door. Staff E, [NAME] was wearing a hair net that did not cover the sides of her hair or approximately 2-3 inches of her bangs. She plated and served food. Staff C, Food Service Manager (FSM) was wearing a ball cap. Her hair was in a bun under the back of the cap. The bun and approximately 1-2 inches of hair below the bun were not in a hair net. On 8/12/2025 at 7:18 AM the Dietary Manager was wearing a ball cap with her hair in a bun. She was not wearing a hair net. At 7:31 AM observed Staff F, [NAME] left the kitchen pushing the steam table down the hall to another dining room. Her hairnet did not cover the back 2 inches of her hair. Between 7:38 AM and 7:55 AM Staff F leaned over open steam table compartments 6 times and the FSM leaned over them 4 times. Staff F also took food to 3 tables and assisted 2 residents to cut food while leaning over their plates. On 8/12/2025 at 8:16 AM Staff F and the FSM moved to the main dining room with their hair still exposed. On 8/12/2025 during the food puree process Staff D, [NAME] was observed wearing a hairnet that covered her bangs. In the back approximately 4-5 inches of hair was exposed along with about 3 inches on the side. Staff E was observed in the kitchen with her bangs exposed. On 8/12/25 at 12:01 PM the FSM was asked who needed to wear hairnets. She stated all dietary staff had to wear them and that she was told that if she wore a ball cap she did not need a hair net. She acknowledged the other staff were not fully covering their hair and stated she would tell them right away. At 12:05 PM the surveyor observed her tell Staff D to correct hers, and at 12:09 PM tell Staff E to correct hers. During dining room observations at 12:25 PM Staff D had 3 inches of exposed hair in the back and Staff E had hair hanging out of the left side of her hair net. The FSM was wearing the ball cap without a hairnet.On 8/14/2025 at 10:21 AM when asked who completed training with the FSM, the Administrator stated she, the Dietician, and other staff and participated in her training and it was still a work in progress. The Administrator stated she was the one who told the FSM she didn't have to wear a hairnet if she wore a ball cap because in prior facilities that was acceptable. She expected the team to wear hairnets any time they were in the kitchen and when providing meal service.The FDA Food Code 2022, Section 2-402 documented food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and single-service and single-use articles.A policy titled Dietary Department dated 10/1/24 documented the department would comply with all state, federal, and local infection control standards and regulations concerning personnel requirements, food storage, and preparation and handling.

Based on observation, record review, interviews, and policy review the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents. The facility failed to adequately clean toilets and keep them in good repair, ensure beds were made in a timely manner, and to repair damaged or missing window screens. The facility reported a census of 85 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #85 dated 7/10/25 listed diagnoses of cancer, non-Alzheimer's dementia, hip fracture, and dependence on a wheelchair. His Brief Interview for Mental Status (BIMS) assessment score of 5/15 indicated severe cognitive impairment. The Care Plan (CP) for Resident #85 revised 10/23/24 indicated the resident had self care deficits and required the assistance of 1 staff with toileting before and after meals. The care plan documented a risk for falls, with interventions that included therapy evaluation 7/11/25, a toileting program at 7:00 am as of 7/23/25, non-slip footwear, and staying with the resident when using the toilet. During an interview at 11:42 AM on 8/11/25 a resident representative expressed concerns about wheelchair, bathroom, and room cleanliness. They reported the resident's wheelchair was not cleaned regularly and the cushion in the chair smelled of urine. The representative mentioned being embarrassed at a recent appointment because the smell was so bad and stated other members of the resident's family reported similar concerns. They further stated the toilet had been broken and overflowing 'forever' and it was always dirty in there. On 8/11/2025 at 2:49 PM the resident's toilet was running and the floor was damp. On 8/12/2025 at 1:42 PM the resident's bathroom floor remained wet and the toilet was running. Urine odor in bathroom and into room. On 8/13/2025 at 9:57 AM the resident's toilet was running, there was a strong odor of urine. The floor was wet to the corners, about a foot from the base, and about 9 - 12 inches in front of the toilet. On 8/13/2025 at 10:08 AM Staff Q, Housekeeping stated sometimes the residents using that bathroom had a lot of accidents and could use a cleaning twice a day. She indicated in a binder on the cart that the bathroom was scheduled for cleaning on Tuesday, Thursday, and Saturday. She stated the aides were supposed to help monitor and she had not been told there was an odor. During an interview on 8/14/2025 at 9:41 AM Staff J, Maintenance Director stated no one reported an issue with the toilet in the resident's room and should have told him or filled out a form in the maintenance book at the nurses stations. Maintenance documentation from May through August 2025 provided by the facility confirmed there was not a report for this room. An interview with the Administrator on 8/14/2025 at 10:21 AM determined she expected staff to use the maintenance book, verbal communication, or department group chats to get repairs made for safety. The running toilet had not been reported to her. She expected staff to make sure wheelchairs and bathrooms were clean, and equipment in working order. 2. On 8/11/25 at 2:49 p.m. the bed in room [ROOM NUMBER] was not made and had a bare mattress. On 8/12/25 at 8:28 a.m., the bed in room [ROOM NUMBER] was only made with sheets but no blanket or bedspread. On 8/12/25 at 1:09 p.m., the bed in room [ROOM NUMBER] remained not fully made. 3. On 8/13/25 at 9:05 a.m., the bathroom toilet in room [ROOM NUMBER] had black splatters inside the toilet and on the inside of the toilet riser. A graduate sat atop the toilet tank and contained a yellow liquid and the top of the tank had yellow splatters. On 8/13/25 at 2:23 p.m., the bathroom in room [ROOM NUMBER] remained unchanged. 4. The MDS assessment for Resident #17, dated 5/22/25, identified the resident had a BIMS score of 14 out of 15 (indicative of a mild cognitive impairment). On 8/11/25 at 10:43 AM, Resident #17 reported concerns with a broken window screen in her room. She explained the screen had been broken all summer and the other 2 screens were missing. Resident #17 reported housekeeping had broken the window screen when they were cleaning it in either June or July 2025. 5. The MDS assessment for Resident #7, dated 6/5/25, identified the resident had a BIMS score of 13 out of 15 (indicative of a mild cognitive impairment). On 8/11/2025 at 1:48 PM, Resident #7 reported the following concerns: a. Two different wall outlets were loose and her plug for her phone and Continuous Positive Airway Pressure (CPAP- a medical device used to treat sleep apnea or absence of breath when sleeping) machine were half-hanging out of the wall. Resident #7 reported she told the Maintenance Director about the concern in May of 2025, but nothing was done. She reported the Maintenance Director quit working at the facility a couple weeks ago. Observation of the two wall outlets revealed a plug-in for the phone and CPAP both hanging loosely from the outlet. Attempts to re-plug the phone and CPAP machine resulted in both plugs still hanging half-way out of the outlet. b. Resident #7 complained to staff that for 3 days in a row, there was BM (feces) on inside edge and top end of the toilet seat where the resident's upper thigh and leg would touch the seat. Resident #7 reported that the BM was still present on the seat as of today (8/11/25). Resident #7 reported the BM was from an episode of diarrhea her roommate had. Observation of the toilet seat revealed a dark brown, dried substance located on the inner left side of the seat and top end of the seat where the resident's back of their leg would touch. On 8/12/2025 at 12:13 PM, Staff Q, Housekeeping, reported she cleaned residents room daily and some rooms 2 times per day if requested. Staff Q reported when she cleaned the residents rooms she cleaned off counters, tray tables, dressers, toilet, handrails, sink and swept and mopped the floor. On 8/14/2025 at 8:06 AM, during an interview with Staff Q, Housekeeping, when asked if she had received any complaints from residents about their bathrooms not getting cleaned, she responded, It's on my weekend. I have the whole nursing home. Staff Q explained the she was the only housekeeper for the facility every other weekend. Staff Q reported the residents used to having their bathrooms cleaned by a certain time in the morning, but it might be afternoon before she got to them. Staff Q reported she had heard residents complain of not getting their bathrooms cleaned. Staff Q reported being off this last weekend and had not received a complaint about the bathroom from Resident #7. Staff Q reported facility staff had been in the process of cleaning and replacing screens for months. Staff Q was aware there were missing and bent window screens. Staff Q reported Resident #17 was correct that housekeeping staff were cleaning the screens and her window screen got bent by housekeeping. On 8/14/2025 at 8:12 AM, Staff R, housekeeping, reported she had heard complaints from residents about their toilets not getting cleaned. Staff R reported she cleaned Resident #7's toilet on Monday and the resident did not complain to her about staff not cleaning it for three days. On 8/14/25 at approximately 9:00 AM, the Housekeeping Manager provided an audit of window screens and window cleaning and replacement. Housekeeping staff documented they last cleaned Resident #17's windows and screens on 6/23/25. On 8/14/25 at 11:00 AM, during an interview, the Administrator reported they had been working on a facility wide project to replace window screens for the last several months. The Administrator reported being unaware of outlet issue in Resident #7's room. The Administrator contacted maintenance to repair the outlets immediately. Review of the undated facility policy, titled Housekeeping Daily Tasks, revealed directions to housekeeping staff to clean residents toilets daily.

Based on observation, clinical record review, resident interviews, staff interviews, and policy review the facility failed to treat residents with dignity and respect, and to provide care in a dignified manner for 3 of 4 residents reviewed for dignity (Residents #58, #85, #93). Facility staff failed to maintain a resident's wheelchair in a clean and sanitary manner, staff used an expletive when describing a resident's behavior in front of others, and the facility posted signs in a resident's room regarding toileting without consulting them. The facility reported a census of 85 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #85 dated 7/10/25 listed diagnoses of cancer, non-Alzheimer's dementia, hip fracture, and dependence on a wheelchair. His Brief Interview for Mental Status (BIMS) assessment score of 5/15 indicated severe cognitive impairment. The Care Plan (CP) for Resident #85 revised 10/23/24 indicated the resident had limited physical mobility and ambulated with a wheelchair in the hallway. The CP listed a goal to prevent complications related to immobility that included skin breakdown. An intervention initiated 11/7/23 revised on 5/22/25 directed staff to clean the wheelchair weekly. During an interview at 11:42 AM on 8/11/25 a resident representative expressed concerns about cleanliness. They reported the resident did receive a shower twice a week but their wheelchair was not cleaned regularly, and the cushion in the chair smelled of urine. The representative mentioned being embarrassed at a recent appointment because the smell was so bad and stated other members of the resident's family reported similar concerns. The representative stated they asked for the chair to be cleaned more than once. During on observation on 08/11/2025 at 2:49 PM the resident's wheelchair was next to his bed. There was a noticeable odor coming from the chair. When the cushion was lifted it exposed crumbs in all of the fasteners lining the sides of the chair below the arm rests. A follow up observation on 08/12/2025 at 1:42 PM revealed the wheelchair had not been cleaned On 08/13/2025 at 9:52 AM Resident #85 wheeled himself into his room from the hallway. An odor of urine was noticeable from his wheelchair as he pushed himself around the corner and adjusted himself in his seat. At 1:13 PM the resident reported they cleaned his wheelchair when they had time. Upon raising the cushion crumbs remained pressed against the fasteners and smears of an unknown substance were on the arm rests. There was a stain on the back of the cushion and a strong urine odor coming from it. On 08/14/2025 at 9:23 AM Staff I, Certified Nursing Assistant (CNA) confirmed she worked with Resident #85. She stated third shift had a checklist for wheelchair cleaning but any CNA could get crumbs off and bleach wipe a chair, at least that is what she would do. She stated she would inform the restorative staff or maintenance and try to figure out how to get the cushion clean. An interview with the Assistant Director of Nursing (ADON) on 8/14/2025 at 9:54 AM revealed she was aware wheelchairs were not being cleaned according to a schedule she set up 4 months ago. She stated third shift CNAs were supposed to follow a cleaning schedule she provided. They had not been doing it in spite of training, and the facility was planning to roll it out again in September. She stated if staff saw a dirty wheelchair or smelled an odor on one she expected them to clean it up regardless of the schedule. A blank document titled Nightly CNA duty list was provided by the ADON which verified the resident's wheelchair had not been cleaned that week. 2. The MDS assessment tool, dated 6/5/25, listed diagnoses for Resident #93 which included non-Alzheimer's dementia, depression, and anxiety. The MDS stated the resident had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1-3 days out of the 7 day review period. The MDS listed his Brief Interview for Mental Status(BIMS) score as 2 out of 15, indicating severely impaired cognition. The facility policy Promoting/Maintaining Resident Dignity, dated 3/27/25, stated the facility protected and promoted resident rights, treated each resident with respect and dignity, and cared for each resident in a manner that maintained or enhanced quality of life by recognizing each resident's individuality. Care Plan entries, dated 5/2/25, directed staff to give the resident reassurance as needed and visit with him about feelings/events that bothered him. On 8/11/25 at 11:35 a.m., Staff B Certified Nursing Assistant(CNA) walked by the nurses station and stated she attempted to assist Resident #93 but he slapped the s***(expletive) out of me. Staff B stated this while near the nurses station with residents in close proximity at the dining tables and other staff at the nurses station. On 8/13/25 at 4:38 p.m., the Director of Nursing(DON) stated it was not acceptable for staff to state something in public about a resident in front of others. On 8/13/25 at 5:05 p.m., the Administrator stated staff should treat residents with dignity and respect and not speak negatively about them in front of other residents. 3. The MDS assessment for Resident #58, dated 7/11/25, identified the resident had diagnoses of heart failure, repeated falls and difficulty in walking. The MDS assessment revealed a BIMS score of 5 (indicative of severe cognitive impairment) and assessed the resident was dependent on staff for toileting and transfers. The Care Plan, last revised 8/12/25, revealed the resident required assistance by staff with a walker for toileting and transfers. The Care Plan identified the resident was a fall risk and included the following interventions: Sign placed in room to encourage call light use for help getting up (dated 8/5/25); and, sign placed on walker to ask for assistance before getting up (dated 8/9/25). On 8/12/2025 at 8:05 AM, during an interview, Resident #58 reported he did not like the signs posted in his room and walker to use the call light and ask for help. Resident #58 reported the signs were irritating and insulting to his intelligence. Resident #58 explained he had a couple falls back to back last week, one at night and one in the morning. After the falls, Resident #58 described staff as giving him heck and then putting the signs in his room without asking if it was okay. Resident #58 reported he had to go to the bathroom and used his call light prior to each of the falls. Resident #58 explained staff did not respond for about one hour, he got tired of waiting, got up and fell. Review of Progress Notes, titled Nurses Note Narrative, dated 8/5/25 at 5:58 AM and 8/5/25 at 4:05 PM, Resident #58 had falls in relation to trying to use the bathroom in his room. A Nurses Note Narrative, dated 8/9/25, included documentation the resident was found sitting on the floor in front of the toilet in his room. Resident #58 was noted to be continent and reported he lost his footing while entering the bathroom. The Progress Notes lacked documentation facility staff discussed changes to the care plan with either the resident or resident's representative to include the interventions of signs. On 8/13/2025 at 11:13 AM, Staff N, Certified Nurses Aide (CNA), reported Resident #58 did not like to wait when he needed to use the bathroom. When asked by the surveyor if Resident #58 had complained about the signs in his room, Staff N reported Resident #58 did say something the other day after falling about the signs. Staff N reported Resident #58 said that if he had to go, he was going to get up and go no matter what the signs told him. Facility staff failed to consider the dignity and response of the resident when posting signs in the resident room.

Based on clinical record review, facility policy review, resident interview, and staff interview, the facility failed to ensure staff obtained and/or administered medications per physician order and professional standards of practice for 1 of 1 residents sampled (Resident #7) with a resident reported medication error by staff. The facility reported a census of 85 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #7, dated 6/5/25, revealed diagnoses of end stage renal disease and systemic Lupus (an autoimmune disease). The MDS identified the resident had a Brief Interview for Mental Status (BIMS) of 13 out of 15 (indicative of a mild cognitive impairment). The MDS identified the resident received renal dialysis. The Care Plan for Resident #7, last revised 8/1/25, revealed the resident took a sedative/hypnotic for insomnia. On 8/13/2025 at 8:09 AM, Resident #7 reported concerns with nursing staff medication administration for two different medications. Resident #7 explained that she had been taking Zolpidem (Ambien) to treat insomnia for the last 15 years. Resident #7 reported she typically received the medication at 8:00 PM every evening. The resident explained that without the Ambien, she could not sleep at night. Resident #7 report that she was scheduled for an arteriovenous (AV) fistula (surgically created connection between an artery and vein and used as a dialysis access point) on 5/8/25. The cardiovascular surgeon had provided pre-operation orders that included instructions that Resident #7 could receive their nightly dose of Ambien on 5/7/25. Resident #7 explained that the nurse working the evening of 5/7/25 refused to give her the Ambien medication and informed her they were holding the medication due to her upcoming surgery. Resident #7 reported she showed the pre-operative orders to the nurse and tried to explain she was supposed to get the medication, but the nurse refused to do anything further. Resident #7 reported not being able to sleep the night of 5/7/25, and she was angry. Resident #7 reported the surgery ended up being cancelled and rescheduled for 6/16/25. Resident #7 reported the same thing happened again. Nursing staff withheld her Ambien medication even though the pre-operative orders stated that she could have the Ambien. Resident #7 reported arguing with the nurse again, but the nurse told her that the medication was locked up and could not be accessed. Resident #7 reported she did not sleep that night and was very upset. She reported that she complained to nursing staff and specifically identified Staff L, Registered Nurse (RN). Resident #7 reported she did have the AV fistula surgery on 6/19/25. Resident #7 reported concerns with not receiving a second medication, Benlysta (Belimumab) weekly injections to treat her Lupus. Resident #7 showed a medication print out from the facility's electronic record which identified an order for Belimumab 20 milligrams (mg)/ ml, 200 mg subcutaneous every 7 days and a start date of 7/25/25. Resident #7 reported she had not received the medication. She reported her nephrologist ordered the medication and the medication was a specialty medication that could only be obtained from a pharmacy in Omaha. Resident #7 reported she had complained to several staff about not getting her injection, including Staff L, RN. Review of the clinical record for Resident #7 revealed the following: a. Review of the Medication Administration Record (MAR), dated May 2025, revealed nursing staff held Resident #7's scheduled Ambien 10 milligram (mg) by mouth at bedtime dose (scheduled between 7:00 PM to 10:00 PM) on 5/7/25. Review of pre-operative orders from the cardiothoracic and vascular center provider performing the AV fistula surgery scheduled for 5/8/25 revealed an order for the resident to receive her scheduled dose of Ambien 10 mg on 5/7/25. The provider did not write a hold order for the Ambien. A Progress Note, titled Nursing Note, dated 5/7/25 at 9:52 AM, included documentation that Resident #7 was upset because she did not get her medications. The nurse informed the resident that her medications were on hold due to a procedure. The resident informed the nurse that the procedure was cancelled. The nurse informed the resident that she could not give the resident her medications due to the hold order. On 8/14/2025 9:10 AM Staff Q, ARNP, confirmed that the resident should have received her 5/7/25 dose of Ambien based on the pre-operative surgery orders. Review of the MAR, dated June 2025, revealed nursing staff held Resident #7's scheduled Ambien 10 mg by mouth at bedtime dose (scheduled between 7:00 PM to 10:00 PM) on 6/17/25. Review of pre-operative orders from the cardiothoracic and vascular center provider performing the AV fistula surgery scheduled for 6/17/25 revealed an order for the resident to receive her scheduled dose of Ambien 10 mg on 6/16/25. The provider did not write a hold order for the Ambien. On 8/13/2025 at 9:59 AM, the Director of Nursing (DON) reported being unaware that Resident #7 had an issue with not receiving her Ambien. On 8/13/2025 at 10:08 AM, Staff L reported Resident #7 did complain about not getting her Ambien. Staff L was not sure at what point the resident told her about not getting the Ambien and was unaware that the resident did not receive her Ambien on two separate occasions. Staff L told the resident her plan to call and clarify the order with the physician. Staff L reported she followed through with contacting the physician, and the resident received her Ambien before her surgery on 6/19/25. On 8/13/2025 at 12:48 PM Staff M, RN, confirmed she put the 6/17/25 hold order for Ambien in the electronic medical record (EMR) system. Staff M confirmed she did not get an order from Staff Q, Advanced Registered Nurse Practitioner (ARNP), who was also Resident #7's primary care practitioner (PCP) even though the order in the system identified it came from Staff Q, ARNP. Staff M reported she put in the order to hold the Ambien based on pre-operative surgery orders. Staff M explained the EMR had a limited number of providers to chose from, so she chose to place the order to hold under Staff Q, ARNP. Staff M confirmed she put an incorrect hold order for the Ambien in the EMR. b. A document titled Mobile App Encounter, dated 7/21/25, included documentation of Resident #7's appointment with a nephrologist. The nephrologist ordered Belimumab 20 milligrams (mg)/ ml, 200 mg subcutaneous every 7 days starting 7/21/25. On 8/13/25, review of the MAR for Resident #7, dated July 2025 and August 2025, revealed Belimumab had been added to the medications with a start date of 7/25/25, but the resident had not received an injection. On 8/13/25 at 8:45 AM, review of Resident #7's Progress Notes revealed a lack of documentation regarding why the resident was not receiving Belimumab weekly injections. On 8/13/2025 at 9:59 AM, the DON reported she was aware the resident was supposed to get a weekly Belimumab injection. The DON explained that they tried to get this filled through the facility pharmacy, but the pharmacy did not have access to the medication. The DON reported they planned to reach out to the previous pharmacy that the resident was getting the medication from. The DON explained that if they could not get the medication, they would reach out to the provider. The DON agreed to provide contact information for Resident #7's nephrologist.On 8/13/2025 at 10:08 AM, Staff L reported not being aware that the resident was supposed to be getting Belimumab weekly injections and denied the resident said anything to her regarding this medication. On 8/13/2025 at 10:35 AM, during an interview with the DON and the Assistant Director of Nursing (ADON), the ADON reported she had been checking into the Belimumab injections and found that the medication came from a special pharmacy. The ADON denied Resident #7 had said anything to her about not getting the injections. The DON and ADON denied Resident #7's Nephrologist had contacted them. A Progress Note, tiled Nurses Note, dated 8/13/25 at 11:31 AM, included the following documentation: Call placed to (Nephrologist) office on 8/8/25 and 8/11/25 left message to return call. Call placed again today. Was advised that they need to talk to (Nephrologist) and will call back with additional information. A Progress Note, tiled Nurses Note, dated 8/13/25 at 11:36 AM, included the following documentation: rec'd (received) verbal order from (Nephrologist)'s office to hold the injection until they get additional information. A Progress Note, tiled Nurses Note, dated 8/13/25 at 11:54 AM, included the following documentation: Call rec'd from (Nephrologist)'s office, was advised that (Resident #7) only sees the provider when she is at dialysis so the office staff is not always immediately aware of new orders or changes. Provider was in office today so they were able to discuss questions face to face. Was advised that the original order was d/c on 3/19 due to resident self reporting not taking the med for the last year. Provider saw resident on dialysis treatment day 7/21(25). Belimumab was discussed and it was decided to restart the medication. The medication was originally sent to (facility contracted) pharmacy but they are unable to fill. Provider then sent prescription to another specialty pharmacy. Office staff has not seen a PA or a request for additional information as of 8/13(25). Prescription was resent. Provider and staff are aware that resident has not rec'd an injection since the reorder on 7/21/25. Provider did not have any concerns advised they will reach out with any updates from the specialty pharmacy and the pharmacy will reach out to our facility to schedule a delivery once the PA and everything has been completed. On 8/13/2025 at 12:30 PM, Staff V, Pharmacy Technician (facility contracted pharmacy), reported the pharmacy did not have access to Belimumab and could not obtain the medication. Staff V reported they received the order for the medication on 7/21/25. Staff V reported they faxed the facility with a note on 7/21/25, and told them only the medication was only obtainable with a specialty pharmacy and that they needed to reach out to the provider who ordered the medication. On 8/14/2025 at 10:39 AM, the nurse for Resident #7's Nephrologist, reported the facility had not contacted their office from when the Nephrologist ordered Belimumab on 7/21/25 until yesterday, 8/13/25. The nurse explained that they track and document all telephone encounters, and they had not received any calls from facility staff. The Nephrologist was unaware of the need to send the medication order to a specialty pharmacy until nursing home staff contacted their office on 8/13/25 (23 days after the physician order date). Review of the facility policy, titled Medication Administration, dated 3/27/25, identified staff were to administer medications per physician orders and professional standards of practice.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 1 of 1 residents reviewed for activities(Resident #81). The facility reported a census of 85 residents. The admission Minimum Data Set (MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #81 which included anxiety, depression, and weakness. The MDS stated it was very important for the resident to go outside when the weather was good. The MDS listed the Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Activities, dated 3/27/25, stated the facility would provide an ongoing program to support the resident in their choice of activities based on their comprehensive assessment, care plan, and preferences. A 4/23/25 Resident Preferences Evaluation stated it was very important to the resident to go outside to get fresh air when the weather was good. On 8/12/25 at 10:08 a.m., Resident #81 stated she was not able to go outside and she wished to do so. On 8/13/25 at 11:30 a.m., the Administrator provided activity participation calendars and stated the notes covered activities participated in from May 2025 through July 2025. The calendars revealed the following:May 2025: The resident participated in music one time, ladies tea one time, pet therapy two times, bingo two times, pretty nails four times, happy hour four times, Mother's Day party one time, card games two times, exercises two times. The calendar lacked documentation staff offered the resident an outdoor activity. June 2025: The resident did not have a June 2025 activity calendar in the notes provided by the Administrator.July 2025: The resident participated in bingo two times, and pretty nails one time. An additional untitled activity sheet for July 2025 stated the resident participated in an ice cream activity.The facility lacked additional documentation the resident was offered outdoor activities during the period of 5/1/25 to 7/31/25. On 8/13/25 at 12:08 p.m., the Activities Director (AD) stated she just began at the facility last week. She stated her plan for the future was to take residents outside twice per week. She stated activities should be centered on what the residents want to do. On 8/13/25 at 4:38 p.m., the Director of Nursing (DON) stated it the facility had at least 1 activity per day and sometimes 2-3. She stated there was a shift in activities staff and the new AD tried to schedule more events. She stated the residents were able to go outside in the mornings.

Based on clincal record review, staff interview and policy review the facility failed to complete an assessment for 1 of 4 residents (Resident #96) reviewed for hospitalizations. The facility reported a census of 85 residents. Findings include: Progress Notes written on 6/3/25 at 4:28 PM document Resident #96 readmitted to the facility following cholecystitis (inflammation of the gallbladder), sepsis (sepsis happens when an infection you already have triggers a chain reaction throughout the body. It is a life threatening, medical emergency per the Center for Disease Control (CDC)), and septic shock (a severe form of sepsis characterized by dangerously low blood pressure and abnormalities in cellular and metabolic function). The clinical record lacked a physical assessment or vital signs on 6/3 and 6/4. The pre-dialysis assessment completed on 6/5 included vitals of Temperature 97.2 Fahrenheit (F), Pulse 88, Respirations 16, Blood Pressure (BP) 96/56 and oxygen saturation (O2 Sat) of 88%. The post-dialysis assessment completed on 6/5 included vitals of Temperature 98.7 F, Pulse 80, Respirations 18, BP 124/80 and O2 Sat of 98%. The clinical record lacked a physical assessment on 6/5. The clinical record lacked a physical assessment or vital signs on 6/6. The pre and post dialysis assessments on 6/7 lacked vital signs. The clinical record did include a temperature of 97.7 F. The clinical record lacked vital signs on 6/8 and 6/9. The clinical record lacked a physical assessment on 6/7 and 6/8. Progress Note written on 6/8/25 at 1:30 PM documented the resident had picked a scab and staff were unable to stop the bleeding. The nurse completed the dressing change to the resident's legs that started bleeding and running down her leg. The resident was sent to the Emergency Department (ED). The clinical record lacked documentation of the resident returning from the ED, vitals or physical assessment upon return. Progress Note written on 6/9/25 at 11:36 AM documented the resident had copious amounts of drainage from bilateral leg wounds. She had poor circulation to all extremities, fingers and toes purple and cold and difficulty in getting an O2 sat reading. Progress Note written on 6/9/25 at 3:39 PM documented the resident was to be admitted to the hospital per her cardiologist. There were no vital signs documented on 6/9. Progress Note written on 6/10/25 at 12:20 AM documented the resident was admitted to the hospital with diagnosis including sepsis. During an interview on 8/13/2025 at 12:54 PM, the Director of Nursing (DON) explained the resident went out and came back in less than 24 hours so didn't require a full admission assessment on 8/13/25. The DON was unable to locate vital signs or an assessment. At 1:00 PM, the DON reported she would have to ask the Assistant Director of Nursing (ADON) as she was able to locate information in the electronic health record better than I can. On 8/14/25 at 9:57 AM the DON and ADON were unable to provide and additional documentation of vital signs or physical assessments. The undated facility policy titled Change in Condition Protocol directs staff to evaluate the resident's condition when a change from baseline is observed, complete a full assessment and document in Point Click Care (PCC), and every shift is required to perform and document vitals and a focused assessment. The policy further directs staff that there are no exceptions to this requirement.

Based on observation, clinical record review, and staff interviews, the facility failed to utilize foot pedals during wheelchair transport in order to ensure safety and failed to ensure good working order of a walker to prevent falls for 3 of 5 residents reviewed for accidents (Residents #12, #49, and #101). The facility reported a census of 85 residents.Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 6/18/25, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety disorder, and cancer. The MDS stated the resident was dependent on staff to propel her wheelchair and listed her Brief Interview for Mental Status (BIMS) score as 12 out of 15, indicating moderately impaired cognition. On 8/11/25 at approximately 11:00 a.m., Staff A Hospice Tech pushed Resident #12 in her wheelchair from the nursing station to her room, a distance of approximately 50 feet. The resident's feet were not placed on foot pedals and the bottoms of her feet lightly touched the ground while Staff A pushed her. On 8/13/25 at 4:38 p.m., the Director of Nursing(DON) stated foot pedals should be used if staff pushed residents in their wheelchairs. On 8/14/25 at 11:15 a.m., the Administrator stated she did not have a policy related to foot pedals. 2. The MDS for Resident #49 dated 8/7/25 revealed diagnoses of fracture, muscle weakness, and abnormal posture. The BIMS documented a score of 14/15 which indicated intact cognition. Section GG indicated the resident experienced functional limitation in range of motion in both lower extremities. The Care Plan (CP) for the resident dated 5/6/25 indicated they had an activities of daily living (ADL) self care performance deficits and were at risk for falls. Resident #49 needed assistance with maintaining a safe environment. During a dining room observation on 8/13/2025 at 8:54 AM Staff G, Certified Nurses Aide (CNA) pushed Resident #49 in his wheelchair from the dining room down the A hallway to his room without the use of foot pedals for safety. The resident was able to hold his feet up past the nurses station and 3 doors, then his feet started to drop towards the floor as they passed 3 more doors to get to his room. On 8/13/2025 at 9:04 AM the Administrator stopped in the hall while the surveyor was waiting to speak with Staff G. She stated she saw Staff G push the resident in the hallway without pedals and had already provided education to the CNA that residents should not be transported in wheelchairs without foot pedals. On 8/13/2025 at 9:09 AM an interview with the resident revealed that the pedals got in the way at the table in the dining room so staff often just left his pedals in his room. An observation during the interview determined his pedals were on his floor under his sink and there was not a bag for pedals on the back of his wheelchair. During an interview with the Assistant Director of Nursing (ADON) on 8/14/2025 at 9:54 AM she stated the facility did a wheelchair audit recently because it was a common thing for them to catch missing foot pedals and she thought residents needed bags for them on the back of their chairs. 3. The MDS for Resident #101 dated 5/27/25 (3 days after his fall) revealed diagnoses of cancer, hip fracture and other fracture (rib), and malnutrition. The BIMS documented a score of 15/15 which indicated intact cognition. Section GG indicated the resident experienced functional limitation in range of motion in one lower extremity and used a walker with supervision or touch assistance. The baseline Care Plan (CP) for the resident dated 5/20/25 indicated the resident needed physical, occupational, and speech therapies. It documented a history of falls and fall related injuries of right femur fracture and rib fractures. It listed the resident used a walker and wheelchair. A document titled Physical Therapy Treatment Encounter Notes, date of service 5/26/25, documented Resident #101 was weight bearing as tolerated and contact guard staff assist with a four wheel walker for toilet transfers during the session. A Progress Note titled admission Follow-up Note dated 5/25/25 at 12:14 AM documented the resident was found on the floor next to his bed with his back against the bed and his legs out in front of him. He stated he was going from the chair to the bed when his walker collapsed and he fell. The resident told staff he had permission from therapy to transfer in his room. The note further documented staff obtained a different walker for the resident as he was correct in stating the walker collapsed. The writer noted the walker was in poor condition and had screws missing that would keep the walker working properly. The Assistant Director of Nursing (ADON) was notified. On 8/14/2025 at 8:36 AM the Director of Nursing (DON) reported the Assistant Director of Nursing (ADON) was responsible for monitoring cleaning of equipment and ensuring staff monitored it for safety. During an interview with the ADON on 8/14/2025 at 9:54 AM she reported when she thought about the walker, she recalled one of the sides didn't have something right about it and it was discussed in a morning meeting. She stated the restorative aide would have been responsible for checking the walker and it should have been repaired or out of service if not safe. She said she would need to continue to work with the new restorative aide to monitor things like that. On 8/14/2025 at 10:21 AM the Administrator stated she thought the documentation had been over-exaggerated. She recalled the walker was disposed of and discussed that morning in a quality assurance meeting. The restorative aide participated and staff were told to double and triple check equipment for safety after the incident. She also asked maintenance and therapy to look into it.

Based on clinical record review, review of facility policy/protocol, resident and staff interview, the facility failed to ensure that a resident with symptoms of a potential urinary tract infection (UTI) received prompt testing and ongoing assessment to prevent worsening of symptoms for 1 of 1 resident (Resident #17) with a complaint of a possible UTI. The facility reported a census of 85.Findings include:The Minimum Data Set (MDS) assessment for Resident #17, dated 5/22/25, identified diagnoses of atrial fibrillation, heart failure, and chronic kidney disease. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (indicative of mild cognitive impairment).The Care Plan for Resident #17, last revised 7/30/25, included a focus area of bladder incontinence and the following intervention: Monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.On 8/11/25 at 10:43 AM, Resident #17 reported that she thought she had a kidney infection. She explained that she told the nurse today and thought the nurse was going to take care of it today (8/11/25). Resident #17 reported symptoms of pain and burning with urination, lower abdominal pressure and frequency of urination. Resident #17 reported she had a history of getting UTIs frequently. On 8/12/2025 at 3:27 PM, review of Resident #17's Progress Notes revealed the following three Nurses Note narratives:a. Nurses Note narrative by Staff K, Licensed Practical Nurse (LPN) , dated 8/11/25 at 9:25 AM, Messaged (Staff P), ARNP (Advanced Registered Nurse Practitioner) on resident stating dysuria (pain, burning with urination) and abdominal distention. T. (temperature) 97.7 (degrees Fahrenheit).b. Nurses Note narrative, dated 8/11/25 at 8:47 PM, Acetaminophen Oral Tablet 500 MG (milligrams)Give 2 tablet by mouth every 6 hours as needed for Elevated Temp/General Discomfort Not to exceed 3gms (grams) in 24hrs from all sources no new orders.c. Nurses Note narrative, dated 8/11/25 at 10:14 PM, indicated the Acetaminophen was effective. The clinical record lacked any further assessment, documentation or orders related to the resident's complaint of a possible UTI.On 8/13/2025 at 8:39 AM, Resident #17 reported she was still having symptoms of burning with urination, pressure in the lower abdomen, lower back ache, urine frequency, and felt unbalanced. Resident #17 reported nursing staff had not followed up with her or reassessed her condition since she notified nursing staff of the possible UTI on Monday (8/11/25). On 8/13/2025 8:42 AM, Staff L, Registered Nurse (RN), explained that if a resident reported symptoms related to a possible UTI, she would get a set of vitals, ask the provider for a urinary analysis (UA) with culture and sensitivity (C and S, a test used to help determine the type of infectious organism) to rule out UTI or kidney infection. Staff L reported the nursing staff used a secure messaging system to contact the providers. All nursing staff had access to the secure messaging system and could see the messages put in by other nurses and the providers. Staff L reported that the facility did not have a standing protocol for assessment with a change in condition. Staff L reported the resident did not say anything to her yesterday (8/12/25) or today (8/13/25). Staff reported none of the other nurses reported a concern to her regarding Resident #17. On 8/13/2025 at 8:44 AM, Staff M, RN, reported she just processed an order for UA with C and S around 8:00 AM today (8/13/25) for Resident #17 and put the order in the electronic medical record (EMR). Staff M reported that according to the secure messaging system, Staff Q, ARNP sent the order to the facility on 8/11/25 around 2:00 PM. Staff M was unsure why it took so long for the order to be processed.Review of the clinical record revealed a Physician Order, created by Staff M, RN, dated 8/13/25 at 8:15 AM, for a one time UA with C and S to rule out a UTI. The order included an end date of 8/15/25. The clinical record failed to identify Staff Q, ARNP, sent the order request on 8/11/25. On 8/13/2025 at 10:35 AM, during an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON reported nursing staff used a secure messaging system for physician/provider contact, and the messages were available for all nursing staff. The ADON reported that all nurses were required to review the secure messaging system before they left at the end of their shift. The ADON reported the nurses should also give information on any resident condition changes at shift change. Nursing staff should follow up within 24 hours, or sooner if the concern was more urgent, if they had not heard from a provider. The ADON reported they experienced good response time from the providers. The ADON reported the DON and ADON reviewed all faxes and secure messages from the previous day, and if they have not received a response, they resend the fax or reach out to the provider. The ADON reported they expected physician orders to be followed up on right away and denied that they had a problem with this. The ADON and DON did not know why the order for a UA and C and S did not get put in the electronic system right away. The ADON reported she did not look at secure messages as much yesterday.On 8/13/2025 at 3:08 PM, the ADON reported nursing staff put the time they processed orders in the EMR, not the time the provider submitted the order via secure message. The ADON reported an inability to print secure documentation messages. The ADON and surveyor reviewed the following messages sent via the secure message system for Resident #17:a. Staff Q, ARNP, sent an order, dated 8/11/25 at 2:11 PM, for a UA with C and S.b. The DON put a message in the secure messaging documentation system, dated 8/12/25 at 11:20 AM, to process the order.c. Order processed by Staff M, RN, dated 8/13/25 at 8:06 AM.On 8/14/2025 at 9:05 AM, Staff Q, ARNP, and primary care provider for Resident #17 reported the expectation that nursing staff would carry out the order the same day Staff Q issued the order. Staff Q explained if nursing staff had not followed through with the order within 24 hours, then she would expect nursing staff to notify her of the reason why they did not carry the order out. Staff Q, ARNP explained the concern with not following through checking and treating a possible UTI in a timely manner was that the condition could worsen and there was a potential for sepsis (a systemic blood infection).Review of an undated facility protocol, titled Change of Condition Protocol Add/Remove from Hot Chart List, revealed the purpose of the protocol was ensure care of residents through nursing assessments, interventions and appropriate follow up. The protocol identified a change in condition included an alteration in a person's physical, mental and/or psychosocial status from normal status and included direction to staff to complete Hot Charting for residents not limited to, but including the following reasons: 2 or more signs and symptoms of acute infection, new or increased pain, and change in urinary status. Hot charting included the documentation of vital signs and a focused assessment every shift. The protocol included instructions to staff to carry out new orders per facility protocol. Review of the facility policy, titled Consulting Physician/Practitioner Orders, dated 5/27/25, revealed nursing staff were to verify orders received in a timely manner.

Based on clinical record review, the Long Term Care Facility Resident Assessment Instrument 3.0 Version 1.18.11 last updated October 2023 (RAI), and staff interview the facility failed to submit the Minimum Data Set (MDS) within the required time frame for 1 of 1 resident's reviewed for timely submission. The facility reported a census of 85 residents. Findings include: Clinical record review for Resident #92 showed a quarterly MDS dated [DATE]. The resident had an annual MDS dated [DATE]. Both assessments had a status of complete, not accepted. During an interview on 08/13/2025 at 10:31 AM, the MDS coordinator explained the quarterly dated 6/20/25 was flagged as do not submit. She further explained it should have been submitted. She continued, it was discovered the quarterly should have been an annual and the annual assessment was completed. That assessment too was flagged as do not submit and it should have been submitted. During an interview on 8/13/25 at 4:45 PM the MDS coordinator explained they do not have an MDS policy, they follow the RAI.

Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to follow a resident's Care Plan for transfers and to assess a resident immediately after a fall for 1 of 3 residents reviewed (Resident #6). The resident required a mechanical lift with the assistance of 2 staff for transfers. The facility failed to provide assistance of 2 while the resident was transferred in the shower room which resulted in the resident sliding out of the mechanical lift sling. The facility further failed to conduct an assessment of the resident prior to getting her up from the shower room floor. The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) for Resident #6 dated 5/23/24 documented a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated intact cognition. Diagnoses included other acute paralytic poliomyelitis (polio, disease of motor neurons of the spinal cord and brain), repeated falls, and fracture (vertebra). The MDS documented the resident used a wheelchair for mobility and required substantial/maximal assistance for showering and bathing. The resident was dependent on staff for all transfers. Resident #6's Care Plan, with a focus area for ADL self-care performance deficits revised 9/20/23, included bathing and transfer interventions revised 4/12/24. At that time the resident required extensive assistance by 1 staff with showering twice a week and as needed, and transfer assistance of 2 staff with a Sara lift (standing mechanical lift) to shower. On 8/12/24 the bathing section was updated to change the Sara lift to a Hoyer lift (full body mechanical lift), and the resident remained an assist of 2. A Late Entry Progress Note titled Nursing Progress Note, dated 8/10/2024 at 15:02, was entered in Resident #6's electronic health record (EHR) on 8/11/24 at 16:06. It documented the following encounter with the resident and Staff C, Certified Nurses Aide, (CNA): This nurse (Staff B, Registered Nurse (RN)) was sitting in the nurses station when notified by (Staff C) as she was wheeling patient past the nurses station back to her room that the resident did not fall in the shower. (Staff C) stated that (the resident) was supported as her legs were already giving out and it was not possible to lift her even further, she was transferred to her wheelchair using the gait belt. This nurse followed them to her room and did vital signs and an assessment. 120/70, 80, 14, 97.8, 96 RA. Patient denied having pain. Patient stated that she did not fall and that she was ok. A Progress Note dated 8/10/24 at 17:07 titled Nursing Progress Note indicated Staff B was called into the resident's room for two skin tears on her right forearm that needed dressing. One measured 5 mm by 5 mm and the other 20 mm by 10 mm. The note indicated the provider was faxed for an order. The cause of the skin tears was not documented. A form titled Skin Condition Record, initiated 8/10/24, documented the skin tears as they measured in the Progress Note. It indicated the plan of care was updated. The physician and family were notified on 8/11/24. The resident was not experiencing pain related to the wounds. The cause of the skin tears was not documented. The Progress Notes and the EHR lacked an incident report, full resident assessment, family notification, provider notification, or Director of Nursing (DON) and/or Administrator communication completed on 8/10/24 regarding the resident's assisted fall in the shower room. A Progress Note dated 8/11/24 at 9:30 AM documented the resident reported to Staff E, RN that she was in the Sara lift the day before during the 2 PM to 10 PM shift for a shower and fell . The note documented dry dressings on the resident's arm and complaints of increased back and right foot pain without bruising or deformity. Vitals were taken, feet were floated, and pain cream was applied to the resident's back. A Progress Note dated 8/11/24 at 11:36 noted the resident's daughter was in the facility and was aware of the situation. A Progress Note dated 8/11/24 at 12:04 titled Communication - with Physician reported the resident fell out of the Sara lift on 8/10/24 while being transferred for a shower. The resident complained of increased right shoulder/right upper arm and back pain. The note indicated the resident's daughter requested x-rays of the right upper arm, right shoulder, and back. A Progress Note dated 8/11/24 at 15:12 titled Nursing Progress Note reflected an order from the resident's doctor for a one time dose of 800 milligrams oral ibuprofen. A note dated 8/12/2024 at 08:04 titled Nursing Progress Note revealed the resident complained of pain in her right arm, right hip, across chest, and anterior shoulder, especially with ROM (range of motion). She rated her pain at 7/10 and requested to stay in bed that morning. Documentation of the facility investigation dated 8/12/24 at 8:30 AM included an interview with Resident #6 who confirmed Staff C did not have a second helper during the transfer and indicated her arm hurt when she was transferred from the floor. The resident interview documented the nurse did not complete an assessment and it was a long time before she came to bandage her arm. At least an hour. At 10:00 AM, the DON and Administrator interviewed Staff C who revealed she did not have a second person during the transfer but knew she should have. After Staff C lowered the resident to the floor, she got Staff I, Agency CNA to help her. Staff C stated she couldn't find the nurse and that was why she didn't have her do the assessment. The investigation included a statement from Staff C: Resident was given a shower alone and was lifted on the Sara lift and was transferred on her own to her wheelchair. The resident's legs gave out and while it gave out, I supported her shoulder and back while gently lowering her to the floor. I called another CNA and he put a gait belt to help her lift and transfer to the wheelchair. I reported to the nurse what had happened and insisted on giving her an assessment and check her vitals. Investigation documentation also included a statement from Staff I that he went to answer the call light while Resident #6's shower was taking place at around 3:00 PM. When he left that resident's room, Staff C informed him Resident #6 was on the floor. He asked if the nurse knew because he was not going to get her up. Staff C told him no and they could get her up. They lifted her using the gait belt. He saw a skin tear on the resident's right arm. He reported they took her to the nurses station and there was not a nurse there, so they took the resident to her room. 15 minutes later he saw the nurse was assessing her. He reported never transferring a resident alone if they were an EZ Stand (another name for a Sara lift or standing mechanical lift). A Progress Note dated 8/12/2024 at 08:55 AM titled Nursing Progress Note revealed an order was received for spinal, lumbar thoracic, 2 view right hip et 2 view right shoulder X-ray. Order noted in queue. (X-ray company) notified. The resident's power of attorney was notified at 09:04. A note titled Nursing Progress Note on 8/12/24 at 12:48 revealed the X-ray results were negative for fracture and faxed to the resident's provider. A Progress Note dated 8/12/2024 at 13:58 titled Nursing Progress Note indicated she continued to have widespread pain, especially with movement and repositioning. She had not been out of bed during the shift due to her pain. A document from the resident's provider titled ICF Progress Note with an 8/12/24 date of service documented the resident's legs gave out on her when staff transferred her. The resident had increased pain and discomfort. The provider noted a history of chronic pain due to a T12 compression fracture and chronic pain medication, scheduled and as needed. There were no acute findings on the X-rays. The provider added a pain patch to her regimen that would be replaced weekly and ice as needed. A Progress Note dated 8/13/2024 at 12:06 titled Nursing Progress for a follow up on a staff assisted incident revealed the resident continued to complain of right shoulder and right anterior chest wall discomfort. She was able to move her right upper extremities with some discomfort but stated that it felt better. On 8/16/24 at 1:24 PM, during an observation and interview with Resident #6, she stated that on Saturday (8/10/24) she changed from a Sara lift to a Hoyer lift after her legs gave out on her. She pointed to her left arm and said she hurt her right shoulder, arm, knee, and hip and had been spending more time resting. She reported no breaks but that she had pain, and it felt better lying down. She thought the knee and hip pain was from hitting the floor and the arm and shoulder pain from holding on to the stand. Resident #6 was not exhibiting any signs or symptoms of pain at the time of the observation, no grimacing, jerky movements, or holding on to her arm or shoulder. She believed the facility was managing her pain. The following day, 8/17/24 at 12:26 PM, the resident's daughter and the resident offered additional information. Observed skin tears bandaged near the resident's right wrist. Her daughter stated the resident's skin is very fragile and this happened often. Resident #6 stated it felt like a long time to get them wrapped by the nurse the day of the fall, and the CNA had to ask multiple times. The resident confirmed she refused imaging beyond the x-ray and added she was not interested in therapy. Both the resident and daughter endorsed a long history of chronic pain and pain medication. The resident stated the patch the doctor prescribed was helping, and she had both scheduled and as needed pain medication. The resident's daughter mentioned an incident a couple of months prior where an agency CNA transferred the resident without checking her transfer status. They felt the facility handled that well and the resident felt safe. In the most recent incident on 8/10/24, they both mentioned that the lack of a thorough assessment and that the information was not passed between shifts was concerning. On 8/17/24 at 1:58 PM Staff F, Agency CNA, confirmed he worked with Resident #6 and she used a Sara lift. He reported being trained that any time a resident went to the floor it was a fall, and a CNA might have to write a statement about what happened before the fall as part of the investigation. The CNA should make sure the resident was safe, and get a nurse to complete an assessment before a resident was moved. He reported staff on one shift were responsible for reporting resident changes, including falls, to the next shift. He stated he learned about this incident from the resident when he returned to work 2 days later, and she told him she fell out of the lift and hurt her arm and shoulder. During an interview with Staff E, RN on 8/17/24 at 2:16 PM she stated a fall was when a resident landed on the ground. Nurses were expected to complete incident reports immediately, document in the EHR, notify the physician and the family, and report to the next shift. They should notify the provider by phone if the resident was on a blood thinner or was injured and could make the notification by fax if there were no immediate concerns. She stated nothing was reported to her when she arrived the day after Resident #6's fall, and there was no incident report, assessment note, or documentation in the EHR other than a record of 2 skin tears. She learned of the incident from the resident who told her an assessment hadn't been done. Staff E added that this resident had also been transferred in June without a mechanical lift by an agency CNA who had not looked at the resident's transfer status before moving her. That CNA has not been back to the facility. At 2:32 PM on 8/17/24 Staff G, CNA, stated she was not there the day Resident #6 fell but the resident always used a Sara lift and was supposed to have two staff helping her. Staff H, CNA stated on 8/17/24 at 3:59 PM that staff got to know residents and their needs. She reported if a resident fell then CNAs should make sure they were okay and not move them until a nurse completed an assessment. She stated if they were safe she would look out the door for help. If no one was visible she would pull that call light to send a signal that she needed help. During Staff C's initial interview on 8/18/24 at 8:14 AM she stated mechanical lift decisions and changes came from the doctor and the nurse. She confirmed there were no changes for Resident #6 the day she fell . Staff C reported she had fall training when she started and was paired up with another staff who trained her about expectations. She explained a fall happened when a resident landed on the floor. When asked about the incident on 8/10/24 with this resident, she stated she finished the resident's shower and began moving her to her wheelchair with the lift when the resident's legs gave out. She first stated the resident didn't fall on the floor because she supported the resident's back and arm. Staff C later stated the other CNA put a gait belt on the resident and they lifted her from the floor to the wheelchair. She was standing on the resident's right side and he was on the left side, and the resident's arms remained up. Staff C first said the resident didn't have any pain, then stated she complained that her arms were sore. Staff C first stated she had to insist the nurse do an assessment, then admitted to getting the resident up without getting the nurse first. She stated she did not notice skin tears during the shower, and did not notice them until the resident called her in before dinner. Staff C thought the shower was around 3:00 PM, vitals between 3:30 and 4:00 PM, and the wound dressing around 5:00. She didn't think the nurse completed a full body assessment if she missed the skin tears. On 8/18/24 at 1:43 PM the DON, when asked about the facility process when staff do not follow a resident's Care Plan, stated they investigated, determined what led to it, and provided education and/or initiated disciplinary action. She reported Staff C was not following the Care Plan by not having a second staff with her and the expectation was always for 2 staff. When asked about the interventions the facility put in place after this incident to keep residents safe during transfers, she stated the facility re-educated all CNAs regarding the facility's two person transfer requirement when using mechanical lifts and making sure a resident was assessed before they were moved. She provided documentation of that training as well as training for the nursing staff regarding completing full assessments prior to moving a resident after a fall. She provided the disciplinary action that included suspension of both the CNA and the nurse involved. The DON stated staff had access to the most updated transfer information on their tablets and/or nurses report sheets daily. When asked if this incident was preventable, the DON stated upon staff interviews they knew to use two people. She also felt staff had not communicated with her or the MDS coordinator to let them know the resident was getting weaker. That communication would have been helpful to prevent this incident. During an interview on 8/18/24 at 2:37 PM the Administrator stated she was not made aware of the resident's fall until the following day. The DON called and explained the incident stating the family and the nurse were upset. The nurse on duty did not complete an incident report because she was told it was not a fall. They initiated an investigation with in house interviews and the information they were getting was not consistent. She reported she can't honestly say what happened because of the inconsistencies. The Administrator, when asked about the resident's transfer status, did confirm that the resident should have been assisted with the transfer by 2 staff and the resident should have been assessed prior to being moved. At 10:23 AM on 8/19/24 Staff B, RN, confirmed she was the nurse on duty when Resident #6 had her fall and stated it was a very busy day. She reported Staff C wheeled the resident by the nurses station after her shower and told her the resident didn't fall. Staff B indicated she went to the resident's room and took her vitals, which were okay. She wasn't sure why the CNA said the resident didn't fall, and reported the resident had a smile on her face. Staff C again said the resident didn't fall. She said the resident appeared fine, and that was the last she knew until the DON called her. Staff B stated everything surfaced the next day, and Staff C lied to the DON about what happened with the resident's transfer. Staff C reported there had been another CNA with her and that she had to ask 3 times for the nurse to do an assessment. Staff B also stated Staff E told her the next morning she should have filled out an incident report, and called the family and provider, but Staff B was confused because Staff C said the resident didn't fall. She stated she didn't know there was an issue to call about. She clarified Staff C told her they assisted the resident from the lift to the wheelchair, not from the floor to the wheelchair. Staff B then stated she panicked and called the DON. She confirmed she entered the incident report, and notified the POA and provider on 8/11/24 as late entries. Staff B reported that Staff C eventually admitted she was alone during the transfer, apologized for not telling the truth, and told her she did it because she didn't want to get into trouble. Staff B said she resigned when approached with a disciplinary report because of how accusing ' they ' were and because the report was the same as the CNA's even though Staff C lied. She said she couldn't work there like that and there were too many residents for one nurse to be responsible for anyway. On 8/21/24 at 4:07 PM, during an interview with Staff C, she verified she received fall training during her orientation and Resident #6 was an assist of two staff at the time of the fall. She acknowledged the facility requirement was for a 2 person transfer for mechanical lifts and that the resident was not assessed by a nurse prior to getting her up from the floor. She confirmed she chose to transfer the resident alone and stated she felt pressured to move the resident so she didn't get cold. She clarified the resident didn't say she was cold, she just knew it could happen. Staff C stated again that she was on the right side and Staff I was on the left side, and reported not being sure how the resident got the skin tears on her right arm. She avoided the question asking which one of them decided to get the resident up without being assessed. She was aware of the resident's prior incidents of weakness and back pain. Staff C believed this incident could have happened with two people because of that. She reported not knowing why the resident had arm and shoulder pain, and denied the resident reported pain to her at the time of the fall. She stated the resident was never left alone even when she looked for another CNA. She repeated she told the nurse as they walked by the nurses station that the resident needed to be assessed. She didn't know why Staff I said the nurse wasn't there. Staff C stated the resident told the nurse she didn't fall, and the nurse said it wasn't a fall. She denied the nurse's claim that she said the skin tears were there before the fall. At the end of the interview, when asked about staffing, the CNA stated there was a lot of work but they could usually get it done. At 5:02 PM Staff C shared that she wanted to add something about staffing. She stated staffing was actually a big concern of hers. She felt there were not enough staff who actually knew the residents that day, and felt like she had to do everything herself. She did not think 3 CNAs was enough for 70 residents when so many require 2 staff to transfer. In an email dated 8/17/24 at 2:36 PM the Administrator documented the facility did not have a policy or procedure related to resident transfers (technique, training, decision making, etc.). They also did not have a policy related to assessments. The facility's policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated only as October, documented that all residents had the right to be free from abuse and neglect. Page 3 noted the facility would provide a supportive and safe environment for all residents to the extent possible through the deployment of trained and qualified staff to meet resident needs as identified in both the individual resident care plans and the facility assessment.

Based on clinical record review, hospital record review, resident and staff interviews the facility failed to prevent a significant medication error from occurring. Resident #2 received Glimepiride 2 mg for 77 days without a diagnosis of diabetes or a physician's order. The nurse on duty at the time the order was received entered another resident's order in this resident's electronic health record (EHR). Over the 77 day timeframe, 11 nurses/Certified Medication Aides (CMA) who administered the medication, the Director of Nursing (DON), the provider (at least 3 visits including a med review visit), and the pharmacy consultant (at least 3 Drug Regimen Reviews) failed to identify the error. These circumstances posed Immediate Jeopardy to resident health and safety. The facility was notified of the Immediate Jeopardy on 7/19/24 at 4:15 PM which began on 4/23/24. The facility took the appropriate action to remove the Immediate Jeopardy on 7/20/24 at 8:29 AM by taking these steps: 1. Put a new process in place for new orders to be double checked by a 2nd nurse. 2. Ensuring newly prescribed medications are reviewed by the pharmacy consultant for appropriateness for that resident. 3. Providers were contacted to discuss emphasis of thorough review of Physician Order Sheets. 4. Medication order audits put in place. 5. DON/designee to audit new processes to ensure expectations are followed. 6. Medication reconciliation added to QAPI agenda. This lowered the scope and severity from a J to a G. The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 4/25/24 documented a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. It included diagnoses of coronary artery disease, acute respiratory failure with hypoxia (not enough oxygen in tissue), and congestive heart failure. Section E documented the resident did not exhibit hallucinations or delusions, and did not exhibit physical or verbal behaviors. The resident needed set up and clean up assistance with transfers, and substantial assistance with shower transfers. Section I did not include diagnoses of seizures, epilepsy, or diabetes mellitus. Resident #2's Care Plan included a focus area dated 4/30/24 for ADL self-care performance deficit related to fatigue, impaired balance, limited mobility, pain, fibromyalgia, shortness of breath, and congestive heart failure. Another focus area dated 11/6/23 documented the resident was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and was unaware of safety needs. An intervention dated 7/10/24 directed staff to rule out physiological causes. The diagnosis list at the end of the Care Plan did not include diabetes or seizures. During an interview with Resident #2 on 7/19/24 at 8:39 AM observed her in her room, seated on her bed, and eating breakfast. She was still in her pajamas. She stated she could usually get dressed by herself and asked staff if she needed help. The resident stated she was not diabetic and didn't know how the medication (Glimepiride) was added to her record. She stated staff never told her the medication was added and if staff would have told her she would have said she did not need it. She revealed she was hospitalized with low blood sugar due to the error a little over a week prior. She stated she was scared and said the staff tried to kill her. She said she didn't trust 'them' anymore. She was also upset the facility called it a seizure and stated she never had a seizure in her life. A document titled DON recap of events dated 7/11/24 documented Resident #2 was found on floor in room by nursing staff exhibiting seizure like activity. Resident was found to be hypoglycemic upon admission to hospital that continued to fluctuate. Hospital reached out to facility inquiring about indication for Glimepiride on patient's medication list and prescribing provider due to patient not having current diagnosis of diabetes. It was discovered at this time that pharmacy received prescription transmission from the Electronic Health Record (EHR) for medication due to agency nurse entering order into EHR, and it was not electronically prescribed by any physician. Administration reached out to (Staff G, Licensed Practical Nurse) who entered the order, and she could not recall specific order entry, and stated if I put that in, then the order should be there because I noted it after it came through. It was identified that another patient on hallway had written orders for this drug, and was also entered in the EHR. Further record review revealed the following: The Medication Administration Record (MAR) documented Resident #2 received 77 doses of Glimepiride (anti-diabetic medication used to treat high blood sugar levels caused by diabetes) Tablet 2 MG for diabetes between 4/24/24 and 7/11/24. Progress Notes dated from 3/17/24 through 7/15/24 labeled Order Note lacked orders for the Glimepiride entered into the MAR. A document titled Order Details from the EHR documented the order was entered and confirmed by Staff G, Licensed Practical Nurse, on 4/23/24 at 8:13 PM, and ordered by the resident's current primary physician (ARNP, Advanced Registered Nurse Practitioner). A document titled Medical Facsimile Cover Sheet dated 4/23/24 documented another resident in the facility, Resident #5, received an order for Glimepiride 2 mg. It was initialed by the nurse on 4/24/24 with a note that said MAR updated. Progress Notes for Resident #2 labeled Pharmacy Note indicated the resident's medications were reviewed and failed to address the Glimepiride. This included: 5/24/24 at 13:59 Note Text: GDRs (gradual dose reductions) sent last month; NC (no change) in meds due to patient is variable with mood. No pharmacy recommendations; 6/21/24 at 19:59 Note Text: MRR (medication regimen review) completed. PRN (as needed) Ativan documentation requested if order is continued > 14 days; and 7/10/24 at 14:57 Note Text: MRR completed. No pharmacy recommendations. A document for Resident #2 titled: Routing ICF visit with an encounter date of 6/20/24 indicated the reason for the provider visit to the facility was a review of chronic medical conditions. Number 16 on the assessment list was an encounter for medication review. The list did not include diabetes. The provider documented they completed a review of medications and no changes were made that day. A document for Resident #2 titled: Acute ICF visit with an encounter date of 6/21/24 revealed the resident was seen at the facility for acute encephalopathy (rapidly progressive brain dysfunction). The resident had gone unresponsive with oxygen saturation at 73% on room air. She was unable to answer questions and exhibited nonsensical wording. The medications section documented see facility MAR for current medications and indicated there were no medication changes. A document for Resident #2 titled: ICF Progress Note with an encounter date of 6/24/24 documented the facility visit was to review chronic medical conditions. The resident did not remember the events from the past Friday. Family discussed hospice with the provider. The medication section documented see facility MAR for current medications and indicated there were no medication changes. A Progress Note dated 7/10/24 at 6:01 AM titled Nursing Progress Note documented Resident had her call light on, Certified Nurse Aide (CNA) said resident was on the floor shaking and her speech was incoherent. Nurse called 911. Nurse call 911. Resident was taken to (local hospital). A note 7/11/24 at 7:31 AM titled Orders Administration Note indicated the resident was hospitalized . A document titled ED (Emergency Department) to Hosp (Hospital) admitted d 7/10/24 revealed Resident #2 presented for evaluation of altered mental status and shaking and included documentation of the episode on 6/21/24, chronic headaches for a month and a half, and mild intermittent blurred vision. While in the ED the resident's blood glucose was 41 and, despite supplementation the glucose remained low. The hospital admission diagnosis was labeled as hypoglycemia. They were uncertain why Glimepiride was added to the medication list and documented it should NOT be prescribed as she did not have a history of diabetes or elevated blood glucose values. A section titled ED Course noted the following blood sugars on 7/10/24: 0624, 34; 0843, 81; 1113, 54 (despite 500 ml of 10% dextrose, breakfast, and several orange juice containers); 1252, 66 (additional bolus of 10% dextrose); 1358, 88; 1459, patient continues to be hypoglycemic despite 2 full meals and 1 L of 10% dextrose. The resident was admitted at that time. An interview with Staff A, CMA, on 7/20/24 at 10:35 AM determined she thought Glimepiride might be a blood pressure medication. She stated CMA's were alerted to new resident medications on report, by the nurses, or when they showed up on the MAR. She did not talk to the nurse about the Glimepiride when the resident started taking it. An interview with Staff E, Registered Nurse, on 7/20/24 at 10:47 AM revealed she worked at the facility for 4 years. She indicated the diagnoses for medications were located in the electronic health record and the doctors and/or nurse practitioners signed medication orders weekly when they rounded. She stated before the error with Resident #2 there was not a method in place for double checking orders. Staff B, Licensed Practical Nurse, stated on 7/20/24 at 10:55 AM she did not know of any audits for medication errors, other than the people who are passing them checking to make sure the medication and the MAR matched. She said checking medications against orders and diagnoses did not happen often. An interview with agency Staff F, CNA/CMA, on 7/20/24 at 11:09 AM determined she was not aware of any medication concerns, there was no part of her CMA role that required her to check resident diagnoses against medications, and she did not know about any medication audits that might have taken place. During an interview with the Administrator on 7/19/24 at 4:02 PM she confirmed additional interventions with the pharmacy and providers to prevent future incidents had not been put in place according to their initial plan of correction. She indicated staff would benefit from a skills fair and additional internal auditing, and that staff education already provided needed additional documentation and follow up. On 7/20/24 at 3:17 PM the DON stated she considered this an unfortunate incident. The facility did not have a policy for medication errors, just a procedure which was not in writing. She expected if there was an error, the CMA would tell the charge nurse. The charge nurse would assess the resident for side effects, call 911 if needed, notify the family and the provider, complete risk management for root cause, and notify her. The DON confirmed most medications were administered by CMAs and not the nurses. The DON, nurses, pharmacy consultants, and providers were responsible for comparing orders to diagnoses. An undated policy titled Medication Administration Policy documented the facility would provide pharmaceutical services, including procedures to assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident.

Based on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise 1 of 6 residents reviewed in order to prevent a fall with injury (Resident #4). The facility reported a census of 78 residents. Findings include: The MDS (Minimum Data Set) dated 12/14/2023 revealed Resident #4 had severely impaired cognitive abilities, required extensive assistance to transfer from one surface to another, and had a fall that resulted in a major injury. The resident had diagnoses including weakness, depression, and dementia. Resident #4's Care Plan identified she had a a risk for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication, unaware of safety needs, and history of syncope initiated on 10/18/2019. The Care Plan directed staff to provide assistance with all transfers and ambulation initiated on 12/12/2023. The Care Plan identified the resident had an ADL (Activities of Daily Living) self-care performance deficit initiated 10/16/2019. It directed staff to transfer with the assistance of one staff and a 4 wheeled walker initiated 10/18/2019. The MAR (Medication Administration Record) revealed the resident received Tylenol 650 mg on [DATE] at 7:00 A.M. The physician ordered Tylenol 650 mg four times a day for pain control on 12/13/2023. The resident continued to receive Tylenol 650 mg four times a day. The X-ray report dated 12/12/2023 revealed Resident #4 had an acute complete oblique (broken at an angle) fracture of the distal radius (one of the forearm bones) extending to the distal radial ulnar joint (left wrist) with minimal dorsal angulation of the distal fracture fragment. On 12/12/2023 the physician ordered a wrist splint to be worn at all times, except for bathing or showers, Tylenol 650 mg (milligrams) four times a day and repeat X-ray in four weeks. The X-ray report dated 1/15/2024 revealed a healing non-displaced fracture. In a Progress Note dated 12/12/2023 at 1:00 P.M., Staff G, RN documented the resident ambulated with the CNA, lost her balance and fell on to the floor towards the right side. The resident did not hit her head, and she complained of left wrist pain with no swelling or bruising noted at this time. Ice pack applied. The facility Incident/Accident Report dated 12/12/2023 at 1:00 P.M. completed by Staff G, RN revealed Resident #4 ambulated with a CNA, lost her balance and fell on to the floor on her right side without hitting her head. The resident complained of left wrist pain. Additional comments and/or steps to prevent recurrence: Use walker with ambulating. An additional comment added later stated: Gait belt for all transfers. The facility Self Report, submitted to DIA (Department of Inspections and Appeals) on 12/12/2023 by Staff M, the former DON (Director of Nursing) included: Accident with major injury in the main dining room. The resident ambulated in the main dining room with Staff I, CNA. The resident lost her balance and fell toward her right side. She did not hit her head. She complained of left wrist pain without bruising or swelling. The right middle finer had a light purple bruise. Corrective Action Description: Resident will use walker with ambulation. Staff I, CNA Witness Statement Summary: was ambulating with resident when resident lost her balance and fell toward her right side. Staff G, RN Witness Statement Summary: Resident was ambulating in dining room with CNA. Resident lost balance and fell forward toward her right side. She did not hit her head but complained of left wrist pain. No swelling or bruising to wrist. Light bruise to middle finger of right hand. Staff H, Care Plan Coordinator statement dated 4/10/2024: Gait belt education was provided by Staff right away through the communication binder (5 minute binder), through facility postings at nurses area, and covered in a subsequent nursing meeting. Staff L, Interim DON submitted a copy of communication from Staff M to all staff to read. Gait belts are a part of your uniform. They must be used or reprimand will happen. Staff L indicated Staff M wrote the communication after Resident #4's fall. Staff M also posted a sign at the nurse's stations that read: Attention all nursing staff. Gait belts are required as part of your uniform. You must have a gait belt on you at all times. Observation on 4/8/2024 at 12:13 P.M. revealed Staff N, CNA, assisted Resident #4 to the edge of her bed and applied a gait belt around her waist. Staff N assisted the resident to stand with the gait belt and the wheeled walker. Staff N held the gait belt and the resident used the wheeled walker to ambulate with a slow and steady gait to the dining room. The resident was cooperative and alert. On 4/10/2024 at 11:30 A.M., Staff A, Administrator reported working at the facility since January, 2024, and did not work at the facility when Resident #4 fell . She could only provide information that the previous administration reported on line since many of the investigative files were empty. On 4/10/2024 at 8:30 A.M., Staff G reported working on 12/12/2024 when Resident #4 fell . Staff I, CNA walked with the resident and Staff G did not see her in time to correct her. Staff G did not know the resident used a walker, and thought the resident required light contact assistance with ambulation. Staff G said the resident fell in the dining room and she did the investigation. Staff G did not recall seeing the resident with a gait belt on when she fell . All staff were educated to use gait belts. Signs were placed at the nurse's stations reminding staff they are to have gait belts as a part of the uniform and should be worn at all times. Staff G wrote use walker with ambulating. Staff H updates the Care Plans. Staff need to use a gait belt with any resident that requires assistance with transfers or ambulation. Staff I had worked at the facility prior to that day. The facility provides new staff with cheat sheets telling them how each resident transfers. Everyone knows the gait belt policy, it is standard nursing practice. On 4/10/2024 at 8:56 A.M., Staff H, Care Plan Coordinator indicated any resident who transfers or ambulates with assistance requires the use of a gait belt. Staff H reviews each incident, makes sure there is an intervention in place and that it is care planned. When Resident #4 fell , the charge nurse's immediate intervention was to use walker with ambulation. Staff H reviewed the incident and added gait belt for all transfers. The former DON interviewed staff and the investigation determined Staff I did not use a gait belt when the resident fell . If Staff I had used a gait belt, she would have been able to grab it when the resident started to lose her balance. On 4/10/2024 at 10:00 A.M., Staff K, CNA reported working on 12/12/2023, however she had no recall of Staff I and no recall of Resident #4's fall. Staff K knew she needed to wear a gait belt at all times and use it with any resident who required assistance of one to transfer and ambulate. During a phone interview on 4/10/2024 at 10:30 A.M., Staff I reported working on 12/12/2023 when Resident #4 fell , That was her second day at the facility and her first with the resident. Staff I had no cheat sheet and did not know the resident. Staff I reported she walked with the resident from the bathroom to the dining room with a wheeled walker and a gait belt. Staff I held the resident's hand, and stood on her left side. Staff I said the resident also had one hand on the walker. The resident lost her balance and her hand slipped away from Staff I. It happened fast and the resident fell . It took awhile for staff to come and assist. On 4/10/2024 at 9:10 A.M., Staff N, an agency CNA, reported working at the facility for awhile. Staff N knew to use a gait belt with any resident who requires assistance to transfer. If she did not know how a resident transferred, she would ask. On 4/10/2024 at 9:00 A.M., Staff C, CNA reported working at the facility through an agency. Staff C knew she needed to use a gait belt if the resident required assistance to transfer, something she learned in CNA training. The facility Gait Belt (Use of ) policy included: Purpose: To ensure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. Procedure: 2. All residents who require assistance with transfers and do not require and electric lift will utilize a gait belt with all transfers. 10. The staff person will utilize safe transfer technique, moving with the resident, with the knees bent and a strong grasp on the transfer belt.

Based on observation, record review and staff interviews the facility failed to prevent the development of a facility acquired unstageable (obscured full thickness skin and tissue loss) pressure ulcer and failed to implement a treatment order for the wound for one of two residents reviewed for pressure ulcers (Resident #22). The facility reported a census of 44 residents. Findings Include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was rarely to never understood. The resident required the extensive assistance of two persons physical assist for bed mobility and transfer. Per the assessment, the resident identified at risk for pressure ulcer development, and had no unhealed pressure ulcers/injuries. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/20/22, Resident #22's Care Plan did not address alterations in skin integrity or the presence of wounds. The Braden Scale for Predicting Pressure Ulcer Risk dated 2/10/22 revealed the resident scored 13, which identified the resident at high risk. The Progress Note dated 3/1/22 at 4:00 PM, documented, Fax sent regarding a 4 centimeter (cm) x 4 cm black eschar (dead or devitalized tissue) to the left (L) heel. The Visit/Consult Sheet dated 3/1/22 documented, in part, 4 cm x 4 cm Thick black Eschar L heel. No drainage. Heels Floated on pillow. Treatment (Tx?) Bunny boots? - Yes. The New orders/provider response section of the form documented, Wound Clinic Consult please. The Progress Note dated 3/2/22 at 1:00 PM documented, Received return Fax re: Black eschar on L heel and tip of 2nd toe, right foot, Wound Clinic Consult. The Progress Note dated 3/3/22 at 1:20 PM, documented, Call to Power of Attorney (POA) to inform of black eschar on L heel and discuss treatment plan, had to leave message to call facility. The Visit/Consult sheet dated 3/3/22 documented, the POA refuses the Wound Clinic Consult, she would like resident managed at the facility. How would you like to proceed? The New orders/provider response section of the form documented: What is the treatment currently? Bunny boots & float heels. [MEDICATION(S)] applied twice a day (BID) to R (right) 2nd toe. I will still have to look at next week. Did she say why? No. The Progress Note dated 3/3/22 at 4:00 PM, documented, POA called; she declines Wound Clinic Consult, would like the resident to be cared for here. Fax sent to notify the Primary Care Provider PCP). Review of the Long Term Care Facility Acute Visit note by the Nurse Practitioner (NP) dated 3/10/22 for a chief complaint of acute visit for wound on left heel documented, the is a [age] year old female who is seen for a wound on her left heel. I had recommended staff for her to see the Wound Clinic for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient reports that it is painful. No fever or chills. Staff are unsure why the POA refused the referral to the Wound Clinic. Per the Impression and Plan section of form the following had been documented for the resident's Open wound of left heel; initial encounter: Assessment/Plan: Recommend Wound Consult but POA does not want this at this time Dakin's 0.125% solution; cleanse left heel daily and apply [MEDICATION(S)] with [MEDICATION(S)] cover. Review of signed Physician's Orders sheets active 2/1/22 to 3/31/22 and 4/1/22 to 6/30/22 did not include the treatment order which had been documented in the Long Term Care Facility Acute Visit note dated 3/10/22. The Treatment Administration Record (TAR) for March 2022 and April 2022 for Resident #22 did not address treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Weekly Pressure Injury Record for left heel black eschar (date of onset 3/1/22) revealed the following: a. On 3/1/22: Stage II classification had been crossed off, measurements 4 cm x 4 cm, depth documented undeterminable, no exudate or odor, black wound bed, and pink surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented, doctor notified 3/1/22 unstageable. Pressure relieving interventions documented, float heels. b. On 3/9/22: Line present through stage, measurements 4 cm x 3 cm, no depth or exudate, odor left blank, thick black eschar wound bed, and pink surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented: no change. Pressure relieving interventions had been left blank. c. On 3/15/22: Stage documented unstageable, measurements 4 cm x 3.2 cm, depth documented ?, no exudate or odor, thick black eschar wound bed, normal pink surrounding skin color, and dry pale pink surrounding tissue/wound edges. Response to treatment/comments documented: no change. Pressure relieving interventions documented, Bunny boots when in bed. d. On 3/23 (year not documented): Stage had been left blank, measurements 3 cm x 3.5 cm, depth documented ?, no exudate or odor, thick black eschar wound bed, normal surrounding skin color, and pale pink surrounding tissue/wound edges. Response to treatment/comments documented, healing slowly, no drainage noted. Pressure relieving interventions had been left blank. e. On 4/6/22: Stage had been left blank, measurements 4 cm x 2 cm, depth had a line through the box, no exudate or odor, thick eschar wound bed, normal surrounding skin color, and surrounding tissue/wound edges had been left blank. Response to treatment/comments documented: no change. Pressure relieving interventions had been left blank. f. On 4/13/22: Stage had been left blank, measurements 4 cm x 3 cm, depth had a line through the box, no exudate or odor, black eschar wound bed, normal surrounding skin color and surrounding tissue/wound edges. Response to treatment/commends documented: no change, no odor, no drainage. Pressure relieving interventions documented, wears boots in bed. g. On 4/20/22: Stage had been left blank, measurements 3.8 cm x 2.5 cm, depth had a line through the box, no exudate or odor, black eschar wound bed, normal surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented: small amount of improvement. Pressure relieving interventions had been left blank. On 4/20/22 at approximately 12:55 PM, an observation of Resident #22's left heel was conducted with Staff B, Licensed Practical Nurse (LPN), and Staff C, LPN. Resident #22 observed in bed with soft boots to the bilateral feet. Observation of the left foot revealed a black area present to the resident's left heel. On 4/19/22 at 9:07 AM, Staff B, LPN, was queried about Resident #22's heel. Per Staff B, they were monitoring and keeping pressure off of it, the edges were loosening up a little bit and it was still pretty firmly attached. Staff B acknowledged the area was black in color, had been going on for a little while, then clarified as at least a month. Per Staff B, there was no treatment now other than just keeping pressure off it. On 4/20/22 at 12:55 PM, Staff C, LPN, who assisted with treatments at the facility, was queried about wounds. Staff C explained they would measure the wounds when they were at the facility, and Staff B would measure in the area they worked as they worked that area all the time. It was noted Resident #22 resided in the area where Staff B worked. Staff C explained she believed at one time the resident had been referred, and the family didn't want to take the resident to the Wound Clinic. When queried about how doctor recommendations for wound care would be implemented, Staff C explained the nurse would call the family, the family would decide, and it would go from there. If the Doctor or NP had a treatment order recommendation, it would be faxed over to them, the orders would be done and the treatment would be started. When queried if Resident #22 had been receiving treatment to the left heel, Staff C responded before we were just leaving it, and were just watching it and putting boots on Resident #22 and being really careful with it. Per Staff C, she did not think they ever had a treatment going to debride it. Staff C acknowledged the wound had been treated like a pressure ulcer as the facility had it on a Pressure Ulcer Sheet. When queried if the wound had been facility acquired, Staff C explained she did not know. On 4/20/22 at 1:06 PM, Staff B, LPN, acknowledged Resident #22's wound was facility acquired. When queried about whether they knew of any treatment order to the heel, Staff B explained the resident had bunny boots while in bed to keep pressure off it. Per Staff B, reported the Primary Care Physician had wanted to send the resident to the Wound Clinic and the family did not want to do all of that considering the resident's age and general condition. Per Staff B, the wound was not open. Staff B explained the wound did not seem to hurt the resident much, and medication was effective. Per Staff B, the resident got the boots right after the heel wound had been discovered. When queried about weekly skin assessments Staff B explained that there were the sheets that they measured on. Per Staff B, there were not scheduled skin assessments, and the aides would report when giving showers and getting resident up if they saw anything that they had not seen before. Then, it would be reported, assessed and the doctor and family would be notified. Staff B acknowledged the area for Resident #22 was a pressure wound. When queried if the doctor had a recommendation for treatment how this would be put in an order, Staff B explained that they would Fax or write the order out if they were here, or would verbally give the order and then the order would be written as a verbal order. Staff B acknowledged if there were treatment orders they would go on the TAR. When queried the treatment order on the Long Term Care Facility Acute Visit note by the Nurse Practitioner (NP) dated 3/10/22, Staff B explained she did not know that it had been there, and how it had got in the chart and she did not know about it. Per Staff B, generally when the Visit Progress Report was faxed over it went to another staff member so that she could log in that she got a Progress Note, and generally she would say there was a new order. On 4/20/22 at 1:17 PM, Staff D, MDS Coordinator, acknowledged that she would write the Care Plans. When queried about Wound Care Plans for Resident #22, Staff D responded she did not have the resident Care Planned for her vascular issues, and the resident needed an At Risk Pressure Ulcer Care Plan. When queried if Resident #22 had any pressure ulcers, Staff D responded she was pretty sure they were calling the one on her toe vascular. When queried if she was aware of any heel sites for Resident #22, Staff D responded no. Per Staff D, when the provider came in generally if there were new orders that day, telephone orders were written, and were signed on the spot. Then the Charge Nurse would take care of the telephone order and implement it. Per Staff D, a week later the Progress Notes would get sent over in a big group for whoever they saw that week. Staff D acknowledged sometimes it took a week before the notes were Faxed to the facility. When queried about the treatment recommendation included in the 3/10/22 note, Staff D explained the sheet had been faxed to the facility 3/20/22. Per Staff D, staff did not round with the NP who had authored the note for Resident #22 when the provider was in the facility. On 4/20/22 at 1:36 PM, the Director of Nursing (DON) explained typically orders were not written on the notes, and usually if (the provider) was in for a visit, they would write it on the Telephone Orders so that the nurse was aware of it right away. Per the DON, sometimes they write it on a Fax Sheet, and typically a Telephone Order would be written. When queried what should have occurred in this situation, the DON explained ideally the order should have been written on a Telephone Order. When the visit notes come in, the DON explained she was not sure if the nurses looked at them or if they would go to other staff first. The DON acknowledged she did not normally see the Visit Notes, and further explained it should have been looked over either by the Charge Nurse or another staff member and should have been caught. When queried about implementation of Pressure Ulcer Care Plans, the DON acknowledged the MDS Coordinator usually did the Care Plans. Per the DON, the facility had been using boots to keep the resident's heels off of the bed. When queried as to what had been done prior to prevent a wound, the DON acknowledged this would ideally be in the Care Plan. When queried if there was a process for nurses to check skin at a set frequency, the DON explained this would occur on admission, and aides would come to the nurses if they noticed red areas or something like that. The DON explained that they did not have something in place for before, and acknowledged after a Wound Development Assessment would occur weekly. Review of the Facility Policy titled Skin Care: Risk Assessment and Treatment, dated 9/30/04, revealed, it is the policy of the facility that a resident with any type of skin condition (i.e. any red areas, skin tears, decubitus ulcers) shall receive appropriate treatment. The treatment will have as its aim to promote healing, prevent infection, and prevent new conditions from arising. The policy also documented, A Pressure Ulcer Progress Report will be initiated when observed by the Charge Nurse. Progress Reports on all pressure ulcers are to be documented weekly. Included in the report will be date, location, stage of ulcer, size, depth, any drainage, any odors, color of site and surrounding tissues, date of doctor notification and subsequent orders. (i.e. Cultures, treatment, new medications, or change in diet.)

Based on observation, clinical record review, staff and resident interviews, the facility failed to appropriately transfer 1 of 5 residents reviewed (Resident #1). Resident #1 was transferred without the correct device and assistance resulting in bilateral femur fractures. The facility reported a census of 70 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The resident required extensive assistance of 2 staff for bed mobility, transfers and toilet use, the resident did not walk but utilized a wheelchair for mobility. Resident #1 had severe cognitive ability. Review of the care plan dated 10/21/15 indicated the resident required assistance with activities of daily living due to her [MEDICAL CONDITION] and directed the staff to utilize 2 staff for repositioning, turning in bed, moving between surfaces and to utilize a Hoyer lift as needed for weakness. Review of a mobility/safety assessment dated [DATE], the assessment revealed the resident required assistance of 2 staff for transfers, position changes and toilet use. Review of a Nurses Notes dated 10/25/18 at 6:30 a.m. Staff A documented she was informed from the overnight staff they noticed swelling and bruising on the previous evening shift. Staff A assessed the resident at 7:20 a.m. and noted swelling and purple bruises to the resident's right knee and minimal swelling to the resident's left knee, the resident exhibited signs and symptoms of pain during the assessment. At 9:10 a.m. Staff A contacted the physician and orders were obtained for portable x-ray to the knees. The resident had a series of x-rays completed to both knees at 11:30 a.m. The Nurses Notes indicated the family denied surgical intervention and placed the resident on Hospice services, the resident passed away on 10/28/18. Review of the incident/accident report dated 10/25/18 revealed the resident had irregular sized purple bruise on the inner and back of right and left knees. The knees are swollen and slightly red, the resident exhibited symptoms of pain and grimacing with movement. Review of an x-ray report dated 10/25/18 revealed the resident had acute distal femoral fracture of her right leg and acute [MEDICAL CONDITION] femoral diaphysis of the left leg. Review of the Major Injury Determination form dated 10/25/18, Resident #1's physician determined after reviewing the circumstances of the incident it was determined the resident sustained [REDACTED]. During an interview with Staff B-C.N.A. on 12/5/18 at 5:10 pm, the staff stated she worked the evening shift on 10/24/18. Early in her shift at about 4:00-5:00 p.m. she went to get Resident #1 up for her evening meal. At that time Staff B noted both of her legs were swollen and didn't look normal. Staff B notified the Medication Aide on the unit who contacted the nurse for the back hall. Staff B stated on the evening shift they always utilize a Hoyer lift for the resident because she cannot stand well. Staff B stated she did not get any report of an injury or fall from the day shift staff on 10/24/18. During an interview with Staff C-C.N.A. on 12/5/18 at 5:20 p.m., the staff stated she worked the evening shift on 10/24/18 with Staff B. Staff C stated when she rolled the resident to do cares she noted a bruise on the back of the resident's legs, she indicated both areas around her knees were swollen. Staff C stated on the evening shift they always use a Hoyer lift to move the resident about, form bed to chair. Staff C stated she did not get any report of an injury or fall from the day shift on 10/24/18. During an interview with Staff D-Certified Mediation Aide on 12/5/18 at 5:30 p.m., the C.N.A. stated she worked the previous evening shift on 10/23/18 and Resident #1 did not have swelling or discoloration to her knees. Staff D stated the evening shift always utilize a Hoyer lift to get the resident up from bed or wheelchair because she feels it safer for the resident. During an interview with Staff E-R.N. on 12/5/18 at 11:08 a.m. Staff E stated he worked the evening shift on 10/24/18 and was called to assess the knees/legs of Resident #1. Upon assessment Staff E noted bruising on the resident's inner thighs and faint discoloration, he stated both knees appeared to be swollen and discolored. Staff E traced around the redness with a marker to be able to further assess in the discoloration/swelling increased in size. Staff E directed the staff to keep the resident in bed. Staff E failed to document or notify the physician of the findings of his assessments. During an interview with Staff G-R.N., Staff G stated she worked the night shift on 10/24/18 into the morning of 10/25/18. She stated she assessed the resident's legs and noted her right leg was reddened but didn't notice any bruising, she reports looking at the residents legs twice that shift during rounds. The resident experienced symptoms of pain when the staff moved her to do cares on her. When she received report at the beginning of her shift she was aware of the swollen knees but no injury or trauma reported to her. During an interview with Staff H-C.N.A. on 12/6/18 at 2:30 p.m., Staff H stated she was responsible for Resident #1 on the day shift of 10/24/18. She stated she worked with an Agency aide-Staff I on that day. Staff H stated she used a two person transfer with a gait belt to transfer the resident from bed to her wheelchair for breakfast and after breakfast she utilized a Sara Lift (a Sara Lift is a mechanical lift, the resident is to hang on to handle bars and stand up on the lift platform. If unable to stand pressure is put on the resident's knees and back until the staff can lower the resident back down onto a firm surface) to lift the resident up into the air to complete cares so the resident could attend an activity. Staff H stated she has worked at the facility for 4.5 years and reports she didn't have anything to look at to describe how the resident is to transfer from surface to surface. Staff H stated Staff I assisted her with the Sara Lift and the cares. Staff H stated later in the afternoon she placed a gait belt around the resident stood her up by herself and pivoted her to her bed. During an interview with Staff I-Agency C.N.A. on 12/5/18 at 9:17 a.m., Staff I stated she did not assist Staff H with a transfer for Resident #1 on 10/24/18 using a Sara Lift on 10/24/18. During an interview with Resident #1's physician on 12/6/18 at 10:17 a.m., the physician stated the resident had a bilateral injury force across both knees, in the same location. It is his opinion the resident sustained [REDACTED].