Every finding on record at Park Place

Based on observation, policy review and staff interview, the facility failed to ensure 3 of 3 residents on a pureed diet received margarine and the correct portion of bread and vegetables and failed to ensure multiple residents on a regular diet received the correct portion of meatloaf. The facility reported a census of 29 residents.Findings included:a. The Week 1 Tuesday menu for the noon meal directed staff to serve those on a pureed diet a #10 scoop( to a half cup) of italian blend vegetables and 1 piece of bread with margarine.On 8/11/26 at 10:51 a.m., Staff M [NAME] added 2 4 ounce scoops of vegetables to the food processor and blended to a pureed consistency. Staff M then added 2 pieces of bread without margarine. Staff M stated she was making 2 servings of vegetables. During the meal service on 8/11/26 at 12:00 p.m., Staff M used a cup scoop to divide the 2 portions of vegetables/bread into 3 portions. Staff M did not add margarine to the pureed bread.b. The Week 1 Tuesday menu for the noon meal directed staff to serve those on a regular diet 3 ounces of meatloaf. During the meal service on 8/11/26 at 12:00 p.m., Staff M served slices of meatloaf to residents on a regular diet. It appeared that the sizes of the meatloaf varied greatly from person to person and approximately 10 residents received much smaller slices than others. After the meal service, the Dietary Manager weighed 3 slices of meatloaf:Slice 1: 2 ouncesSlices 2 and 3: just under 3 ounces.The undated facility policy Nutrition Services stated the facility would meet the nutritional needs of residents in a manner consistent with recognized dietary practices. The facility would provide therapeutic diets in accordance with orders from a practitioner. On 8/12/26 at 3:12 p.m., the Dietary Manager stated she was not sure which pan Staff M used to weigh a slice of meatloaf in order to gauge subsequent pieces. She stated Staff M may not have cut all of the pieces of meatloaf the same way and stated she(the CDM) was surprised to see the slices. She stated residents who received pureed food should receive bread and butter and staff should measure the total amount of food in order to divide it equally.

Based on observation, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 29 residents.Findings included:During the initial kitchen tour on 8/10/26 at 9:15 a.m., thick dust particles hung down from the spigots of the fire suppression system located above the stove burners. A pot simmered on a stove burner under the dusty spigots.During a follow-up tour of the kitchen on 8/11/26 at 10:28 a.m., dust remained on 3 spigots of the fire suppression system located above the stove burners. The dust particles appeared loose as if they could easily fall off. The undated facility policy Nutrition Services stated the facility would implement cleaning schedules and monitor for cleanliness. The policy stated staff cleaned the exhaust hood regularly. On 8/12/26 at 3:12 p.m., the Dietary Manager stated a company came to the facility and cleaned the fire suppression system 2 times per year. She stated the maintenance department would not allow anyone else to clean them.

Based on observations, clinical record review, policy review, and staff interview, the facility failed to carry out adequate infection control practices for 1 of 2 residents observed during a dressing change(Resident #8), 1 of 1 resident observed during catheter cares(Resident #2), 1 of 1 resident observed during a blood sugar check(Resident #24), and for 1 of 1 resident observed during perineal cares(Resident #7). The facility reported a policy of 29 residents. Findings included: 1. The Minimum Data Set(MDS) assessment, dated 6/10/26, listed diagnoses for Resident #8 which included high blood pressure, hip fracture, and osteoporosis(brittle bones). The MDS stated the resident had an indwelling catheter and listed her Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The 6/14/26 Care Plan entries stated the resident had a catheter and would have no complications related to this. On 8/12/26 at 8:58 a.m., Staff A Registered Nurse(RN) measured an open area on the resident's buttock as 0.3 centimeters(cm) x 1.1 cm. Staff L RN assisted Staff A by assisting the resident to roll onto her side. The resident had an indwelling urinary catheter. Staff A applied cream to the resident's bottom and covered the area with a foam dressing. During the care, neither Staff A or Staff L wore a gown. The facility policy Enhanced Barrier Precautions(EBP), revised 3/2026, directed staff to wear a gown during high-contact resident care activities for residents who had open wounds or indwelling devices. 2. The MDS assessment tool, dated 5/27/26, listed diagnoses for Resident #2 which included heart failure, urinary retention, and obesity and stated the resident had an indwelling catheter. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. A 7/10/26 Care Plan entry stated the resident would have no complications from an indwelling catheter. The undated facility policy Steps for Emptying a Foley Catheter Drainage Bag directed staff to place a barrier between the surface and the measuring container and to disinfect the drainage spout according to the facility policy. On 8/12/26 at 12:38 p.m., Staff D placed a graduate directly on the carpet and emptied the resident's urinary catheter into the graduate. Staff D then placed the drainage spout back into the drainage bag without cleaning the spout. After completing the task, Staff D stated the graduate had been used prior to this as she began using it at the start of the week. On 8/13/26 at 10:13 a.m., the Director of Nursing(DON) stated staff should have carried out EBP while assisting with Resident #8. She stated staff should place the graduate on a barrier and clean the spout after emptying the bag. 3. Review of the MDS Assessment for Resident #3, dated 6/3/26, revealed a diagnosis of diabetes mellitus. Review of a Physician Order, dated 6/23/26, revealed an order for blood glucose (sugar) meter four times daily before meals and at bedtime. On 8/11/2026 at 4:00 PM, during an observation, Staff B, Registered Nurse (RN), entered Resident #6's room with a blood glucose monitoring machine, test strips, alcohol pad, disposable finger stick, and cotton ball. Staff B washed her hands, gloved, scanned and put a test strip in the blood glucose machine, rubbed an alcohol pad on the resident's finger, stuck the resident with a disposable finger stick device, and placed a drop of the resident's blood on the test strip in the blood glucose machine. Staff B, applied a cotton ball to the resident's finger, disposed of the finger stick device, removed her gloves, washed her hands and took the blood glucose machine to her nursing cart. Staff B opened her cart, gloved and used a disposable Sani Cloth to wipe the device surfaces off. Staff B then left the blood glucose machine on top of the cart. The machine dried within seconds. Review of the Sani Cloth package revealed, in part, the following, To Disinfect and Deodorize hard, non-porous surfaces .unfold wipe and thoroughly wet surface. Allow surface to remain wet for 2 minutes. On 8/11/26 at 4:12 PM, during an interview, Staff B, RN, reported she had kind of read the instructions on the Sani-Cloth. She reported she wiped the whole machine down and then let the machine air dry on top of her cart after use each time. She could not explain how she ensured the machine stayed wet for two minutes. Staff B reported the facility had two machines for the whole building, and used the machines on multiple residents. On 8/12/26 at 9:41 AM, during an interview, the Director of Nursing (DON), confirmed the use of Sani-Cloth wipes to clean the blood glucose monitoring machines. The DON confirmed the instructions on the Sani-Cloth package include leaving the machine wet for two minutes. The DON explained she had seen nursing staff wipe the machine and then leave the Sani-Cloth wrapped around the machine to keep it wet for two minutes. Review of an untitled, undated document, identified by facility staff as instructions for cleaning the blood glucose monitoring machines, revealed, in part, obtain a non-saturated PDI wipe (type of sanitizing wipe). Thoroughly wipe all sides of the meter for a minimum of three times vertically and three times horizontally. The meter should stay wet for two (2) minutes and then allow to dry for one (1) minute. 4) The Minimum Data Set (MDS) for Resident #7, dated 7/15/26, identified diagnoses of non-Alzheimer's dementia, cerebrovascular disease(CVA), and reduced mobility. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severe cognitive impairment. A Care Plan entry, dated 6/4/26, listed a problem of urinary incontinence with a goal to be free of complications related to urinary incontinence. A 7/17/26 interventions included providing prompt incontinence care and the use of incontinence products. A 6/15/26 intervention directed staff to carry out Enhanced Barrier Precautions(EPB). During an observation on 8/12/26 at 8:45 a.m. Staff C and Staff D Certified Nursing Assistants (CNAs) entered Resident #7s room where both put gloves on without completing hand hygiene. After putting on gloves they touched a full body lift machine and transferred the resident from chair to bed. Staff C started to pull the resident's incontinence brief down and when someone started to walk in, pulled it back on again. Up until this point, Staff C and D did not have a gown on. Staff C and D removed gloves and washed hands, then they donned a mask, gown, and gloves. Staff C provided frontal incontinence care, using the same side of the wipe more than once during cleansing. Staff C failed to change her gloves in between the removal of a soiled brief and the replacement of a new brief. On 8/12/26 at 2:10 p.m., Staff C stated the yellow EBP sign outside Resident #7's room meant she was on precautions and staff needed to wear gloves, gown and mask. Staff C also stated that hand hygiene should be completed before and after cares, and gloves needed to be changed after checking if a resident was soiled and hand hygiene should be completed between glove changes. On 8/12/26 at 2:13 p.m., Staff E CNA stated she was unsure what the yellow EBP sign meant and stated that hand hygiene should be done on entering and leaving resident rooms, and would change gloves often. On 8/12/26 at 2:22 p.m., Staff F CNA stated the yellow EBP sign indicated the resident had an infection in their urine, she stated hand hygiene should be completed before and after resident cares and would change her gloves often. On 8/12/26 at 2:40 p.m., the Director of Nursing (DON), stated she expected staff to understand the meaning of the EBP signs outside resident rooms, and expected staff to wear a gown and gloves when providing resident care. The DON expected staff to complete hand hygiene before and after cares as well as between glove changes. The facility Hand Hygiene Guidelines, last reviewed May 2026, stated hand hygiene should be frequently performed by all personnel, especially between patient contact and following glove removal.

Based on observation, clinical record review, and staff interview, the facility failed to ensure staff administered medicated inhalers per physician order for 1 of 1 sampled residents (Resident #24). The facility reported a census of 29 residents. Findings included:Review of the Minimum Data Set (MDS) Assessment for Resident #24, dated 6/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated an intact cognition, and a diagnosis of chronic obstructive pulmonary disease (obstructive lung disease). Review of a Physician Order, dated 6/5/26, revealed an order for Fluticasone Propion-Salmeterol (Advair Diskus; type of corticosteriod inhaler) 100-50 mcg (microgram) puff/diskus inhaler 1 puff two times daily. Rinse mouth with water after use to reduce aftertaste and incidence of candidiasis (oral thrush). Do not swallow. On 8/11/2026 at 4:16 PM, during an observation, Staff B, Registered Nurse (RN), entered Resident #24's room, gave Res #24 pills in a cup with water. Resident #24 then gloved, handed the Advair inhaler to the resident. The resident exhaled, and then inhaled one puff of the medication. Staff B, RN, used an alcohol pad to cleanse the mouth piece on the inhaler, removed her gloves, washed her hands and exited the room with the resident's inhaler. The resident did not rinse her mouth and spit after using the inhaler and Staff B, RN, did not instruct the resident to rinse her mouth and spit after use of inhaler. On 8/12/2026 at 9:41 AM, during an interview, the Director of Nursing (DON) reported nursing staff needed to instruct residents to rinse and spit after use of a steriod-based inhaler in order to prevent thrush. The DON confirmed Advair was a steriod based inhaler. Review of the Advair Diskus medication box insert revealed, in part, instructions to the user to rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow.

Based on observation, clinical record review, review of facility Call Logs, resident interview and staff interviews, the facility failed to ensure sufficient staff available to answer resident calls lights in a timely manner for 2 of 3 residents sampled (Residents #5 and #11). The facility reported a census of 29 residents.Findings included:1.Review of the Minimum Data Set (MDS) assessment for Resident #5, dated 5/20/26, revealed diagnoses of cancer and renal failure and the Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS indicated the resident utilized a wheelchair for mobility, required partial to moderate assistance for toileting and personal hygiene and required substantial to maxium assistance for transfers. The resident was continent of bowel and occasionally incontinent of urine. On 8/10/26 at 9:50 AM, during an interview, Resident #5 reported staff were slow to answer the call light, and it was worse on weekends and around meal times, both before and after meals. The resident reported she needed help with one staff and the standing lift for transferring. The resident explained most of the time when she used her call light, it was to go to the bathroom. The longest she had to wait was 45 minutes, but recently, this weekend she had to wait for 20 minutes. The resident reported she was usually continent of bowel and bladder, but had a two to three accidents in the past due to having to wait so long on staff. The resident denied any recent accidents. On 8/12/26 at 7:53 AM, during a continous observation, Resident #5 turned her call light system on in her room. At 8:12 AM (19 minutes after the resident turned the call light on), Staff G, Certified Nurses Aide (CNA), responded to the resident's call light. Staff G brought the mechanical standing lift into the room. Staff G assisted the resident with transferring from her wheelchair to the standing lift, and then push the standing lift into the resident's bathroom. Staff G transferred the resident to the toilet, and exited the bathroom. Staff G waited for the resident to indicate she was finished and returned to the bathroom to assist the resident. Review of the Call Log for Resident #5 revealed:a. On 8/5/26, call light on at 12:16 PM. A CNA responded their intent to To Take 27 minutes after the resident had turned her call light on. The Call Log did not identify the reason the resident turned their call light on.b. On 8/6/26, call light on at 5:22 PM. A CNA responded their intent to To Take 24 minutes after the resident had turned her call light on. The Call Log did not identify the reason the resident turned their call light on. c. On 8/7/26, call light on at 12:52 PM for assistance with toileting. A CNA responded their intent to To Take 29 minutes after the resident had turned her call light on. d. On 8/10/26, call light on at 7:56 AM. A CNA responded their intent to To Take 27 minutes after the resident had turned her call light on. The Call Log did not identify the reason the resident turned their call light on.e. On 8/12/26, call light on at 7:53 AM for assistance with toileting. A CNA responded their intent to To Take 19 minutes after the resident had turned her call light on. 2. Review of the MDS Assessment for Resident #11, dated 6/24/26, revealed diagnoses of osteoarthritis and weakness and a BIMS score of 14 out 15, which indicated intact cognition. The MDS indicated the resident utilized a wheelchair for mobility, required supervision or touch assistance for transfers, toilet hygiene and upper body dressing, and was dependent on staff for lower body dressing. On 8/10/26 at 10:22 AM, during an interview, Resident #11 reported staff were sometimes not good about answering the call light. The resident reported having to wait sometimes for 30 minutes. Review of the Call Log for Resident #11 revealed:On 8/4/26, call light turned on at 10:27 AM for assistance with toileting. A CNA responded their intent to To Take 21 minutes after the resident had turned her call light on. On 8/13/26 at 10:33 AM, during an interview, Staff J, CNA, reported it could take more than 15 minutes to answer a resident's call light if they were in assisting another resident with toileting and all of the staff were tied up with helping others. Staff J denied having seen resident's call lights not being answered within 15 minutes while she had been working. Staff J explained that when a resident turned their call light on, the call came over the staffs' phones. When a CNA took the call, they hit take on their phone. Staff J explained she did not hit take for a call light until she was getting ready to enter that resident's room, and then she turned off the resident's call light once she entered the room. On 8/13/26 at 10:35 AM, during an interview, Staff I, CNA, reported that when a resident used their call light, the staffs' phones would chime. Staff I reported she hit take on her phone as she entered the residents' rooms. Staff I CNA reported their phones would continue to chime if no one took the call light. Staff I reported it took staff a little longer around meal times to answer call lights, but denied there were times that staff was not able to answer call lights within 15 minutes. On 8/13/26 at 10:38 AM, during an interview, Staff H, CNA, denied their were times it took staff more than 15 minutes to answer call lights. Staff H reported a float staff person helped to answer call lights during meals times. Staff H reported she hit take on her phone when she was walking in the residents' rooms to answer call lights. On 8/13/26 at 10:45 AM, during an interview, the Director of Nursing (DON) reported staff hit take on their phones when they were ready to enter the residents' rooms to answer call lights. The DON reviewed the Call Logs for Resident #5 and #11, and confirmed the late response time for call lights. On 8/13/26 at 10:55 AM, during an interview, the Adminstrator reported they had had mechanical issues with their call light system. The Administrator explained there had been an issue with the delay in calls not showing up for 12 minutes after the resident had turned their lights on and issues with staff shutting the call light off in the room, but the light remaining on. The Administrator reported these issues were now fixed. The Administrator reported answering of call lights had been an ongoing Quality Assurance and Performance Improvement project. The Administrator reported facility staff had improved their response, but the response time was still not where they wanted it to be. Staff had been instructed and educated on not taking resident call lights until they were ready to go in the room, take the longest to newest, and don't take more than one resident call light at a time. The Administrator reported they had also added a float person on to help answer call lights during meal times and instructed nurses to check into call lights that had been on for longer than 15 minutes.

Based on clinical record review, facility policy review, physician and staff interviews, the facility failed to ensure the prescribing practitioner evaluated residents for the appropriateness of use of as needed anti-psychotic medications every 14 days for 2 of 5 residents sampled (Residents #29 and #7) and failed to ensure a physician response to a pharmacy recommended gradual dose reduction of a psychotropic medication for for 1 of 5 residents sampled. The facility reported a census of 29 residents. Findings include: 1.Review of the Minimum Data Set (MDS) Assessment for Resident #29, dated 6/24/26, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which was indicative of a severe cognitive impairment. The assessment identified the resident diagnoses of dementia, depression and anxiety, and had disorganized thinking, delusions, verbal and physical aggression towards others and behaviors not directed towards others. The assessment identified the resident took antianxiety, antidepressant and antipsychotic medications. Review of a document, titled LTC (long term care) All Orders-All Statuses, revealed a Physician Order, dated 4/3/26, for Risperidone (a type of anti-psychotic medication used to treat symptoms psychosis such as delusions, hallucinations and aggression) 0.25 milligrams (mg), oral, twice (bid) per day as needed (prn) for severe aggression. The Physician Assistant (PA) for the resident's Primary Care Physician (PCP) prescribed the medication and the medication order did not include an end date. Review of subsequent Physician Orders for Risperidone 0.25 mg tablet bid prn revealed Resident #19's PCP renewed the prn anti-psychotic medication order on 6/6/26 and 7/7/26. The Risperidone order, dated 7/7/26, did not include an end date. Review of a faxed document, titled Communication to Physician, dated 6/23/26, revealed, in part, the DON reported to Resident #19's PCP that prn Risperdal (Risperidone) 0.25 mg was given 14 out of 16 days. On 8/12/26 at 11:55 AM, during an interview, the Director of Nursing (DON) reported when the facility switched over to the Electronic Healthcare Record (EHR), Resident #19's PCP no longer had access to their system. Facility staff had not been able to scan documents into the new system, and she would have to look for documentation of any healthcare practitioner visits. The DON was unaware if the resident's PCP had evaluated the appropriateness of the prn Risperidone every 14 days. On 8/12/26 at 3:45 PM, during an interview, the PCP for Resident #19 reported being unaware that the resident's order for Risperidone was prn. The PCP reported he last saw the resident about a month ago. The PCP explained he thought the resident was receiving Risperidone as a scheduled medication, and he had not been doing an evaluation of the medication every 14 days. He reported he did not know if his PA was aware and had been doing evaluations more often. The clinical record included documentation of Resident #19's PCP visits on 3/24/26 and 8/12/26. The clinical record included documentation of a healthcare practitioner visit performed by the PCP's physician assistant on 6/18/26. Each of the visits included documentation of an assessment of the appropriateness of the resident's psychotropic medications. The visit, dated 8/12/26 at 4:00 PM, included documentation, in part, the resident was on Risperidone which was started by the PA to help with the resident's aggression .if in fact it is an as needed order and she is not using it every day, it needs to be reviewed every 14 days. The clinical record lacked documentation of a healthcare practitioner's assessment of the appropriateness of the use of prn Risperidone every 14 days. 2. The Minimum Data Set (MDS) for Resident #7, dated 7/15/26, identified diagnoses of non-Alzheimer's dementia, anxiety, and depression, and indicated the use of a routine antipsychotic. The MDS listed the resident's Brief Interview for Mental Status (BIMS) a score of 01 out of 15 indicating severe cognitive impairment. A Care Plan entry, dated 7/21/2026, listed a problem of psychotropic drug use with a goal of requiring a minimum dose of medications. The 7/17/26 interventions included a drug review by the pharmacist every 6 months and as needed to recommend to the physician a dose reduction and to consult the physician regarding medication response and side effects. Review of the Active Order Set included quetiapine(an antipsychotic)25 milligrams(mg) twice daily with a start date of 6/1/25. On 7/28/26, the Pharmacist completed a drug regimen review and recommended a gradual dose reduction of quetiapine from 25 mg twice a day to 12.5 mg in the morning and 25 mg at bedtime. Review of the resident's medical records lacked documentation the facility communicated the pharmacist's recommendation to the provider. On 8/12/26 at 2:18 p.m. Staff A Registered Nurse(RN) stated the facility communicated pharmacist recommendations to the provider either through the electronic health record or fax, and would expect a response from the provider in a couple days. If the facility did not receive a response, staff should follow up again. On 8/12/26 at 2:40 p.m., the Director of Nursing (DON) stated that she expected staff to fax pharmacist recommendations to the provider for review, and if there was no response in 2-3 days, to follow up with the provider to obtain a response. The DON confirmed that there was no documentation the facility related the pharmacist recommendation with the provider. The facility Drug Regimen Review Policy, last reviewed July 2025, indicated a pharmacist would complete a monthly drug regimen review on each resident that was individualized. The facility would document irregularities on a separate form and communicate this to the resident's provider, the facility medical director and the facility DON. 3) The MDS for Resident #6, dated 6/3/26, identified chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), anxiety, depression, and indicated Hospice Care. The MDS listed a BIMS of 15 out of 15 indicating intact cognition. A Care Plan entry, dated 6/3/26, listed a problem of psychotropic drug use with a goal of requiring a minimum dose of medications. A 6/3/26 intervention directed staff to assess anxiety and the efficacy of drug therapy. Review of the Active Order Sets included haloperidol (an antipsychotic) concentrate solution 0.5 mg every 4 hours as needed for agitation, nausea, or vomiting with a start date of 7/23/26. The order did not specify a stop date of 14 days after the order. The facility lacked documentation that a provider assessed the resident 14 days after the 7/23/26 order in order to extend the medication's usage. On 8/12/26 at 2:18 p.m. Staff A stated when writing an as needed order for a medication in the antipsychotic drug class it would need to include the name of the medication, dose, frequency and a 14 day end date as the provider would need to reassess resident's need for the medication. On 8/12/26 at 2:40 p.m., the DON stated she would expect an as needed antipsychotic medication to have a diagnosis with behaviors it is treating and a 14 day end date at which time the provider would need to reassess the resident. The facility policy Long Term Care Medication Administration, last reviewed May 2026, indicated the nurse must be aware of the action and side effects of each medication she/he administered. The facility Drug Regimen Review Policy, last reviewed July 2025, stated the pharmacy consultant arranged with facility staff a review of the drug regimens for residents on hospice.

Based on clinical record review, policy review, and staff interview, the facility failed to implement care plan interventions to prevent a fall with a major injury for 1 of 3 residents (Resident #2) reviewed with a high fall risk. The facility reported a census of 34 residents.Findings include:The Minimum Data Set (MDS) assessment tool dated 4/8/26, listed Resident #2 diagnoses, which included the presence of a left artificial knee joint, osteoarthritis (inflammation of the bones and joints), and heart failure. The MDS identified that the resident depended on staff for toileting hygiene, toilet transfers, and chair transfers. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. The MDS listed an admission date of 12/29/23. The MDS documented Resident #1 discharged on 4/8/26 for a short-term hospital stay. Review of a hospital Discharge Noted dated 4/29/26, Summary of Events Leading to admission section revealed, in part.admitted to [name of hospital redacted] following a fall [NAME] resulted in a closed, comminuted, intra-articular distal femur fracture (a broken thigh bone just above the knee) adjacent to her left knee prosthesis. She underwent retrograde intramedullary nailing with cable cerclage (type of procedure completed - use of metal rod into the center of bone and wrapping of cables around outside the bone to hold fractured fragments in place) for surgical fixation on 4/10/26.Care Plan entries dated 6/3/25, revealed the resident would not sustain any bony injury from a fall and directed staff to ensure the call light was within reach. A Morse Fall scale dated 2/25/26 indicated Resident #2 at high risk for falls. Review of a documents titled Patient Event [facility name redacted] Fall Form revealed:a. On 4/8/26 the resident's call light was not in reach and she attempted to get up unassisted from the recliner. The form indicated the event occurred at 1:35 p.m. and the resident was last toileted at 7:00 a.m. Another resident's visitor called the nurse to her room and the resident was on her knees leaning towards the bed with her head resting on the bed. The resident asked where her call light was. The resident sustained a spiral fracture to the left femur (thigh bone) and transferred to the hospital. The form stated the actual or potential most likely severity of injury associated with this event was major permanent lessening of bodily functioning not related to underlying conditions. b. On 6/6/26 the resident got up unattended and her call light was not in reach. The report stated the facility re-educated staff regarding call light placement. Review of a Performance Management Memo dated 4/10/26 documented Staff A, Certified Nursing Assistant (CNA) provided care to a resident on 4/8/26 and the resident's call light was not within the resident's immediate reach following care interactions. As a result, the resident was unable to summon assistance and fell from the recliner, sustaining a major injury. Staff A received a written warning.Review of a Performance Management Memo dated 4/10/26 documented stated Staff B, Registered Nurse (RN) provided care to a resident on 4/8/26 and the resident's call light was not within the resident's immediate reach following care interactions. As a result, the resident was unable to summon assistance and fell from the recliner, sustaining a major injury. Staff B received a written warning.During an interview on 6/9/26 at 11:37 a.m., Staff A, CNA stated she assisted the resident to her chair around 9:00 a.m. on the day of the fall [4/8/26]. She stated she did not recall where the call light was when she left the room but stated staff usually clipped it to her.During an interview on 6/9/26 at 11:51 a.m. Staff B, RN stated on the day of the fall [4/6/26], another resident's visitor alerted her that the resident was on the floor. She stated the resident asked where her call light was. Staff B stated the call light was not in reach but clipped to itself (hanging down from the wall). Staff B stated the resident reported that her leg was broken. The resident left the facility for x-rays and then admitted to the hospital. Staff B stated prior to the fall she saw the resident around lunchtime when she gave her medications. She stated she didn't remember giving the resident her call light and stated she received disciplinary action due to this. During an interview on 6/10/26 at 9:44 a.m., the Director of Nursing (DON) stated on the day the resident fell [4/8/26], she did not have her call light. She stated she spoke with all individuals who took care of the resident that day and carried out disciplinary actions due to the staff not ensuring the resident had her call light.On 6/10/26 at 9:20 a.m., via email, the Administrator stated the facility did not have a written policy related to fall prevention. The facility policy Baseline Care Plan Policy, dated 8/2021, stated staff would implement interventions to assist the resident to achieve care plan goals and objectives.

Based on clinical record review, facility policy review, family and staff interview, the facility to failed to ensure they held, managed, safeguarded and accounted for resident's personal funds entrusted in the care of facility staff for 2 of 4 residents sampled (Residents #1 and #4). The facility reported a census of 35. Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 Brief Interview for Mental Status (BIMS) assessment resulted in a score of 5 out of 15, which indicated severely impaired cognition. The MDS list of diagnoses included Non-Alzheimer's dementia. The MDS indicated Resident #1 admitted to the facility on [DATE]. Review of the Care Plan, dated 6/6/25, revealed a plan to address Cognitive Loss. During an interview on 11/24/25 at 10:45 AM, the Administrator reported Staff A, former Social Services Specialist worked at the facility from June 24, 2024 to October 17, 2025. The Administrator explained that within the scope of her position, Staff A made deposits and withdraws from resident trust accounts. The Administrator explained on 10/14/2025, a family friend who assisted Resident #1 with finances questioned her about the amount of money left in the resident's trust account. The Administrator stated the family friend informed her a family member had given Resident #1 a check for $2500 in October of 2024, which Staff A cashed and then deposited in Resident #1 facility account. The Administrator stated she attempted to review Resident #1's account information on 10/14/25 and found the resident did not have aa resident trust account. Review of the clinical record revealed a lack of documentation requesting the facility manage Resident #1 monetary funds. The review also revealed a lack of quarterly account statements provided to the resident or a representative. The Administrator explained Resident #1 could not be interviewed due to a severe cognitive impairment. The Administrator stated Resident #1's family friend searched the resident's room and did not find any money. The Administrator reported she then questioned Staff A, former Social Services Specialist about Resident #1's money, and Staff A informed her Resident #1's money was at Staff A's home. The Administrator stated Staff A explained she took Resident #1's money home during a leave of absence. The Administrator explained Staff A took a leave of absence for 12 weeks between June 2025 and September 2025. The Administrator stated she asked Staff A to bring in the money when Staff A returned to work the next day (10/15/25). The Administrator reported on 10/15/25, Staff A did bring in the money and an accounting of the money. The Administrator reported she opened a resident trust account for Resident #1 with the money that Staff A returned to the facility. The Administrator stated she started her position on 12/16/24, and could not speak to the specific education Staff A, former Social Services Specialist received in regards to resident trust accounts. The Administrator explained Staff A had sole responsibility of resident accounts when she started in December of 2024. The Administrator reported she gradually had taken over managing resident accounts, but Staff A still had access. The Administrator explained the facility maintained resident trust accounts for any resident who wanted the facility to hold funds for them. The resident trust account money was accounted for on a spreadsheet. The Administrator reported Staff A had used the spreadsheet for the resident trust accounts to enter in deposits and withdrawals from residents' funds. The facility maintained the residents' funds in an account with a local bank. The Administrator reported the termination of employment of Staff A on 10/17/25. During an interview on 11/25/25 at 6:37 PM, Staff A, former Social Services Specialist, reported she had worked at the facility for 1 year and 5 months. Staff A reported having an Associates in Arts and Science Degree. Staff A described one of her duties as providing financial assistance to residents. Staff A reported getting half a day training with another social worker on her job duties and computer training on facility policies at the start of her job. Staff A denied getting any training regarding her duties related to resident trust accounts. Staff A reported she had a leave of absence from work, but was unsure of the exact dates and length of time of the absence. Staff A explained she thought she was off sometime between June 2025 and September 2025. Staff A reported that when she went to go on leave, she grabbed Resident #1's money due to having to leave her desk unlocked. Staff A explained she didn't want to leave the money unsafe. Staff A explained that she felt like she didn't have anybody to go to and she wanted to protect the money. Staff A stated that she didn't realize it should have gone in the resident trust account.2. Review of the MDS, dated [DATE] revealed a BIMS score for Resident #4 of 12 out of 15 which indicated intact cognition. The MDS indicated Resident #4 admitted to the facility on [DATE]. Review of the Care Plan, dated 9/5/24 revealed plans to address Elopement Risk, Psychosocial Well-Being, Communication and Cognitive Loss. During the interview on 11/24/25 which started at 10:45 AM, the Administrator explained that some time the week of 10/31/25, while cleaning out the office of Staff A, former Social Services Specialist, she found the checkbook that belonged to Resident #4. The Administrator reported that Resident #4 did not have a resident trust account during the time the resident resided at the facility. Per the Administrator Resident #4 admitted to the facility in August 2024 and passed away in December 2024. The Administrator stated she did not report this finding to the State Agency, or complete an investigation. The Administrator explained she had been unsure how she would determine there was anything missing from the account since the resident had passed. Review of the clinical record revealed a lack of written request by the resident or a resident representative to manage the resident funds. The clinical record also lacked documentation of quarterly statements be provided to the resident and/or resident representative. During an interview on 11/25/25 at 10:57 AM, a family member of Resident #4 reported the resident had control of his finances and debit card at first, but in the end Staff A, former Social Services Specialist had the resident's debit card. The family member stated Resident #4 wanted Staff A to hold on to his debit card because he was always losing his wallet. They explained Staff A would give the card to the resident when the family member came to take him out and the resident would save the receipts from his debit purchases and give them to Staff A, or the family would take a picture of the receipt and sent it to Staff A.During an interview on 11/25/25 at 6:37 PM, Staff A, former Social Services Specialist, reported she got involved with helping Resident #4 right from the get go. She explained Resident #4 came from another care facility. Staff A reported the resident had lost his wallet and did not come with any of his cards or driver's license. Staff A reported that she helped the resident to get a replacement Social Security card and debit card. Staff A reported she helped the resident to write out his payment for the facility's client participation, helped the resident to get clothes and helped him with anything he needed. Staff A explained the resident already had a bank account when he came to the facility. On 11/25/25 at 12:30 PM, during an interview with the Administrator and Director of Nursing (DON), the Administrator explained that she had been the previous Administrator at this facility until 5/31/24, left for 6 months, and then returned to the Administrator position on 12/16/24. The DON explained that she had been at the facility by herself administratively, as the former Administrator had oversight over two facilities. The former Administrator would come to the facility maybe once a week per the DON. Both the Administrator and DON reported being aware that Staff A had taken the resident's belongings after this death to drop off to the family. They both reported being unaware that Staff A held the resident's debit card. The Administrator reported staff should tell residents that they can't hold on to their debit cards, unless they were the payee. If facility staff were the representative payee, they would not have had a debit card for the resident, they would have used checks and the money would be deposited in a resident trust account. Both the Administrator and DON reported not having a form related to resident cremation, and thought this would have had to come from the funeral home. The Administrator reported having a family sign a financial obligation form for cremation was not a duty assigned to the facility social services specialist. On 12/2/25 at 3:32 PM, the Administrator emailed the dates of Staff A's leave of work absence, dated 6/13/25 to 9/21/25. Review of the facility policy titled Long Term Care Resident Trust Account, dated 10/29/25, revealed the Facility established, designated a Resident Trust Account with a local financial institution for designating the trust account funds for facility to manage, account for, and safeguard resident's funds. All funds will be deposited and withdrawn in a pooled account through a financial institution designated by the facility and a separate record for each individual resident will be kept on site at the facility. All deposits and withdrawals will be recorded in designated trust account management system, and receipt will be provided to resident or resident representative.

Based on observation, review of Resident Council Meeting minutes, review of Call Light Logs, clinical record review, resident, resident family member, and staff interviews, the facility failed to ensure staff responded to call lights within in 15 minutes for 5 of 5 residents reviewed for call lights (Residents #3, #15, #38, #14 and #18). The facility reported a census of 38 residents. Findings include: Review of April 2025 Resident Council Meeting minutes, dated 4/23/25, revealed the following comments: One resident mentioned that it seems as though the call light response times have improved, except on weekends. Another resident disagreed with the wait time improvement and remarked that she still has to wait for extended periods for her call light to be answered. 1. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 12 out of 15 on a BIMS exam, which indicated a moderately impaired cognition. The MDS list of diagnoses included heart failure, stroke, and urine retention. The MDS indicated Resident #3 dependent on staff for transfers to the toilet and maximum assistance with toileting hygiene. Review of the Call Light Log for Resident #3 from 5/6/2025 to 5/19/25 revealed: a. On 5/06/25, the resident's call light on for 22 minutes before staff responded. b. On 5/10/25, the resident's call light on for 19 minutes before staff responded. c. On 5/11/25, the resident's call light on for 22 minutes before staff responded. d. On 5/12/25, the resident's call light on for 21 minutes before staff responded. e. On 5/13/25, the resident's call light on for 19 minutes before staff responded. f. On 5/14/25, the resident's call light on for 38 minutes before staff responded. g. On 5/16/25, the resident's call light on for 22 minutes before staff responded. h. On 5/17/25, the resident's call light on for 1 hour and 31 minutes before staff responded. i. On 5/18/25, the resident's call light on for 1 hour and 12 minutes before staff responded. j. On 5/19/25, the resident's call light on for 23 minutes before staff responded. A continuous observation on 05/20/25 starting at 11:19 AM and ending at 11:56 AM revealed: a. At 11:19 AM, Resident #3 sat in his wheelchair at the entrance to his room. Resident #3 stopped Staff A, Certified Nurses Aide (CNA) in the hall and requested assistance with going to the toilet. Staff A told Resident #3 she would come back with the machine [mechanical lift device] and another staff to transfer the resident. b. At 11:25 AM, Resident #23 stopped and ask Resident #3 if he needed something. Resident #3 said he needed to use the toilet. Resident #23 stopped Staff B, CNA, and told Staff B that Resident #3 needed assistance. Staff B, CNA said that she knew and staff were coming. Staff B said that she had to go check on the alarm and walked to the west hallway to the sound of an alarm. c. At 11:27 AM, Staff B, CNA went by Resident #3 and said staff were coming. Resident #3 reiterated that he had to go to the toilet. d. At 11:29 AM, Staff C, Housekeeper, walked by Resident #3 who continued to sit in his wheelchair at the entrance to his room. Staff C asked Resident #3 if he was going to go to lunch. Resident #3 responded that he was waiting for staff to help him, and that he had been waiting for 20 minutes. e. At 11:33 AM, Staff B, CNA, informed Staff D, CNA, that she was going on break. Staff B, CNA, told Staff D, CNA, that she could help, but had not had a break yet. Staff D, CNA, told her to go ahead and go on break. f. At 11:36 AM, Staff D, CNA, asked Staff A over a communication device to meet her in Resident #3's room. Staff D, CNA then saw Resident #28 walking down the hallway with her walker, and stopped to help Resident #28 into her room. Staff D entered the room with Resident #28 and shut the door. g. At 11:40 AM, Staff A, CNA, pushed a resident in their wheelchair down the hall to the dining room. Staff D, CNA, came out of Resident #28's room and went down the west hall. h. At 11:41 AM, Staff D, CNA, came down the hall with a stand lift and entered Resident #3's room with Staff A, CNA. Resident #3 waited 22 minutes for assistance. f. At 11:44 AM, Staff A, CNA, exited Resident #3's room and told Staff D, CNA, to let her know when the resident was ready to transfer back to the wheelchair. She confirmed that she just helped transfer Resident #3 to the toilet. g. At 11:56 AM, Staff D, CNA, and Staff A, CNA exited Resident #3's room. Staff D, CNA, reported Resident #3 was continent and had used the toilet to urinate. 2. Review of the MDS Significant Change in Condition assessment dated [DATE], and the Quarterly MDS assessment dated [DATE], revealed Resident #15 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS assessment dated [DATE], identified a diagnosis of congestive heart failure and that Resident #15 required partial to moderate assistance with toilet transfer, walking 10 or more, and personal hygiene. The MDS dated [DATE], assessed that the resident independent with toileting, personal hygiene, and mobility. Review of the Care Plan dated 2/14/25, included an intervention to provide assistance of one staff with a gait belt and walker with transfers and ambulation. The Care Plan dated 5/16/25, included an intervention for staff to supervise the resident during ambulation while in the hallway with her walker, and the resident was independent for transfers and ambulation in her room with her walker. Review of the call light system log for Resident #15, dated 5/10/25 to 5/11/25, revealed the following: a. On 5/10/25, the resident's call light on for 34 minutes before staff responded. b. On 5/11/25, the resident's call light on for 31 minutes before staff responded. During an interview on 05/19/25 at 11:06 AM, Resident #15 reported concerns with the length of time it took staff to answer the call light. She explained that sometimes it took staff up to an hour to answer regardless of the time of day, or day of the week. Resident #15 reported she has timed it, and had to wait 42 minutes two days in a row. Resident #15 explained she had reported call light concerns to the Director of Nursing (DON). Resident #15 explained staff would sometimes come into her room, cancel the call light button, tell Resident #15 that they would be right back, and then not come back for up to an hour. Resident #15 reported staff always complain of being short-staffed. Resident #15 explained that she was independent in going to the bathroom and transferring to the toilet now, but a couple months ago, she needed help. A couple months ago, staff left her in the bathroom [ROOM NUMBER] to 40 minutes. Resident #15 explained that she got tired of waiting for staff to come back, and ended up walking by herself back to her bedroom. She was not supposed to walk by herself at that time, because she recently had a fall. During an interview on 5/21/25 at 2:24 PM, Staff E, Registered Nurse (RN) explained that when the residents activated the call light system, all staff received a notification on their work phone and any staff could respond. Whoever responded to the call light would go to the resident's room and shut the call light prior to assisting the resident with whatever task they needed. Staff E, RN, had not heard of any staff going to the residents' rooms, shutting off the call light and then telling the resident they would be back. When asked if she was aware of any residents having to wait more than 15 minutes for their call light to be answered, Staff E, RN, was not sure. Staff E reported that sometimes days ran smoother than others, and sometimes they could use more staff due to issues going on with residents. During an interview on 5/21/25 at 2:30 PM, Staff F, Certified Nurses Aide (CNA), reported she worked third shift and also picked up second shifts. Staff F, CNA, explained that when a resident used their call light, any staff could respond to help the resident no matter what hall facility management had assigned them. Once a staff person indicated they accepted the call light, all other staff received a phone notification which identified which staff person responded. Staff then went to the resident's room and reset the call light button, assisted the resident, marked complete on their phone and documented the reason for the call light. Staff F, CNA, reported she had responded to residents' call lights, went to the room and shut the light off, and then told the resident that she would be back. Staff F, CNA, explained that she would shut of the call light, because the call lights were timed. Staff F, CNA, reported the busiest times were in the morning when everyone was trying to get up and after dinner when everyone wanted to go to bed. Staff F, CNA, explained that residents that needed assistance with transfers, but could wheel themselves to their rooms, might have to wait awhile, longer than 15 minutes, to get assistance. Staff F, CNA, further explained that staff had to clear the dining room of residents first before assisting residents with cares due to risks of choking hazard and falls. During an interview on 5/21/25 at 2:36 PM Staff G, CNA, reported she worked on second shift. Staff G, CNA, reported that she has answered residents' call lights, reset the call light, and told the resident she would be back. Staff G, CNA, explained that if she was busy trying to help other residents, and if the resident needed to go to the bathroom, she would assist the resident, but if they only needed something like water, she would tell them she would be back. Staff G, CNA, reported the busy time in the evening was right after dinner, because everyone wanted to go to bed. Staff G, CNA, explained sometimes people had to wait for assistance while staff got everyone out of the dining room. Staff G, CNA, did not know how long residents had to wait. During an interview on 05/22/25 at 11:24 AM, Staff I, CNA, reported she worked day shift and had worked at the facility for about 18 years. She reported that staff response time to call lights was usually really quick. Staff I reported after lunch was the busiest time. There were some residents that might have to wait a while for assistance while staff got everybody out of the dining room, but Staff I still did not think that the call light response time was very long. Staff I reported that she had not gone to a resident's room and shut the call light off without helping the resident, unless the resident denied that they needed help right away and said they could wait. If the resident could wait, Staff I explained she would shut the call light off and she would get back to that resident as quickly as possible. 3. The MDS assessment dated [DATE] revealed Resident #38 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS indicated the resident needed substantial/maximal assistance with toileting hygiene and needed partial/ moderate assistance with personal hygiene, lower body dressing, and put on and taking off footwear. During an interview on 5/19/25 at 11:09 AM, Resident #38 queried on the call light response and he stated sometimes it took 40 minutes. Resident #38 asked how that made him feel and he stated he would get upset, especially when he needed assistance with his ostomy. Review of the Call Light Log for Resident #39 from 5/6/25 to 5/19/25 revealed: a. On 5/06/25, the resident's call light on for 23 minutes before staff responded. b. On 5/07/25, the resident's call light on for 1 hour and 23 minutes before staff responded. c. On 5/08/25 at 8:08 AM, the resident's call light on for 20 minutes before staff responded. d. On 5/08/25 at 10:15 AM, the resident's call light on for 26 minutes before staff responded. e. On 5/09/25, the resident's call light on for 22 minutes before staff responded. f. On 5/11/25, the resident's call light on for 20 minutes before staff responded. g. On 5/12/25, the resident's call light on for 1 hour and 16 minutes before staff responded. h. On 5/13/25, the resident's call light on for 25 minutes before staff responded. i. On 5/15/25, the resident's call light on for 28 minutes before staff responded. j. On 5/16/25, the resident's call light on for 1 hour and 29 minutes before staff responded. k. On 5/17/25, the resident's call light on for 32 minutes before staff responded. l. On 5/18/25, the resident's call light on for 44 minutes before staff responded. m. On 5/19/25, resident's call light on for 1 hour and 2 minutes before staff responded. 4. Review of the MDS assessment dated [DATE], revealed Resident #14 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS indicated impairment in one upper extremity and both of the lower extremities. The MDS revealed substantial/maximal assistance with toileting hygiene, upper and lower body dressing. The MDS revealed the resident required partial/moderate assistance with sitting to stand; chair/bed to chair transfer, and toilet transfer. The MDS indicated resident occasionally incontinent of urine. The MDS indicated medical diagnoses for unspecified osteoarthritis and spinal stenosis. The MDS revealed the resident took a diuretic. During an interview on 5/19/25 at 9:45 AM, Resident #14 queried on call light response and she stated she puts her light on at a quarter til 7 in the morning and waited at least a half an hour for assistance. Resident #14 stated the day before, she waited almost an hour for someone to answer her call light after one of her meals. Resident #14 stated there were times she didn't make it to the bathroom on time because she had to wait for staff to come and help Resident #14. Resident #14 stated she didn't like being helpless and needing help. Resident #14 stated she knew how long she had to wait because she looked at her watch to see how long it took. Review of the Call Light Log for Resident #14 from 5/7/25 to 5/19/25 revealed: a. On 5/07/25, the resident's call light on for 21 minutes before staff responded. b. On 5/10/25, the resident's call light on for 28 minutes before staff responded. c. On 5/11/25 at 7:15 AM, the resident's call light on for 24 minutes before staff responded. d. On 5/11/25 at 10:12 AM, the resident's call light on for 29 minutes before staff responded. e. On 5/15/25, the resident's call light on for 25 minutes before staff responded. f. On 5/16/25, the resident's call light on for 37 minutes before staff responded. g. On 5/18/25, the resident's call light on for 51 minutes before staff responded h. On 5/19/25, the resident's call light on for 26 minutes before staff responded. 5. Review of the MDS assessment dated [DATE], revealed Resident #18 scored a 6 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS indicated impairment on one upper and lower extremity. The MDS revealed resident dependent with toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, roll left to right; sit to lying, lying to sitting on bedside, sit to stand, and chair/bed to chair transfer. The MDS indicated resident always incontinent of bowel and bladder. The MDS revealed medical diagnoses of non-Alzheimer's dementia. During an interview dated 5/19/25 at 10:14 AM, a family member of Resident #18's queried about call light response and she stated she thought the facility was short staffed because sometimes Resident #18 waited 40 minutes for help. The family member stated it upset her and Resident #18 waiting for assistance. The family member stated she looked at her watch to know how long Resident #18 waited. Review of the Call Light Log for Resident #18 from 5/11/25 to 5/12/25 revealed: a. 5/11/25, the resident's call light on for 42 minutes before staff responded. b. 5/12/25, the resident's call light on for 39 minutes before staff responded. During an interview on 5/22/25 at 1:53 PM, the Director of Nursing (DON) stated the facility put in a new call light system and she didn't believe all the times on reports were correct. The DON stated if a staff member clicked they would answer the light, that staff member was the only person who could close it on the system. The DON stated call lights were always a topic at the all staff meetings. The DON stated she printed off the call light reports for the staff to review. The DON stated call lights discussed at the resident council and the DON and the Administrator attended the meeting and explained the new system to the residents. The DON stated she encouraged the residents to push their call light if staff turned it off and said they would be back. The DON stated she received complaints from the residents about call light response during care conference meetings. The DON stated the she expected the call lights to be answered within 20 minutes. During an interview on 5/22/25 at 2:25 PM, the Administrator stated they were talking about developing a Quality Assurance Performance Improvement (QAPI) for call lights because they were an issue. The Administrator confirmed the call lights are on longer than they should and the residents discussed it at resident council. Per email from the DON on 5/22/25 at 3:38 PM, the facility lacked a policy for call lights.

Based on clinical record review, receiving facility staff interview, and discharging staff interviews the facility failed to provide an accurate representation of a resident's behaviors and to ensure discharge needs are identified within the discharge planning process for one of one residents (Resident #1) reviewed. The facility reported census was 36. Findings include: The Minimum Data Set (MDS) dated [DATE], included an incomplete Brief Interview for Mental Status (BIMS). The BIMS is used to determine cognitive status. Section C, for Cognitive Patterns indicated Resident #1 had short term and long term memory problems, and moderate impaired cognitive skills for daily decision making. Section E, for Behavior indicated Resident #1 wandered daily; and wandering significantly intruded on the privacy or activities of others. Section E indicated Resident #1 did not display hallucinations or delusions. The MDS documented Resident #1 independent with transfers and ambulation. The MDS list of diagnoses included: non-Alzheimer's disease, anxiety disorder, and depression. The Care Plan, dated 9/11/24 included a plan to address LTC (long term care) Elopement Risk. Interventions included, in part; Code Alert Bracelet on My Wrist or Ankle, Staff Will Keep Areas Safe for Me When I Am Wandering. The Care Plan also included a plan to address LTC Behavioral Symptoms, and a plan to address LTC Delirium. During an interview on 12/23/24 at 12:50 p.m., Staff A, Certified Nurse Aide (CNA), stated Resident #1 was confused and would wander into other resident rooms and may get in their bed or use their bathroom. Resident #1 was easily redirected, but the behavior was almost constant while awake. During an interview on 12/23/24 at 1:25 p.m. Staff B, CNA stated resident Resident #1 would often wander into other resident's rooms and beds and was difficult to get out. Resident #1 would exit seek and wore a wander guard. During an interview on 12/23/24 at 4:05 p.m. Staff D, Social Worker, stated they had accepted some residents from a closing facility on an emergency basis with no intention of keeping them permanently. Staff D stated she put out faxed referrals to facilities and called some. One local facility voiced an interest. Staff D was queried whether family was involved in the decision to transfer and she stated she was uncertain. Staff D was then queried what information was shared with the facility, specifically to Resident #1's behaviors. Staff D stated she knew Resident #1 wandered, but was unaware of him going into other resident rooms. During an interview on 12/23/24 at 4:50 p.m. the Director of Nursing (DON) stated their organization took 14-16 residents when another facility closed unexpectedly. Two of those residents, including Resident #1, ended up at their facility. Both residents had been on a memory care unit and were not suitable for their environment, so they quickly started looking for placement. The DON recalled another facility showing interest and remembered briefly meeting with their Director of Nursing. The DON stated Resident #1 was hard of hearing and wandered, but was easily redirected. The DON was not aware of Resident #1 frequently entering other resident rooms. The DON stated she had visited with the family and discussed finding Resident #1 a suitable living place. The DON stated she thought the layout of the other facility, which did not have a memory care unit, would be more suitable for Resident #1. During an interview on 12/23/24 at 3:00 p.m. the Director of Nursing at the receiving facility stated she made an on-site visit to see Resident #1 prior to accepting him to their facility. The receiving facility Director of Nursing stated Resident #1 was presented as a resident from another facility that had closed and who had no significant behaviors. The day of the visit, Resident #1 was laying in his bed watching TV. The Social Worker, Staff D stated this is all he does. Staff D stated he wanders some and has a wander guard, but does not exit seek. Staff D never disclosed Resident #1's behavior of going into other resident rooms. Upon arrival at their facility on 9/25/24, Resident #1 immediately started following female residents into their rooms and required frequent redirection to the point of 1:1 supervision within the first 24 hours of admission. They were able to get family to come in and help and within two days found a more suitable placement to address Resident #1's supervision needs.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure timely follow-up completed in response to Medication Regimen Review recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident #24). The facility reported a census of 34 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 5/15/24 revealed the resident was rarely to never understood, and took hypnotic medication. The Care Plan dated 10/1/23 titled LTC Psychotropic Medication Use revealed the following intervention: Monitor for adverse reactions r/t (related to) temazepam, quetipine, trazodone. The Physician Order First Dose Date/Time dated 12/4/2023 at 9:00 PM revealed an order for Temazepam 7.5 mg (milligram) oral cap at HS (night). Review of the Phone Message/Call Note dated 3/31/24 at 3:59 PM revealed, in part, the following: In December, the dose of temazepam was successfully decreased to 7.5 mg daily at bedtime. There have been some behaviors during the day time with agitation and crying and it looks like nursing has successfully utilized non pharmacological measures most of the time with success. Would you like to try reducing the temazepam 7.5 mg HS to PRN (as needed) for 2 weeks and see if the patient still requires this medication? Please indicate one of the following: 1) New dose and directions for medication; or 2) Denial of reduction because resident's function will be impaired, cause increased distress, or exacerbate and underlying psychiatric disorder. 3) Any new medications or behavior interventions to be tried. On 7/24/24 at 3:18 PM, the following requested via email from the facility's RN (Registered Nurse) Manager: Physician response to the pharmacist recommendation made on 3/31/24 for Resident #24. On 7/24/24 at 3:38 PM, the RN Manager responded via email that she did not see where he responded to the request. The Phone Message/Call Note dated 5/23/24 at 6:13 PM revealed, I sent a communication about possibly decreasing the temazepam to 7.5mg at bedtime to PRN and see if she still needs it scheduled and I just didn't see a response. Did Dr.[Name Redacted] get back to us? The response per the RN Manager, present in the same note and dated 5/28/24 at 12:51 PM revealed, No we have not. During an interview on 7/25/24 at 9:29 AM, the RN Manager when queried about physician response to the recommendation, responded it would ideally be 24 to 48 hours for physician response. Review of the Facility Policy titled Drug Regimen Review Policy, origination date 8/19/21, revealed the following: The attending provider will document in the resident record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record.

Based on the clinical record review, interviews, and the facility policy, the facility failed to implement interventions prior to the administration of an antianxiety medication, and failed to attempt a gradual dose reduction for a resident on an antidepressant for 2 of 5 residents reviewed for unnecessary medications (Resident #19 and Resident #21). The facility reported a census 34 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely or never understood. The MDS revealed the resident wandered 4 to 6 days out of the last 14 day look back period. The MDS revealed the resident took antipsychotics, antianxiety, and antidepressants. The Care Plan, initiated on 6/10/24, for LTC Behavioral Symptoms IPOC (Interdisplinary Plan of Care) included Interventions to: provide care with smile, gentle touch, voice, reassurance; evaluate for signs of pain during care and intervene prior to giving care; evaluate usual time, duration, and frequency of behavior, evaluate medications for desired and adverse outcomes; offer redirection;diversions as appropriate. The Care Plan, initiated on 10/31/23, for LTC Psychotropic Medications Use IPOC included Interventions to: maintain a safe environment; monitor/report side effects; adverse reactions/related to quetiapine use and monitor/report adverse effects related to fluoxetine or lorazepam use. A review of the clinical record revealed the following Physician Order: a. lorazepam 0.5 mg (milligram) BID (twice daily) PRN anxiety, First Dose: 9/26/23. Diagnosis: unspecified dementia, unspecified severity, with other behavioral disturbance A review of the MAR (Medication Administration Record) documented lorazepam 0.5 mg administered on: a. 6/23/24 at 8:14 PM b. 6/26/24 at 7:09 PM c. 6/26/24 at 8:22 PM d. 7/4/24 at 7:01 PM e. 7/6/24 at 5:19 PM f. 7/15/24 at 8:05 AM A review of Progress Notes, and the Behaviors and Behavioral Management interactive view lacked documentation for non-pharmalogical interventions used prior to the administration of lorazepam 0.5 mg twice daily as needed for the following: a. 6/23/24 at 8:14 PM b. 6/26/24 at 7:09 PM c. 6/26/24 at 8:22 PM d. 7/4/24 at 7:01 PM e. 7/6/24 at 5:19 PM f. 7/15/24 at 8:05 AM During an interview on 7/24/24 at 3:59 PM, Staff A, RN (Registered Nurse) stated before she gave lorazepam for anxiety she went into the computer and documented the interventions she tried prior to administration. Staff A stated the interventions were either documented under the progress notes or a specific tab that she checked the specific interventions tried prior to administration. During an interview on 7/24/24 at 4:09 , Staff B, RN stated they needed to try at least 3 interventions prior to administration of lorazepam and documented under a specific tab in the EMR and clicked the interventions they tried. Staff B stated at time Resident #19 displayed behaviors such as arguing with other residents or getting up and sitting down which could be a safety concern. During an interview on 7/25/24 at 9:25 AM, the DON (Director of Nursing) stated she expected staff to do 3 interventions and chart them before they gave the medication. During an interview on 7/25/24 at 11:06 AM, the DON stated she didn't see any interventions completed on the dates provided to her prior to the lorazepam administered. The DON stated some of the nurses better than others at documenting the interventions and now they had a charge nurse who oversees the process to make sure the interventions are tried and charted prior to the medication being administered. The DON stated it was an ongoing process. 2. The MDS dated [DATE] revealed Resident #21 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. The MDS included a diagnosis of depression. The MDS listed Resident #21 prescribed an antipsychotic and antidepressant. The Care Plan, initiated on 10/17/23 for LTC Mood State IPOC included an intervention to monitor for signs and symptoms of depression. A review of the clinical record revealed the following Physician Orders: a. Escitalopram (antidepressant) 10 mg tablet take every PM, first dose 9/27/23. b. Mood/ behavior assessment, ordered on 5/11/24 at 5:00 PM, BID, on psychotropic therapy The facility lacked documentation for the any attempted GDR for escitalopram 10 mg. Per an email [from the DON] dated 7/25/24 at 9:07 AM, the DON spoke to the pharmacist and the pharmacist stated she included all antipsychotic medications in the note. The pharmacist stated she attempted to reduce or discontinue the antipsychotic before the antidepressant. The pharmacist stated she must of missed adding the escitalopram to the note in March. During an interview on 7/25/24 at 9:23 AM, the DON stated she spoke to the pharmacist and the pharmacist thought she missed putting the escitalopram on the GDR progress note. Per an email [from the DON] dated 7/25/24 at 10:28 AM, the DON stated she couldn't locate a request for a dose reduction for Resident #21 for the escitalopram. Per an email [from the DON] dated 7/25/24 at 10:46 AM, the DON stated Resident #21 started the escitalopram on 5/8/23. During an interview on 7/25/24 at 10:59 AM, the DON stated the thought the GDR were completed every 3 months but she wasn't sure because the pharmacy took care of all that. The Facility Psychotropic Medication Policy dated 8/31/23 revealed the following: a. Based on individualized assessment, determined non-pharmalogical approaches that could be implemented prior to use of the psychotropic medication. Documentation will reflect attempts to implement care planned, non pharmacological approaches and ongoing effectiveness of these interventions. b. Within the first year the resident admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt 2 GDR in the first year in separate quarters (with at least one month between them) unless clinically contraindicated.

Based on clinical record review, policy review and staff interviews, the facility failed to provide transfers using mechanical lifts in a dignified, and respectful manner for 2 of 3 residents reviewed (Resident #1 and Resident #4). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 2/14/24, revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS revealed the resident required substantial/maximal assistance with lying to sitting on the side of the bed and chair/bed to chair transfers. The MDS revealed the resident required partial/moderate assistance with rolling from left to right and sitting to lying. The MDS revealed medical diagnoses of generalized muscle weakness and cerebral vascular accident (CVA), transient ischemic attack (TIA), or stroke. The Care Plan revealed a focus area for Activity of Daily Living (ADL) mobility dated 9/22/23. The interventions (no date provided) included providing assistance to support level of need; encouraging, cueing, and prompting to participate in ADLs; and up with assistance of 1 with the gait belt and walker. 2. The Facility BIMS list revealed Resident #4 scored a 11 out of 15 on the BIMS exam on 12/20/23, indicating moderately impaired cognition. The Care Plan revealed a focus area of ADL Mobility dated 10/1/23. The interventions (no date provided) included assist of 2 with brown hoyer [mechanical lift]. During an interview on 5/13/24 at 12:33 PM, Staff A, Certified Nursing Assistant (CNA) stated she witnessed a transfer from a wheelchair to the Sara Steady [brand name of a type of mechanical life which helps a person move from sitting to standing] with Staff B, CNA and Staff C, CNA. Staff A stated Staff C stood Resident #1 up by the pockets of his pants and Staff B then put the flaps [two flaps provide a seat when lowered] down. She stated Staff C then moved Resident #1 to the bed and grabbed Resident #1 again by the pant pockets and pulled him forward, Staff B moved the flaps up, and told him to let go of the machine, but Staff C grabbed Resident #1 by the wrists with both hands and pushed him back and he landed on the bed. Staff A stated Staff B caught him on his back and lowered him down. Staff A stated that is when she walked out of the room. During an interview on 5/14/24 at 8:57 AM, Staff B stated she and Staff C went to lay Resident #1 in bed and they decided to use the Sara Steady [mechanical lift] to help him because the resident was kind of shaky earlier in the morning. Staff B stated the resident had trouble grabbing the bar, so Staff C grabbed him by the wrist and yanked him to the bar and counted to three. Resident #1 had issues getting up so Staff C grabbed his pants and yanked him up using his pants. Staff B stated they moved the wheelchair out of the way and then moved the Sara Steady out of the way after the resident sat on the bed. Staff C swung his legs on to the bed. Staff B stated the resident didn't roll the best, but he wanted to roll and Staff B tried to help him, but Staff C told the resident to roll and then said roll again and then Staff C proceeded to roll him again. Staff B stated the roll wasn't gentle but not forceful, but she got him to roll. Staff B stated Resident #1 appeared upset after and kept apologizing like he did something wrong. Staff B stated she transferred Resident #4 with the mechanical lift with Staff C another time. During that transfer, Staff C pushed the emergency button and Resident #4 plopped into her chair. Staff C stated the resident was probably a foot off the chair when the emergency button was used. Staff C stated she never saw someone use the emergency button before to get someone down faster. During an interview on 5/14/24 at 2:34 PM, Staff C stated she used the emergency brake when she did mechanical life transfers because the emergency brake would just drop them. She stated Resident #4 pulled down and kicked her feet and tried to put her feet down and when they lowered her the mechanical lift tipped and they complained it was hard on their back so when they would get her above the chair, they slowly ease her down with the brake and then pull the red button when she was approximately 3 or 4 inches from the chair and it would release her. Staff C stated Staff G, CNA done it a lot that way. Staff C stated she worked with Staff H, CNA and when Staff H did mechanical lift transfers she dropped the residents in the air all the time. During an interview on 5/15/24 at 10:33 AM, Staff D, CNA stated the staff shouldn't use the emergency brake with mechanical lift transfers. Staff D stated Staff G used it one time with her when they transferred Resident #4 in the mechanical lift. Staff D stated she told Staff G not to do it again. Staff D stated staff used the emergency brake with Resident #4 because of her weight and the emergency stop hurried up the transfer. Staff D stated the arm of the mechanical lift drops and almost hit the resident in the head because it got really close to the resident's face when you use the emergency stop. During an interview on 5/16/24, Staff E, CNA stated everyone knew Staff C had been rough. Staff E stated one time she worked with Staff C for a two person pivot transfer and Staff C turned the resident so fast, Staff E almost tumbled onto the resident. Staff E stated she told Staff C to go slower. Staff E asked how Staff C took the information and she stated she felt the information went right through Staff C head. Staff E asked if she ever saw staff use the emergency brake when doing mechanical lift transfers and she stated one time she worked with Staff G, CNA and they used it on Resident #4. Staff E stated they were not supposed to use the emergency brake when transferring residents. During an interview on 5/16/24 at 10:00 AM, Staff F, CNA stated she witnessed Staff C push a resident onto the toilet during a transfer. Staff F stated she gave Staff C a look and turned and walked away and told the nurse the next day. During an interview on 5/16/24 at 1:32 PM, the Director of Nursing (DON) stated she was shocked about the incident with Staff C. She stated no one said anything else about Staff C. The DON stated she came to the conclusion Resident #1 wasn't treated appropriately and if Staff C could treat the residents like that around coworkers, what was she doing when she took care of the residents by herself. The DON stated they knew they needed to report the incident and couldn't keep Staff C at the facility, so they terminated her. During an interview on 5/16/24 at 1:32 PM, the DON stated the emergency brake should not used with mechanical lift transfers, unless something malfunctioned. The Facility Resident's [NAME] of Rights (no date indicated) revealed the following: a. Resident's Rights: The resident had a right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside the facility. 1. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. b. Planning and Implementing Care: The resident had a right to be informed of, and participate in, his or her treatment 1. The right to receive the services and/or items included in the plan of care. 2. The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. c. Safe Environment: The resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The EZ Way Smart Lift [specific brand of mechanical lift at the facility] Operator's Instructions dated 8/10/18 revealed the following: a. Lower patient into the wheelchair, toilet, or chair. 1. Position the wheelchair under the resident and lock the wheels of the wheelchair. If transferring the resident to the chair or toilet, position the resident over the chair or toilet. Use the handles located on the back of the sling, position the resident so he/she properly aligned to be lowered to the chair, toilet, or wheelchair. 2. Push the down bottom on the hand control. 3. Stand behind the resident and hold onto the center handle located on the back of the sling 4. When the resident's weight supported by the wheelchair, chair, or toilet, continue lowering the lift to release the tension on the loops.

Based on clinical record review, policy review and interview, the facility failed to report a staff to resident alleged assault within the required 24 hour time frame for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 34 residents. Findings include: A review of a Facility Reported Incident revealed a submission date of 4/12/24 at 4:02 PM for an allegation of abuse that occurred on 4/9/24 at approximately 1:00 PM. The incident summary revealed Staff A, CNA (Certified Nurse Aide) came to the DON (Director of Nursing) on 4/9/24 and stated that during a transfer she observed Staff C, CNA grab the resident by the waist band and pull him up from the wheelchair. She stated once the paddles [two paddles that when lowered form a seat] on the lift were in place, Staff C let go of the resident and then he flopped down onto the paddles [seat]. When transferring Resident #1 to bed, Staff C told the resident to stand up. Resident #1 stated he was trying and to give him a minute. Staff C then leaned forward and grabbed the resident by the pockets of his pants to stand him. Staff A reported Staff B, CNA assisted in the room and she moved the paddles from behind the resident, Staff C then let go of the resident and let him fall back onto the bed. Staff C then took the resident by the hand/wrist and removed his hands from the lift. Staff B reported that Staff C was rough with residents in the way of not telling the resident what was happening or guiding them, or counting to three. When using a mechanical lift, Staff B witnessed Staff C transfer residents and placed them on top of the bed or chair and use the emergency button to lower them instead of using the control to lower them. During an interview on 5/13/24 at 12:33 PM, Staff A, CNA stated she reported the incident she witnessed with Resident #1 to the DON an hour after it happened. During an interview on 5/14/24 at 8:57 AM, Staff B, CNA stated she reported the incident that occurred with Resident #1 to the DON the day after it happened. During an interview on 5/16/24 at 1:32 PM, the DON confirmed she didn't report the alleged abuse in a timely manner. She stated it needed to be reported within 24 hours. She stated one of the witnesses should of came to her as soon as the incident occurred. The Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 3/27/24 revealed the following information: a. Allegations of resident abuse needed reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, the Administrator, or designated representative. b. If a staff member or employee required to make a report pursuant to this section, the staff member or employee shall immediately notify the person in charge or the person's designated agent who shall then notify the Iowa Department of Inspections and Appeals immediately and in no event later than 24 hours of any allegations, even on a weekend or holiday.

Based on clinical record review, policy review, and staff interviews the facility failed to thoroughly investigate a staff to resident alleged abuse for 1 of 3 residents reviewed for abuse (Resident #1). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 2/14/24, revealed Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS revealed the resident required substantial/maximal assistance with lying to sitting on the side of the bed and chair/bed to chair transfers. The MDS revealed the resident required partial/moderate assistance with rolling from left to right and sitting to lying. The MDS revealed medical diagnoses of generalized muscle weakness and cerebral vascular accident (CVA), transient ischemic attack (TIA), or stroke. The Care Plan revealed a focus area for Activity of Daily Living (ADL) mobility dated 9/22/23. The interventions (no date provided) included providing assistance to support level of need; encouraged, cued, and prompted to participate in ADLs; and up with assistance of 1 with the gait belt and walker. The Self Report revealed submission date of 4/12/24 at 4:02 PM for an allegation of abuse that occurred on 4/9/24 at approximately 1:00 PM. The incident summary revealed Staff A, CNA (Certified Nurse Aide) came to the DON (Director of Nursing) on 4/9/24 and stated that she observed Staff C, CNA transferring the resident. Staff A stated she observed Staff C grab the resident by the waist band and pulled him up from the wheelchair. She stated once the paddles on the lift were in place, Staff C let go of the resident and then he flopped down onto the paddles. Resident #1 transferred to bed and Staff C told the resident to stand up , and Resident #1 stated he was trying and to give him a minute. Staff C then leaned forward and grabbed the resident by the pockets of his pants to stand him. Staff B, CNA assisted in the room and she moved the paddles from behind the resident , Staff C then let go of the resident and let him fall back onto the bed. Staff C then took the resident by the hand/wrist and removed his hands from the lift. Staff B reported that Staff C was rough with residents in the way of not telling the resident what was happening or guiding them, or counting to three. When used a Hoyer lift, Staff B witnessed Staff C transfer residents and placed them on top of the bed or chair and used the emergency button to lower them instead of using the control to lower them. The Staff A Witness Statement dated 4/11/24 revealed on 4/9/24, Staff A walked into a resident's room to tell another CNA she given the nurse the weights they needed. When Staff A went into Resident #1 room Staff C and Staff B were in the process of doing a transfer using the Sara Steady [type of mechanical lift] and Resident #1 had a hard time standing so Staff C leaned forward and grabbed his pants at the hips to pull him forward, when Staff B put the flaps [two flaps when put down form a seat] down, Staff C let go of Resident #1 and he fell backwards onto the lift. They moved him from the wheelchair over to the bed. Staff C kept telling Resident #1 to stand up and hold on to the lift. Resident #1 was really shaky and having a hard time and Resident #1 said he was trying and to give him a minute. Staff C got frustrated and leaned forward and when Staff B moved the flaps, Staff C let go of Resident #1 and he fell back onto the bed without being lowered because Staff B didn't have time to put her hands on Resident #1. Staff C then grabbed Resident #1 hand/wrist and jerked his hands off of the lift and Staff B had Resident #1 upper half supported as the lift moved and Staff A left the room. Staff A reported to the DON because Staff C was so rough and Staff A thought Resident #1 would have bruises because the resident was so fragile. The Staff B Witness Statement dated 4/11/24, revealed on 4/9/24, Staff C and Staff B went to go lay down Resident #1. Resident #1 very unsteady and shaky in the morning, so we decided to use the Sara Steady for transfers. Staff B and Staff C counted to three and got him stood up and Resident #1 had trouble standing up enough to get the pads under his butt so Staff C proceeded to grab his pants and yank him up to be placed on the pads. They got him moved in front of his bed, Resident #1 stood up to be sat down on the bed. Once the resident sat down on the bed, Staff C grabbed his wrist and yanked then off of the bar on the lift. Staff B moved the lift out of the way and she grabbed his legs with no warning and tossed them into bed. Resident #1 needed check and changed so Staff B got the stuff ready and Staff C looked at Resident #1 and told Resident #1 to roll, Staff C said roll and then proceeded to roll Resident #1 herself. Both CNAs changed him and when it was time to roll back towards us, Staff C rolled Resident #1 without warning. Resident #1 kept apologizing like it was his fault. Staff C was very rough with the resident. While doing a lot of the Hoyer transfers, she waited until the resident placed either on top of the bed or chair and used the emergency drop. When Staff C completed regular transfers, she rarely let the resident know what she did and didn't count to three. When Staff C sat the residents, she didn't wait patiently and sat them down as soon as they were close to the bed. The Progress Notes lacked documentation of an assessment after the alleged incident that occurred on 4/9/24. The Facility lacked documentation for any other staff or residents interviewed pertaining to the incident that occurred on 4/9/24. During an interview on 5/14/24 at 1:50 PM, the DON stated if she would of known about the incident immediately she would of removed Staff C. She stated when she found out about the incident, Staff C already left the building, so she looked at the schedule to see when her next workday was and knew she had a few days to investigate. The DON stated she assessed Resident #1 wrists and didn't see anything. She stated she didn't chart it. She stated she spoke with the Assistant Administrator and they knew they needed to report the incident. During an interview on 5/15/24 at 4:35 PM, the DON stated she didn't have any additional notes from the investigation and the facility didn't interview any additional staff or residents after the incident. The Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 3/27/24 revealed the following information: a. Should an incident or suspected incident of resident abuse be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. b. The Administrator or designee completed documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident. c. The investigations should include consideration of the following, based on circumstances of the allegations as applicable: 1. Review the completed documentation of the allegation of resident abuse 2. Review the resident's medical record to determine events leading up to the incident 3. If there is an indication of injury has or may have occurred, a physical assessment must be completed by the DON or charge nurse immediately. 4. Documentation of any physical assessment conducted will be made in the resident's medical record and a copy of this documentation included in the abuse investigation file 5. The DON or designated nurse notified the resident's attending physician of the alleged incident. The responsible family member or responsible party, as documented in the resident's chart notified of the incident and advised of the status of the investigation and the actions and reporting being taken. 6. Interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident. 7. Interview the resident's roommate, family members, and visitors as appropriate. 8. In circumstances where the allegation involves an employee, interview other residents to whom the accused employee provided care or services

Based on interview, record review, facility job description review, the facility failed to ensure the Administrator was appropriately licensed to act as the Administrator for the facility. The facility reported a census of 31. During the entrance conference on 7/24/23 at 11:12 AM, the DON (Director of Nursing) stated the Administrator was currently at the other facility she managed and wouldn't make it to this facility today. During an interview on 7/26/23 at 9:25 AM, the Administrator queried to supply a copy of her license and she stated she didn't have a license, she had a provisional license for the other facility (not facility surveyed at present time). She stated she was in the process of getting a waiver. The Administrator asked if when she took the Administrator position she would be managing both facilities and she stated yes. She stated the provisional license couldn't be used for both facilities and the provisional license was issued for the other facility. She stated she applied for the waiver and if all else failed someone at this facility needed to get a provisional license until she got licensed for both places. The Administrator stated she started the Administrator position on 3/20/23. The Record Review revealed the Administrator was issued a Provisional License on 4/18/23 for the other facility. The Administrator submitted a Petition for Waiver from a administrative rule on 7/25/23. During an interview on 7/27/23 at 11:27 AM, the Administrator stated the previous Administrator worked at the facility when she first started and the previous Administrator ended her employment in the middle of June. The Nursing Home Administrator Position Description dated 7/1/2011 revealed the applicant needed to maintain a current Iowa Nursing Home Administrator License.

Based on interview and record review, the facility failed to develop a focus care area for diabetes on the care plan for 1 of 12 residents reviewed for care planning development (Resident #10). The facility reported a census of 31. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognition impairment. The MDS revealed a diagnosis of diabetes mellitus (DM). The MDS documented the resident received insulin injections 7 out of 7 days. The Care Plan with initiated date of 4/4/23 lacked documentation of a focused care area and interventions for the diagnosis of DM. The Electronic Medical Record revealed a diagnosis of Type II DM without complications dated 4/4/23. The Physician Orders revealed the following orders: a. Lantus 100 units/ml (milliliter) solution insulin vial- Inject 12 units subcutaneously once daily ordered on 4/4/23 b. Metformin 1000 mg (milligram) tablet- Give 1 tablet by mouth twice daily ordered on 4/4/23 c. blood glucose checks once daily ordered on 4/5/23 d. blood glucose check as needed for signs and symptoms of hypoglycemia (low blood sugar) ordered on 4/5/23 During an interview on 7/31/23 at 12:42 PM, Staff C, RN (Registered Nurse), MDS Coordinator queried on the expectation of DM being addressed on the care plan and she stated yes, it would be. She stated DM was normally on the care plan because they put the protocols the provider wanted to address things like hyperglycemia (high blood sugar) and hypoglycemia. During an interview on 7/31/23 at 3:15 PM, the DON (Director of Nursing) queried on the expectation of DM being addressed on the care plan and she stated it should be addressed on the care plan. During an interview on 7/31/23 at 3:50 PM, the DON stated they didn't have a policy for care plans, they followed CMS (Center for Medicare and Medicaid Services).

Based on observation, interview, and record review the facility failed to consistently document non-pharmacological interventions attempted prior to the administration of as needed antianxiety medication for one of five residents reviewed for unnecessary medications (Resident #19). The facility reported a census of 31 residents. Findings include: Review of the Annual Minimum Data Set (MDS) assessment for Resident #19 dated 6/21/23 revealed the resident had severely impaired cognition. Per this assessment, Resident #19 had received antianxiety medication for four of the last seven days. The Care Plan dated 10/15/20 revised on 8/4/21 documented, [Resident #19] receives psychotropic medications (Seroquel) r/t (related to) increased aggression secondary to dementia and subarachnoid hemorrhage secondary to fall prior to admission. The Physician Order dated 6/30/23 documented, Lorazepam Tab 0.5MG (Milligram), also known as Ativan, an antianxiety medication, with instruction for 1 tablet by mouth twice daily as needed for anxiety/agitation for 90 days (6/30-9/28/23) for Anxiety disorder, unspecified. Review of the Medication Administration Record (MAR) for Resident #19 for June 2023 revealed the resident had received as needed (PRN) Lorazepam on ten instances during the month, administered on 6/10/23, 6/14/23 two times, 6/15/23, 6/17/23, 6/19/23, 6/20/23, 6/23/23, 6/24/23, and 6/26/23. Review of documentation at the bottom of the MAR revealed the doses of Ativan had been administered due to the following documented reasons: anxiety and agitation. Review of progress notes during the date range the PRN Lorazepam had been administered revealed non-pharmacological interventions attempted had been documented on the dates of 6/15/23, 6/19/23, and 6/24/23. On 7/27/23 at 1:29 PM when queried about documentation of non-pharmacological medication for PRN antianxiety medications, Staff B, Registered Nurse (RN) explained non-pharmacologicals would be charted in the progress notes. On 7/31/23 at 2:45 PM when queried about documentation of non-pharmacological interventions, the Director of Nursing (DON) acknowledged information would usually be in the nurses notes, and she believed there was a spot in the medication system as well. The DON explained she would look into the medication system again. The Facility Policy titled Psychoactive Drug Monitoring, undated, documented, in part, c. Nonpharmacological interventions such as behavior modification or social services and their effects are documented as a part of the care planning process, and are utilized by the prescriber in assessing the continued need for psychoactive medication.

Based on observation, interview, and record review the facility failed to implement timely interventions and provide adequate supervision for residents with a history of falls and a resident with a history of wandering behavior for two of four residents reviewed for accidents (Resident #18, Resident #5). The facility reported a census of 31 residents. Findings include: 1A. The Minimum Data Set (MDS) assessment for Resident #18 dated dated 4/26/23 and 7/19/23 revealed Resident #18 had severely impaired cognition. Per the MDS dated [DATE] the resident had wandered one to three days during the look back period, and the MDS dated [DATE] revealed the resident and had wandered four to six days but less than daily. The Care Plan for Resident #18 dated 7/30/20 revised on 4/13/22 revealed, [Resident #18] has impaired cognitive function r/t (related to) dementia. She displays short and long term memory loss, disorientation to time, place and situation, confusion and impaired communication/difficulty finding words and/or finishing thoughts. She requires assistance with medical and financial decisions. She has a POA (Power of Attorney) in place. The Wandering assessment dated [DATE] revealed the resident scored 12 on the assessment, which indicated high risk to wander. The Wandering assessment dated [DATE] revealed Resident #18 scored 13 on the assessment, which indicated high risk to wander. Progress Notes for Resident #18 revealed, in part, the following: a. The Nurses Note for Resident #18 dated 1/18/23 at 1:36 PM documented, in part, Did not wish to come to DR (dining room) for breakfast but ate lunch and has been wheeling herself around facility in wheelchair. b. The Behavior Note dated 1/19/23 at 5:05 AM documented, She was resting in her bed and a recliner at the nurse's station. She was wandering the unit in a wheelchair for a short time this shift. c. The Psychosocial Note dated 2/3/23 at 5:05 PM documented, She continues to exhibit severe cognitive impairment displaying short- and long-term memory loss, confusion, disorientation to time, place and situation .She has wandered in her wheelchair about the facility most days as well. d. The Psychosocial Note dated 4/5/23 at 8:58 AM documented, [Resident #18] continues to wander in her wheelchair about the facility most days. e. The Behavior Note dated 5/31/23 at 12:47 PM documented, Resident also going into other people rooms then getting mad at staff when removed from other rooms. f. The Nurses Note dated 6/19/23 at 11:10 AM documented, Resident was seen in her wheelchair attempting to go out the front door this morning. g. The Nurses Note dated 6/21/23 at 3:32 PM documented, in part, Elder propelling throughout the hallways in wheelchair. Elder at west exit door, setting off alarm after door released. Review of an Incident Report dated 6/21/23 at 3:23 PM documented, in part, the following description of the event/concern: Elder in wheelchair propelling throughout the hallways. Elder exited out the west exit door after holding the door until it released. Elder was able to get herself in wheelchair out into the grass lawn. Alarm sounded, 2nd elder saw 1st elder exit building. The Administrator Notes section of the form documented, Follow up done. [Exit Alert Device] applied to the elder's wheelchair. This is prevent the exit door from opening unless staff assist. Observation on 7/26/23 at 2:45 PM revealed Resident #18 propelled herself down the hallway in her wheelchair. Observation on 7/26/23 at approximately 3:30 PM revealed Resident #18 wheeling themselves in their wheelchair towards the direction of the conference room at the end of the hallway. On 7/27/23 at 12:33 PM, Staff A, Environmental Services, had been queried about Resident #18's behaviors. When queried if the resident wandered, Staff A acknowledged she did, then explained it was the resident's home. Per Staff A, the resident had not been outside or anything. Staff A acknowledged sometimes Resident #18 went into other resident rooms, and further explained this did not happen a lot. Staff acknowledged the resident would move down the halls. On 7/27/23 at 1:29 PM, Staff B, Registered Nurse (RN) had been queried about wandering for Resident #18. Staff B acknowledged the resident did so which was why the resident had a [wander alert device] on. On 7/31/23 at 2:48 PM, when queried about when the resident had gotten out, the Director of Nursing (DON) explained she had been helping staff in a room on the North hall, and all the girls had been in rooms. The DON explained she heard the door alarm, came out, went up to the nurse's station, and a nurse had been down at the exit door motioning to come down. The DON explained the resident had gone through both doors onto the sidewalk, and was gotten in right away. 1B. The Minimum Data Set (MDS) assessment for Resident #18 dated dated 4/26/23 revealed Resident #18 had severely impaired cognition. The assessment also revealed the resident required the extensive assistance of two plus persons for transfers. Per this assessment, Resident #18 had no falls since admit, entry, re-entry, or prior assessment. Review of the resident's Falls Interventions Plan marked the following intervention: Up with assistance of 1-2 staff with gait belt and stand pivot. The Care Guide posted in the resident's room revealed, Transfer: Stand pivot c (with) gait belt assist x1-2. The Incident Report for Resident #18 dated 6/4/23 at 7:00 PM revealed the resident had slipped. Per the Incident Report, Resident #18 required assist x 1. The Incident Report also documented, Resident woke up, staff went in-changed resident. Sat on edge of bed- CNA (Certified Nursing Assistant) turned around to grab & resident slid out of bed. The Incident Report revealed the initial cause of the fall as, new staff, wheelchair not right by the bed. The Incident Report indicated the fall could have likely been prevented. The Incident Report for Resident #18 dated 7/2/23 at 12:30 PM revealed the resident had been sitting on the shower/toilet chair during or just prior to the fall, documented the resident's current level of assist per Care Plan as assist x1, and explained the following: Transferred to toilet with assist of 1 per care plan. When transferring back to wheelchair, leg not as strong as before, nurse lowered elder to the floor. The intervention put in place to prevent future falls documented, Utilize 2 staff when elder is weak. The incident report documented the fall could have likely been prevented. On 7/27/23 at 1:20 PM when queried about assist of 1 to 2, Staff B explained one could tell how the person was being that day, how alert and functional, and further explained a lot of the time in the evening when more tired needed 2 assist. On 7/31/23 at 2:54 PM when queried about 1 to 2 assist, the Director of Nursing (DON) explained they would take the recommendation from therapy or from another facility. Per the DON, if they did not have any recommendation they would ask therapy to come down and do a screen on them. The DON explained with Resident #18, she is a one assist per her care plan but acknowledged the staff could always choose to use two. When queried if staff should have prepared everything they needed before they started to move the person, the DON confirmed they would. On 7/31/23 at 3:00 PM, when queried about the resident MDS documentation of extensive assist, the DON said they she would need to look into where they info was gathered. 2. The Annual MDS for Resident #5 dated 12/14/22 revealed the resident scored 8 out of 15 on a BIMs assessment, which indicated moderately impaired cognition. Per this assessment, the resident had one fall with injury and one fall with no injury since admission, entry, re-entry, or prior assessment. Review of the resident's Falls Interventions Plan revealed the intervention of Ensure appropriate footwear is used/assess appropriate tread had been selected. The following had also been written on the form, dated 2/11/23 with date crossed off, date of 11/28/22 written above the crossed off date, and dated again as 2/28/23: Gripper socks while in bed. The Nurse Note dated 2/11/23 at 7:29 AM documented, in part, the following: This writer responded to room at request of on coming nurse to continue assessment. Resident was seen to be sitting on her bottom on the floor. No obvious injuries were noted. She was assisted to sit on her bed. Once there she stated that she needed to void. Staff assisted her to ambulate to the bathroom. Review of the Incident Report for the event on 2/11/23 revealed the resident had bare feet at the time of the fall. The new interventions put in place to prevent future falls revealed, Use of gripper socks or footwear on when getting up. The Communication with Physician Note dated 2/28/23 at 2:52 AM documented, in part, the following: 02/28/2023@ 0150- FYI (for your information)-Resident called staff to her room where she had slipped from her bed on to the floor. She was seen to be sitting on her bottom on the floor with back to the bed. Resident stated that she was going to the bathroom and slid from the bed. Resident is wearing a tricot nightgown. Staff assisted her to sit on the bed and then to stand to ambulate to the bathroom. Her gait was steady with the use of a walker. She did not hit her head. No injuries noted. Review of the Incident Report for the event dated 2/28/23 revealed the resident had bare feet at the time of the fall. The new interventions put in place to prevent future falls revealed, Non-skin socks at night while in bed. Consider a bolstered mattress. On 7/31/23 at 3:01 PM when queried about the process for falls, the DON explained it was done as a team effort. Nurses minus travel nurses or agency would put information into the risk management program. The DON would be notified of the fall, and would assist to come up with an intervention. If the DON did not care for the intervention, they could change it later. The DON explained they tried to gather as much information, input, and opinions in trying to come up with interventions that were good and relevant to the situation. In terms of a policy, the DON explained the falls protocol would be used, which included interventions, updated care plans, and updated care card in the room.

Based on interview and record review, the facility failed to respond timely to address and treat a resident's symptoms of a urinary tract infection (UTI) for 1 of 4 residents reviewed for urinary tract infections (Resident #17). The facility reported a census of 31. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented the resident always continent of urine. The MDS revealed the resident a UTI in the last 30 days. The MDS revealed the resident received an antibiotic 5 out of 7 days. The Care Plan revealed a focus care area dated 7/11/23 of a history of UTIs leading to hospitalization if not treated promptly. The interventions dated 7/11/23 revealed the resident and family chose to opt out of the UTI protocol and wanted the provider notified as soon as symptoms were reported. The Progress Note dated 7/4/2023 at 11:07 AM revealed the resident complained of burning with urination, frequency and urgency and initiated UTI protocol. The Progress Note dated 7/7/2023 at 11:10 AM revealed the resident continued to complain of burning with urination, urgency and frequency. UTI protocol completed. Fax sent to provider with condition update. The Communication to Physician paperwork dated 7/7/23 revealed the nursing concern of the resident complaining of burning with urination, urgency, and frequency, UTI protocol initiated on 7/4/23 and completed today. Resident had no change in symptoms. Any new orders? Please advise. The Physician Orders/Response signed/dated 7/13/23 revealed the following information to obtain urinalysis, culture and sensitivity if indicated (if have not already). The Physician Orders noted on 7/14/23 at 7:02 AM with the remarks of UA already completed. The Progress Note dated 7/8/2023 at 2:26 PM revealed resident continued to complain of burning on urination, frequency and urgency. The Progress Note dated 7/9/2023 at 8:20 AM revealed the resident continued to complain of frequency, urgency, burning with urination, and general body aches and lack of appetite. A call placed to the on call provider with condition update given and received new order for UA (urinalysis) with culture and sensitivity. The Progress Note dated 7/9/2023 at 8:50 AM revealed the UA obtained and sent to the lab. Urine cloudy yellow with strong odor. The Communication with Physician Progress Note dated 7/9/2023 at 10:48 AM revealed call placed to provider regarding the UA preliminary results and message left to call for update. The Communication with Physician Progress Note dated 7/9/2023 at 11:15 AM revealed the results of UA given to the provider and received new orders. The Progress Note dated 7/9/2023 at 11:57 AM revealed Ciprofloxacin 250 mg initiated at 11:15 am, and taken from E-kit (emergency kit). The Physician Orders revealed the following orders for a UTI: a. Ciprofloxacin 250 mg (milligram) tablet- take 1 tablet by mouth twice daily for 3 days, start on 7/9/23 and end on 7/12/23 The Labs ordered on 7/9/23 at 10:25 AM resulted on 7/10/23 at 6:28 AM with a preliminary urine culture gram negative rod isolated greater than 100,000 colony count. ID pending with further ID and sensitivity in progress. Lab results on 7/11/23 at 6:22 AM with a final of klebsiella pneumoniae colony count organism greater than 100,000 and noted by the nurse on 7/11/23 at 9:00 AM. The Plan of Care Note dated 7/11/2023 at 11:43 AM revealed during the care conference the son voices concern about the UTI protocol and no follow up UA from a previous round of antibiotics and provider wasn't called until day 5 after current UTI protocol. The family wanted the provider to be notified if/when [NAME] complained of urinary symptoms rather than the initiation the UTI protocol. During an interview on 7/24/23 at 12:37 PM, the resident stated she just got over a urinary infection and she toileted herself. She stated she had a history of UTIs. During an interview on 7/26/23 at 11:25 AM, Staff C, RN (Registered Nurse) MDS Coordinator queried about the UTI protocol and she stated the protocol used to ward off any unnecessary use of antibiotics and monitored symptoms for 72 hours and if still had symptoms after 72 hours, notified the provider for an order for a UA. She stated they had one instance with Resident #17 where the provider didn't get contacted until Day 5 and the doctor needed notified on Day 3 not Day 5. During an interview on 7/27/23 at 9:54 AM, Staff D, RN queried about Resident #17 UTI and she stated the resident started having symptoms around 7/4/23 and she started the UTI protocol and notified the provider through fax and then on Sunday, 7/9/23 Resident #17 still had symptoms and she notified the on call and received an order for a UA and antibiotics. Staff D asked what the response time for the provider to respond to faxes and she states it depended on the provider and sometimes it could take a week. She stated faxing was the communication they used with the providers unless it was an emergency. Staff D stated when they sent labs to the office on Friday they didn't always get a response depending on the time of the day and the office might only have one person in the office on Saturdays. During an interview on 7/31/23 at 3:16 PM, the DON (Director of Nursing) queried what happened after the UTI protocol ended and she stated the nurses notified the providers with the outcome and reviewed the recommendations from the providers. The DON asked on the expectation of the response time for the providers to respond and she stated sooner that what it was and she liked between 12 and 24 hours. She stated the expectation would be the physician to respond quicker and put a process in place for the nurses to respond better. During an interview on 7/31/23 at 3:50PM, the DON stated the facility didn't have a policy for UTIs or a change of condition, they used nursing judgement.

Based on record review and staff interviews, the facility failed to ensure the proper mechanical lift was used during transfers for 1 of 4 residents reviewed. (Resident #1). The facility reported a census of 46 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 10/18/17. The MDS identified the resident had a brief interview for mental Status (BIMS) score of 9. A score of 9 indicated the resident had a moderately impaired cognitive status. The MDS indicated the resident required extensive assistance from staff with transfers, dressing, toilet use and personal hygiene needs. The MDS identified Resident #1's [DIAGNOSES REDACTED]. The Care Plan dated 7/8/13 and interventions revised on 4/19/17, identified a problem with self care deficit and directed the staff to do the following included: Transfers: Resident #1 requires a mechanical lift and assistance of two staff for all transfers. Resident #1 cannot safely participate when using a standing lift. (i.e. EZ stand or sit to stand). The care sheet (posted in Resident #1's room) directed the staff to transfer the resident with a total mechanical lift with 2 (person)assistance. Transfer and Mobility assessment dated [DATE] and signed by Staff A, restorative nurse, indicated Resident #1 used a Sit to Stand (transfer device), then begun to let go of the handles and could not bear weight. Staff A identified the Sit to Stand no longer safe to use. The assessment identified the transfer level and method was a total mechanical lift with the assistance of 2 staff members. On 1/22/18 at 1:20 p.m., Staff A, restorative nurse, was interviewed and stated in April 2017, Resident #1 had lost her strength and ability to bear weight. Staff A stated following multiple assessments, he had determined it no longer safe for Resident #1 to use the sit and stand lift. Staff A stated at that time (4/18/17) he changed Resident #1's transfer status to total mechanical lift with the assistance of two staff members ( Hoyer lift only). On 1/22/18 at 1:23 p.m. Staff B, certified nurse aide, was interviewed and stated on the morning of 12/19/17, while getting Resident #1 dressed, she noticed a lump on Resident #1's left shoulder and Resident #1 complained of pain. Staff A reported her observations to the nurse, Staff C. On 1/23/18 at 10:37 a.m. Staff C, registered nurse, was interviewed and stated on the morning of Monday 12/18/17, Staff D, certified nurse aide, reported Resident #1 was complaining of left shoulder pain. Staff C assessed Resident #1 and noted limited, but normal range of motion in Resident #1's left arm and no complaints of pain when moved. Staff C stated she noticed a bruise on Resident #1's right hand. On Tuesday 12/19/17, Staff C had completed Resident #1's vital signs early that morning and didn't notice anything unusual at that time. Several minutes later, Staff C was called back to Resident #1's room by Staff B. The Director of Nursing was in the room when Staff C arrived and pointed out that Resident #1's left shoulder appeared deformed. Staff C stated it was notably different than the day before. Staff C left the room and called the physician leaving an urgent message. They received an order for [REDACTED]. The Progress note dated 12/19/17 at 11:12 p.m. indicated the physician had tried to to reset the resident's shoulder (into the socket) and unsuccessful. The physician ordered an immobilizer be put in place and an order for [REDACTED]. On 1/22/18 at 1:00 p.m. the Administrator was interviewed and stated upon learning of Resident #1's dislocated shoulder, the facility initiated an investigation. Resident #1 was interviewed and voiced no complaints or concerns regarding her care and offered no explanation for her condition. Resident #1 denied being abused or mistreated. The Administrator interviewed all care givers and nurses and during those interviews discovered on the afternoon of 12/14/17, Resident #1 was transferred by two aides (Staff E and Staff F) using the sit to stand lift. During that transfer, Resident #1's legs gave out (This would have put additional pressure under the arms of Resident #1 from the harness). It was following this transfer that Resident #1 began complaining of left arm pain and developed some bruising. The Administrator stated although there was no immediate indication of dislocation, this may have been a contributing factor for the shoulder ball joint to eventually dislodge from the socket. The Administrator stated Resident #1 was Care Planned to be transferred using a Hoyer lift due to her weakness and inability to bear weight. Upon Review of the POS [REDACTED]. The Administrator stated she immediately corrected the care signs to be more specific and re-educated their staff (on 12/22/17). On 1/22/18 at 3:20 p.m. Staff G, certified nurse aide, was interviewed and stated on the evening of 12/15/17 she noticed a bruise on the right hand of Resident #1 and the resident complained of left elbow pain. Staff G reported the observation to the nurse. Staff G stated she used the sit to stand lift to transfer that evening and through the weekend and Resident #1 seemed fine. Staff G stated she never noticed any disfigurement in Resident #1's left shoulder. In an interview on 1/22/18 at 1:56 p.m. Staff H, certified nurse aide, stated she worked double shifts (day and evening) the weekend of 12/16/17 and 12/17/17. Staff H noticed Resident #1 complained of left arm pain when moved and bruising noted on her right thumb area. Resident #1 indicated pain in her left elbow area. Staff H stated since Resident #1 was having left arm pain, she used the Hoyer lift for transfers, but she admitted prior to the day, she used the sit to stand lift.