Every finding on record at Suites at Someren Glen Care Center, The

Based on record review and interviews, the facility failed to ensure residents were informed of the treatment, including the risks and benefits, of proposed care and to choose the alternative option if they preferred for three (#4, #9 and #76) of six residents reviewed out of 51 sample residents.Specifically, the facility failed to: -Ensure Resident #4's consent explained the risks versus benefits for psychotropic medications; -Ensure Resident #9 and/or Resident #9's representative were informed and agreed to an increase in the dose of the resident's psychotropic medication; and, -Ensure Resident #76 and/or the resident's representative consented to antibiotic therapy prior to the administration of antibiotics.Findings include: I. Facility policy and procedure The Psychotropic Medication Management policy and procedure, dated [DATE], was provided by the vice president of clinical services on [DATE] at 12:32 p.m. It read in pertinent part, Residents and or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. Consent will be obtained, as indicated. It is recommended that the community use the psychotropic medication management Consent and Disclosure form. The Resident Rights policy and procedure, revised [DATE], was provided by the vice president of clinical services on [DATE] at 12:32 p.m. It read in pertinent part, You have the right to request, refuse and or discontinue medications and treatments (but this could be harmful to your health), and to know the consequences of such actions. II. Failed to ensure Resident #4's consent explained the risks versus benefits for psychotropic medications A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included displaced fracture of left femur, hypertension, history of falling, aortic stenosis, dementia, osteoarthritis, anxiety and depression. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He used a walker. He required set up assistance with eating. He required substantial assistance with oral hygiene, toileting, showering, dressing and personal hygiene. The assessment revealed he had an anxiety disorder and depression. He took an antipsychotic and an antidepressant medication with an indication noted. B. Record review Review of Resident #4's [DATE] CPO revealed the following physician's orders: Risperidone (an antipsychotic medication) 0.5 milligrams (mg). Take one tablet by mouth at bedtime for dementia with behaviors, ordered [DATE]. Sertaline (an antidepressant medication) 50 mg. Take one tablet by mouth a day for depression, ordered [DATE]. Review of Resident #4's [DATE] medication administration record (MAR) revealed the resident's first dose of risperidone was given on [DATE]. Review of Resident #4's [DATE] MAR revealed the resident's first dose of sertraline was given on [DATE]. -A review of the consent for risperidone and sertraline failed to reveal if the facility had explained the risks versus benefits of risperidone and sertraline to the resident or the resident's representative. C. Staff interviews Registered nurse (RN) #1 and RN #3 were interviewed together on [DATE] at 2:26 p.m. RN #1 and RN #3 said nursing staff was responsible for obtaining consent at the time of a resident's admission to the facility for medications with black box warnings (when clinical data shows a medication carries a severe risk of death or life threatening adverse reactions, serious physical injury or permanent disability or high addiction or dependence potential). RN #1 said the nurses should explain the side effects, what symptoms the facility was monitoring the resident for and inform the resident or the resident's representative to report back to staff if they observed symptoms or behaviors so nursing staff could inform the physician. RN #1 and RN #3 said risks versus benefits were covered to let the resident know what to look out for. RN #1 and RN #3 said they used a consent form so nursing staff could provide the resident something in writing for them to reference if they had any questions. RN #1 said consent needed to be obtained before the medication was administered. RN #1 said risperidone was an antipsychotic medication and sertraline was an antidepressant medication. RN #1 said Resident #4 took both medications. RN #1 looked at Resident #4's electronic medical record (EMR) and looked at Resident #4's consent form for psychotropic medications. She said she did not know why the consent form did not document the risks versus benefits of the resident's psychotropic medications. Social services assistant #1, Social services assistant #2, unit manager #1, and unit manager #2 were interviewed together on [DATE] at 4:48 p.m. Social services assistant #1 said the unit manager was responsible for obtaining consent for medications with black box warnings. Social services assistant #1 said consent was obtained because the facility needed to explain the side effects of medications with black box warnings and so the residents or their representatives knew the risks versus benefits of the medication. Social services assistant #1 said the consent covered the benefits, the adverse reactions and concerns. She said consent should be obtained before the medication was administered Unit manager #2 said she explained the risks versus benefits of the psychotropic medications and she documented that consent was obtained on a consent form. Unit manager #2 said she completed a progress note as well Social services assistant #1 said she was familiar with Resident #4. Social services assistant #1 said risperidone was a psychotropic medication and sertraline was an antidepressant medication. Social services assistant #1 said Resident #4 took both medications. Social services assistant #1 said she did not know where Resident #4's consent form was and said the consent should document the risks versus benefits of the medications. Social services assistant #1 said she did not know Resident #4's consent form for the psychotropic medications did not have the risks versus benefits documented on it. The director of nursing (DON) and the vice president of clinical services were interviewed together on [DATE] at 4:43 p.m. The DON said nursing staff was responsible for obtaining consent at time of a resident's admission to the facility for medications with black box warnings. The DON said the nurses should explain the side effects, what symptoms the facility was monitoring for and inform the resident or the resident's representative to report back to staff if they observed symptoms or behaviors so nursing could inform the physician. The DON said risks versus benefits were covered to let the resident or the resident's representative know what to look out for. The DON said the facility used a consent form so nursing staff could provide the resident something in writing for them to reference if they had any questions. The DON said consent needed to be obtained before the medication was administered. The DON and the vice president of clinical services said risperidone was a psychotropic medication and sertraline was an antidepressant medication. The DON said Resident #4 took both medications. The vice president of clinical services said the consent form used for Resident #4's psychotropic medications did not indicate the risks versus benefits of the medications, so it was unknown if it was explained to the resident and or the resident's representative. The vice president of clinical services said there were two consent forms the facility used and she needed to change the process so the consent form that included risks versus benefits was consistently used. III. Failed to ensure Resident #9 and/or Resident #9's representative were informed and agreed to an increase in the dose of the resident's psychotropic medication A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included senile degeneration of the brain, unspecified dementia with other behavioral disturbance, encephalopathy and hypertension. The [DATE] MDS assessment revealed the resident had severe impairment with making decisions regarding tasks of daily life, per the staff assessment for mental status. She was dependent on staff to assist with oral hygiene, toileting hygiene, bathing and dressing. The assessment indicated Resident #9 received antipsychotic medications. B. Record review Review of Resident #9's [DATE] CPO revealed the following physician's order: Seroquel (antipsychotic medication) oral tablet 50 mg) (Quetiapine Fumarate), give one tablet by mouth two times a day, ordered [DATE]. A review of the resident's psychotropic medication informed consent form, dated [DATE], revealed Resident #9 consented to Seroquel 12.5 mg twice daily. A review of the psychotropic medication review, dated [DATE], revealed Resident #9 continued on Seroquel 12.5 mg twice daily. Additional recommendations included increasing the resident's Seroquel dose to 25 mg twice daily and adding behavior and side effect monitoring. -However, there was no documentation in the resident's EMR to indicate the resident's representative had been informed of the recommendation and subsequent increase in the dosage increase of Seroquel. A review of the psychotropic medication review, dated [DATE], revealed Resident #9's Seroquel dosage was 50 mg twice daily for dementia with behaviors. The psychotropic committee recommendations included consolidating the medication to 50 mg tablets. A review of the psychotropic medication review, dated [DATE], revealed Resident #9 remained on Seroquel 50 mg twice daily. -However, a review of Resident #9's EMR revealed no updated psychotropic medication informed consent forms for the resident's increased Seroquel dosage from 12.5 mg twice daily to 50 mg twice daily. Review of Resident #9's [DATE] medication administration record (MAR) revealed Seroquel oral tablet 25 mg (Quetiapine Fumarate), give one tablet by mouth two times a day for encephalopathy, was started on [DATE]. Review of Resident #9's [DATE] MAR revealed Seroquel oral tablet 25 mg (Quetiapine Fumarate), give two tablets by mouth two times a day for encephalopathy, was started on [DATE]. (Seroquel 25 mg one tablet two times per day was discontinued.) A review of Resident #9's [DATE] MAR revealed Seroquel oral tablet 50 mg (Quetiapine Fumarate), give one tablet by mouth two times a day for dementia with behaviors, was started on [DATE]. (Seroquel 25 mg two tablets two times per day was discontinued.) A review of Resident #9's [DATE], [DATE], February 2026, [DATE], [DATE] and [DATE] (from [DATE] to [DATE]) MARs revealed Resident #9 received Seroquel 50 mg one tablet twice daily for dementia with behaviors. C. Staff interviews The executive director was interviewed on [DATE] at 6:23 p.m. The executive director said every time there was an increase in dosage for a resident's psychotropic medications, a consent should have been obtained. The executive director said he could not find the consent form for Resident #9's dosage increase of Seroquel from 25 mg to 50 mg. The executive director said the social services department or unit managers were responsible for obtaining consents. Unit manager #1 was interviewed on [DATE] at 6:28 p.m. Unit manager #1 said the interdisciplinary team (IDT) reviewed residents' behaviors and nursing notes to determine whether a psychotropic medication dosage increase was needed after the resident's first month of stay in the facility. Unit manager #1 said social services staff obtained consents in the past, however, the unit managers now participated in IDT meetings and were responsible for obtaining updated consents. Unit manager #1 said it was important to obtain consent for psychotropic medication increases because higher dosages increased the risk for side effects and adverse reactions. The staff development coordinator was interviewed on [DATE] at 6:41 p.m. The staff development coordinator said Resident #9 went to the hospital in [DATE] for an eye infection and the Seroquel dose may have been increased while she was in the hospital. -However, according to the resident's MARs, the resident's Seroquel was increased in [DATE] (see record review above). The DON and the vice president of clinical services were interviewed together on [DATE] at 7:15 p.m. The DON said a new consent for Resident #9 should have been obtained when the dosage of her psychotropic medication increased. The DON said the social services department was responsible for obtaining consent forms and it was a team effort to get updated consent forms. The DON said she could not find an updated consent form for when Resident #9's dosage of Seroquel increased. The DON said the facility had health information management issues and staff were trying to get caught up and may have lost the updated consent form for the resident. IV. Failed to ensure ensure Resident #76 and/or the resident's representative consented to antibiotic therapy prior to the administration of antibiotics A. Resident status Resident #76, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included senile degeneration of the brain (progressive loss of brain cells and cognitive function associated with advanced age), major depressive disorder, motor neuron disease, dementia and peripheral vascular disease. The [DATE] MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of seven out of 15. B. Resident's representative interview Resident #76's representative was interviewed on [DATE] at 1:49 p.m. Resident #76's representative said she was so upset that Resident #76 was treated with antibiotics for a urinary tract infection (UTI) and that he was not allowed to die with dignity. She said the resident had begged herself and their children to let him die. Resident #76's representative said when she was notified of a suspected UTI, she said she did not want the resident to begin antibiotic therapy. She said she wanted hospice to evaluate her husband to re-establish hospice services. However, she said the facility treated Resident #76 with antibiotics two of the three days the antibiotic therapy was ordered for. Resident #76's representative said she spoke to the physician about not starting antibiotic therapy and he said he would talk to the nurse about their choice. She said the facility told her there was a note in the EMR that the physician was going to call the nurse, but for some unexplained reason, the nurse did not get the information from the physician. Resident #76's representative said the facility told her they worked hard to communicate but they had had problems with their phone system and could not provide documentation of the physician notifying the nurse not to administer the antibiotic therapy. C. Record review Review of Resident #76's EMR revealed the resident appointed his wife to be his general durable power of attorney, signed [DATE]. Resident #76's EMR revealed the medical orders for scope of treatment (MOST) form documented the resident did not want cardiopulmonary resuscitation (CPR) and wanted comfort-focused treatment only, signed [DATE]. Review of Resident #76's CPO revealed the following physician's order: Ceftriaxone sodium (antibiotic) injection solution reconstituted 1 gram (gm). Inject one gm intramuscularly (IM) one time per day for three days for a pending urine culture, ordered [DATE]. Review of Resident #76's February 2026 medication administration record (MAR) revealed the following: Ceftriaxone sodium (Rocephin)1 gm IM injection was administered on [DATE] and [DATE]. Review of Resident #76's progress notes revealed the following documentation: On [DATE] at 4:17 p.m. an alert note documented Resident #76 was lethargic, had dysuria (pain with urination), altered mental status (AMS) and had pus-like urine noted with a brief change at 3:30 p.m. The nurse practitioner (NP) was notified and she gave orders for a culture and sensitivity (C&S - a urine test used to identify the specific germ causing an infection and to find the most effective medication to treat it), complete metabolic panel (CMP) and a complete blood count (CBC) stat (immediately). The staff were awaiting a laboratory (lab) draw and urine collection, the resident's representative was notified and the nurse would notify the incoming shift for monitoring. On [DATE] at 5:33 a.m. a nursing note documented that the nurse received a call back from the facility's on-call physician and received new orders to administer Rocephin one gm daily for three days, pending the urine culture after obtaining the urine sample. On [DATE] at 4:29 a.m. a nursing note documented Resident #76 was on monitoring for antibiotic use. The resident was on Rocephin one gm IM daily for three days post-urinalysis and pending a urine culture. On [DATE] at 1:10 p.m. a nursing note documented that the nurse spoke to Resident #76 and the resident's representative about treatment for UTI, and they requested that treatment be held until hospice re-evaluated the resident on [DATE]. On [DATE] at 12:00 a.m. a physician encounter note documented Resident #76 was seen for UTI follow-up and a goals of care discussion with the resident's representative. The resident recently graduated from hospice care because he no longer met hospice requirements. He had labs and a urine culture obtained over the weekend due to increased confusion and abnormal vital signs. The on-call team was notified of the results and gave an order for Rocephin for three days while awaiting the final urine culture. The resident's representative discussed with the bedside nurse and the on-call physician to hold the Rocephin. However, the Saturday [DATE] dose had already been given at that point. -The facility failed to ensure Resident #76 and the resident's representative consented to antibiotic therapy before Rocephin was administered. The [DATE] at 12:00 a.m. physician's encounter note documented the resident's wife reiterated that Resident #76 made his wishes very clear to her early on in his diagnosis, prior to increased cognitive impairment, that he did not want to live in his current condition, and she knew he would not want to be treated for something acute to prolong his life. Per documentation, the on-call team was calling the nurses' station to put a hold on the Rocephin dose on Sunday, [DATE]. -However, the facility failed to provide documentation that the on-call physician attempted to notify the bedside nurse not to administer the Rocephin. The [DATE] at 12:00 a.m. physician's encounter note documented the physician's order had since been cancelled and Resident #76 did not receive Rocephin on [DATE], nor would he receive any further antibiotics for the UTI with greater than (>) 100,000 colony-forming units (cfu) per milliliter (ml) proteus mirabilis (a gram-negative, anaerobic bacterium - typically indicates a significant UTI). However, the resident received two doses of Rocephin prior to this. The resident recently graduated off hospice and hospice would re-evaluate to see if he met criteria for readmission to hospice services. Discussion of goals of care with the resident's representative and staff today included no treatments of any kind - comfort goals of care with no life sustaining measures or treatments. Created alerts in the facility's EMR that the resident was not to receive antibiotics of any kind for future infections. On [DATE] at 12:16 p.m. a nursing note documented the nurse spoke with the resident's wife regarding Resident #76 receiving two doses of antibiotics to treat a UTI, which was opposite of her wishes. She directly told the nurse and the facility's on-call physician to not treat based on the resident's wishes. The care profile was updated to reflect no labs or hospital transfer was to happen without the resident representative's permission. Review of the [DATE] grievance form and investigation revealed Resident #76's representative was notified of a change of condition by the bedside nurse, but the representative approved laboratory tests and not antibiotic therapy. Review of the [DATE] ethics committee consultation revealed the resident's representative's wish was to allow the UTI to lead to sepsis and, ultimately death, as in her mind this would be her way of honoring Resident #76 to die once his quality of life was gone. Review of the meeting notes with Resident #76's representative, which occurred on [DATE] at 1:00 p.m., revealed that a review confirmed that antibiotics had been discussed with the facility's on-call physician and nursing staff, and documentation reflected the intent to notify the nursing staff. However, there was no record confirming the nurse received direct communication and the exact point of communication breakdown remained unclear. The gap was acknowledged as not acceptable and had been addressed with the on-call physician company and nursing teams. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 10:55 a.m. CNA #2 said when a resident or their family refused care, she had to notify the nurse and see if the nurse could try to convince the resident. She said sometimes giving the resident space helped them change their mind. She said if the resident continued to refuse she would document it in the facility's charting system. CNA #2 said she was familiar with Resident #76. She said sometimes the resident refused care, but after waiting an hour to two he would change his mind. CNA #2 said Resident #76's mood and behavior had not changed since she met him, and she thought he was at his baseline. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:12 a.m. LPN #2 said when a resident or family member refused care, the nurse would document it in their notes before notifying the unit manager and the physician. She said refusals should be documented in the facility's charting system. LPN #2 said she was familiar with Resident #76 and she knew there was a time when the resident had a suspected UTI that the facility tested for and initiated antibiotic therapy. She said at the time, the resident's wife was notified she did not want any treatment for the UTI. LPN #2 said the facility now had special instructions not to do anything without first letting the resident's representative know. She said she did not think Resident #76 had negative psychological impact from receiving antibiotic therapy and she thought the resident's mood and behavior were at his baseline. The DON and the MDS coordinator were interviewed together on [DATE] at 6:20 p.m. The DON said when a resident refused care the nursing staff would document the refusal. The MDS coordinator said she was familiar with Resident #76 and the resident had never refused antibiotic therapy. She said the resident's representative did not want lifesaving measures, and his MOST form said to provide comfort care only. The MDS coordinator said Resident #76 was having symptoms of a possible UTI so a urinalysis (UA) was completed, the antibiotic was ordered and the resident's wife was notified. She said before the physician discontinued the medication, one dose was administered. After she searched the EMR, the MDS coordinator said Resident #76 received two total doses of the antibiotic. She said after the event, a care conference was held and the facility made sure they understood the wishes of Resident #76 and his representative. The MDS coordinator said she did not think Resident #76 experienced psychological impact as a result of receiving antibiotic therapy, but the resident's wife had a really hard time with it. She said during the facility's investigation, the on-call physician's notes were requested and the facility confirmed the on-call physician spoke with Resident #76's representative. The MDS coordinator said the facility pulled reports but were unable to verify that a phone call from the on-call physician came through, and the facility was unable to identify where the breakdown occurred. She said they provided education to nursing staff that they were required to follow the physician's orders but it was okay to hold the medication to get ahold of the physician or resident's representative prior to administration.

Based on record review and interviews, the facility failed to ensure a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve, and demonstrate the facility's response to group grievances regarding long call light wait times.Findings include:I. Facility policy and procedureThe Grievance Management policy, dated September 2025, was provided by the executive director on 5/8/26 at 12:32 p.m. It read in pertinent part, A complaint or issue brought to the attention of the facility by a resident or resident representative that is not resolved more informally and in a very timely manner, generally within three days, will be referred to the formal problem-resolution procedure outlined in this policy. The nursing home administrator (NHA), or designee, is the designated facility associate responsible for receiving grievances. Any resident, resident representative or resident council that wishes to complain about treatment, conditions, or violations of rights, shall present such grievance to the facility NHA orally or in writing within 14 calendar days of the alleged incident giving rise to the grievance. The NHA or designee shall investigate and confer with persons involved in the alleged incident and other relevant persons and, within three calendar days of receiving the grievance, shall provide a written explanation of findings and proposed remedies to the complainant. The final written outcome will be provided within a reasonable time, not to exceed thirty (30) days following receipt of the grievance. The written report shall include at a minimum, the date the grievance was received, the date the report is written, a summary statement of the grievance, steps taken to address the grievance, a summary of the findings or conclusions of the investigation, a statement as to whether the grievance was confirmed or not confirmed, and any corrective action taken to be taken by the facility because of the grievance.II. Resident group interviewA group interview was conducted on 5/6/26 at 10:30 a.m. with four residents (#24, #54, #55, and #87) who were identified as interviewable through facility and assessment. The residents said call light wait times were long and were usually worse during the night shift. The residents said there were not enough certified nurse aides (CNA) on the floor during the night shift to help residents in a timely manner. The residents said their needs were not always met in a timely manner due to low staffing. They said it could take up to two hours for staff to help them. The residents said they did not like waiting that long because a lot of things could go wrong. They said some residents activated neighboring residents' call lights in an effort to get a staff member's attention so assistance could be provided. Resident #87 said she waited one hour that morning (5/6/26) for staff to answer her bathroom call light. Resident #87 said there were times she got up without assistance because staff did not respond timely to call lights. She said she was concerned about falls because she was not supposed to get up on her own.The residents said concerns regarding call light response times and staffing had been brought up during resident council meetings for several months. The residents said the issues continued and were not resolved.III. Additional resident interviewResident #79 was interviewed on 5/4/26 at 12:43 p.m. Resident #79 said she waited one hour the previous day for staff to respond to her call light. She said she usually waited for assistance to go to the bathroom because she had fallen a few times. Resident #79 said even when she pulled the bathroom call light cord five times, staff rarely responded.IV. Resident council meeting minutesResident council meeting minutes from November 2025, December 2025, January 2026, February 2026, March 2026 and April 2026 were provided by the NHA on 5/5/26 at 2:38 p.m.The 1/14/26 resident council meeting minutes revealed concerns that CNAs and nurses needed to be more aware of bathroom call lights. The assistant executive director told residents that the management team planned to complete call light audits to ensure call lights were working and that CNAs and nursing staff answered call lights in a timely manner.The 2/18/26 resident council meeting minutes revealed concerns that call light times were getting very long. Residents said call light wait times sometimes were 30 minutes and sometimes could be two hours due to insufficient staffing.The 3/11/26 resident council meeting minutes revealed that the assistant director of nursing (ADON) asked whether the call light times had improved and the general consensus from the residents was that they had improved a little bit. The management team implemented a new process to ensure call lights were answered more quickly.The 4/8/26 resident council meeting minutes revealed concerns regarding staffing and requests for more CNAs. The ADON told the residents that staffing numbers were based on census and said she would follow up with the management team regarding the residents' staffing concerns.-However, the resident council meeting minutes failed to reveal that the facility resolved the ongoing concerns related to long call light wait times and staffing concerns identified during the January 2026, February 2026, March 2026 and April 2026 resident council meetings.V. Staff interviewsThe executive director and the vice president of clinical services were interviewed together on 5/6/26 at 1:46 p.m. The executive director said the facility installed a new call light system in July 2025 because the previous system was outdated and difficult to replace. The executive director said staff received training from the company that installed the system and the nurse managers continued to train staff. The executive director said nurses and CNAs received the call light notifications through an application on their phones and staff could accept and cancel call lights through the application. The executive director said call lights were expected to be answered within 10 minutes. The executive director said if a call light was not answered within 10 minutes, the alert escalated to a nurse and after another 10 minutes, it escalated to the management team. The executive director said the NHA, the director of nursing (DON) and the nurse managers reviewed call light reports weekly and reviewed timing concerns to identify trends related to delayed responses.CNA #4 was interviewed on 5/6/26 at 4:38 p.m. CNA #4 said one CNA was responsible for approximately 11 to 12 residents on the Ponderosa unit and it was difficult to get residents up, toileted and showered before breakfast. CNA #4 said morning care responsibilities were nonstop and staff did not always have enough time to complete resident care timely. CNA #4 said residents sometimes waited 30 minutes to one hour for assistance during busy shifts. CNA #4 said residents complained about waiting for assistance and some residents toileted themselves because they could not wait for staff assistance.Social services assistant #1 was interviewed on 5/7/26 at 7:21 p.m. Social services assistant #1 said the facility documented resident concerns on a grievance form. Social services assistant #1 said grievances related to nursing were forwarded to the DON and grievances related to dining services were forwarded to the appropriate department. Social services assistant #1 said concerns related to call lights were reported to the DON and the NHA.The executive director was interviewed again on 5/7/26 at 7:26 p.m. The executive director said the facility had received complaints about call lights from residents. The executive director said the facility began discussing call lights in April 2026 through a Performance Improvement Plan (PIP), discussed the issue during an all-staff meeting and completed an in-service with staff. The executive director said delayed call light responses occurred more often during meal times and when staff were getting residents up or back to bed.-However, residents continued to experience long call wait times, including on the morning of 5/6/26 (see resident group interviews above).

Based on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for three of six allegations of abuse.Specifically, the facility failed to:-Report an allegation of verbal abuse between Resident #46 and Resident #56 on 2/18/26 within two hours of the incident;-Report an allegation of sexual abuse between Resident #82 and certified nurse aide (CNA) #6 on 12/19/25 within two hours of the incident; and,-Report an allegation of sexual abuse between Resident #79 and CNA #6 on 1/3/26 within two hours of the incident.Findings include:I. Facility policy and procedureThe Abuse policy, dated March 2024, was provided by the nursing home administrator (NHA) on 5/4/26 at 4:35 p.m. It read in pertinent part, The (facility) will strive to prevent abuse and report, investigate and respond to actual and suspected abuse, as well as care for and treat those who may be victims of abuse. The facility will meet the requirements of Federal, State, and local law in its response to actual or suspected abuse. Occurrence reporting policies and procedures must be similarly followed. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include but are not limited to, threats of harm and saying things to frighten a resident. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Reporting suspected abuse occurrences: after trying to intervene to stop the abuse, neglect, exploitation or other mistreatment, associates and volunteers must report suspected or actual abuse to the executive director; the community will ensure the resident(s) are protected from potential future abuse, neglect and/or exploitation while the investigation is being conducted; the executive director, on behalf of the community, will ensure that law enforcement and all other applicable regulatory agencies are notified within 24 hours of becoming aware of the allegation of abuse, neglect or exploitation; the executive director must also notify the resident's family or other legal representative about the allegation within 24 hours of becoming aware of the allegation; Colorado law also requires that personnel engaged in the admission, care of treatment of at-risk elders to report suspected physical or sexual abuse, mistreatment, exploitation and neglect to law enforcement within 24 hours of observation or discovery; any suspected or witnessed abuse, neglect, involuntary seclusion or misappropriation of resident property may result in immediate suspension of the associate(s) pending further investigation; and, refusal to report abuse or suspected abuse in violation of this policy in a timely manner is grounds for immediate disciplinary action up to and including termination.II. Record reviewThe facility investigations for three verbal and sexual abuse allegations were provided by the NHA on 5/5/26 at 2:00 p.m. The investigations documented the following:The alleged sexual abuse between Resident #82 and CNA #6 occurred on 12/19/25 at 3:45 p.m.Cross-reference F550 for failure to treat residents with dignity and respect.-However, the facility failed to report the allegation of potential sexual abuse until 12/20/25 at 11:51 a.m., 20 hours after the incident occurred.The alleged sexual abuse between Resident #79 and CNA #6 occurred on 1/3/26 at 7:00 p.m.Cross-reference F550 for failure to treat residents with dignity and respect.-However, the facility failed to report the allegation of potential sexual abuse until 1/7/26 at 1:49 p.m., 90 hours after the incident occurred.The alleged verbal abuse between Resident #46 and Resident #56 occurred on 2/18/26 at 4:00 p.m. -However, the facility failed to report the allegation of potential verbal abuse until 2/19/26 at 12:15 p.m., 20 hours after the incident occurred.III. Staff interviewsThe NHA was interviewed on 5/5/26 at 3:07 p.m. The NHA said staff should report potential abuse immediately to the director of nursing (DON) or herself, as the abuse coordinator. She said the first step with an abuse allegation was to ensure the resident was safe and removed from the situation, then a registered nurse (RN) should complete an assessment of the resident. The NHA said she would then report the allegation of abuse to the ombudsman, corporate and the human resources (HR) department before she involved the police, nursing board and adult protective services (APS). She said she would get the initial incident report submitted to the State Agency before immediately and quickly investigating the incident to determine if the allegation of potential abuse was actual abuse. The NHA said the initial incident report would be submitted to the State Agency within two hours if the resident experienced an injury or harm.Social services assistant #2 was interviewed on 5/6/26 at 3:37 p.m. Social services assistant #2 said the NHA was the abuse coordinator for the facility. She said staff should report potential abuse immediately if there was harm, but the facility had two hours to report abuse to the State Agency after it was discovered. Social services assistant #2 said facility staff were to report abuse to their supervisor, who would then report the allegation directly to the NHA.The executive director and the DON were interviewed together on 5/8/26 at 11:46 a.m. The DON said abuse should be reported to the State Agency within two hours of the incident. She said investigations should be completed within five days of the incident.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for three out of six allegations reviewed for abuse.Specifically, the facility failed to:-Thoroughly investigate a sexual abuse allegation by certified nurse aide (CNA) #6 towards Resident #82 on 12/19/25;-Thoroughly investigate a sexual abuse allegation by CNA #6 towards Resident #79 on 1/3/26; and,-Thoroughly investigate a neglect allegation involving CNA #5 on 4/1/26.Findings include: I. Facility policy and procedure The Abuse policy and procedure, dated March 2024, was provided by the nursing home administrator (NHA) on 5/4/26 at 4:03 p.m. It read in pertinent part, Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Examples of neglect include but are not limited to, failing to provide needed care such as not responding to a call light, failing to nourish, toilet, or hydrate a resident. The community will strive to prevent abuse from occurring by doing the following: education, staffing levels, communicating and reporting concerns and resident rights. A detailed investigation will be completed. The senior staff member on duty will initiate an investigation immediately and notify the executive director. Applicable assessments will be completed. The investigation will determine if the allegation was verified, not verified or inconclusive. All potential relevant physical evidence will be saved, and the circumstances thoroughly documented. Care planning and corrective action will be taken to prevent future occurrences. In situations where an associate is the alleged perpetrator, action taken will depend on the severity of the incident and information provided during the investigation. II. Failed to thoroughly investigate an allegation of sexual abuse between Resident #82 and CNA #6 A. Facility investigation The facility's investigation of the 12/19/25 allegation of sexual abuse was provided by the NHA on 5/5/26 at 2:00 p.m. The facility's investigation report revealed an interview with Resident #82 was conducted on 12/22/25 (three days after the allegation was made) by the social services director (SSD). The interview revealed Resident #82 felt like the male care giver (CNA #6) had his hands where they should not be. When the resident was asked to clarify, she stated she was referring to her breasts. The SSD asked Resident #82 if she would feel more comfortable during cares if the male care giver asked her to move her own breasts out of the way and Resident #82 said yes. Resident #82 stated that she felt safe and did not like being touched by male care givers when possible. -The investigation failed to reveal documentation to indicate that an interview was conducted with the assailant, the date the interview with the alleged assailant took place, or what questions were asked of the alleged assailant, CNA #6. -The investigation failed to reveal documentation that Resident #82's representative was informed of the incident or interviewed. The facility's investigation revealed education was given to CNA #6. The topics that were discussed included residents' rights, abuse nontolerance and avoiding abuse allegations. The education was provided to the CNA over the phone. A note on the back of the education, dated 12/29/25 at 11:56 a.m. (10 days after the allegation was made), documented that a registered nurse (RN) had spoken to CNA #6 over the phone and CNA #6 verbalized understanding and he would utilize the techniques that were discussed. The facility's investigation revealed there were five additional residents interviewed on 12/20/25. The interview questions were as follows: Have you ever been treated roughly by a staff member or anyone else here? Have staff, residents or anyone else been rude to you? Do you feel afraid because of how you or someone else is treated here? The facility's investigation revealed two other residents' family members were interviewed on 12/22/25. The interview questions were as follows: Have you seen anyone here being treated roughly by staff, or residents, or anyone else here? Have you seen staff, other residents or anyone else here yell or be rude to your loved one or anyone else? Do you ever feel afraid because of the way your loved one is treated? -However, the interview questions did not address Resident #82's allegation of sexual abuse. -The investigation failed to document any interviews with staff members regarding the incident. B. Resident #82 (alleged victim) 1. Resident status Resident #82, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), depression, muscle weakness, difficulty in walking and overactive bladder. The 4/30/26 minimum data set (MDS) assessment revealed Resident #82 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She needed substantial to maximal assistance from staff for most of her activities of daily living (ADL) and was dependent on staff for toileting. 2. Resident interview Resident #82 was interviewed on 5/4/26 at 11:12 a.m. Resident #82 said an employee (CNA #6) had touched her inappropriately. She said that the CNA no longer worked at the facility. She said she told her pastor about the incident and he went with her to report it to the facility staff. She said she did not want to talk about it. 3. Record review Resident #82's ADL care plan, revised 4/4/23, revealed she had an ADL self-care deficit due to her muscle weakness and COPD. Pertinent interventions included transferring her with stand-pivot (assisting the resident to a standing position, having them pivot on their feet, and then sitting down) with one-person assist. On days that she was weak, staff were to use the Hoyer lift (mechanical lift). On 12/22/25 the intervention of cares in pairs and that the resident preferred female care workers was added to the care plan. Resident #82's unmet needs care plan, initiated 8/13/25, revealed she would periodically become tearful and would not be able to explain why and would become very anxious when waiting for care, which would sometimes result with her making allegations about staff. Pertinent interventions included acknowledging the resident's emotions without judgment and reminding her that she did not do anything wrong, informing social services if frequency or intensity of episodes increased, providing reassurance when she appeared tearful or anxious and using a calming tone and validating statements. -Review of the resident's electronic medical record (EMR) did not reveal any documentation of the allegation. C. Staff interviews The NHA was interviewed on 5/5/26 at 5:05 p.m. The NHA said she was at the facility on 12/19/25 when the assistant director of nursing (ADON) contacted her and told her about the allegation of Resident #82's breasts being touched inappropriately by CNA #6. The NHA said she checked in with Resident #82 and the nurse who was on duty. She said she spoke to Resident #82's son the next day. She said if Resident #82 did not have her hearing aids in, she would get really nervous and she liked to do things for herself. She said she had found out that CNA #6 was trying to move the resident's breasts out of the way as Resident #82 was transferring from the toilet back to her wheelchair because Resident #82's breasts hung down to her waistline. She said CNA #6 was not assigned to Resident #82's hall that day but the resident asked him for assistance when he was walking by. She said the facility suspended CNA #6 during the duration of the investigation. She said that social services had done a psychosocial evaluation on Resident #82. The NHA said that she had the interview with Resident #82's son documented somewhere, along with the staff interviews and the interview with CNA #6. She said she had recently moved offices and her things were in different boxes. -However, the facility was unable to provide the documentation by the end of the survey exit. The NHA said the facility determined the incident with CNA #6 and Resident #82 was more of a dignity issue related to not informing the resident what was going to happen during the transfer. She said education was done with CNA #6 and that it was done over the phone because he was suspended during the investigation. She said CNA #6 was educated on methods to use to avoid abuse allegations, resident rights and the abuse policy. She said Resident #82's biggest triggers were making sure her hearing aids were in and empowering her to do things for herself. She said when she spoke to Resident #82's son, he said he was familiar with CNA #6 and trusted him with his mother. She said CNA #6 was well liked and loved by residents, staff and family members. She said that CNA #6 was still employed with the company but he was not allowed to work on their campus. CNA #2 was interviewed on 5/6/26 at 11:02 a.m. CNA #2 said if a resident ever complained of being touched inappropriately, she would report it. She said she was familiar with Resident #82. She said that Resident #82 would have called the police if she thought she was being abused. CNA #7 was interviewed on 5/6/26 at 11:59 a.m. CNA #7 said he had only been with the facility for a month. He said if a resident were to ever report any kind of mistreatment, he would report it right away. He said he would ask the resident questions and then let his nurse know. He said he would then follow up with the nurse about the situation. He said he knew that there were a few residents that preferred to not have male care givers. He said that he honored and respected their wishes. Licensed practical nurse (LPN) #3 was interviewed on 5/6/26 at 1:35 p.m. LPN #3 said she had only been working for the facility for two months. She said if a resident reported any inappropriate touching or feeling, she would report it to her supervisor. She said she had only worked on Resident #82's hall. She said that Resident #82 had high anxiety because she could not hear very well. She said Resident #82's anxiety would go even higher when her hearing aids were not in her ears. She said Resident #82 would sometimes become frustrated and become accusatory. LPN #1 was interviewed on 5/6/26 at 2:13 p.m. LPN #1 said if a resident were to report being touched inappropriately, she would report it to her supervisor. She said that the managers were the people in charge of putting in interventions to keep the residents safe. She said they reviewed the situation and added in the interventions. She said regular floor staff would also make suggestions to the interventions. CNA #6 was interviewed on 5/7/26 at 8:43 a.m. He said he had been employed with the company for two years but had been working in the facility for about 12 months. He said Resident #82 was very nervous that day (12/19/25). He said he assisted her to the toilet and tried not to spend too much time on the maneuver so she would not become frustrated. He said she was more anxious that day than she had been on previous days that he had helped her. He said he was trying to clean her after her bowel movement and Resident #82 insisted that he was touching her. He said he told her that he was not touching her and that his hands were on her sides. CNA #6 said that Resident #82 became even more anxious and began saying Let me go, let me go! He said he then sat her back on the toilet and told her he was going to finish cleaning her, and that he was not going to touch her in any place that she did not want touched. He said he finished the transfer and placed her in her wheelchair and asked her if she was okay. He said he later found out that she had accused him of sexual abuse. He said he never made contact with her breasts. He said her breasts were very long and could get caught in the waistband of her pants while pulling her pants up and while pulling her pants down. He said she did not wear a bra. He said he did receive education on proper maneuvers, not touching residents in inappropriate ways, explaining procedures, and getting feedback from residents. He said the education was mostly about the proper procedure of what he was doing with the resident. He said he was educated on abuse and dementia monthly or bimonthly. The facility's chaplain was interviewed on 5/7/26 at 10:54 a.m. The chaplain said he was not sure if he was the first person that Resident #82 told about the incident with CNA #6. He said she had missed Bible study that day (12/19/25), which was unusual. He said when he saw her, she had told him that she had been waiting for someone to help her to the restroom. He said she told him that a CNA had come in to help her and that her clothes needed to be rearranged and when the CNA began to help her with her clothes he touched her breasts. He said he asked Resident #82 what she wanted to do and she told him that she wanted to call her son. The chaplain said he took her back to her room and they called her son. He said he thought that she might have some past trauma. He said she was so upset that she could not get the sentences out so she had him talk to her son. He said that her son did not believe that CNA #6 would have touched the resident in that way. III. Failed to thoroughly investigate an allegation of sexual abuse between Resident #79 and CNA #6 A. Facility investigation The facility's investigation was provided by the NHA on 5/5/26 at 2:00 p.m. The investigation, dated 1/7/26 at 1:49 p.m., documented Resident #79 said CNA #6 patted the area of her leg right below her bottom during a transfer. The investigation revealed the social services director (SSD) interviewed Resident #79 about the incident. The investigation documented Resident #79 said she was sitting on the edge of her bed and needed her feet to be put up onto the bed. Resident #79 said she was clothed and in her brief when CNA #6 tapped her bottom. The investigation documented Resident #79 said she felt safe at the facility, but she felt the interaction was sexual in nature. The SSD asked Resident #79 if she asked CNA #6 to stop or if she told the CNA she was uncomfortable. Resident #79 said she did not. The investigation revealed the NHA and the interim director of nursing (DON) conducted a follow-up interview with Resident #79. The investigation documented Resident #79 said CNA #6 patted the back of her leg right below her bottom during a transfer, and she thought it might have been sexual in nature. CNA #6 was suspended during the investigation. The facility's investigation documented the facility was unable to substantiate the allegation of sexual abuse because the incident did not meet the criteria of: knowingly; consent not given; and/or, sexual intrusion/penetration, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than [NAME] fide medical purposes or, observes or photographs another person's intimate parts or, physical force/threat. The investigation documented CNA #6 and Resident #79 both said the CNA put his hands on the resident's leg for the purpose of the bed transfer. -However, the investigation documented that Resident #79 told the SSD, the NHA and the interim DON that she felt the contact by CNA #6 was sexual in nature. The facility's investigation failed to reveal documentation of the following: -The facility's investigation failed to document CNA #6's interview. -The facility's investigation failed to document education provided to CNA #6 following the incident. -The facility's investigation failed to document any training CNA #6 received related to abuse and transfers. -The facility's investigation failed to include documentation to indicate attempts were made to observe and assess CNA #6's performance while the CNA provided transfer assistance to ensure his understanding of safe and appropriate transfers. B. Resident #79 (alleged victim) 1. Resident status Resident #79, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system which leads to movement issues), gastro-esophageal reflux disease (GERD), anxiety disorder and depression. The 4/7/26 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 12 out of 15. The MDS assessment revealed the resident required set-up assistance with ADLs including eating, oral hygiene and personal hygiene. She required partial/moderate assistance with toileting, dressing and mobilizing from sitting to lying. 2. Resident interview Resident #79 was interviewed on 5/4/26 at 12:00 p.m. Resident #79 said she had been touched by a staff member in a way that made her feel uncomfortable. She said CNA #6 put her to bed and assisted her from a sitting to a lying position. Resident #79 said CNA #6 patted her on the bottom and she thought that was why he did not work there anymore. Resident #79 was interviewed again on 5/7/26 at 8:20 a.m. Resident #79 said she thought CNA #6 intentionally touched her inappropriately when he laid her in bed. She said she felt safe at the facility and was not fearful of abuse. 3. Record review Review of Resident #79's comprehensive care plan, initiated 12/22/25, revealed the resident had a personal preference to have female caregivers when possible, and for female caregivers to accompany male caregivers if any were present, including outside vendors. Pertinent interventions, initiated 2/20/26, included to give the resident the option to wait for a female caregiver and ensure a female caregiver was present when male vendors or caregivers were present; and, provide female caregivers as frequently as possible. Review of Resident #79's Kardex (tool utilized by staff to provide consistent care for residents) report revealed the following intervention: Give the resident the option to wait for a female caregiver and ensure a female caregiver is present when male vendors or caregivers are present. C. Staff interviews The NHA was interviewed on 5/5/26 at 5:04 p.m. The NHA said CNA #6 was interviewed during the investigation of the incident involving Resident #79. She said CNA #6's interview and education were not in the facility's investigation because she had moved offices and was unable to locate the documentation. The NHA said she would try to locate the documentation. CNA #2 was interviewed on 5/6/26 at 11:02 a.m. CNA #2 said she was familiar with Resident #82 and Resident #79. She said Resident #79 had never complained about being touched inappropriately. CNA #6 was interviewed on 5/7/26 at 8:43 a.m. CNA #6 said there were many ways to assist a resident from sitting to lying and it depended on the resident's ability. CNA #6 said during the nightshift on 1/3/26, Resident #79 activated her call light every two to three minutes, even though he tried to ensure she had everything she needed within reach and asked if there was anything else he could do before he left her room. He said at some point during the shift, Resident #79 started to change her stance to him, but he was not sure what happened. CNA #6 said he spent his shift going into her room every five to 15 minutes to provide her with assistance. CNA #6 said he did not recall patting Resident #79 on or near the bottom. He said 1/3/26 was the last nightshift he worked at the facility and during his dayshift on 1/6/26, he received a call and was told that he abused a resident and was being suspended. CNA #6 said the facility spoke to him about taps but he did not know why he would ever tap a resident on the bottom. He said he was told he was cleared to work at other facilities, but not this one IV. Failed to thoroughly investigate an allegation of potential neglect involving CNA #5 A. Facility investigation The investigation of the alleged neglect between involving CNA #5 was provided by the executive director on 5/5/26 at 2:30 p.m. The facility's investigation revealed CNA #4 worked on the rehabilitation unit and she observed CNA #5 working in the same unit, sleeping while working the overnight shift on 4/1/26. The neighborhood had a maximum of 18 residents with one registered nurse (RN) and two CNAs assigned for the night shift. All residents were cared for by the RN and CNA #4 during the time when CNA #5 was allegedly sleeping. The investigation started on 4/2/26 and consisted of interviewing residents and other staff members. The investigation included a review of CNA #5's employee personnel file and a review of the residents' call lights report. CNA #5 was suspended pending the investigation. The investigation documented that the residents were not assessed because all residents were cared for during the time the staff member was allegedly sleeping. CNA #5 was interviewed and did not deny sleeping at work. Int The staff interviews revealed a pattern of CNA #5 sleeping on shift. Interviews with staff revealed a lack of knowledge amongst staff regarding company's policies regarding sleeping while at work. All staff were educated on the employee handbook that indicated sleeping on the job was prohibited. Staff were educated on neglect standards which stated sleeping was against the standard of practice and a reportable event. The investigation documented staff understood the expectations and that sleeping on the job would result in official disciplinary action, up to and including termination. As a result of the facility's investigation, CNA #5 was terminated on 4/7/26. It was verified CNA #5 was sleeping during his shifts. It could not be verified whether CNA #5 was on lunch break or not. CNA #5 was terminated as sleeping was a violation of the employee handbook. The investigation documented that all residents were cared for by RN #9 and CNA #4 on 4/1/26, so no resident was at risk at any time during the shift. -The investigation failed to reveal documentation of CNA #4's (the staff member who reported the alleged neglect) statement or interview. -A request for documentation to indicate CNA #5 was not allowed to work during the facility's investigation was made on 5/7/26, however the facility was unable to provide documentation. B. CNA #4's interview (reporter of potential neglect allegation) CNA #4 was interviewed on 5/6/26 at 4:38 p.m. CNA #4 said she had worked at the facility for almost a year and she started in June 2025. She said she worked per diem (as needed) for the facility and worked in all of the units. She said the abuse coordinator for the facility was the NHA and she reported abuse to the director of nursing (DON) or the NHA. She said she reported abuse when staff were not doing their job, such as sleeping on the job. She said she documented everything on an application on her phone so she did not forget anything and so if the NHA or the DON had any questions, she had something to reference. CNA #4 said she emailed the NHA regarding what she saw with CNA #5 on 4/1/26. CNA #4 said she reported the instance of potential neglect from CNA #5 on 4/2/26. She said she was working a night shift on 4/1/26 in the rehabilitation unit. She said she was working with a RN #9 and CNA #5. She said CNA # 5 did not have his phone while he was working that night. CNA #4 said it was important for him to have his phone because it was the facility issued phone that had the call light application on it, which CNAs if a resident used their call light. CNA #4 said CNA #5's phone ran out of battery power. CNA#4 said CNA #5 was asleep on the couch in the unit. CNA #4 said RN #9 said CNA #5 sleeping happened all the time. CNA #4 said she wrote everything down that CNA #5 was not doing. She said at 12:00 a.m., CNA did not do one round and at 3:50 a.m., he did not do any additional rounds. CNA #4 said he was sleeping from at least 12:00 a.m. to 3:00 a.m CNA#4 said RN#9 woke up CNA #5 by telling him his call lights were going off. She said he jumped and he appeared not to care. CNA #4 said she and RN #9 completed the nursing responsibilities that CNA #5 should have done so residents did not go without care. CNA #4 said the NHA interviewed her last week (week of 4/26/26). CNA #4 said before the interview last week, the administration's response was that they were going to investigate. CNA #4 said she noticed in the semi-secure unit that once or twice a different CNA, who was a woman, slept during her shift. CNA #4 said she had checked on that CNA's residents while the CNA was asleep too. CNA #4 said she told the unit nurse and the nurse's response was that the female CNA slept often. CNA #4 said it was important to report because if the two-hour rounding was not done, residents who required incontinence care could sit in their own feces and urine for a long period. C. Record review The email sent by CNA #4 to the NHA was provided by CNA #4 on 5/8/26 at 10:17 a.m. The email was sent on 4/2/26 at 6:31 a.m. It read in pertinent part, On 4/1/26 CNA #5 was sleeping and multiple call lights were going off. After being woken by RN #9, he went to the nurses' station to ask which call light was going off. His phone was dead and he did not have one nearby. The only rounds CNA #5 did were at 6:00 p.m. when he arrived on shift to do vital signs and breakfast orders and at 5:00 a.m. before the shift was up. At 12:00 a.m. CNA #5 did not do a single round. At 3:50 a.m., CNA #5 still did not do a single round. CNA #5 made my nurse and me extremely uncomfortable with the lack of care he gave to these residents. Here is a photo of CNA #5 sleeping while on shift. He did not communicate to my nurse or me that he was taking a break and again, multiple call lights were going off. A picture was attached to the email which revealed a male lying on a couch in the rehabilitation unit. D. Staff interviews RN #9 was interviewed on 5/5/26 at 5:25 p.m. RN #9 said she had worked at the facility for seven months. She said she reported abuse based on the chain of command. She said she reported abuse to her unit manager who reported it to the DON who reported it to the NHA. She said the only time neglect was suspected, it was because CNA #5 was asleep. RN #9 said she rounded consistently throughout her shift to ensure the two CNAs scheduled in her unit met the residents' needs, such as wanting water and incontinence care. RN #9 said she had some CNAs who were really good at rounding and responding to call lights and she had other CNAs she had to police more. RN #9 said CNA #5 slept and was on his phone throughout his shift. RN #9 said she knew residents on her shift were not neglected because if the CNA did not provide care, she provided the care herself. RN #9 said she reported CNA #5 to the facility's previous DON who worked at the facility for a couple of weeks, but she did not know the outcome from that report. -However record review revealed no documentation related to allegations previous night, CNA #5 slept during his shift. The NHA, the DON and the executive director were interviewed together on 5/5/26 at 3:07 p.m. The NHA said she was the abuse coordinator for the facility and she started working at the facility in June 2025. She said staff should report abuse immediately to the DON or to her. She said when there was suspected abuse, she first determined the residents involved were safe and then she reported to the police, adult protective services (APS), the State Agency, corporate human resource and the nursing board. She said she reported to the different agencies depending on the type of abuse and who was involved. She said corporate human resources would be involved if staff were involved in the allegation and the nursing board was involved if staff were involved and she wanted to ensure the community was kept safe. The NHA said she divided the work between the DON, SSD and herself. She said the SSD interviewed the victim, additional residents and family members. The NHA said the DON interviewed the staff members and the NHA helped where needed. The NHA said the SSD interviewed the victim to determine if the resident was safe. The NHA said the facility did not use cameras or recordings when investigating because there were no cameras in the building. The NHA said if a resident was unable to communicate, they used non-verbal observations for signs of distress. The NHA said the SSD and the DON also checked in with the family and the floor staff to see if they noticed a change in a resident after an allegation. The NHA said they monitored the residents to see if they were okay. The NHA said she was not sure how the SSD monitored residents but she would find out. The NHA said she determined which residents to interview based on the type of abuse. The NHA said most of the time, it was based on the unit because it was a good sample of the residents involved. The NHA said she interviewed staff who worked in the unit the alleged abuse took place in because the staff would have good insight. The DON said she interviewed CNA #5 regarding the incident on 4/1/26. The DON said she used open-ended questions and said the allegation was that other staff members had to wake him up, answer his call lights and had to make sure his residents were safe. The NHA said CNA #4 called the NHA on 4/2/26 early in the morning and said she was not sure if it was okay that CNA #5 slept on their shift. The NHA said it was the first time she heard about CNA #5 sleeping while working. The NHA said she talked to RN #9 who confirmed what CNA #4 said. The NHA said she did not substantiate the allegation of potential neglect because RN #9 and CNA #4 said they addressed the residents' needs while CNA #5 was sleeping. The executive director and the DON were interviewed together on 5/8/26 at 11:46 a.m. The executive director said on 4/2/26 at 3:30 a.m. CNA #4 and RN #9 reported to the NHA that CNA #5 was sleeping during their shift. The DON said staff were trained on 4/2/26 and staff in all units were trained that sleeping on the job was prohibited and was considered neglect of resident care. The DON said an abuse investigation would be started. The executive director said interviews with staff and residents were conducted on 4/6/26. He said the DON and the NHA interviewed the staff and the social services staff interviewed the residents. The executive director said he was not sure who specifically interviewed the residents and the interview forms did not have a section to indicate who completed the resident interviews for the 4/1/26 neglect allegation. The executive director said CNA #5's personnel file was reviewed on 4/6/26 and the CNA was terminated on 4/7/26. The executive director and the DON said they did not know CNA #4 reported that she was not interviewed until last week. The executive director said there was not a statement from CNA #4 in the investigation and he was not aware CNA #4 reported that she saw other staff sleeping in other units. The executive director and the DON said they did not know RN #9 reported she knew CNA #5 slept on other shifts. The executive director said based on that information, it was hard to substantiate or unsubstantiate the allegation of neglect since there was a pattern of CNA #5 sleeping on his shift.

Based on record review and interviews, the facility failed to ensure two (#82 and #79) of four residents out of 51 sample residents were treated with respect, dignity and care in a manner that promoted quality of life or recognized the residents' individuality. Specifically, the facility failed to ensure Resident #82 and Resident #79 were treated with dignity and respect during transfers.Findings include: I. Resident #82 A. Facility investigation The facility's investigation of the 12/19/25 allegation of sexual abuse was provided by the NHA on 5/5/26 at 2:00 p.m. The facility's investigation report revealed an interview with Resident #82 was conducted on 12/22/25 (three days after the allegation was made) by the social services director (SSD). The interview revealed Resident #82 felt like the male care giver (CNA #6) had his hands where they should not be. When the resident was asked to clarify, she stated she was referring to her breasts. The SSD asked Resident #82 if she would feel more comfortable during cares if the male care giver asked her to move her own breasts out of the way and Resident #82 said yes. Resident #82 stated that she felt safe and did not like being touched by male care givers when possible. The facility's investigation revealed education was given to CNA #6. The topics that were discussed included residents' rights, abuse nontolerance and avoiding abuse allegations. The education was provided to the CNA over the phone. A note on the back of the education, dated 12/29/25 at 11:56 a.m. (10 days after the allegation was made), documented that a registered nurse (RN) had spoken to CNA #6 over the phone and CNA #6 verbalized understanding and he would utilize the techniques that were discussed. Cross-reference F609 for failure to report allegations of abuse within two hours of the incident. B. Resident status Resident #82, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), depression, muscle weakness, difficulty in walking and overactive bladder. The 4/30/26 minimum data set (MDS) assessment revealed Resident #82 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She needed substantial to maximal assistance for most of her activities of daily living (ADL) and was dependent on staff for toileting. C. Resident interview Resident #82 was interviewed on 5/4/26 at 11:12 a.m. Resident #82 said an employee had touched her inappropriately. She said that the employee no longer worked at the facility. She said she told her pastor and that he went with her to report it to the facility staff. She said she did not want to talk about it. D. Record review Resident #82's ADL care plan, revised 4/4/23, revealed she had an ADL self-care deficit due to her muscle weakness and COPD. Pertinent interventions included transferring her with stand-pivot (assisting the resident to a standing position, having them pivot on their feet, and then sitting down) with one-person assist. On days that she was weak, staff were to use the Hoyer lift (mechanical lift). On 12/22/25 the intervention of cares in pairs and the resident preferred female care workers was added to the care plan. Resident #82's unmet needs care plan, initiated 8/13/25, revealed she would periodically become tearful and would not be able to explain why and would become very anxious when waiting for care, which would sometimes result with her making allegations about staff. Pertinent interventions included acknowledging the resident's emotions without judgment and reminding her that she did not do anything wrong, informing social services if frequency or intensity of episodes increased, providing reassurance when she appeared tearful or anxious, and using a calming tone and validating statements. E. Staff interviews The nursing home administrator (NHA) was interviewed on 5/5/26 at 5:05 p.m. The NHA said she was at the facility on 12/19/25 when the assistant director of nursing (ADON) contacted her and told her about the allegation of Resident #82's breasts being touched inappropriately. She said she checked in with Resident #82 and the nurse who was on duty. She said she had found out that certified nurse aide (CNA) #6 was trying to move the resident's breasts out of the way as Resident #82 was transferring from the toilet back to her wheelchair because Resident #82's breasts hung down to her waistline. The NHA said the facility determined the incident was more of a dignity issue related to not informing the resident what was going to happen during the transfer. She said education was done with CNA #6 and that it was done over the phone because he was suspended during the investigation. She said CNA #6 was educated on methods to use to avoid abuse allegations, resident rights and the abuse policy. CNA #2 was interviewed on 5/6/26 at 11:02 a.m. CNA #2 said that when she was helping a female resident in the bathroom and her breasts hung low, she said she would use the resident's shirt to help hold her breasts up and out of the way. She said when she was helping a resident go from sitting to a lying position, she would not touch the resident's buttocks area or upper thigh area. CNA #7 was interviewed on 5/6/26 at 11:59 a.m. CNA #7 said he had only been employed at the facility for a month. He said when he transferred a resident from the sitting position to a lying position, he never touched the resident's buttocks area or upper thigh area. He said he would support their back and hold their legs around the knee area. He said when he would help a resident in the bathroom, he would always ask them for permission before he touched them. He said there were times when a female resident would accept his help with care one day and then decline his help on a different day, which was why he would ask them for permission first. He said he was informed of residents who preferred female CNAs from the report sheets. He said he would also let the nurse know if a resident expressed feeling uncomfortable when he offered care. Licensed practical nurse (LPN) #3 was interviewed on 5/6/26 at 1:35 p.m. LPN #3 said when she assisted a resident with going from sitting to lying, she supported the resident's shoulders or lower back and if she had to help with their legs, she would be touching their lower leg area, not around the buttocks area. She said if she was helping a resident in the bathroom and the resident's breasts were in the way of pulling up their pants, she would ask the resident permission to move her breasts or see if the resident could move her breasts herself. LPN #1 was interviewed on 5/6/26 at 2:13 p.m. LPN #1 said when assisting a resident from sitting to lying, she would touch their back and under their knees or calves, but not their buttocks area. She said when assisting a resident in the bathroom, she would communicate everything that she was doing. She said if the resident's breasts were in the way, she would ask the resident to move them. The director of nursing (DON) and the executive director were interviewed together on 5/8/26 at 11:46 a.m. The DON said she would expect her staff, when assisting a resident from sitting to lying, to support the resident's side and their legs. She said they should not be touching the buttocks area. She said when her staff was assisting a female resident in the bathroom and their breasts were in the way, she would expect her staff to talk to the resident and explain everything that they were doing. She said she would expect her staff to communicate to the resident that they would have to touch them. The DON said she was not employed at the facility when the incident with Resident #82 and CNA #6 occurred. She said she would have conducted CNA #6's training in person and that she would have had a second manager with her to offer assistance and more training. She said she would have followed up with Resident #82 and Resident #79 (see Resident #79 investigation below) and would have let the physicians know what had happened and also have the nurses monitor the resident's behaviors for any adverse reactions to the incidents. She said she would then follow up with the residents again to make sure they felt like they were being treated with respect and dignity. II. Resident #79 A. Facility investigation The facility's investigation was provided by the NHA on 5/5/26 at 2:00 p.m. The investigation, dated 1/7/26 at 1:49 p.m., documented Resident #79 said CNA #6 patted the area of her leg right below her bottom during a transfer on 1/3/26. The investigation revealed the social services director (SSD) interviewed Resident #79 about the incident. The investigation documented Resident #79 said she was sitting on the edge of her bed and needed her feet to be put up onto the bed. Resident #79 said she was clothed and in her brief when CNA #6 tapped her bottom. The investigation documented Resident #79 said she felt safe at the facility, but she felt the interaction was sexual in nature. The SSD asked Resident #79 if she asked CNA #6 to stop or if she told the CNA she was uncomfortable. Resident #79 said she did not. The investigation revealed the NHA and the interim director of nursing (DON) conducted a follow-up interview with Resident #79. The investigation documented Resident #79 said CNA #6 patted the back of her leg right below her bottom during a transfer, and she thought it might have been sexual in nature. CNA #6 was suspended during the investigation. The facility's investigation documented the facility was unable to substantiate the allegation of sexual abuse because the incident did not meet the criteria of: knowingly; consent not given; and/or, sexual intrusion/penetration, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than [NAME] fide medical purposes or, observes or photographs another person's intimate parts or, physical force/threat. The investigation documented CNA #6 and Resident #79 both said the CNA put his hands on the resident's leg for the purpose of the bed transfer. -However, the investigation documented that Resident #79 told the SSD, the NHA and the interim DON that she felt the contact by CNA #6 was sexual in nature. Cross-reference F609 for failure to report allegations of abuse within two hours of the incident. B. Resident status Resident #79, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system which leads to movement issues), gastro-esophageal reflux disease (GERD), anxiety disorder and depression. The 4/7/26 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 12 out of 15. The MDS assessment revealed the resident required set-up assistance with ADLs including eating, oral hygiene and personal hygiene. She required partial/moderate assistance with toileting, dressing and mobilizing from sitting to lying. C. Resident interview Resident #79 was interviewed on 5/4/26 at 12:00 p.m. Resident #79 said she had been touched by a staff member in a way that made her feel uncomfortable. She said CNA #6 put her to bed and assisted her from a sitting position to a lying position. Resident #79 said CNA #6 patted her on the bottom and she thought that was why he did not work there anymore. Resident #79 was interviewed again on 5/7/26 at 8:20 a.m. Resident #79 said she thought CNA #6 intentionally touched her inappropriately when he laid her in bed. She said she felt safe at the facility and was not fearful of abuse. D. Record review Review of Resident #79's comprehensive care plan, initiated 12/22/25, revealed the resident had a personal preference to have female caregivers when possible, and for female caregivers to accompany male caregivers if any were present, including outside vendors. Pertinent interventions, initiated 2/20/26, included to give the resident the option to wait for a female caregiver and ensure a female caregiver was present when male vendors or caregivers were present and provide female caregivers as frequently as possible. Review of Resident #79's Kardex (tool utilized by staff to provide consistent care for residents) report revealed the following intervention: Give the resident the option to wait for a female caregiver and ensure a female caregiver was present when male vendors or caregivers were present. E. Staff interviews The NHA was interviewed on 5/5/26 at 5:04 p.m. The NHA said she thought the SSD notified her about the incident involving Resident #79 and CNA #6, but she did not fully remember. She said CNA #6 was interviewed during the investigation of the incident involving Resident #79, and he said the resident did not like how he transferred the resident from an upright seated position to a flat lying position. The NHA said CNA #6 said that he put his hand on the back of her leg to help support her lower back. She said CNA #6's phone interview and education were not in the facility's investigation because she had moved offices and was unable to locate the documentation. The NHA said the facility suspended CNA #6 pending the investigation, performed an assessment on Resident #79, contacted the resident's representative and all of the parties, including the police department and the ombudsman in effort to protect Resident #79 and other residents from future occurrences. She said the facility interviewed other residents to ensure their safety and interviewed staff to see if they had seen any behaviors from CNA #6. She said CNA #6 was very well loved by staff and residents alike and the whole team raved about him. The NHA said CNA #6 no longer worked at the facility, due in part to the allegations of Resident #79 and Resident #82 (see Resident #82 investigation above). However, the NHA said she would not have allowed CNA #6 to continue working with his CNA license if she thought he was an unsafe caregiver.The NHA said CNA #6 remained a part of the as needed (PRN) pool with the company, not at the facility specifically, because he did not show signs of abusive behavior and the residents seemed to really like him and felt safe with him. The NHA said Resident #79 was high anxiety and if her call lights were not answered immediately, her anxiety went way up and she continued to press her call light. She said Resident #79 averaged 27 to 30 call light activations per shift and the interdisciplinary team (IDT) met daily in an effort to decrease her anxiety. The NHA said the facility tried to ease Resident #79's transition to the facility by having care conferences with the resident's representative. CNA #2 was interviewed on 5/6/26 at 11:02 a.m. CNA #2 said she was familiar with Resident #79. She said Resident #79 had never complained about being touched inappropriately. CNA #6 was interviewed on 5/7/26 at 8:43 a.m. CNA #6 said there were many ways to assist a resident from sitting to lying and it depended on the resident's ability. CNA #6 said during the nightshift on 1/3/26, Resident #79 activated her call light every two to three minutes, even though he tried to ensure she had everything she needed within reach and asked if there was anything else he could do before he left her room. He said at some point during the shift, Resident #79 started to change her stance to him, but he was not sure what happened. CNA #6 said he spent his shift going into her room every five to 15 minutes to provide her with assistance. CNA #6 said he did not recall patting Resident #79 on or near the bottom. He said 1/3/26 was the last nightshift he worked at the facility and during his dayshift on 1/6/26, he received a call and was told that he abused a resident and was being suspended. CNA #6 said the facility spoke to him about taps but he did not know why he would ever tap a resident on the bottom. He said he was told he was cleared to work at other facilities, but not this one.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for two (#53 and #79) of five residents out of 51 sample residents. Specifically, the facility failed to ensure assessments were conducted to determine whether the self-administration of medications was clinically appropriate for Resident #53 and Resident #79.Findings include: I. Facility policy and procedure The Medication Administration: Self-Administration by Resident policy, dated January 2026, was provided by the executive director on 5/8/26 at 12:34 p.m. It read in pertinent part, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Facilities must adhere to state specific laws and regulations. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability to carry out this responsibility during the care planning process. The results of the interdisciplinary team assessment are recorded on the medication self-administration assessment, which is placed in the resident's medical record. II. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic atrial fibrillation (rapid irregular heartbeat), chronic obstructive pulmonary disease (emphysema and difficulty breathing), peripheral vascular disease (progressive circulation disorder, narrowing blood vessels), prediabetes, chronic kidney disease stage three, obesity, and left artificial knee joint. According to the 4/16/26 MDS assessment, Resident #53 was moderately cognitively impaired with a BIMS score of 12 out of 15. Resident #53 required set-up assistance with eating, oral hygiene, and personal hygiene. He required substantial assistance with toileting and showering. B. Observation and resident/resident's representative interviews On 5/4/26 at 12:13 p.m., during an interview with Resident #53 and his representative, there were three containers sitting on top of the bedside table next to the resident's telephone. One container was a four-ounce tube labeled Remedy clinical prevent silicone cream. The second container was a jar labeled with Resident #53's name and nystatin (a prescription antifungal medicine used to treat yeast infections), zinc (treats skin irritation) and lidocaine (an anesthetic for numbing) cream. The third container was labeled with Resident #53's name and Nystop (a prescription antifungal to treat skin infections). Resident #53 and his representative said they did not know what the medications were for and when they were last used. Resident #53's representative said she thought the medications might have come from the hospital. C. Record review Review of Resident #53's May 2026 CPO revealed the following physician's orders: Nystop external powder 100,0000 units/gram (gm). Apply to the urethral opening topically three times a day for candidiasis, ordered 5/1/26. Nystatin, zinc, and lidocaine cream. Apply to the buttocks topically three times a day for fungal infection, ordered 5/2/26. -A review of Resident #53's May 2026 CPO did not reveal a physician's order for the use of silicone cream. -A review of Resident #53's EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #53 was able to safely administer her own medications. D. Staff interviews Registered nurse (RN) #1 was interviewed on 5/7/26 at 2:26 p.m. RN #1 said medications should never be left at a resident's bedside. RN #1 said the only time a medication could be left with the resident was if the resident had an assessment indicating the resident was able to self-administer medications. RN #1 said she always worked in the rehabilitation unit and said there were no residents in the rehabilitation unit who could self-administer medications. RN #1 said she was familiar with Resident #53 and said she saw the medicated creams left on top of the resident's bedside table on 5/4/26. RN #1 said she thought the night nurse may have left the medications on top of the resident's bedside table because the treatment creams were locked in the bedside table drawer for any residents who required treatment in the rehabilitation unit. RN #1 said Resident #53 could not self-administer the treatment medications. RN #1 said the medication cart nurse had one key and the unit manager had the other key for the residents' treatment medication drawers on the bedside tables. RN #1 said it was important to not leave medications unattended because sometimes they had residents with dementia who may try to take the medication and the unit had a lot of family and friends who visited who may take the medication. RN #1 said it was important to not leave the medications at a resident's bedside to avoid accidents. The DON and the vice president of clinical services were interviewed together on 5/7/26 at 4:43 p.m. The DON said medications could be left at a resident's bedside if a resident had an assessment indicating the resident could self-administer medications. The DON said all residents' rooms in the rehabilitation unit had a drawer in the bedside table to store treatment supplies, including creams. The DON said the drawers were locked. The DON and the vice president of clinical services said RN #1 did not notify them the treatment medications were left on top of Resident ##53's bedside table by the night nurse. The DON said Resident #53 could not self-administer the treatment medications and the creams should not have been left unattended with the resident. III. Resident #79 A. Resident status Resident #79, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system which leads to movement issues), gastro-esophageal reflux disease (GERD), anxiety disorder and depression. The 4/3/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. She required set-up assistance with activities of daily living (ADL) including eating, oral hygiene and personal hygiene. B. Observations On 5/4/26 at 12:00 p.m. Resident #79 had one bottle of circulation and vein support supplements and one bottle of glucosamine chondroitin supplements sitting on her bedside table. On 5/6/26 at 11:16 a.m. Resident #79 had one bottle of circulation and vein support supplements and one bottle of glucosamine chondroitin supplements sitting on her bedside table. On 5/7/26 at 8:25 a.m. Resident #79 had one bottle of circulation and vein support supplements and one bottle of glucosamine chondroitin supplements sitting on her bedside table. C. Record review Review of Resident #79's May 2026 CPO revealed the following physician's order: The resident may self-administer lion's mane, circulation and vein support and glucosamine chondroitin, ordered 3/2/26. -However, review of Resident #79's electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #79 was able to safely administer her own medications. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/6/26 at 11:58 a.m. LPN #1 said some of the residents at the facility had assessments completed to evaluate if the resident was able to self-administer medications at the bedside. She said she was not sure if Resident #79 had a completed self-administration assessment. LPN #1 said it was important to never leave medications at the bedside unless there was a self-administration assessment because the resident could administer the wrong dose of medication. The director of nursing (DON) and the MDS coordinator were interviewed together on 5/7/26 at 4:43 p.m. The DON said medications should never be left at a resident's bedside unless there was an evaluation for the resident to self-administer the medications, because the resident could confuse the medications, a visiting family member might assist the resident to take the medication unknowingly and to avoid dementia related accidents. The DON and the MDS coordinator were interviewed together a second time on 5/7/26 at 6:20 p.m. The DON said there should have been an assessment to evaluate the appropriateness of Resident #79 storing and self-administering supplements independently at her bedside. She said it was important to ensure the self-administration evaluation was completed so the staff could confidently say the resident was able to identify what they were taking, that they could read the label and that they could remember which medications they took and when.

Based on observations and interviews, the facility failed to ensure one (#80) of one resident reviewed out of 51 sample residents was provided personal privacy in his room. Specifically, the facility staff failed to knock before entering Resident #80's room to protect the resident's right to personal privacy.Findings include:I. Facility policy and procedure The Know Your Rights policy, revised October 2023, was provided by the executive director on 5/8/26 at 12:32 p.m. It read in pertinent part, You have the right to be treated with respect and dignity and in a manner that promotes maintenance and enhancement of your quality of life. You have the right to use a phone, including your own personal cell phone, and talk privately. You have the right to privacy in treatment and caring for your personal needs. II. Resident #80A. Resident statusResident #80, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia without behavioral disturbance and type 2 diabetes. The 2/23/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required set-up assistance with oral hygiene, toileting hygiene and dressing.The assessment documented Resident #80 had no behaviors.B. Resident interview and observations Resident #80 was interviewed on 5/4/26 at 4:01 p.m. Resident #80 said staff sometimes entered his room without knocking. Resident #80 said it occurred across all shifts and was not related to a specific staff member. Resident #80 said he preferred staff to knock before entering because he frequently used the phone or watched television and preferred privacy. Resident #80 said it had happened a few times and he would wave his phone at staff when they entered without knocking to let them know he was on the phone, and staff would then leave the room.During the interview, at 4:03 p.m., two unidentified staff members entered Resident #80's room without knocking and said they were checking on his roommate. Resident #80 said it was annoying when staff did not knock before entering his room. Resident #80 said he had not reported the issue to anyone. Resident #80 said if the issue became worse, he would place a sign on his door reminding staff to knock before entering.III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 5/7/26 at 12:15 p.m. CNA #2 said the facility expected staff to knock and wait for a response before entering a resident's room. CNA #2 said staff should still knock before entering a resident's room, even if the resident could not respond or if the call light was activated. CNA #2 said she was aware Resident #80 preferred staff to knock before entering his room because Resident #80 would ask staff to knock before entering his room. CNA #2 said the staff protected Resident #80's privacy by pulling the privacy curtain when checking on the resident's roommate. CNA #2 said she did not know why staff entered Resident #80's room without knocking across different shifts.Registered nurse (RN) #4 was interviewed on 5/7/26 at 12:25 p.m. RN #4 said the expectation for facility staff was to always knock before entering a resident's room, even if the resident's door was closed. RN #4 said staff were educated during orientation to knock and provide privacy before entering resident's rooms. RN #4 said Resident #80 preferred his door to remain closed and preferred staff to knock before entering his room. RN #4 said Resident #80 did not want anyone entering his room without knocking. RN #4 said staff understood residents' privacy should be protected, regardless of whether a resident specifically requested staff to knock before entering. RN #4 said staff who failed to knock before entering a resident's room were first provided education regarding the expectations for resident privacy. RN #4 said repeated concerns were reported to the supervisor for follow-up.

Based on record review and interviews, the facility failed to ensure residents were free from chemical restraints for two (#4 and #79) of five residents out of 51 sample residents.Specifically, the facility failed to -Ensure Resident #4's use of an antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary (IDT) for continued medical necessity; -Ensure Resident #4 and Resident #79's behaviors related to the use of psychotropic medications were identified and monitored; and, -Ensure Resident #4 and Resident #79's care plans included resident-specific non-pharmacological care approaches for the residents' behaviors.Findings include: I. Facility policy and procedure The Psychotropic Medication Management policy and procedure, revised December 2024, was provided by the vice president of clinical services on 5/8/26 at 12:32 p.m. It read in pertinent part, The IDT (interdisciplinary team) will first identify and address any medical, physical, psychological causes and or social and environmental triggers. If antipsychotic medications are prescribed, documentation must show ongoing evaluation of the effectiveness of the interventions with a rationale for decisions. A regular psychotropic IDT committee will evaluate the effects of the medications on a resident's physical, mental, and psychosocial well-being and to consider whether the medication should be continued, reduced, discontinued, or otherwise modified. Antipsychotic medications and care plans will be reevaluated during quarterly care plan reviews or more often if indicated. II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included displaced fracture of left femur, hypertension, history of falling, aortic stenosis, dementia, osteoarthritis, anxiety and depression. According to the 4/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He used a walker. He required set up assistance with eating. He required substantial assistance with oral hygiene, toileting, showering, dressing and personal hygiene. The assessment revealed he had an anxiety disorder and depression. He took an antipsychotic medication and an antidepressant medication with an indication noted. The assessment revealed antipsychotic medications were rec The assessment revealed the resident did not have hallucinations, delusions, physical behavioral symptoms or verbal behavioral symptoms directed towards others. The resident did not wander during the assessment look-back period. The patient health questionnaire-9 (PHQ-9 - a tool utilized to determine depression levels) revealed the resident scored a one out of 27, which indicated the resident had minimal depression. The resident reported he felt down depressed or hopeless on two to six days over the last two-week assessment look-back period. B. Record review The depression and dementia with behavior care plan, initiated and revised on 4/20/26, revealed Resident #4 lived with depression and dementia. Interventions included monitoring for drowsiness, dizziness, vertigo, headache, tremor, weakness, fatigue, insomnia, postural hypotension, edema, dry mouth, anorexia, weight gain and urine retention, monitoring for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, extrapyramidal (EPS) symptoms, assisting in developing a program of activities that were meaningful and of interest, assisting to identify strengths and coping skills, administering medications per physician order, monitoring and recording the resident's mood to determine if problems seemed to be related to external causes and monitoring, recording and reporting to the physician as needed any acute episodes or feelings of sadness. The elopement care plan, initiated and revised on 4/22/26, revealed Resident #4 was at risk for harm or injury to himself due to the family expressing concerns about him wandering. Interventions included distracting the resident from wandering by offering pleasant diversions, following facility protocols for elopement risk and facility procedures for missing persons, personalizing his environment with familiar objects and providing structured activities. The sleep cycle disturbance care plan, initiated and revised on 4/22/26, revealed Resident #4 had reported insomnia. Interventions included discussing and helping the resident to reduce any physical symptoms affecting sleep, ensuring decreased stimuli two hours before bedtime, increasing activity during the day time, medicating per physician order, reducing unnecessary interruptions in his sleep cycles and talking about suggestions about sleep comfort. -Review of Resident #4's depression, dementia, elopement, and sleep cycle care plans revealed there were no person-centered non-pharmacological interventions identified on the care plans. Review of Resident #4's May 2026 CPO revealed the following physician orders: Melatonin (a medication used for treating sleep issues) 5 milligrams (mg). Take one tablet by mouth one time a day for insomnia, ordered 4/17/26. Quetiapine fumarate 25 mg (an antipsychotic medication). Take one tablet by mouth one time a day for anxiety with behavioral disturbances, ordered 4/12/26 and discontinued 4/15/26. Risperidone 0.5 mg (an antipsychotic medication). Take one tablet by mouth at bedtime for dementia with behaviors, ordered 4/15/26. Sertraline 50 mg (an antidepressant medication). Take one tablet by mouth one time a day for depression, ordered 4/13/26. Antidepressant medication. Monitor for drowsiness, dizziness, vertigo, headache, tremor, weakness, fatigue, insomnia, postural hypotension, edema, dry mouth, anorexia, weight gain, urine retention every day and night shift, ordered 4/13/26. Antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS symptoms, every day and night shift, ordered 4/13/26. -However, there was no physician's order for what resident-specific behaviors to monitor for each psychotropic medication in order to justify the medications. -Review of Resident #4's electronic medical record (EMR) revealed there was no documentation to indicate what resident-specific behaviors were being monitored, what interventions were offered and if the interventions were effective, in order to justify the continuation or addition of the resident's psychotropic medications. C. Staff interviews Registered nurse (RN) #1 and RN #3 were interviewed together on 5/7/26 at 2:26 p.m. RN #1 and RN #3 said they monitored sleep when a resident took melatonin or trazodone or if the resident reported they could not sleep. They both said they monitored sleep based on a physician's order that indicated to document the resident's hours of sleep per shift. RN #1 said she knew what behaviors to monitor based on monitoring the resident when they were first admitted to the facility and having frequent checks. RN #1 said when the resident was first admitted , the facility's admissions team would know the resident had a behavior. RN #1 said she also received a report from the hospital regarding a resident's behaviors. RN #1 and RN #3 said they both worked the day shift and they did not see a lot of resident behaviors. They both said most of the behaviors occurred during the night shift and they were told about the behaviors during the shift report. RN #1 said there was a physician's order for the night shift to document when they observed the behavior and they could also document behaviors as a progress note. RN #1 and RN #3 said they were both familiar with Resident #4. RN #1 said when he was first admitted to the facility, he was agitated and wanted to get out of bed and the antipsychotic medication helped him. RN #1 said they were concerned for him getting out of bed because he had limitations due to his fractured femur. They both said he did not exhibit any behaviors. RN #1 said she knew if the melatonin was effective because there was a three-day monitoring period at admission, and then the physician determined if the melatonin should be continued. Social services assistant #1, social services assistant #2, unit manager #1, and unit manager #2 were interviewed together on 5/7/26 at 4:48 p.m. Social services assistant #1 said the IDT reviewed residents who were on psychotropic medications monthly. Social services assistant #1 said the IDT should document the meetings, but she said she did not know how they documented the meetings because she did not attend the meetings. Social services assistant #1 said she did not know what was covered in the meeting because she did not attend the meetings. Social services assistant #1 said she did not know who (from social services) was part of the psychotropic meetings. Unit manager #1 said if a medication was used for sleep, they wanted to make sure it was effective by tracking it during the day and the night. Unit manager #1 said they made adjustments if the resident was drowsy during the day. Unit manager #1 said the nurse documented the amount of sleep in the medication administration record (MAR) because it would be a physician's order to monitor sleep. Unit manager #1 said she knew what behaviors to monitor for because there would be a physician's order based on the medication. Unit manager #1 said they knew what interventions were effective for the resident by talking to the resident and the resident's family. -However, Resident #4's physician's orders did not include resident-specific behaviors to monitor for each medication. -Additionally, the physician's orders did not include an order to monitor for hours of sleep for Resident #4. Unit manager #1 and social services assistant #1 said they were familiar with Resident #4. Unit manager #1 and social services assistant #1 said they did not know if there were any behaviors to monitor. Social services assistant #1 said Resident #4 was very confused when he was first admitted to the facility but she had not see any behaviors from the resident recently. Unit manager #1 said Resident #4 did not have any behaviors and his sleeping was fine. Unit manager #1 said the resident was more engaged, more alert and more mobile. Unit manager #1 said since Resident #4 did not have any behaviors there were no interventions for him. The director of nursing (DON) and the vice president of clinical services were interviewed together on 5/7/26 at 4:43 p.m. The DON said she monitored sleep when a resident took melatonin, trazodone or if the resident reported they could not sleep. The DON said the facility monitored a resident's sleep based on a physician's order that indicated to document hours of sleep per shift. The DON said she knew what behaviors to monitor each resident for based on monitoring the resident when they were first admitted to the facility and conducting frequent checks on the resident. The DON said when a resident was first admitted to the facility, the facility's admissions team would know the resident had a behavior. The DON said the unit nurses received a report from the hospital. The vice president of clinical services said there should be a physician's order for behavior monitoring that had a list of generic interventions for nursing to use during their shift. The vice president of clinical services said the list was modified as the unit staff learned what worked and what did not work for each resident. The vice president of clinical services said the IDT met monthly and as needed to review residents who were on psychotropic medications. The DON said she was familiar with Resident #4. The DON said the IDT had not met to review Resident #4's psychotropic medications. The vice president of clinical services said she reviewed Resident #4's EMR and did not see a physician's order to monitor his behaviors or a physician's order to offer interventions and to document if the interventions were effective. III. Resident #79 A. Resident status Resident #79, age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system which leads to movement issues), anxiety disorder and depression. The 4/7/26 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 12 out of 15. The MDS assessment revealed the resident required set-up assistance with activities of daily living (ADL), including eating, oral hygiene and personal hygiene. She required partial/moderate assistance with toileting, dressing and ambulation. The MDS assessment indicated Resident #79 did not demonstrate verbal or physical behavioral symptoms toward others, reject care or wandered during the assessment look-back period. The MDS assessment revealed the resident was mildly depressed with a PHQ-9 (patient health questionnaire - a diagnostic tool designed to screen, monitor, and measure the severity of depression in adult patients) score of five out of 27. B. Record review Review of Resident #79's May 2026 CPO revealed the following physician's orders: Venlafaxine hydrochloride (HCl) 24-hour extended release (ER) (antidepressant medication) oral tablet, 37.5 mg. Give three tablets by mouth one time per day for depression, for a total of 112.5 mg, ordered 4/17/26. Antidepressant medication - Monitor for drowsiness, dizziness, vertigo (the sensation of movement), headache, tremor, weakness, fatigue, insomnia, postural hypotension (a sudden drop in blood pressure occurring when standing up from a seated or lying position), edema, dry mouth, anorexia, weight gain and urine retention. Every day and night shift, document: 'Y' if monitored and none of the above observed and document: 'N' if monitored and any of the above was observed and also select chart code 'Other/See Nurses Notes' and document findings in a progress note, ordered 12/23/25. Clonazepam (anti-anxiety medication) oral tablet, 0.5 mg. Give one tablet by mouth one time per day for generalized anxiety, ordered 12/23/25. Anti-anxiety medication (clonazepam) - Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Every day and night shift, document: 'Y' if monitored and none of the above observed and document: 'N' if monitored and any of the above was observed and also select chart code 'Other/ See Nurses Notes' and document findings in a progress note, ordered 12/23/25. Monitor for the following behaviors: (0) No behavior noted. (1) Biting/hitting/striking out. (2) Continuous crying. (3) Continuous screaming/yelling. (4) Continuous pacing/wandering/elopement. (5) Danger to self. (6) Danger to others. (7) Extreme fear. (8) Hallucinations. (9) Delusions. (10) Paranoia. (11) Repetitive anxious verbalizations. (12) Verbal abuse. (13) Refusing to do independent tasks, every day and night shift. Record the behavior code(s) and the number of episodes in supplemental documentation. Use C for continuous number of episodes, ordered 1/14/26. -However, the behaviors the physician's order indicated were to be monitored were not resident-specific to Resident #79. Non-pharmacological interventions: (1) Dim lights. (2) Warm blanket. (3) Aromatherapy. (4) Music. (5) Repositioning. (6) Heat. (7) Ice. (8) Other. Every day and night shift record each intervention attempted, ordered 12/22/25. -However, the non-pharmacological interventions were not resident-specific to Resident #79 and did not indicate which intervention should be used for which behaviors. Review of Resident #79's comprehensive care plan, initiated 12/23/25, revealed the resident's anxiety and moderately impaired cognition sometimes resulted in the resident pressing her call light repeatedly and not remembering what she needed assistance with. Additionally, if someone assisted the resident, the resident may not ask for everything she needed at that time, resulting in her pressing the call light again after someone had assisted her. The care plan revealed Resident #79 often stated that her needs had not been met after they had been met. Pertinent interventions, initiated 1/9/26, included anticipating and meeting the resident's needs and making sure she felt heard by using rephrasing and feedback, encouraging the resident to express her feelings appropriately, using active listening and responding to the resident's feelings and tone and explaining all procedures to the resident before starting care and allowing the resident time to adjust to changes. Resident #79's anxiety care plan, initiated 12/23/25, revealed the resident used anti-anxiety medications related to anxiety disorder. Pertinent interventions, initiated 12/23/25, included administering anti-anxiety medications as ordered by the physician and monitoring for side effects and effectiveness every shift, monitoring for drowsiness, slurred speech, nausea and aggressive/impulsive behavior, monitoring the resident for safety - anti-anxiety medications were associated with an increased risk of confusion, amnesia, loss of balance, cognitive impairment that looked like dementia and increased risk of falls, broken hips and legs and monitoring/recording the occurrences of target behavior symptoms, such as pacing, wandering, disrobing, inappropriate response to verbal communication and violence/aggression towards staff or others. Resident #79's depression care plan, initiated 12/23/25, revealed the resident used antidepressant medication for depression and sleep. Pertinent interventions, initiated 12/23/25, included administering antidepressant medications as ordered by the physician and documenting side effects and effectiveness every shift, monitoring for drowsiness, dizziness, vertigo, headache, tremor, weakness, fatigue, insomnia, postural hypotension, edema, dry mouth, anorexia, weight gain and urine retention and monitoring/documenting/reporting as needed any adverse reactions to antidepressant therapy, such as changes in behavior/mood/cognition, hallucinations/delusions, social isolation and suicidal thoughts. -A review of Resident #79's EMR revealed there was no documentation of what specific interventions were offered to the resident and if the interventions were effective when the resident was exhibiting behaviors. -A review of Resident #79's EMR revealed there was no documentation on what individualized behaviors the facility was specifically monitoring for Resident #79 and what interventions were identified to help Resident #79 if she exhibited any behaviors. C. Staff interviews The nursing home administrator (NHA) was interviewed on 5/5/26 at 5:04 p.m. The NHA said Resident #79 had high anxiety and if her call lights were not answered immediately, her anxiety went way up and she continued to press her call light. She said Resident #79 averaged 27 to 30 call light activations per shift and the IDT met daily in an effort to decrease her anxiety. The NHA said the facility tried to ease Resident #79's transition to the facility by having care conferences with the resident's representative. CNA #6 was interviewed on 5/7/26 at 8:43 a.m. CNA #6 said Resident #79 activated her call light every two to three minutes, even though he tried to ensure everything was in reach and asked her if there was anything else he could do for her before he left her room. He said he spent his shift on 1/3/26 going to her room every five to 15 minutes to answer her call light for basic things. The DON and the MDS coordinator were interviewed together on 5/7/26 at 6:20 p.m. The DON said depending on the medication, there were template orders in the MAR that the facility used as a guide and modified based on each resident's behaviors. She said the psychopharmacological committee discussed each resident's use of psychotropic medications with the physician, the pharmacist, the behavioral health provider, the bedside nurses and herself. The DON said the committee discussed resident updates, any new or changed behaviors and determined if it was reasonable to wean or discontinue a resident from a psychotropic medication. She said if the committee was concerned about a particular resident, they might continue to monitor the resident the following month or they might complete the quarterly regulatory reviews if no behaviors were demonstrated. The DON said progress notes, documentation, care plans and consents were reviewed at that time. She said the psychopharmacological committee utilized the residents progress notes for documentation rather than specific psychiatric pharmacology documentation. The MDS coordinator said the non-pharmacological interventions in Resident #79's MAR were not resident specific and were not effective interventions. She said the effectiveness of interventions implemented should be documented. The MDS coordinator searched Resident #79's EMR and said the nursing staff did not document the effectiveness of behavioral or non-pharmacological interventions for the resident. She said an E for effectiveness should be documented in the MAR. The MDS coordinator said Resident #79's care plan should have included specific interventions and identified triggers to help manage the resident's anxiety.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#93) of one resident reviewed for a safe and orderly discharge out of 51 sample residents. Specifically, the facility failed to ensure a discharge summary was completed at the time of Resident #93's hospital transfer.Findings include:I. Facility policy and procedureThe Discharge and Transfer policy, dated May 2025, was provided by the executive director on 5/8/26 at 12:34 p.m. It read in pertinent part, For a transfer to another provider, for any reason, the following information will be provided to the receiving physician: contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; and, all other information necessary to meet the resident's needs. Anticipated transfers or discharges - resident initiated discharges. Obtain physician orders for transfer or discharge and instructions or precautions for ongoing care; provide transfer/discharge notice to the resident/representative and ombudsman as indicated; complete discharge summary; the facility will educate the resident about transfer or discharge; assist with transportation arrangements as needed; and, supporting documentation shall include evidence of the resident's or representative's verbal or written notice of intent to leave the facility, a discharge plan and documented discussions with the resident and/or resident representative.II. Resident #93A. Resident statusResident #93, age greater than 65, was admitted on [DATE] and discharged to the hospital on 3/17/26. According to the May 2026 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), atrial fibrillation (a rapid, chaotic, and irregular heartbeat originating in the heart's upper chambers), hyperlipidemia and long term use of anticoagulants (blood thinner medication).The 3/21/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident required partial/moderate assistance with activities of daily living (ADL), including dressing and showering. She required set-up assistance with toileting and oral hygiene and was independent with eating.The MDS assessment documented the resident was discharged with an anticipated return to the facility.B. Record reviewReview of Resident #93's progress notes revealed the resident was admitted to the facility on [DATE] following hospitalization for a fecal impaction. The resident was admitted to the facility with some confusion.The following was documented in Resident #93's progress notes on 3/17/26:At 1:00 a.m. a physician documented that since Resident #93's arrival to the facility, there had been concern that she now seemed to be exhibiting more right-sided clumsiness/weakness that was not present before arriving at the facility. Previous providers documented a discussion with the family about needing to go back to the hospital due to new changes, but after a discussion with the family, it appeared that observation was not pursued. However, she continued to exhibit right-sided weakness despite the most recent stroke that caused left-sided weakness. Her left side appeared to be doing better than her right. The physician discussed this with physical therapy (PT)/occupational therapy (OT) and her bedside nurse, who all agreed that her right side seemed to be now the problematic side. The physician reviewed her imaging, which did show some findings of chronic old left-sided infarcts (strokes) - but again, the right-sided weakness/clumsiness was more pronounced over the past week. -However, the progress note documentation should have a documentation time of 1:00 p.m. (see interview below).At 4:00 p.m. nursing staff documented that Resident #93 was taken to the local hospital via ambulance on a stretcher accompanied by two emergency medical technicians (EMT). The resident's son followed in his own car. The family requested the emergency department (ED) visit as the resident had new increased right-sided weakness. The resident was in stable condition upon exit from the facility.Resident #93's electronic medical record (EMR) revealed the resident was discharged to the local hospital on 3/17/26.-However, review of the EMR did not indicate that documentation of transfer information was provided to the hospital on 3/17/26 when Resident #93 was transferred to the hospital.III. Staff interviewsThe director of nursing (DON) and the MDS coordinator were interviewed together on 5/7/26 at 6:20 p.m. The DON said when a resident was being transferred out of the facility to the hospital, the nurse should first get an order from the physician, call the family and print the transfer move out record. She said the resident's facesheet and medical orders for scope of treatment (MOST) form were sent with the resident when she left the building. The DON said sometimes the nurses at the facility did not use the same version of the hospital transfer form, but the hospital transfer form did not get completed for Resident #93. She said the nurse probably printed the hospital transfer document and sent it to the hospital with the resident, but ideally they would have made two copies so that the facility would have a record of the documentation provided to the hospital. The DON said she searched Resident #93's EMR for documentation that the physician was notified of the resident's discharge from the facility. She said she would have to call the physician, but the facility's process would be to ensure the physician was notified. The DON said she was pretty confident the facility notified the physician and she could find the documentation.The DON was interviewed again on 5/7/26 at 8:35 p.m. The DON said she spoke to the physician to confirm an assessment was performed on Resident #93 at 1:00 p.m. on 3/17/26, not 1:00 a.m. She said there was a note at the bottom of the assessment that said the physician would contact the family about possibly sending the resident out of the facility, so both the physician and the family were aware of the resident's discharge.Registered nurse (RN) #6 was interviewed on 5/8/26 at 9:24 a.m. RN #6 said when a resident was transferred out of the facility, there was a transfer document in the computer that needed to be completed by the nurse. She said the resident's representative, physician and any other staff pertinent to the resident's care should be notified of the transfer and it should be documented on the hospital transfer documentation. RN #6 said the hospital transfer form, along with the resident's vital signs history, medical history, MOST form, medications, lab work and any other relevant history, such as ultrasounds, were sent with the resident once the ambulance arrived. She said the nurse gave a report to the receiving facility once the ambulance arrived. RN #6 said it was important that the required documentation was provided to the receiving facility so that the facility would know the resident. She said there was no reason the hospital transfer form would not be completed - because it was an online document.RN #6 said she was not familiar with Resident #93 because she was a float nurse, and the resident was admitted to the facility for a short period of time. She said a hospital transfer form and required documentation should always be completed when a resident left the facility.

Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive care plan for two (#12 and #53) of two residents out of 51 sample residents.Specifically, the facility failed to:-Ensure Resident #12's care planned intervention for a positioning pillow was consistently implemented to support and elevate her right arm while seated in her wheelchair;-Ensure Resident #12's care plan was updated when the resident refused the wrist-hand-finger orthosis (WHFO) brace intervention for her right hand contractures;-Develop and implement a care plan focus for Resident #53's knee contracture, including identifying interventions to prevent worsening of the resident's contractures; and,-Include the interventions for physician-ordered heel booties on Resident #53's skin integrity care plan.Findings include: I. Facility policy and procedure The Care Plan policy, dated January 2026, was provided by the executive director on 5/8/26 at 12:32 p.m. It read in pertinent part, The comprehensive care plan will describe, at a minimum, the following:-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and,Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor resident's progress. Alternative interventions will be documented as needed. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, with significant change of condition, when desired outcome has not been achieved, readmission from hospital or other community and as needed. The facility will attempt alternative methods for refusal of treatment and services and document such attempts and discussions in the medical record. Qualified associates/staff/ancillary providers responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out interventions, initially and when changes are made as well as their responsibility of communicating to the appropriate staff any change in condition. II. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke caused by blocked blood flow), hemiplegia (paralysis on one side of the body) and major depressive disorder. According to the 3/13/26 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. She required substantial assistance with personal hygiene, upper body dressing and transfers. She was dependent on staff for toileting hygiene and bathing. The MDS assessment documented the resident did not reject care. B. Resident observations On 5/4/26 at 11:45 a.m. Resident #12 was sitting in her wheelchair in the dining room. The resident's contracted right hand rested on her lap without a pillow for support. The resident did not have an orthotic device on her right hand. On 5/5/26 at 10:11 a.m. Resident #12 was assisted from her room to the dining room in her wheelchair. The resident's right hand rested on her lap without a pillow for support. The resident did not have an orthotic device on her right hand. On 5/6/26 at 12:54 p.m. Resident #12 was sitting in the dining room in her wheelchair holding her contracted right arm against her chest without a pillow for support. The resident did not have an orthotic device on her right hand. On 5/6/26 at 5:25 p.m. Resident #12 was sitting in the dining room eating with her left hand while holding her contracted right hand against her chest without a pillow for support. The resident did not have an orthotic device on her right hand. On 5/7/26 at 9:01 a.m. Resident #12 was sitting in the dining room holding her contracted right hand against her chest without a pillow for support. The resident did not have an orthotic device on her right hand. On 5/7/26 at 9:15 a.m. Resident #12 used her left hand on the hallway handrail to propel herself to her room in her wheelchair. The resident's right hand rested on her lap without pillow support. The resident did not have an orthotic device on her right hand. C. Record review The activities of daily living (ADL) care plan, initiated 12/9/2020 and revised 4/30/25, revealed Resident #12 had an ADL self-care performance deficit related to a history of cerebrovascular accident with right-sided hemiplegia, cognitive deficit, limited mobility and impaired balance. The care plan revealed the resident's right side was affected and she had a contracture to the right hand. Interventions included placing a small pillow on the right side of the resident's wheelchair to keep her arm elevated every day and night shift. Additional interventions included applying a wrist-hand-finger orthosis (WHFO) brace to the resident's right hand and arm, either during the day or at night in bed as tolerated and monitoring comfort and skin twice daily for the resident's right hand contracture. -However, Resident #12 was not observed with a support pillow under her right hand or wearing the WHFO brace during the survey process (see observations above). A 11/28/24 restorative progress note revealed Resident #12 used her left side to assist with wheelchair propulsion. The note revealed increased stiffness through the resident's right upper extremity was observed. A 12/17/24 physician progress note revealed Resident #12 had stiffness of her right hand, chronic, worsening contracture with worsening pain when the orthotic brace was applied. A 3/26/25 nursing progress note revealed Resident #12 had arthritis pain in her right hand during the orthotic brace placement. The Kardex (a tool utilized by staff to provide consistent resident care) revealed Resident #12 required extensive assistance from staff with dressing and was dependent on extensive assistance from staff with transfers and bed mobility. Interventions included placing a small pillow on the right side of the resident's wheelchair to keep her arm elevated every day and night shift. -However, Resident #12 was not observed with a support pillow under her right hand during the survey process (see observations above). D. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 5/7/26 at 9:22 a.m. CNA #8 said staff reviewed the residents' electronic medical records (EMR) and the Kardex to identify care plan interventions for residents. CNA #8 said Resident #12 previously used a hand sling (orthotic device) but refused to wear it because it was uncomfortable. CNA #8 said Resident #12 required a pillow under her right arm while seated in the wheelchair to keep the arm elevated because the resident leaned to the right side. CNA #8 said staff were supposed to place the pillow under the resident's right arm when the resident got up in the morning and whenever she sat in the wheelchair. CNA #8 said the resident sometimes refused the pillow in the morning but later accepted it during the day. CNA #8 said staff documented any resident refusals in the EMR and notified the nurse. Registered nurse (RN) #10 was interviewed on 5/7/26 at 9:42 a.m. RN #10 said interventions for Resident #12's right arm included placing a pillow under the resident's right arm for support. RN #10 said CNAs were expected to notify nurses of resident refusals. RN #10 said no CNA had notified her of any refusals from Resident #12 for the right arm pillow during the time she had worked with the resident. RN #10 said it was important for CNAs to notify nurses of refusals to ensure continuity of care. RN #10 said if the resident refused care, she would wait a while, speak with the resident, ensure the resident's hearing aids were in place and attempt the intervention again. RN #10 said if the resident continued to refuse, she would document the refusal in a progress note. RN #10 said nurses ensured CNAs followed positioning interventions by reminding staff to follow the residents' care plan interventions and ensure residents were positioned safely and comfortably. The director of nursing (DON) and unit manager (UM) #2 were interviewed together on 5/7/26 at 10:03 a.m. The DON said staff were expected to be familiar with residents' care plans and follow the Kardex. The DON said resident interventions appeared in the resident's EMR dashboard. The DON said Resident #12's right hand contracture required monitoring to ensure there was no skin breakdown. The DON said nurses were expected to complete skin assessments, evaluate residents for pain and discomfort and notify the physician of concerns. The DON said staff were expected to follow interventions directing the use of a pillow to support the resident's arm. The DON said the interventions on the care plan for Resident #12's right hand contractures were from 2020 and should have been updated to reflect the resident's refusals and current needs. The DON said nurse managers and the therapy team updated residents' care plans. The DON was interviewed again on 5/7/26 at 12:10 p.m. The DON said she did not have documentation to indicate Resident #12 refused the right arm support pillow intervention. The DON said the CNAs task documentation included a yes or no option for placement of the pillow. The DON said she provided education to staff regarding documenting resident tasks accurately. III. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic atrial fibrillation (rapid irregular heartbeat), chronic obstructive pulmonary disease (emphysema and difficulty breathing), peripheral vascular disease (progressive circulation disorder, narrowing blood vessels), prediabetes, chronic kidney disease stage three, obesity and left artificial knee joint. According to the 4/16/26 MDS assessment, Resident #53 was moderately cognitively impaired with a BIMS score of 12 out of 15. Resident #53 required set-up assistance with eating, oral hygiene and personal hygiene. He required substantial assistance with toileting and showering. The assessment revealed he had one unstageable pressure injury as a deep tissue injury at admission. B. Resident and resident's representative interview Resident #53 and Resident #53's representative were interviewed together on 5/4/26 at 12:07 p.m. in his room. Resident #53's representative said Resident #53 had been in and out of the hospital and the facility for multiple reasons, including a knee surgery that had complications. During the interview, Resident #53 was observed sitting in his recliner with a blanket covering him from his chest to his feet. The resident's bed had a wooden footboard at the bottom of it and two blue booties were observed under the resident's desk. Resident #53's representative said before Resident #53 was admitted to the facility, he had callouses on the heels of both feet that resolved before he was admitted to the facility. She said the facility put the booties on the resident at night when he was in bed. Resident #53 said the facility did not always put the booties on when he was in bed. Resident #53 was observed to be a tall man. Resident #53 said he was six feet two inches tall and the bed was too small for him because the foot board hit the heels of his feet. C. Observations On 5/5/26 at 8:14 a.m. Resident #53 was lying in his bed awake with no blanket covering his legs. Both feet were observed touching the footboard at the bottom of the bed. The blue booties were observed underneath the desk in his room. The head of the resident's bed was elevated to approximately 60 degrees and the knee section of the bed was raised to approximately 30 to 45 degrees. On 5/6/26 at 5:40 a.m. Resident #53 was lying in his bed sleeping with a blanket covering his legs. The blue booties were again observed underneath the desk in his room. The head of the resident's bed was elevated to approximately 60 degrees and the knee section of the bed was raised approximately 30 to 45 degrees. Both feet were observed touching the footboard at the bottom of the bed. D. Record review Review of Resident #53's 4/30/26 hospital discharge instructions, prior to his readmission to the facility following a hospital stay for sepsis, revealed the following wound care recommendations: Left heel and left second toe. Cleanse with normal saline and gauze, remove old drainage, pat dry. Apply Anasept gel (hydrogel used to treat and prevent infections in various wounds) to wounds, cover with bordered foam, and change every other day. Keep heel boots in place at all times. -However, review of Resident #53's electronic medical record (EMR) did not identify heel boots as a physician's order or as a care plan intervention to prevent pressure injuries or worsening of the resident's knee contractures. Review of Resident #53's 5/1/26 facility admission assessment revealed the care planning section on the assessment, including the focus area, goal and interventions was not completed. The skin integrity care plan, no revision date, revealed Resident #53 had an actual impairment to his skin integrity, including a wound on his toe, heel and left knee, one skin tear and a rash. Interventions included following the facility's protocol for treatment of injuries, identifying and documenting potential causative factors and eliminating when possible, monitoring and documenting skin injuries, using caution during transfers, weekly documentation, including measurement of each skin breakdown and wound monitoring and treatment per physician's order. -However, the care plan interventions did not include the use of booties. -Review of Resident #53's care plan did not identify his risk for knee contractures. E. Staff interviews RN #1 was interviewed on 5/7/26 at 2:26 p.m. RN #1 said typical interventions to prevent pressure injuries included frequent elevation, boots and a dressing-like cushion. RN #1 said she was responsible for implementing the care plan interventions. RN #1 said she knew the interventions because it was a physician's order. RN #1 said if it was an intervention CNAs carried out, the nurses told the CNAs about the intervention. RN #1 said if a resident refused an intervention, she documented the refusal and notified the physician. RN #1 said she was familiar with Resident #53. She said he had the booties because he was supposed to wear them when he was in bed. She said she did not see him wear them while in bed and said he was not in bed when she worked her shifts. RN #1 said she would talk to the physician to get an order for the booties. RN #1 said Resident #53 needed to wear the booties because he had knee surgery which caused his knee to not straighten completely and he was at risk for knee contractures. She said the booties helped prevent knee contractures. The DON and the vice president of clinical services were interviewed together on 5/7/26 at 4:43 p.m. The DON said typical interventions to prevent pressure injuries included frequent elevation, boots and dressings that acted as a cushion. The DON said the nurses were responsible for implementing the interventions. The DON said the nurses knew the interventions for resident's skin integrity based on physician's orders. The DON said the nurses told the CNAs if it was an intervention for the CNA to carry out. The DON said if the resident refused interventions, nurses were to chart the refusal and follow up with the wound care physician or primary care physician. The DON said she was familiar with Resident #53. The DON said Resident #53 had the booties for both feet because he was at risk for his knee contractures worsening. The DON said she was not aware the booties were not being worn while he was in bed. The vice president of clinical services said the facility should reassess how Resident #53 was positioned while in bed. She said the facility could look into a bed extender or remove the board at the foot of the resident's bed. The DON and the vice president of clinical services said they did not know the heel booties not included as a physician's order and were care planned as an intervention on Resident #53's comprehensive care plan.

Based on observations, record review and interviews, the facility failed to ensure one (#40) of five residents out of 51 sample residents were provided services that maintained professional standards of quality. Specifically, the facility failed to: -Ensure staff obtained a physician's order specifying personalized settings for air mattresses for Resident #40; and, -Ensure staff maintained air mattresses according to the manufacturer's recommendations for Resident #40.Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers and Injuries(3/17/26), retrieved on 5/14/26 from https://www.guidelinecentral.com/guideline/23835, It is good practice for organizations to maintain an inventory of, or access to, a range of full body support surfaces appropriate to the clinical context. The inventory should be maintained, stored and used in accordance with manufacturer recommendations. It is good practice to use a full body support surface or integrated bed system that appropriately accommodates the weight, height, size and body mass distribution of the individual.II. Manufacturer's instructionsAccording to Pressure Guard's Alternating Pressure Mattresses (APM) Bariatric owner's manual, provided by the vice president of clinical services on 5/8/26 at 12:32 p.m. The system consists of a foam shell with a high-density foam topper serving as the support surface underneath the patient. The foam shell also includes contoured foam bolsters at the sides and ends of the mattress, providing added patient stability and positioning. The system also includes the unique Heel Slope feature, designed to further reduce pressure for the sensitive heel area. Within the foam shell is housed the inflation system, consisting of air cylinders which run lengthwise within the mattress. The Air Control Unit connects to the mattress at the patient's foot-end. The product is intended to be operated by personnel who are qualified to perform general nursing procedures and have received adequate training in the treatment and prevention of pressure injuries.III. Resident #40 A. Resident statusResident #40, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders, diagnoses included osteoporosis, hypertension, prediabetes, open wound on left knee, osteoarthritis and anxiety.According to the 4/30/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had an impairment on one side of her lower extremity and used a walker. She required set up assistance with eating, supervision with oral hygiene and with personal hygiene. She required substantial assistance with toileting and partial assistance with dressing. B. ObservationsOn 5/5/26 at 8:45 a.m. Resident #40 was sitting in her recliner on the left side of her bed. There was an air mattress attached to her bed. On 5/6/26 at 10:57 a.m. Resident #40 was sitting in her recliner. There was an air mattress attached to her bed.On 5/6/26 at 12:28 p.m. Resident #40 was sitting in her recliner. There was an air mattress attached to her bed. C. Record review -Review of Resident #40's May 2026 CPO failed to reveal a physician's order for an air mattress. -There was no documentation in the resident's electronic medical record (EMR) to indicate the resident's mattress was being monitored and maintained on a routine basis and documentation of what the air mattress setting should be on and if an assessment was completed. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 5/7/26 at 2:26 p.m. RN #1 said the admissions staff determined who required an air mattress and they placed an order with the durable medical equipment (DME) company for the mattress to be delivered. RN #1 said there should be a physician's order for an air mattress to monitor the function of the mattress every shift. RN #1 said nursing staff was responsible for routine maintenance checks of air mattresses and if there was anything faulty, they notified maintenance. RN #1 said she did not know who was responsible for setting the mattress function parameters for residents' air mattresses RN #1 said she was familiar with Resident #40. She said Resident #40 had a special air mattress because she rarely moved and the mattress helped prevent pressure injuries. RN #1 said Resident #40 also had a surgical procedure on her left leg and she did not like the original mattress. At 4:08 p.m. RN #1 went into Resident #40's room and the air mattress was turned on. RN #1 said she did not know if the air mattress settings were correct for the resident. RN #1 said she would ask the physician for an order. The director of nursing (DON) and the vice president of clinical services were interviewed together on 5/7/26 at 4:43 p.m. The vice president of clinical services said all residents had the same mattress and the residents' regular mattress setting was set to stage 2. If a resident had a condition that required a low air loss, then a special mattress was ordered. The vice president of clinical services said an assessment was not completed prior to a mattress being utilized. The vice president of clinical services said the facility's wound care physician may recommend a special mattress and that would be reflected in a physician's order. The DON said she was familiar with Resident #40. The DON said the resident had a special mattress because she complained about the original mattress. The vice president of clinical services said they would look into the resident's air mattress.

Based on record review and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for two (#48 and #82) of four residents reviewed for accident hazards out of 51 sample residents.Specifically, the facility failed to:-Ensure staff provided adequate assistance when transferring Resident #48 with a sit-to-stand lift (a mobility device designed to help individuals with partial weight-bearing capability transition from a seated to a standing position), which resulted in a fall for the resident; -Ensure staff notified the appropriate individuals when Resident #48 sustained a fall when staff were transferring her with the sit-to-stand lift; and,-Ensure staff transported Resident #82 in her wheelchair in a safe manner, which resulted in a skin tear to the resident's left forearm.Findings include: I. Failures for Resident #48's sit-to-stand lift transfer and fall from the sit-to-stand A. Facility policy and procedure The Mechanical Lifts to Transfer Residents policy, dated August 2025, was provided by the executive director on 5/8/26 at 12:34 p.m. It read in pertinent part, Mechanical lifts must be used in a dignified, respectful manner, and with discretion when transferring a resident. The operation of any mechanical lift for resident transfers will be consistent with state regulations. Evaluation of the resident's need for assistance with transferring from one surface to another is to be completed upon move-in, significant change in condition and on return to the community from hospitalization or other treatment centers. If a resident requires use of a mechanical lift, then the community will provide information to the resident on the appropriateness of a mechanical lift to meet his/her transfer needs. Types of mechanical lifts may include: sit-to-stand; and, Hoyer. Safety issues for both the resident and associates will be evaluated. Once a resident is evaluated and clinically approved for the use of a mechanical lift, the following steps will be taken: notify the practitioner as appropriate and obtain an order for evaluation by physical therapist (PT) or physical therapist assistant (PTA) to determine specific transfer needs; PT/PTA will evaluate the resident and will be reviewed regularly; and, associates are responsible for reporting to a supervisor any problems or concerns with a resident's ability to participate in a sit-to-stand transfer or whole body transfer immediately. If concerns occur, the resident will be re-evaluated to determine whether the resident is capable of transfers. B. Resident status Resident #48, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system which leads to movement issues), acute kidney failure and obstructive sleep apnea (the muscles of the throat relax and block the airway during sleep, pausing breath during sleep). The 4/22/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment revealed the resident was dependent or required substantial/maximal assistance from staff with activities of daily living (ADL), including dressing, showering, toileting and mobilizing from sitting to standing. C. Resident interview Resident #48 was interviewed on 5/4/26 at 2:40 p.m. Resident #48 said she fell from a mechanical lift a few months back and she still had a bruise on her right leg. She said one staff member operated the lift and told her not to hang on to the machine, so she fell. Resident #48 was unable to recall the staff member's name who told her not to hang onto the lift. Resident #48 was interviewed again on 5/6/26 at 4:55 p.m. Resident #48 said her fall from the mechanical lift happened a long time ago. She said the staff educated her on how to use the sit-to-stand lift when she first started using it. Resident #48 said she felt safe with how the nursing staff had been using the sit-to-stand lift and transferring her between surfaces since the fall. D. Record review Review of Resident #48's Kardex (tool utilized by staff to provide consistent care for residents) report revealed the resident was dependent on the sit-to-stand mechanical lift for transfers, and the resident required assistance from one to two staff members to move between surfaces. Review of Resident #48's fall care plan, initiated 11/9/23, revealed the resident was at risk for falls related to Parkinson's disease, history of falls, cognitive deficit, difficulty walking, lack of coordination, muscle weakness, limited mobility, poor safety awareness, use of psychotropic medication, chronic knee pain, functional incontinence of the bladder and bowel and unsteady gait and balance. A pertinent intervention, initiated 8/22/25, included providing the resident education regarding her role in using the sit-to-stand lift. Review of Resident #48's ADL care plan revealed the resident needed assistance with ADLs and had a self-care performance deficit related to muscle weakness from Parkinson's disease, cognitive deficit, limited mobility, poor safety awareness, use of psychotropic medication, chronic knee pain, functional incontinence of the bladder and bowel and unsteady gait and balance. Pertinent interventions included utilizing the sit-to-stand lift for transfers (revised 8/22/25) and providing the resident with extensive assistance from one to two staff members to move between surfaces using the sit-to-stand (revised 1/3/25). Review of Resident #48's electronic medical record (EMR) revealed the following progress notes: A progress note, dated 2/20/26 at 12:03 a.m., revealed a certified nurse aide (CNA) was assisting Resident #48 to and from the bathroom and while being lowered to the bed, the resident released her hands from the sit-to-stand lift. The CNA lowered the resident to the floor for her safety. The nurse was alerted and found the resident sitting on the floor crying. The resident was helped back to bed by two CNAs and did not complain of pain or discomfort. An advanced practice provider note, dated 3/5/26 at 9:30 a.m., revealed that Resident #48 expressed concern about an incident that occurred approximately two weeks ago when a new CNA with only one week of experience operated the mechanical lift without supervision. The resident reported that during the transfer, another CNA she had previously declined to work with took over the lift and told her not to hang on, which resulted in her falling a short distance and sustaining a small bump. -However, review of the resident's EMR did not reveal documentation of an assessment by a registered nurse (RN) or report/notification of a fall to the physician or resident's representative following the fall from the mechanical lift. -Review of Resident #48's EMR failed to reveal documentation that indicated the resident was re-evaluated by physical therapy (PT)/occupational therapy (OT) for mechanical lift use after she sustained the fall from the sit-to-stand lift on 2/20/26. E. Staff interviews CNA #1 was interviewed on 5/6/26 at 5:00 p.m. CNA #1 said when a resident started to use a mechanical lift for the first time, she would check their medical record to see what kind of assistance the resident required. She said because she would be assigned rehabilitation residents in the Ponderosa unit, she would go one step further and get a report from the rehabilitation nurse upstairs. CNA #1 said she would never transfer a resident without first knowing their transfer status. She said she would educate the resident on how to use the device, where to hold on to and where to place their feet to feel secure. The executive director was interviewed on 5/6/26 at 6:00 p.m. The executive director said he and the regional director of clinical services searched but could not find an incident report for Resident #48's fall from the sit-to-stand lift on 2/20/26. He said the CNA who transferred the resident was working tonight (5/6/26) and he interviewed her. The executive director said the CNA believed that because Resident #48's fall had been witnessed and another staff member was there, the event did not need to be reported and the resident did not need to be assessed. He said there was no incident report or investigation for the incident, but there should have been one. The executive director said staff would be educated on reporting falls and completing incident reports and investigations. CNA #2 was interviewed on 5/7/26 at 10:55 a.m. CNA #2 said if she noticed a resident fell, she would call the nurse or push the call light so as never to leave the resident. She said the resident should be assessed by the nurse and the assessment should be documented in the facility's electronic medical system. CNA #2 said she used the sit-to-stand lift with Resident #48 often, and the resident was supposed to be a one-person assist but sometimes the resident lets go of the lift. She said if staff did not really know the resident, the resident should be a two-person assist for transfers using the sit-to-stand lift. CNA #2 said this was communicated to newer staff members in shift-to-shift report. Licensed practical nurse (LPN) #2 was interviewed on 5/7/26 at 11:12 a.m. LPN #2 said if she noticed a resident fell, she would first ensure the resident was safe. She said since she was an LPN, it was not within her scope of practice to thoroughly assess the resident, so she would call the RN to do the assessment together with her. LPN #2 said the assessment should be documented and the unit manager, the physician and the resident's representative should be notified. LPN #2 said Resident #48 was a one-person assist to transfer with the sit-to-stand lift, but she knew there were times when the resident needed a two-person assist because her legs and arms were not that strong. She said Resident #48's Parkinson's disease had progressed and the resident was not always able to hold on to the mechanical lift that well. LPN #2 said she did not think it was normal for the resident to let go of the sit-to-stand lift, but she said she thought Resident #48 was not able to hold on because of her Parkinson's disease. LPN #2 said PT/OT and restorative nursing were responsible for determining the resident's mechanical lift use. She said PT would re-evaluate the resident for mechanical lift use if there was a significant change in the resident. She said it was documented on the medication administration record (MAR) for the nurses, and she believed the CNA report sheets said what type of transfer the resident required. LPN #2 was interviewed again on 5/7/26 at 2:45 p.m. LPN #2 said she was not sure if anyone had reported Resident #48's mechanical lift transfer change of condition. The director of rehabilitation was interviewed on 5/7/26 at 3:19 p.m. The director of rehabilitation said residents were re-evaluated based on condition changes, such as a fall. She said the facility held biweekly meetings involving the therapy, nursing and restorative teams and they discussed change of conditions and determined if therapy services were appropriate. The director of rehabilitation said she would determine if a mechanical lift was appropriate for a resident by observing the nursing staff perform the sit-to-stand lift transfer with the resident. She said the PT team would look at the resident's upper extremity (arms and core) strength and determine if the resident was able to bear their own weight to hold on to the lift. The director of rehabilitation said if the resident was unable to meet those requirements, the PT would have recommended a Hoyer lift (full-body mechanical lift). The director of rehabilitation said Resident #48 was initiated with restorative therapy at the end of 2024, and the resident's last PT evaluation was in 2024. The director of rehabilitation said Resident #48 required maximal assistance for transfers and she knew Resident #48 had some knee pain. She said Resident #48 was a one-person assist to transfer unless she used a Hoyer lift, which required a two-person assist. The director of rehabilitation said she did not believe she had been notified about a change of condition related to transfer status for Resident #48. She said she could not recall that she was notified or aware of Resident #48's sit-to-stand fall on 2/20/26. The director of rehabilitation said after becoming aware of Resident #48's fall, she would still say a sit-to-stand transfer would be the safest option for Resident #48. She said therapy could definitely re-evaluate Resident #48's mechanical lift use. II. Failed to ensure staff transported Resident #82 in her wheelchair in a safe manner, which resulted in a skin tear to the resident's left forearm A. Resident status Resident #82 age greater than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), depression, muscle weakness, difficulty in walking and overactive bladder. The 4/30/26 MDS assessment revealed Resident #82 had moderate cognitive impairment with a BIMS score of 10 out of 15. She needed substantial to maximal assistance for most of her ADL and was dependent on staff assistance for toileting. B. Resident interview and observation Resident #82 was interviewed on 5/4/26 at 11:38 a.m. Resident #82 said one of the CNAs was taking her down to the dining room in her wheelchair for breakfast. She said the CNA was probably going too fast and her (Resident #82) arm hit the dining room table. She said the nursing staff changed her bandage on a regular basis. She said she was supposed to have it changed that day (5/4/26). During the interview, Resident #82 was observed with a large bandage on her left forearm with the date of 5/2/26 written on it. C. Record review The skin integrity care plan, revised 4/28/25, revealed Resident #82 was at risk for skin impairment due to decreased mobility. Pertinent interventions included applying Eucerin cream twice daily to dry areas as requested by the resident (initiated 5/24/23), following the facility's protocol for treatment of injuries (6/29/22) and using caution during transfers and bed mobility to prevent striking the resident's arms, legs and hands against any sharp or hard surface (6/29/22). A nursing progress note, dated 4/25/26 at 9:49 a.m., revealed a CNA reported that she was taking Resident #82 to the dining room for breakfast and while wheeling her to the table, the resident's left outer arm accidentally got hit on the dining room table and the resident sustained a skin tear. The CNA immediately brought the resident to the nurse. The skin tear was located on the resident's left outer arm near the elbow. The skin tear measured 6.5 centimeters (cm) by 3.5 cm. The note documented that the wound was cleansed with normal saline and steristrips and Xerofoam (wound dressing) were applied and covered with bordered gauze. Resident #82 denied any pain and the unit manager and the resident's son were notified. Review of Resident #82's May 2026 CPO revealed the following physician's order: Remove optifoam dressing carefully. Keep steristrips intact. Cleanse/pat dry. Recover with optifoam every three days and as needed, ordered 4/29/26. D. Staff interviews CNA #9 and CNA #10 were interviewed together on 5/7/26 at 11:01 a.m. CNA #9 said she had only been working at the facility for one month and CNA #10 said she had worked at the facility for a year and a half. CNA #9 and CNA #10 said that if they saw any new skin issues on a resident, they would let their nurse know immediately. CNA #9 said she did not know how Resident #82 got her skin tear on her arm. She said she only knew that the resident had a bandage on her forearm. CNA #10 said she had heard that Resident #82's arm had gotten scraped on a dining room table because a CNA was going too fast when pushing the resident's wheelchair. CNA #9 and CNA #10 said they said they had not received any recent training on preventing skin tears. Registered nurse (RN) #11 was interviewed on 5/7/26 at 11:15 a.m. She said when she was notified of a new skin issue or skin tear for a resident, she would do an assessment. She said she would measure the wound and then report it to the unit manager. She said she would document a skin issue note and get orders from the physician. She said she was the nurse that was on duty the day that Resident #82 got the skin tear (4/25/26). She said the CNA was taking her down to the dining room in her wheelchair and Resident #82's left forearm hit the corner of the dining room table. RN #11 said the CNA immediately brought Resident ##82 back to her (RN #11) so she could assess her. She said she treated the wound and dressed it. She said the physician's assistant saw the resident's skin tear the next day and told the staff to change the dressing every other day. RN #11 said there were not any interventions that were put in place to prevent the injury from happening again. She said she was unsure if education was given to the CNA. She said she had told the CNA to be careful. The director of nursing (DON) and the regional director of clinical services were interviewed together on 5/7/26 at 1:27 p.m. The regional director of clinical services said she did not see an interdisciplinary (IDT) note regarding Resident #82's skin tear so she was not sure if any education was given to the CNAs about preventing skin tears. The DON said she had not given any education to the CNAs regarding how to prevent further skin tears.

Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for one (#4) of two residents reviewed for oxygen services out of 51 sample residents. Specifically, the facility failed to ensure there was a physician's order in place for Resident #4's oxygen.Findings include: I. Professional referenceAccording to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 5/14/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11)II. Facility policy and procedureThe Oxygen Use policy and procedure, revised December 2024, was provided by the vice president of clinical services on 5/8/26 at 12:32 p.m. It read in pertinent part, Prescriber orders will be obtained for residents requiring assistance with oxygen. Orders shall include liter flow, frequency, and route.III. Resident #4A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included displaced fracture of left femur, hypertension, history of falling, aortic stenosis, dementia, osteoarthritis, anxiety and depression. According to the 4/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He used a walker. He required set up assistance with eating. He required substantial assistance with oral hygiene, toileting, showering, dressing, and personal hygiene. The 4/24/26 MDS assessment indicated Resident #4 was not receiving oxygen therapy. B. Resident interview and observation Resident #4 was interviewed in his room on 5/4/26 at 3:37 p.m. Resident #4 was lying in bed and had a nasal cannula in his nose. An oxygen concentrator was observed next to the head of the resident's bed with the power turned on. Resident #4 said his oxygen was great. Resident #4 said he did not know how long he had used oxygen or what it was used for. C. Record review-Review of Resident #4's May 2026 CPO revealed no physician's orders for oxygen. The oxygen therapy care plan, initiated 4/22/26, revealed Resident #4 had oxygen therapy. Interventions included for residents who were ambulatory, providing extension tubing or portable oxygen apparatus, monitoring for signs and symptoms of respiratory distress and reporting to the physician as needed, and oxygen settings were to be oxygen via nasal cannula per physician's order. IV. Staff interviews Registered nurse (RN) #1 and RN #3 were interviewed together on 5/7/26 at 2:26 p.m. RN #1 and RN #3 said they knew which residents needed to be on oxygen based on the hospital report and discharge orders. RN #1 and RN #3 said nurses were responsible for the oxygen settings and placing oxygen on residents. RN #3 said the certified nurse aides (CNA) did vital signs but they could not adjust oxygen settings. RN #1 and RN #3 said there needed to be a physician's order for a resident to receive oxygen therapy. RN #1 said she was familiar with Resident #4. She said the resident was not on oxygen. RN #1 said there might have been an oxygen concentrator in the resident's room because therapy sometimes left concentrators in the residents' rooms when therapy was determining if the resident needed oxygen when discharging from the facility. RN #1 said she did not see Resident #4 sleep much and RN #3 said she did not see Resident #4 with oxygen on while asleep. RN #1 went to Resident #4's room, after the interview, at 3:43 p.m. observed Resident #4 with a nasal cannula in his nose and the oxygen concentrator next to his bed was on. RN #1 said she did not know why he had oxygen on while he was resting and she thought maybe a CNA placed oxygen on him when they transferred him to bed. RN #1 said she would follow up because if he required oxygen, there should be a physician's order. The director of nursing (DON) and the vice president of clinical services were interviewed together on 5/7/26 at 4:43 p.m. The DON said nurses were responsible for oxygen therapy. The DON said there needed to be a physician's order for any resident who used oxygen. The DON said she was familiar with Resident #4 and said he was admitted to the facility with oxygen therapy. The DON said there should either be a physician's order for Resident #4 to receive oxygen as needed or the oxygen concentrator needed to be removed from Resident #4's room.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one of three medication carts and two of two medication rooms.Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Professional referencesAccording to Sanofi Pasteur's Tubersol: Tuberculin (Tb) purified protein derivative (PPD), (2022), retrieved on 5/12/26 from https://www.sanofi.com/assets/countries/canada/docs/products/vaccines/tubersol-en.pdf, Storage, stability and disposal: a vial of Tubersol which has been opened and in use for 30 days should be discarded.According to GlaxoSmithKline (GSK) Biologicals' Arexvy: Respiratory syncytial virus (RSV) vaccine, (2026), retrieved on 5/12/26 from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert-AREXVY.pdf, Storage after reconstitution (adding a liquid to a powdered medication to create a liquid solution for administration): discard the reconstituted vaccine if it is not used within four hours or if the vaccine has been frozen.B. Facility policy and procedureThe Medication Storage policy, dated January 2026, was provided by the executive director on 5/8/26 at 12:34 p.m. It read in pertinent part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from the stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.II. ObservationsOn 5/7/26 at 11:59 a.m. the transitional care unit's medication storage room was observed with registered nurse (RN) #3. The following item was found: One bottle of bisacodyl 5 milligram (mg) tablets, with an expiration date of April 2026.-However, the expired medication should have been removed from the medication supply upon its expiration.On 5/7/26 at 1:50 p.m. the Aspen medication cart was observed with licensed practical nurse (LPN) #2. The following item was found:One opened Spiriva Respimat (tiotropium bromide) 2.5 microgram (mcg) inhaler stored in an appropriately labeled medication box. -However, the individual inhalation device inside the box was not labelled with the date the medication was opened for Resident #63.On 5/7/26 at 2:00 p.m. the Aspen medication storage room refrigerator was observed with LPN #2. The following items were found:One Arexvy respiratory syncytial virus (RSV) vaccine vial kit stored in an appropriately labeled medication box for Resident #107.-However, Resident #107 was discharged from the facility on 4/3/26 and the vaccine should have been removed from the medication supply.One opened multi-use vial of Tubersol Tb PPD, 5 tuberculin units (TU) per 0.1 milliliter (ml), opened 2/1/26.One used multi-use vial of Tubersol Tb PPD, 5 TU/0.1ml, opened 2/19/26.-However, both vials of Tubersol had been open for more than 30 days and should have been removed from the medication supply (see professional reference above).III. Staff interviewsRN #3 was interviewed on 5/7/26 at 11:59 a.m. RN #3 said the bottle of bisacodyl tablets were expired and she would remove it from the supply.LPN #2 was interviewed on 5/7/26 at 1:50 p.m. LPN #2 said the individual Spiriva inhaler inside the medication box should have been labeled with the date the inhaler was opened.LPN #2 was interviewed again on 5/7/26 at 2:00 p.m. LPN #2 said the RSV vaccine should have been removed from the medication room after Resident #107's discharge from the facility. She said the pharmacist checked the medication carts regularly, but she did not know if they also checked the refrigerators. LPN #2 read the side of the Tubersol boxes and said the vials should have been discarded 30 days after they were opened. The director of nursing (DON) and the minimum data set (MDS) coordinator were interviewed together on 5/7/26 at 6:20 p.m. The DON said she would not have expected the expired bisacodyl tablets to be in the transitional care unit's medication room. She said the central supply person should have been managing the stock medication supply to ensure there were no expired medications that could have accidentally been grabbed for use.The DON said Resident #63's individual Spiriva inhalation device should have been labeled with the date the medication was opened. She said it was important for the staff to know the expiration date of the medication so they could make sure it was still effective. The DON said she would provide nursing staff with additional education on medication labeling and storage.The DON said she would not have expected to find a discharged resident's medications in the medication room. She said the nurses should have moved any medications belonging to discharged residents to the expired stock as they were noticed.The DON said the Tubersol multi-use vials were good for 30 days after opening, then should have been moved to expired stock by nursing staff. She said it was important to monitor the medication supply for expired vaccines because the facility would never want to give a resident an expired vaccine. She said the vials of Tubersol might have been given accidentally after the expiration date.

Based on record review and interviews, the facility failed to maintain accurately documented medical records for one (#106) of four residents reviewed out of 51 sample residents. Specifically, the facility failed to ensure Resident #106's electronic medical record (EMR) was amended to ensure the events that occurred at the time of the resident's death in the facility were accurately documented.Findings include: I. Resident #106A. Resident statusResident #106, age [AGE], was admitted on [DATE] and passed away in the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included acute systolic (congestive) heart failure (left ventricle loses ability to pump), chronic kidney disease, metabolic encephalopathy (brain dysfunction) and dementia. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment revealed the resident needed substantial to maximal assistance with most of his activities of daily living (ADL). B. Record reviewReview of Resident #106's final wishes care plan, initiated [DATE], revealed the resident's code status (dictates the exact medical interventions a patient wants, or does not want, if their breathing or heart stops) was no cardiopulmonary resuscitation (CPR). Pertinent interventions included informing staff of the resident's code status, monitoring and reporting changes in condition to the physician and the resident's responsible party, ensuring the resident or the resident's responsible party signed the code status sheet and the sheet was in the medical record and reviewing code status at least quarterly. A nursing note, dated [DATE] at 1:15 p.m., documented the nurse found Resident #106 taking his last breath when the nurse went to give him his medication at 11:50 a.m. The note documented all attempts to rouse Resident #106 failed; the resident's vital signs were checked with no readings. The note documented Resident #106's lips were purple and he had cold fingers and was unresponsive. The note documented the nurse called a code and called 911. The emergency staff arrived around 12:00 p.m. and the resident's death was confirmed at 12:15 p.m.-However, there was no documentation in the resident's EMR to indicate that CPR was not actually conducted due to the resident's code status of no CPR, despite the fact that the nurse called a code and 911 (see interviews below). II. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on [DATE] at 7:25 p.m. LPN #4 said Resident #106's medical orders for the scope of treatment (MOST) form was found in a binder at the nurses' station on the rehabilitation unit. He said Resident #106 was fine in the morning (on [DATE]), he said he took his medication and there were no signs or symptoms of a decline. He said Resident #106 was a do-not-resuscitate (DNR) code status. He said CPR was not conducted on the resident, but he did call a code blue (emergency announcement indicating a life-threatening medical emergency). LPN #4 said he did call 911 which he said he thought was the facility protocol. He said when emergency services first got to the facility, they asked what the resident's code status was. He said he had notified the assistant director of nursing (ADON) at the time of the event. He said the event was very traumatic because Resident #106's death was not expected. He said he did get training on how to handle death and who to notify at the debriefing after the death. The ADON was interviewed on [DATE] at 8:05 p.m.The ADON said Resident #106 was at the facility for therapy, but he was planning on discharging because was not improving during therapy. She said the day that he passed away, speech therapy was working with him and he had been complaining of pain. She said the speech therapist rearranged some pillows to help him feel more comfortable and then she left and let the nurse know so he could get the resident some Tylenol. She said by the time the nurse got to his room, Resident #106 was already unresponsive. She said the nurse called 911 and then called her. The ADON said CPR was not performed on Resident #106 at all, even though LPN #4 did call a code and 911. She said LPN #4 called the code and 911 because the resident was unresponsive and it was unexpected, but she said CPR was not performed. She said the resident's MOST form was reviewed and the coroner was called but did not come out but did release the body. She said Resident #106's representative was present at the facility at the time the resident's death certificate was signed. She said within a couple of hours after the resident's death, the funeral home came and got his body. She said when a death occurred in the facility, the documentation should be narrative progress notes that document everything that happened.-However, the facility failed to document in Resident #106's EMR that CPR was not conducted on the resident (see record review above). The director of nursing (DON) and the minimum data set (MDS) coordinator were interviewed together on [DATE] at 10:25 a.m. The DON and the MDS coordinator said if a resident was found unresponsive, they would check the resident's vital signs. They said if the resident was a DNR then they would not call 911, they would respect the resident's wishes. They said they would call the physician and the family. The DON and the MDS coordinator said the terminology call a code or coded was not normally used in their facility. They said it insinuated that CPR was performed and respiratory therapy came, which was not what happened with Resident #106.-However, the facility failed to document in Resident #106's EMR that CPR was not conducted on the resident (see record review above).

Based on record review and interviews, the facility failed to meet all the requirements for the provisions of hospice care for two (#75 and #38) of two residents reviewed for hospice care services out of 51 sample residents. Specifically, the facility failed to:-Ensure hospice notes were readily available in Resident #75 and Resident #38's electronic medical records (EMR);-Ensure Resident #75 and Resident #38's comprehensive care plans were developed with a delineation of care responsibilities between the facility staff and the hospice care services team; and, -Ensure there was a designated hospice care services coordinator.Findings include: I. Facility policy and procedure The Hospice/Palliative Care Coordination policy and procedure, dated December 2024, was provided by the executive director on 5/8/26 at 12:32 p.m. It read in pertinent part: How the community and hospice/palliative care will communicate with each other and coordinate services: The provision that is the responsibility of the hospice and/or palliative care to determine the appropriate course of care and the responsibility of the community to provide room and board and follow the regulations. The director of nursing (DON)/health wellness director/ assisted living director or designee is responsible for coordinating care that is ordered by the practitioner/healthcare provider and documenting this in the resident's service plan/care plan. The hospice and/or palliative care provider sign and shall adhere to standards set forth in the agreement. Which include but are not limited to the following: Provide documentation for the resident record as soon as practicable.II. Resident #75A. Resident statusResident #75, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders, diagnoses included anxiety disorder, chronic kidney disorder, and cerebral arteriosclerosis (hardening, thickening, or narrowing of the arteries within the brain). The 4/13/26 minimum data set (MDS) assessment revealed Resident #75 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The assessment indicated Resident #75 needed substantial to maximal assistance with most of her activities of daily living (ADL). The assessment revealed the was receiving hospice care services. B. Resident's representative interviewResident #75's representative was interviewed on 5/6/26 at 3:52 p.m. The representative said the hospice nurse that had been taking care of Resident #75 had not been around for three weeks and the facility nurses told her that the resident was running low on some supplies. She said the unit nurse did not know who to reach out to. She said that the hospice certified nurse aide (CNA) had also been out for a few weeks due to school and she had not seen anyone from the hospice care team recently. C. Record reviewThe May 2026 CPO revealed Resident #75 was admitted to hospice care services on 4/1/26 with the diagnosis of cerebral atherosclerosis. -A review of the comprehensive care plan, initiated 4/2/26, revealed Resident #72 was receiving hospice care services, however, it failed to include interventions and a delineation of care services between the facility and hospice care services team. A review of Resident #75's EMR revealed a hospice plan of care from when she was living at the assisted living community. -A review of Resident #75's EMR revealed the resident's routine hospice care service notes not uploaded into the system until 5/5/26 (during the survey process).III. Resident #38A. Resident statusResident #38, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included acute kidney failure, chronic obstructive pulmonary disease (COPD), and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the right dominant side. The 4/1/26 MDS assessment revealed Resident #38 was cognitively intact with a BIMS score of 13 out 15. The assessment revealed Resident #38 needed substantial to maximal assistance with most of his ADL. The assessment indicated that Resident #38 was receiving hospice care services. B. Record reviewThe May 2026 CPO documented Resident #38 was admitted to hospice care services on 12/8/25. -A review of the comprehensive care plan, initiated 10/28/25, revealed Resident #38's hospice care plan was initiated on 4/1/26, four months after he was first admitted to hospice care services. -Resident #38's hospice care plan failed to include a delineation of care responsibilities between the facility and the hospice care services team. Review of Resident #38's EMR revealed the resident's routine hospice care service notes were not uploaded into the system until 5/5/26 (during the survey process). IV. Staff interviewsRegistered nurse (RN) #5 was interviewed on 5/5/26 at 3:35 p.m. RN #5 said the hospice team communicated with the facility staff using binders. She said she could not find the binders for any of the facility's current residents who were receiving hospice care services. CNA #2 was interviewed on 5/6/26 at 11:30 a.m. CNA #2 said she knew who was on hospice because it was written on her report sheet. She said the nurses would let her know when the hospice CNA would be coming. She said the nurses would look in a book to see the days that hospice was coming. She said she did not know where that book was. CNA #7 was interviewed on 5/6/26 at 11:59 a.m. CNA #7 said he had only been employed with the facility for a month. He said he knew who was on hospice because the nurse would let him know and it was also on his report sheet. He said the nurse would tell him when the hospice CNAs were going to be coming. Licensed practical nurse (LPN) #3 was interviewed on 5/6/26 at 1:35 p.m. LPN #3 said the facility did not utilize a communication binder for the hospice residents. She said the hospice team was good at verbally communicating with the facility staff. She said she did not know the scheduled days that hospice staff would come and see their residents. She said she knew who was on hospice by looking at the hospice order. She said she did not formally know what care hospice was in charge of providing for each resident, she just knew because she had worked as a nurse for so long. LPN #1 was interviewed on 5/6/26 at 2:13 p.m. LPN #1 said when a resident first was accepted on hospice care services and when they had picked which hospice provider they wanted, there would be an initial care meeting. She said when a hospice CNA came into the facility, they would verbally let the facility staff know what cares they had done. She said the hospice nurses would do the same and they communicated verbally. LPN #1 said the hospice CNAs would also write on a whiteboard in the residents' rooms to indicate which days they came to the facility. She said there used to be a binder that hospice staff would sign off in, but the binder was no longer there. She said the facility might have changed the process. The hospice CNA was interviewed on 5/7/26 at 8:25 a.m. The hospice CNA said she had been out for three weeks due to an injury. She said she was the CNA for Resident #38 and Resident #75. She said someone from the hospice team should have been filling in for her while she was out. She said she was not sure who it was. She said she only charted in the hospice charting system. She said she did not document anywhere at the facility. She said she did verbally check in with the facility nurses. The director of nursing (DON) and the regional director of clinical services were interviewed together on 5/7/26 at approximately 2:15 p.m. The regional director of clinical services said there was not a specific hospice coordinator. She said there were multiple layers and different people involved. She said nursing staff knew when hospice staff visited because the hospice staff would check in with them and the nurses were in charge of coordinating care. She said preferred providers were able to chart directly into the facility's EMR. She said the hospice nurses should be able to chart directly in the EMR. She said she hoped that the hospice team would communicate if one of their caregivers was going to be out for an extended period of time. She said there did not have to be a specific care plan for hospice, as long as there was a delineation of care within the care plan. She said that the medical records staff member had just started working at the facility in February 2026, so the facility was playing catch up on getting records scanned into the electronic medical system. The executive director and the regional director of clinical services were interviewed together on 5/7/26 at 3:20 p.m. The executive director said he would think that the unit managers would be the hospice coordinators because they knew the residents best. He said nursing should know when the hospice team visited because it should be in the residents' EMRs. He said if hospice was unable to chart in the EMR, then they could handwrite a note and the facility could upload it for them into the EMR. He said hospice notes should be readily available to the staff, but he said he was unsure of how quickly the documentation should be uploaded. He said the unit managers should be the ones who ensured the hospice notes were readily available. He said the hospice care plans should be integrated into the facility's care plans. He said the interdisciplinary team (IDT) developed the care plan. He said there should be a delineation of care in the care plan. He said the hospice care plan should be initiated when the resident first was accepted on hospice care services. He said the nursing team and people from their sister community were helping upload documentation when the facility did not have a medical records person.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas; -Ensure housekeeping staff performed hand hygiene and glove changes appropriately; and,-Ensure staff followed chemical dwell times and appropriately disinfected the blood pressure device between residents. Findings include: I. Housekeeping failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 5/11/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bedrails; IV (intravenous) poles; sink handles; bedside tables; counters where medications and supplies are prepared; edges of privacy curtains; patient monitoring equipment (keyboards, control panels); call bells; door knobs and light switches. According to the CDC's Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 5/11/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, To protect yourself and your patients from deadly germs, all healthcare personnel should understand how to care for and clean their hands. Hand hygiene, which protects both healthcare personnel and patients, involves cleaning hands by washing with soap and water, using antiseptic hand rubs (such as alcohol-based foams or gels), or performing surgical hand antisepsis. Cleaning your hands reduces the potential spread of deadly germs, including those resistant to antibiotics. It also lowers the risk of healthcare personnel becoming colonized or infected by germs acquired from patients. Because some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep everyone safe, maintaining healthy skin is a common challenge. According to the CDC's Hand Sanitizer Guidelines and Recommendations (3/12/24), retrieved on 5/11/26 from https://www.cdc.gov/clean-hands/about/hand-sanitizer.html, Germs are everywhere. They can get onto hands and items we touch during daily activities and make us sick. Cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you. There are important differences between washing hands with soap and water and using hand sanitizer. Apply the gel product to the palm of one hand (read the label to learn the correct amount). Cover all surfaces of hands. Rub your hands and fingers together until they are dry. This should take around 20 seconds. B. Facility policy and procedures The Infection Control and Prevention policy, dated July 2025, was provided by the executive director on 5/4/26 at 1:35 p.m. It read in pertinent part, Residents and associates of the facility will follow comprehensive infection control standards based on preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, and complying with regulation, including mandatory reporting guidelines. Standard precautions, including hand hygiene are taught and monitored. All associates and volunteers are expected to follow proper hand hygiene techniques, per the Hand Hygiene policy. C. Observations During a continuous observation on 5/6/26, beginning at 1:07 p.m. and ending at 1:13 p.m., the following was observed: At 1:07 p.m., housekeeper (HK) #1 entered resident room [ROOM NUMBER] on the Evergreen unit with a bottle containing a clear solution labeled bleach and began cleaning the room. HK #1 used the bleach solution to clean the toilet. HK #1 wiped the counter and sink area and removed trash from the room. -HK #1 failed to clean the sink prior to cleaning the toilet. -HK #1 did not clean the resident's call light. During a continuous observation on 5/6/26, beginning at 1:42 p.m. and ending at 2:02 p.m., the following was observed: At 1:42 p.m. HK #2 entered resident room [ROOM NUMBER] on the Ponderosa unit. At 1:43 p.m. HK #2 cleaned the sink and toilet using acid free restroom cleaner (AFRC). HK #2 returned to his cart, and without changing his gloves, picked up a mop pad and mop stick and began mopping the floor with an unlabeled spray bottle of cleaner. -HK #2 failed to perform hand hygiene after cleaning the bathroom and prior to mopping the resident's floor. At 1:46 p.m. HK #2 returned to his cart, retrieved a rag and began cleaning the bedside table, window and window sills without changing his gloves. At 1:48 p.m. HK #2 vacuumed the floor and then adjusted the trash bag beside the resident's bed without changing his gloves. -HK #2 failed to change his gloves and perform hand hygiene during the entire cleaning of room [ROOM NUMBER]. D. Staff interviews HK #1 was interviewed on 5/6/26 at 1:14 p.m. using Spanish interpreter services. HK #1 said she used bleach to clean the residents' toilets and would use acid free restroom cleaner (AFRC) to deodorize the rooms. HK #1 said she would also use Victoria's Secret spray to deodorize the room. HK #1 said she did not sanitize the residents' call lights because certified nurse aides (CNA) were responsible for sanitizing call lights. CNA #3 was interviewed on 5/6/26 at 2:10 p.m. CNA #3 said CNAs cleaned the resident's call buttons two times per day. CNA #3 said she wiped the call buttons with bleach wipes and staff were supposed to clean them two times during their shift. HK #2 was interviewed on 5/6/26 at 2:03 p.m. HK #2 said he identified the cleaning solutions by the color of the bottles. HK #2 said he should have changed his gloves, performed hand hygiene and donned a new pair of gloves after completing one task and before moving on to a new task when cleaning room [ROOM NUMBER]. The housekeeping supervisor was interviewed on 5/6/26 at 3:08 p.m. The housekeeping supervisor said housekeeping staff identified the cleaning products by the color of the liquid, however, the bottle used by HK #2 to mop the floor in room [ROOM NUMBER] should have had a label on it. The housekeeping supervisor said housekeeping staff should start cleaning the toilet areas first, then remove their gloves, perform hand hygiene and don a new pair of gloves before moving to the sink area. The housekeeping supervisor said staff should remove gloves before cleaning high touch areas. The housekeeping supervisor said housekeeping staff should clean the floor last using a microfiber mop. The housekeeping supervisor said these steps were important for infection control to prevent the spread of germs. The housekeeping supervisor said housekeeping staff were responsible for cleaning and sanitizing residents' remotes and call lights; however, CNAs were also expected to sanitize those items. The housekeeping supervisor said housekeeping staff used acid free restroom cleaner (AFRC) to clean the toilets and did not use it to deodorize residents' rooms. The housekeeping supervisor said housekeeping staff did not use bleach to clean toilets. The housekeeping supervisor said HK #1 was confused because housekeeping staff used bleach to remove odors from the floor. The housekeeping supervisor said he would provide education to the housekeeping staff regarding the proper cleaners to use. The infection preventionist (IP) was interviewed on 5/7/26 at 11:30 a.m. The IP said the facility provided infection prevention education to housekeeping staff and supervisors to ensure staff understood infection prevention concerns. The IP said cleaning and sanitizing residents' call lights was part of the housekeeping staffs' daily tasks; however, CNAs also sanitized the residents' call lights. The IP said HK #2 should have changed gloves and performed hand hygiene and donned new gloves between cleaning tasks to prevent bringing bacteria from one area to another area, which increased the potential for infection. II. Failed to follow chemical dwell times and appropriately disinfect the blood pressure device between residents A. Professional reference According to Diversey's Oxivir Tuberculin (Tb) Wipes manufacturer instructions, dated 2023, retrieved on 5/12/26 from https://s3.amazonaws.com/imperialdade.com/apps/catalog/digital-assets/24241/product-documentation/cca87d44a11f11c146f7a445cd92110316e3ec9e.pdf, Effective against key pathogens – Tb, Methicillin-resistant Staphylococcus aureus (MRSA), Norovirus (gastrointestinal - GI virus), Vancomycin-resistant enterococci (VRE) and Candida auris (a fungus that can cause multidrug-resistant infections). Kills Hepatitis B virus (HBV), Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in one minute. Tuberculocidal in five minutes. Fungicidal in three minutes and kills Candida auris in five minutes. Use instructions: pre-clean heavily soiled areas; apply product by coarse trigger spray or disposable wipe to hard, non-porous inanimate surfaces; all surfaces must remain visibly wet for one minute; use a five minute contact time for Tb, a three minute contact for fungi and a five minute contact time for Candida auris; and, air dry, wipe surfaces to dry and remove any residue, or rinse with potable water as necessary. B. Observations On 5/6/26 licensed practical nurse (LPN) #1 was observed during medication administration. The following was observed: At 11:16 a.m. LPN #1 was preparing to administer medications, including a blood pressure medication with specific parameters for administration, to Resident #79. LPN #1 removed a basket of vital signs equipment, including a thermometer, automated blood pressure device and pulse oximetry device (measures the oxygen saturation in the blood), from the medication cart. She then donned (put on) clean gloves and removed one Diversey Oxivir Tb wipe from its container. The Oxivir Tb's chemical dwell time (time that a surface area should remain wet to ensure proper disinfection) was printed and visible on the container's label. The chemical dwell time was one minute. LPN #1 wiped the front and back surfaces of the blood pressure cuff in 15 seconds. The blood pressure cuff did not look shiny or wet. She then returned the blood pressure cuff to the basket of vital signs equipment. -LPN #1 failed to allow the disinfectant to remain on the surfaces of the blood pressure cuff for the recommended one-minute dwell time (see professional reference above). After she measured Resident #79's blood pressure, LPN #1 removed the blood pressure cuff from the resident's left upper arm and placed it back into the basket of vital signs equipment without disinfecting it again. At 11:39 a.m. LPN #1 was preparing to administer medications, including a blood pressure medication with specific parameters for administration, to Resident #62. LPN #1 collected the basket of vital signs equipment and the resident's crushed medications in applesauce before she entered Resident #62's room. Without disinfecting the blood pressure cuff, LPN #1 measured Resident #62's blood pressure on his left upper arm over a long sleeve shirt. After she measured Resident #62's blood pressure, LPN #1 removed the blood pressure cuff from the resident's left upper arm and placed it in the basket of vital signs equipment without disinfecting the blood pressure cuff. -LPN #1 failed to disinfect the blood pressure cuff between obtaining blood pressures for Resident #79 and Resident #62. C. Staff interviews LPN #1 was interviewed on 5/6/26 at 11:58 a.m. LPN #1 said she did not disinfect the blood pressure cuff before she used it on Resident #62. She said the Oxivir wipe dwell time was one minute, but she said she was not sure whether the one-minute dwell time meant the product should be allowed to dry for one minute or if the product should remain wet with chemicals for one minute. LPN #1 said the blood pressure cuff was not wet or shiny looking when she wiped it before using it to obtain Resident #79's blood pressure. She said it was important to appropriately disinfect the blood pressure cuff and to follow chemical dwell times in order to prevent the contamination of pathogens between residents. The IP was interviewed on 5/7/26 at 12:30 p.m. The IP said the nursing staff should wipe the vital signs equipment with an Oxivir wipe between residents and after each use. She said she did not know the chemical dwell time for the Oxivir wipes off the top of her head, but she educated the staff that the dwell time was printed on the back of the Oxivir container. The IP said the blood pressure cuff should have been disinfected between using it to obtain blood pressures for Resident #79 and Resident #62. She said it was important to disinfect the vital signs equipment appropriately between residents because the facility did not want to transfer bacteria between residents. The DON and the minimum data set (MDS) coordinator were interviewed together on 5/7/26 at 6:20 p.m. The DON said vital signs equipment should be cleaned between each resident. She said the facility used Oxivir wipes, and the chemical dwell time was one minute. The DON said it was important to follow chemical dwell times so that the facility did not share any potential infections amongst residents. She said this was an opportunity for education.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of six residents out of six sample residents.Specifically, the facility failed to administer Resident #1's blood pressure medication per physician's orders. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/3/26 and 2/4/26, resulting in the deficiency being cited as past noncompliance with a correction date of 12/20/25.I. Facility plan The nursing home administrator (NHA) and the regional corporate nurse provided the facility's medication administration parameter plan dated 12/16/25, on 2/3/26. The plan documented the following:On 12/16/25 a record review for Resident #1 who lived on the memory care unit, was performed by the regional clinical nurse which revealed the medication midodrine was not administered according to the parameters set by the facility physician 49 times. On 12/16/25 the former director of nursing (DON) provided a verbal education to the nursing staff on the memory care unit on following physician's orders for blood pressure parameters. The regional corporate nurse said no one else on the memory care unit received midodrine. On 12/17/25 a medication review was completed for all residents in the facility on midodrine, and all nurses who had provided the medication outside of parameters were identified for upcoming one to one education.On 12/19/25 a plan of action was discussed with the interdisciplinary team (IDT) and its implementation began the following day on 12/20/25.On 12/20/25 all residents who had orders for midodrine were identified and reviewed to ensure compliance. An audit began to review residents with cardiac medications to determine if the parameters were followed as ordered. Four instances were revealed as non-compliant. Corrective measures were put in place for the four instances as well as education for any staff who did not comply with the physician's orders for Resident #1.12/23/25 the audit that was completed on 12/17/25 was reviewed and revealed 12 facility nurse employees did not provide Resident #1's midodrine medication in accordance with the parameters set by physicians. There were also three nursing agency employees identified who provided Resident #1 with midodrine outside of the physician set parameters. The facility management provided disciplinary action to the 12 nurses who did not follow the physician's orders. The nursing staff agency was notified that three of their nurses did not comply with physician's orders for medication parameters. On 1/5/26 the physician's provider team reviewed all midodrine orders to determine any changes that might be needed to blood pressure parameters for administration.From 12/20/25 through 1/5/26 a follow-up audit was conducted to determine if the education for the 12 nurses who had disciplinary action for not following the blood pressure parameters for Midodrine was being followed. On 1/6/26 it was revealed one nurse after the parameter education and disciplinary action provided a resident with a medication not according to the blood pressure parameters. The nurse was immediately released from their position at the facility.On 1/7/26 all nursing staff had voicemail reminders to take a training course about the administration of medications according to parameters set by the physicians on the facility's computer based education program. All nurses complied with the required education by 1/14/26.On 1/12/26 the facility's all staff training included medication parameters in its training.The facility will review the incident, corrective action, and monitoring in the monthly quality assurance and performance improvement (QAPI) meeting. The first post-incident QAPI meeting will be held in February 2026.II. Facility policy and procedureThe Medication Administration Guidelines policy and procedure, dated 2007, was provided by the NHA on 2/3/26 at 12:08 p.m. via email. It revealed in pertinent part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to (the) label if directions have changed from the current label. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Obtain and record any vital signs as necessary prior to medication administration.III. Resident #1A. Resident statusResident #1, age over 70, was admitted to the facility on [DATE], and readmitted on [DATE]. He was discharged from the facility on 12/6/25. According to the December 2025 computerized physician orders (CPO), the diagnoses included orthostatic hypotension (low blood pressure), unspecified dementia with unspecified behavioral disturbances, chronic kidney disease, hypomagnesemia (low levels of magnesium), and osteoarthritis (a degenerative joint disease).The 11/17/25 minimum data set (MDS) assessment revealed the resident had short and long term memory problems, severe impairment with cognitive daily decision making skills, and delusions. He did not reject care from staff. He ambulated with a front wheel walker. B. Record reviewReview of the resident's August 2025 physician's orders revealed the following physician's order:Midodrine 10 mg (milligrams) by mouth two times per day for orthostatic hypotension. Hold the administration of the medication if the systolic blood pressure was greater than 100 millimeters of mercury (mmHG), ordered on 8/12/25.After the resident returned on 9/10/25 from a hospital stay, the physician's order was updated to the following:Midodrine 10 mg (milligrams) by mouth three times per day (an increase of one dose per day) for orthostatic hypotension. Hold the administration of the medication if the systolic blood pressure was greater than 100 mmHg, ordered 9/10/25.Review of the resident's medication administration record from 8/12/25 to 9/10/25 revealed the resident was administered Midronen 49 times when the resident's blood pressure was documented outside the parameters from the physician's orders. IV. Staff interviewsThe regional corporate nurse was interviewed on 2/3/26 3:30 p.m. The regional corporate nurse said on 12/16/25 the she completed an audit of Resident #1's EMR, which revealed Resident #1 had systolic blood pressure parameters for midodrine. She said the medication was to be held when Resident #1's systolic blood pressure was over 100 mmHg. The RCN said it was discovered that the nursing staff had not held the medication 49 times when his systolic blood pressure was over 100 mmHg. The regional corporate nurse said the situation needed to be self-reported to the state agency. The RCN said immediate education began when the situation was found on 12/16/25 to the nursing staff who worked on the memory care unit where the resident lived. The RCN said by 12/20/25 medications were reviewed for everyone on the same medication as Resident #1, as well as other medications which required blood pressure parameters to administer. The RCN said education was provided to all of the nursing staff, and was ongoing to ensure professional standards of practice continued. The RCN said on 12/16/25 no other residents on the memory care unit were on midodrine. The facility's medical director was interviewed on 2/3/26 at 3:20 p.m. via the telephone. The medical director said his company took over the building in responsibility at the end of October 2025. The medical director said the facility had a systemic problem with following physician's orders for medication parameters but the facility staff had worked on fixing the situation in different ways. The medical director said he expected the nursing staff to follow physician's orders for the residents. The medical director said when a resident on midodrine had a systolic blood pressure of over 130 mmHg, it was not good and the medication may need to be adjusted. The medical director said Resident #1 went to the hospital in December 2025 because of pneumonia and acute kidney problems. The medical director said not following the medications systolic blood pressure parameters would not be the reason for Resident #1's hospitalization. LPN #1 was interviewed on 2/4/26 at 11:20 a.m. LPN #1 said the assistant director of nursing (ADON) called her about a required training about medication parameters. LPN #1 said the training was somewhere between mid to late December 2025. LPN #1 said she had to read a packet with information about a medication called midodrine. LPN #1 said the information was how each resident on that medication needed to have their blood pressure parameters checked because each person had different parameters with that medication.Registered nurse (RN) #2 was interviewed on 2/4/26 at 12:35 p.m. RN #2 said the former DON gave nurses individual training about medication parameters somewhere around mid December 2025. RN #2 said the nurses were also required to do training on the company's computer education system on the same subject. RN #2 said medications may need parameters with blood pressure and nurses need to follow the physician's orders or a resident could be at risk. RN #2 said if a nurse needed guidance with a resident and their parameters, the medical provider should be called. The NHA was interviewed on 2/4/26 at 2:00 p.m. The NHA said the facility had a systemic problem with nurses following physician's orders about medication administration and adherence to a physician's orders for blood pressure parameters. The NHA provided all of the documented training that had been provided to the nursing staff about the subject since the matter was discovered. The NHA said the nurses would continue to be audited and monitored to make sure all facility nurses continued to follow the professional standard of practice for medication administration The NHA said the subject would be reviewed for at least three months in the monthly QAPI meeting until substantial compliance was met.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for one (#6) of three residents out of seven sample residents. Specifically, the facility failed to ensure Resident #6 experienced a dignified learning experience when certified nurse aide (CNA) #1 provided inappropriate redirection to the resident after the resident spilled a drink. Findings include: I. Resident #6 A. Resident status Resident #6, age 70, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, severe with mood disturbances and Parkinson's disease. The 4/17/25 minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) assessment. Per the staff assessment for mental status, the resident had short-term and long-term memory impairment and required substantial assistance with decisions regarding tasks of daily life. The MDS assessment revealed the resident did not display physical behaviors directed towards others. B. Resident observation On 4/29/25 at 12:55 p.m., during observation of the lunch meal service, Resident #6 got up from her dining room chair and walked to the food preparation counter located within the common area space on the unit. Resident #6 spilled a glass of clear liquid, either juice or water, that was on the counter. CNA #1 approached Resident #6 from behind. Without saying anything to the resident, CNA #1 placed both hands under the resident's armpits and physically redirected Resident #6 away from the area. -CNA #1 did not provide any verbal explanation, reassurance, or calming interaction to support the resident during this redirection. -CNA #1 did not implement the person-centered redirection strategies as outlined in the resident's care plan (see record review below). C. Record review Resident #6's communication care plan, revised 3/16/25, revealed the resident had impaired communication related to dementia and primarily spoke Vietnamese. Interventions included providing verbal redirection and allowing adequate time for the resident to respond, repeating statements as necessary, not rushing the resident to respond to verbal cues, facing the resident while speaking, reducing environmental noise and using simple and consistent words. Resident #6's behavior care plan, revised 4/21/25, revealed the resident had impaired cognitive functioning related to dementia, with non-aggressive behaviors, such as pacing, wandering and placing non-food objects in the mouth, as reported by family. Interventions included explaining all procedures before starting a care task, allowing the resident time to adjust to changes, intervening to protect the rights and safety of others, speaking to the resident in a calm manner, redirecting the resident to a safe alternate location as needed, and minimizing disruptive behavior and offering activities and tasks that diverted the resident's attention. Resident #6's cognition care plan, revised 4/21/25, revealed the resident had impaired cognitive functioning related to dementia and senile degeneration of the brain. Interventions included providing verbal and visual cues to support recall and orientation, reorienting the resident as appropriate and supervising tasks of daily life. -Review of the comprehensive care plan revealed that physical redirection was not included as an intervention approach. -Despite the development of the person-centered care plan interventions for Resident #6, CNA #1 failed to implement any of the interventions when the resident spilled water on the kitchen counter. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/30/25 at 8:47 a.m. LPN #1 said she observed CNA #1 attempt to stop Resident #6 after the resident spilled her drink by grabbing her under the arms and physically redirecting her. LPN #1 said CNA #1 should have provided the resident with verbal redirection instead. LPN #1 said she pulled CNA #1 aside afterward and told her to be more careful and advised CNA #1 that next time she should reach for the cup rather than the resident. LPN #1 explained that the facility expected staff to use verbal redirection or offer comforting objects such as a baby doll to effectively redirect residents. The director of nursing (DON) was interviewed on 4/30/25 at 4:19 p.m. The DON said CNA #1 told her that Resident #6 was pouring water onto food and that she reacted by moving the resident's arm down to stop her. The DON said Resident #6 had a history of pouring hot liquids, such as soup, and staff were expected to respond quickly out of concern for her safety. The DON said the reaction of CNA #1 was not well thought through but was a reflex due to the resident's unpredictable behavior. The DON acknowledged that CNA #1's actions were inappropriate, but she said they were not intentional. The DON said staff received education on how to respond to potentially dangerous resident behavior while still acting appropriately as a caregiver. The DON said she planned to provide additional education to CNA #1 regarding appropriate redirection of residents.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain personal hygiene for two (#7 and #3) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to offer toileting or timely incontinence care for Resident #7 and Resident #3. Findings include: I. Facility policy and procedure The Urinary Management (UM) policy, dated December 2024, was provided by the nursing home administrator (NHA) on 4/30/25 at 7:03 p.m. It read in pertinent part, The facility will manage urinary incontinence as part of the person-centered resident care. Treatment for urinary incontinence depends on the type of incontinence, its causes, and the capabilities of the resident. A comprehensive assessment will be completed upon move-in, change of condition and annually to determine diagnosis or reason for incontinence. Residents will be monitored through the standard MDS/RAI (minimum data set /resident assessment instrument) process. If incontinence is identified and based on the type of incontinence, a care plan will be written for incontinent residents, utilizing the appropriate interventions to achieve or maintain as much as normal urinary function as possible. The interdisciplinary team (IDT) will determine if the resident is appropriate for a bladder re-training program or a toileting schedule following a review of the three-day data collection, assessment, and cognitive status of the resident. The care plan will be updated and communicated to the nursing associates if there are any suggested toileting plans for the resident based upon the information obtained from the data collection and assessment. A resident with or without a catheter receives the appropriate care and services to prevent infections to the greatest extent possible. II. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 4/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS) assessment. Per the staff assessment for mental status, the resident was unable to make decisions regarding tasks of daily life.The resident was dependent on one staff member for assistance with eating, oral care, personal hygiene, toileting, bathing, dressing and transferring. B. Observations During a continuous observation on 4/30/25, beginning at 8:25 a.m. and ending at 12:30 p.m., the following was observed: At 8:25 a.m. Resident #7 was eating breakfast in the dining room, where she was assisted with eating and hydration. At 10:24 a.m. Resident #7 finished her breakfast and an unidentified staff member wheeled her from the dining room to the common area. -The unidentified staff member did not check the resident for incontinence or provide toileting assistance to the resident before placing the resident in the common area. At 11:46 a.m. the resident's hospice aide (HA) arrived and wheeled her from the common area to the spa room for a shower. -Per staff interview, Resident #7 was provided incontinent care at 7:45 a.m., four hours prior to the HA taking the resident for a shower (see certified nurse aide (CNA) #2's interview below). C. Record review Resident #7's bladder incontinence care plan, revised 2/16/24, revealed the resident had bladder incontinence and was at risk for falls, skin irritation, moisture-associated skin damage (MASD), urinary tract infections (UTI), social isolation, embarrassment, curtailment of fluids and reduced activity participation. Interventions included observing and reporting any potential causes of incontinence, such as bladder infection, constipation, loss of bladder tone, weakening of control muscles and decreased bladder capacity. Staff were directed to observe and document signs and symptoms of UTI, including pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, fever, chills, urinary frequency, foul-smelling urine, altered mental status or changes in behavior or eating patterns. Resident #7's activities of daily living (ADL) care plan, revised 2/9/23, revealed the resident had a self-care performance deficit related to muscle weakness from Alzheimer's disease with late onset. Interventions included assisting the resident with toileting throughout the day and always upon rising in the morning. Resident #7's skin care plan, revised 4/21/25, documented the resident was at risk for pressure ulcers related to bladder and bowel incontinence, fragile skin, limited mobility, and low body mass index (BMI). D. Staff interviews The HA was interviewed on 4/30/25 at 12:10 p.m. The HA said she worked for Resident #7's hospice services provider, not the facility, and came to the facility twice a week to provide the resident with showers. The HA said when she changed Resident #7's incontinence brief, the resident was soiled with urine and had a small red area near her tailbone that was not open. The HA said she applied barrier cream to the reddened area. CNA #2 was interviewed on 4/30/25 at 12:26 p.m. CNA #2 said she was aware of the expectation to provide incontinence care and change a resident's brief every two hours. She said she typically provided incontinence care for Resident #7 in the morning when the resident got up, after breakfast, after lunch and before dinner. CNA #2 said today (4/30/25) the resident got up sometime between 7:00 a.m. and 8:00 a.m. and she changed the resident's briefs around 7:45 a.m. She said she intended to change Resident #7 again after breakfast but decided not to because the HA was scheduled to arrive and provide care. CNA #2 said, based on her experience, the resident typically did not get very wet and usually did not require frequent changes. She said that during the 7:45 a.m. change, the resident's incontinence brief was damp with urine, but not heavily soiled, and there was no bowel movement. -Resident #7 was not offered or provided with incontinence care or toileting assistance for four hours (see observation above). The director of nursing (DON) was interviewed on 4/30/25 at 4:19 p.m. The DON said incontinence care was provided on an as-needed basis, with general expectations that day shift staff provide a resident's incontinence care or toileting assistance when getting a resident up out of bed, between breakfast and lunch and again between lunch and dinner. She said staff were expected to offer care assistance when checking on a resident. The DON said it was important for nursing staff to follow the facility's rigorous skin check process and monitor residents closely for skin concerns. The DON said Resident #7 could not tell staff when she needed to be changed and said that the presence of redness near the tailbone would require increased monitoring and potentially more frequent changes. 52094 III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included Parkinsonism, neurogenic bladder and chronic pain. The 2/10/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required assistance with all of her ADLs and was on a urinary and bowel toileting program. She was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS assessment indicated the resident was dependent on staff assistance for toileting hygiene. B. Observations and interviews During a continuous observation on 4/30/25, beginning at 8:00 a.m. and ending at 11:30 a.m., the following was observed: At 8:00 a.m., Resident #3 was lying in her bed. At 8:30 a.m. CNA #4 brought breakfast to the resident. CNA #4 placed the meal on the over-the-bed table in front of Resident #3, uncovered the meal and left the resident without asking her if she needed any care assistance or incontinence care. Resident #3 started eating her meal as CNA #4 left the room. At 9:30 a.m. CNA #4 entered the resident's room a second time to retrieve the resident's meal tray. CNA #4 asked Resident #3 if she wanted to get up. Resident #3 said no. CNA #4 left the resident's room and did not check the resident's brief or ask her if she needed to be changed or toileted. CNA #4 was interviewed on 4/30/25 at 9:32 a.m. CNA #4 said that the morning shift CNA told her Resident #3 was last changed around 5:00 a.m. (on 4/30/25).CNA #4 said the day shift was running behind in providing care for residents and she had not had enough time to change Resident #3 yet because her morning was so busy with other tasks. She said she thought that Resident #3 would use her call light if she needed to be changed. CNA #4 said she was familiar enough with Resident #3 that she knew when she needed to be changed. CNA #4 said she usually changed the resident before breakfast and after lunch. At 10:40 a.m. CNA #4 and a hospice nurse entered Resident #3's room. Resident #3 was found to be soiled with urine and CNA #4 and the hospice nurse proceeded to change the resident's wet incontinence brief while she remained in bed. The soiled incontinence brief was wet and heavy and it made a thudding sound when it was thrown in the trash can. Resident #3 was interviewed on 4/30/25 at 2:00 p.m. Resident #3 said she was wet (soiled with urine) but she was not sure how long she had been wet. She said she needed the staff's assistance with getting cleaned up and changed. Resident #3 said she would press the call light when she needed to be changed. She did not mention having a whistle to call for staff assistance (see DON interview below). Resident #3 attempted to press her call light, but she did not have the strength to fully press and activate the call light. At 2:20 p.m. CNA #5 entered Resident #3`s room. Resident #3 asked for water and CNA #5 assisted her. The resident did not ask CNA #5 for assistance with incontinence care and CNA #5 did not ask the resident if she needed to be changed or toileted before exiting the resident's room. C. Resident's representative interview Resident #3's representative was interviewed on 4/29/25 at 2:45 p.m. Resident #3's representative said Resident #3 had some continence ability and was able to get up and sit on the toilet with assistance and a Hoyer lift. However, she said because the resident was dependent on staff to complete toileting tasks, she wore an incontinence brief in case she was unable to wait for staff assistance. The representative said a CNA told her it was easier on the staff if residents urinated into their briefs and then staff changed them in their beds. The representative did not remember which CNA had told her that. D. Record review The Bowel and Bladder Elimination record from 4/29/25 to 4/30/25 was reviewed on 4/30/25 at 10:03 a.m. The record revealed that the last recorded toileting assistance was provided for Resident #3 on 4/30/25 at 5:03 a.m. for urinary incontinence. Review of Resident #3's progress notes between 3/25/25 and 4/30/25 revealed there was no documentation to indicate that Resident #3 refused incontinence care assistance from staff. E. Staff Interviews Licensed practical nurse (LPN) #2 was interviewed on 4/30/25 at 11:30 a.m. LPN #2 said it was the CNAs responsibility to check and change residents. She said CNAs recorded incontinence brief changes in the electronic medical record (EMR) for the nurses to reference. She said the CNAs gave verbal reports to each other at shift change so they would be aware of any resident needs. She said the CNAs knew the residents well enough to know when they needed to be changed, but she said staff should ask residents before and after meals if they needed to get cleaned up or get changed. LPN #2 said the general rule was for CNAs to check a resident every two to three hours and assist them with toileting or brief changes when needed. LPN #2 looked at Resident #3's Bowel and Bladder Elimination records and found said Resident #3 had last been changed at 5:03 a.m. that morning (4/30/25). The assistant director of nursing (ADON) was interviewed on 4/30/25 at approximately 3:00 p.m. The ADON said she had met with Resident #3 and asked her about the timing of her care this morning (4/30/25). She said Resident#3 told her she had not been changed before breakfast (see observation above). The DON was interviewed on 4/30/25 at 4:33 p.m. The DON said Resident #3 would call for staff assistance if she needed help. She said the resident was having difficulty with the call button so they had provided her with a whistle to call staff if she was unable to use the call light button. The DON said the resident had both the call button and the whistle because she sometimes forgot she had the whistle. The DON said a lot of residents in the facility had mixed incontinence and sometimes knew when they had to go to the bathroom and sometimes did not know they had to go and experienced incontinent episodes. She said Resident #3 did not always know when she had to go to the bathroom and was occasionally incontinent. The DON said for residents with mixed incontinence, the checking frequency could appropriately be every four hours because they sometimes were able to recognize they needed to be changed and could call for staff assistance. The DON said the CNAs knew the residents well enough to know how often to check on them for toileting or incontinence care. As a practice, she said the overnight staff should be toileting the residents between 9:00 p.m. and 6:00 a.m. and the day and evening shifts should check and change the residents before and after meals. -However, observations revealed staff did not offer toileting or incontinence care to Resident #3 for two hours and 40 minutes, even though she had not been toileted or provided incontinence care prior to breakfast (see observations above). -Additionally, record review and interviews revealed Resident #3 had not been changed or toileted from 5:03 a.m. until 10:40 a.m. (a period of five hours and seven minutes) when the hospice nurse and CNA #4 provided the resident with incontinence care (see record review and CNA #4's interview above).

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. However, the care plan failed to include an intervention to encourage the resident to reposition while he was sitting in his recliner and offer toileting/incontinence care to the resident frequently. Continuous observations during the survey revealed Resident #27 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #27 with timely interventions, such as frequent repositioning and incontinent care, the resident developed two Stage 3 pressure injuries to his left and right ischium. Additionally, Resident #1, who was frequently incontinent of urine, always incontinent of bowel and at risk for developing pressure injuries due to a decrease in mobility, was identified by a nurse to have an open area to her coccyx on 4/1/24 during a routine skin assessment. However, there was no further documentation in the resident's electronic medical record (EMR) to indicate the wound care physician (WCP) was notified of the wound and no new physician's orders were obtained to treat the wound. On 4/14/24, Resident #1 it was identified by another nurse that she had pressure wounds on her coccyx and left buttock. A physician's order was obtained for wound treatment. The facility failed to initiate a treatment to the unstageable pressure wounds to Resident #1's coccyx and left buttock for 13 days following the initial identification. Furthermore, Resident #1's care plan failed to include interventions for frequently repositioning the resident while she was in her recliner and providing frequent incontinent care. Continuous observations during the survey revealed Resident #1 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #1 with timely interventions, such as frequent repositioning and incontinent care, the resident developed unstageable pressure injuries to her coccyx and left buttock. Findings include: I. Professional reference The Pressure Ulcer and Other Wounds in the Post-Acute and Long-Term Care Settings (2018), retrieved on 4/29/24 from https://online.fliphtml5.com/zlds/jffd/#p=2, revealed in pertinent part Employ repositioning or offloading measures for wound prevention. According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 4/29/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injury Prevention and Management policy and procedure, dated November 2022, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It revealed in pertinent part To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries. Preventative interventions can be, but not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care and application of barrier cream for incontinence, proper lifting technique, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity. Compliance with interventions will be documented in the medical record. III. Resident #27 A. Resident status Resident #27, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, type II diabetes, chronic kidney disease and atrial fibrillation (abnormal heart function). The 3/21/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive one to two person assistance with toileting, transfers and bed mobility. He required set up assistance with personal hygiene and eating. The assessment documented Resident #27 was at risk for developing pressure injuries but did not have a pressure injury. B. Observations On 4/22/24 at 12:35 p.m. Resident #27 was sitting in his recliner in his room. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:04 p.m., Resident #27 was sitting in his recliner. At 12:22 p.m. Resident #27's lunch tray was delivered by CNA #1. Resident #27 remained sitting in his recliner for lunch. -CNA #1 failed to offer Resident #27 repositioning or toileting before lunch. At 2:04 p.m. Resident #27 was assisted by CNA #1 and licensed practical nurse (LPN) #1 to lay in bed. CNA #1 exited Resident #27 room with a trash bag containing Resident #27's brief. The brief was observed to be visibly wet as the inside of the trash bag was noted to be wet. -Resident #27 was not provided with toileting or repositioning in his recliner for three hours and 30 minutes. On 4/24/24 at 1:04 p.m. the regional nurse consultant (RNC) assessed the edge of the cushion Resident #27 was sitting on in his recliner and said it was a gel type cushion. The RNC assessed Resident #27's air mattress and said it was a mattress that could alternate pressure. On 4/24/24 at 2:00 p.m. Resident #27's wound care was observed with the wound care physician (WCP). The old dressings were removed from the resident's wounds and the wound beds were pink with no signs of infection. The wounds were cleaned with normal saline, skin prep applied to the peri wounds, honey gel applied to the wound beds and covered with border dressings. -On 4/24/24 at 2:30 p.m. the gel cushion in Resident #27's recliner did not have cushion cover on it and the resident was sitting directly on the plastic surface of the gel cushion. C. Record review Resident #27's comprehensive care plan, dated 3/27/24, revealed Resident #27 had a potential for impairment to skin related to decreased mobility. The interventions included a pressure reducing cushion to chair and mattress (initiated 8/3/22), offering to reposition Resident #27 at night during care and encouraging the resident to lie on his bed after lunch (initiated on 1/20/23). -The care plan only addressed repositioning the resident during night care and not throughout the day. The 4/17/24 skin and wound evaluation form identified two new stage three pressure injuries to the left and right ischium. The wound appeared pink and moist with no signs of infection. The wound area was cleansed with Dakin's, honey gel was applied to the wound bed, skin prep the peri wound and covered with border gauze. Resident #27's 4/19/24 Braden scale (a tool used to determine the risk of pressure injury development) revealed Resident #27 was at risk of developing a pressure ulcer. It revealed his skin was occasionally moist requiring an extra linen change daily. Resident #27 was chair fast, his ability to walk was severely limited and he was unable to bear weight and required assistance into a chair or wheelchair. Resident #27 had very limited mobility, was able to make occasional slight changes in body position but was unable to make frequent or significant changes independently. Resident #27's April 2024 CPO revealed the following physician's order: Cleanse the left and right ischium with Dakin's (specialized wound cleaner), apply honey gel (used to remove dead tissue)to the wound bed, skin prep the peri wound (area around the opening) and cover with border gauze dressing once daily, ordered on 4/18/24. Resident #27's initial wound physician visit on 4/17/24 revealed stage three pressure injuries to both the right and left ischium. The left ischium wound measured 3.4 centimeters (cm) by 2 cm by 0.2 cm with 100% granulation (new connective tissue) tissue and minimal drainage. The right ischium measured 1 cm by 2.5 cm by 0.2 cm with 100 % granulation tissue and no drainage. Orders were given to cleanse the wounds with Dakin's, apply skin prep to peri wounds, apply honey gel to wound beds and cover with bordered gauze dressings daily and as needed. -Review of Resident #27's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviews CNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said Resident #27 was changed this morning (4/23/24) when he got up and then when he was laid in bed around 2:00 p.m. CNA #1 said Resident #27 did not always tell staff when he needed to be changed so staff should be checking in with him every couple of hours. CNA #1 was aware Resident #27 had a wound on his bottom and should be offered repositioning. CNA #1 said Resident #27 often refused to be repositioned when asked, however, she said the resident had not refused care that day (4/23/24). CNA #1 did not know where to document any refusal of care for repositioning. -Despite CNA #1's interview indicating Resident #27 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). -Despite CNA #1's interview indicating Resident #27 should be offered repositioning and staff should check on him every couple of hours, the resident was not offered repositioning during continuous observations for three and half hours (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said she was unaware Resident #27 had not been offered repositioning in at least three and a half hours. LPN #1 said Resident #27 would benefit from repositioning due to the pressure injuries on his bottom. The WCP was interviewed on 4/24/24 at 2:29 p.m. The WCP said he was unable to determine if Resident #27's pressure injuries were avoidable or unavoidable as he was still speaking with facility staff to determine possible causes of the wounds. The WCP said facility staff told him Resident #27 refused to change positions and preferred to sit in his recliner during the day. -However, there was no evidence of documented refusals of care (see record review above). IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the April 2024 CPOs, diagnoses included diabetes mellitus (abnormal blood glucose), dementia (memory impairment) and chronic kidney disease (abnormal kidney function). The 4/9/24 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required substantial assistance for transfers, toileting, dressing and supervision for eating. The assessment documented the resident was at risk of developing a pressure injury but did not have a pressure injury. B. Observations On 4/22/24 at 10:30 a.m. Resident #1 was sitting in her recliner leaning to her left side. On 4/22/24 at 1:35 p.m. Resident #1 was sitting in her recliner and continued to lean to her left. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:51 p.m., Resident #1 was sitting in her recliner, leaning to her left side. At 12:22 p.m. Resident #1's lunch tray was delivered while the resident was asleep and remained sitting in the recliner. At 12:34 p.m. LPN #1 entered Resident #1's room, woke the resident up and offered her assistance with eating. Resident #1 said she was not having a good day because her bottom hurt. LPN #1 told Resident #1 that she got a new dressing on her bottom and the wound physician would be in the next day. -LPN did not offer repositioning to the resident. At 2:26 p.m. LPN #1 entered Resident #1's room and told the resident as soon as the CNA returned from lunch, she would assist the CNA to lay the resident in bed. Resident #1 remained sitting in the recliner leaning to her left side. -At 2:51 p.m. LPN #1 and CNA #1 entered Resident #1's room with the sit to stand mechanical lift. Resident #1 was assisted with the use of the sit to stand lift to the bathroom. Resident #1's brief was removed and was observed to have been soiled with bowel and urine. -Resident #1 was not provided with toileting or repositioning in her recliner for four hours and 15 minutes. LPN #1 collected items to complete the resident's dressing change due to the dressing being soiled. CNA #1 used the sit to stand lift to take Resident #1 out of the bathroom. The old dressing was removed and noted to be soiled with feces on the edges of the dressing. The wound bed to the coccyx was pink and moist and the area around the wound was nonblanchable (discoloration of skin that does not turn white when pressed) when the nurse pressed the surrounding tissue with her finger. The left buttock wound had eschar (dead tissue) around the upper edge of the wound and yellow tissue (slough) throughout. The surrounding tissue of the wound was nonblanchable. LPN #1 cleaned the wounds with Dakins, dried the wounds with gauze, applied skin prep to the peri wounds, added honey gel to the wound beds, and covered the wounds with a border dressing. Resident #1 told LPN #1 it hurt when the nurse was cleaning the wounds. On 4/24/24 at 1:01 p.m. Resident #1 was observed to be seated on a cushion in her recliner. The RNC touched the chair cushion without moving Resident #1 from her seated position in the recliner and identified the cushion as a standard foam cushion. The RNC identified the resident's pressure relieving mattress as an air mattress that could alternate pressure. On 4/24/24 at 2:10 p.m. Resident #1's wound dressing changes were observed with the WCP. The coccyx wound had a pink wound bed. The wound area was cleansed with Dakin's, dried with gauze, skin prep was applied to the periwound, honey gel was applied to the wound bed and the area was covered with border gauze. The left buttock wound was observed to have yellow colored tissue in the center and the upper corner of the wound was observed to have eschar (dead tissue). The wound area was cleaned with Dakin's, dried with gauze, skin prep was applied to the peri wound, honey gel was applied to the wound bed and the area was covered with border gauze. C. Record Review Resident #1's comprehensive care plan, dated 3/29/24, revealed potential impairment to skin related to decreased mobility with interventions of pressure reducing cushion while up in chair, pressure reducing mattress and follow facility protocol for treatment of injury, initiated 12/13/22. Apply nutrishield cream to coccyx every shift and at each incontinence episode initiated on 5/24/23 -There was no intervention for repositioning or frequent incontinent care documented on Resident #1's care plan Resident #1's 1/7/24 Braden scale assessment revealed Resident #1 was at moderate risk for developing pressure injuries. It revealed Resident #1's skin was very moist requiring extra linen changes, the resident was chair fast (requiring assistance to a chair or wheelchair) and had very limited mobility (unable to make frequent or significant changes independently). Resident #1's weekly skin assessment dated [DATE] revealed the resident had an open area starting on her coccyx but did not document a stage of the wound or measurements. It revealed Resident #1 was more comfortable lying on her sides than lying flat because lying flat caused her extreme pain. -The assessment did not document Resident #1 frequently refused repositioning (see interviews below). -There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. Resident #1's weekly skin assessment dated [DATE] revealed a pressure injury to the resident's coccyx but had no measurements or narrative notes. -There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. A progress note dated 4/14/24 revealed CNAs were changing Resident #1 and an open area to the resident's coccyx measuring 2 cm by 2.2 cm was found. The area was cleaned and a dry dressing was applied. Resident #1 also had a shearing area to the left buttock measuring 3 cm by 2.2 cm, the area was cleansed with normal saline and nutrashield cream was applied. The nurse notified the unit manager to speak with Resident #1's representative about getting a new cushion for her wheelchair. -The wounds were initially identified by a nurse on 4/1/24, however, there was no further documentation of the wounds or treatment orders obtained until 4/14/24. -There was no documentation to indicate whether a new cushion was provided to Resident #1. Resident #1's April 2024 CPO documented the following physician's orders: Pressure relief mattress: check inflation and settings every shift, ordered on 2/2/24. Apply nutrishield cream to coccyx every shift and with every incontinence episode, ordered on 5/23/23. Wound care order for coccyx: Clean open areas to coccyx with normal saline and apply dry dressing once daily, ordered on 4/14/23. -The order did not specify a treatment for the left buttock wound. -The order was not put into place until 13 days after the initial identification of the open area to Resident #1's coccyx. Wound care order for coccyx and left buttock, cleanse with Dakin's, apply honey gel to wound bed, skin prep the periwound and cover with border gauze once daily, ordered on 4/18/24. The WCPs initial encounter with Residents #1's wounds for the coccyx and left buttock on 4/17/24 revealed the coccyx and left buttocks were unstageable pressure injuries. The coccyx wound measured 1.1 (cm) by 1 cm by 0.1 cm and the left buttock wound measured 0.9 cm by 1.3 cm by 0.1. -Review of Resident #1's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviews CNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said residents should be offered toileting or repositioning every two hours to ensure they were not soiled and to off load pressure areas. CNA #1 said Resident #1 would not call if she was soiled so staff needed to offer toileting and check her for incontinence episodes. CNA #1 said Resident #1 was changed around 9:00 a.m. and then at around 3:00 p.m. (on 4/23/24). CNA #1 did not have a response as to why Resident #1 was not offered repositioning or toileting in almost six hours. CNA #1 said Resident #1 had wounds on her buttocks. -Despite CNA #1's interview indicating Resident #1 should be offered repositioning and staff should check on her every couple of hours, the resident was not offered repositioning during continuous observations for four hours and 15 minutes (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said residents should be offered repositioning every two hours especially if they had pressure injuries or were at risk of developing pressure injuries. LPN #1 said repositioning would be beneficial to residents with pressure injuries to promote healing. LPN #1 was unaware if Resident #1 was not offered repositioning or toileting between 10:35 a.m. and 2:51 p.m. LPN #1 said Resident #1 had not had the pressure injuries long but would refuse staff when she was asked to reposition. LPN #1 said she had not documented any Resident #1 refusal of repositioning. -Despite LPN #1's interview indicating Resident #1 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). The WCP was interviewed on 4/24/24 at 2:10 p.m. The WCP said he felt Resident #1's pressure injuries were avoidable but when he talked with the facility staff he was told Resident #1 refused to change positions. -However, there was no documented refusal of care (see record review above). V. Additional interviews The WCP was interviewed again on 4/24/24 at 2:48 p.m. The WCP said Resident #1's and #27's wounds would benefit from frequent positioning changes despite them both sitting on cushions when up in their recliners. The WCP said a pressure injury could develop within two hours and incontinence increased the risk of a wound developing or worsening. The WCP said wound textbooks recommended a resident in bed be repositioned every two to three hours and, when in a chair, they should be repositioned every two hours to offload pressure. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said Resident #1 started having skin issues on 4/1/24, however, she said the floor nurse did not relay this information to the unit manager. The DON said Resident #1's skin issue was brought up again on 4/14/24 by another nurse. She said the facility started to review what could have caused the wounds and found the weekly skin documentation dated 4/1/24. The DON said the facility immediately started wound care treatment for Resident #1's wounds on 4/14/24 and had the WCP see the resident on his next wound round visit, which was 4/17/24. The DON said Resident #1 did not like to be repositioned and liked to sit in her recliner. The DON said Resident #27 did not like to be moved from his recliner but should still be offered position changes every two hours. -Despite the DON's interview indicating Resident #1 and Resident #27 frequently refused repositioning, the residents' EMRs did not reveal documentation that the residents refused care or repositioning (see record review above). -The DON did not provide any documentation for refusal of care for Resident #1 or Resident #27. The DON said residents should be repositioned every two hours to help prevent pressure injuries and promote wound healing if they had a pressure injury. The DON said if a resident refused to be repositioned it should be documented in the nurses progress notes. The DON said residents should be offered toileting upon rising, before and after meals and as needed.

Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident individuality for one (#1) resident out of five sample residents. Specifically, the facility failed to answer the resident's call light and provide services in a timely manner to the resident. The resident said it could be frustrating at times and he reacted with behaviors of becoming angry, calling out for help, and banging on walls. This caused the resident distress. Findings include: I. Resident status Resident #1, age 83, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, essential hypertension, post-polio syndrome, diabetes mellitus type 2, osteoarthritis of left shoulder, lack of coordination, and muscle weakness. The 11/25/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He exhibited verbal behaviors. He required extensive assistance of two staff members with mobility and activities of daily living (ADLs). He had two or more falls with no major injuries. II. Resident interview Resident #1 was interviewed on 11/30/22 at 9:30 a.m. He stated he frequently waited 30 minutes to an hour for his call light to be answered. He stated the staff also frequently came into his room, turned off his call light and told him they would be back but did not return. He stated the long call light wait times were very frustrating for him and he did yell out and bang on walls at times when waiting for long periods of time for the care and services he wanted and needed. III. Family interview The resident's representative was interviewed on 12/1/22 at 11:00 a.m. He stated he had witnessed long call light wait times while visiting in the facility. He stated the resident could be impatient and demanding at times, though he should not have to wait for 40 minutes to an hour for care. IV. Record review An ADL care plan initiated on 8/19/2020 and revised on 9/6/22 read: I have an ADL self-care performance deficit r/t (related to) muscle weakness from chronic obstructive pulmonary disease, type 2 diabetes mellitus, primary generalized osteoarthritis, hypertension, insomnia, and vitamin D deficiency. Please provide a consistent rotation of staff for my care needs to improve motivation, flexibility, & learning. Interventions included: Please provide a consistent rotation of staff for my care needs to improve motivation, flexibility, & learning. Tips for caring for me: Attempt to get me up first thing in the day; Communicate times with me in advance; Remind me others need morning care too when I use call light frequently and you will be back soon; Remember I may have 'unmet needs' and I need your help; Assure me you are here to help me, please no arguing; Please don't take any issues personally; If I am safe, leave the room and come back with help if needed; Stay calm and gentle - you are the amazing professional here!; Ask for help from leadership communicating with me - THEY WILL HELP YOU. A behavior care plan initiated on 2/15/21 and revised on 10/17/22 read: I exhibit the following behaviors: Verbal aggressive behaviors: Screaming, cursing, negativism, verbally degrading staff, verbal aggression. Told staff he would defecate on the floor in the past to get attention. Placed himself on the floor in the past to get attention. Banging very loudly on the wall for attention (within just a few minutes of being in the bathroom). Interventions included: Anticipate and meet my needs. Make sure I feel heard by using rephrasing and feedback; Encourage me to express my feelings appropriately. Use active listening and respond to my feeling and tone; Explain all procedures to me before starting and allow me time to adjust to changes; Explain/reinforce to me why my behavior is inappropriate and/or unacceptable; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of the resident's progress notes revealed the resident had exhibited behaviors of being demanding and impatient with staff since admission. Behaviors included yelling out, banging on walls, and pulling the call light out of the wall. Review of the resident's call light record from 10/30/22 to 11/30/22 revealed 77 call light times that were over 20 minutes long. Sixteen call lights were between 30 and 40 minutes, 10 were between 40 and 50 minutes, six were between 50 and 60 minutes, eight were over an hour and one was over two hours. V. Staff interviews Registered nurse (RN) #1 was interviewed on 11/30/22 at 9:45 a.m. She stated call lights should not remain on past 15 minutes, but the facility staff tried to get to them as soon as possible. Licensed practical nurse (LPN) #1 was interviewed on 11/30/22 at 9:50 a.m. She stated the resident call lights would ideally be answered within five minutes. She stated it was not always possible to answer call lights that quickly. She stated she felt ten minutes was too long and she would probably get frustrated and upset if she had to wait longer than ten minutes. She stated she had worked with Resident #1 and he wanted care immediately when putting on his call light and would yell out if the call light was not answered immediately. She stated the staff tried to get him up first thing in the morning. Certified nurse aide (CNA) #1 was interviewed on 11/30/22 at 10:01 a.m. He stated the residents should not wait longer than ten minutes to have their call light answered. He stated he worked with Resident #1 and he expected care immediately after he activated his light. CNA #2 was interviewed on 11/30/22 at 10:07 a.m. She stated she tried to get to resident call lights within five minutes. The nursing home administrator (NHA) was interviewed on 11/30/22 at 12:00 p.m. She stated the facility had been working on call light timeliness in the facility. She stated 15 minutes was acceptable and 20 minutes was not desirable. She stated anything over 30 minutes was a real concern and residents should not have to wait that long. She stated the call light system in the facility was all digital to devices the staff carried with them while working and administration also had devices and could monitor call light times remotely. She stated there was no light outside the resident rooms or audible alert for a call light activation, so some of the long call light times were from staff forgetting to deactivate the call. The director of nursing (DON) was interviewed on 12/1/22 at 1:30 p.m. She stated resident call lights should not go longer than 15 minutes at the most. She stated the facility staff including administrative staff were working very hard to decrease call light wait times. She stated Resident #1 received care from staff and they would leave the room and he would put his call light on right after staff left for more care and he did not accept staff explaining there were other residents who needed care as well. She stated the resident also frequently would not let staff turn off his light and return to provide the care and would insist the light stay on until staff could return. She stated the residents should not have to wait 30 minutes or longer for care to be provided.

Based on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for two (#85 and #300) of four residents reviewed for falls out of 34 sample residents. Record review and interview revealed the facility failed to effectively and consistently develop and implement care plan interventions to ensure the residents were provided the assessed levels of supervision recommended by nursing and therapy staff. Resident #85 had a history of [REDACTED].#85's initial admission on 2/20/19, that she had a history of [REDACTED]. Documentation starting in December 2019, with her second fall revealed the resident was experiencing increased confusion and unsteadiness of her gait/balance and her care plan documented that she was at significant risk for future falls due to weakness, impulsivity, and unawareness of safety needs. The facility failed to reassess, develop and implement care planned interventions to effectively prevent a fall where the resident sustained [REDACTED]. Resident #85 fell three times while in care of the facility. The first two falls occurred on 2/25/19 and 12/12/19 when the resident tried to get up unassisted. The most recent fall occurred on 1/30/2020 while the resident was trying to get into bed and did not have non-slip socks on per her care plan. The latest fall resulted in the resident sustaining a major injury requiring surgical intervention to repair damaged bone and tissue of both the femur (thigh bone) and the tibia (shinbone). The femoral bone was fractured at both ends, the head of the bone and at just above the knee joint. The tibia was fractured at the top of the bone just below the knee. The hospital discharge report dated 2/2/2020 documented this degree of damage was caused by a hard hit to the joint. The facility was also aware upon Resident #300's 2/8/2020 admission of her history of falling, she had been a resident of this facility on the transitional care neighborhood (TCN) unit, months prior, to recover from a fractured right hip after falling at home. The facility was aware, based on the hospital referral document dated 2/8/2020, at her admission, that she was in a weakened condition due to gastrointestinal illness and risk for falling. However, the facility failed to assess, communicate and implement effective fall prevention measures to prevent a fall within two days of admission to the TCN for rehabilitation services. Findings include: I. Facility policies and procedures The Fall Prevention and Management policy, last reviewed January 2019, was provided by the director of nursing (DON) on 2/11/2020 at 1:15 p.m. The policy read in pertinent part: As a facility that provides care and services to seniors and promotes a culture of safety. It is important to prevent and manage falls in order to minimize the harm and potential risk to residents. -The purpose of the fall prevention and management program is to identify residents and areas at risk for falls, initiate interventions to prevent and respond to falls and thus reduce the risk of injury due to falls. -Falls are the leading cause of morbidity (illness) and mortality (death) among nursing home residents and can result in serious injury, especially [MEDICAL CONDITION]. -Previous falls, especially recurrent falls and falls with injury, are the most important predictors of future falls and injurious falls. Muscle weakness and gait problems account for about 24 percent of nursing home falls. -Fall risk assessment will be completed upon move-in, with signifying changes in condition, readmission, quarterly and annually. The fall risk assessment will result in person centered care planning to reduce the risk of falls, if appropriate. -Fall prevention: It is the goal of this facility to prevent falls in all areas of care and services and it is the responsibility of all associates to prevent falls, striving to provide the safest environment possible. Skilled neighborhoods may offer the following fall prevention interventions based on response to individualized needs: fall risk assessment, low bed, fall mat, appropriate footwear, intentional rounding, education to resident and families, life enrichment activities focused on strengthening and balance, environmental assessment, to keep it clean and free of clutter and hazards, person centered fall interventions fall prevention care planning, referral to rehab services, quality improvement projects, environmental safety rounding, providing adequate lighting, routine preventative equipment, maintenance program ,oxygen tubing management, hip protectors, wheelchair positioning, toileting plan, moving resident's suite closer to nurses area, removing clutter/equipment, pharmacy review of medications, alterations in resident's area to allow easy accesses to desired items, increased need for supervision, call light positioning, and wet floor signs available in each neighborhoods for use in the event of a spill, medication review for high risk fall medications and so forth. -Designated associates will perform quality improvement to reduce falls, as needed. A request was made for policies on assisting dependent residents with activities of daily living (ADL) and transfers on 2/11/2020 at 4:50 p.m. The DON said the facility did not have policies on either topic but provided procedural instructions for transfers and assistance to ambulate, on 2/12/2020 at 8:00 a.m. The procedural guide documented step by step instructions for assisting a dependent resident, but did not document taking the residents assessed ability or therapy recommendations for transfer techniques into account. II. Resident #85 A. Resident status Resident #85, age 78, admitted on [DATE]. According to the January 2020 computerized physician's orders [REDACTED]. The 1/9/2020 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She required supervision- oversight, encouragement and/or cuing form one staff person with transfers; toileting; locomotion on and off the unit bed mobility; and dressing. She was not able to stand from a seated position, transfer form surface to surface, walk short distances, or turn around while walking without assistance form one staff and a walker to stabilize and balance. She used a manual wheelchair to get around the community. She did not refuse care. She was on routine antipsychotic medication, and last received occupational therapy on 11/12/19 and physical therapy on 3/5/19, and was not on a restorative nursing program. She had two falls since admission. B. Resident interview Resident #85 was interviewed on 2/10/2020 at 11:44 a.m. She said she had fallen about a week ago when she was trying to get into bed. Staff were not available to help me get into bed; sometimes it takes a little longer for them to answer my call light and I thought I could get in bed by myself. I got up out of my chair; I slipped and fell . I probably should have waited for staff to help me. The doctor said I broke my bone right in half. It's hard to believe because it's a pretty big bone (she pointed to her thigh). They haven ' t changed the bandage yet, so I'm not sure how it looks under there. Staff will help me with things if I ask them to when they are here helping me. The resident showed the fracture site, it was covered with a long bandage from hip to just below the right kneecap. The bandage was starting to come loose, but looked clean and covered the wound. Resident #85 was interviewed again on 2/11/2020 at 1:50 p.m., during a resident group meeting with six other residents present. Resident #85 said we can have long waits for staff to answer our call lights. I think they could use more help. I don ' t push the button unless I absolutely have to, it takes a lot out of me to sit and wonder who is coming or when they will show up to help me. I feel unimportant when I have to wait a long time to get help; I don ' t think I am a priority when the staff stop in only to turn off my light and tell me they will be right back and they don ' t come right back. C. Record review The resident's comprehensive care plan reflecting move in date 2/20/19 revealed the following care plan needs, it read in pertinent part: Focus - ADLs: I have an ADL self-care performance deficit Fatigue, impaired balance. Date initiated: 2/25/19. Goal: I will maintain my current level of function. Date initiated: 6/5/19 Interventions/tasks: -I will improve my current level of function. Date initiated: 2/25/19 -Bathing/showering: I need limited physical assistance. Date initiated: 6/5/19, revision on 12/5/19. Focus-Dressing: I need supervision and cueing by staff to provide assistance for dressing. Date initiated: 6/5/19, revision on 6/5/19. -Toileting use: I require supervision and cuing by staff to provide assistance with toileting. Do Not Leave me alone on the toilet until I have been evaluated. Date initiated: 6/5/19, revision on 6/5/19. -Transfer: I require extensive and limited physical assistance by staff to provide assistance to move between surfaces. Date initiated: 6/5/19, revision on 9/3/19. -ADL - bed mobility every shift. Date initiated: 2/20/19 -ADL - dressing assistance every shift. Date initiated: 2/20/19. -ADL - toilet use assistance ever shift. Date initiated: 2/20/19. -ADL - bathing assistance every Monday and Thursday. Date initiated: 2/20/19, revision on 1/20/20. -ADL - transfers assistance every shift. Date initiated: 2/20/19. Focus- falls: I am at high risk for falls, related to deconditioning/weakness and a history of past falls. Date initiated: 3/2/19. Goal: -I will be free of falls. Date initiated: 3/2/19. -I will be free of minor injury. Safety measures will be maintained to prevent or lessen any injury from a fall. Date initiated: 3/2/19. Interventions/tasks: -Educate and remind me about safety reminders and what to do if a fall occurs. Date Initiated: 3/2/19. -Ensure that I am wearing appropriate non skid footwear when ambulating or mobilizing in my wheelchair. Date initiated: 3/2/19. -Despite the care plan documenting that staff should ensure the resident was wearing non slip socks when ambulating or mobilizing when in her wheelchair the resident did not have non slip socks or other non slip footwear on the day the she fell and fractured her femur and tibia bones. Focus- falls: I have had one fall with no injury in the last quarter. Related to deconditioning/weakness, impulsivity and unawareness of safety needs. Date initiated: 2/25/19., revision on 1/21/2020. Goal: Fall related complications such as injury or change in cognitive function, will be promptly assessed and treated to prevent adverse outcomes. Date initiated: 2/25/19. -I will be free of minor injury. Date Initiated: 2/25/19 -I will resume usual activities without further incident through. Date initiated: 2/25/19. -Underlying medical conditions causing or contributing to the event will be evaluated. Date initiated: 2/25/19. Focus - I have Diabetes Mellitus I am insulin dependent. I am at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Date initiated: 6/5/19. Goal: I will have no complications related to diabetes. Date initiated: 6/5/19. Interventions/tasks: Monitor/document/report signs and symptoms of [DIAGNOSES REDACTED]; examples include by not limited to confusion, lack of coordination and staggered gait. Date initiated: 6/5/19. The point of care system (POC) documented customized care assistance and level of service provided by the CNAs. The documentation showed the residents abilities and need for staff assistance varied but the care plan did not document development of care interventions to address the unpredictable nature of her ability to transfer herself. Nursing note dated 12/1/19 at 8:01 a.m., read in pertinent part: Daily skilled note: Short-term memory impairment, impaired decision making ability, sleeps very soundly and is forgetful. Up and dressed this morning at 5:30 a.m., she thought it was evening. Has periods of increased confusion. Functional status: Balance/gait impaired balance weakness. Nursing note dated 12/12/19 at 4:35 p.m. Read: Incident note: Resident found lying on floor with her head on pillow, alert and oriented times three, states she was getting up to water her plants, and she went one way and the wheelchair went the other way. Resident did not put brakes on the wheelchair before attempting to stand up, did not call for assistance, states landed on buttock, denies hitting head or loss of consciousness, vital signs stable, no obvious deformities, range of motion (ROM) to extremities without pain or discomfort, resident assisted by two person to standing position and assisted to sitting on side of bed, no injuries noted, neuro checks initiated and were within normal limits. Will continue to monitor, call light within reach, resident resting quietly on low bed. Nursing note dated 12/13/19 10:13 a.m., read in pertinent part: Incident note: Resident up to wheelchair this morning needing limited physical assistance of one staff. Nursing note dated 1/1/2020 at 9:22 a.m., read in pertinent part: Change of condition note: Resident presented with increased confusion this morning. She attempted to go into another resident's room, talking about needing to write on the chalkboards. Vital signs: oxygen saturation was 88 percent on room air, 92 percent while on two liters of oxygen by nasal cannula, blood pressure 151/78, pulse 103 beats per minute, respirations 18 breaths per minute even and unlabored, temperature was 98.4 degrees Fahrenheit, blood sugar was 545, lung sounds clear, abdomen soft resident denies pain or burning with urination. Physician notified, labs and urine analysis ordered. Treatment provided for resident symptoms. Physician visit note dated 1/2/2020, revealed the resident was seen by the nurse practitioner (NP) for an acute/reassessment visit, the resident in bed when examined the NP did not observe her walk or stand and balance. The note documented: The physician's office was notified of a change in condition starting on 1/1/2020. The resident had increased confusion and elevated fasting blood sugar (FSBS) levels . Blood/lab work and urinalysis ordered. The documented results of the medical exam and chart review included prescribed antibiotic treatment for [REDACTED]. Fall assessment dated [DATE] revealed the resident was at a moderate risk for falls with a score of 5.5 out of 15 (any score over 10 indicates a high risk for falls). She was on high risk medication (antidepressant, antihypertensive, antipsychotic, cardiovascular and hypoglycemic medication) with numerous health conditions placing her at increased risk for falls. She was not steady on her feet, and used a walking aid device. The assessments accuracy is in question because the assessor did not answer all questions and did not document the resident prior fall over the prior six months (fall date - 12/12/19). If this question was answered correctly it would have brought her score to an 8.5 out of 15 making her a higher risk rating for falls or even a higher if other questions were not answered accurately. The POC documented customized care assistance and level of service provided by the CNAs to the Resident #85 on a day to day basis revealed the following care service and care needs: Transfer assistance: The documented outcomes of the resident's ability for self-performance and how resident moved between surfaces including to or from the bed, chair, wheelchair and standing position (excludes to/from bath/toilet) between 1/13/2020 and 1/30/2020 revealed: While the resident was able to perform transfers independently on an occasional basis; she needed assistance from one staff at least once daily, some days she needed physical assistance, supervision, cuing and/or encouragement more than once a day for successful transfers between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). -The resident's need for assistance varied from day to day with no consistent pattern of need. This care task area showed the resident's need and level support needed was not predictable. Movement support: The documented outcomes of the resident's ability to move between locations in her room and adjacent corridor on same floor between 1/13/2020 and 1/30/2020 revealed: The resident needed daily assistance to provide guided maneuvering of limbs or other non-weight-bearing assistance, supervision, cuing and/or encouragement from one staff to move about. On the day the resident fell and fractured her femur (1/30/2020), she needed and received weight-bearing support by staff to move between locations. -This care task area showed the resident's need and level support needed was not predictable. Dressing support: The documented outcomes of the resident's ability to put on, fasten and take off all items of clothing, including putting on and removing footwear between 1/13/2020 and 1/30/2020 revealed: The resident needed daily physical assistance, supervision, cuing and/or encouragement from one staff to get dressed. She needed assistance at least once daily, some days she needed staff assistance more than once throughout the day. -This care task area showed the resident's need and level support needed was not predictable. Walking: The documented outcomes of the resident's ability to walk in her room between 1/13/2020 and 1/30/2020 revealed this service was not applicable; she did not perform this task independently or with staff assistance. Monthly nursing observation dated 1/22/2020 revealed the resident had short-term memory impairment with impaired decision making ability. Nursing note dated 1/30/2020 at 9:30 p.m., read in pertinent part: Incident note: At around 8:00 p.m., the CNA notified this writer that the resident is on the floor. Per assessment, the resident stated, I was transferring from my wheelchair to bed then I slid and fell on my right hip and right knee. Resident denies hitting her head. Neuro checks were initiated and were within normal limits per resident's baseline. ROM to both upper extremities were within normal limits. No pain noted with ROM to both upper extremities. ROM within normal limits to both lower extremities. Pain/discomfort noted to right hip and right knee with ROM. No visible injuries noted. Vital signs stable, blood glucose of 174. No signs of symptoms of hypo/[MEDICAL CONDITION] noted. Resident was assisted to bed. Tylenol 1000 milligrams (mg) was administered for pain. Resident did not place her call light for help before transfer. Call light was within reach. She was not wearing non-skidding socks. Her wheelchair brakes were not on prior transfer. Physician notified me and x-ray was ordered. According to the nursing note dated 1/30/2020 at 9:30 p.m., Resident #85's fall occurred in her room on 1/30/2020 at approximately 8:00 p.m. as she was attempting to transfer herself without staff assistance and without safe and proper footwear, she slipped and fell . Staff found the resident lying on the floor on her right side and noted in the facility investigation report that the predisposing factor to her fall was transferring without staff assistance and improper footwear (not wearing non slip socks), as she was wearing regular socks (see DON interview below), without the plastic grip strips on the bottom. However, the resident's comprehensive care plan documented an intervention that the resident needed daily supervision assistance from staff to get dressed; daily extensive and/or limited physical assistance to transfer from surface to surface; and for staff to ensure she was wearing appropriate non skid footwear when ambulating and moving about in order to be free of minor injury and prevent or lessen any injury from a fall. These interventions were not followed consistently and Resident #85 sustained a major injury from falling. Nursing note dated 1/31/2020 at 12:48 a.m., read: Radiology Note: Result called in to physician's office, received orders to send resident to the hospital. Hospital admission and treatment paperwork dated 1/31/2020 revealed in pertinent part: The resident was seen in the emergency room for right leg pain following a fall at the facility on 1/30/2020 at approximately 8:00 p.m. She was evaluated and treated for [REDACTED]. The hospital assessed treatment plan documented: -Patient without urinary complaints, but did have significant pyuria (pus typically form a bacterial infection) in her urine sample. Treat for acute [MEDICATION NAME] (inflammation of the urinary bladder) with intravenous antibiotics. -Distal femur fracture from a mechanical fall. X-ray confirmed a comminuted (a break or splinter of the bone into more than two fragments) intra-articular (crossing into the joint) supracondylar (just above the joint) distal femoral fracture, comminuted intra-articular proximal tibia (widest part of the shin bone near the knee) fracture. Pain management provided in the emergency room , via a nerve block. -Surgical correction to repair fractured bone on 2/1/2020. Social services summary note dated 2/5/2020 3:00 p.m., read in part: Change of condition summary: Resident recently fell while transferring self and broke her femur. After acute hospital stay, she returned to the rehab transitional care unit neighborhood for skilled therapy/treatment. She will eventually return to her long term care suite. Resident is alert times three, indicated she has broken several other bones in her past and glad to have returned from the hospital to her home. She will have weekly progress grand round meetings with the interdisciplinary team (IDT) and her family. Social services will continue to follow for support services and monitor for needs. Fall risk assessment dated [DATE] revealed the resident was at high risk for falls. She had one fall since the last quarterly fall assessment and was on high risk medication (antidepressant, cardiovascular and narcotic [MEDICATION NAME] medication) with numerous health conditions placing her at increased risk for falls. She was not able to attempt standing without assistance needed assistance with toileting and was confined to a chair. D. Staff interviews The DON was interviewed on 2/11/2020 at 4:35 p.m. The resident's fall investigative report was reviewed during the interview. The DON said Resident #85 fell on [DATE]. Following a resident fall the nursing staff would assess the resident for potential injuries and provide medical care as needed. A registered nurse (RN) conducts a full assessment of the resident's condition and makes notifications to the physician, family and other appropriate persons. The staff will hold a post fall huddle to determine potential factors in the fall. The IDT is notified of all falls and they will review the falls to ensure a systematic approach to identify, evaluate, implement and monitoring of all contributing factors to eliminate and prevent future falls to the degree possible. I conducted a full investigation of the incident. We have a new system that incorporates the nursing note from the resident's electronic record and merges it with the investigative database. I review the nurse's notes detailing the fall, injury and treatment notes, and the 72 hour report notes looking for predisposing factors relating to the resident's fall. The investigative report for Resident #85s fall on 1/30/2020 showed the RN on duty assessed the resident's condition and found no injuries during the immediate assessment. The nurse provided Tylenol for expressed pain, and assisted the resident to bed. The nurse made sure the call light was in reach and educated the resident to use her call light to ask for staff help with transfers, the resident agreed to this. Based on the investigative findings there were no predisposing factors noted other than the resident had on regular socks and was not wearing non skid socks. Also the resident had not locked her wheelchair prior to attempting to transfer herself to bed. The resident's pain continued to worsen and x-ray results confirmed she fractured her femur. The resident was transported to the hospital on [DATE] at 12:48 a.m., she had surgery on 2/1/2020 and returned to the facility on [DATE]. The DON said the care plans are updated by the unit managers and the minimum data set coordinator and CNA and nurses were responsible to make sure care planned interventions were carried out. The CNA would have primary responsibility to make sure the resident had on non slip footwear for safe transfers. CNA #6 was interviewed on 2/12/2020 at 10:24 a.m. He said the CNAs are responsible to offer reminders to residents to be safe and put on non slip socks or other non slip footwear. Some residents are more fashion minded than others so we would have to work with them to make sure they are safe when walking around and transferring from place to place. If non slip socks are ordered for fall prevention we make sure to help the resident to put them on in the morning when assisting then to get dressed and throughout the day we would make sure they had on non slip footwear before any transfers and we would also check their feet for compliance with wearing the non slip socks at ever encounter. If the resident refused due to fashion sense or other personal preference, we would work with the resident and nurses to find an acceptable solution and document any refusal to comply with the order for safety. I am not aware of Resident #85 ever refusing to wear non slip socks when encouraged to wear them. RN #4 was interviewed on 2/12/2020 at 10:34 a.m. RN #4 said ensuring safe transfer and making sure the resident wears safe footwear is a twofold process. The CNAs use and access POC care plans to see the types and levels of care needs of each individual resident that they should be attending to. If a resident is at risk for falls there should be a care planned intervention under the safety care task section in POC which address interventions for safe transfers including nonslip and safe footwear. The CNAs should check the resident for application of safe footwear at the beginning of each shift, throughout the shift; during check-ins and each time they see or interact with the resident to ensure the resident has the prescribed intervention in place. Staff should not assist a resident with transfer unless the prescribed safety interventions are in place and they should intervene if they see a resident in an unsafe situation. If the resident was prescribed to wear non slip socks for fall prevention it should be on the resident's treatment administration record (TAR) and the nurse should be checking for compliance during medication pass and at every encounter. We have extra non slip socks in the clean utility room, and staff can pass them out to any resident in need. The nurse looked at the resident TAR and was unable to find an order for [REDACTED]. The nurses are primarily assigned the task of updating the care plan but sometimes it gets hectic on the unit. If we are not able to make the updates, due to patient care needs we will pass the task of updating to the care plan to the unit manager. In addition the CNAs will alert us to changes in care needs when POC is indicating a care need that is no longer relevant and we can go into the system and update the care plan. III. Resident #300 The resident fell in her room on 2/10/2020 sometime between 7:28 a.m. and 7:48 a.m. when the certified nursing aide (CNA) left her unassisted in the bathroom. The resident was left alone standing at the sink brushing her teeth when she lost her balance and fell . The resident was found minutes later, lying on the floor in the bathroom after the fall. The facility failed to provide a sufficient level of supervision and assistance per the resident's assessed need, as documented in the 2/9/2020 therapy assessment, to ensure the resident was safe. A. Resident status Resident #300, age 98, admitted on [DATE]. According to the January 2020 computerized physician's orders [REDACTED]. The MDS had not been completed as the resident was recently admitted less than 14 days ago. The initial nursing assessment dated [DATE] revealed Resident #300: -Was admitted due weakness and chronic diarrhea [MEDICATION NAME] six days. -Had full use of both upper and lower extremities. She had a gait disturbance and was unsteady and needed assistance from one staff person for transfers and walking using a walker and a wheelchair for longer distances. -Was alert and oriented to person, place, time and situation. The admission physical therapy evaluation and plan of treatment dated 2/9/2020 revealed: Referral: The resident was referred for skilled physical therapy services due to decreased functional activity tolerance, decreased functional strength, decreased balance and decreased independence with functional mobility. Precautions: Resident was a fall risk. Functional and underlying impairments: The resident required: Hand on assistance of one or more staff cuing for the majority of tasks. She became dizzy upon sitting up; she had poorly controlled descent (ability to lower herself into a seated position) and required assistance for immediate standing balance; and she had reduced proactive and reactive balance with weakness in the muscles that aid in the ability to extend the trunk and hip for movement. B. Resident interview Resident #300 was interviewed on 2/10/2020 at 9:44 a.m. The resident was lying flat on her back, she said I'm not doing so well, I just fell . The girl helped me to the bathroom but she didn ' t have time to help me brush my teeth. She helped me back to my recliner. After she left I got up and went to the bathroom to brush my teeth and wash my face. She came in to check on me in the bathroom, but did not stay. She left me alone to finish brushing my teeth. As I was finishing, I turned and lost my balance; I fell . I must have laid on the floor for 15 minutes before they came in to help me up. The nurse hasn ' t been back in to see me and I'm in terrible pain. My left side hurts terribly, I can barely move my leg. They better help me, I wish they would hurry up. I recently healed from a braking my right hip after a fall at home. C. Record review The fall risk assessment dated [DATE] revealed the resident was assessed to be at high risk for falls with a score of 15 out of 1. She was not steady and only able to stabilize with assistance. Ambulates with problems, assistive device and required assistance. Daily skilled observations note dated 2/8/2020 and 2/9/2020 revealed the resident had unsteady gait requiring supervision and weakness. She needed partial to moderate assistance with toileting, bed mobility, moving from a sitting to standing position, and chair to chair transfers due to extreme weakness. The admission physical therapy evaluation and plan of treatment dated 2/9/2020 documented the following test measures and outcomes based on the assessment completed on 2/9/2020. This section revealed the resident needed supervision and touching assistance with lying to sitting on the side of the bed, sitting to lying and rolling left to right. She needs partial moderate assistance to move from sitting to standing, chair to chair transfers and with toileting assistance. She could walk greater than 150 feet with supervision and touching assistance. Additional areas of need including: needing substantia(TRUNCATED)

Based on observation, record review and interviews, the facility failed to ensure two (#48 and #75) of five residents identified with skin impairment of 35 sample residents, received the necessary treatment and services to prevent pressure ulcers (pressure injuries) from developing, to promote healing, and to prevent new pressure injuries from developing. Specifically: Resident #75 was readmitted on [DATE] with intact skin but was identified at-risk for pressure injury. Record review and interviews revealed the facility failed to meet regulatory and facility expectations to prevent the resident from developing multiple pressure injuries after admission, including wounds on his left and right heels, coccyx/sacrum (5/12/17) and then his right buttock (5/29/17). The facility failed to ensure the resident's wounds were assessed by a qualified individual weekly, failed to timely obtain physician orders, and failed to provide wound care treatments. Finally, the facility did not provide evidence the above failures had been identified and addressed to prevent reoccurrence. Resident #48, too, acquired a pressure injury in the facility that worsened. Although an order for [REDACTED]. The findings included: I. Professional reference A. The National Pressure Ulcer Advisory Panel, NPUAP Pressure Injury Stages 2016, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (July, 2017), reveals the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A stage 2 pressure injury is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. An unstageable pressure injury is an injury with obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. - Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. - Heels should be placed in a position that eliminates pressure, referred to as floating the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure injuries and to promote healing: -- Positioning that places pressure on the pressure injury should be avoided. -- For heel injuries, the heel should be floated. -- The pressure injury should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -- The pressure injury should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -- Signs of deterioration in the wound should be addressed immediately. -- The assessment should include: Location Category/stage Size Tissue types Color Periwound (the skin around the wound) condition Wound edges Any undermining or tunneling Exudate Odor National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. II. Facility policy and procedure The 4/17 Skin Integrity Clinical Standard policy was provided by the health information director (HID) 7/6/17 at 10:30 a.m. The document revealed the following pertinent information: - Skin observations are completed upon admission and/or as needed. A weekly body check is done weekly or as needed . - Following the identification of a skin issue, A progress note will be completed in the resident's chart to include injury or wound type, size, location, color, drainage and amount, odor, signs or symptoms of infection, pain, treatments and notification of physician and family. Incident documentation will occur every shift for the next 72 hours . - Care plan will reflect current interventions for skin integrity issue and include preventive measures . - Weekly documentation of skin issue will include response to current treatment plan as well as wound type, size, location, color, drainage and amount, odor, signs and symptoms of infection, pain and resident's tolerance of treatment . III. Resident #75 Resident #75, age 94, was admitted on [DATE] and readmitted on [DATE]. According to the 6/3/17 minimum data set assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required supervision of one staff member with bed mobility, dressing, and toilet use, and supervision with set up assistance with transfers, eating, and personal hygiene. According to the resident's readmission face sheet, [DIAGNOSES REDACTED]. The resident's [DIAGNOSES REDACTED]. According to the 2/17/17 admission and 3/3/17 significant change Minimum Data Set (MDS) assessments, the resident had no unhealed pressure injuries, including [MEDICAL CONDITION], surgical wounds, skin tears, and moisture associated skin damage. The 6/3/17 MDS assessment, however, documented the resident was at-risk for the development of pressure injuries, and had one stage 2 pressure injury and two unstageable pressure injuries. The resident's care plan initiated on 2/10/17 and updated on 6/1/17, identified the resident had one or more pressure injury on the coccyx. See TAR (treatment administration record) for details. Interventions included: - Assess, record, and monitor wound healing weekly; - Measure length, width, and depth where possible; - Assess and document status of wound perimeters, wound bed, and healing progress; - Report improvements and decline to the medical doctor (MD); and - If the resident declined treatment, educate and confer with resident, interdisciplinary team (IDT), and family to determine why and try alternative methods to gain compliance. Document alternative methods. The care plan initiated on 3/24/17 and updated on 6/1/17, identified the resident had actual skin impairment to skin integrity. The resident's left and right heel, abrasion to the right buttock, abrasion to the right posterior thigh, and weeping [MEDICAL CONDITION] on the right lower leg. Interventions included: - Dressing changes as ordered by the MD. See the TAR for wound orders; - Follow protocols for treatment of [REDACTED].>- Identify and document potential causative factors and eliminate and resolve where possible; - Monitor and document location, size, and treatment of [REDACTED].>- Report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the MD; and - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and any other notable changes or observations. The 6/15/17 Monthly Nursing Observation read the resident the resident did not reject evaluation or care. The 6/17 Bathing Self Performance report was reviewed. The document did not reveal skin checks. A. Resident skin status 5/12/17-7/2/17 1. Record review Record review revealed the resident developed a stage 2 pressure injury to the coccyx (5/12/17), a buttock injury from shearing (5/29/17), and an unstageable injuries to the areas on right and left heel (onset date not documented). The injuries were not assessed weekly, not monitored as expected, and not properly documented. There was insufficient evidence to show orders to treat the injuries were timely obtained and consistently implemented. Coccyx wound: The 5/12/17 Weekly Wound Observations revealed the resident had a stage 2 pressure injury to the coccyx. The measurements were 0.6 cm x 0.6 cm x 0.2 cm. The wound was acquired and not present upon admission, and the date of onset was 5/12/17. There was serous drainage, and the surrounding skin color, tissue, and wound edges were normal for skin. The treatment plan revealed, cleanse area with normal saline, skin prep (protective barrier cream), and cover with duoderm. There were areas of blanchable redness on the left buttock 9 x 5 and right buttock 8 x 4.5. The 6/13/17 Weekly Body Check, revealed the resident had a pressure injury to the coccyx. The document did not reveal the wound size, stage, color, drainage and amount, odor, signs and symptoms of infection, pain, and resident's tolerance to treatment. The 6/13/17 Weekly Wound Observations revealed the resident had a stage 2 pressure injury to the coccyx. The measurements were 0.8 cm x 0.3 cm x 0.2 cm. This represented an increase in the size of the coccyx wound since the onset date of 5/12/17. Despite the documentation above, neither the 6/15/17 Monthly Nursing Observation nor the 6/20/17 Weekly Body Check documented the resident's coccyx wound. The 6/22/17 Weekly Wound Observations revealed the resident had a stage 2 pressure injury to the coccyx. The measurements were 0.8 cm x 0.3 cm x 0.2 cm. There was serous drainage, and the surround skin color, tissue, and wound edges were normal for skin. The treatment plan revealed calazyme to the affected area. The assessment was completed by Unit Manager (UM) #2, a licensed practical nurse (LPN). Between 5/12/17 and 6/22/17, the Weekly Wound Observations documented a treatment change. However, review of the medication review report and 6/17 TAR did not reveal treatment orders for the coccyx wound. The 6/27/17 weekly body check revealed the resident had a pressure injury to the coccyx. The document did not reveal the wound size, stage, color, drainage and amount, odor, signs and symptoms of infection, pain and resident's tolerance of treatment. Buttock shear: A 5/29/17 Incident Note revealed when the resident's coccyx dressing was removed, the adhesive area sheared off a 1.2 cm x 0.5 cm of skin on the buttock. There was red blood noted from the sheared area, and the area was cleaned and border gauze applied. According to the Medication Review Report, treatment was ordered on [DATE] for a right buttock abrasion, see below for additional details. Record review (confirmed in staff interviews below) revealed no further documentation to show the buttock wound was observed weekly until 7/5/17 (during survey). Although a 6/10/17 incident note revealed the resident had a superficial abrasion to the right buttock, it could not be determined if this was a new shear injury or the injury that occurred 5/29/17. Heel wounds: The 6/13/17 weekly wound observations, completed by UM #2, revealed the resident had an unstageable injury to the right heel. The wound was acquired and not present upon admission. The date of onset was not documented. The 6/22/17 Weekly Wound Observations revealed the resident had unstageable injuries to the right and left heel. The assessments were completed by UM #2. The 6/28/17 TAR did not reveal treatments were provided to the two open areas on the inner left heel, one area on the left out heel, one area on the right heel, and an abrasion to the right buttock. There were no progress notes on 6/28/17 explaining why the treatments were not completed. The 6/29/17 and 6/30/17 weekly wound observations revealed the resident had a unstageable injuries to the right and left heel. The assessments were completed by UM #2. 2. Staff interviews Staff interviews revealed a system for assessment and monitoring of pressure injuries which was not reflected in resident #75's record (see above). UM #2 was interviewed on 7/3/17 at 2:23 p.m. She said she was responsible for completing all of the residents' weekly wound observations. -She said she was a LPN and was responsible for assessing, measuring and staging the wounds. She said at times, a wound nurse or the director of nursing (DON) would assist on the wound rounds, but said she was unable to provide documentation that showed the resident's wounds had been observed by the wound nurse or the DON. She was not aware of any restrictions or expectation that a registered nurse (RN) was required to assess the wounds. -She said Weekly Wound Observations were not completed exactly one week apart from one another. Different wounds were observed on different days, and concerns related to the wounds were reported the physician. There was no physician order requiring weekly monitoring of the wounds, and an order was not required. -She said floor nurses, some RNs, were responsible for completing the weekly body checks. The body checks did not include descriptions, measuring and staging of the wounds. -She reviewed the 6/28/17 TAR and progress notes, and confirmed the documentation of treatments on this date was incomplete. She said the nurses were required to write a progress note revealing why the treatments were not completed, or if the information was not documented by error. LPN #2 was interviewed on 7/3/17 at 3:18 p.m. She said the nurses were responsible for completing the weekly body checks. The checks were not an assessment, but observations. The checks did not reveal the wound size, stage, color, drainage and amount, odor, signs and symptoms of infection, pain, and resident's tolerance of treatment. Concerns were required to be recorded in the progress notes as needed. RN #4 was interviewed on 7/5/17 at 11:50 a.m. She said she was responsible for completing the weekly body checks. -She said the body checks were completed weekly by an RN or LPN, and the findings documented on the assessment or a progress note. The assessment did not include observation, measuring or staging of the wounds. RN #4 said UM #2 was responsible for monitoring wounds and completing the Weekly Wound Observations. RN #4 agreed, however, that a LPN can observed wounds, but cannot assess the wounds. -She reviewed the resident's clinical record and confirmed the 6/28/17 treatments were not completed. She revealed the nurses were required to complete a progress note identifying why the treatment was not completed. -RN #4 agreed weekly assessments were important for monitoring and tracking wounds, and determining possible growth and infection. RN #2 was interviewed on 7/5/17 at 5:20 p.m. She said skin checks and wound observations were completed weekly. The skin checks were completed by the nurses and the wound observations were completed by the UM #2. Following the identification of a new wound, an incident report was created to determine the cause and appropriate treatments for the wound. Open wounds required medicated treatment, where reddened or sensitive areas required skin prep. The DON was interviewed on 7/5/17 at 5:51 p.m. She said wound observations were required to be completed weekly following the identification of a new injury. UM #2 was responsible for the Weekly Wound Observations and was assisted at times by a wound nurse. The wound nurse was responsible for observing and making treatment recommendations. She said the wound nurse does not document her findings or visits. The assistant director of nursing (ADON) was interviewed on 7/5/17 at 6:05 p.m. She said body checks were required to be completed weekly, and wound observations were required to be completed weekly following the identification of a new injury. The physician and family were notified, and treatment orders were obtained and implemented. A LPN can observe wounds, but cannot assess. A wound nurse was available twice a month, and her role was to observe and make treatment recommendations. She does not document her findings. Missed wound treatments were required to be documented, and the findings documented in the progress notes. The ADON said weekly skin assessments were important for the identification of new injuries, and the weekly wound checks were important for tracking progress and interventions. B. Resident status 7/3/17 1. Wound Observation The resident's coccyx and buttock wounds were observed on 7/3/17 at 3:18 p.m. with UM #2 and LPN #2. The right buttock wound was unopened, pink, and had an area of excoriation. The coccyx wound was pink and had a one-half inch open area at the top, located inside of the folds of the buttock. UM #2 observed the area and reported the wound was a stage 2 pressure injury. The resident revealed he was able to feel the sore spot on his bottom if he sat a certain way. 2. Record review The 7/3/17 medication review report revealed orders to cleanse and treat two open areas on the inner left heel, one area on the left out heel, one area on the right heel, and an abrasion to the right buttock. The 5/31/17 order for the right buttock abrasion revealed, cleanse area with normal saline, apply thin layer of calazyme, and open to air every day shift. Document the appearance, and any signs and symptoms of infection with each dressing change. The 5/29/17 order details revealed monitor the sheered area to the right side of the buttock, and cover with dry dressing until resolved. There were no orders for the treatment of [REDACTED]. The 7/3/17 progress notes, including physician note, did not reveal the resident's wounds to the buttock and coccyx. 3. Staff interviews LPN #2 was interviewed on 7/3/17 at 11:50 a.m. She said the resident had an open area to the coccyx and shearing on the right buttock. She reviewed the orders and reported there were no orders for the treatment of [REDACTED]. UM #2 was interviewed on 7/3/17 at 2:23 p.m. She said the resident had one pressure injury to the right heel, two pressure injuries to the left heel, and one stage 2 pressure injury to the coccyx. She said the buttock wound was shearing. She reviewed the resident's medical record and revealed the coccyx wound did not have orders for treatment, and weekly skin observations were not completed weekly for the coccyx and buttock wounds. At 3:18 p.m. she said the open area on the coccyx did not have dressing orders and [MEDICATION NAME] cream was used on the wound without an order. C. Resident status 7/4/17 1. Record review Between 6/22/17 and 7/4/17 (12 days) there were no Weekly Wound Observations completed for the coccyx wound. The 7/4/17 weekly body check revealed the resident had a pressure injury to the coccyx and moisture associated skin damage to the right buttock. The document did not reveal the wound size, stage, color, drainage and amount, odor, signs and symptoms of infection, pain and resident's tolerance of treatment. D. Resident status 7/5/17 and 7/6/17 1. Wound observation The coccyx and buttock wounds were observed on 7/5/17 at 5:20 p.m. with RN #2 and RN #4. Both RNs revealed they provided wound care to the resident on a regular basis. The wound was open, the bed of the coccyx wound was yellow, and there was a scant amount of serous drainage noted on the resident's incontinence brief. The nurses measured the wound, concluding the wound was 1.0 cm x 0.7 cm x 0.2 cm and stage 2 pressure injury. Additionally, the nurses noted the resident had a scabbed area to the right buttock, measuring 2.0 cm x 0.2 cm x 0.2 cm, and a surrounding area measuring 0.8 cm x 0.5 cm which was a stage 2. The nurses cleansed and applied a thick layer of [MEDICATION NAME] cream to all areas. 2. Record review Record review revealed inconsistent documentation of the resident's buttock wound and orders for treatment of [REDACTED]. The 7/5/17 weekly wound observation revealed the resident had a stage 2 pressure injury to the coccyx. The measurements were 1.0 cm x 0.5 cm x 0.2 cm. There was serous drainage, and the surround skin color, tissue, and wound edges were normal for skin. There were no changes made to the treatment plan, and the document revealed continue to monitor two times a day. There were orders to cleanse with normal saline and apply thin layer of [MEDICATION NAME] to the affected area. The assessment was completed by UM #2. Between 5/12/17 (onset date), 6/22/17, and 7/5/17, the coccyx wound increased in size. The 7/5/17 telephone order revealed for the coccyx wound, cleanse the area with normal saline, apply thin layer of [MEDICATION NAME] barrier protection cream as needed. Document the appearance, and any signs and symptoms of infection with each dressing change. For the right buttock abrasion, cleanse areas with normal saline, apply thin layer of calazyme, and leave open to air. Document the appearance, and any signs and symptoms of infection with each dressing change and every day shift, document appearance, and any signs and symptoms of infection with each dressing change. On 7/6/17 at 10:08 a.m. the Weekly Wound Observation for the new open area, stage 2, on the right buttock was provided. The document was incomplete, but revealed the wound was acquired with a date of onset of 7/5/17. The document did not reveal the wound size, stage, color, drainage and amount, odor, signs and symptoms of infection, pain and resident's tolerance of treatment, or the buttock wound. On 7/6/17 at 11:45 a.m. the completed Weekly Wound Observation was received and revealed the resident had a stage 2 pressure injury to the right buttocks. The measurements were 1.4 cm x 0.4 cm. The new date of onset was 5/29/17. The wound bed had [MEDICATION NAME] tissue, the surrounding skin was pink, and the surrounding tissue/wound edges had hardness/induration. The [MEDICATION NAME] was discontinued and nutrashield with silicone blends was started. A 7/6/17 telephone order revealed for the buttock wound, cleanse with normal saline, and apply thin layer of nutrashield barrier cream. The order details revealed the resident had an open area, stage 2 to the right buttock. 3. Staff interviews UM #2 was interviewed on 7/5/17 at 10:57 a.m. She said she contacted the physician assistant on 7/5/17 and asked for treatment order clarification. She revealed she observed the coccyx wound and determined it was an open stage 2. She did not complete an observation for the buttock shearing, but revealed the wound was moisture associated skin damage, not a pressure injury. She confirmed after the lack of treatment orders for the coccyx wound were brought to her attention on 7/3/17, new orders were not obtained until 7/5/17 and a Weekly Wound Observation was not completed until 7/5/17. At 5:38 p.m. UM #2 said she had completed her wound rounds for the day. She had documented the coccyx wound was 1.0 cm x 0.5 cm x 0.2 cm., and RN #2 and RN #4 had documented the wound was measured at 1.0 cm x 0.7 cm x 0.2 cm The documentation did not note the buttock wound was an open stage 2 pressure injury, and a new Weekly Wound Observation was not started. UM #2 revealed she did not observe the buttock wound to assess and determine the area was moisture related skin damage She said following the identification of an open wound, the physician and family were required to be contacted and new interventions put into place, including a medication treatment and dressing for the buttock wound. IV. Resident #48 Resident #48, age 86, was admitted on [DATE]. According to the 6/17 computerized physician orders (CPOs), the resident's [DIAGNOSES REDACTED]. According to the 5/8/17 minimum data set (MDS) assessment, the resident had short-term and long-term memory problems and moderately impaired decision-making skills regarding tasks of daily life. He required total dependence of two people with transfers. He required extensive assistance of two people with bed mobility, dressing, eating, toileting and personal hygiene. The MDS indicated the resident did not have one or more unhealed pressure ulcers stage one or higher. A. Resident wound status Review of resident's medical record revealed he acquired a pressure injury at the facility. The skin integrity care plan, initiated on 3/25/17 and revised on 6/29/17, revealed the resident had a small open area to the left buttock. The interventions included: encouraging the resident to lay on his side or allow staff to prop the resident to the side to offload the pressure from the buttocks; monitor/document location, size and treatment of [REDACTED]. The 5/6/17 quarterly Braden scale for predicting pressure injuries revealed the resident was at a moderate risk for pressure injuries with a score of 14 out of 18. The 6/28/17 nursing progress note revealed a certified nurse aide (CNA) informed the nurse the resident had an open area to the left buttocks. The note indicated the open area measured 0.7 centimeters (cm) by 0.4 cm. The note further read the nurse cleansed the open area and applied [MEDICATION NAME] treatment and staff was to continue to monitor the open area. The 6/29/17 weekly wound observation assessment revealed the resident had an open area to the left buttocks. The assessment read the open area was a stage two pressure injury which measured: 0.7 cm by 0.4 cm by 0.2 cm. The family and physician were notified of the newly acquired pressure injury on 6/29/17. B. Failure to implement wound treatment as ordered and prevent worsening of the pressure injury Record review revealed no documentation physician orders to treat the resident's pressure injury were implemented and the resident's injury had worsened. The 6/17 physician's orders revealed the following treatment order: - [MEDICATION NAME] to open area on left buttock twice a day and as needed - ordered started on 6/29/17 at 6:00 p.m. The 6/17 medication administration record (MAR) and treatment administration record (TAR) did not reveal the treatment order for the left buttock pressure injury. The 7/17 MAR and TAR did not reveal the treatment order for the left buttock pressure injury. The 7/5/17 weekly wound observation assessment revealed the resident had an open area to the left buttocks. The assessment read the pressure injury was acquired at the facility and the wound had deteriorated in response to the current treatment. The wound was described as a stage 2, measuring 2.5 cm by 3.0 cm by 0.2 cm. The pressure injury was observed on 7/6/17 at 3:55 p.m. The pressure injury measured 2.5 cm x 3 cm, with a pink wound bed with no drainage. After observing the wound on 7/6/17, the unit manager (UM) #1 and the director of nursing (DON) confirmed the pressure injury was a stage 2 and the wound had significantly increased in size. C. Staff interviews Registered nurse (RN) #1 was interviewed on 7/5/17 at 2:52 p.m. She said when a resident was identified to have an open area, the physician or nurse practitioner should be contacted immediately and a treatment order obtained. She said the treatment order was then input into the resident's electronic medical record. She said the treatment order should automatically be transcribed to the TAR by the computer. -She confirmed the MAR or TAR did not indicate a treatment order for the resident's pressure injury to the left buttocks. She said the physician's treatment order was input incorrectly into the resident's electronic medical record. She said the physician's order was classified as other order with no documentation required. -She confirmed the resident's medical record did not indicate the treatment order had been implemented or completed as ordered by the physician. -She indicated the treatment ordered 6/29/17 would continue until the facility wound nurse would be able to assess the pressure injury five days later, on 7/11/17. The DON and assistant director of nursing (ADON) were interviewed on 7/5/17 at 3:11 p.m. -The DON said when a new open area was identified on a resident, a risk watch should be completed and the physician or nurse practitioner notified to obtain a treatment order. She said the treatment order should be input into the resident's electronic medical record and indicate the order to be transcribed onto the TAR and all treatments should be signed off when completed on the TAR. -She confirmed the TAR did not reveal the ordered treatment to the left buttock had been completed by staff since the order date of 6/29/17 to 7/5/17. The DON and ADON were interviewed again on 7/5/17 at 5:41 p.m. The DON confirmed the physician's treatment order was not entered into the resident's electronic medical record correctly. She said the staff member who entered the initial treatment order should have ensured it was entered correctly and transcribed onto the TAR.