Colorow Health Care Llc

F-F600: failure to protect residents from abuse.

-The 2/18/25 nursing note did not document what kind of injuries were on her arms and where the injuries were on her arms.

-The note did not identify how Resident #3 sustained the old bruising to her arms or when the bruising occurred.

-The review of the resident's EMR did not identify what the old bruising was from or when it occurred.

C. Staff interviews

The NHA and the director of nursing (DON) were interviewed together on 5/7/25 at 4:03 p.m. The NHA said Resident #3's injuries to her arms on 2/18/25 were identified after she was involved in a resident-to-resident altercation on 2/17/25.

The NHA and the DON said they did not know what the old bruising was from, when it occurred or if there was old bruising actually present, even though it was documented on a 2/18/25 nursing note. The NHA and

the DON said they were not aware of the bruising/discoloration documented in the 2/4/25 weekly nursing documentation.

The DON said the last known bruising on the resident's arms prior to 2/4/25 was in December 2024 when Resident #3 was combative with care.

The NHA said she reviewed Resident #3's EMR. The NHA said the 2/4/25 bruising/discoloration to the resident's forearms and the old bruising to the resident's arms, identified on 2/18/25, were not documented anywhere else. The NHA said the staff should go back into Resident #3's EMR to create a risk management report or document when the bruising was first observed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The NHA said bruises and injuries of unknown origin needed to be investigated according to the facility's policy. She said the bruising on Resident #3's arms should have been investigated to rule out abuse. The Level of Harm - Minimal harm or NHA said the documented 2/4/25 bruises and the old bruises identified on 2/18/25 were not investigated. potential for actual harm She said she should have been notified of the bruising so she could have started an investigation if Resident #3's bruising was of unknown origin. The NHA said she would interview staff today (5/7/25) regarding the Residents Affected - Few 2/4/25 and 2/18/25 bruising. The NHA said she would look at the resident's skin to determine if the resident still showed bruising or discoloration.

III. Facility follow-up

The NHA provided documentation of a staff interview that was conducted on 5/8/25, physician notes and skin

observation sheet (2/1/25 to 2/16/25) on 5/8/25 via email.

The 5/8/25 staff interview was conducted by the unit manager (UM). It documented she interviewed licensed practical nurse (LPN) #3 regarding her 2/18/25 documentation (on Resident #3). The UM documented LPN #3 did not recall any skin issues. The staff interview sheet documented the nurse who wrote the 2/4/25 note (weekly nursing documentation) no longer worked at the facility.

The 2/5/25 physician encounter note did not identify if there was bruising or discoloration on Resident #3's arms at the time of the exam. The note documented the resident's skin was examined and there were no physical findings pertinent to the encounter. The note identified the physician saw Resident #3 on 2/5/25 due to her lethargy and lack of intake.

The 2/17/25 physician encounter note documented Resident #3 was involved in a resident-to-resident incident. The encounter note did not identify if there was old bruising, new or any bruising or discoloration on Resident #3's arms. The note documented the resident's skin was examined and there were no physical findings pertinent to the encounter. The note identified the physician saw Resident #3 on 2/17/25 due to the resident's family's request to review her pain control.

The February 2025 (2/1/25 to 2/16/25) skin sheet identified the nursing staff marked no to the question is there a new skin issue on the skin observation sheet.

-A record of the skin observation sheet after 2/16/25 was not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 065354

F-F610: failure to investigate abuse.

According to the 2/18/25 note, Resident #3 remained in the common area so staff could monitor her safety.

The note indicated Resident #3 continued to be on 15-minute checks to observe and monitor Resident #3's whereabouts and safety.

C. Resident #1 (assailant)

1. Record review

The 2/17/25 nursing progress note, documented Resident #1 walked to the dining room after the resident-to-resident altercation. According to the note, Resident #1 was very anxious and restless during the shift. The note indicated Resident #1 would be monitored of her whereabouts and continue on 15-minute checks.

The 2/21/25 interdisciplinary team (IDT) risk management review note documented Resident #1's physical aggression on 2/17/25 was related to her constipation, anxiety and possible pain. According to the note her medications were reviewed. Her bowel medication was discontinued and she was placed on a new bowel medication. Staff were educated to utilize Resident #1's PRN morphine. Resident #1 was newer to the facility and staff were still learning her behavior triggers. Resident #1 had excessive anxiety which hospice was trying to manage, she had a difficult time communicating and at times would use a white board to communicate.

IV. Incident of physical abuse of Resident #1 by Resident #4 on 2/28/25

A. Facility investigation

The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation documented there was a physical abuse altercation that was witnessed between Resident #1 and Resident #4 on 2/28/25.

The investigation report included three interviews from staff witnesses and notification of the incident to the appropriate parties. The investigation report documented that neither resident involved in the altercation and no resident witnesses were able to be interviewed due to significant memory impairments. Resident #1, Resident #4, and three other resident witnesses were placed on observation for physical or behavioral changes for 72 hours after the altercation occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The investigated report documented Resident #4 pushed Resident #1 causing Resident #1 to fall backward when Resident #4 attempted to take Resident #1's shoe on 2/28/25 at 6:00 p.m. The two residents were Level of Harm - Minimal harm or separated and LPN #1 contacted the DON who was on site. The residents were separated and no injuries potential for actual harm were observed. The residents were placed on 15-minute checks 72 hours after the altercation. The investigation documented Resident #4 did not like clutter and liked to clean, which led to the altercation. The Residents Affected - Some investigation documented the underlying cause for the altercation was that Resident #1 was unable to communicate verbally and recently had her routine changed when her roommate had to move to a different room. Staff were educated following the interdisciplinary team (IDT) meeting 3/3/25.

The investigation report documented LPN #1 who witnessed the event was interviewed. LPN # 1 said she observed Resident #4 attempt to take Resident #1's shoe. Resident #1 pulled the shoe back, then Resident #4 pushed Resident #1 causing Resident #1 to fall backward. LPN #1 contacted the DON who was on site. LPN #1 said that she felt she had adequate training related to preventing resident-to-resident abuse but she just could not get to the residents in time to stop the altercation.

B. Resident #4 (assailant)

1. Resident status

Resident #4, age greater than 65, was admitted on [DATE REDACTED]. According to the May 2025 CPO, diagnoses included anxiety and dementia with restlessness and agitation.

The 4/1/25 MDS assessment revealed the resident had short-term and long-term memory deficits, per staff assessment. She required substantial assistance with personal hygiene, bathing and dressing. She required cues and supervision with toileting.

The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) towards others.

The assessment indicated the resident exhibited physical behaviors (hitting, kicking, pushing, or grabbing) towards others.

The assessment indicated the resident wandered daily and the wandering, as well as behaviors, significantly intruded on the privacy or activity of others.

2. Record review

The dementia care plan, initiated 4/10/24 and revised 3/11/25, indicated Resident #4 had behaviors of being disruptive or intrusive towards other residents, wandering and exit seeking, mood issues or tearfulness, sleep disturbances, poor safety awareness and delusions or hallucinations. Pertinent interventions included offering non-pharmacological interventions prior to administering PRN medication. The care plan indicated

the non-pharmacological interventions included removing clutter from areas to reduce her anxiety, redirecting her to activities she was interested in, including gardening and cleaning, range of motion therapy, massage, relaxation and breathing techniques, imagery and distraction techniques, aromatherapy, or offering snacks or drinks, separating her from other residents when agitated and providing one-to-one support if needed until

she was calm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The anti-psychotic medication care plan, initiated 4/10/24 and revised 3/5/25, indicated Resident #4 had behaviors of physical aggression, including hitting, kicking, or biting and verbal aggression, including yelling, Level of Harm - Minimal harm or screaming, or cursing at others. Pertinent interventions included offering non-pharmacological interventions potential for actual harm prior to administering a PRN medications. The care plan indicated the non-pharmacological interventions included cold therapy, range of motion therapy, massage, relaxation and breathing techniques, and use of Residents Affected - Some imagery and distraction techniques to redirect the resident.

The nursing progress note, dated 2/28/25 at 9:14 p.m., documented Resident #4 attempted to take a shoe from Resident #1. Resident #1 pulled her shoe back and Resident #4 pushed Resident #1 down causing Resident #1 to fall down. Interventions included separating the residents and initiating 15-minute checks. Both residents were assessed for injuries and no physical injuries were noted.

C. Resident #1 (victim)

1. Record review

The nursing progress note, dated 2/28/25 at 8:48 p.m., documented Resident #4 attempted to take a shoe from Resident #1. Resident #1 pulled her shoe back and Resident #4 pushed Resident #1 down causing Resident #1 to fall down on her bottom with her back against the tray table. Interventions included separating

the residents and initiating 15-minute checks. Both residents were assessed for injuries and no physical injuries were noted.

V. Incident of abuse between Resident #3 and Resident #1 on 3/22/25

A. Facility investigation

The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation documented on 3/22/25 at 3:35 p.m. Resident #3 was making her rounds and stopped at Resident #1's doorway. Resident #3 was looking in Resident #1's room. According to a CNA witness statement, the CNA saw Resident #3 attempt to force her way into Resident #1's room. The investigation documented Resident #3's walker touched Resident #1 and Resident #1 pushed against the walker. According to the nursing note, Resident #3 made contact with Resident #1's left side of her face.

-The note did not identify in what way Resident #3 made contact with Resident #1's face. Resident #1 then pushed Resident #3, causing Resident #3 to hit her right side hip on the floor and the right back side of her head on the door frame as the CNA entered the room.

According to a nurse witness statement the registered nurse (RN) heard a resident's loud voice in the hallway. The RN observed Resident #3 laying on the floor on the right side of her body and the CNA was holding her head. Another resident (Resident #1) was standing in front of Resident #3 and was touching the left side of her face. There was slight redness to her face. According to the witness statement, there was no obvious injuries to Resident #3 but she complained of pain in her right elbow. The statement documented the CNA told the nurse she was redirecting another resident when she saw Resident #3 make contact with Resident #1's left side of her face. The CNA said Resident #1 placed her hands on Resident #3's bilateral arms, resulting in Resident #3 losing balance and falling to the floor. The CNA who witnessed the incident was able to hold Resident #3's head as she fell to soften the hit to the head and the resident's head made contact with the door frame.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 According to the staff interview, the RN felt one-on-one conversations, companionship and speaking in a calm and positive tone were interventions that worked well with Resident #3. The investigation identified staff Level of Harm - Minimal harm or placed stop signs at both resident's doors. Resident #1 received more speech therapy treatments with potential for actual harm collaboration with hospice to include devices such as picture boards.

Residents Affected - Some B. Resident #3 (victim and assailant)

1. Record review

The 3/22/25 nursing progress note documented Resident #3 was on 15-minute checks due to a resident-to-resident altercation this shift (3/22/25). According to the note, Resident #3 had a witnessed fall with head involvement from the altercation.

The 3/23/25 at 4:39 a.m. nursing progress note identified Resident #3 was on alert charting for a resident-to-resident altercation and a witnessed fall. According to the note, Resident #3 started hitting and yelling at staff to get out (of her room) when they attempted to get her vital signs. The staff attempted to try to reassure the resident but she continued to yell and hit the staff.

C. Resident #1 (victim and assailant)

1. Record review

The 3/22/25 nursing progress note documented the nurse heard a resident's loud voice in the hallway. The nurse then observed Resident #1 standing in front of her door and another resident (Resident #3) was on the floor with the CNA holding Resident #3's head. Resident #1's left hand was touching the left side of her face which was slightly red. There were no open wounds identified on either resident. Resident #1 was redirected and was kept separated from Resident #3 throughout the shift. According to the note, the residents were placed on 15-minute checks and a stop sign was placed over Resident #1's door to ensure other residents would not enter her room. The note identified the redness on Resident #1's face dissipated by the end of the shift. The note documented a CNA witnessed the event and reported the CNA was standing outside of the room, redirecting another resident. The CNA witnessed Resident #1 make contact with Resident #3's walker. Resident #3 made contact with the left side of Resident #1's face. Resident #1 then placed her hands on Resident #3's bilateral arms, which made Resident #3 lose her balance and fall to the floor.

VI. Staff education

The 3/24/25 staff education was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The education agenda identified 10 staff members, which included two licensed practical nurses (LPN) and eight CNAs who worked on the memory care unit, attended the education. The education outlined the interventions of a stop sign on the doorway of Resident #1's and Resident #3's rooms to help keep others out of their space, utilizing pictures/whiteboard for communication speech working with Resident #1 to help her with better communication, speaking to Resident #3 in a calm manner, not telling her what to do and monitoring Resident #3 so that she does not intrude on other spaces and cause behaviors.

VII. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The unit manager (UM) and the NHA were interviewed together on 5/7/25 at 12:15 p.m. The UM said the staff on the memory care unit should know the residents and their preferences to develop interventions and Level of Harm - Minimal harm or individualized care plans. She said to help prevent resident-to-resident altercations, the staff should have potential for actual harm eyes on the residents and de-escalate/redirect residents if they became agitated. The UM said individualized resident information sheets were created. The UM said the sheets identified residents' preferences, behavior Residents Affected - Some triggers, what to watch for and a quick reference to residents' interventions. The UM said sometimes behaviors were an unmet need.

The UM said Resident #3 had behaviors with staff during care and had difficulty trusting people. She said

she needed familiar and consistent staff. The UM said Resident #3 would round the hallways, checking on residents because she used to work at an assisted living facility. The UM said staff watched her as she rounded the halls to make sure she was not intrusive or disruptive to other residents. She said Resident #1 did mind if Resident #3 peeked in her room, she just did not want Resident #3 to enter her room.

The UM said to prevent more resident-to-resident altercations from occurring between Resident #1 and Resident #3, the staff placed a stop sign across the Resident #1's room so Resident #3 did not enter her room. The UM said they also encouraged the staff to speak to the residents in a calm manner because they did not like being told what to do, offering the residents walks, intervening when needed and watching for chronic pain. The UM said staff needed to keep Resident #1 in direct line of sight when she was out of her room. She said Resident #3 did not require a direct line of sight. She said staff should just generally watch her. The UM said the resident-to-resident altercations between Resident #1 and Resident #3 occurred mainly because Resident #3 entered Resident #1's room. The UM said Resident #1 would put up her own sign and shut her door.

The NHA said Resident #1 was not having physically aggressive behaviors prior to the 2/15/25 altercation.

She said neither resident was involved in resident-to-resident altercations prior to 2/15/25. The UM said Resident #1 had no known altercations prior to the 2/15/25 until she was hit by Resident #3. The UM said

after the 2/15/25 resident to resident altercation, Resident #1 initiated the other resident-to-resident altercations. The NHA said Resident #1 did not like other people in her space. The NHA said the first three resident-to-resident altercations (2/15/25, 2/17/25 and 2/28/25) involved Resident #1 and Resident #3. The UM said she thought Resident #1 recognized Resident #3 from prior[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40467 potential for actual harm Based on record review and interviews, the facility failed to investigate an allegation of abuse and neglect for Residents Affected - Few one (#3) of four residents out of six sample residents.

Specifically, the facility failed to complete thorough and timely investigations when Resident #3 sustained injuries of unknown origin.

Findings include:

I. Facility policy and procedure

The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 5/7/25 at 3:45 p. m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms.

If resident abuse, neglect, exploration, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

According to the abuse policy, the facility would conduct an investigation to include interviews with staff members, residents, or family members who may have knowledge of the incident.

II. Resident #1

A. Resident status

Resident #3, age greater than 65, was admitted on [DATE REDACTED]. According to the May 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia and other diseases elsewhere classified, severe with agitation, lack of coordination and anxiety disorder.

The 4/1/25 minimum data set (MDS) assessment identified Resident #3 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #3 needed staff assistance with most of her activities of daily living (ADL).

B. Record review

The dementia care plan, revised 3/6/25, identified Resident #3 had impaired cognitive function/dementia or impaired thought processes related to dementia.

The ADL care plan, initiated 12/18/24, identified Resident #3 required skin inspections and directed staff to observe for redness, open areas, scratches, cuts and bruises and report changes to the nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 065354 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065354 B. Wing 05/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The skin care plan, initiated 4/4/25, documented if the resident had a bruise or skin tear, staff should treat the injury per facility protocol and notify the physician and family. The care plan directed staff to identify potential Level of Harm - Minimal harm or causative factors and eliminate/resolve the causation factors when possible. potential for actual harm

The 2/4/25 weekly nursing documentation form documented Resident #3 had an existing skin condition Residents Affected - Few identified as bruising and noted the resident had some discoloration on her forearms.

Review of Resident #3's electronic medical record (EMR) did not identify the bruising or discoloration on her forearms prior to the 2/4/25 weekly nursing documentation form.

The 2/18/25 nursing progress note documented Resident #3 was on alert charting for a resident-to-resident incident on 2/17/25. The note documented Resident #3 was observed to have injuries to her arms. The nursing progress note identified Resident #3 also had old bruising to her arms.

Cross reference: