Every finding on record at Peak Resources-Wilmington, Inc

Based on record review, and interviews with staff, resident, and the Physician Assistant, the facility failed to transfer Resident #17 using a mechanical lift, placing the resident at risk for an avoidable injury. On 11/19/25, Nurse Aide #1 attempted to transfer Resident #17 from her bed using a slide board (a board used to transfer a resident from one sitting position to another such as chair, bed, etc.). At the time of the transfer, staff had not yet been educated or trained by the Therapy Department for the use of a slide board for transferring Resident #17 and Resident #17 fell to the floor. Results from x-rays noted a fractured left humerus (long bone in the upper arm), mildly displaced fracture of left tibia (shin bone) and right medial malleolus (inner side of ankle), and a partial dislocated shoulder. Resident #17 was sent to the Emergency Department for further evaluation. The hospital record revealed the Orthopedic Department (bone specialist) was consulted and recommended non operative management of fractures. The right ankle was splinted and left arm brace was placed, and 2) failed to prevent a moderately cognitively impaired resident who was identified as high risk for elopement and with prior exit seeking behaviors, from exiting the facility without a staff member present. This deficient practice affected 2 of 7 residents reviewed for accidents (Resident #27 and Resident #17). Findings included: 1. Resident #17 was admitted to the facility on [DATE]. Diagnoses included stroke with left sided weakness, contracture to left hand and left ankle. Review of the Minimum Data Set quarterly assessment dated [DATE] revealed Resident #17 was cognitively intact. She was dependent (Staff member does all of the effort. Resident does none of the effort to complete the activity; or the assistance of 2 or more staff members were required for the resident to complete the activity) with transfers. A one page copy of a care plan provided by the facility indicated Problem Start Date 01/09/25 Point of Care Resident Profile (a section in the residents' electronic record that was accessible to all nursing staff. The section included how to transfer a resident): Standards of Care Required for Resident with an Approach Start Date of 01/09/25 and discontinued on 11/21/25. The approach was: discontinued devices for ambulation / transfer: may use sliding board transfers per resident request. The discontinued reason was documented as no longer needed. A care plan dated 01/09/25 revealed a point of care resident profile: standards of care required for resident. Interventions included resident required maximum assist for all activities of daily living, bed mobility and hygiene and a mechanical lift. A physical therapy evaluation and plan completed by Physical Therapist (PT) #1 dated 11/04/25 was reviewed. The evaluation indicated the reason for the referral was to evaluate Resident #17 to assess general functional mobility and wheelchair positioning due to reports of discomfort and attempts at out of bed time and a desire to be able to self-propel in a better fitting chair. The evaluation indicated the objective and short term goals for Resident #17 were as follows: Resident would demonstrate improved bilateral (both sides) hip flexion (bending) passive range of motion in order to facilitate improved comfort with seated position in a standard chair with a target date of 11/17/25. Resident would demonstrate improved sitting balance at the edge of the bed to require no more than a minimum assist while utilizing upper extremity support in order to improve core strength required for sustain out of bed sitting tolerance with a target date of 11/17/25. Resident would demonstrate tolerating sustained out of bed time greater than or equal to 4 hours in a wheelchair with necessary modifications for positioning/comfort in order to reduce bedbound behaviors and increase engagement in her long term care community with a target date of 12/01/25. The initial assessment on this evaluation by PT #1 revealed Resident #17's prior level of function was dependent when going from a sitting position to lying down position and lying down to sitting up on the side of the bed. Resident #17's transfer function was dependent with a mechanical lift. Resident #17's balance assessment indicated she required maximum assistance of 2 staff members to sit at the edge of the bed and was unable to sit unsupported. The assessment summary by PT #1 indicated Resident #17 presented with impaired postural control and profound core weakness associated with deconditioning and weakness from a prior stroke. There was no mention of Resident #17 being assessed to use a slide board to assist with transfers out of bed. A Physical Therapy Discharge Summary completed by PT #1 revealed Resident #17 was seen for 3 days during the 11/18/25 to 11/25/25 progress period. The discharge summary revealed Resident #17 demonstrated increased participation and motivation during this session, gradually progressing with her out of bed tolerance to 3 hours in recent sessions and progressing exceptionally well with regards to improving overall core strength. Progressive edge of the bed task was consistently introduced and tolerated well including postural holds and weight shifting with eventual successful incorporation of a slide board in order to minimize functional core usage. Transfer status remained as a mechanical lift with nursing staff secondary to the level of physical assistance needed and cueing strategies that were required with slide board usage during therapy sessions. Resident #17 sustained a fall from the edge of the bed on 11/19/25 with a nurse aide resulting in a left humerus fracture, anterior shoulder dislocation and right medial malleolus fracture. An interview was attempted with PT #1 on 05/21/26. PT #1 no longer worked at the facility and did not return the call. A phone interview was conducted with Nurse Aide (NA) #1 on 05/21/26 at 3:05 PM. NA #1 stated on 11/19/25 she was assigned to Resident #17 and she was attempting to get her out of bed. She stated therapy was supposed to be in the room with Resident #17 but they were not. She stated she moved Resident #17 to the edge of the bed and got her feet down on the floor and then placed the slide board under her buttocks. NA #1 stated the slide board was flat on the bed and was not across to the wheelchair when she asked Resident #17 to move forward a little and then she started to fall. NA #1 stated she broke Resident #17's fall and guided her to the floor. NA #1 stated at that time the Restorative Aide, Nurse #3 and a therapy staff member came into the room and they all transferred her with a mechanical lift back to the wheelchair. NA #1 stated the previous Rehabilitation (Rehab) Director told her it was okay to use the slide board to transfer Resident #17. NA #1 stated she did not receive any instruction or demonstration on how to use it, but she knew therapy was trying it out, so she thought it was okay to use. NA #1 stated using a slide board for Resident #17 was not on her resident care guide, and for as long as she worked at the facility (about a year), Resident #17 was always required to be transferred with a mechanical lift with two staff. NA #1 stated she should have waited for therapy to come into the room before she tried to transfer Resident #17 with the slide board. An interview was conducted with the Restorative Aide (RA) on 05/21/26 at 10:30 AM. The RA stated she was not in the room at the time Resident #17 fell on [DATE], but when she walked into the room and saw Resident #17 on the floor she went and told Nurse #3. She stated NA #1 was sitting on the floor with Resident #17 holding her up from behind. The RA stated she had only worked with therapy one time when therapy was trying the slide board with Resident #17. The RA stated Resident #17 was not at a goal yet to use it and no education was given to her to begin to use the slide board. The RA stated she had been working at the facility for 2 years and as long as she had been here, Resident #17 always used a mechanical lift with 2 staff members to get out of bed. A phone interview with Nurse #3 on 05/21/26 at 9:30 AM was conducted. Nurse #3 reported on 11/19/25 she was the nurse assigned on the hall Resident #17 resided on. She stated she was in a room with another resident, and the Restorative Aide came and notified her that Resident #17 was on the floor in her room. Nurse #3 stated when she entered the room, she noticed Resident #17 sitting on the floor and Nurse Aide (NA) #1 was sitting on the floor keeping Resident #17 propped up in a sitting position. Nurse #3 reported she completed a head-to-toe assessment on Resident #17 and she did not have any complaints of pain at the time and she was transferred to the wheelchair with four staff members using the mechanical lift. Nurse #3 stated Nurse Aide #1 was using a slide board and Resident #17 was a not a safe transfer with a slide board. Nurse #3 stated Resident #17 always required a mechanical lift with the assistance of two staff members whenever she was transferring out of bed. Nurse #3 stated that therapy was working with Resident #17 to use a slide board, but it had not been signed off by therapy for staff to use. Nurse #3 explained that once the Therapy Department determined a resident was at goal with a task, they would write a communication slip and instruct by demonstration to the nurses and nurse aides how the task should be done. Nurse #3 stated she never received any demonstration or education to use a slide board on Resident #17. She stated once the communication slip was done, the Director of Nursing would update the care plan and resident care guide (a reference for nursing staff to know how to transfer a resident) to reflect how the resident should be transferred. Nurse #3 stated on 11/19/25 after Resident #17 was transferred to her wheelchair she went to her hair dressing appointment, and it was not until later that day that Resident #17 said she was in pain in her left arm and she notified the provider and obtained an order for x-rays. Review of a summary of investigation form completed by Nurse #3 dated 11/19/25 revealed a Nurse Aide tried to use a sliding board to transfer resident to the wheelchair. The Nurse Aide had to let resident slide to the floor. Resident did not hit her head and was assisted to the wheelchair with four staff members using a mechanical lift. A physician's order written on 11/19/25 revealed an order entered by Nurse #3 to x-ray Resident #17's left arm. A progress note written on 11/19/25 at 10:22 PM by Nurse #5 revealed the x-ray company called the facility and reported they would be at the facility on 11/20/25 to do the x-ray. The on call provider was made aware and Norco (an opioid pain medication combined with Tylenol) 5mg/325 milligrams (mg) 1 tablet every 6 hours for pain was ordered for Resident's complaint of arm pain. Medicated resident with one tablet of Norco at this time. A progress note written on 11/20/25 by Nurse #8 at 5:57 AM revealed at 3:00 AM medicated resident with Norco 1 tablet by mouth for left arm pain. Resident stated the last pill helped a lot. Left arm remains up on pillow and during activity of daily living (ADL) care, two staff assisted to prevent further pain to arm. A progress note written on 11/20/25 at 8:17 AM by the Director of Nursing revealed the Nurse Practitioner was notified of complaints of right foot pain and edema. Requesting foot x-ray due to fall on 11/19/25. A physician's order written on 11/20/25 revealed an order entered by the Director of Nursing for x-ray of Resident #17's right foot. A progress note written on 11/21/25 at 2:12 PM revealed x-ray of left arm completed, showed fracture of left humerus. Resident was transported to the hospital at 1:30 PM. Resident complained of left arm pain; 9 out 10 on pain scale and was medicated for pain. X-ray results dated 11/21/25 of the left humerus revealed acute fracture to proximal and mid humerus (the upper section of the middle part of the bone), and anterior (front) dislocation of the left shoulder. X-ray results dated 11/21/25 for the left foot revealed no definite acute fracture. Consider more sensitive imaging evaluation with CT (computed tomography) scan as clinically directed. X-ray results dated 11/21/25 for the left ankle revealed ankle swelling but no definite acute fracture. X-rays results dated 11/21/25 of the right foot revealed no acute bone abnormality. Mild to moderate degenerative (worsening) changes and osteopenia (reduced bone mass) are noted. A progress note written by the Physician Assistant (PA) on 11/21/25 revealed Resident was seen on rounds and discussed x-ray images. Resident had left arm pain after the fall. The PA's assessment included vital signs: heartrate 76 beats per minute (bpm) (normal range between 60 and 100 bpm), respiration rate 18 breaths per minute (bpm), (normal range 12 to 20 bpm) temperature 97.7, (normal range 97 to 99) blood pressure was 122/72 (normal range 120/80) and oxygen saturation was 95% on room air (normal range 95% to 100%). The assessment also included that resident had complaints of left arm pain, foot pain, and left elbow upper arm edema. Resident was alert and pleasant with left sided hemiparesis (weakness or inability to move one entire side of the body). The progress note indicated the PA reviewed the x-ray images and sent Resident to the Emergency Department (ED) for further evaluation. Review of the hospital record dated 11/21/25 revealed the CT scans for Resident #17 showed resident was noted to have severe muscular atrophy (wasting of muscle tissue) and bones were osteoporotic (bones that were weak and brittle). The CT scan results for the left humerus revealed severe bone demineralization and atrophy with comminuted (when bone shatters, splinters or breaks into fragments) fracture of the left humeral (upper end of the upper arm) neck with fracture involved at the proximal mid humeral shaft and anterior inferior subluxation (partial dislocation) of the humeral head (shoulder). The CT scan results for the right ankle revealed severe osteopenia, mildly displaced distal tibial fracture involving the medial malleolus (inner side of ankle). The hospital record revealed the Orthopedic Department (bone specialist) was consulted and recommended non operative management of fractures. The right ankle was splinted and left arm brace was placed. Resident was non weight bearing to left upper extremity and non-weight bearing to right lower extremity with left side residual weakness from a stroke to left upper and left lower extremities. Resident was discharged in stable condition back to the skilled nursing facility on 11/23/25. A progress note written by Nurse #3 on 11/23/25 at 12:46 PM revealed Resident returned to facility from hospital. Resident received pain medication prior to discharge and voiced no pain. Sling noted to left arm and right foot in soft cast/brace. A progress note written by Nurse #5 on 11/23/25 at 10:48 PM revealed Resident in bed with sling to the left arm and soft cast to the right lower extremity. Medicated with Norco one tablet at 3:15 PM and 9:15 PM for pain relief with good results. Resident stating pain was improved and manageable. An interview was conducted with Resident #17 on 05/18/26 at 11:20 AM. Resident #17 reported that she was being transferred out of bed by a Nurse Aide who was using a slide board and she fell off the slide board, but the nurse aide tried to stop her from falling and lowered her to the floor. Resident #17 stated she dislocated her shoulder and broke her arm and ankle. Resident #17 stated no one else was in the room except for her and the Nurse Aide when she fell. Resident #17 stated she had been always transferred with a mechanical lift with 2 nurse aides but the therapy staff was working with her just before she fell to try and transfer her out of bed with a slide board. An interview was conducted with the current Rehabilitation (Rehab) Director on 05/21/26 at 9:36 AM. The current Rehab Director stated at the time of Resident #17's fall in November she was working as an as needed Physical Therapist Assistant (PTA) and was not the Rehab Director. The current Rehab Director reviewed the goals on the evaluation for Resident #17 dated 11/04/25. She stated none of the goals addressed transferring with a slide board. She stated in the middle of the treatment plan which ran from 11/18/25 thru 11/25/25, Physical Therapist (PT) #1 attempted transfer training with a slide board on Resident #17. The current Rehab Director stated at this point, using a slide board was only being done by therapy and no training or education was given to the nursing staff for them to use a slide board on Resident #17 per the treatment plan. The current Rehab Director stated the nurse aide who attempted to transfer Resident #17 on 11/19/25 should not have tried to transfer her with a slide board since it was only attempted in one session by therapy on 11/18/25. The current Rehab Director stated there was a process for nurses and nurse aides to utilize a slide board on a resident. She stated the slide board use would have been implemented after Resident #17 was trained for a couple of weeks and was able to complete the slide board transfer with one person, then the Therapy Department would demonstrate to the nurses and nurse aides and then have the staff do a return demonstration in front of therapy staff to show that they were able to do the transfer safely with one person. The current Rehab Director stated a communication slip was to be used to communicate any transfer changes and that she would not verbally tell staff without completing a communicate slip. The current Rehab Director stated she kept the communication slips on file and was not able to find any communication slip indicating Resident #17 was to use a slide board for transfers. The current Rehab Director stated the communication slip would then be given to the Director of Nursing and the MDS Nurse so that the care plan and resident care guide would be updated to reflect the new transfer status. An interview was conducted with NA #6 on 05/21/26 at 10:37 AM. NA #6 stated she had worked at the facility for 6.5 years. She stated if she needed to know how to transfer a resident she would look at the resident care guide in the electronic record. She stated the resident care guide tells her everything she needs to know about a resident. NA #6 stated as long has she has been at the facility she has never known Resident #17 to use a slide board and her care guide says to use a mechanical lift with 2 staff members. An interview was conducted with MDS Nurse #1 on 05/21/26 at 11:10 AM. MDS Nurse #1 stated she was responsible for updating the care plans. She stated usually therapy would give her a communication slip to indicate any change in a resident's plan of care and she would use that communication slip to update the care plan. She stated she did not save the communication slips after she updated the care plan. She stated sometimes she would be told verbally in an Interdisciplinary Team (IDT) (includes Director of Nursing, MDS Nurses) meeting to make the change in the care plan. MDS Nurse #1 stated she was not able to see within the electronic record who entered the approach for using a slide board for transfers on 01/09/25 and she did not know how the Point of Care (resident care guide) was updated to reflect Resident #17 used a slide board. MDS Nurse #1 stated the interdisciplinary team just started updating the Point of Care during Interdisciplinary Team meetings when discussing new interventions but was not certain when it started but it was after Resident #17 fell. A phone interview was conducted with the previous Rehab Director on 05/21/26 at 3:26 PM. The previous Rehab Director stated she had started training the Restorative Aide the slide board transfer just before the fall but Resident #17 was not deemed appropriate for the slide board transfer at the time of the fall. The previous Rehab Director stated the only time nursing staff should have attempted to transfer Resident #17 with the slide board was if someone from the Therapy Department was in the room with them and they had received education on how to do it. The previous Rehab Director stated she was not in the room at the time of fall and added that someone came to her and told her Resident #17 fell. The previous Rehab Director stated she never told NA #1 that it was okay to use the slide board for Resident #17. The previous Rehab Director stated once the Therapy Department determined that Resident #17 was appropriate for the slide board, a demonstration would have been done with the nursing staff with a return demonstration to ensure the staff could transfer the resident safely. She stated a communication slip would then be filled out and given to the Interdisciplinary Team (IDT) to communicate that this was how the resident was going to transfer and the care plan would be updated. The previous Rehab Director stated the process was to use a communication slip and not share verbally. She added, she never verbally told any staff that Resident #17 was appropriate to use a slide board. She stated the communication slips had 3 carbon copies and she would keep a copy for the Therapy Department on file. An interview was conducted with the Physician Assistant (PA) on 05/22/26 at 10:00 AM. The PA stated that she did not know why the x-ray that was ordered on 11/19/25 did not actually get done until 11/21/25, but that at times the x-ray company had been known to take up to 48 hours to come out unless she put STAT (immediate) on the order which she did not. The PA stated she felt there was no delay in treatment and that on 11/20/25 she assessed Resident #17 and reported her arm did not look right, but she knew the x-ray was ordered. The PA stated she was made aware of Resident #17 having foot pain on 11/20/25 by Resident #17 and had x-rays for her right foot ordered too. She stated when the x-ray results resulted on 11/21/25 she reviewed the images and realized it was worse than she thought and saw that Resident #17 also had a dislocated her left shoulder, but when she assessed her on 11/20/25, Resident #17 had no concerns with her shoulder and she did not see any other concerns with her exam. The PA stated Orthopedics evaluated Resident #17 in the Emergency Department and determined that she would not have surgery. The PA stated, as it pertained to the fall, she felt that Resident #17 was not appropriate at all for a slide board transfer especially with her severe left sided weakness. She stated the Nurse Aide should have never attempted to try to transfer Resident #17 with the slide board and she should have been only been transferred using the mechanical lift with another staff member. An interview was conducted with the Director of Nursing (DON) on 05/22/26 at 10:30 AM. The DON reported Resident #17 was recorded as utilizing a slide board for transfers at the time of fall according to Point of Care page she provided. The DON stated she was unable to determine how this transfer status was determined or who entered the intervention on 01/09/25 and as there was no communication slip to confirm this transfer change. The DON added that transfer devise was recorded in Resident #17's resident care guide for 11 months and no staff ever questioned it. The DON stated she did not transfer residents so she did not know if Resident #17 had a decline and was not using the slide board anymore. The interview further revealed the name of the x-ray company was Dynamic Imaging when the order was placed. She stated the company changed hands on 11/20/25 and was now Trident Care and she believed that could have been the reason for them coming on 11/21/25 instead of 11/20/25. The DON also stated that unless an x-ray order was put in as a STAT order, it had at times taken up to 48 hours to get done. The DON added the facility treated Resident #17 in house before sending her to the hospital until the x-ray results were obtained. The DON stated that the facility trained their nursing staff to utilize the Point of Care (resident care guide) to know how to transfer a resident and at the time of the fall, Resident #17's care guide indicated using a slide board. The DON acknowledged that there was no other documentation to support Resident #17 was to use a slide board, that therapy notes indicated she remained a mechanical lift from Resident #17's discharge summary progress period from 11/18/25 through 11/25/25, and that according to staff and resident interviews, Resident #17 had always been transferred with a mechanical lift. 2.) Resident #27 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia and muscle wasting and atrophy (muscle shrinkage). A facility Elopement Risk assessment was conducted by the Director of Nursing (DON) on 4/5/26. The assessment indicated Resident #27 was cognitively impaired, had poor decision-making skills, dementia, and a history of wandering into unsafe places. Resident #27 was coded for being an elopement risk. The interventions listed were staff monitoring with every 15-minute checks. The assessment indicated the interventions were added to the care plan. An active physician's order initiated on 4/18/26 directed staff to check Resident #27's right wrist for proper alarm placement, test the battery every shift, and check the alarm device expiration date and replace it prior to expiration. Resident #27's care plan revised on 4/24/26, revealed a plan of care addressing cognitive loss/dementia related to dementia and Brief Interview for Mental Status (BIMS) score of less than 13 (a score less than 13 indicates cognitive impairment). Resident #27 displayed the following cognitive problems: inattention and disorganized thinking. The interventions included asking yes/no questions to determine the residents' needs and cueing, reorienting, redirecting, and supervising as needed. The care also indicated the resident experienced wandering. The interventions included ensuring the resident had properly fitting and appropriate footwear, ensuring she was appropriately dressed and provided supervision when outside on the porch, and on 4/22/26 the intervention for every 15- minute checks by staff for safety. Resident #27's care plan further indicated she was at moderately to high risk for falling related to cognitive function, weakness, and deconditioning. The interventions included encouraging her to use rollator walker with all transfers and ambulation. On 4/22/26 the intervention for every 15 minutes by staff for safety was added. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was moderately cognitively impaired. She was independent with transfers and was ambulatory with a walker. Resident #27 was not coded yes for wandering or having a wander/elopement alarm. Review of the May 2026 Medication Administration record for Resident #27 revealed on 5/5/26 the 7:00 AM to 3:00 PM Nurse #11 documented that the safety alarm device was on the resident's right wrist. Medication Aide #1 (MA #1) documented the safety alarm device was not on her wrist on the 11:00 PM to 7:00 AM shift. Nurse #9 who was working the 3:00 PM to 11:00 PM shift didn't document whether the safety alarm device was on or not. An interview with Nurse #9 was conducted on 5/21/26 at 9:06 PM. Nurse #9 stated that Resident #27 had removed her safety alarm device on 5/5/26 and they had not been able to find it. She further stated that Resident #27 had refused to allow staff to place another safety alarm device on her. Nurse #9 indicated that she must have forgotten to document on the MAR on 5/5/26 that Resident #27 had removed her safety alarm device. She stated that she had made the DON aware that Resident #27 was not wearing a safety alarm device on 5/5/2026. Nurse #9 indicated that Resident #27 was on every 15-minute checks by staff. An observation and interview with Resident #27 were conducted on 5/19/26 at 1:19 PM. Observation of Resident # 27 in her room revealed she was not wearing an safety alarm device. Resident #27 stated she was not wearing a safety alarm device. She indicated she didn't want to wear a safety alarm device and didn't like it. On 5/19/26 at 4:56 PM the survey team exited the facility and observed Resident #27 sitting outside on the right side of the front porch of the facility without staff supervision. A survey team member immediately notified the Evening Receptionist that Resident #27 was outside while the remaining team members stayed with Resident #27. At 5:02 PM the Business Office Manager assisted Resident #27 back into the building. An interview with the Evening Receptionist was conducted on 5/19/26 PM at 5:00 PM. The Evening Receptionist stated she was aware Resident #27 was outside on the porch. She further stated that Resident #27's safety alarm device had not set the alarm off when she approached the door, so she thought it was okay for the resident to go outside. The Evening Receptionist did not report what time Resident #27 went outside. The Evening Receptionist indicated she was aware that Resident #27 was identified as a high risk for elopement and that her information was in the High Risk for Elopement book at the desk. She indicated she was educated regarding residents with high risk for elopement prior to today. The Evening Receptionist stated she was aware Resident #27 went outside but she was not able to see her from behind the receptionist desk. An interview with Business Office Manager was completed on 5/21/26 at 11:52 AM. The Business Office Manager stated her office was right behind the receptionist desk in the front lobby of the facility. She further stated that on 5/19/26 at approximately 5:00 PM she had overheard the Evening Receptionist telling another staff member that Resident #27 was outside unsupervised. The Business Office Manager indicated she was the staff member that went outside and assisted Resident #27 back into the facility. She stated she had received training regarding residents with high risk for elopement. An interview with Nurse #10 was completed on 5/22/26 at 7:44 AM. Nurse #10 stated she was the nurse assigned to Resident #27 on 5/19/26 at 5:00 PM. She further stated that she had observed Resident #27 ambulating with her walker down the hall towards the dining room a little before 5:00 PM. She indicated she had documented DR for dining room on the facility 15-minute Observation Monitoring Tool sheet. Nurse #10 stated Resident #27 was in the dining room eating at 5:15 PM and she had documented DR on the monitoring tool. She indicated she was unaware that Resident #27 was outside without staff supervision on 5/19/26 in between the 15-minute c

Based on observations and staff interviews, the facility failed to ensure the dumpster area and exterior exit leading to the dumpster area remained free of garbage and refuse for 2 of 2 dumpsters. This failure had the potential to attract pests and rodents. Findings included: An initial observation of the kitchen exterior exit leading to the dumpster area with the two dumpsters was made on 5/18/26 at 11:37 AM with the Dietary Manager (DM). Observed next to the dumpster area wall were scattered leaves, broken tree limbs, a discarded large white wooden door, a large pile of broken pieces of white door trim, seven intact wooden pallets, and a large quantity of scattered cigarette butts. A follow-up observation of the kitchen's exterior exit leading to the dumpster area was made on 5/20/26 at 8:10 AM with the Dietary Manager (DM). The area remained in the same condition observed on 05/18/26 and in addition, there were 11 total intact wooden pallets, a large plastic discarded children's play kitchen and two full 20-gallon plastic garbage cans at the kitchen exit door. The DM said she was aware the area should have been cleaned up by Maintenance months ago, she had asked them, but nothing had been done. A follow-up observation of the kitchen's exterior exit leading to the dumpster area was made on 5/20/26 at 9:15 AM with the Maintenance Assistant and Dietary Manager (DM). The area remained in the same condition as observed on 5/20/26. The Maintenance Assistant stated the dumpster and kitchen exit areas should have been cleaned up by maintenance months ago but just hadn't got around to cleaning up the areas yet. A follow-up observation was conducted of the kitchen exit area and dumpster area on 05/20/26 at 9:55 AM with the Administrator. She stated she expected maintenance and kitchen personnel to ensure the dumpster area to be free of debris and refuse, which currently was not, and a potential for pests and rodents. A follow-up observation and interview were conducted of the kitchen exit area and dumpster area on 05/20/26 at 12:41 PM with the Maintenance Director and District Dietary Manager. Observed up against and around the dumpster area wall included: Scattered leaves, broken tree limbs, discarded large white wooden door, large pile of broken pieces of white door trim, 11- intact wooden pallets, and large quantity of scattered cigarette butts, a discarded children's play kitchen, as well as two full 20-gallon plastic garbage cans near the kitchen exit. The Maintenance Director stated it was the responsibility of Dietary and Maintenance to ensure the area around the kitchen exit and dumpster area to be clean and free of debris and was not. The Maintenance Director stated he knew for a couple of months that the refuse and garbage by the dumpster, and kitchen area should have been removed but he had not gotten to it yet. A follow-up interview was conducted on 05/20/26 at 3:00 PM with the Administrator. She said she expected maintenance to ensure the exterior exit leading to the dumpster area and dumpster area were free of debris and cleaned up within the next couple of weeks and not remain a potential home for pests and rodents.

Based on record review, staff and Nurse Practitioner interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications for 9 of 9 residents reviewed for unnecessary medications (Resident #8, #31, #46, #84, #27, #12, #3, #6, and #9). Findings included: a. Resident #8 was admitted on [DATE] with a diagnosis of depression. Review of Resident #8's electronic health record revealed physician orders dated 3/23/26 for duloxetine (an antidepressant) 60 milligrams (mg) twice per day, lorazepam (an antianxiety medication) 0.5 mg four times per day and Seroquel (an antipsychotic medication) 25 mg twice per day. Review of Resident #8's electronic health record revealed no consent form dated 3/23/26 for the psychotropic medications duloxetine, lorazepam and Seroquel. There was no evidence that the resident or resident representative were informed in advance of the risks and benefits of the psychotropic medications. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that Resident #8 had a severe cognitive impairment, demonstrated no behaviors, and received the following psychotropic medications: antipsychotics, antianxiety and antidepressant medications. Review of Resident #8's electronic Medication Administration Record (MAR) for March 2026 revealed that the resident received the psychotropic medications duloxetine, lorazepam and Seroquel daily as ordered. b. Resident #31 was admitted on [DATE] with diagnosis that included dementia and depression. Review of Resident #31's electronic health record revealed physician orders dated 11/3/25 for mirtazapine (an antidepressant) 7.5 mg at bedtime for insomnia and sertraline (an antidepressant) 50 mg once daily for depression. Review of Resident #31's electronic health record revealed no documentation of consent for the administration of mirtazapine and sertraline dated 11/3/25. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of psychotropic medication. Review of Resident #31's electronic MARs from November 2025 through May 2026 revealed the resident received the psychotropic medications mirtazapine and sertraline daily as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 had a severe cognitive impairment, demonstrated no behaviors, and received the following psychotropic medication: antidepressant. c. Resident #46 was admitted on [DATE] with diagnosis which included Parkinson's disease and dementia with behaviors including restlessness, agitation, resisting care and verbal behaviors. Review of Resident #46's electronic health record revealed an order dated 2/12/26 for Seroquel (an antipsychotic medication) 25 mg twice daily. Review of Resident #46's electronic health record revealed there was no consent form for Seroquel dated 2/12/26. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #46's electronic MARs for February, March, April and May 2026 revealed that the resident received the psychotropic medication Seroquel 25 mg twice daily as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #46 had a severe cognitive impairment, demonstrated verbal behaviors and rejection of care, and received an antipsychotic medication. d. Resident #84 was admitted on [DATE] with diagnosis of hypertension and depression. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #84 had a severe cognitive impairment, demonstrated no behaviors, and did not receive any psychotropic medications. Review of Resident #84's electronic health record revealed that the face sheet demographic information listed the resident as his own responsible party. Review of Resident #84's electronic health record revealed a physician order dated 5/6/26 for mirtazapine (an antidepressant) 7.5 mg at bedtime for insomnia. Review of Resident #84's electronic health record revealed no resident or responsible party consent signed and dated 5/6/26 for mirtazapine 7.5 mg at bedtime for insomnia. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #84's electronic MAR for May 2026 revealed that the resident received the psychotropic medication mirtazapine 7.5 mg at bedtime daily starting on 5/6/26. e). Resident #27 was admitted to the facility on [DATE] with a diagnosis of dementia and anxiety. Review of the Resident #27's physicians' orders revealed an order dated 2/4/2026 for quetiapine 25 milligrams (mg) tablet; administer 25 mg at bedtime for restlessness and agitation. Review of Resident #27's physicians' orders revealed an order dated 3/3/2026 for the antipsychotic medication quetiapine 25 (mg) tablet; administer one tablet twice a day for dementia. Review of Resident #27's electronic Medication Administration Records from 3/3/2026 through 5/21/2026 revealed that the resident was administered quetiapine 25 mg twice a day starting 3/4/2026. A review of Resident #27's electronic medical record (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic antipsychotic medication quetiapine prescribed for dementia on 3/3/2026. In addition, there was no documentation of consent to treat with the psychotropic medication quetiapine in the record. Review of Resident #27's annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #27 was moderately cognitively impaired and received an antipsychotic medication. f). Resident #12 was admitted to the facility on [DATE] with mild recurrent major depressive disorder and muscle spasms. Resident #12's physician orders revealed the following orders dated 12/22/2025 for the antianxiety medication diazepam 2 mg tablet; administer 2 tablets for 4 mg once day for muscle spasms and duloxetine 60 mg capsule; administer one capsule orally every day for mild recurrent major depressive disorder. Review of Resident #12's (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic medication duloxetine prescribed for depression and the antianxiety medication diazepam prescribed for muscle spasms. In addition, there was no documentation of consent to treat with the psychotropic medications duloxetine and quetiapine and diazepam in the record. Review of Resident #12's electronic Medication Administration Record from 12/22/2025 through 5/21/2026 revealed that the resident received the antidepressant duloxetine and the antianxiety diazepam as ordered. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed he was cognitively intact and received an antianxiety medication and an antidepressant medication. g). Resident #3 was admitted to the facility on [DATE]. Diagnoses included, in part, schizophrenia and major depressive disorder. Review of Resident #3's electronic health record revealed a physician order dated 01/06/26 for Fluoxetine (an antidepressant) 40 milligrams (mg) daily and an additional order written on 04/13/26 for Fluoxetine 10mg daily. The order indicated Resident #3 was to take a total of 50mg daily effective 04/13/26. Review of Resident #3's electronic health record revealed there was no consent form dated 01/06/26 for the psychotropic medication Fluoxetine 40mg daily and no consent form dated 04/13/26 for the Fluoxetine 10mg daily for a total of 50 mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #3's electronic health record revealed a physician order dated 01/06/26 for Buspirone (an antidepressant) 15mg twice daily. Review of Resident #3's electronic health record revealed there was no consent form dated 01/06/26 for the psychotropic medication Buspirone 15mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #3's electronic health record revealed a physician order dated 04/06/26 for Trazodone (an antidepressant) 150mg daily at night. Review of Resident #3's electronic health record revealed there was no consent form dated 04/06/26 for the psychotropic medication Trazodone 150mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 was cognitively intact, demonstrated no behaviors, and received the following psychotropic medications: antipsychotics, antianxiety and antidepressant medications. h). Resident #6 was admitted to the facility on [DATE]. Diagnoses included, in part, schizoaffective disorder, bipolar, anxiety, and depression. Review of Resident 6's electronic health record revealed a physician order dated 01/03/26 for Risperdal Consta (an antipsychotic medication) Extended Release 25mg/2milliliters (ml) give 25 mg intramuscular once every two weeks on Monday. Review of Resident #6's electronic health record revealed there was no consent form dated 01/03/26 for the psychotropic medication Risperdal Consta 25mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. The MDS quarterly review dated 03/01/26 revealed Resident #6 was moderately cognitively impaired, demonstrated no behaviors and received the following psychotropic medications: antipsychotics and antidepressant medications. i). Resident #9 was admitted to the facility on [DATE]. Diagnoses included, in part, anxiety, depression and dementia with behavioral disturbance. Review of Resident #9's electronic health record revealed a physician order dated 02/04/26 for Seroquel (an antipsychotic) 25mg twice per day and an order for Seroquel 50mg give with 25mg dose to equal 75mg daily at night. Review of Resident #9's electronic health record revealed there was no consent form dated 02/04/26 for the psychotropic medication Seroquel 25mg or 50mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #9's electronic health record revealed a physician order dated 02/04/26 for Trazodone (an antidepressant) 50mg one tablet daily at night. Review of Resident #9's electronic health record revealed there was no consent form dated 02/04/26 for the psychotropic medication Trazodone 50mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. Review of Resident #9's electronic health record revealed a physician order dated 02/05/26 for Escitalopram Oxalate (an antidepressant) 5mg once daily. Review of Resident #9's electronic health record revealed there was no consent form dated 02/05/26 for the psychotropic medication Escitalopram Oxalate 5mg. There was no evidence that the resident or resident representative was informed in advance of the risks and benefits of the psychotropic medication. The MDS quarterly review dated 03/24/26 revealed Resident #9 was moderately cognitively impaired, demonstrated no behaviors was receiving the following psychotropic medication: antidepressant medication. An interview with Nurse #1 on 05/20/26 at 2:40 PM revealed he believed the Admissions Nurse; the Director of Nursing or the Unit Manager were responsible for obtaining a consent for residents on psychotropic medication. He stated he had never obtained the consents for Resident #9's psychotropic medications. An interview was conducted with the Director of Nursing (DON) on 05/20/26 at 4:15 PM. The Director of Nursing stated that the nurses assigned to the resident were expected to obtain the consent for the psychotropic medications on admission and whenever the physician orders were changed with increases or any addition of a new medication. The DON stated that she was overall responsible to ensure that the consents was obtained prior to the medication being initiated. The DON confirmed that there were times that the consents were not obtained prior to the medication being administered. The DON indicated that she had been working on trying to improve the process of obtaining the consents and informing the resident and resident representative of the risks verses benefits of the psychotropic medications. The DON stated she has been trying to reeducate the staff about this but not all staff have been educated yet.

Based on record review, and staff, resident and the Physician Assistant interviews, the facility failed to provide a resident with dignity and respect when she was not provided incontinence care when requested and was left in a soiled brief and felt gross as a result of having to wait. This was for 1 of 2 residents observed for dignity (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE]. The Minimum Data Set quarterly assessment dated [DATE] revealed resident was cognitively intact, with adequate vision and demonstrated no behaviors such as refusal of care. Resident #3 was fully dependent on all activities of daily living (ADL) care. Resident was always incontinent of bowel and had an indwelling urinary catheter. An interview with Resident #3, who had a tracheostomy (a procedure to include placing a breathing tube into the trachea or windpipe) and she wears a Passy Muir Valve (PMV) which is a one-way speaking and swallowing valve for tracheostomy residents to aide in verbally communicating, on 05/19/26 at 11:10 AM. Resident #3 revealed that on 05/13/26 she reported to Nurse Aide (NA) #3 at 12:30 PM she was incontinent of bowel in her brief. She stated she was already out of bed in her wheelchair and it would have required two staff members to put her back into bed to change her. She stated she was told by NA #3 that she could not get to her right now because she had to go to the dining room. Resident #3 reported she was not eating lunch so she was not eating while being soiled, but she wanted to go outside on the porch and did not want to go out smelling of poop. Resident #3 stated she had to wait until after lunch to be changed. Resident #3 stated she reminded NA #3 after lunch at 1:10 PM that she needed to be changed again and NA #3 stated she needed to find another staff member to assist with getting her changed. Resident #3 stated it was not until 2:50 PM that she was finally changed. Resident #3 stated she did not go outside on the porch and felt gross sitting in a brief filled with feces for almost 2.5 hours. A phone interview was conducted with NA #3 on 05/21/26 at 2:00 PM. NA #3 stated on 05/13/26 she was assigned to Resident #3. She stated Resident #3 required 2 staff members when providing incontinence care. NA #3 stated on 05/13/26, Resident #3 told her she was incontinent of bowel and needed to be changed. NA #3 did not recall the exact time, but she told Resident #3 she had to feed the residents in the dining room and she would take care of her when she got back. NA #3 stated it usually took 30 to 35 minutes in the dining room. NA #3 stated when she returned from the dining room, she was waiting for NA #2 to be available and assist her with changing Resident #3 which took about another 15 minutes. NA #3 stated Resident #3 had to wait about 45 minutes and was changed before 1:30 PM not 2:50 PM. NA #3 stated she knew Resident #3 was waiting to go out on the porch. An interview was conducted with NA #2 on 05/22/26 at 12:30 PM. NA #2 stated on 05/13/26 Resident #3 told her she was incontinent of bowel and needed to be changed about 1:00 PM. NA #2 stated she told Resident #3 she would let NA #3 know so that she could assist her. NA #2 stated she told NA #3 and NA #3 told NA #2 to give her a second. NA #2 stated she was not sure how long it actually took until NA #3 was ready to assist with changing Resident #3. NA #2 stated NA #3 was in the dining room, but she was back on the hall by 12:30 because lunch time was 12:00 PM in the dining room and usually took about 30 minutes. NA #2 stated when she and NA #3 changed her the bowel had not leaked through the brief and her skin was intact. An interview with Nurse #1 on 05/22/26 at 2:10 PM was conducted. Nurse #1 stated he was not made aware by Resident #3 or the nurse aides that Resident #3 was incontinent and needed to be changed. He stated had he been told he would have assisted NA #2 with changing Resident #3. An interview with the Director of Nursing (DON) on 05/22/26 at 3:00 PM revealed she would have expected NA #3 to assist with changing Resident #3 before she left for the dining room and not to let Resident #3 sit in her soiled brief. The DON added that this unit had 14 residents and had one of the nurse aides notified the Nurse, he could have assisted with changing Resident #3. The DON stated she had given education several times due to multiple grievances to the staff on this unit that anytime another nurse aide was not available to assist with Resident #3, the nurse aides should be seeking help from the floor Nurse, a Unit Manager, other aides from other units, or herself to help assist. An interview with the Physician Assistant on 05/22/26 at 3:30 PM revealed there was no reason Resident #3 had to sit in her soiled brief for an extended period of time. The Physician Assistant stated she was not sure how long exactly Resident #3 sat in her brief but that it was close to an hour. The Physician Assistant stated no resident should have to sit in soiled brief for this long when staff were made aware she needed to be changed.

Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to notify the provider and responsible party (RP) of transfer from dialysis to the emergency department (ED) due to a shunt bleeding event at dialysis for 1 of 2 sampled resident reviewed for dialysis (Resident #2). Findings included:Facility's Dialysis Policy dated 7/9/23 read in part: Facility staff will monitor for any signs and symptoms of potential dialysis related complications, including bleeding. The facility staff will notify the resident's physician immediately of any of the above findings.Resident #2 was admitted on [DATE]. His medical diagnoses included end state renal disease (ESRD) and stroke.Reviewof Resident #2's Medical Administration Record (MAR) dated 5/2026 revealed to give Eliquis (a prescription anticoagulant/blood thinner used to prevent risk of stroke) 2.5 mg (milligram) twice daily due to stroke, and to monitor dialysis fistula site for sign or symptom of increased drainage. Further review of the medical record for Resident #2 revealed no documentation of the resident being sent to the ED from dialysis on 03/30/26. There was no documentation that the physician or the Resident's Responsible Party (RP) were notified of resident's 3/30/26 bleeding event at the dialysis center and transfer to the ED. A nursing note dated 3/30/26 at 10:22 PM from Nurse #8 revealed Resident #2 returned from hospital via ambulance on stretcher. His vital signs were within normal limits, with no bleeding noted through pressure dressing to fistula site. An interview was conducted on 5/19/26 at 8:25 AM with Nurse #6. She stated on 3/30/26 she neither the DON were not notified of Resident #2 being sent to the ED by the dialysis center, due to fistula bleeding. She stated the dialysis center should have notified the facility and resident's RP of the ED visit on 3/30/26 and did not.An interview was conducted on 5/20/26 at 8:25 AM with Nurse #6. She stated she was Resident #2's nurse on 3/30/26, which was resident's dialysis day. She said she assessed the resident that morning before dialysis and made sure he had a snack with him. She said she never received a call anytime throughout the day from dialysis saying they had transported the resident to the ED due to a fistula bleed. She stated it wasn't until the end of her shift, around 6:00 PM, that dialysis called, saying they had sent the resident to the ED. Nurse #6 said she thought the dialysis center would have contacted resident's Physician (MD) and RP when they first transferred him to the ED, so she did not have to. She stated now looking back she should have contacted resident's MD and RP when she was first notified around 6:00 PM from the ED, that Resident #2 was transferred to the ED from dialysis and to not have relied on the dialysis center to have notified them. She said it was her fault for not calling resident's MD and RP of resident's transfer to ED. A follow-up interview was conducted on 5/20/26 at 10:45 AM with Nurse #6. She stated on 3/30/26 she worked the 7:00 AM to 7:00 PM shift and was Resident #2's nurse. She stated around 6:00 PM she was notified by the hospital that Resident #2 was sent to the ED from dialysis due to fistula shunt bleeding while at dialysis. She stated she did not notify resident's RP or MD, because she thought dialysis would have done it since they were the ones who transferred the resident to the ED. She stated the dialysis center never contacted the facility that they had sent the resident to the ED. She said at the time, she thought the resident was still at dialysis until the hospital contacted her around 6:00 PM notifying her that they had transferred Resident #2 to the ED. The nurse stated she should have then immediately notified the MD and RP once she received the 6:00 PM phone call from the ED that Resident #2 was at the ED, and to not have expected the dialysis center to have notified MD and RP, since the resident was her patient and her responsibility, and not the dialysis centers. A follow-up interview was conducted on 5/20/26 at 10:50 AM with the DON. She stated the dialysis center contacted her on 03/31/26 to say that on 3/30/26 when Resident #2 was transferred from dialysis to ED, dialysis staff did not contact resident's RP or MD of the ED visit. DON stated that it was her expectation, that on 03/30/26, around 6:00 PM, when Nurse #6 first heard that Resident #2 was sent to the hospital from dialysis, that she should have immediately notified resident's RP and MD, since Resident #2 was still her patient, even though he was sent to the hospital from dialysis.An interview was conducted on 5/20/26 at 11:15 AM with the Physician Assistant (PA). She stated she was not notified on the evening of 3/30/26, that Resident #2 had been transferred to the ED from dialysis. She stated it was her expectation that Resident #2's physician should have been notified by his nurse the evening of 3/20/26 once the nurse was informed by the ED of the resident's transfer, so she could have then assessed the resident's situation and treated the resident if needed once he returned from the ED.An interview was conducted on 5/19/26 at 1:45 PM with the Administrator. She stated when Resident #2 was at dialysis on 3/30/26 his shunt site started to bleed so dialysis sent him to the ED for observation and treatment and failed to notify the facility or RP of the ED visit. The Administrator said the facility's nursing staff found out about the ED visit around 6:00 PM on 3/30/26 when the ED called the facility, informing them that Resident #2 was transferred from dialysis to ED, due to a fistula bleeding event, while at dialysis. The Administrator said the dialysis center should have notified the facility and RP of the ED visit and did not. She also said to the nurse, once she became aware Resident #2 transfer to the ED, she should have called the attending physician and resident's RP and did not.A follow-up interview was conducted on 5/19/26 at 3:47 PM with the Administrator. She said it was her expectation that when Nurse #6 was notified by the hospital around 6:00 PM on 03/30/26 that Resident #2 was at the ED, she should have immediately notified resident's MD and RP, since it was the facility's responsibility to notify resident's family and MD, and not dialysis.

Based on observations, record review, resident and staff interviews, the facility failed to provide incontinence care to 1 of 2 dependent residents reviewed for activity of daily living (ADL) care (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE]. Diagnoses included stroke and dermatitis (a broad term that describes various types of skin inflammation and skin rashes). Review of Resident #9's care plan revealed a plan of care updated on 01/23/2025 for urinary incontinence with a goal that Resident will be remain free from complications of incontinence such as skin breakdown and urinary tract infections (UTI). Approaches for this goal included to clean peri-area with each incontinent episode and observe for signs and symptoms of UTI such as pain, burning, blood tinged urine, no urine output, and change of behavior/mental status. The Minimum Data Set quarterly review dated 03/24/26 revealed Resident #9 was moderately cognitively impaired and did not have any behaviors such as refusal of care. Resident #9 required substantial to maximum assistance with personal hygiene and toileting and was coded as being frequently incontinent of bladder and bowel. An interview with Resident #9 on 05/18/26 at 10:30 AM revealed he asked his Nurse Aide to change him earlier this morning before breakfast and the Nurse Aide said he would be back and has not come back yet. The Resident's call light was not activated during the interview. Resident #9 stated his brief was very wet and he needed to be changed. Resident #9 stated the last time he was changed was during the night shift on 05/18/26. An interview was conducted with Nurse Aide (NA) #4 on 05/18/26 at 11:00 AM. NA #4 reported he had completed his rounds this morning on Resident #9 when he came in at 7:00 AM. NA #4 stated he was incontinent of urine at that time and he changed Resident #9. On 05/18/26 at 11:00 AM NA #4 was accompanied to Resident #9's room and NA #4 was asked to check on Resident #9 at this time. NA #4 pulled Resident #9's bed sheets down and stated when he checked Resident #9 this morning during rounds, he checked his chuck pad (a pad placed under the resident) and it was not wet so he thought Resident #9 did not need to be changed. NA #4 checked Resident #9's brief at this time and it was noted to be saturated with urine, and the chuck pad was dry. NA #4 then stated he did change Resident #9 this morning during his first round and Resident #9 stated, he absolutely did not! NA #4 then clarified that he did not actually change Resident #9 during his rounds this morning at 7:00 AM or when Resident #9 told him he needed to be changed before breakfast and that he just checked the chuck pad. NA #4 stated he should have checked Resident #9's brief and not the pad underneath the resident. Incontinence care was provided at the completion of the interview. An interview was conducted with the Treatment Nurse on 05/18/26 at 12:20 PM. The Treatment Nurse stated that Resident #9 had no skin breakdown to his peri area. An interview was conducted with the Director of Nursing (DON) on 05/22/26 at 3:00 PM. The DON reported she expected her nursing aide staff to be checking and changing residents every 2 hours during their rounds or whenever a resident requested to be changed. The DON stated NA #4 should have been checking the resident's brief and not the pad underneath him.

Based on record review and staff, Physician Assistant (PA), and Pharmacy Services Director interviews, the facility failed to provide the discharge summary needed for the pharmacist to conduct a comprehensive medication review. As a result, the pharmacist did not identify a medication error, leading to the administration of 27 doses of the anticoagulant Eliquis (a prescription blood thinner used to prevent and treat blood clots and reduce stroke risk) for 1 of 5 residents reviewed for unnecessary medications (Resident #8). Findings included: Resident #8 was admitted on [DATE] with diagnosis which included atrial fibrillation (an irregular heart rhythm) and history of falls. Review of Resident #8's electronic health record revealed that the resident was discharged to the hospital on 3/18/26 due to weakness, recurrent falls and a fall with a head strike resulting in increased confusion. Resident #8 was readmitted to the facility on [DATE]. Review of Resident #8's electronic health record revealed a hospital Discharge summary dated [DATE] which indicated to discontinue the anticoagulant medication Eliquis due to repetitive falls and the risk of bleeding. A review of the hospital discharge summary listed medications which had not changed included Eliquis 5 mg two times daily. A handwritten notation indicated the medication Eliquis was crossed out with a notation to discontinue the medication initialed by the facility Physician Assistant (PA). A review of Resident #8's electronic physician orders included an order dated 3/23/26 at 11:36 AM entered by Nurse #12 for Eliquis 5 milligrams (mg) twice per day. The start date of the medication was 3/23/36. A review of Resident #8's electronic Medication Administration Record (MAR) for March 2026 indicated that Eliquis 5 mg was administered twice daily at 8:00 AM and 6:00 PM from March 23 through March 31, 2026, with the first dose administered on 3/23/26 at 6:00 PM (a total of 17 doses were documented as administered). A review of a New admission Pharmacy Review dated 3/23/26 completed by the Pharmacy Services Director indicated no medication therapy issues were identified upon initial review. An interview was conducted by phone with the Pharmacy Services Director on 5/20/26 at 3:15 PM. He stated that he completed the initial pharmacy review of Resident #8's medications when the resident returned from the hospital on 3/23/26. During this review, he did not identify any medication therapy issues. He explained that he relied on the physician orders entered into the computer and assumed they had been transcribed accurately. Although he had access to the electronic health record, he reported that he did not review the hospital discharge summary as part of his initial pharmacy assessment as this information was frequently not available at the time of the initial review.Review of Resident #8's electronic MAR for April 2026 indicated that Eliquis 5 mg was administered twice daily on 4/1/26, 4/2/26, 4/3/26, 4/4/26, and 4/5/26 (a total of 10 doses were documented as administered). An interview with the Physician Assistant (PA) on 5/20/26 at 1:30 PM stated that when Resident #8 returned from the hospital on 3/23/26, she documented on the paper copy of the medication orders from the hospital and in her clinical notes that Eliquis was to be discontinued. She emphasized that Resident #8 was at heightened risk of bleeding and other complications if she were to fall while receiving an anticoagulant. The PA reported that she later discovered Resident #8 had erroneously received Eliquis from 3/23/26 through 4/6/26, and the pharmacist had not identified the error on the initial medication regimen review.An interview with the Director of Nursing (DON) on 5/20/26 at 4:30 PM revealed that the hospital medication orders were not faxed to the pharmacy, resulting in the Pharmacist not having the orders when the admission medication regimen was completed. Although the Pharmacist would typically be able to access the orders once they were scanned into the resident's electronic health record, this scanning did not occur for several days. The DON acknowledged that the pharmacist's inability to obtain the orders in a timely manner affected their ability to complete an accurate medication review and represented a breakdown in the facility's process.

Based on record review and staff, Physician Assistant (PA), Physician and Pharmacy Manager interviews, the facility failed to discontinue an anticoagulant medication following readmission to the facility resulting in 27 doses of the anticoagulant Eliquis (a prescription blood thinner used to prevent and treat blood clots and reduce stroke risk) administered in error to a resident that was a high fall risk. This occurred for 1 of 5 residents reviewed for unnecessary medications (Resident #8). Findings included: Resident #8 was admitted on [DATE] with diagnosis which included atrial fibrillation (an irregular heart rhythm) and history of falls. Review of Resident #8's electronic health record revealed that the resident was discharged to the hospital on 3/18/26 due to weakness, recurrent falls and a fall with a head strike resulting in increased confusion. Resident #8 was readmitted to the facility on [DATE]. Review of Resident #8's electronic health record revealed a hospital Discharge summary dated [DATE] which indicated that the resident was on a chronic anticoagulant medication for atrial fibrillation prior to hospitalization, however it was deemed unsafe for anticoagulant therapy to be continued due to repetitive falls. The hospital discharge summary indicated that a discussion was held in the hospital with Resident #8's Power of Attorney and the Physician. It was decided to discontinue the anticoagulant medication due to repetitive falls and the risk of bleeding. A review of the hospital Discharge summary dated [DATE] listed medications which had not changed included Eliquis 5 mg two times daily. However, a handwritten notation on the paper copy of the medication orders from the hospital indicated the medication Eliquis was crossed out with a notation to discontinue the medication initialed by the Physician Assistant (PA). A review of Resident #8's electronic physician orders included an order dated 3/23/26 at 11:36 AM entered by Nurse #12 for Eliquis 5 milligrams (mg) twice per day. The start date of the medication was 3/23/26. An interview was conducted via phone with Nurse #12 on 5/20/26 at 3:55 PM. Nurse #12 was identified as the nurse who inputted into the computer the medication order for Resident #8 for Eliquis 5 mg twice per day on 3/23/26. Nurse #12 stated that she had worked at the facility for a few months on an as needed basis and had only entered orders into the computer a few times. Nurse #12 reported that she was trained that the process was when a resident was admitted or readmitted the nurse received the admission packet with the medication list included and the orders were entered from that list. The Nurse stated that the provider reviewed the orders and made changes as needed. Nurse #12 reported the provider was supposed to check the orders before the nurse entered the medications into the computer. The Nurse stated that she did not recall what information she used to enter the orders for Resident #8 when she was readmitted on [DATE] and did not recall if she saw the written copy of the orders that the PA verified in which the medication Eliquis was discontinued. Nurse # 12 stated she was unaware that she had entered Resident #8's medication orders incorrectly resulting in a significant medication error. A review of the PA progress note dated 3/24/26 indicated that Resident #8 had experienced recurrent falls, and the risks of continued anticoagulation therapy were determined to outweigh the benefits. As a result, Eliquis was discontinued after the hospital physician discussed this with the resident's Power of Attorney during the recent hospitalization.An interview with the Physician Assistant (PA) on 5/20/26 at 1:30 PM revealed that Resident #8 was identified as high risk for falls upon admission on [DATE]. The PA stated that the anticoagulant Eliquis was contraindicated for Resident #8 due to her elevated fall risk and history of falls. The PA further explained that when Resident #8 returned from the hospital on 3/23/26, she documented in the paper copy of the medication orders from the hospital and in her clinical notes that Eliquis was to be discontinued and the resident was not to receive the anticoagulant. The PA stated that she reviewed the hospital documentation and was reassured to see that the hospital physician addressed the anticoagulant therapy with the resident's Power of Attorney, and Eliquis was discontinued at that time. She emphasized that Resident #8 was at heightened risk of bleeding and other complications if she were to fall while receiving an anticoagulant. A review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #8 had severe cognitive impairment and received an anticoagulant medication.A review of Resident #8's electronic Medication Administration Record (MAR) for March 2026 indicated that Eliquis 5 mg was administered twice daily at 8:00 AM and 6:00 PM from 3/23/26 through 3/31/26, with the first dose administered on 3/23/26 at 6:00 PM (a total of 17 doses were documented as administered).Review of Resident #8's electronic MAR for April 2026 indicated that Eliquis 5 mg was administered twice daily on 4/1/26, 4/2/26, 4/3/26, 4/4/26, and 4/5/26 (a total of 10 doses were documented as administered). A nursing progress note dated 4/6/26 at 8:46 AM written by Nurse #1 indicated that Resident #8 was noted sitting on the floor mat beside the bed. The resident stated she tried to get out of bed when she fell and hit her head on the side table. The note indicated Resident #8 voiced no complaints of pain or discomfort at the time of the incident and neurological checks were within normal limits. The provider was notified of the incident. A Physician Assistant (PA) progress note dated 4/6/26 at 1:30 PM indicated Resident #8 had a fall this morning in which she hit her head. The resident was seen after the fall. Resident #8 reported a headache but denied dizziness. Nursing reported Resident #8 had been receiving Eliquis since 3/23/26. The PA progress note indicated that this was a medication error which was discussed with the Director of Nursing (DON). A CT (computed tomography) scan of the head was ordered STAT (as soon as possible) instead of sending the resident out to the emergency department. If neurological checks changed or she developed signs and symptoms of head bleed or headache worsens the resident will be sent to the emergency department. Resident #8 was seen on afternoon rounds and continued to have a headache. A physician order dated 4/6/26 indicated to discontinue Eliquis 5 mg twice per day. A nursing progress note dated 4/6/26 at 6:00 PM written by Nurse #13 indicated that a new order was received to send Resident #8 to the emergency department for evaluation and treatment due to a fall with a head strike and the facility was unable to obtain a Stat CT scan. A nursing progress note written by the Director of Nursing dated 4/7/26 at 12:45 PM listed as a late entry recorded on 4/8/26 at 12:48 PM indicated Resident #8 had a fall on 4/6/26 and received Eliquis in error. The note indicated that Eliquis was now discontinued. A PA progress note dated 4/7/26 at 1:47 PM indicated that a Stat CT could not be scheduled for 4/6/26 so Resident #8 was sent to the emergency department for evaluation. A CT scan obtained at the hospital indicated no evidence of acute intracranial abnormality. Resident #8 returned to the facility with no new orders. An interview with the Physician Assistant (PA) on 5/20/26 at 1:30 PM revealed she later discovered Resident #8 had erroneously received Eliquis from 3/23/26 through 4/6/26, describing this as a significant medication error. An interview with the Director of Nursing (DON) on 5/20/26 at 4:30 PM revealed that when a resident was admitted or readmitted to the facility the physician orders were to be verified by the Physician Assistant (PA) or the physician, after which the first nurse was responsible for entering the orders into the computer system. She reported that the hospital medication orders were not faxed to the pharmacy and, as a result, the pharmacy did not receive a copy of the orders. Although the pharmacy would normally be able to access the orders once they were scanned into the resident's electronic health record, this scanning did not occur until several days later. She clarified that the intended process required the nurse on the next shift to verify the orders entered by the first nurse, and to sign off confirming that the verification had been completed. According to the DON, the error occurred because Nurse #12 did not see the orders that had been verified and signed by the PA and the second check by the next shift nurse was not completed. She acknowledged that there was a breakdown in the order-entry and order-verification process. The DON further indicated that she did not investigate the medication error, did not implement a plan of correction, and was unable to explain why these steps were not taken. She stated that following the incident, she provided re-education to the nursing staff on the correct process for entering and verifying orders and she expected orders to be transcribed accurately. The DON indicated the facility did not have a process for reviewing new orders in morning meeting or a manager assigned to do this and therefore the error was not identified until the resident fell and the staff informed the PA that Resident #8 received the anticoagulant Eliquis. An interview conducted with the Physician on 5/21/26 at 4:30 PM via phone revealed that he expected the medication orders to be entered into the computer accurately. He stated that the resident receiving 27 doses of Eliquis in error constituted a significant medication error and placed the resident at an increased risk for bleeding especially with her increased fall risk.

Based on observations, record review, and staff interviews, the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to Resident #9 who had a Stage IV pressure ulcer on his heel. This occurred with 1 of 3 staff members observed for infection control practices (Treatment Nurse). Findings included: The Infection Control Policy dated 02/28/25 revealed Enhanced Barrier Precautions referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. During an observation on 05/22/26 at 10:52 AM Resident #9 was observed lying in bed. There was no Enhanced Barrier Precaution sign observed on the door of Resident #9's room and there was no Personal Protective Equipment (PPE) on the door or outside of the room. The Treatment Nurse was observed applying gloves. She then removed the offloading boot (a soft boot to protect heels while in bed) to the left heel, removed the resident's sock, and then removed the existing dressing from the left heel. The Treatment Nurse washed her hands, applied new gloves, cleansed the wound with normal saline, applied the treatment ordered for the wound and covered the wound with a foam dressing. The Treatment Nurse did not apply a gown when she was doing this pressure ulcer wound care. An interview was conducted with the Treatment Nurse on 05/22/26 at 11:02 AM. The Treatment Nurse stated she should have had a gown on while she doing the treatment on Resident #9. She stated there should have been an Enhanced Barrier Precaution sign on Resident #9's door as well as PPE set up at the resident's doorway. The Treatment Nurse stated up until a week or so, Resident #9 had a deep tissue injury to the left heel and the wound was not opened so he was not on Enhanced Barrier Precautions. The Treatment Nurse stated once that left heel opened and became a Stage IV opened wound, she should have put the Enhanced Barrier Precaution sign on his door with PPE and she should have been wearing a gown while changing this dressing. An interview was conducted with the Director of Nursing (DON) on 05/22/26 at 3:00 PM revealed the facility did not have an Infection Preventionist (IP) at this time and the Director of Nursing (DON) was acting as the IP. The DON stated all staff had received infection control training and should be following the infection control guidelines and wearing the appropriate PPE when providing direct care to residents who had any skin opening requiring a dressing. The DON added that Resident #9 should have had a sign on his door for Enhanced Barrier Precautions since he had an opened Stage IV pressure ulcer wound.

Based on observations, record review, and interviews with staff, Responsible Party (RP), Nurse Practitioner (NP), and Medical Director, the facility failed to provide the necessary supervision to prevent Resident #1, a resident with severe cognitive impairment and a known history of an unsupervised exit, from leaving the facility at night without staff's knowledge when the outside temperature was 30 degrees Fahrenheit (F). On 2/9/2026 at approximately 11:55 PM, two individuals unknown to the facility who had been walking through the facility's parking lot, returned Resident #1 in her wheelchair to the facility and alerted Nurse #3 that they had found the resident outside by herself, sitting in a ditch. Staff were unaware the resident was missing and outside unsupervised. The facility's alarm device system (an electronic system utilized to manage wandering behaviors for residents by triggering an alarm and locking doors when a resident wearing an electronic monitoring device approached an exit) was not functioning at all exit doors. Resident #1, who wore an electronic monitoring device, was supposed to be on observational monitoring every 15 minutes, but these checks were not implemented. Resident #1 was last seen approximately 1 hour and 10 minutes prior to the time she was brought back to the facility. Resident #1 was not injured; however, there was a high likelihood of serious harm, injury, or death, with risks that included hypothermia (a life threatening medical emergency that occurs when core body temperature drops below 95 F) and injuries from falling and/or being struck by a vehicle. This deficient practice affected 1 of 3 residents reviewed for accidents.Immediate Jeopardy began on 2/9/2026 when Resident #1 exited the facility unsupervised at night in below freezing temperatures. The immediate jeopardy was removed on 2/27/2026 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit and dementia with agitation. Resident #1 resided on the 200 hall.Resident #1's care plan, initiated on 10/23/2024 and last reviewed/revised on 12/8/2025, revealed a plan of care addressing cognitive loss/dementia or impaired thought processes related to dementia and a Brief Interview for Mental Status (BIMS) score of less than 13 (a score of less than 13 indicates cognitive impairment). Resident #1 displayed the following cognitive problems: inattention, disorganized thinking, and an altered level of consciousness. The interventions included asking yes/no questions to determine the resident's needs and cueing, reorienting, and supervising as needed. The care plan also indicated the resident experienced wandering. The interventions included ensuring the resident had properly fitting and appropriate footwear, equipping her with a device that alarmed when she approached exit doors, checking the device for proper functioning daily, and checking its placement every shift. Resident #1's care plan further indicated she was at high risk for falling related to cognitive function, weakness, and deconditioning. The interventions included for her to have a low bed with fall mats to both sides of bed, nonskid footwear, and staff to provide frequent checks for safety The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired. She was dependent on staff for transfers to a wheelchair and was able to independently wheel 150 feet once seated. Resident #1 was coded for wandering behaviors that occurred 4-6 days a week and for wearing a wandering/elopement alarm device. An active physician's order (initiated on 10/2/2024) directed staff to check Resident #1 for proper alarm device placement, test the battery every shift, and check the alarm device expiration date and replace it prior to expiration.An interview was completed with the Director of Nursing (DON) on 2/25/2026 at 11:29 AM. She indicated that Resident #1 had exited the facility without supervision in the past (previously cited by the State Agency). She stated that the first time Resident #1 exited the facility, she had gotten approximately 20 feet from the front entrance of the facility and fell at the end of the sidewalk. The DON revealed that the facility's alarm device system had not been working properly since the beginning of January 2026. She indicated the audio alert signal was not functioning properly for the 200 hall exit door and they were unable to hear the alert when residents wearing a safety alarm device approached the door. She explained that the annunciator (the device that provided visible and audio alerts to staff when a resident wearing alarm device approached the door or exited the door) for the door was not functioning and the alarm for the 200 hall exit door was not able to be heard in the facility. She stated that all other doors in the facility were functioning. She further stated the system was unable to be repaired until 3/23/2026. She indicated in the interim, she had initiated every 15-minute checks by staff for safety for the residents who were identified as high risk for elopement, including Resident #1. The DON stated the nursing staff were supposed to be documenting the every 15-minute checks on the residents. An interview with the Administrator was completed on 2/25/2026 at 1:45 PM. The Administrator stated she was aware that the facility's alarm device system was not working properly for the 200 hall exit door. She indicated that she had contacted the door safety alarm company on 1/8/2026 regarding the system not functioning properly. The Administrator indicated that the alarm device company had sent a representative to determine the problem and identified that the annunciator needed to be repaired. She indicated that the project manager had informed her the repairs would be done on 3/23/2026. The Administrator indicated that in the interim, the nursing staff had implemented every 15-minute checks for the residents identified as at high risk of elopement. She reported that Resident #1 was at high risk for elopement. An interview was completed with the Maintenance Director on 2/26/2026 1:45 PM. The Maintenance Director stated he was the person responsible for changing the codes on the security alarm doors that exited to the outside of the facility. This included the 200-hall exit door. He further stated that the code was only given to staff members and that it was changed frequently. The Maintenance Director stated that he was aware the door alarm system had not been working properly for the 200 hall exit door due to annunciator not sounding. The Maintenance Director indicated that the system was going to be replaced by the manufacturer on 3/23/2026 because someone had tampered with the audio part of the system to try to decrease the loudness of the alarm. He stated that the 200 hall exit door was the only door affected, and that the front door and all other door alarm systems were operating. The Maintenance Director indicated that all of the doors would open after being pushed on for 15 seconds for fire safety, but the 200 hall exit door was the only door that was not alarming when a resident with an alarm security device approached the door or exited the door. Review of the February 2026 Medication Administration Record for Resident #1 revealed on 2/9/2026 on the 3:00 PM to 11:00 PM shift Nurse #1 documented the electronic alarm device was on Resident #1's left ankle and the battery was working. A telephone interview was completed with Nurse #2 on 2/26/2026 at 10:56 AM. Nurse #2 stated that she was the charge nurse on the 300 hall on the 3:00 PM to 11:00 PM shift on 2/9/2026. She further stated that at around 10:45 PM that night she observed Resident #1 self-propelling in her wheelchair on the 300 hall. Nurse #2 stated she called Nurse #1 and told her Resident #1 was on her hall. She indicated Nurse #1 came and retrieved Resident #1 from the 300 hall and took her back to the 200 hall. Nurse #2 stated that was the last time she observed Resident #1 that night.A nurses' progress note written by the Director of Nursing (DON) on 2/10/2026 at 12:05 AM indicated staff reported to the DON that the resident was observed by the 100 hall exit door. She was assisted from the area back to her room. A skin check was completed with no areas of concern. Vital signs were within normal limits, her temperature was 98.0 F. The Physician and Responsible Party (RP) were made aware of the event and staff were to maintain close supervision.WeatherUnderground.com listed the temperature in [NAME] as 30 degrees F on 2/9/2026 at 11:53 PM. An interview was conducted on 2/25/2026 at 2:50 PM with Medication Aide (MA) #1 who was working on 2/9/2026 at 3:00 PM to 2/10/2026 at 7:00 AM on the 200 hall, the hall where Resident #1 resided. MA #1 explained that the assignment for the 200 hall was split into the front section of the hall and the back section of the hall. Resident #1 resided on the front section of the 200 hall. MA #1 stated that she was assigned to the back section of the 200 hall on the 3:00 PM to 11:00 PM shift and Nurse #1 was assigned to the front section of the hall that shift. MA #1 further stated that Resident #1's every 15-minute checks were supposed to be done by Nurse #1 as Resident #1 resided on Nurse #1's assignment. MA #1 explained that she was working a double shift that night and that she was supposed to have picked up the front section of the 200 hall on the 11:00 PM to 7:00 AM shift (beginning on 2/9/2026 and ending on 2/10/2026), but that Nurse #1 had been charting at the desk, they had not counted the narcotics together, and she had not received the keys to the medication cart at 11:00 PM on 2/9/2026. MA #1 indicated that she felt Nurse #1 was still responsible for Resident #1's every 15-minute checks after 11:00 PM because Nurse #1 was still in the building and she (MA #1) had not assumed responsibility for the medication cart and the sheet with the Resident #1's every 15 minutes checks on it. MA #1 stated that she was unaware that Resident #1 was missing from the facility until Nurse #2 brought Resident #1 back to the unit around 12:00 AM. She indicated that she last saw Resident #1 on 2/9/2026 prior to her unsupervised exit when Nurse #1 returned the resident to the 200 hall around 10:45 PM.An interview was completed with Nurse #1 on 2/25/2026 at 3:09 PM. Nurse #1 stated that she was the charge nurse on the 200 hall on the 3:00 PM to 11:00 PM shift on 2/9/2026. She explained she was responsible for the 3 residents on every 15-minute checks on the front end of the 200 hall during that shift. Nurse #1 stated that at around 10:15 PM on 2/9/2026, Resident #1 lowered herself onto the floor from her floor bed (a bed in which the mattress is floor level utilized for residents that were at risk for falls) and was scooting on her bottom on the floor. She indicated this wasn't an abnormal behavior for Resident #1. Nurse #1 indicated that she had gotten Resident #1 up in her wheelchair and that the resident was self-propelling herself down the hallway via wheelchair. She stated that at around 10:45 PM Nurse #2 (the nurse on the 300 hall) had called her and let her know that Resident #1 was on the 300 hall. She indicated she went to get the resident and returned her to the 200 hall and positioned her beside the nurses' station. Nurse #1 indicated that she (Nurse #1) sat down at the nurses' station to complete her computer documentation at around 11:00 PM and that she was not conducting every 15 minutes checks on Resident #1 like she was supposed to do. She explained she was trying to get her computer charting completed because her shift was over at 11:00 PM. Nurse #1 stated she felt responsible for Resident #1 exiting the facility because she was the nurse and she was still in the building at the time of the unsupervised exit. She indicated that when the resident was brought back inside the facility, Nurse #3 had placed blankets on Resident #1 because the resident was complaining of being cold. She stated that Resident #1 did not have any scratches or injuries on her, and her clothes were not dirty or soiled from being outside. Nurse #1 stated that she had called the on-call provider, the RP, and the DON. Nurse #1 stated that the DON arrived at the facility within a few minutes.A telephone interview was completed with Nurse #3 on 2/26/2026 at 4:10 AM. Nurse #3 stated she was the charge nurse on the 100 hall on 2/09/2026 at 11:00 PM through 2/10/2026 at 7:00 AM. She further stated that she was sitting at the nurses' station documenting on the computer, when she heard a loud banging on the rear glass door of the unit a little before midnight. Nurse #3 indicated two random individuals were standing at the door with Resident #1 in her wheelchair and they had stated they found her sitting in a ditch and assumed she was a resident at the facility. She stated she was unable to get any more information from them before they had taken off walking when she brought Resident #1 into the facility. Nurse #3 indicated she was not exactly sure which ditch they were talking about or if Resident #1 had fallen out of her wheelchair. Nurse #3 explained that she did not know the people that returned her to the facility, but that homeless people frequently cut across the back parking lot from the park that was located behind the facility. Nurse #3 stated she had gotten Resident #1 in the building and quickly applied several blankets on her because she (the resident) was complaining of being cold. Nurse #3 indicated it was very cold that night and Resident #1 was just wearing a light jacket, pants, shirt, and socks and shoes. She stated that she had quickly took Resident #1 to her room on the 200 hall, so she and the DON could take her vital signs and assess her for injuries. Nurse #3 indicated Resident #1's temperature was 98.0 F, her vital signs were stable, and she had no bruising, scratches, or dirt on her clothing. She explained that the resident did not appear to have fallen out of her wheelchair based on her appearance. She stated Resident #1 was not shivering and her lips were pink. Nurse #3 stated prior to Resident #1 being returned to the facility after the unsupervised exit, she had not seen Resident #1 that night and she was not aware Resident #1 was outside. Review of the medical record revealed Nurse #3 did not document her assessment of Resident #1 on 2/9/26. A telephone interview was conducted on 2/26/2026 at 4:25 AM with NA #2. NA #2 confirmed she was the NA assigned to care for Resident #1 on 2/9/2026 beginning at 11:00 PM through 2/10/2026 at 7:00 AM. She indicated that at the beginning of her shift the first thing she did was stock her cart with supplies for incontinence rounds. She stated she was answering call lights and was not conducting every 15-minute checks on Resident #1. She further stated that she thought Resident #1 was in bed during this time and that the nurse was conducting every 15-minute checks. NA #2 explained she was unaware Resident #1 was not in the facility until she was returned to the unit by Nurse #3.An interview was completed with Nurse Aide (NA) #1 on 2/25/2026 at 2:05 PM. NA #1 stated she was assigned to work the 200 hall on 2/9/2026 at 11:00 PM through 2/10/2026 at 7:00 AM. She stated that she was not the NA assigned to care for Resident #1 as she was working the back section of the 200 hall (Resident #1 resided on the front section of the 200 hall). NA #1 indicated she didn't know Resident #1 was missing and she had not seen her until Nurse #2 returned her to the unit in her wheelchair. She indicated that it was about 12:00 AM when Resident #1 was returned to the unit. NA #1 stated that the assigned nurse was responsible for conducting every 15-minute checks on the residents on her assignment that wore alarm devices. She indicated that it was everyone's responsibility to keep an eye on the residents wearing the alarm devices. An interview with the Administrator was completed on 2/25/2026 at 3:25 PM. The Administrator stated that there had been some security camera videos of the incident that occurred on 2/9/2026 involving Resident #1 exiting the facility without staff knowledge or supervision. She further stated that the view of the 200 hall exit door from the security camera was obscured by a tree and the dumpster area. The Administrator indicated that they had determined Resident #1 must have exited from the 200 hall door by process of elimination because the other exit doors were visible on the security camera and the resident had not exited through any of those doors. The Administrator explained that the only video footage that had shown Resident #1 was of her being pushed across the back parking lot by two people to the 100 hall door on 2/9/2026 at 11:55 PM. The Administrator indicated the facility was unable to determine the exact time of exit but none of the staff recalled seeing her after 10:45 PM. During an interview with the Administrator on 2/25/2026 at 1:45 PM she stated that she no longer had the security camera video from 2/9/2026 of Resident #1 being outside. She explained that the security system tapes were recorded over every 7 days. An observation of the 200 hall exit door and the back parking lot was conducted in the presence of the Administrator on 2/25/2026 at 3:45 PM. The 200 hall exit door was a fire door that led to the back parking lot of the facility. The Administrator entered the code to exit the door and explained that if someone pushed on it for 15 seconds it would open due to fire safety regulations. Upon exiting the 200 hall door there was a tree with branches that obscured the full view of the exit door. There was a sidewalk to the right of the 200 hall exit door that led to the 300 hall door and to the left led into the staff parking lot. Directly in front of the 200 hall door was a dirt path that went into the trees behind the facility. The dirt path was covered with pine needles and led down to a 2-lane road approximately a hundred yards from the 200 hall exit door of the facility. During the observation, two random men wearing coats and backpacks emerged from the woods and cut across the back of the parking lot. There were 2 large security light poles and security lights were observed on the building. The staff parking lot to the left of the 200 hall door led to a large approximately 8-foot-deep ditch and a water retention pond with a fence around it. The facility was the last building on the street and there was a cul-de-sac that led to the guest parking lot in front of the building and the staff parking lot was in the back of the building.An interview with the DON in the presence of the Administrator was completed on 2/25/2026 at 3:15 PM. The DON stated that she had received a call from the facility on 2/9/2026 around 12:00 AM regarding Resident #1's elopement and she had arrived at the facility within minutes. She stated the facility had immediately conducted a full census bed count and all residents were accounted for. The DON stated that she assessed Resident #1 for any injuries and there were no bruises or scratches upon assessment. She stated that Resident #1's vital signs were within normal limits and her temperature was 98.0 F. The DON indicated the nursing staff were supposed to conduct every 15-minute checks on Resident #1, but the incident occurred because it happened around the change of shift and there was some ambiguity about who was responsible for performing the 15 minutes checks at the time of the incident. She explained that because Nurse #1 was still in the building completing her documentation after 11:00 PM, Nurse #1 had not technically handed over the front hall assignment to conduct every 15-minute checks on Resident #1. The DON stated that she believed Resident #1 was outside the facility for less than an hour, but they could not determine the exact time of exit. She stated that none of the nursing staff recalled seeing Resident #1 after 10:45 PM on 2/9/2026. The DON indicated that according to the staff assignment sheets, MA #1 and NA #2 were the staff members that were responsible for every 15-minute checks on Resident #1 on 2/9/2026 beginning at 11:00 PM through 2/10/2026 at 7:00 AM. She explained that there was a list of residents that were identified as high risk for wandering assigned to each medication cart that the nurse or MA were responsible for performing every 15-minute checks on. During an interview with the DON on 2/25/2026 at 11:29 AM she indicated that the investigation into the 2/9/2026 incident revealed Resident #1 had exited through the 200 hall fire door at the back of the building and was returned to the facility at the 100 hall back door at approximately 11:55 PM by two individuals who were walking through the parking lot. She stated that homeless people frequently cut through their parking lot from the trees behind the facility to the street. An interview was completed with Resident #1's Responsible Party (RP) on 2/25/2026 at 1:35 PM. The RP stated that she was notified by a nurse on 2/9/2026 at around midnight that Resident #1 had been found outside the facility. She stated she was very concerned because it had been extremely cold that night. The RP reported that the Administrator had shown her a few video clips from security camera footage depicting Resident #1 being pushed in her wheelchair across the parking lot toward the facility door by two individuals who had found her outside while walking by. She stated that Resident #1 had been dressed in a shirt, pants, a light jacket, and shoes, but her hands and face had no protection from the cold.An interview was completed with the Nurse Practitioner (NP) on 2/26/2026 at 11:00 AM. The NP stated that the facility had called the on-call provider that night at 12:25 AM and informed them that Resident #1 was found outside without supervision for an undetermined amount of time. She stated that according to the message Resident #1's vital signs were stable. The NP indicated there was a high risk for an elderly person to develop hypothermia from being outside even a short period of time with a temperature outside below 32 degrees F. The NP indicated Resident #1 had dementia and was not safe to be outside alone. She explained Resident #1 was at high risk for elopement, had exited the facility without staff supervision before, and had sustained a laceration (cut) to her head during the previous incident. The NP stated she had assessed Resident #1 for any injuries and checked her skin on 2/10/2026 and there were no bruises or scratches on her. The NP stated that if Resident #1 had fallen out of her wheelchair, she would have expected her to have some kind of injury. A telephone interview with the Medical Director was completed on 2/26/2026 at 1:38 PM. The Medical Director stated that the greatest risk for Resident #1 being outside for any length of time in below 32-degree temperature without protection from the cold would be hypothermia. The Administrator was notified of Immediate Jeopardy on 2/25/2026 at 4:35 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 was admitted to the facility on [DATE] with diagnoses of dementia, severity, with agitation. Resident #1's baseline cognitive status was confused. Resident #1 was able to self-propel via wheelchair throughout the unit, at times requiring redirection to her room. Resident #1 had a history of exit seeking behavior and was considered a high risk for elopement. Resident #1 was on 15-minute checks, which were supposed to be completed by nursing staff. These checks were assigned to the nursing staff that were assigned to the resident. However, any staff on the unit that have checked on the resident could also provide a 15-minute check as needed. On the evening of 2/09/2026 at approximately 11:55 pm, Resident #1 was escorted from the parking lot into the facility by non-facility staff. Facility staff conducted a full census bed count immediately. All residents were accounted for. Upon return to the facility, Resident #1 was assisted to her room by Nurse #3. The Director of Nursing (DON) performed a comprehensive assessment of Resident #1. Resident #1 did not have any observed injuries or other adverse findings. Her body temperature was 98 degrees Fahrenheit. Her skin was intact. Her lips were pink and she was not observed to be shivering. She was dressed in pants, shirt, jacket and shoes and socks. Resident #1 was alert and oriented to person. Resident #1 does not remember being outside and is unable to explain where she was going/what she was doing. According to Nurse #1 and Nurse #2, the resident had last been observed on 2/09/2026 at 10:45 pm. She was being returned to her unit from another area at that time. Resident #1 was continued on 15-minute monitoring checks. There were no subsequent attempts to exit the facility without supervision. Resident #1 has been placed on one-to-one monitoring beginning on 2/25/2026. One to one monitoring will continue until an electronic monitoring device can be applied. This will occur when the annunciator to the door alarm is repaired or she is able to transfer to a facility with a secure, locked unit. The annunciator is what produces the alarm sounds at the nursing stations. The quote for the repair was received on 1/14/2026 and was signed the same day by the Administrator. On 1/23/2026 the Administrator was informed by the project manager that the soonest this task could be completed would be 3/23/2026. The resident's representative and physician were notified of the incident by facility nursing staff on 2/10/2026 at 12:05am. An investigation into the incident was completed on 2/10/2026 by the Administrator and it was found that the resident had exited the 200-hall door. It was determined that Resident #1 exited the 200-hall door by reviewing security footage of each exit door. Through process of elimination, we were able to determine that Resident #1 did not exit through any other door. Resident #1 is identified in the cameras that have view of the area of the 200-hall door. During staff interviews, it was determined that 15-minute checks were not completed during shift change and for the scheduled check that followed. The staff assigned to care for the resident was responsible for the 15-minute checks, however, it had not been made clear which staff (outgoing or incoming) would complete these checks and at what time the 15-minute checks ended for one staff member and started for another. Formal assignments were not made during this event, which led to confusion about who was actually performing the task. An Elopement assessment was completed on Resident #1 on 2/25/2026 by the DON. It was determined that Resident #1 was at continued risk for elopement. Resident #1's picture and name remain in the elopement book. The elopement book contains enlarged photographs and names of residents at risk for elopement. This book is maintained at the nursing station and front desk at the facility. A Resident experiences wandering care plan was revised by the DON on 2/25/2026 to include one to one monitoring. This care plan also included the following: remove resident from other residents' rooms and unsafe situations; when the resident begins to wander, provide comfort measures for basic needs (e.g. pain, hunger, toileting, to hot / cold , etc.); and provide care, activities, and a daily schedule that resembles the resident's prior lifestyle. An audit was completed by the Administrator on 2/10/2026. The Administrator reviewed all residents who are currently at risk for elopement to ensure that appropriate interventions are in place to prevent elopement and ensure resident safety. This was done by reviewing the Elopement Risk Assessment. This assessment assists in determining who may be at high risk for elopement. It was determined that 11 residents are at high risk of elopement. None of these additional residents have exited the facility and continue on 15-minute checks. The 15-minute checks will be on-going for all high-risk residents until the wanderguard annunciators are replaced on 3/23/2026. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.A wanderer custom banner flag was added to the face sheet of all residents identified as being high risk for elopement. This was completed by the DON on 2/25/2026.A list of all residents with this banner flag will be maintained by the DON/designee and will be placed in front of the elopement books at each nursing station and the receptionist desk.An elopement drill will be conducted by the Maintenance Director on 2/26/2026. The purpose of this drill is to heighten awareness for all staff. This drill will entail the Administrator/designee safely move a resident to an undisclosed location, announcing CODE FIND (which is the facility's emergency code for a missing resident) and observing the actions of staff to determine appropriate actions per the Elopement policy. Discussions occur after the drill to highlight successes and failures of the actions. A 15-minute Resident Monitoring Tool was revised by the Corporate Compliance Manager on 02/26/2026 to include instructions for the initiation and completion of the tasks required for 15-minute checks. The revisions include the formal assignment of staff to perform 15-minutes checks, how to complete the form, who to give the form to when completed, and time changes to shifts so that the off-going shift will complete the check on the hour to ensure the oncoming shift has time to get report and assignments. The process for assignments has been revised to include the following:The assignment sheets for 15-minute monitoring checks will be completed by the DON/designee. The NA assigned to care for the resident will be assigned the responsibility of completing the 15-minute checksThe nurse in charge on the unit will delegate who will cover the checks as needed. All facility staff will be in-serviced beginning 2/25/2026 by the Staff Development Coordinator (SDC), DON and/or RN Supervisor on the above and the following: Elopement Policy: Procedures to determine residents at high risk for elopement and actions to take when a high-risk resident exits the facility unsupervised. Location of the elopement book with information on who has been identified as an elopement risk. 15-minute monitoring checks - purpose, procedure, documentation. Staff that are being in-serviced will perform a teach-back method to the individual providing the education. The teach-back method is where the staff being educated will repeat, in their own words, what they need to know or do regarding what the task is and the importance of it. The importance of supervising residents and ensuring that residents are safe while in the facility. Ensuring that during shift change, breaks and mealtimes, another employee is assigned to complete the checks. Any facility staff out on leave or on PRN (as needed) status will be educated prior to returning to duty by the Director of Nursing, Staff Development Coordinator, and/or the Nursing Supervisor. The Director of Nursing, Staff Development Coordinator and the Nurse Supervisor were advised of this responsibility on 02/25/2026 by the Administrator. The SDC will be responsible for tracking staff that have not received the education. Any newly hired staff are educated on the policy and procedures during orientation by the Staff Development Coordinator/designee. The Administrator and the Director of Nursing will be ultimately responsible to ensure the implementation of credible allegation to remove this alleged immediate jeopardy. Immediate Jeopardy Removal Date: 02-27-2026 The immediate jeopardy removal plan was validated on 3/2/2026. Resident #1 was observed to have a 1:1 sitter with her at all times. The audit conducted on 2/10/26 was verified. The education sign in sheets were reviewed for the in-services conducted with [TRUNCAT

Based on resident and staff interviews and record review, the facility failed to treat residents in a dignified manner as evidenced by staff interactions with residents that included cursing, slamming doors and arguing with residents for 3 of 5 residents reviewed for dignity (Resident #26, Resident #54, and Resident #85). Findings included: 1. Resident #26 was admitted on [DATE]. A review of Resident #26's annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact, had no behaviors, required assistance with bed mobility, transfers and toileting and was non-ambulatory. a. Review of a grievance form dated 11/11/24 indicated a grievance was completed by the Director of Nursing (DON) on behalf of Resident #26. The form indicated an incident occurred on 11/11/24 during the 7:00 AM to 3:00 PM shift between Nursing Assistant (NA) #5, Resident #26 and her family member. The incident was witnessed by the DON. The form indicated that the DON was called to Resident #26's room by the family member. A typed statement attached to the form signed by the DON dated 11/11/24 indicated: the nurse alerted the DON that the family member wished to speak with a manager. The DON went to Resident #26's room and observed NA #5 was removing dirty linens from the room and the family member was removing gloves from her hands. The family member started to explain that upon her arrival to visit she walked into the room and noticed it smelled of urine. The family member expressed concern about Resident #26's care and asked NA #5 when Resident #26 last received incontinence care. The statement indicated that as the DON, the family member and Resident #26 were talking, NA #5 came back into the room and started arguing with the family member and Resident #26. The DON informed NA #5 that she was being rude and asked her to leave the room. The family member said something, NA #5 responded using curse words and left the room. The family member stated she did not want NA #5 to provide care to Resident #26 again. The investigation concluded that NA #5 was disrespectful to the family member and the resident. Corrective action was taken and indicated that NA #5 was not to provide care for Resident #26 again. Education was provided to NA #5 regarding customer service verbally on 11/11/24 and in writing on 11/12/24. Attempts to interview NA #5 on 3/6/25 and 3/7/25 at 9:00 AM were unsuccessful. Voice messages were left and text messages sent with no return call. An interview was conducted on 3/7/25 at 11:50 AM with Nurse #4 who was assigned to Resident #26 on 11/11/24. Nurse #4 indicated he was working on 11/11/24 from 7:00 AM to 3:00 PM when Resident #26's family member came to him (Nurse #4) and had care concerns for the resident. Nurse #4 stated the family member requested to talk to the DON. Nurse #4 stated he informed the DON, and she went to Resident #26's room to talk to the family member. Nurse #4 indicated he was not involved in the discussion that ensued. Nurse #4 stated he worked with NA #5 a few times and was not aware of any problems. An interview with the DON on 3/7/25 at 12:37 PM revealed she was informed on 11/11/24 by Nurse #4 that Resident #26's family member had concerns regarding the resident's care and requested to speak with her. The DON stated she went to Resident #26's room and observed NA #5 and the family member were completing the resident's care. The DON stated she observed NA #5 arguing with the family member and Resident #26. The DON indicated NA #5 cursed in front of Resident #26. The DON asked NA #5 to leave the room. The DON stated she did not think Resident #26 was affected by the altercation at the time, but she did not recall. The DON indicated NA #5 received a written warning regarding cursing and arguing with the family member and the resident. The DON stated she started in the position at the facility in late August of 2024 and she did not know NA #5 at the time of the incident. The DON stated she was not aware of any reports of other issues involving NA #5. The DON stated she was not sure why there were customer service issues with staff members and there seemed to be a pattern of issues. The DON indicated arguing with a resident and family member and cursing were not appropriate behaviors and did not demonstrate treating a resident with dignity and respect. b. A review of a grievance reporting form dated 1/10/25 completed by Resident #26's family member stated an incident happened on the 11:00 PM to 7:00 AM shift on 1/9/25 involving Nursing Assistant (NA) #1. A description of the grievance indicated that the family member witnessed NA #1 being rude and arguing with the resident, the resident was not provided with good customer service and the NA was slamming doors. NA #1 had an attitude with the resident when asked to pick something from the floor, cursed at her, refused to pick up the item and left the room. The grievance was referred to the DON to investigate. The conclusion of the investigation was that NA #1 did not provide good customer service. The corrective action taken was that the NA was not to be assigned to the hallway that Resident #26 resided or in her room. The grievance reporting form indicated NA #1 received education regarding customer service and treatment of residents with dignity and respect. The form included no indication that other residents were interviewed to determine if they had experienced similar behaviors when NA #1 provided care. An interview was conducted with Resident #26 on 3/7/25 at 2:00 PM. Resident #26 stated she recalled the incident with NA #1 in January. Resident #26 stated that night, NA #1 came in and she was really mad. Resident #26 indicated she could tell NA #1 was mad because she kept slamming the door, she was rude and abrupt and refused to pick something up for her from on the floor. Resident #26 stated it upset her how NA #1 treated her. An interview with the Administrator on 3/7/25 at 8:30 AM revealed that NA #1 received a verbal warning and education regarding customer service and was not to be assigned to Resident #26's room. The Administrator stated the facility was going through the process with NA #1 according to the facility human resources policy. The Administrator stated NA #1 did not treat Resident #26 with dignity and respect. The Administrator indicated that she expected that all residents would be treated with dignity and respect. An interview conducted with the Director of Nursing on 3/7/25 at 9:00 AM indicated Resident #26's responsible party voiced a grievance that NA #1 was rude and disrespectful on the 11:00 PM to 7:00 AM shift on 1/9/25. The DON stated she interviewed NA #1 as part of the investigation and NA #1 stated she did not think she (NA #1) was rude. The DON stated NA #1 can be abrasive and can come across as not very nice. The DON stated she did not want to say it was just the NA's personality to not be nice, but maybe that was the problem. The DON indicated she (the DON) started in the position in August 2024, she had not gotten to know NA #1 and was not familiar with the care she provided. The DON stated that a few days after this incident there was an incident with another resident (Resident #54) and NA #1, and this indicated there was a pattern of concerns with this NA. The DON stated NA #1 was not written up for this incident on 1/9/25 and was not suspended for this incident. The DON indicated she addressed the issue as a customer service issue not an abuse issue. The DON indicated she interviewed some of the nurses that work the 11:00 PM to 7:00 AM shift and they did not report a concern regarding NA #1. The DON stated she thought there was training on the computer regarding customer service, but she did not know how often it was required. The DON stated the facility conducted a monthly meeting that was mandatory, and customer service was discussed but staff didn't always attend. NA #1 did not attend the meeting in February. There were two halls that NA #1 was not allowed to work on. The DON stated the facility was progressing through the steps of the human resources process to address the issues with this NA. The DON indicated she interviewed some residents following the incidents with NA #1 but did not record this information. The DON stated it was not appropriate for NA #1 to curse at or in front of a resident, to be rude or refuse to provide care. An interview was conducted with the NA #1 on 3/7/25 at 10:30 AM. NA #1 confirmed she was assigned to Resident #26 on 1/9/25 from 11:00 PM to 7:00 AM. NA #1 indicated the DON never talked to her about an incident with Resident # 26 or any other resident. NA #1 stated she did not recall any problems with Resident #26 and was assigned to her a few weeks ago. NA #1 stated she did not recall having any education in January regarding customer service. NA #1 stated she might have had an online in-service regarding customer service and resident rights a few months ago but she did not recall. A telephone interview was conducted with Nurse #3 on 3/7/25 at 1:35 PM. Nurse #3 indicated he was working on the 11:00 PM to 7:00 AM shift on 1/9/25 when the incident occurred between Resident #26 and NA #1. Nurse #3 stated there were incidents with other residents and NA #1 prior to this incident. Nurse #3 stated he was aware there was another resident that requested to not have NA #1 provide her care due to her attitude. Nurse #3 stated he had witnessed episodes including the night of 1/9/25 in which NA #1 was argumentative and rude to Resident #26, but he had not reported the incidents because he did not realize it was a dignity issue. An interview was conducted with Nurse #1 on 3/7/25 at 10:05 AM. Nurse #1 stated she worked 11:00 PM to 7:00 AM shift sometimes and worked with NA # 1. Nurse #1 indicated NA #1 was thorough with her work but was not friendly and came across as rude sometimes. 44890 2. A grievance reporting form dated 1/15/2025 completed by Director of Nursing (DON) stated an incident happened on the 11:00 P.M. to 7 A.M. shift on 1/14/2025 involving Nurse Assistant (NA) #1 and Resident #54 and Resident #85. A description of the grievance indicated NA #1 was speaking rudely to the resident, slamming doors, and slamming water cups on the table. She didn't change the resident when she came into the room. The grievance was investigated by the DON. The conclusion of the investigation was that NA #1 didn't provide good customer service. The corrective action taken was that NA #1 was suspended pending an investigation, education, and she was not to take care of Residents #54 and #85. The grievance reporting form indicated NA #1 had received education regarding customer service and treatment of residents with dignity and respect. The form included no indication that other residents were interviewed to determine if they had experienced similar behaviors when NA #1 was assigned to their care. a. Resident #54 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment for Resident #54 dated 11/15/2024 revealed she was cognitively intact, had no behaviors, and required assistance of staff with toileting, bed mobility, and transfers. She was coded for using a walker and a wheelchair for mobility. An interview was completed with Resident #54 on 3/7/2025 at 8:20 A.M. Resident #54 stated she recalled the incident that occurred with NA #1 on the 11:00 P.M. to 7:00 A.M shift on 1/14/2025. She further stated that NA #1 seemed mad when she came into her room to change her that night, because she turned on both bright lights, was being loud, cursing and slamming things around. Resident #54 stated she had asked NA #1 to pick something up off the floor for her and that NA #1 had started cursing and yelling at her and said she wasn't going to change her and left slamming the door. She stated that it made her feel bad and like there was something wrong with her for NA #1 to act that way. Resident #54 stated she couldn't understand why NA #1 would treat her like that and it made her feel sad. She indicated that she told the Medication Aid (MA) on the 7:00 A.M. to 3:00 P.M. shift about the incident and the DON came and filled out the grievance for her. b. Resident #85 was admitted to the facility 8/27/2024. The quarterly MDS assessment for Resident #85 dated 12/4/2024 revealed Resident #85 was cognitively intact. An interview was conducted with Resident #54's roommate, Resident #85, on 3/7/2025 at 8:27 A.M. Resident #85 stated that on 1/14/2025 at 4:00 A.M when NA #1 came into the room to change Resident #54 she was being very loud and cursing. She further stated that NA #1 slammed Resident #54's bedside table against the wall and her (Resident #54) pink plastic water cup had fallen off and broke. Resident #85 indicated that NA #1 was mad and left the room without changing Resident #54. She stated when NA #1 was acting that way it made her feel like she didn't have any rights. An interview was completed with Medication Aid (MA) #1 on 3/7/2025 at 8:35 A.M. MA #1 stated that on 1/14/2025 both Resident #54 and Resident #85 had complained to her about NA #1 being rude. She further stated that Resident #85 had shared that NA #1 was rude and slamming doors. MA #1 indicated she had informed the DON, and she said she would handle it. A facility employee action form-performance for NA #1 indicated NA#1 was written up and suspended on 1/15/2025 for residents' complaints of poor attitude, slamming doors, slamming cups on table, and not picking up something from the floor when asked. It was noted on the form that NA #1 was suspended from 1/15/20205 through 1/17/2025 and that she refused to sign the form. A telephone interview was completed with NA #1 on 3/7/2025 at 10:13 A.M. NA #1 stated that she had worked at the facility for 3 years. She further stated that when she was suspended the DON had told her she was being accused of being rude and slamming things. NA #1 indicated that she was not allowed to go in Resident #54's and Resident #85's room anymore. She further indicated she could not recall ever having an incident with Resident #54 or Resident #85. NA #1 stated she could not recall receiving any customer service education but that she had received education on dignity, respect, and abuse. She further stated most of the education provided was through online healthcare training. An interview was completed with the DON on 3/7/2025 at 09:00 A.M. The DON stated that when the incident occurred between NA #1 and Resident #54 in the presence of Resident #85 on 1/14/2025, there had already been a prior event just a few days before involving the same allegations with another resident (Resident #26). She further stated that NA #1 was written up for the first incident but received a 2-day suspension for the incident involving Resident #54 because it was starting to be a pattern. The DON indicated that NA #1 was suspended for poor customer service, for speaking rudely and being loud, slamming doors, and not changing the resident. She further indicated that NA #1 refused to sign the employee action performance form. The DON explained NA #1 was not a friendly type person and could come across as abrasive at times. The DON stated that customer service was a topic they focused on at the monthly staff meetings, and that was covered in the online healthcare training provided by the facility. An interview was completed with the Administrator on 3/7/2025 at 9:45 A.M. The Administrator stated that NA #1 was suspended for her poor customer service and rude behavior. She further stated when a disciplinary issue arose with a staff member, the facility followed the procedure outlined in the employee handbook, verbal counseling, written warning, suspension, and termination. The Administrator indicated that she considered being rude, loud, and slamming doors a customer service issue. She further indicated that she expected the residents to be treated with dignity and respect.

Based on record review and interviews with resident, staff, and Physician Assistant (PA), the facility failed to protect the resident's right to be free from physical abuse when the resident reported pain during care and the Nurse Aide (NA) willfully disregarded the resident's complaint and continued to provide care to the resident despite the NA's knowledge that she was hurting the resident. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #25). The findings included: Resident # 25 was admitted to the facility on [DATE] with diagnoses including [a condition where there is partial paralysis of all four limbs], chronic pain, anxiety, and neuromuscular dysfunction (a problem with the nerves that control muscles and communication between them, resulting in muscle weakness, fatigue, and loss of function). Resident #25's care plan included a problem area (initiated on 09/09/21) of an activities of daily living (ADL) deficit related to [a condition where there is partial paralysis of all four limbs]. The interventions included to ensure effective pain management prior to ADL activity (initiated on 09/09/21). The care plan also included the problem area (initiated on 09/09/21) of potential pain related to chronic pain. The interventions included handle the resident gently (initiated 09/09/2021) and position resident for comfort (initiated 09/09/21). Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was fully intact. She had no behaviors and no rejection of care. She had functional limitations with range of motion on both sides of her upper and lower extremities and required assistance with toileting hygiene, personal hygiene, bathing and bed mobility. Resident #25 received routine and as needed pain medication and experienced moderate pain frequently. She was administered opioid medication. The facility's 5-day investigation report completed by the Administrator and submitted to the state on 11/13/24 indicated the facility was made aware of an abuse allegation on 11/08/24 at 11:00 AM for an incident that occurred on 11/03/24 involving NA #6 and Resident #25. The abuse allegation summary indicated Resident #25 requested a grievance after receiving care from NA #6 that she described as rough. The resident reported that she complained of pain and discomfort during the care and NA #6 ignored her requests to stop and kept providing care. NA #6 stated that she heard the resident tell her that she was being rough and was in pain but continued to provide the care anyway. NA #6 did not provide any reason for continuing to provide care to Resident #25 despite being asked to stop. NA #6 was placed on leave on 11/08/24 for the facility to complete an investigation of the incident and was terminated on 11/13/24. A typed statement completed by the Director of Nursing (DON) dated 11/08/24 indicated she (the DON) spoke with NA #6 regarding Resident #25's statement. The NA stated she did provide care for the resident in question on the weekend. When asked if the resident told her that she was hurting her while providing care, NA #6 replied, Yes, I did hear her say that. When asked what she did after hearing the resident say that, NA #6 replied, I continued to finish performing care. NA #6 stated she did not respond to the resident after hearing her say she (NA #6) hurt her. The DON explained to NA #6 that if a resident says that she is hurting during care, then she needs to stop doing what she is doing and re-evaluate how to do the care. An interview was conducted on 03/07/25 at 12:45 PM with Resident #25. She said on 11/03/24 around 10:30 AM NA #6 gave her a bath and provided incontinence care and was rough while providing the care. Resident #25 said NA #6 pushed on her back and side while turning and cleaning her, and it hurt. Resident #25 said she told NA #6 to stop, that it was hurting, but NA #6 did not stop. Resident #25 said her pain was mostly on her backside. She said she had chronic pain in her back, but after the bath and incontinence care, she had increased pain but had no bruise or injury. She said she was not scared or tearful and had no physical or emotional injuries. She indicated she was just concerned that the NA did not stop when she was asked to stop multiple times. An interview was attempted with Nurse Aide #6, but she was not available for interview. An interview was conducted on 03/07/25 at 10:00 AM with the Physician Assistant (PA) and Administrator. Both stated on 11/3/24 NA #6 should have stopped Resident #25's ADL care when the resident complained of pain and told the nursing aide to stop. The Administrator said NA #6 did not stop ADL care when the resident asked her to stop. The Administrator indicated she asked NA #6 why she did not stop, she gave no answer. An interview was conducted on 03/07/25 at 1:00 PM with the DON. She stated on 11/03/24, NA #6 should have stopped incontinence care immediately when asked to stop and she did not. The facility provided a corrective action plan that was not acceptable to the State Agency. When identifying other residents who had the potential to be affected by the deficient practice, the facility completed resident interviews only with alert and oriented residents on NA #6's assignment. The facility did not consider that all residents had the potential to be affected by abuse and did not interview all alert and oriented residents in the facility to ensure no other residents had been affected by the same deficient practice. The facility provided education on abuse and behaviors only to nursing staff. Other facility staff, to include therapy staff who provided hands on resident care and had the potential to encounter residents who refused care, were not provided with education. Additionally, the facility's monitoring audits did not include any observations of care.

Based on record review, and interviews with staff and Physician Assistant, the facility failed to follow the plan of care for 2 staff members to assist with activities for daily living (ADL) for 1 of 4 residents (Resident #25) whose care plans were reviewed. The findings included: Resident # 25 was admitted to the facility on [DATE] with diagnoses including [a condition where there is partial paralysis of all four limbs], chronic pain, anxiety, and neuromuscular dysfunction (a problem with the nerves that control muscles and communication between them, resulting in muscle weakness, fatigue, and loss of function). Resident #25's care plan initiated on 12/12/23 included a focus area of activities of daily living (ADL) deficit related to [a condition where there is partial paralysis of all four limbs]. A care plan intervention included Resident #25 required 2 or more staff members for care at all times. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed she had no cognitive impairments and needed substantial to maximum assistance for personal hygiene. An interview was conducted on 03/07/25 at 12:45 PM with Resident #25. She said on 11/03/24 NA #6 was alone when she performed resident's ADL care and repositioning, and that there should have been two NAs who changed her and turned her. A brief description of Resident #25's grievance interview dated 11/08/24 from the Director of Nursing (DON) revealed she spoke with Nurse Aide (NA) #6 regarding Resident #25's statement about being treated roughly by NA #6 during her personal care on 11/03/24. NA #6 stated she did provide care for the resident in question on the weekend. I asked her how many people were in the room providing care during this time. She stated, it was just me. I explained to NA #6 that the resident had a care plan for 2-people to provide care and that she needed to have a second person with her. NA #6 responded with an okay. An interview was conducted on 03/06/25 at 3:15 PM. with Nurse #5 during which she stated on 11/03/24, NA #6 who provided the bath and ADL care for Resident #25 should not have done it alone. Nurse #5 added per the resident's care plan stated Resident #25 required 2 staff for all care. Nurse #5 also stated, whenever care was provided to Resident #25, there should always be 2 staff present, and there wasn't. An interview was not conducted with NA#6 due to being unavailable to interview. An interview was conducted on 03/07/25 at 1:00 PM. with the DON. She stated on 11/03/24 there should not have been only one NA giving Resident #25 ADL care, and that there should have been 2 NAs per resident's care plan. An interview was conducted on 03/07/25 at 10:00 AM with the Physician Assistant (PA) and Administrator. They stated per Resident #25's care plan there should have been two nursing aides assisting with her care, not just NA #6.

Based on observations, record review, and staff and resident interviews, the facility failed to provide supervision to Resident #44, a severely cognitively impaired resident, who was inadvertently let out of the facility by some visiting children, who held the front door open preventing the wander guard system from locking the door, and she exited the building. The resident was outside without staff knowledge for approximately 5 minutes, where she self-propelled her wheelchair to the curb cut for wheelchairs leading to the parking lot, and overturned hitting her head, resulting in her having to be transported by emergency medical services (EMS) to the emergency department for evaluation and treatment. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit and unspecified dementia with agitation. A physician's order dated 10/2/2024 for Resident #44 was to check for wander guard placement on resident and to test the battery every shift and to check wander guard expiration date and replace prior to expiration date. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #44 was severely cognitively impaired. She was coded for using a wheelchair for mobility and being dependent on staff for transfers to wheelchair. Resident #44 was not coded for wandering behavior or for wearing a wander guard. The care plan for Resident #44 initiated on 1/5/2023 and reviewed on 1/19/2025 revealed a plan of care for cognitive loss/ dementia-resident has a history of alteration in cognitive function/dementia or impaired thought processes related to dementia with a goal of being able to communicate basic needs on a daily basis for the next 90 days. Interventions included to ask yes/no questions in order to determine the resident's needs and cue, reorient, and supervise as needed. The care plan included resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety, resident is difficult to redirect) with a goal for her to not injure/harm- self secondary to wandering for next 90 days. Interventions included to assure resident has proper fitting and appropriate foot attire; to equip resident with a device that alarms when she wanders close to exit doors; check for proper functioning of device daily; and check placement every shift. Review of the February Medication Administration Record (MAR) for Resident #44 revealed on 2/14/2025 on the 3:00 PM-11:00 PM shift Nurse #14 documented the wander guard was on Resident #44's right ankle and the battery was working. A nurses' progress note written by Nurse #14 on 2/14/2025 at 8:59 P.M. read in part, Resident observed on ground after attempting to exit facility in wheelchair without assistance. Had previously propelled self in wheelchair from door to door in facility on multiple occasions this shift; stating she was leaving and going back to [NAME] Falls. Redirection by this writer and other staff of multiple attempts without success; resident setting off multiple facility door alarms from wader guard. Children exiting facility during her many attempts to leave inadvertently assisted resident out front door by mistake, which resulted in resident sustaining a fall out of her wheelchair onto the ground; resulting in laceration to right scalp just above ear. Neuro checks within normal limits, 911 activated. Healthcare Provider notified via on call as well as resident's Responsible Party (RP) and also the Director of Nursing. Transferred to the emergency department for further evaluation and treatment. No acute distress upon departure from this facility. Respirations even and unlabored. Moves all extremities without complaints of pain. Remains at baseline. Scalp wound covered with compression bandage to control bleeding. Hemostasis achieved by the time of paramedics' arrival. Resident was alert and talking. Denied pain or discomfort at that time. Report to oncoming as well. A Fall Report completed by Nurse #14 dated 2/14/2025 at 8:44 P.M. revealed Resident #44 was found outside on facility grounds lying on the pavement. She was noted to have a laceration to the right side of her scalp, just above the ear. Resident #44 was alert, and she was not complaining of pain. A possible contributing factor was listed as dementia/progressive cognitive decline. The interventions for Resident #44 listed direct pressure to wound and transferred to the hospital emergency department. A telephone interview was completed with Nurse #14 on 3/6/20205 at 4:17 P.M. Nurse #14 stated that on 2/14/2025 she was working the 3:00 P.M. to 11:00 PM shift. She further stated Resident #44 was very active in her wheelchair that night and was going from door to door in the facility trying to exit and was setting off the wander guard door alarms. She further stated that she was chasing Resident #44 all evening trying to redirect her away from the doors. Nurse #14 indicated that she had retrieved Resident #44 each time she had set off the door alarms that evening. She further indicated that at around 7:30 P.M. as she was starting her medication pass, she had noticed 2 young girls approximately [AGE] years old to [AGE] years old exiting the facility. Nurse #14 stated that about 5 minutes after she noticed the girls leaving, they had come running back into the facility stating a resident was outside on the ground. She stated the young girls must have held the door open for Resident #44, because otherwise the doors would have locked when she got too close, and the alarms would have continued to go off. Nurse #14 indicated the alarms were not going off when Resident #44 was found outside in front of the facility at the end of the sidewalk in the yellow area for wheelchair access to the parking lot. She stated that Resident #44 was lying on her right side and there was blood coming from a laceration on her scalp. Nurse #14 stated it was dark outside but there were lights in the parking lot, so she was able to assess the resident. She stated she left Resident #44 outside with Nursing Assistant (NA) #9, and she ran to call 911, and notify the provider and the Responsible Party (RP). Nurse #14 indicated the Nursing Supervisor was outside administering first aid to Resident #44 while she was notifying everyone. The emergency department encounter note written by the Emergency Department Physician on 2/14/2025 read in part that Resident #44 was brought to the hospital by ambulance for an unwitnessed fall. She was found in the parking lot of the nursing facility, and it was unknown if she had a loss of consciousness, no blood thinners, and she was not in any acute pain. The report further read that Resident #44 sustained a 1 centimeter (cm) jagged abrasion to forehead and it was repaired with 4 steri strips. Computed tomography (CT) scans of the head and neck were completed for Resident #44 with no evidence of intracranial pathology, fracture, or malalignment. Resident #44 was diagnosed with a urinary tract infection and discharged back to the facility on [DATE]. A telephone interview was completed with Nursing Assistant (NA) #9 on 3/7/2025 at 10:07 AM. NA #9 stated that Resident #44 managed to get outside on 2/14/2025 because some young girls held the door open for her. She further stated that she ran outside with Nurse #14 when the children came running back into the facility and stated a resident was outside lying on the ground. NA #9 indicated Resident #44 was found outside at the end of the sidewalk that leads to the parking lot. She further indicated that Resident #44 was bleeding from her head and that the Unit Supervisor came outside and was applying pressure and a dressing to the wound. NA #9 stated that she and the Unit Supervisor waited with Resident #44 until EMS arrived and took her to the emergency department. An interview was conducted with the Nursing Supervisor on 3/5/2025 at 3:50 P.M. The Unit Supervisor explained that on 2/14/2025 at around 7:30 P.M. someone came and told her Nurse #14 needed assistance outside with a resident. She stated when she ran outside, she found Resident #44 at the end of the sidewalk where the curb is lower for the wheelchairs to exit to the parking lot. The Unit Supervisor further stated that it was dark outside but there were security lights in the parking lot so she could see the resident. She indicated that Resident #44's wheelchair was overturned, and she was lying on her right side on the sidewalk and Nurse #14 was already assisting the resident. The Unit Supervisor further indicated she and NA #9 had stayed with the resident until EMS arrived, and Nurse #14 went and called the provider and EMS. She stated Resident #14 had a laceration to her head and that she had applied a pressure dressing to get it to stop bleeding. The Nursing Supervisor further stated that she was told some young girls about [AGE] years old or [AGE] years old had held the door open for Resident #44 and that was how she was able to get outside with a wander guard on. An observation and interview with the Unit Supervisor of Resident #44's wander guard was completed on 3/5/2025 at 4:25 P.M. The Unit Supervisor stated there was a machine on each hall that was for testing the wander guards to make sure the batteries were functioning properly. The wander guard was intact to Resident #44's right ankle and when the Unit Supervisor scanned it with the machine a light came on indicating the wander guard was functioning properly. An interview and observation of the facility wander guard system was completed with the Maintenance Director on 3/6/2025 at 9:35 A.M. The Maintenance Director stated the front lobby door was locked automatically every day from 8:00 P.M. to 7:00 A.M. He further stated that after 8:00 P.M. a code was needed to unlock the keypad and open the door. The Maintenance Director indicated that during the day there was a receptionist that monitored the door and at night the door was locked to keep the residents from wandering outside. He demonstrated that when a person wearing a wander guard got within approximately 5 feet of the exit doors the wander guard would begin to chirp. The Maintenance Director stated that as the resident approached closer the alarm would chirp louder and faster, and if the resident was within a few inches of the door, it would automatically lock. He further stated that if the door was being held open and was unable to reset then once the person with wander guard got over 5 feet away from the door outside the alarm would stop. The Maintenance Director measured the distance from the front door to the edge of the sidewalk and the parking lot as 60.8 feet. The facility and the parking lot is located off of a cul-de-sac on a dead-end street with not a lot of traffic except visitors to the facility. An interview was completed with Receptionist #1 on 3/7/20205 at 11:55 A.M. Receptionist #1 stated that she had worked at the facility for 2 years. She further stated that part of her responsibilities included preventing residents with wander guards from exiting the building. Receptionist #1 stated she worked Monday through Friday and from 8:00 A.M. to 4:30 P.M. and that Receptionist #2 worked from 4:30 P.M. to 8:00 P.M. Receptionist #1 Monday through Friday and 8:00 A.M to 4:30 P.M. on the weekend. She indicated that someone was responsible for monitoring the door when she was at lunch. Receptionist #1 stated she checked the elopement book several times a week to make sure nobody had left or had been added to the list. She further stated the book contained current pictures of the residents that wore wander guards and were not allowed outside without supervision. She stated that she usually tried to distract residents from setting off the alarm and get them away from the door. Receptionist #1 further stated if she was unable to distract the residents or they became agitated she would call the nurse for help. She further stated that she recalled that Receptionist #1 called in on 2/14/2025, so there was no one assigned to watch the front door from 4:30 P.M. to 8:00 P.M . An interview was completed with the Director of Nursing (DON) on 3/7/2025 at 10:55 A.M. The DON stated that she heard Resident #44 got outside because some children had held the front door open for her. She further stated that the doors were unable to lock when Resident #44 got too close to the door because they were holding the door open. The DON stated that Resident #44 was only outside for about 5 minutes, and it was unfortunate that her wheelchair had turned over at the end of the sidewalk and she was injured. She stated that she did not expect someone wearing a wander guard to be found outside and injured. An interview was completed with the Administrator on 3/7/2025 at 9:45 A.M. The Administrator stated that the facility employed a receptionist that worked from 8:00 A.M. to 4:30 P.M. Monday through Friday and another one that usually works 4: 30 P.M to 8:00 P.M. She stated that the receptionist for the 4:30 P.M. to 8:00 P.M. shift had called in sick on 2/14/2025. The Administrator further stated that it was everyone's responsibility to respond if a wander guard alarm was going off. She indicated she didn't believe the incident involving Resident #44 that occurred on 2/14/2025 was the facility's fault, because some children had held the door open for her. The Administrator stated that Resident #44 was only outside for a few minutes, but unfortunately, she had already fallen out of her wheelchair when she was found. She further stated there was sign in the lobby by the front door that says, Please check with Nurse before assisting residents outside.

Based on record review, observations, and staff and resident interviews, the facility failed to provide nutritional supplements to 1 of 11 residents reviewed for nutrition ( Resident #89). Findings included: Resident #89 was admitted on [DATE] with diagnosis of protein calorie malnutrition, Alzheimer's, and dysphagia (swallowing difficulty). Review of Resident #89's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had cognitive impairment, severe cognitive impairment, and hold food in mouth or cheeks after meals, coughing or choking during meals or when swallowing and weight loss. Review of Resident #89's electronic health record revealed the following weights were recorded: 10/20/2024 130.4 Pounds (Lbs.) 10/27/2024 132.8 Lbs. 11/03/2024 133.2 Lbs. 11/10/2024133.1 Lbs. 11/17/2024 133 Lbs. 12/17/2024 132.8 Lbs. 1/08/2025 118.2 Lbs. 2/05/2025 116.2 Lbs. 2/24/2025 103 Lbs. 3/01/2025 106.3 Lbs. 3/03/2025 104.9 Lbs. A review of Resident #89's care plan revealed a problem initiated on 10/23/24 and last revised on 2/20/25 of nutrition impairment related to multiple chronic diseases, cognitive impairment, Alzheimer's, protein calorie malnutrition, underweight status, increased nutrient needs with a pressure ulcer, mechanically altered diet, and honey thick liquids. Interventions indicated to provide and serve supplements as indicated. Review of Resident #89's physician orders revealed an order dated 2/19/25 for frozen nutritional cup with meals. A review of Resident #89's electronic health record revealed an interdisciplinary team note dated 2/27/25 which indicated in part resident with noted weight loss and nutritional decline the past few months, worsening dysphagia and dislikes pureed foods. Resident #89 had significant weight loss this month and was primarily only consuming frozen nutritional magic cups, yogurts, and pureed desserts with meals. Observation of resident on 3/3/25 at 12:50 PM revealed resident in bed with his meal tray in front of him. The meal tray ticket on the tray indicated Resident #89 was to receive a regular pureed diet with honey thickened liquids. The meal tray ticket indicated Resident #89 was to receive a frozen nutritional treat. The meal tray ticket indicated to send frozen nutritional cup. No frozen nutritional treat was noted on the meal tray. An interview with the Registered Dietitian (RD) on 3/5/25 at 4:00 PM revealed Resident #89 had weight loss and was to receive a nutritional supplement. The RD indicated he was not aware of Resident #89 receiving the frozen nutrtional treat as ordered. The RD stated he was not informed of a problem with the supplier of the supplement and that the resident should receive the nutritional supplement as ordered. An observation of Resident #89's lunch meal on 3/6/25 at 12:50 PM revealed resident was sitting up at his bedside with his meal tray in front of him. Resident #89 had a pureed meal with honey thick lemonade. No frozen nutritional treat was observed on the meal tray. Resident #89's meal tray had a small dish of pudding on the tray that was unopened. An interview with the Dietary Manager on 03/06/25 at 2:00 PM revealed the facility was out of several items including the frozen nutritional treat that week and were waiting for a food vendor shipment at the end of the week. The Dietary Manager stated that they should have frozen nutritional treats and other needed items on hand per the physician orders and they did not. She said she was new to the position and was still learning about the facility and the ordering process. The Dietary Manager stated that today the kitchen sent pudding instead of the frozen nutritional treat.

Based on observations, record review, and staff and resident interviews, the facility failed to honor food preferences for 1 of 12 residents reviewed for nutrition (Resident # 76) reviewed for meal preferences. Findings included: Resident #76 was admitted on [DATE] with diagnoses which included dysphagia and gastroesophageal reflux. Resident #76's care plan dated 4/30/23 revealed a nutritional status problem that was last revised on 2/26/25. The nutritional status problem indicated Resident #76 had potential for nutritional and hydration impairment and the approaches indicated to determine resident's food likes and dislikes. Resident #76's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact, had no weight recorded and weight loss or weight gain was coded as no or unknown. Resident #76's electronic health record revealed a dietary progress note written by the Registered Dietitian (RD) dated 12/23/24 which indicated the resident received a regular diet with thin liquids and received vanilla ice cream and extra sandwiches with lunch and dinner. A grievance filed on behalf of Resident #76 dated 2/3/25 indicated the resident was not supposed to receive rice but she received rice on two occasions in the last week. The steps taken to investigate revealed the Dietary Manager was interviewed and she stated that the meal tickets were misread by the staff preparing the meal tray. The corrective action revealed that the kitchen staff was instructed to thoroughly read the meal tickets and the diet order was updated on 2/3/25 for no rice. Resident #76's electronic health record revealed a physician order dated 2/3/25 for a regular diet with no rice. A list of alternate entrees indicated the following items were always available: hamburger, cheeseburger, deli sandwich, chef salad, grilled cheese and the sides were French fries, potato chips, tossed salad, cream of tomato soup, and chicken noodle soup. An interview and meal observation of Resident #76 were conducted on 3/03/25 at 12:50 PM. Resident #76 was in bed with a meal tray on the overbed table in front of her. The meal ticket indicated Resident #76 was to receive a regular diet with extra items, a peanut butter sandwich and vanilla ice cream. No vanilla ice cream was observed on the meal tray. Resident #76 stated she does not like peanut butter sandwiches, and she was not able to eat the fish that was served. Resident #76 stated she tried to eat the fish twice before and it made her sick. Resident #76 stated she asked for a salad yesterday and today for lunch and was told the facility did not have any dressing so she could not get a salad as requested. She stated she just ate her cake for lunch. Resident #76 stated she frequently received foods that she did not like or could not eat so she just ate snacks her family provided, or she did not eat. An interview was conducted with the corporate Dietary Consultant on 3/3/25 at 2:45 PM. The Dietary Consultant stated the Dietary Manager was only in the position for a few weeks and she (the Consultant) assisted at the facility a few days per week. The Dietary Consultant stated resident preferences are updated as needed. The Dietary Consultant indicated that residents could request a salad anytime per their preference as part of the always available options. The Dietary Consultant stated she expected the facility would have salad dressing available. If pre-made salad dressing was not available, the facility could have made salad dressing from scratch. The Dietary Consultant indicated a resident should receive items as requested per their preference and the items should be available. An interview and observation of Resident #76's dinner tray on 3/4/25 at 6:00 PM revealed she was served greens, mashed potatoes, barbecue chicken, fruit cocktail and a grilled cheese sandwich. Resident #76 stated she does not eat greens, and the potatoes did not taste good. Resident #76's meal tray ticket indicated the resident was to receive vanilla ice cream and a grilled cheese sandwich in addition to the regular diet. An interview was conducted with the Registered Dietitian (RD) on 3/5/25 at 4:00 PM. The RD stated items should be available to meet residents' preferences. The RD stated he visited Resident #76 at times when he was in the facility. The RD reviewed Resident #76's record and stated it looked like neither he nor the Dietary Manager had updated the resident's profile of preferences since last year. The RD stated that the Dietary Manager was supposed to update resident preferences quarterly and as needed. The RD stated the Dietary Manager was new to the position and was still learning. The RD stated he was not aware that Resident #76 did not eat fish or collards and did not like peanut butter sandwiches. A meal observation and interview with Resident #76 on 3/6/25 at 12:50 PM revealed the resident was in bed with the head of bed elevated and the meal tray was in front of resident on the overbed table. The meal tray consisted of a chef salad with ranch dressing, peanut butter sandwich, water and iced tea. The meal ticket indicated resident was to receive a salad with French dressing. Resident #76 stated she does not eat the peanut butter sandwiches they keep sending on her meal trays. Resident #76 stated she liked the salad and was eating it with ranch dressing even though she had requested French dressing. An interview with the Administrator on 3/7/25 at 4:30 PM revealed she expected that resident preferences would be honored and that food items would be available to meet resident preferences.

Based on observations and interviews with staff and residents, the facility failed to provide a clean, homelike environment for 4 resident rooms on 2 of 5 halls reviewed for the environment (200 hall and 300 hall). Findings: Review of the resident council meeting minutes revealed the minutes dated 12/10/24 indicated a concern of resident rooms were not clean. a. The following observations were made of room [ROOM NUMBER]: On 3/3/25 at 12:00 PM Observation of Bed 2 revealed the top of the nightstand was cluttered and dirty with a sticky substance and an unwrapped cough drop was stuck to the top. Scratches were observed on the front of the nightstand. The floor under Bed 2 and around the bed was observed with cough drop wrappers, food and other debris. The dressers for both residents in the room had scratches and the drawers did not fully close. The privacy curtain was observed with scattered orange food stains. Observation of Bed 1 revealed the nightstand was scratched and cluttered, and a recliner chair was piled with pillows and linens. A bag of incontinence pads was observed on the floor. On 3/4/25 at 2:15 PM. room [ROOM NUMBER] Beds 1 and 2. The dressers in the room had scratches and the drawers did not fully close. A recliner chair piled with pillows and linens was observed beside the resident in Bed 1. The floor underneath and around Bed 2 was observed with cough drop wrappers, food and other debris. The nightstand was cluttered with multiple tubes and bottles of creams and lotions, the drawers of the nightstand would not close The privacy curtain was observed with stains. A bag of incontinence pads was observed on the floor. On 3/5/25 at 1:30 PM room [ROOM NUMBER]. Beds 1 and 2. The dressers in the room had scratches and the drawers did not fully close. A recliner chair piled with pillows and linens was observed beside the resident in Bed 1. The floor underneath and around Bed 2 was observed with cough drop wrappers, food and other debris. The nightstand was cluttered with multiple tubes and bottles of creams and lotions, the drawers of the nightstand would not close The privacy curtain was observed with stains. A bag of incontinence pads was observed on the floor. On 3/6/25 at 1:45 PM room [ROOM NUMBER]. Beds 1 and 2. The dressers in the room had scratches and the drawers did not fully close. A recliner chair piled with pillows and linens was observed beside the resident in Bed 1. The floor underneath and around Bed 2 was observed with cough drop wrappers, food and other debris. The nightstand was cluttered with multiple tubes and bottles of creams and lotions, the drawers of the nightstand would not close The privacy curtain was observed with stains. A bag of incontinence pads was observed on the floor. b. The following observations were made of room [ROOM NUMBER]: On 3/3/25 at 12:15 PM. Soiled towels were observed on the floor in the bathroom. A soiled brief was noted on top of the plastic cabinet in the bathroom. A green plastic soda cap was observed under the bed by the wall. The bed rails were visibly dirty and sticky. The bedside table was cluttered with bottles of lotion and tubes of cream. There were scratches on the dressers. A recliner chair was piled with bed linens, pillows and personal items. A rollator (a rolling walker with a seat) was piled with personal items in the corner of the room by the window. The resident in the window bed was not ambulatory. On 3/4/25 at 2:45 PM. The bedside table was observed to be cluttered with bottles of lotion and tubes of cream. The front of the dressers were scratched. The floor in the room was dirty with a white substance observed and various food debris and trash. A soda bottle cap was observed on the floor under the bed by the wall, an empty plastic medication cup and a plastic drinking cup were observed. An empty soda bottle was on the floor next to the bed. A recliner chair was piled with bed linens, pillows and personal items. A rollator piled with personal items was observed in the corner by the window bed. The resident in the window bed is not ambulatory. On 3/5/25 at 1:30 PM: The bedside table was observed to be cluttered with bottles of lotion and tubes of cream and the front of the dressers were scratched. The green soda cap was by the wall, an empty plastic medication cup and a plastic drinking cup were observed. An empty soda bottle was on the floor next to the bed. Items were piled in the recliner chair including bed linens, pillows and personal items. The unused rollator was in the corner piled with items. On 3/6/25 at 1:45 PM. The bedside table was observed to be cluttered with bottles of lotions and tubes of cream and the front of the dressers were scratched. The same green bottle cap was in the same place under the bed as it had been the past 3 days. The plastic cup and plastic medicine cup were observed in the same place under the resident's bed. The over bed table was covered in sticky substance. c. The following observations were made of room [ROOM NUMBER]: On 3/3/25 at 12:20 PM. Black marks were observed on the wall beside the bed and the overbed table was observed with a sticky substance. On 3/4/25 at 2:20 PM. Black marks were observed on the wall beside the bed and the overbed table was covered with a sticky substance. On 3/5/25 at 1:45 PM. Black marks were observed on the wall beside the bed and the overbed table was covered with a sticky substance. d. An observation of room [ROOM NUMBER] and interview with the resident representative was conducted on 3/3/25 at 11:45 AM and revealed the floor was dirty and sticky. The resident representative stated the room did not get cleaned regularly and the floor needed to be swept and mopped more frequently. An interview on 3/03/25 at 2:41 PM with Resident #28 in room [ROOM NUMBER] revealed there were black marks on the wall beside the bed. Resident #28 stated her room was cleaned every 3 days. Resident #28 stated she tried to not get her room too dirty since it doesn't get cleaned that often and she tries to clean up for herself as much as she can. Interviews were conducted with Housekeepers #1 and #2 on 3/4/25 at 9:30 AM. Housekeepers #1 and #2 stated all rooms were supposed to be cleaned daily but sometimes when there are call outs or someone was scheduled to be off, they were not able to clean all the rooms. Housekeepers #1 and #2 stated the facility was usually staffed with 3 housekeepers and a floor technician. Housekeeper #1 and #2 stated even when they were fully staffed, it was hard to get everything done as they were assigned 20 or more resident rooms plus the common areas and offices. Housekeepers #1 and #2 stated they completed the 5 steps of cleaning resident rooms which consisted of empty trash, clean the horizontal surfaces, spot clean the vertical surfaces, dust mop and damp mop the room. An interview was conducted with the Housekeeping Account Manager on 3/5/25 at 10:00 AM. The Account Manager stated she was the manager of the housekeeping department. The Account Manager stated the housekeeping department was fully staffed with 10 employees. The Account Manager indicated the facility was staffed with 3 housekeepers and a floor technician daily. The Account Manager indicated all resident rooms were to be cleaned daily as well as the common areas. The Account Manager indicated she was in the position with the contracted company in the facility for the past 8 months. The Account Manager indicated she completed daily rounds to spot check random rooms for cleanliness and she had found that rooms were not always done per standard. The Account Manager stated she brought it to the assigned staff member's attention when she found rooms not meeting the standard. The Account Manager stated she had new staff members and had call outs which impacted on the cleaning of the rooms. The Account Manager indicated she received some grievances recently regarding the cleanliness of the facility and was trying to address them. The Account Manager stated she expected the following to be completed in each room: empty the trash, clean the trash can, put in extra bags, disinfect the horizontal surfaces including door knobs, air conditioner, light fixtures, disinfect the vertical surfaces including the walls, dust and damp mop the floors. Each housekeeper was assigned approximately 20 rooms per day plus cleaning of the common areas and the offices. An interview was conducted with the Unit Manager on 3/5/25 at 11:45 AM. The Unit Manager stated he assumed that the rooms were cleaned daily or at least every other day. The Unit Manager indicated it was a team effort to keep rooms clean and clutter free, but he did not know who should clean the rooms of spills or trash when housekeeping was not available or who removed no longer used medical equipment from rooms. The Unit Manager stated the managers were assigned rooms to complete concierge rounds daily which consisted of observing the cleanliness of the rooms. A resident council meeting was held on 3/5/25 at 1:30 PM as part of the recertification survey process. The resident council meeting included a sample of cognitively intact residents. The residents in attendance at the meeting stated the cleanliness of the rooms was improving but the floors in their rooms were often sticky. A follow-up interview and observation of room [ROOM NUMBER] was completed with the Housekeeping Account Manager on 3/6/25 at 2:20 PM. The Housekeeping Account Manager stated there was an issue with clutter in the rooms and the facility planned on working on this. The Housekeeping Account Manager indicated the privacy curtains were supposed to be cleaned monthly and as needed. The Housekeepers were expected to check the privacy curtains daily and if soiled replace it. The Housekeeping Account Manager stated the housekeepers can't clean the surfaces in the rooms due to the clutter and they don't think they can move anything in the rooms. An interview with the Administrator on 3/7/25 at 2:30 PM revealed that she expected that resident rooms would be clean, homelike and clutter free. The Administrator stated that the scratched furniture should be addressed.

Based on record review, and staff and Nurse Practitioner interviews the facility failed to assess Resident #4 before transferring her back to bed after she was found on the floor for 1 of 2 residents reviewed for falls. The findings included: Resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses included Alzheimer's disease, anxiety, failure to thrive, and cerebrovascular disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 had severe cognitive impairment and required one-person supervision with transfers. There were behaviors and rejection of care noted during the assessment reference period. There was also a history of falls since admission to the facility. The MDS also revealed that Resident #4 had a prognosis of less than 6-months to live and received Hospice care. Resident #4's Medication Administration Record dated 04/2024 revealed the resident was only receiving one medication, Tylenol 500-milligrams three times a day. Review of an initial allegation report dated 04/17/24 at 1:20 PM read, staff reported Resident #4 was observed in bed with a hematoma over right eye, an injury of unknown origin. The resident was not interviewable. The facility staff-initiated skin checks and interviews for residents on the same wing. Staff interviews were initiated. The resident appeared at baseline currently and will be monitored for any negative outcomes. The initial allegation report was completed by Former Administrator #1. A handwritten statement from NA #2 read in part, On 04/17/2024 at 6:30 AM., I found resident #4 on the floor on her mat. She didn't seem hurt, but I placed her up and placed her back on the bed. I changed her and put the bed at the lowest position. The statement was signed by NA #2. A phone interview was conducted on 09/17/24 at 9:57 AM with Nurse Aide (NA) #2. NA #2 confirmed that she was working the night 11:00 PM to 7:00 AM shift on 04/16/24. She stated she was walking past Resident #4's room and found her lying flat on the floor on her fall mat. NA #2 stated she was exhausted that night, and normally would have requested assistance from the nurse but instead she lowered resident's bed and put the resident back in bed. NA #2 stated the resident did not appear to be injured or in any pain. NA #2 stated she should have gone to get the nurse to assess the resident before putting her back to bed and was fired for it. An interview was conducted on 09/17/24 at 1:30 PM with Nurse #1. He confirmed that he was working the day shift on 04/17/24. He stated NA #3 approached him about something. It was reported to him that Resident #4 had a hematoma above her eye, and that NA #2 got her back into the bed without being assessed. Nurse #1 stated that it was not reported to him that Resident #4 had fallen until after NA #2 had transferred her back to bed. He stated when he found out he did go and fully assess Resident #4 for injuries, completed neuro-check, and range of motion but could not identify any other injuries sustained from the fall, except for the hematoma above the resident's eye. After the assessment, Nurse #1 stated he notified the Medical Director (MD)/Physician Assistant (PA), Administrator, Director of Nursing (DON), and resident's Responsible Party (RP). A handwritten statement from NA #3 read in part, I entered Resident #4's room to perform patient care, and noticed a knot on patient's forehead. I notified my nurse and nurse manager. The statement was signed by NA #3. An interview was conducted on 09/18/24 at 9:53 AM with NA #3. NA #3 confirmed that she was working the 7:00 to 3:00 PM day shift on 04/17/24. NA #3 stated she recalled that while making her morning rounds of her residents on the 200-hall, she observed Resident #4 lying in bed with a goose-egg hematoma over her left eye. She said she reported it to Nurse #1 who came, assessed the resident, and notified the Physician Assistant (PA) to also assess, which she did. NA #3 stated the resident did not appear in pain and ate well that morning. NA #3 stated the resident was a one-person assist with transfers, and could pivot and transfer with one NA. NA #3 stated during morning report, before making her rounds NA #2 never mentioned Resident #4 had a fall or injury. An interview was conducted on 09/18/24 at 9:50 AM with the Director of Nursing (DON) and the Corporate Consultant. The DON stated when a resident had a fall they have to be assessed by a nurse before being moved. The NAs should never get anyone up including Resident #4 without an assessment from the nurse. Once the nurse assessed the resident and deemed it safe to move the resident then the resident can be assisted back to bed or chair. They both stated that any resident that had a fall should be assessed by a nurse for injury before being moved. An interview was conducted on 09/18/24 at 12:45 PM with the Physician Assistant (PA). She stated that any resident that had a fall should be assessed by a nurse for injury before being moved. An interview was conducted on 09/19/24 at 1:15 PM with the Administrator. She stated that any resident that had a fall should be assessed by a nurse for injury before being moved.

Based on observations, record review, staff, and the Physician Assistant interviews the facility failed to notify the physician of a residents change in condition and transport to the hospital for 1 of 1 resident (Resident #1) reviewed for hospitalization . Findings included. Resident #1 was readmitted to the facility on [DATE]. Her diagnosis included heart failure, respiratory failure, diabetes, anemia, and GI (gastrointestinal) bleeding. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was cognitively intact. She was dependent on staff for bed mobility, transfers, and activities of daily living (ADLs.) She exhibited no rejection of care. A progress note dated 02/11/24 at 2:00 PM documented by Nurse #1 revealed he was called to Resident #1's room by the Nurse Aide who stated that Resident #1 had some vaginal bleeding. Upon exam a small amount of dark brown blood was observed on the brief with a few clots. Her abdomen was soft and non-tender, bowel sounds were active. Resident #1 denied abdominal, vaginal, or rectal pain. Her blood pressure was 126/76, pulse 78, respirations were 20 breaths per minute and temperature 97.8 degrees Fahrenheit. Her Pulse Oximetry (measure of blood oxygen saturation) was 96% on 2 liters of oxygen via nasal cannula. A progress note dated 02/11/24 at 2:30 PM documented by Nurse #1 revealed EMS (emergency medical services) was here, report given. Resident #1 left via stretcher to the emergency department. During an interview on 02/28/24 at 1:00 PM Nurse Aide #1 stated she was routinely assigned to Resident #1. She stated she arrived to work at 7:00 AM on the day Resident #1 was sent to the hospital. She reported around lunch time that day Resident #1 told her she was soaked and need to be changed so she provided incontinence care at that time. She reported she observed a moderate amount of blood on her glove that was bright red, not pink tinged, and covered from the fingertips of her glove to the palm of her hand along with blood clots. She immediately reported this to Nurse #1. She stated during that time Resident #1 was saying she wanted to go to the hospital. She reported that Resident #1's Responsible Party (RP) came in the facility during that time and also wanted her to go to the hospital. During a phone interview on 02/29/24 at 1:48 PM Nurse Aide #2 stated she assisted Nurse Aide #1 on the day Resident #1 was sent to the hospital. She reported that around 1:30 to 2:00 PM Nurse Aide #1 asked her to help provide incontinence care to Resident #1. She stated she observed a substantial amount of blood with blood clots. She stated there were a few blood clots observed, some were large and some small and described it as being similar to a heavy menstrual cycle. She stated Nurse #1 was notified immediately. During a phone interview on 02/28/24 at 3:50 PM Nurse #1 reported he was Resident #1's assigned nurse on the day she was transported to the hospital. He stated around 1:30 PM the Nurse Aide informed him that she had vaginal bleeding. He completed a full assessment, and she was awake and oriented to person, place, and time. She had no pain, no shortness of breath, and stated she had a small amount of bleeding, Her vital signs were stable. He stated Resident #1's Responsible Party (RP) came in during that time and also told him she wanted her sent out to the hospital due to bleeding. He stated he called the Director of Nursing who told him to send Resident #1 to the hospital. He stated he did not notify the physician of a change in condition or that Resident #1 would be transferred to the hospital. He stated he should have called the physician, but he got sidetracked with another resident. He stated the process was that anytime a resident had a change in condition and needed to be sent out to the hospital you were required to notify the providers. He stated he forgot to do that. During an interview on 02/29/24 at 10:40 AM the Physician Assistant stated Resident #1 was transported to the hospital on 02/11/24 due to complaints of bleeding. She reported Resident #1 had a history of GI bleeding and they monitored her hemoglobin and hematocrit depending on her clinical assessment. She stated the providers should have been notified that Resident #1 was having vaginal bleeding on 02/11/24 and was being transferred to the hospital and indicated that was not done. During an interview on 02/29/24 at 4:30 PM the Director of Nursing stated Nurse #1 should have notified the providers that Resident #1 had vaginal bleeding and was being sent to the hospital. She reported Nurse #1 failed to notify the physician.

Based on observations, record review, staff, and the Physician Assistant interviews the facility failed to hold a short acting insulin as ordered by the physician for blood sugar readings less than 120 mg/dl (milligrams per deciliter). This resulted in the resident receiving 20 additional units of insulin. There was no significant outcome related to the insulin administration. This occurred for 1 of 1 resident (Resident #1) reviewed for medication administration. Findings included. Resident #1 was readmitted to the facility on [DATE]. Her diagnosis included heart failure, respiratory failure, GI (gastrointestinal) bleeding, chronic kidney disease, and diabetes. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was cognitively intact. She was dependent on staff for bed mobility, transfers, and activities of daily living (ADLs.) She received insulin. A physicians order dated 01/03/24 for Resident #1 revealed Insulin Lispro 100 units/milliliter administer 10 units subcutaneous before meals. Hold for blood sugar less than 120 mg/dl. Review of Resident #1's Medication Administration Record (MAR) dated February 2024 revealed on 02/02/24 at 7:30 AM Resident #1's blood sugar reading was recorded by Nurse #2 as 108 mg/dl. The insulin administration site was documented as 10 units of insulin administered into the abdomen. Review of Resident #1's Medication Administration Record (MAR) dated February 2024 revealed on 02/02/24 at 11:30 AM Resident #1's blood sugar reading was recorded by Nurse #2 as 114 mg/dl. The insulin administration site was documented as 10 units of insulin administered to the left arm. During a phone interview on 02/29/24 at 1:00 PM Nurse #2 stated she was assigned to Resident #1 at times and did not recall the details of her care. She stated she did not recall the parameters regarding holding Resident #1's insulin. She stated she did not recall what occurred on 02/02/24. She did not provide any additional information. During an interview on 02/29/24 at 3:45 PM the Physician Assistant stated Resident #1 was diabetic and received sliding scale insulin before meals. She also had orders for an additional 10 units of insulin lispro before meals with orders to hold the additional 10 units of insulin lispro if the blood sugar was 120 mg/dl or less. She stated Resident #1 should not have received the 10 units that was administered on 02/02/24 at 7:30 AM or at 11:30 AM for blood sugar readings of 108 and 114 mg/dl. She stated Resident #1's blood sugar later that day at 4:30 PM was 132 mg/dl. so there was no significant outcome. During an interview on 02/29/24 at 4:30 PM the Director of Nursing stated Nurse #2 should have followed the physicians order and held the insulin for Resident #1. She indicated education would be provided.

Based on observations, record review, and Psychiatric Nurse Practitioner, Physician Assistant, and staff interviews, the facility failed to protect a vulnerable female resident's right to be free from sexual abuse when Resident #62 was observed by Nurse Aide (NA) #1 to have his hand under a severely cognitively impaired resident's (Resident #57) dress above the resident's thigh. A reasonable person would not expect to experience intentional inappropriate touching in their home and would have experienced intimidation and fear. This was for 1 of 5 residents reviewed for abuse (Resident #57). Findings included: Resident #62 was admitted to the facility on [DATE]. Diagnoses included stroke with weakness, non-traumatic brain dysfunction, depression, and vascular dementia. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired and did not exhibit any behaviors. He required extensive assistance with one staff physical assistance with transfers and bed mobility, used a wheelchair and had no impairments. Resident #62 received antidepressant medications. A plan of care dated 11/20/23 for behavioral symptoms not directed toward others (scratching self, removes briefs, and urinates on self) with a goal that resident would not harm self/and or others secondary to socially inappropriate and or disruptive behaviors with interventions to include: when resident begins to become socially inappropriate/disruptive, provide comfort measure for basic needs, provide care, activities and a daily schedule that resembles the resident's prior lifestyle, avoid over stimulation, maintain a calm environment and approach toward the resident. Assess whether the behavior endangers the resident and or others. A plan of care dated 11/23/23 was also in place for history of alteration in cognitive function/dementia or impaired thought process with a goal that the resident would be able to communicate basic needs on a daily basis. Interventions included ask yes/no questions in order to determine the resident's needs, keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Reorient and supervise as needed. Resident #57 was admitted to the facility on [DATE]. Diagnoses included early onset Alzheimer's Disease, traumatic subdural bleed, anxiety, need for assistance with personal care, muscle wasting and atrophy. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #57 was severely impaired and demonstrated no behaviors. Resident #57 required extensive assistance of two staff with bed mobility, transfers, and eating. Resident #57 was totally dependent on one staff physical assistance with toileting and used a wheelchair. Review of Resident #57's care plan updated on 12/01/23 revealed a plan of care for history of alteration in cognitive function/dementia or impaired thought processes related to early onset Alzheimer's Disease and for communication deficit related to little speech with a goal that resident would be able to communicate basic needs on a daily basis with interventions to include use paddle call bell as able for ease of use, keep the resident's routine consistent and try to provide consistent care givers as much as possible and allow time for resident to express needs or wants, repeat resident requests to assure understanding, and anticipate and meet needs. A written statement dated 12/11/23 by Nurse Aide #1 revealed As I was walking down the hall, I heard [Resident #57] making sounds. As I got closer to the TV room, I saw [Resident #62] with his hand under her dress. I immediately took the trash and sat it on the floor and removed her [Resident #57] from the TV room and explained that it was inappropriate. I asked him why he did what he did and he stated he did not know. An interview was conducted with Nurse Aide (NA) #1 on 01/08/24 at 4:00 PM. NA #1 revealed on the day of 12/11/23, Resident #57 was in the day room waiting to go to activities. When NA #1 headed back down the hall toward the day room, she heard a noise coming from the day room. NA #1 stated Resident #57 made a distinct sound any time anyone touched her. NA #1 described the sound and stated it was like a giggle, because she would be smiling so it seemed as though it was a giggle, but it was just a distinct sound Resident #57 always made. NA #1 stated that was the sound she heard as she was heading down the hall toward the day room. Resident #62 was in his wheelchair sitting next to Resident #57 who was sitting in her Geri chair. As she entered the day room, she noticed Resident #62's hand was up Resident #57's dress. The NA stated she could not see Resident #62's hand and did not know what his hand was doing while it was under the dress and did not recall seeing any movement of the hand while it was under the dress. She stated she immediately approached Resident #57 and Resident #62 and Resident #62 pulled his hand out from under Resident #57's dress as soon as he saw her (NA #1). NA #1 explained she asked Resident #62 what are you doing? followed by why would you do that? NA #1 reported Resident #62's response was I don't know. NA #1 stated she had never seen Resident #62 demonstrate this kind of behavior before. She stated she separated the residents immediately and brought Resident #57 to her room and Resident #62 to his room. NA #1 reported she immediately reported what she had observed to the Unit Manager, the Director of Nursing, and the Physician Assistant. NA #1 stated Resident #57 was her usual smiley self and did not seem to understand or know what was happening. NA #1 stated the staff were instructed to monitor Resident #62 every 30 minutes after this occurred. NA #1 added, after Resident #62 was brought to his room, he did not seem to recall what had happened when he was asked why he had his hand under Resident #57's dress. A follow up interview via phone on 01/09/24 at 5:30 PM with NA #1 revealed on the day of 12/11/23, Resident #57 was wearing a dress that came to right above her knee. NA #1 stated the only thing she saw was Resident #62's hand under her dress and could not say if he was inside her brief from where she was standing in the hallway. She did not see his hand moving underneath the dress. She stated his hand did not look wet when he pulled it out from Resident #57's dress but she did not touch or smell his hand. She stated she could see Resident #57's thigh and Resident #62's hand was higher than her thigh. NA #1 added it took two staff to change Resident #62 because it was very difficult to release the tension on her legs. NA #1 stated and anytime they changed Resident #57 she made the same sound she heard when she saw Resident #62 with his hand up her dress. NA #1 stated Resident #62 also had very weak hands and she did not think he would have the strength to open Resident #57's legs. NA #1 stated there were no other residents in the day room and she did not know how long Resident #62 was in the day room with Resident #57. NA #1 stated Resident #62 required assistance getting into his wheelchair, but he could propel himself throughout the facility. NA #1 stated after this incident occurred Resident #62 stayed in his room and 30-minute checks were started. An interview was conducted with the Unit Manager on 01/08/24 at 4:15 PM. The Unit Manager (UM) stated NA #1 came to her and reported to her and the Director of Nursing Resident #62 had his hand under Resident #57's dress and that she had separated them. The UM stated she got the Physician Assistant and the three of them went to see Resident #57 immediately. When she arrived to the room, Resident #57 was sitting in her Geri chair and was not in any distress. They transferred her to the bed. The UM stated Resident #57's brief was completely intact. They took the brief down and the PA assessed her. There were no visible signs of physical trauma, no redness, and no bruising. The UM stated Resident #57 was at her baseline with her cognition and had no change in her affect during the assessment. A nursing progress note written on 12/11/23 by the Director of Nursing (DON) revealed Resident #62 was witnessed by a nurse aide in the common TV room with other residents. A male resident [Resident #62] was observed with his hand up the dress of a female resident [Resident #57]. The Nurse Aide immediately separated the residents to ensure safety. Unit Manager, DON and Administrator notified. A nursing progress note written by the DON on 12/11/23 at 4:10 PM revealed Resident [#57] was sitting in a wheelchair in the common area TV room with other residents. A male resident was observed by staff to have his hand up this resident's dress. Staff member immediately separated the two residents, taking Resident [#57] to the nurse's station for close supervision. Resident [#57] did not appear to have any non-verbal cues of being traumatized. The resident's mood appeared to be at baseline. The resident's baseline was non-verbal and smiling. The PA and DON had staff put Resident [#57] into bed for an assessment. The PA and DON performed a visual assessment of the resident. There was no visible physical or emotional trauma observed. A Physician Assistant (PA) progress note written on 12/11/23 at 3:10 PM revealed she was notified by staff that another resident [Resident #62] was seen having inappropriate sexual contact with Resident [#57]. The PA and DON went in to see Resident [#57] immediately after the incident was reported. Resident [#57] resting comfortably in her bed. She was smiling and pleasant when spoken to by PA. She appeared at her baseline for mentation and affect. She had no signs of trauma on exam. Staff to monitor closely. A review of the Physician Assistant's assessment conducted on 12/11/23 at 3:10 PM revealed, in part, vital signs temperature 97.8F, heart rate 70 beats per minute, respiration rate 16 breaths per minutes, blood pressure 128//70. Resident #57 was alert and in no acute distress. Genitourinary (perineal area) showed no outward signs of trauma or redness, and no bruising. Skin was intact. Resident confused at baseline with incoherent garbled speech. An interview was conducted with the Physician Assistant on 01/10/24 at 9:47 AM. The PA reported she was notified by the Unit Manager that Resident #62 was observed with his hand up Resident #57's dress. She stated she knew Resident #57 very well and went to assess her. The PA reported Resident #57 was not demonstrating any signs of distress or agitation. She was smiling when she entered the room and seemed her complete normal self. The PA stated once the Unit Manager and the DON were able to separate her legs due to her being so rigid, the PA noticed her brief was completely intact. The PA added, while she assessed her perineal area, Resident #57 did not push her hand away or seem as though it was bothering her to be examined. There was no redness to her hips, thighs or groin and no evidence of trauma. The PA stated after she assessed Resident #57, she went to assess Resident #62. The PA stated Resident #62 had no recall of what he had done. The PA stated Resident #62 had never had any sexual behaviors in the past and she was surprised that this had even happened. The PA stated Resident #62 has had no sexual behaviors since 12/11/23 and he was monitored every 30 minutes by staff until he was seen by the Psych Nurse Practitioner. A nursing progress note written on 12/11/23 at 4:38 PM by the DON revealed Resident #62 was to be on every 30-minute safety checks until evaluated by Psychiatry. Staff were informed. A written statement dated 12/11/23 by the DON revealed DON spoke to [Resident #62] regarding event that occurred and was witnessed today in the common TV room by nurse aide. [Resident#62] had no memory of the event and stated, I did not do anything. A review of the Resident Observation / 30 Minutes Monitoring Tool revealed as of 12/11/23 every 30 minutes starting at 3:30 PM until 12/21/23 at 7:30 AM, Resident #62 had been documented as being visually monitored every 30 minutes on all shifts as evidenced by the nursing initials, with a time and date. A nursing progress note written by the DON on 12/11/23 at 4:39 PM revealed nursing staff were instructed by DON to watch for any change in physical, emotional, or psychological demeanor of Resident #57 and notify the DON if any change was observed. A nursing progress note written by Nurse #17 on 12/12/23 at 1:13 PM revealed Resident #62 was being monitored frequently. Resident noted in bed resting. A nursing progress note written by Nurse #17 on 12/12/23 at 6:40 AM revealed continued to monitor Resident #62 throughout the night. Resting in bed. A Social Worker (SW) progress note written on 12/12/23 at 9:34 AM revealed the clinical team discussed a room change for Resident #62. Resident #62 would be moving to a new room away from Resident #57. A nursing progress note written by the DON on 12/12/23 at 11:47 AM revealed notified Psychiatry Nurse Practitioner regarding recent event involving Resident #62. The note indicated that a complete medication review would be performed by the Psych Nurse Practitioner when she would see the resident next week. A 5 day investigation summary was written by the Administrator on 12/15/23 was as follows: On 12/11/23 at 3:03 PM nurse aides notified the Unit Manager that she witnessed a male resident [Resident #62] with his hand up the dress of female resident [Resident #57] in the common area TV room. Nurse Aide separated the residents immediately. The DON and Administrator were notified by the Unit Manager of the event. The Administrator notified Corporate Compliance and the DON notified the local police department. The Administrator submitted an initial report to the Department of Health and Human Services (DHHS) on 12/11/23 at 5:20 PM. and submitted a completed investigation report on 12/15/23. These reports included in part: The Physician Assistant and the DON visually assessed Resident [#57] for visible trauma and resident's brief was intact. No trauma identified. On 12/11/23, the PA evaluated Resident #62 with nothing remarkable noted. Two floor Unit Managers began skin checks and interviews with residents on the 300 short hall. Police arrived and took statement from the Administrator and DON. On 12/11/23 the facility initiated 30-minute checks on [Resident #62] until Resident was evaluated by Psych Services. Resident [#62] was interviewed on 12/11/23 and he stated he did not recall the incident. On 12/13/23 the facility initiated a room change for Resident [#62] from station 3 to station 2. Based on staff statements, observation and facility investigation, the allegation of abuse was substantiated. Resident [#62] was moved to a different station in the building to limit any interaction between the two residents Resident [#57] has not suffered any observable psychosocial harm from the incident. Resident [#62] was referred to psych services and has been scheduled to be seen on 12/21/23 with an accompanying medication review. Resident [#62] has had no further episodes of sexually aggressive behavior. Resident [#62] will continue to be monitored for any adverse effects related to this incident. Resident [#62] will continue to be on every 30 minute checks by staff until psych visit was completed and medication review has been conducted and deemed effective. Resident [#62]'s care plan and profile have been updated to reflect this behavior. A review of an updated care plan dated 12/14/23 revealed Resident #62 had a plan of care for having physical behavioral symptoms toward others (abusing others sexually) with a goal that resident would not harm others secondary to physically abusive behavior with interventions to include avoid power struggles with resident, avoid over stimulation, maintain a calm environment and approach to the resident, assess whether the behavior endangers the resident and or others. Intervene, as necessary. A Psychiatric Nurse Practitioner note dated 12/21/23 for Resident #62 revealed under assessment and plan: Major neurocognitive disorder likely due to vascular dementia with likely associated depression. Lexapro (antidepressant) started by the Primary Care Physician currently at 10 milligrams (mg) by mouth daily. Informed by the DON that Resident #62 had inappropriate sexual behaviors recently towards a peer. Will taper Lexapro and start Sertraline (antidepressant) to aide in decreasing hypersexual behaviors due to the high incidence of a common side effect of sexual dysfunction/hyposexuality with Sertraline. An interview was conducted with the Psychiatric Nurse Practitioner (NP) via phone on 01/11/23 at 10:19 AM. The NP revealed she was notified Resident #62 had inappropriate sexual behaviors recently towards a female resident. She stated she evaluated Resident #62 and there had been no previous history of sexual behaviors and none since 12/11/23, but she had discontinued the Lexapro and started Sertraline to aide in decreasing hypersexual behaviors. The NP stated Sertraline had a very strong side effect of decreasing sexual urges. A review of the Psychiatric Nurse Practitioner orders for Resident #62 on 12/21/23 revealed decrease Lexapro to 5 mg by mouth daily for 7 days then discontinue. Sertraline 25 mg by mouth daily for 7 days then increase to 50 mg by mouth daily. Review of the Medication Administration Record (MAR) revealed Resident #62 received the medications as ordered as evidenced by a nursing check mark on the MAR from 12/21/23 through 01/11/24. An observation was conducted of Resident #57 on 01/08/24 with Nurse Aide (NA) #1 at 4:10 PM. NA #1 attempted to reposition Resident #57's arm and she did make a giggle like sound, and she was smiling. NA #1 attempted to reposition Resident #57's legs and when she touched her legs, they were difficult to open with significant resistance from Resident #57. An observation of Resident #62 on 01/08/24 at 10:00 AM revealed an alert resident lying in bed resting in his room. Writer attempted to interview Resident #62 on 01/08/24 at 10:00 AM. He was confused and not able to answer questions reliably. An interview was conducted with the Director of Nursing on 01/12/23 at 12:30 PM. The DON reported the residents were in a common area 12/11/23 and the staff had no way of knowing Resident #62 was going to put his hand up Resident 57's dress. The DON added, Resident #62 had never demonstrated any sexual behaviors. The DON stated we monitored Resident #62 every 30 minutes until he was seen by psych services. She stated since that event happened, Resident #62 rarely came out of his room, but he was now on a different hall and did not go anywhere near Resident #57's hall. The DON stated they monitored the resident for 10 days, he was evaluated by psych, had a med change and no other issues since so they thought they had done all they could do. An interview was conducted with the Administrator on 01/12/23 at 1:45 PM. He stated he completed the initial report within 2 hours and submitted it to the state and completed a 5- day investigation. He stated he notified the police and Adult Protective Services. The Administrator stated he monitored the two residents and did education with staff regarding the types of abuse and who to report it to, but he did not do continued audits. The Administrator provided the in-service records regarding abuse education and stated all the information he had was in the file. There were no audits found in the file.

Based on record review, resident interview and staff and Physician interviews, the facility failed to follow the resident ' s care plan to utilize two staff members with bed mobility for 1 of 2 residents observed for falls. Resident #43 sustained a fall which resulted in a left fractured femur that required surgery. Findings included: Resident #43 was admitted to the facility on [DATE], discharged on [DATE] to the hospital and readmitted to the facility on [DATE]. Diagnoses included, in part, fracture to left femur (02/09/21) and stroke with left side weakness. A care plan dated 04/19/19 and last reviewed on 02/26/21 revealed a plan of care for Activity of Daily Living (ADL) self-care deficit related to stroke with left sided [CONDITION(S)] and [CONDITION(S)]. The approach included, in part, bed mobility required assistance of two staff. The care plan indicated to include this approach on the resident profile. A review of the resident ' s profile (located in the electronic records) revealed, in part, on 04/04/19 bed mobility required the assistance of two staff. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #43 was cognitively aware and demonstrated no moods or behaviors. Resident #43 required extensive assistance with two staff physical assistance with bed mobility and transfers. Resident #43 had impairments on one side to both lower and upper extremities and was always incontinent of bowel and bladder. A progress note written on 02/08/21 revealed Nurse #2 and Nurse #7 were called to Resident #43 ' s room at 10:20 PM on 02/07/21. The Nursing Assistant (NA #3) was present in the room giving care. The resident was observed on her knees between the bed and the wall. The bed was moved, and resident was gently assisted to a supine position. Passive range of motion was within normal limits for baseline. The resident demonstrated no facial grimacing and first aid was administered for a 0.5 centimeters (cm) abrasion to the left knee. No other injuries were noted. The resident denied any pain when asked and was transferred back to bed using a mechanical lift. She was noted to be alert and oriented, pleasant toward staff, and could make her needs known. The note indicated it was a witnessed fall by the assigned NA (NA #3). On 02/08/21, a progress note revealed Resident #43 requested the nurses to assess her hip. The resident complained of severe pain related to her fall on 2nd shift. The nurse assessed her hip and no visible abnormalities were noted. Resident #43 requested that a note be left for the physician to order an x-ray for her left hip. On 02/08/21 at 10:23 AM, Resident #43 had a new order for an x-ray to the left hip due to complaints of pain. A review of the x-ray result on 02/08/21 time stamped at 9:58 PM revealed there was a fracture of the distal femur, there was impaction, [CONDITION(S)] and knee replacement and the fibula was normal. A progress note written at 3:20 AM on 02/09/21 revealed the x-ray results were received and a call was attempted three times to the Nurse Practioner, and messages were left on the voicemail. The note indicated the Director of Nursing, Supervisor, and Power of Attorney (POA) were notified. The note stated the resident had been given pain medication at 10:00 PM and was resting comfortably with eyes close and no complaints of pain or discomfort. On 02/09/21 at 5:36 AM, a progress note revealed the resident woke up in pain and [MEDICATION(S)] (a narcotic pain reliever) was given. The nurse sent the resident out to the emergency department for treatment and evaluation of fracture post fall. On 02/10/21 at 4:28 AM the nurse contacted the hospital to receive an update on Resident #43. The nurse was informed the resident was scheduled for surgery on 02/10/21 at 10:30 AM for left distal femur fracture. Hospital Discharge Summary on 02/12/21 revealed Resident #43 had a closed fracture of left distal femur secondary to falling out of bed at facility and underwent a retrograde nailing to left femur on 02/10/21. discharged back to facility on 02/12/21. The MDS assessment for significant change dated 02/16/21 revealed the resident was cognitively aware and demonstrated no moods or behaviors. Resident #43 required extensive assistance with two staff physical assistance for bed mobility and transfers. Resident #43 had impairments on one side to both lower and upper extremities and was always incontinent of bowel and bladder. Resident #43 had a fall with major injury during this assessment. A review of the revised care plan on 02/26/21 revealed a plan of care for ADL self-care deficit related to stroke with left sided [CONDITION(S)], [CONDITION(S)], and fractured left femur. The approach included, in part, bed mobility required assistance of two staff. The care plan indicated to include this approach on the resident profile. An interview was conducted with Resident #43 on 04/07/21 at 10:30 AM. Resident #43 reported she had a fall and fractured her left leg. The resident stated the nursing assistant was changing her and rolled her too far over on the bed and she fell on her knees. The resident reported she was supposed to have two staff members doing her incontinent care at all times. The resident reported there was only one nursing assistant changing her the night she fell . An interview was conducted with NA #3 via phone on 04/09/21 at 11:58 AM. NA #3 reported she was assigned to Resident #43 on the night of 02/07/21. NA #3 stated she went in to change Resident #43 and when she turned her over on to her left side she kept rolling and she got caught between the wall and the bed. NA #3 stated the resident usually could assist with rolling and would grab the ¼ side rails whenever she was turning and repositioning, but this time she had rolled her too far over and gravity took over. The NA stated she checked in the hall for help, but no one was nearby, and the resident was squirming and moving around, and she did not want to leave her. The NA stated the resident was getting a little anxious and scared because she was lodged between the bed and the wall and she was scared she was going to fall. NA #3 stated the bed was raised about hip height and she was 5 ' 2. She stated the resident had left sided weakness and her bed was about 15 feet or so from the wall. NA #3 stated she was not able to move the resident herself so she went to the door to call for help, but there was no one available and she was acting quickly to help the resident because the resident was anxious and moving her leg around which was making the bed move some. The NA stated she called out for somebody to come help her and then the resident slowly started to fall to the floor. NA #3 stated when she started to fall she went down knee first and her left knee hit the floor first. The NA stated once the resident was on the floor, she moved the locked bed away further from the wall and added that the bed needed to be in its lowest position in order to move it freely. NA #3 reported Nurse #7 and Nurse #2 and NA #1 came running into the room and both nurses assessed the resident. NA #3 stated she only saw a skin tear on her knee, and she had no redness, bruising and no complaints of pain, but she was upset because it happened. NA #3 stated she got the mechanical lift and they all assisted her back to bed. NA #3 stated she had always done Resident #43 ' s bed mobility care by herself. She stated she was able to change the resident by herself because the resident could assist. NA #3 stated if she needed to learn anything new about a resident, she would ask the nurses or ask other nursing assistants. She stated she had been trained on the computer on how to retrieve information about the resident, but she was not very savvy with it and preferred to get any information she needed about the residents from the staff. NA #3 was never informed the resident needed two assist with bed mobility until after the fall had happened. An interview was conducted with Nurse #2 via phone on 04/09/21 at 2:35 PM. Nurse #2 stated she was very familiar with Resident #43 and stated 02/07/21 at about 10:30 PM she heard a yell for help coming from Resident #43 ' s room. Nurse #2 stated when she entered the room, the resident was beside the bed on the floor on her knees. She stated NA #3 reported she was changing Resident #43 and she rolled the resident too far over onto her left side and the resident became lodged between the bed and wall and then fell to the floor. NA #3 stated the resident was able to reposition herself with help and could hold onto the ¼ side rails once you got her started to a rolling position. Nurse #2 stated that she and Nurse #7 and the two NAs that were present in the room repositioned the resident on to her back and assisted her on the mechanical lift after she was assessed by herself and Nurse #7. Nurse #2 stated she had no complaints of pain, range of motion was within normal limits, no bruising or redness was noted except for a skin tear to her left knee that was cleaned and dressed. Nurse #2 stated the resident requested a snack and she provided one for her. Nurse #2 stated she had seen only one NA doing care on her, but she believed Resident #43 required assistance of two staff and stated it would be documented in her care plan how many staff were needed to assist her. An interview was conducted with Nurse #3 on 04/08/21 at 12:45 PM. Nurse #3 stated Resident #43 needed two staff members to do all her care since her fall on 02/07/21, and prior to 02/07/21, she required two staff members to assist with transfers and bed mobility. Nurse #3 stated the information of how the resident needed to be transferred was noted in the resident ' s care plan. An interview was conducted with NA #4 on 04/08/21 at 1:55 PM. NA #4 stated she had been in serviced regarding turning and repositioning after the resident had a fall on 02/07/21. NA #4 reported she was educated to have two people assisting with all care. NA #4 stated she last took care of Resident #43 on 04/05/21 and she completed the care alone including bed mobility and stated she was able to do the residents ' care with no difficulty without a second person. NA #4 stated if she needed to know how many staff were required with assistance with a resident she would look in the Kardex. NA #4 attempted to find the Kardex book and asked a nurse nearby who stated, We do not use the Kardex anymore, the information was in the electronic record under Resident Profile. NA #4 stated she would ask another NA or a nurse how many staff were required to assist residents if she did not know. An interview was conducted with the Director of Nursing (DON) on 04/09/21 at 3:53 PM via phone. The DON reported she was aware the care plan and the MDS indicated Resident #43 required the assistance of two staff with bed mobility, but she added, the resident was able to help with repositioning by holding on to the ¼ rails once she had been assisted to roll on to her side so one person was able to do care. The DON stated she felt it was a freak accident. The DON reported she did not know if the fall could have been avoided if there were two staff present while doing care. An interview was conducted with the attending Physician via phone on 04/09/21 at 4:02 PM. The Physician stated he cared for the resident ' s fractured femur when she was at the hospital post fall. The Physician stated if she was care planned for two staff to assist with bed mobility then she should have had two people assisting her. An interview with the Administrator on 04/09/21 at 4:15 PM revealed her expectation of the nursing staff was to follow the care plan for bed mobility to ensure the safety of the resident