Every finding on record at Correctionville Specialty Care

Based on clinical record review, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 4 out of 4 residents (Resident #3, #4, #6 & #8) reviewed from abuse. The facility reported a census of 35 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of depression, anxiety disorder and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the facility provided Incident Report dated 4/10/26 at 1:00 p.m., revealed Certified Nursing Assistant (CNA) reported that while giving the resident a bath the resident stated, I was eating in the living room but today I moved back to the dining room. She was asked why by the CNA. The resident responded I am afraid male resident is going to grope me. CNA verified the male resident. Resident continued to state last night male resident tried to put his hand up my shirt. CNA asked the resident if she told the male to stop. The resident stated yes, I said stop people are going to see, we are going to get into trouble. The resident stated, you are not going to like what I have to say. Male resident put his hand up my shirt twice. I told him no and he kept doing it. She explained what the male looked like, then stated that the resident did stop when she told him no. The resident denied wanting to call the police. The resident stated this happened at dinner in the dining room. Review of the Progress Notes revealed late entry dated 4/10/26 at 1:38 p.m., with a created date of 4/14/26 at 8:00 a.m., entered by the Administrator revealed resident reported to CNA that a male resident tried to touch her breast while eating supper. Resident was asked by the CNA if she had told the male resident to stop. Resident stated that yes I told him to stop, people are going to see and we're going to get into trouble. Interview on 5/4/26 at 10:25 a.m., with Resident #4 revealed has only had one incident where another resident has touched her breast. She explained she could not remember his name but they were sitting in the other dining room area and he took his hand and went under her t-shirt and touched the outside of her left breast area. She told him no and that she didn't want him to do that. She told him that everyone was looking and he said he didn't give a damn if everyone wanted to look. She stated she did tell the lady that gave her her bath. She explained that she does not feel unsafe in the facility and she just wants him to stay away from her and doesn't want him around her. She stated that she has had no further concerns with him after this one incident. Interview on 5/5/26 at 1:31 p.m., with Resident #5 revealed he was aware of the situation he was being asked about. He stated that he was sitting next to Resident #4 at the table and he doesn't exactly remember how it happened but he did touch her breast area 1 time and it was on the outside of her blouse. Resident #5 explained Resident #4 changed her story the next day and told them he went up her blouse and touched her breast 4-5 times. Resident #5 denied touching Resident #4 under her blouse and that he only touched her one time. Resident #5 explained Resident #4 never told him to stop or not to touch her. He thought they were friends. Review of written statement dated 4/10/26 with witness name as Staff Q, CNA revealed CNA had Resident #4 in the bath. She told CNA that she was eating in the dining room. She was asked why by CNA. She said she was afraid Resident #5 is going to grope her. She called Resident #5 the half bald guy. Staff Q verified she was talking about Resident #5. She told Staff Q last night Resident #5 was trying to put his hands up her shirt. Staff Q asked did you ask him to stop. She said yes, I said stop, people are going to see, we're going to get into trouble. Interview on 5/5/26 at 2:24 p.m., with Staff Q revealed Resident #4 mentioned the incident during her bath. She said she was out in the dining room by the living room and they were sitting at the table. Resident #5 put his hand up her shirt and she told him to stop and he wouldn't so she told him to stop and that people were going to see. Staff Q stated after the bath was complete she reported it to the Administrator and the Director of Nursing. Review of written statement dated 4/10/26 by Staff A, CNA revealed she had Resident #4 on the scale getting her weight. She said that man is going to get in trouble and proceeded to tell me that someone put his hand up her shirt. She told him to stop and proceeded to do it again a few more times being told to stop. 2. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of hypertension, muscle weakness and depression. The MDS showed the BIMS score of 12 indicating moderate cognitive impairment. Review of the facility provided Incident Report dated 3/24/26 at 8:30 p.m., revealed resident stated she was sleeping and the male resident from across the hall came into her room around 8:30 p.m., on 3/24/26 and kissed her on her neck area and she stated she told him no, I don't want that. She said he proceeded to say come on she said she told him to leave. She states he stood up and pulled up his shirt and acted as if he was pulling his pants down near his waist and she told him, I don't want to see your butt, leave. She stated he was in her room for approximately 10 minutes before he left. Review of Resident #6's Progress Notes dated 3/24/26 at 12:53 p.m., entered on 3/30/26 at 12:54 p.m., by Staff F, Registered Nurse (RN) revealed mother was notified of physical aggression received by another resident. Explained interventions provided to resident and residents current status. Mother verbalized understanding, she has no further complaints or concerns as long as Resident #6 is okay. Interview on 5/5/26 at 10:44 a.m., with Resident #6 revealed she was sleeping in bed unclothed when that old man (Resident #7) came into her room. Resident #6 revealed he was sitting next to her bed and she asked him what he was doing and he leaned over and kissed her around her mouth area. Resident #6 again asked him what he was doing and he said come on and he kissed her again on the cheek area. Resident #6 told Resident #7 no and to leave and get out of her room. She explained he finally left the room and she got up and got dressed and walked all the way down to the desk where there was some young staff working. Resident #6 told the staff Resident #7 kissed her. She explained the staff thought it was funny and she told them it was not funny she did not want that old man kissing her. The staff told her they would watch him and make sure he didn't bother her the rest of the night and she went back to her room and closed the door. Review of written statement by Staff B, Certified Nursing Assistant (CNA) dated 3/25/26 revealed the following, On March 24, 2026 around 8:30 p.m., Resident #6 came up to the nurses station where Staff C CNA and I were sitting and charting. Staff D, Licensed Practical Nurse (LPN) was at her medication cart. I had seen Resident #6 when I looked up and waved and she had an upset expression. She then proceeded to ask us all who that old guy was that came into her room. We asked what had happened and she stated that when he had came into her room, she was sleeping naked and woke up to him trying to kiss her. She also stated that he asked her to have sex with him. Staff C asked her if she would feel more comfortable sleeping in a different room, she was not interested. Staff D told her we could keep an eye out if she wanted to stay in her room. Later on my shift around 3:00 a.m., I went to go into her room to refresh her water pitcher, I could not get the door open. She had barricaded the door to the point where I couldn't see in or move the door open. Signed and dated 3/25/26 by Staff B. Interview on 5/4/26 at 12:28 p.m., with Staff B, CNA revealed she was sitting at the nurses station and it was around 8:00 p.m., and stated that another staff and the nurse was there when Resident #6 came to the desk. She was coming down the hallway and she looked disgruntled which was unusual for her. She usually goes to bed early and it was unusual to see her up after she had gone to bed. She told us that Resident #7 came into her room and she didn't have any clothing on and she was sleeping under her covers and he tried to kiss her and proceeded to ask her to have intercourse with him. Resident #6 stated she told him she wanted to punch him in the face and he is an old man and no way. She explained he was standing so she was not able to pull her call light and she finally got him out of her room. They offered to move her room for the night and she denied as she wanted to stay in her room with her stuff. She stated that later during her shift that night she attempted to enter her room and she was unable to get into her room. She had barricaded the door as no one was able to enter her room after the incident occurred. Review of written statement by Staff C, CNA on March 24, 2026 Resident #6 came up the hallway to the nurse's station where Staff B and Staff D and I were sitting by the nurse's station. Staff D was standing at her medication cart. Staff B and I were sitting behind the nurses station. Resident #6 stood beside Staff D and asked who that old guy was. This happened around 8:30 p.m., About 30 minutes prior to Resident #6 coming up to the station, I had noticed Resident #7 wandering the hallway, then go into Resident #6's room. Resident #6 is an independent resident who sleeps with no clothes on at night because normally only staff that are working go in there. She is always covered up with multiple blankets. When Resident #6 came up to the nurses station. She was asking about who that old guy was. I asked her if she was talking about Resident #7 and told her she looked upset. She stated she was upset because Resident #7 came into her room while she was sleeping and kissed her. She then stated she was naked. I asked her if that's all that happened. She said no that he asked her to have sex with him. I asked her if she would like to stay in a different room for the night, she declined. Staff D then told her she could go back to her room, and that we would make sure Resident #7 did not go in there. Resident #7 returned to her room. I informed the other CNA's on duty, then returned to my work. Signed by Staff C. Interview on 5/4/26 at 12:40 p.m., with Staff C, CNA revealed that she was at the nurses station and Resident #6 had been sleeping in her room. She sleeps naked as she is independent and the staff usually just checks on her. She was coming down the hallway and it was weird to see her out of her room at that time of the night. Resident #6 came up to her and asked who is that old guy? She stated Resident #7 had walked down the hallway and came into her room and she was under her blankets and he tried to kiss her and have sex with her. Resident #6 was noted to be very uncomfortable. Staff offered a different room for the night and resident declined as she wanted to stay in her own room Interview on 5/5/26 at 12:52 p.m., with Staff D, LPN revealed she was at the nurses station when Resident #6 came to the nurses station. Resident #6 explained Resident #7 came into her room and attempted to kiss her and she told him no and asked what was wrong with him as he came into her room and tried to kiss her. Resident #6 said he was messing with the front of his pants but never said if he had exposed himself but did say he wanted to have sex. Staff D explained they offered her another room but she declined as she wanted to stay in her room with her stuff. 3. The MDS assessment dated [DATE] for Resident #8 documented diagnoses of difficulty walking, muscle weakness and respiratory failure. The MDS showed the BIMS score of 11 indicating moderate cognitive impairment. Review of the facility provided Incident Report dated 4/18/26 at 8:00 a.m., revealed the resident came up to the nurses station asking who she had to talk to report something. Asked what happened multiple times at different times and got the same story, skin assessment was performed. The resident stated that she was hit last night and staff made her use a bedpan. Wasn't able to name staff and states that we all look alike with height and dark hair. Once they pulled the bed pan out from under her, the staff raised the bed pan unsure of its exact posture and struck the resident in hip and other thigh with the bedpan. Resident stated there was yelling between self and staff. The resident wasn't able to give a time but did state she was in a nightgown and hours after eating meals. The resident was asked how many people were in the room, stated 1 she was asked and she reported the abuse last night she stated no I just went back to sleep. Review of Resident #8's Progress Notes revealed the following: On 4/18/26 at 10:58 a.m., resident came up to the nurses station requesting to report abuse stating that the overnight staff had struck her with a bed pan after they pulled it out from underneath her striking her in the hip and thigh. Skin assessment was performed and found two 4 centimeter (cm) superficial scratches with no drainage on the lower back. The resident denies any pain related to those. The resident was not able to give the name or description of the staff stating we all look alike with dark hair and size. The resident stated there was yelling in between self and staff. A neighboring resident was asked if she heard anything. She also heard yelling around 1:00 a.m., but wasn't able to directly say what she heard. The family was called and updated on issues. Son did come to the facility at bedside with the resident. Managers updated. On 4/18/26 at 11:23 a.m., Resident called daughter and had complaints of pain in the hip. Nurse went down to resident room asking about pain. Denies any pain at this time, no bruising or edema noted. Pain medication was offered. Non-pharmacological comforts were offered and resident denied. On 4/18/26 at 12:09 a.m., skin issues- new skin issue on lower middle back noted to be a new wound acquired in house. Abrasion. Length- 0.96 cm, Width- 0.86 cm. Interview on 5/6/26 at 1:41 p.m., with Resident #8 revealed that she didn't want anyone to get into trouble. She explained that she didn't know the staff's name but there was only one incident where they hurt her with the bed pan. She stated it was at nighttime and the staff member kept pushing the bedpan and Resident #8 didn't want to use the bed pan. Resident #8 stated the staff member told her she needed to use the bed pan and the resident wanted to use the toilet. The resident said when the staff put the bedpan under her it hurt. Resident #8 said several times, she hurt me with the bedpan. Resident #8 stated she has been here for 3 years and has learned how to hold her urine. Resident #8 stated she wants to use the toilet and not use the bedpan. Interview on 5/6/26 at 10:03 a.m., with Staff L, Business Office Manager revealed Resident #8's daughter called and was upset about an incident the night before her mother called. Staff L explained to Resident #8's daughter the facility was aware of the situation and had already turned the incident into the state and started investigating the incident. Staff L stated the daughter stated the resident told her someone hit her with a bed pan that night. Staff L revealed she called Staff M, Administrator that was covering for the facility Administrator and she started the investigation. Staff L revealed the facility assessed the resident and she was found to have 2 scratches on her back after the assessment. Interview on 5/6/26 at 10:42 a.m., with Staff N, Licensed Practical Nurse (LPN) revealed Resident #8 came up to her after breakfast and started telling her that one of the staff members working the night shift hit her with the bedpan. She stated that she was unable to state which staff member it was only that it was the nightshift staff. Staff N explained she would turn in her concern for her. Staff N explained she was unsure what to do with the allegation of abuse as this was her first one and that she went and talked to Staff L. Resident #8 explained to Staff N that the incident was with the bedpan and the staff was rough with her. Staff N explained Resident #8 was not sure where the bedpan was put and explained she thought it was over her head in the air and struck her hip, leg or thigh area with the bedpan. Staff L assessed Resident #8 and stated that there was no bruising or redness in that area at the time. She did have 2 superficial scratches on her back, noted the area to be dried and not red around the scratches. Interview on 5/6/26 at 11:23 a.m., with Staff O, CNA revealed she worked the night of the incident. She explained Resident #8 had called and wanted to go to the bathroom. Staff O stated she had been up during the night shift on the previous rounds. Staff O explained Resident #8 usually will try to get up at different times during the night for the day. She explained that night had called during the last rounds and asked to use the bathroom. Staff O explained Resident #8 had been up approximately 30 minutes prior to her calling and had not voided or had a bowel movement any of those times so Staff O asked her if she would use the bedpan. Staff O stated Resident #8 would try it but had never used it before. She stated that Resident #8 said it hurt when she put her on the bedpan so she took her off of it right away. She asked Resident #8 If she wanted to use the toilet, she told Staff O she would just wait for the next shift. Staff O denies Resident #8 verbalizing any other pain at the time of helping her. Staff O denied seeing any scratches, bruising, redness or open areas on her back or coccyx area. Staff O denies having any other staff assist her during her shift with Resident #8 the night of the incident. Interview on 5/6/26 at 1:24 p.m., with Staff M, Administrator revealed she had been covering the facility as their administrator had been gone. Staff M revealed she had received a phone call from Staff L regarding the incident. Staff M told the facility to start gathering information and statements and was informed that the night shift beat her with the bedpan. She was also told Resident #8's daughter had called and was upset. Staff M called the resident's daughter and talked to her about what was reported. Staff M revealed Resident #8's daughter told her her mother called her and told her someone knocked her out with the bedpan and the daughter told her that her mother should not be even using the bedpan as she is able to use the toilet and staff was taking shortcuts. She explained her mother had hip pain and Staff M explained to the daughter she would have her assessed immediately. After the interviews and statements were done and assessments were completed she contacted the regional support team and was advised to turn the self report into the state as required. Staff M explained she typed out her statements and turned the investigation over to the facility administrator when she returned to the facility to complete the 5 day investigation and had no further involvement after she turned it over. Interview on 5/7/26 at 8:53 a.m., with Resident #8's daughter revealed Resident #8 called her crying. She said the staff at night didn't want to get her up and take her to the bathroom and the staff shoved a bed pan underneath her and then ripped it out and hurt her. She stated that her mom should not be using a bed pan and the staff is just being lazy and not wanting to take her to the toilet as she is able to use it. She stated that it is unusual for Resident #8 to cry as she is an old farm wife and she didn't let anything bother her. She had never had her call her crying like that before. She was told that the facility suspended the staff and some lady called her and told her the facility was making their report to the state and did everything they were supposed to do if they had an incident like this happen. Resident #8 has not discussed it since and she didn't want to bring it up as her mother was very upset about the incident. Review of facility provided policy titled Resident Rights with a revised date of December 2016 revealed the following: Employees shall treat all residents with kindness, respect and dignity. These rights include the resident's rights to be free from abuse, neglect, misappropriation of property and exploitation. Interview on 5/6/26 at 3:15 p.m., with the Administrator revealed she expects all staff to treat each other with respect and dignity and other residents to respect each other and personal boundaries. 4. The MDS assessment dated [DATE] for Resident #3 showed reentry to the facility from home occurred on 4/13/2026. The Medical Diagnosis record for Resident #3 showed a diagnosis of muscle wasting, abnormal posture, and morbid obesity. The Progress Note dated 4/16/26 for Resident #3 showed the BIMS score of 15, which indicated no cognitive impairment. During an interview on 5/4/26 at 10:17 AM, the Administrator reported that she submitted a self-report identifying that Resident #3 reported Staff L, LPN as verbally aggressive. The Administrator reported that Resident #3 reported the incident to a social worker at an outside care provider; the provider then filed a grievance which the facility received via email. The Administrator reported that she followed up with Staff L that day and suspended Staff L, who has not returned since the night of the incident. The Administrator added Resident #3 reported to her and the sheriff that Staff L did not aggressively pull on her legs to get her out of bed. During an interview on 5/4/26 at 2:02 PM, the Director Clinic of Operations (DCO) of an outside care provider stated she followed up with Resident #3 after a social worker filed a grievance. The grievance alleged Resident #3 was unhappy with her care and that a staff member was mean to her. During their conversation, Resident #3 reported that Staff L, LPN, yelled at her. Resident #3 stated that Staff L stood at her door and hollered, Let's go. The resident also reported that Staff L pulled on her legs aggressively to get her out of bed. Resident #3 denied issues with other staff and spoke highly of the therapy staff. The DCO notified the facility of the grievance via email. During an interview on 5/4/26 at 12:50 PM, Staff C, Certified Nursing Assistant (CNA), reported Staff L, LPN, was rude with residents. Staff C stated, Someone would ask Staff L if they could go to the bathroom; she would tell them they could wait. Staff L is a very rude, passive person toward residents. Residents tell me they don't like her, but none of the residents said why. During an interview on 5/5/26 at 10:43 AM, the social worker for the outside care provider reported that she was the first person Resident #3 told about the verbal aggression from Staff L, LPN. The resident reported that Staff L yells at her and makes her feel bad. The social worker stated the resident did not mention any physical concerns, and the social worker did not inquire about them. The social worker subsequently filed a grievance report, which was followed up with the facility by their grievance officer to the facility where the resident resided. During the interview conducted on 5/5/26 at 9:11 AM, Resident #3 stated that one staff member had not been nice. Resident #3 reported that the incident occurred at night with a staff member, identified as either a nurse or aide, whose name the resident could not recall. Resident #3 stated, She was being verbally abusive. The resident needed to get up to use the bathroom, and the staff member started yelling come on, let's go. When asked about the staff member raising her voice, Resident #3 confirmed, Yes. Following the incident, Resident #3 attended a meeting with the administrator and two other individuals, and two days later, the sheriff arrived. Resident #2 stated, I told him she yelled at me about the bathroom. Resident #3 confirmed the staff member was not physically rough when caring for her, stating, No, she wasn't physical. When asked if the staff member grabbed her legs, Resident #3 replied, She never grabbed my legs or anything else. The resident reported that no witnesses were present. Resident #3 stated, She kept yelling at me. She wanted to get my feet up in bed. I was trying to get my feet on the bed but she didn't offer to help at all. Resident #3 stated that the staff member never refused assistance when asked, responding, No. When describing her feelings about the incident, Resident #3 replied, Sad and a little afraid, uneasy. Resident #3 noted that the staff member typically worked three to four consecutive days. Resident #3 stated, I was scared when I turned on my call light thinking she was coming down. The resident confirmed this fear sometimes prevented her from using the call light, stating, Yes, sometimes. During an interview on 5/4/26 at 1:11 PM, Staff K (CNA) reported that Staff L was verbally abusive toward residents. Staff K noted that she asked Staff L to step out of a resident's room a couple times due to her behavior. Staff K recalled an incident from a few weeks prior where Resident #3 struggled to hold a drink and spilled it. Staff L stated in front of the resident that she shouldn't have fucking water in the room. Staff K stated, I told the Administrator multiple times that Staff L was rude. The Police Report from the County Sheriff's Office documented the following: On 4/29/26 at 8:20 AM Deputies dispatched to the facility for a past assault. Deputies talked to the resident and asked her what happened, she said the worker was rude and mean to her. Deputies asked her if anything physical had been done to her, the resident said no. No actual physical assault, so no charges will be filed. The facility is going to handle the investigation in house. A handwritten note dated 4/28/26 and signed by Staff B, CNA documented the following: I have witnessed a staff member being unkind to residents. In some situations, they were rude to them as well. For example, Resident #3 one night pulled her call light, so Staff L and I went to answer it together. When we reached her room, Staff L asked her what she needed, Resident #3 replied that she needed to use the restroom. Staff L then told her she needed to get up on the side of the bed herself. Resident #3 responded with, I need help. I can't do it. Staff L told her she was not going to help her and that she was not going to break her back, helping her. She did end up helping her, but she was not nice and while she was having this conversation with Resident #3, her voice was raised. The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation: Reporting and Investigating, last revised April 2021, indicated that allegations involving abuse or resulting in serious bodily injury must be reported within two hours to local, state, and federal agencies. The policy instructs that if abuse, neglect, exploitation, misappropriation of property, or an injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and other officials according to regulations. The Administrator or the individual making the allegation is responsible for reporting the suspicion immediately. In an interview on 5/6/26 at 2:13 PM, the Administrator stated she had contacted the relevant outside agencies to establish an abuse reporting process. She also evaluated internal protocols to ensure the facility receives and processes reports of abuse allegations in a timely manner, consistent with regulatory requirements. The Administrator further reported that recent staff meetings yielded additional information regarding Staff L. Consequently, she provided supplemental education to all staff regarding abuse reporting, emphasizing that she must be notified immediately of any concerns, including via her personal cell phone.

Based on observation, clinical record review, and resident and staff interviews, the facility failed to ensure that a resident who experienced a fall received the necessary care and services to maintain their highest practicable physical well-being. For 1 of 3 residents reviewed (Resident #1), nursing staff failed to conduct a thorough assessment, implement immediate interventions, perform required neurological checks, or notify the resident's physician and family following an unwitnessed fall for 1 of 3 residents reviewed (Resident #1).Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During the interview on 5/4/26 at 3:40 PM, Staff A, Certified Nursing Assistant (CNA) stated she found Resident #1 on the floor near the wheelchair upon entering the room. Resident #1 reported losing his footing and falling while walking from the bathroom to his wheelchair. Staff A reported the incident occurred between 7:00 and 7:15 AM on the second or third Sunday of April 2025, before Resident #1 ate breakfast and attended church. Staff A reported the fall to Staff E (RN). Staff E reported Staff A entered the room, asked Resident #1 about a head injury, and assisted the resident from the floor. Resident #1 denied injuries. During an interview on 5/5/26 at 11:16 AM, Staff E, Registered Nurse (RN) recalled a fall involving Resident #1 in April 2026. The RN remembered the resident attempted to walk from the bathroom to his wheelchair when he fell by the wheelchair. The resident reported his legs gave out and denied hitting his head or sustaining other injuries. When asked if she completed and documented an assessment, the nurse replied, I don't remember but I should have. When asked if the nurse completed and documented a neurological assessment, the nurse stated, I would hope so. When asked about documenting the fall details, the nurse reported she hoped she performed them and thought she documented the specifics. Regarding protocol for an unwitnessed fall, the RN reported risk management information, a head-to-toe assessment, an intervention, neurological assessments and documentation are required per facility policy. The RN failed to recall who found the resident, though she remembered the incident occurred on a Sunday morning before church. Review of the Care Plan for Resident #1 showed no documentation of interventions for a fall that occurred in April 2026. Review of the Progress Notes for Resident #1 showed no documentation for a fall that occurred in April 2026. Review of the Clinical Assessment for Resident #1 revealed no documentation of an assessment, including vital signs, head-to-toe evaluation, or neurological assessment, for a fall that occurred in April 2026. The facility's April 2026 Incident Reports for Resident #1 lacked any record of a fall. As a result, the documentation omitted an immediate assessment, neurological assessment, cause identification, and root cause analysis. The Resident Examination and Assessment policy revised 2014 instructed staff how to complete and document an assessment. The policy failed to identify what and specific assessments are to be completed after a fall. The Accidents and Incidents policy revised July 2017 required staff to investigate and report all resident accidents and incidents to the Administrator. The policy also mandated staff to conduct and document the resident's condition and vital signs, and notify the physician and family. The Fall and Fall Risk policy revised September 2017 indicated that for an individual who has fallen, the staff and practitioners will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse medication consequence, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After more than one fall, the physician should at least review the resident/patient's neurological status, medical conditions, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. During an interview on 5/6/26 at 2:13 PM, the Administrator denied knowledge of Resident #1 falling in April. She determined the nurse on duty as Staff E and reported following up with her regarding incomplete tasks and documentation. She emphasized the requirement for staff to follow facility policy for falls. The Administrator stated the nurse failed to complete required assessments, neurological checks, cause identification, and immediate interventions. Additionally, the nurse failed to notify the physician, family, or administration.

Based on record review and staff interviews, the facility failed to provide and maintain accurate resident records to reflect incidents that occurred in the facility for 2 of 3 residents (Residents #1 and #6). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During the interview on 5/4/26 at 3:40 PM, Staff A, Certified Nursing Assistant (CNA) stated she found Resident #1 on the floor near the wheelchair upon entering the room. Resident #1 reported losing his footing and falling while walking from the bathroom to his wheelchair. Staff A reported the incident occurred between 7:00 and 7:15 AM on the second or third Sunday of April 2025, before Resident #1 ate breakfast and attended church. Staff A reported the fall to Staff E, RN. Staff E reported Staff A entered the room, asked Resident #1 about a head injury, and assisted the resident from the floor. Resident #1 denied injuries. During an interview on 5/5/26 at 11:16 AM, Staff E, RN recalled a fall involving Resident #1 in early April. The RN remembered the resident attempted to walk from the bathroom to his wheelchair when he fell by the wheelchair. The resident reported his legs gave out and denied hitting his head or sustaining other injuries. When asked if she completed and documented an assessment, the nurse replied, I don't remember but I should have. When asked if the nurse completed and documented a neurological assessment, the nurse stated, I would hope so. When asked about documenting the fall details, the nurse reported she hoped she performed them and thought she documented the specifics. Regarding protocol for an unwitnessed fall, the RN reported risk management information, a head-to-toe assessment, an intervention, neurological assessments and documentation are required per facility policy. The RN failed to recall who found the resident, though she remembered the incident occurred on a Sunday morning before church. Review of the Care Plan for Resident #1 showed no documentation of interventions for a fall that occurred in April 2026. Review of the Progress Notes for Resident #1 showed no documentation for a fall that occurred in April 2026. Review of the Clinical Assessment for Resident #1 showed no documentation for a fall that occurred in April 2026. Review of the facility's April 2026 incident reports for Resident #1 showed no report of a fall in April 2026. The Documentation policy dated January 2015 required that all documentation (patient records, financial records, etc.) be accurate, timely and prepared in a professional manner. No employee should ever knowingly falsify any document prepared for, or submitted to, any government agency or private payor source for any purpose. All individuals who contribute information to a medical record must provide accurate and complete information. During an interview on 5/6/26 at 2:13 PM, the Administrator stated she had no knowledge of Resident #1 falling in April. She determined the nurse to be Staff E, RN and recently followed up with Staff A for not completing tasks and documentation. She emphasized that staff must follow facility policy regarding documentation. 2. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of hypertension, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Interview on 5/5/26 at 10:44 a.m., with Resident #6 revealed she was sleeping in bed unclothed when that old man (Resident #7) came into her room. Resident #6 revealed he was sitting next to her bed and she asked him what he was doing and he leaned over and kissed her around her mouth area. Resident #6 again asked him what he was doing and he said come on and he kissed her again on the cheek area. Resident #6 told Resident #7 no and to leave and get out of her room. She explained he finally left the room and she got up and got dressed and walked all the way down to the desk where there was some young staff working. Resident #6 told the staff Resident #7 kissed her. She explained the staff thought it was funny and she told them it was not funny she did not want that old man kissing her. The staff told her they would watch him and make sure he didn't bother her the rest of the night and she went back to her room and closed the door. Review of written stated by Staff B, Certified Nursing Assistant (CNA) dated 3/25/26 revealed the following, On March 24, 2026 around 8:30 p.m., Resident #6 came up to the nurses station where Staff C. CNA and I were sitting and charting. Staff D, Licensed Practical Nurse (LPN) was at her medication cart. I had seen Resident #6 when I looked up and waved and she had an upset expression. She then proceeded to ask us all who that old guy was that came into her room. We asked what had happened and she stated that when he had came into her room, she was sleeping naked and woke up to him trying to kiss her. She also stated that he asked her to have sex with him. Staff C asked her if she would feel more comfortable sleeping in a different room, she was not interested. Staff D told her we could keep an eye out if she wanted to stay in her room. Later on my shift around 3:00 a.m., I went to go into her room to refresh her water pitcher, I could not get the door open. She had barricaded the door to the point where I couldn't see in or move the door open. Signed and dated 3/25/26 by Staff B. Review of written statement by Staff C, CNA on March 24, 2026 Resident #6 came up the hallway to the nurse's station where Staff B and Staff D and I were sitting by the nurse's station. Staff D was standing at her medication cart. Staff B and I were sitting behind the nurses station. Resident #6 stood beside Staff D and asked who that old guy was. This happened around 8:30 p.m., About 30 minutes prior to Resident #6 coming up to the station, I had noticed Resident #7 wandering the hallway, then go into Resident #6's room. Resident #6 is an independent resident who sleeps with no clothes on at night because normally only staff that are working go in there. She is always covered up with multiple blankets. When Resident #6 came up to the nurses station. She was asking about who that old guy was. I asked her if she was talking about Resident #7 and told her she looked upset. She stated she was upset because Resident #7 came into her room while she was sleeping and kissed her. She then stated she was naked. I asked her if that's all that happened. She said no that he asked her to have sex with him. I asked her if she would like to stay in a different room for the night, she declined. Staff D then told her she could go back to her room, and that we would make sure Resident #7 did not go in there. Resident #7 returned to her room. I informed the other CNA's on duty, then returned to my work. Signed by Staff C. Review of facility reported incident revealed submission date of 3/25/26 at 12:22 p.m Review of Resident #6's Progress Notes dated 3/24/26 at 12:53 p.m., entered on 3/30/26 at 12:54 p.m., by Staff F, Registered Nurse (RN) revealed mother was notified of physical aggression received by another resident. Explained interventions provided to resident and residents current status. Mother verbalized understanding, she has no further complaints or concerns as long as Resident #6 is okay. Review of facility provided policy titled Documentation Policy dated January 2015 revealed the policy requires that all documentation be accurate, timely and prepared in a professional manner. If you are using the late entry to document an omission, make sure you validate the source of additional information as much as possible. Interview on 5/6/26 at 3:15 p.m., with the Administrator revealed staff should be accurately documenting the incidents when they happen. The nurse that was working at the time should have documented the incident that night.

Based on clinical record review, policy review and staff interview the facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and resident to resident altercations for 2 out of 3 residents reviewed (Resident #1 and #4). The facility reported a census of 35 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and history of falling. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. During an interview on 5/5/26 at 11:16 AM, Staff E, Registered Nurse (RN) recalled a fall involving Resident #1 in April 2026. The RN remembered the resident attempted to walk from the bathroom to his wheelchair when he fell by the wheelchair. When asked about documenting the fall details, the nurse reported she hoped she performed them and thought she documented the specifics. Regarding protocol for an unwitnessed fall, the RN reported risk management information, a head-to-toe assessment, an intervention, neurological assessments and documentation are required per facility policy. Review of the Care Plan for Resident #1 showed no documentation of interventions for a fall that occurred in April 2026. During an interview on 5/6/26 at 2:13 PM, the Administrator stated she had no knowledge of Resident #1 falling in April. The Administrator stated the nurse failed to determine immediate interventions. The Administrator explained for the care plan process the nurse determined and documented immediate interventions based on the fall. Leadership reviews the fall, determines if the intervention was appropriate, and then adds the intervention to the care plan. The Administrator acknowledged that because the fall was not identified, no interventions were determined to prevent future falls. 2. The MDS assessment dated [DATE] for Resident #4 documented diagnoses of depression, anxiety disorder and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the Progress Notes revealed late entry dated 4/10/26 at 1:38 p.m., with a created date of 4/14/26 at 8:00 a.m., entered by the Administrator revealed resident reported to CNA that a male resident tried to touch her breast while eating supper. Resident was asked by the CNA if she had told the male resident to stop. Resident stated that yes I told him to stop people are going to see and we're going to get into trouble Review of the facility provided Incident Report dated 4/10/26 at 1:00 p.m., revealed immediate action taken included resident asked the staff if they could just have boundaries with male resident, she would feel comfortable. She stated that she sees him in common areas and stated that she would tell him to stay away from her or ask someone to help her. The Care Plan with a revision date of 4/14/26 lacked interventions following the incident on 4/9/26. Review of the facility provided policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Interview on 5/6/26 at 3:15 p.m., with the Administrator revealed the care plans should be updated with interventions as they are implemented for the residents.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 2 of 4 residents reviewed for abuse (Resident #3 & #6). The facility reported a census of 35 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of hypertension, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Interview on 5/5/26 at 10:44 a.m., with Resident #6 revealed she was sleeping in bed unclothed when that old man (Resident #7) came into her room. Resident #6 revealed he was sitting next to her bed and she asked him what he was doing and he leaned over and kissed her around her mouth area. Resident #6 again asked him what he was doing and he said come on and he kissed her again on the cheek area. Resident #6 told Resident #7 no and to leave and get out of her room. She explained he finally left the room and she got up and got dressed and walked all the way down to the desk where there was some young staff working. Resident #6 told the staff Resident #7 kissed her. She explained the staff thought it was funny and she told them it was not funny she did not want that old man kissing her. The staff told her they would watch him and make sure he didn't bother her the rest of the night and she went back to her room and closed the door. Review of written stated by Staff B, Certified Nursing Assistant (CNA) dated 3/25/26 revealed the following, On March 24, 2026 around 8:30 p.m., Resident #6 came up to the nurses station where Staff C. CNA and I were sitting and charting. Staff D, Licensed Practical Nurse (LPN) was at her medication cart. I had seen Resident #6 when I looked up and waved and she had an upset expression. She then proceeded to ask us all who that old guy was that came into her room. We asked what had happened and she stated that when he had came into her room, she was sleeping naked and woke up to him trying to kiss her. She also stated that he asked her to have sex with him. Staff C asked her if she would feel more comfortable sleeping in a different room, she was not interested. Staff D told her we could keep an eye out if she wanted to stay in her room. Later on my shift around 3:00 a.m., I went to go into her room to refresh her water pitcher, I could not get the door open. She had barricaded the door to the point where I couldn't see in or move the door open. Signed and dated 3/25/26 by Staff B. Review of written statement by Staff C, CNA on March 24, 2026 Resident #6 came up the hallway to the nurse's station where Staff B and Staff D and I were sitting by the nurse's station. Staff D was standing at her medication cart. Staff B and I were sitting behind the nurses station. Resident #6 stood beside Staff D and asked who that old guy was. This happened around 8:30 p.m., About 30 minutes prior to Resident #6 coming up to the station, I had noticed Resident #7 wandering the hallway, then go into Resident #6's room. Resident #6 is an independent resident who sleeps with no clothes on at night because normally only staff that are working go in there. She is always covered up with multiple blankets. When Resident #6 came up to the nurses station. She was asking about who that old guy was. I asked her if she was talking about Resident #7 and told her she looked upset. She stated she was upset because Resident #7 came into her room while she was sleeping and kissed her. She then stated she was naked. I asked her if that's all that happened. She said no that he asked her to have sex with him. I asked her if she would like to stay in a different room for the night, she declined. Staff D then told her she could go back to her room, and that we would make sure Resident #7 did not go in there. Resident #7 returned to her room. I informed the other CNA's on duty, then returned to my work. Signed by Staff C. Review of Resident #6's Progress Notes dated 3/24/26 at 12:53 p.m., entered on 3/30/26 at 12:54 p.m., by Staff F, Registered Nurse (RN) revealed mother was notified of physical aggression received by another resident. Explained interventions provided to resident and residents current status. Mother verbalized understanding, she has no further complaints or concerns as long as Resident #6 is okay. Review of facility reported incident revealed submission date of 3/25/26 at 12:22 p.m Interview on 5/5/26 at 9:42 a.m., with Staff F revealed she talked to the Administrator and Regional Nurse Consultant on the phone as they were out of the facility and that she did the Incident Report as the nurse that was working that evening did not do it as she did not think it was an incident and that's why they didn't call anyone. She explained she educated the staff they needed to call especially with an incident like this. Interview on 5/6/26 at 3:15 p.m., with the Administrator revealed if there is an allegation of abuse reported to staff that is to be reported within 2 hours of the allegation. Staff should have called right away about the incident. 2. The MDS assessment dated [DATE] for Resident #3 showed reentry to the facility from home occurred on 4/13/2026. The Medical Diagnosis record for Resident #3 showed a diagnosis of muscle wasting, abnormal posture, and morbid obesity. Review of the email dated 4/28/26 at 4:09 PM showed that an outside care provider notified the facility regarding Resident #3's report of mistreatment by an overnight nurse. The email stated the nurse opened Resident #3's door and hollered, come on lets go. The nurse aggressively pulled Resident #3's legs to move her out of bed. The resident indicated she did not report this incident to leadership. The untitled documented interview the Administrator conducted with the nurse accused of mistreating Resident #3 was dated and timed for 4/28/26 at 6:10 PM. Review of facility intake information the facility submitted a self report on 4/28/2926 at 8:15 PM. The facility failed to report an allegation of abuse to DIAL within 2 hours of an allegation of abuse. The Abuse, Neglect, Exploitation or Misapproiation- Reporting and Investigating policy last revised April 2021 indicated allegations involving abuse or result in serious bodily injury needed to be reported within two hours to local, state and federal agencies as required by current regulations. During an interview on 5/6/26 at 2:13 PM, the Administrator stated she contacted the receiving agency to establish an abuse reporting process. She also evaluated other agencies for necessary process changes to ensure the facility receives reports of abuse allegations involving residents in a timely manner to meet regulation requirements.

Based on observation, clinical record review, family and staff interviews, the facility failed to provide appropriate supervision to ensure each resident's individual safety while using the commode for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 35 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of dementia, anxiety disorder, and repeated falls. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The Care Plan for Resident #2 indicated a risk for falls due to increased restlessness and anxiety. Resident #2 was documented as non-ambulatory and required assistance with a stand lift, though the resident expressed a preference for using the commode. During an interview on 5/5/26 at 11:05 AM, Resident #2's roommate recalled an incident on the night before Easter when Resident #2 waited on the commode around bedtime. The roommate noted that Resident #2 did not mention a missing call light. Staff informed Resident #2 they would allow her time and set an alarm. The roommate eventually pulled her own call light and started down the hall to find staff, but saw them approaching. The roommate estimated that staff returned after 30-45 minutes total, though she did not know exactly when Resident #2 finished and possibly signaled for help. The roommate confirmed she did not watch the clock during this time. During an interview on 5/4/25 at 11:33 AM, Resident #2 stated, I was on the commode for about an hour. Resident #2 reported this happened once, although she failed to remember the date. When asked if she held the call light, Resident #2 stated, I can't remember if I had the call light. When asked how she knew an hour passed without a clock, Resident #2 stated, It felt like an hour or two. I don't have a clock. When asked for the duration of her bowel movement, she reported she did not know and could not recall if she had a bowel movement at that time. When asked if she experienced skin issues or soreness from waiting on the commode, Resident #2 responded, no. When asked if staff acted rough or disrespectful, Resident #2 stated, no. When asked if the staff acted nice, Resident #2 stated, yes. During an interview on 5/4/26 at 3:40 PM, Staff A, a Certified Nursing Assistant, stated that she forgot Resident #2 on the toilet one night. Staff A and another colleague working in that hall set a timer to prompt them to assist Resident #2 off the commode. When the timer sounded, Staff A was in another resident's room and forgot about the alert. Staff A could not recall the exact time of the incident but estimated it was around 8:30 PM. Staff A stated that the night shift found the resident still on the commode around 10:00 PM. When asked if Resident #2 had a call light, Staff A replied no, because the cord was too short to reach the commode. When asked if the short cord prevented Resident #2 from using the call light while on the commode, Staff A stated that it sometimes did, depending on the room arrangement and the location of the commode. In an interview on 5/5/26 at 12:47 PM, Staff D, a Licensed Practical Nurse (LPN), acknowledged that Resident #2 remained on the commode for an extended period. Staff D explained that her staff informed her that the resident had been on the commode since the previous shift. She noted that staff typically placed the resident on the commode around 8:00 PM for 10 to 15 minutes. When asked if Resident #2 could reach the call light, Staff D stated, no. She explained that the roommate eventually activated her own call light to alert staff. Staff D admitted she previously instructed the staff to keep the call light within reach, noting it was not the first time the resident could not access it. She recalled finding the call light behind the bed or hearing from the resident directly that it was unreachable. Staff D confirmed she did not check on or assess Resident #2 after receiving the report because the staff claimed the resident was fine. She also admitted she did not complete risk management documentation or an incident report. Staff D noted that the resident mentioned the incident the following night but did not report any soreness. Staff D stated she was unaware of any skin issues resulting from the incident. She estimated that staff found the resident around 10:30 PM. During an interview on 5/5/26 at 12:31 PM, Staff O stated, I was working when Staff A put Resident #2 on the commode at about 8:30 PM. During the report, Staff A, CNA, told staff that everyone in her hall was good. After the report the light came on; I came around the corner and saw the stand lift with the brakes on. Resident #2 said she was sitting there for a while. We got her off and cleaned her; she had a very deep indentation. By the time she was wet again about 2:00 AM, the indentation was gone. Resident #2 said that her butt hurt and that she couldn't feel her feet. We used the stand lift; she was okay. I didn't speak with Staff A about it. Staff A worked the day shift the next day, but Staff D, LPN, talked to her about the resident not having a call light. That is a problem because they set timers and use alarms on their watches. They tuck Resident #2's call light behind the bed. They don't want to give her the call light because then she calls them back in 15 to 20 minutes. The Accidents and Incidents policy, last revised in July 2017, requires staff to investigate and report all resident accidents or incidents to the Administrator and the immediate supervisor or department director. Staff must promptly initiate a documented investigation, assess the resident, monitor vital signs, and implement corrective actions. The policy also instructed staff to complete an incident form and submit the form to the Director of Nursing Services. During an interview on 5/6/26 at 2:13 PM, the Administrator stated that she was unaware of the incident involving Resident #2. The Administrator explained that staff must always provide the resident with a call light, regardless of how frequently she requests assistance. She also reported that staff use a timer in addition to the call light to prevent Resident #2 from sitting for too long, which allows the resident extra time to empty her bladder. The Administrator noted she was unaware that the call light cord was too short to reach the commode and stated that maintenance would fix the length immediately. Furthermore, she reported she was unaware that staff were tucking the call light away to prevent its use and committed to addressing this with staff immediately.

Based on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents (Residents #3, #9, and #12) reviewed. The facility reported a census of 35 residents.Findings include: 1. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview 12/29/2025 at 10:56 AM with Resident #9 revealed that the food is not always hot when it is delivered on the meal tray. 2. Review of Resident #12's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview 12/29/2025 at 1:00 PM with Resident #12 revealed that food is absolute garbage at the facility, and is always cold. Continuous observation 12/30/25 from 11:19 AM until 12:14 PM dining service was completed in the dining room. Pre-temp meal temperature on the food items in the steam table revealed gravy was 161 degrees, mashed potatoes were 170.9 degrees, spinach with mushrooms were 164.4 degrees, and the chicken dijon was 152 degrees. During observations on 12/30/25 at 12:15 PM the first of the 10 room trays were prepared and placed on the meal cart for room service. These trays were then sent from the kitchen to the rooms at 12:23 PM. A sample tray was obtained at 12:28 PM with a temperature check completed revealing chicken was 131.7 degrees, and the mashed potatoes were 139 degrees. Interview 12/30/2025 at 12:36 PM with the Certified Dietary Manager (CDM) revealed that she would expect temps of food to be appropriate at the time of service. The CDM then confirmed the temp of the chicken from the room tray was low. 3. The Quarterly MDS dated [DATE] for Resident #3 revealed a BIMS score of 15/15 indicating normal cognitive impairment. The MDS included diagnoses of neurogenic bladder, paraplegia and post polio syndrome. The document revealed the resident was independent with eating and had gained weight during the past reporting period due to a physician prescribed weight gaining program The resident's Care Plan updated 12/18/25 identified an activities of daily living (ADL) focus dated 11/3/24 and the intervention for eating was independent. A focus related to nutrition identified the resident consumed a regular diet/regular texture and thin liquid consistency revised 12/16/24 with interventions of providing diet within her consistencies, meal preferences and reviewing/monitoring her diet. On 12/29/25 at 1:27 PM Resident #3 stated the hot food was served cold. The resident stated she frequently receives room trays and the food will be cold or not be what she ordered. The facility's Food Preparation and Service Policy, revised 4/19, revealed the danger zone for rapid growth of pathogenic microorganisms that cause foodborne illness was 41 degrees and 135 degrees Fahrenheit (F). The document further indicated those food items included meats, poultry, seafood, milk, yogurt and cottage cheese. The document included those items must be maintained below 41 degrees and above 135 degrees F.

Based on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 4 residents reviewed (Residents #9) requiring the use of oxygen. The facility reported a census of 35 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of hypertension (high blood pressure), renal insufficiency, and anxiety disorder. Observation on 12/29/2025 10:58 AM Resident #9 was observed to be utilizing oxygen via a concentrator at 2 liters by nasal cannula at that time. It was also observed that the oxygen tubing was not dated. Interview on 12/29/25 at 10:58 AM with Resident #9 revealed that Resident #9 was unsure as to when the staff last changed the oxygen tubing. Review of Resident #9's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for oxygen continuously at 2 liters to keep oxygen saturation above 90% every shift for shortness of breath, and hypoxemia (a medical condition with abnormally low oxygen levels in the blood) with a start date of 11/13/25. Further review revealed an order for oxygen tubing and nebulizer mask to be changed every Tuesday with a start date of 12/24/25. Interview 12/30/2025 10:18 AM with the Director of Nursing (DON) revealed that oxygen tubing should be dated when changed, and changed per the orders.Review of a facility provided policy titled, Oxygen Administration with a revision date of 10/2010 revealed:a. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record. The date and time that the procedure was performed.

Based on clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings include:Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document provided resident diagnoses of Post polio syndrome, neuromuscular dysfunction of bladder and Raynaud's Syndrome. The document disclosed the resident had an indwelling catheter and ostomy.Resident #3's Care Plan dated 12/18/25 revealed a focus of urinary catheter suprapubic 16fr with 10cc bulb initiated 12/16/24 and revised 6/9/25. Interventions dated 12/16/24 and 4/11/25 included monitoring kinks, encouraging fluids, enhanced barrier precautions (EBP) An additional focus area identified risk for urinary tract infection (UTI) related to suprapubic catheterization initiated 7/24/25 and revised 12/18/25. Interventions dated 7/25 included administration of antibiotics as ordered, EBP, education, fluids, monitor urine for color, clarity, odor and quality, signs and symptoms of UTI. A focus area disclosed a risk for potential UTI, chronic bladder infections initiated 7/22/25 and revised 7/31/25. Interventions included monitoring for signs/symptoms of UTIs revised 7/31/25.On 12/29/25 at 11:39 AM Resident #3 stated staff were supposed to empty her catheter every shift and it did not always happen. The resident stated staff do not consistently clean her catheter with alcohol swab after emptying or wear personal protective equipment (PPE). The resident stated she has had UTI's and bladder infections. Review of the Electronic Health Record (EHR) Clinical Physician Notes found Resident #3 had a history of UTIs and bladder infections. The EHR revealed the following:7/10/25 Resident was prescribed Cephalexin 1 tablet twice daily (BID) x 7 days, discontinued 7/15/25.7/24/25 Doxycycline Hyclate 100 mg x 10 days, 1 tablet by mouth two times a day for UTI for 10 Days per emergency room (ER) visit, end date 8/3/25.7/31/25 Cefpodoxime Proxetil 200 mg x10 days, give 1 tablet by mouth BID for cystitis, end date 7/31/25.8/1/25 Cefpodoxime Proxetil 200 mg x10 days, give 1 tablet by mouth BID for cystitis, end date 8/11/25. 10/15/25 report of low output, dark urine.The EHR Point of Care (POC) Response History for bowel and bladder, catheter care - cleanse with soap and water every shift; use alcohol swabs for past 29 days revealed 3 days of care provided twice in a single day:12/3/25 5:59 AM, 1:38 PM12/14/25 5:59 AM, 11:43 AM12/19/25 5:43 AM, 9:39 PMThe EHR POC Response History for monitoring of urine output revealed 3 days of care provided emptying of catheter twice in a single day. 12/3/25 5:59 AM 1100 cc, 1:39 PM 650 cc.The next documented emptying of the catheter on 12/4/25 at 5:55 AM output was 1800 cc.12/14/25 5:59 AM 675 cc, 8:35 AM 400 cc.The next documented emptying of the catheter on 12/15/25 at 5:59 AM output was 300 cc. 12/19/25 5:43 AM 550 cc, 9:40 PM 2200 cc.On the date of the document review, 12/30/25 at 12:40 PM it was noted that the emptying of the catheter had not been documented for the first shift. Observation of Resident #3's catheter bag at 2:30 PM revealed the catheter bag with 1500 cc of urine with sediment in the tubing. The Resident stated the first shift had not emptied her catheter bag. Observed Staff A, Certified Nurse Assistant (CNA), on 12/30/25 at 2:40 PM complete emptying of Resident #3's catheter. The staff utilized proper techniques and drained 1500 cc of urine from the resident's bag. The staff stated she was concerned the resident's catheter bag was leaking and was going to notify the nurse.Observed Staff B, Licensed Practical Nurse (LPN), on 12/30/25 at 2:48 PM assess Resident #3's catheter and determined there was no leakage. The staff did state the resident had sediment in the tubing and needed to monitor the catheter. On 12/30/25 at 2:01 PM the Director of Nursing (DON) stated catheter care and emptying should occur every shift and PRN. The DON stated documentation would be in the POC for catheter care and catheter emptying. The staff stated if the document(s) did not contain documentation for a specific shift, she could not state with certainty the task had been completed as required. On 12/30/25 at 2:10 PM the Administrator stated catheter bags should be emptied every shift and documented. On 12/30/25 at 2:33 PM when asked about shift exchange, the DON indicated a shift typically ended at 2:00 PM with an occasional CNA working past that time. When provided with a photo of Resident #3's catheter bag taken at 2:30 PM the DON stated the bag should not be that way and needed to be emptied. On 12/30/25 at 2:35 PM the Administrator when provided with the photo of Resident #3's catheter bag stated the drainage bag should have been emptied. On 12/31/25 at 7:55 AM the DON stated she had spoken with the staff responsible for Resident #3 on the previous date during the day shift; the staff had been working past 2:00 and had planned to empty the catheter. The DON acknowledged the catheter drainage bag was full and should have been emptied prior to that time. The DON concurred the resident had a history of UTI's and the bag being that full was concerning. On 12/31/25 at 8:00 AM the Administrator indicated understanding the concern of the catheter drainage bag having 1500 cc of urine. The Administrator stated staff should be checking throughout the day. On 12/31/25 at 8:20 AM Staff B stated catheters should be emptied at least once a shift and as needed. The staff stated if a catheter drainage bag appeared full it needed to be emptied.On 12/31/25 at 8:40 AM Staff C, CNA, stated catheters should be emptied at least once per shift and those residents who have frequent urination their catheters need to be emptied more frequently. The facility's Catheter Care, Urinary Policy, revised 9/14, revealed the resident's level of urine required monitoring of noticeable increases or decreases and physician notification if necessary. The document revealed the collection bag should be emptied at least every 8 hours.

Based on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to oxygen use for 1 of 5 residents (Resident #9) reviewed. The facility reported a census of 35 residents.Findings include: Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of hypertension (high blood pressure), renal insufficiency, and anxiety disorder. Review of a facility provided document titled, Order Summary Report with a date of 12/17/25 revealed a physician's order with a start date of 11/13/25 for oxygen continuously at 2 liters to keep oxygen saturation above 90% every shift for shortness of breath, and hypoxemia (a medical condition with abnormally low oxygen levels in the blood). Review of Resident #9's Care Plan with a revision date of 11/13/25 revealed no focus, goals, or interventions for oxygen utilization.Interview 12/30/25 at 10:18 AM with the Director of Nursing (DON) revealed that her expectation would be for oxygen use to be involved on the care plan. Review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered with a revision date of 12/2016 revealed:a. The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review the facility failed to provide thorough and timely assessment and intervention for 1 of 16 residents reviewed. Resident #24 was diagnosed with Covid-19 and was admitted to the hospital with pneumonia. The resident returned to the facility on 11/25 and the staff failed to assess the resident's Vital Signs (VS; heart rate, oxygen saturation, blood pressure and respirations) until 12/4/25 when she was found to have a change in condition, including low blood pressures. The resident was sent back to the hospital on [DATE]. The facility reported a census of 35 residents. Findings include:According to the Minimum Data Set (MDS), Resident #24 was admitted to the facility on [DATE]. She had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) Resident #24 required substantial assistance with sit to stand transfers, and was totally dependent on staff for dressing, toileting and showering. The resident was on oxygen therapy as needed. Her diagnoses included: anemia, coronary artery disease, heart failure, pneumonia, diabetes mellitus and chronic respiratory failure. The Care Plan for Resident #24, updated on 11/13/25, showed that she had oxygen therapy related to respiratory illness and hypertension (high blood pressure.) Staff were to monitor for unsteady gait. The Census tab in the electronic chart, showed that Resident #24 went to the hospital on [DATE] and returned on 11/25/25. She was sent back in the hospital on [DATE].The following was found in the Nursing Progress Notes:a. On 11/20/25 at 11:50 AM. Resident #24 tested positive for Covid-19 on 11/12/25, had increased confusion and several falls with an intervention to increased monitoring. A chest x-ray showed that she was positive for pneumonia and placed on antibiotic. b. On 11/20/25 at 1:06 PM, Resident #24 was having difficulty with breathing and was using supplemental oxygen at 2 liters (L). The oxygen saturations (O2 sats) came up to 92% but dropped to 66% without supplemental oxygen (normal oxygen levels are between 95%-100%, drops below 80%-85% may affect brain function.) The resident's Blood Pressure (BP) reading was 70/48 (American Heart Association describes hypotension, or low blood pressure, as less than 90/60.) The Nurse Practitioner (NP) was called Resident #24 was sent to the hospital. c. On 11/25/25, the NP Encounter note included vital signs; Heart Rate (HR) 100 beats per minute, BP; 126/82, and oxygen level; 94% on room air. Resident #24 was admitted to the hospital on [DATE] with diagnoses of respiratory failure with hypoxia, and she returned back to the facility on [DATE]. The plan included continued supplemental oxygen at 2 L to keep sats greater than 90%. Encourage the resident to cough and take deep breaths, monitor heart rate and rhythm.d. On 12/1/25, NP Encounter note showed the HR, BP, O2 sats and respirations were the same as documented on 11/25/25. The plan included continued monitoring of heart rate and rhythm, O2 to keep sats greater than 90%. e. On 12/3/25 at 3:05 PM, nursing received orders to check vital signs daily for 7 days and notify provider if BP was less than 90 systolic (upper number) or great than 160 systolic. The clinical records lacked vital signs for Resident #24 from 11/26/25 through 12/3/25.A written Physician Order Form, dated 12/1/25, showed that the NP wrote an order to take daily BP readings. The order was signed by the NP on 12/1/25, and it was noted by nursing on 12/2/25. A Nursing Note (NN) dated 12/4/25 at 2:56 PM, showed that the nurse had checked the BP for Resident #24 multiple times, but each pressure continued to drop. The resident was weak with increased confusion, the NP was called and the resident was sent to the emergency room. An Emergency Department (ED) report dated 12/4/25 at 3:44 PM, showed that Resident #24 presented to the ED for hypotension as low as 76/46. The resident had a history of hypertension, septic shock, and atrial fibrillation. The physician documented that the hypotension was secondary to her hypertension medication. The resident was admitted to the hospital for monitoring. On 12/30/2025 at 1:57 PM, Staff D, Assistant Director of Nursing (ADON) said that Resident #24 had a significant change in condition when she had Covid. She was moving around less and had low oxygen saturations. She thought the nurses were monitoring her more closely during that time. On 12/30/25 at 3:30 PM, the Administrator said that Resident #24 had been very sick with Covid, she was unsteady and had a couple of falls. She agreed that on-going vital signs would have been important during that time. On 12/30/25 at 2:26 PM, Staff E, NP, said that she had noticed that there weren't any vitals in the chart from 11/25 - 12/4. When she came in to see the resident on 12/1/25, she had asked the nurses where the vitals were, they responded that they thought they were getting done and it was just a case of them not getting them documented. According to the facility policy titled: Resident Examination and Assessment, dated February 2014, the purpose of the procedure was to examine and assess resident for any abnormalities in health status. Documentation of information that should be recorded in the resident medical record: all assessment data obtained during procedure, and how the resident tolerated the procedure.

Based on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance as scheduled for 3 of 4 residents reviewed for bathing (Resident #2, #6 and #9). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented a new admission to the facility from the hospital. The Medical Diagnosis report for Resident #2 showed a diagnoses of Diabetes Mellitus, diabetic ulcer and pain in the lower leg. The Care Plan with an initiated date of 2/19/25 for Resident #2 showed the resident required assistance from one person for bathing. In an interview on 2/24/25 at 4:33 PM, Resident #2 reported he doesn't want to get anyone in trouble but hasn't been offered a bath since admission on 2/19/25. When asked if he refused a bath Resident #2 stated, I was never offered one, so I couldn't refuse one. The Documentation Survey Report dated February 2025 showed the resident scheduled for baths on Mondays and Thursdays. The report also showed staff documented a bath not applicable on Thursday, February 20th and Monday, February 24th. 2. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of difficulty walking and muscle wasting. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS also revealed Resident #6 dependent for bathing. The Care Plan with an initiated date of 10/24/23 for Resident #6 showed the resident required assistance of one person for bathing. In an interview on 2/25/25 at 9:28 AM, Resident #6 reported a bath is scheduled once a week but isn't offered once a week. When asked if she refused baths Resident #6 stated, sometimes. When asked if she refused a bath in the last few weeks, Resident #6 stated no. The Documentation Survey Report v2 for Resident #6 revealed the resident to shower every Wednesday. The report also showed staff documented Resident #6 refused a bath two consecutive Wednesdays, February 11th and 19th. 3. The MDS assessment dated [DATE] for Resident #9 documented an admission to the facility from the hospital. The Medical Diagnosis report for Resident #9 showed a diagnoses of legal blindness, muscle weakness, impingement syndrome of the right shoulder. The Brief Interview for Mental Status Evaluation for Resident #9 showed a score of 15, which indicated no cognitive impairment. The Care Plan with an initiated date of 2/13/25 for Resident #9 showed the resident required partial assistance of one person for bathing. In an interview on 2/25/25 at 9:47 AM, Resident #9 reported he hasn't been offered a bath since a week from last Sunday (February 16th). When asked if he refused baths when offered by staff, the resident replied no. Review of report titled Documentation Survey Report v2 for Resident #9 baths are to be completed on bath days as needed. No bath documented since February 16th. In an interview on 2/19/25 at 11:30 AM, Staff B, Certified Nursing Assistant (CNA) stated, we are short staffed. That's the reason why baths aren't being done. We do other grooming at the same time like nails, so that doesn't get done either. With all the new residents it has been impossible. A lot of them are Hoyer machines which need two staff to do. Look at Resident #6's bath documentation. I know she isn't getting baths. In an interview on 2/20/25 at 2:38 PM, when asked if residents received scheduled baths Staff C, CNA replied no. Just because we are short staffed because there are only two of us on the floor, plus the new residents need two people at a time. We at least try to give them a bed bath so they get something. In an interview on 2/24/25 at 9:20 AM, Staff D, CNA stated some residents lately haven't gotten baths done due to being short on staff and with new residents. In an interview on 2/24/25 at 9:58 AM, when asked if residents received scheduled baths, Staff E, CNA stated we used to have time to give baths before we got all these new residents and had things under control. We had a bath aide scheduled and everyone got baths. Now the bath aide is pulled to the floor. Tomorrow there is a bath aide scheduled, it's me but they will need me to help them on the floor. A lot of the new residents are two assist. The night shift only has two CNA's scheduled. If residents don't get a bath I documented they refused their bath. When asked why a refusal is documented when the resident didn't refuse, the CNA replied, the prior Director of Nursing (DON) told us to document that the resident refused if they didn't get a bath. In an interview on 2/24/25 at 11:23 AM, Staff F, Registered Nurse (RN) stated the residents are not getting baths. There just isn't the staff. They try to schedule the bath aide. The bath aides have been pulled to the floor. When asked how baths are documented when staff didn't have time, Staff F replied some of the CNA's told me the old DON told them to document that residents refused baths instead of not getting a bath. In an interview on 2/24/25 at 1:03 PM, Staff G, RN stated baths are not getting done. Staff mark as refused even if they don't have time to give baths. The Bath Shower/Tub policy last revised February 2018 identified staff need to notify the supervisor if the resident refuses a bath and to document the reason why and intervention. In an interview on 2/24/25 at 1:16 PM, when asked about bath documentation discrepancies Staff H, RN reported staff have the option to document the bath wasn't applicable, or the resident refused. Staff H explained there isn't an option that accurately reflected staff did not complete the bath. Staff H reported she would talk to Informatics about adding another option. Staff H also reported the bathing schedule wasn't entered into the electronic chart accurately for residents which failed to prompt staff to document. Staff H planned to correct the bathing schedules in the electronic charts. Staff H reported paper documentation showed baths are completed as scheduled. In an interview on 2/24/25 at 2:05 PM, when asked about the paper bathing documentation that failed to match the electronic chart bathing documentation the Administrator stated, if staff don't have time to give baths we need to know so we can fix it. Staff shouldn't be documenting baths are being done when they're not.

Based on clinical record review, staff interviews, and policy review the facility failed to complete assessments for the necessary care and services to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff failed to perform neurological assessments for 1 out 3 residents reviewed for falls (Resident#1). The facility reported a census of 32 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of polyneuropathy, muscle weakness and repeated falls. The MDS showed the BIMS score of 9, which indicated moderate cognitive impairment. The Progress Notes for Resident #1 revealed the resident had unwitnessed falls on the following dates: a. 2/17/25 b. 2/18/25 c. 2/19/25 The neurological assessments for Resident #1 revealed the facility failed to complete and/or properly complete neurological assessments on the following dates: a. 2/17/25 b. 2/19/25 c. 2/20/25 The neurological assessment policy last revised on March 18th, 2021 revealed after fall neurological assessments per the following schedule: a. Initial assessment b. Every 15 minutes x4 c. Every 30 minutes x2 d. Every hour x2 e. Every 8 hours x9 In an interview on 2/24/25 at 8:46 AM, Staff A, Registered Nurse (RN) when asked if nurses had time to complete necessary care to residents. Staff A stated, we have had a lot of new admits lately, it's hard for staff to get things done. In an interview on 2/25/25 at 10:21 AM, the Administrator reported that she expected staff to complete neurological assessments per policy after an unwitnessed fall. The Administrator reported the facility received eight new admits in three weeks and staff needed time to adjust to the additional workload. The Administrator reported she planned to hire a nurse to work weekdays to provide additional assistance to the whole team.

Based on observation, clinical record review, resident, family and staff family interviews, the facility failed to provide an environment that is free from accidents and hazards for 2 of 2 residents reviewed (Resident #1 and #10). The facility reported a census of 32 residents. Findings include: In an interview on 2/20/25 at 2:38 PM, Staff C Certified Nursing Assistant (CNA) stated Resident #10 kept pulling on TV wires thinking it was the call light and almost pulled the TV off the wall, Resident #10 was directly below the TV. In an interview on 2/20/25 at 3:52 PM, Resident #1's family stated, the TV cords were close to the call lights. Mom kept pulling on the TV cords. She thought it was the call light. The TV is over the bed. We were afraid she was going to pull down the TV. Observations on 2/24/25 at 1:50 PM showed Resident #1's TV cords hanging down from the TV and inches from the call light string. The TV hung over the resident's bed. Observations on 2/24/25 at 1:55 PM showed Resident #10's TV cords hanging down from the TV and inches from the call light string. The TV hung over the resident's bed. The Homelike Environment policy provided by the facility and last revised February 2021 failed to address environmental hazards. In an interview on 2/24/25 at 2:22 PM, the Administrator observed rooms with TV cords hanging close to the call light. When asked if the Administrator felt this could potentially be a hazard she replied I could see that. I ' ll have maintenance work on it. It shouldn't take him long to come up with something.

Based on facility record review and resident and staff interviews, the facility staff did not consistently answer call lights within a reasonable amount of time. Residents reported having to wait over 15 minutes for call lights to be answered for 3 of 3 residents reviewed (Resident #6, #7 and #9). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool with the assessment reference date of 1/30/25 for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS indicated Resident #6 dependent for transfers, toileting and bathing. The MDS identified a diagnoses of difficult walking and muscle wasting. The Care Plan identified Resident #6 required a mechanical stand for transfers. In an interview on 2/25/25 at 9:28 AM, Resident #6 reported she waited over 15 minutes for call lights 1-4 times a day. Resident #6 reported she used a mechanical device for assistance with transfers and felt this sometimes caused delays in assistance. 2. The MDS assessment dated [DATE] for Resident #7 showed the resident admitted to the facility from the hospital. The Brief Interview for Mental Status Evaluation for Resident #7 showed a score of 15, which indicated no cognitive impairment. The Medical Diagnosis report for Resident #7 showed a diagnoses of pressure ulcer, spina bifida and weakness. The Care Plan for Resident #7 showed the resident required partial assistance for bed mobility, moderate assistance for upper body dressing and dependent for lower body dressing. In an interview on 2/25/25 at 9:05 AM, when asked if she had to wait for longer than 15 minutes for call lights, Resident #7 stated yes we wait over an hour most nights before 10 PM. Resident #7 reported she needed assistance to get ready for bed and unable to sleep until staff arrived to assist the bedtime cares. 3. The MDS assessment dated [DATE] for Resident #9 documented an admission to the facility from the hospital. The Medical Diagnosis report for Resident #9 showed a diagnoses of legal blindness, muscle weakness, impingement syndrome of the right shoulder. The Brief Interview for Mental Status Evaluation for Resident #9 showed a score of 15, which indicated no cognitive impairment. The Care Plan with an initiated date of 2/13/25 for Resident #9 showed the resident required partial assistance of one person for bathing, transfers, dressing and hygiene. In an interview on 2/25/25 at 9:47 AM, Resident #9 stated staff took over 15 minutes to answer call lights 2-3 times every evening. When asked how a delayed call light response impacted the resident he replied I get frustrated. In an interview on 2/20/25 at 2:38 PM, when asked if residents received scheduled baths Staff C, CNA replied no. Just because we are short staffed because there are only two of us on the floor, plus the new residents need two people at a time. We at least try to give them a bed bath so they get something.When asked if call lights could be answered within 15 minutes Staff C stated, it's the same thing only two of us on the floor with new residents. In an interview on 2/24/25 at 8:46 AM, Staff A, Registered Nurse (RN) reported it took over 15 minutes to answer call lights for almost all residents every night because there wasn't enough help. When asked if nurses had time to complete necessary care to residents. Staff A stated, we have had a lot of new admits lately, it's hard for staff to get things done. In an interview on 2/24/25 at 1:03 PM, Staff G, RN stated staff can't get call lights answered within 15 minutes with the new admits, more so on the evening shift. They just need more help. The Answering the Call Light policy last revised March 2021 failed to identify a time frame in which staff are required to respond to a call light. In an interview on 2/24/25 at 2:05 PM, when asked for a timeframe in which staff are to respond to a call light the Administrator replied, within 15 minutes.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 27 residents. Findings include: The PBJ Staffing Data Report with a run date 1/8/25 triggered for Excessively Low Weekend Staffing and One Star Staffing Rating. Review of Facility Daily Assignment Sheets revealed staffing for nurses and certified nursing assistants (CNAs) scheduled an extra CNA on weekdays to complete baths, and the Director of Nursing worked extra shifts on the nights and weekends. The Reporting Direct-Care Staffing Information (Payroll-Based Journal) policy October 2017 identifed staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Policy Interpretation and Implementation: 1. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system. 2. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees. 3. Providers who are employed by the facility (including physicians) are included in direct-care staffing information; providers who bill Medicare directly are not included. 4. For auditing purposes, reported staffing information is based on payroll records, or other verifiable information. 5. Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both. 6. The PBJ system is accessed through the QIES at https://www.qtso.com/. 7. Manual entries are made only by designated personnel with training on the PBJ user interface. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. 9. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. 10. Staffing data includes the number of hours worked each day by each staff member. 11. Census data is reported each fiscal quarter and includes resident census on the last day of each month of the quarter. In an interview on 1/12/25 at 1:42 PM, the Administrator and DON reported the DON worked sufficient nights and weekends and failed to report worked hours. Also, an employee from the attached assisted living facility also worked hours that were not included in the reported hours to CMS.

Based on observations, interview, and record review, the facility failed to review and revise care plans for four out of four residents reviewed (Residents #3, #11, #21 and #26). Specifically, the facility failed to identify the targeted behaviors for residents that received anti-psychotic, antidepressant and psychotic medications.The facility reported a census of 27 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #3 documented diagnoses of anxiety disorder, depression, dementia.The MDS showed a BIMS score of 15, which indicated no cognitive impairment. Review of the MDS dated [DATE] revealed Resident #3 is taking antipsychotic medications, and antidepressant medications in the review period. The Clinical Orders and Medication Administration Record for January 2024 for Resident #3 showed: a. Duloxatine started on 1/6/23 for anxiety b. Aripiprazole started on 7/19/23 for major depression. The care plan for Resident #3 failed to include the behaviors resident displayed, non-pharmacological interventions when behaviors were displayed or what targeted behaviors staff were to monitor for. 2. The MDS assessment dated [DATE] for Resident #26 documented diagnoses of anxiety disorder and depression. The MDS showed a BIMS score of 15, which indicated no cognitive impairment. Review of the MDS dated [DATE] revealed Resident #26 is taking antipsychotic medications and antidepressant medications in the review period. The Clinical Orders and Medication Administration Record for January 2024 for Resident #26 showed: a. Mirtazapine started on 10/29/24 for depression b. Seroquel started on 11/13/24 for depression. The care plan for Resident #26 failed to include the behaviors resident displayed, non-pharmacological interventions when behaviors were displayed or what targeted behaviors staff were to monitor for. 44474 3. The MDS assessment dated [DATE] for Resident #3 documented diagnoses of Bipolar Disease, Schizophrenia and depression.The MDS showed a BIMS score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed Resident #3 is taking antipsychotic medications, antianxiety and antidepressant medications in the review period. Review of the Order Review History Report signed 1/11/25 revealed the following orders: a. Bupsirone tablet with a start date of 3/20/24 b. Clozapine tablet with a start date of 3/20/24 c. Divalproex tablet with a start date of 3/20/24 d. Venlafaxine tablet with a start date of 3/20/24 e. Quetiapine tablet with a start date of 9/16/24 f. Rexulti tablet with a start date of 12/20/24 Review of the January Medication Administration Record (MAR) revealed the following orders: a. Bupsirone tablet b. Clozapine tablet c. Divalproex tablet d. Venlafaxine tablet e. Quetiapine tablet f. Rexulti tablet The care plan did not include the behaviors resident displayed, non-pharmacological interventions when behaviors were displayed or what targeted behaviors staff were to monitor for. 4. The MDS assessment dated [DATE] for Resident #21 documented diagnoses of non-Alzheimer ' s dementia and delirium.The MDS showed a BIMS score of 03 indicating severe cognitive impairment. Review of the MDS dated [DATE] revealed Resident #21 is taking antipsychotic medications and antidepressant medications in the review period. Review of the Order Review History Report signed 1/11/25 revealed the following orders: a. Escitalopram tablet with a start date of 10/3/23 b. Quetiapine fumarate tablet with a start date of 8/16/24 c. Trazodone tablet with a start date of 1/3/25 Review of the January Medication Administration Record (MAR) revealed the following orders: a. Escitalopram tablet b. Quetiapine fumarate tablet c. Trazodone tablet The care plan did not include the behaviors resident displayed, non-pharmacological interventions when behaviors were displayed or what targeted behaviors staff were to monitor for. Review of facility provided policy titled Using the Care Plan revised August 2006 revealed the care plan shall be used in developing the resident ' s daily care routines and will be available to staff personnel who have the responsibility for providing care or services to the resident and documentation must be consistent with the resident ' s care plan. Interview on 01/15/25 at 9:35 a.m., with the Director of Nursing revealed she was not aware the targeted behaviors needed to be on the care plan. The targeted behaviors are listed for the nurse to monitor and she would add them to the care plan.

Based on observation, infection control policy, clinical record review and staff interview, the facility failed to conduct blood sugar tests in a manner that protected the resident from blood borne pathogens for 2 out of 2 residents reviewed (Resident #3 and #15). The facility reported a census of 27 residents. Findings included: 1. Observation on 1/14/25 at 11:32 AM Staff A, Licensed Practical Nurse (LPN), entered Resident #15 ' s room with a bag of supplies for a blood sugar test. Staff A placed testing supplies directly on Resident #15 ' s bedside table. Staff A failed to place a barrier between the surface of the bedside table and testing supplies. Staff A placed the blood testing strip into the glucometer. Staff A applied gloves, cleansed the resident's finger with an alcohol swab, allowed the solution to dry, then lanceted the resident ' s finger. Staff A collected a sample of blood using a testing strip. Staff A placed the glucometer back on the resident's table without a barrier. After the glucometer measured the blood sugar results Staff A removed the blood sugar strip from the glucometer then discarded the testing strip and gloves. Staff A failed to perform hand hygiene. Staff A then collected the blood sugar testing supplies and placed the supplies back into the bag. Staff A failed to sanitize the glucometer. Staff A collected the bag and exited the room. Staff A completed hand hygiene in the hall. 2. Observation on 1/14/25 at 11:45 AM Staff A, Licensed Practical Nurse (LPN), entered used a wheelchair to transfer Resident #3 from the dining room to the nurses station. Staff A placed blood sugar testing supplies directly on the countertop of the nurses station. Staff A failed to place a barrier between the surface of the countertop and testing supplies. Staff A placed the blood testing strip into the glucometer. Staff A applied gloves, cleansed the resident's finger with an alcohol swab, allowed the solution to dry, then lanceted the resident ' s finger. Staff A collected a sample of blood using a testing strip. Staff A placed the glucometer back on the countertop without a barrier. After the glucometer measured the blood sugar results Staff A removed the blood sugar strip from the glucometer then discarded the testing strip and gloves. Staff A failed to perform hand hygiene. Staff A then collected the blood sugar testing supplies and placed the supplies back into the bag. Staff A failed to sanitize the glucometer. The Obtaining a Fingerstick Glucose Level policy dated October 2011 identified to clean reusable equipment per the manufacturer instructions and current infection control standards of practice. The policy also instructed staff to wash hands after removing gloves. In an interview on 1/15/25 at 8:23 AM, the Director of Nursing, (DON) reported when a blood sugar is tested , staff are to place a protective barrier between the testing supplies and the surface being used. The DON reported staff should immediately perform hand hygiene after gloves are removed.

Based on clinical record, facility policy, resident, and staff interview, the facility failed to follow dentist referral to obtain specialty dental services for 1 of 3 residents reviewed (Resident #93). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #93 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS assessed the resident as having the following diagnoses: heart failure (may result in fluid buildup within the body creating difficulty in breathing) and asthma (COPD, chronic obstructive pulmonary disease) or chronic lung disease (may result in difficulty breathing). The resident required oxygen therapy and used a walker for assistance in walking. The resident's MDS dated [DATE] revealed she required the limited assistance of 1 person for personal hygiene which includes brushing her teeth. The MDS dated [DATE] revealed the resident obvious or likely cavity or broken natural teeth. The Care Plan focus area revised by the Director of Nursing (DON) on 10/30/23 revealed in pertinent part: My teeth are in poor condition causing me to have tooth pain from time to time. The Dental Visit Notes from visits held in the facility revealed in pertinent part: 1. Visit dated 8/18/23 revealed the patient stated her teeth have not done well, she still had some cold sensitivity from time to time. The Dr. (doctor) found one tooth broken and may be giving her pain #31. The Dr. referred her to oral surgery to have the tooth pulled, as the Dr. couldn't take the tooth out at the facility. 2. Visit dated 10/30/23 revealed patient stated that she is still having pain on her lower right. The DDS (Doctor of Dental Surgery) and RDH (Registered Dental Hygienist) made a referral on 8/18/23 to have the tooth extracted. Please have this completed to relieve the patient of pain. If the patient requires a referral again, please reach out to the office and they will resend one. Progress Notes or other areas of the Clinical Record lacked documentation that the facility assisted the resident with her referral to oral surgery. The Dental Services Policy revised December 2016 revealed in pertinent part: 1. Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 2. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. In an interview on 1/3/24 at 12:15 PM, the resident pointed to her lower right jaw and reported that her tooth broke. She reported the dentist told her, that she needed it pulled but she didn't know when. In an interview on 1/3/24 at 12:30 PM, the DON she doesn't know anything about the issue with the resident's tooth because she wasn't working at the facility in October 2023. In an interview on 1/3/24 at 3:20 PM, Staff A, Clinical Support Manager, for the dental provider reported that they sent a referral to the facility on [DATE] with a list of dental practices that accept the resident's insurance. The dental provider offered the facility that they could contact them for another referral if needed with no contact on record at the dental provider's office. In an interview on 1/4/24 at 8:30 AM, the Regional Nurse Consultant (RNC) reported that the facility never received the referral in August 2023. The dental provider emailed it to a staff member who no longer worked at the facility. The email returned to the dental provider the same day. The dental provider never contacted the facility to ask for a different email address to send the referral. An electronic mail (email) from the dental provider on 1/4/24 at 8:52 AM revealed: 1. An activity log from 8/21/23 to 1/3/24 showed that the facility did not contact the dental provider. 2. An email sent to Staff B, Social Services (SS), on 8/21/23 informing her of the resident's need for a dental referral. An email on 1/4/24 at 9:02 AM from the Administrator confirmed that Staff B's email address used by the dental provider as the same email address on record at the facility. In an interview on 1/4/24 at 9:20 AM, Staff B reported the dental provider didn't include her email address until recently; but she did not know when it started. She reported she didn't know much about the resident's teeth because it's a clinical issue. She confirmed that her email address is the same as the one the Administrator has on record and the referral email sent by the dental provider on 8/21/23. In an interview on 1/4/24 at 10:30 AM, the RNC reported on the day before, the dental provider told her they didn't have a referral email on file from August 2023. She couldn't report who she spoke with at the dental provider's Office.

Based on clinical record review, facility policy review, staff, and resident interviews, the facility failed to report allegations of abuse within 2 hours for 1 of 3 residents reviewed (Resident #1). Resident #1 reported to staff on 10/23/23 that a staff member sexually abused her, in addition to transferring money from her account to staff. The facility did not report the incident to the appropriate authorities until the evening of 10/24/23. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing personal items for residents on 11/10/23. iv. Discharge/transfer policy, highlighted resident-initiated discharge including meeting the needs of the resident welfare on 11/10/23. v. Supervision of outdoor visits on 11/13/23. b. The facility interviewed residents on all the alert and oriented residents on 11/11/23. In addition, the facility audited the remaining residents for any non-verbal signs of abuse. c. The facility updated the Agency Orientation Checklist to include Abuse Protocol to highlight dependent adult abuse reporting policy and professional boundaries. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), and malignant neoplasm of upper lobe (lung cancer). The assessment indicated that Resident #1 almost always had pain. The Care Plan included the following Focuses dated 10/3/23: a. Resident #1 planned to rehab to home. The Goal listed that Resident #1 would transition back to the community. b. Activities of daily living (ADLs). The Interventions directed that Resident #1 could independently provide her own hygiene, toilet use, and transfers. c. Resident #1 is independent in the facility. The Interventions reflected that Resident #1 used a front wheel walker. On 11/8/23 at 10:48 AM, Staff A, Dietary Aide (DA), said that on the evening of 10/23/23 while she waited outside of the facility for a ride after her shift and sat with Resident #1 on the patio. Resident #1 told her that Staff I, Certified Nurse Aide (CNA), bought her cigarettes, then he took her phone and transferred money into his own Cash App. After this, Resident #1 told Staff A that he took her to his car one night and forced her to perform oral sex on him. Resident #1 said that they were drinking alcohol and she did not want anyone to know about it. Staff F, Nurse Aide (NA), then stopped over and entered the conversation when Resident #1 told them that she had a video from Staff I, but she needed to charge her phone, so she could not show them. She said that Resident #1 trembled when she told them the story and expressed fear of what he might do if he knew she told anyone. On 11/8/23 at 10:32 AM, Staff F said that on the evening of 10/23, Resident #1 sat outside with Staff A and when she approached, Staff A looked at her and asked can I tell her? Resident #1 shook her head yes and Staff A proceeded to tell her that Staff I sent her a video of himself masturbating. They agreed that they needed to report this to the Administrator. The next morning at around 10:00 AM they both went in to talk to the Administrator. On 11/8/23 at 2:18 PM, the Administrator said that on 10/24/23, a couple of staff members told her about a situation with Staff I buying cigarettes for Resident #1, and that he used a Cash App on his phone. The Administrator said that she had Staff I come into her office that morning. He showed her the Cash App receipt on his phone for $10.00, and she suspended him from the building. When asked about the allegations of sex, the Administrator said that she confronted Resident #1 about providing sexual favors for cigarettes, but she denied it. She said that Staff I denied any sexual activity with Resident #1. He acknowledged that he would take her out to smoke but denied anything sexual. The Administrator said that Resident #1 wrote a letter stating that it was false and denied everything. A hand-written note dated 10/24/23 at 8:52 AM, signed by Resident #1, indicated that the Administrator confronted Resident #1 and accused her of providing sexual favors for cigarettes. Resident #1 reported being very upset by the allegations, and that she would never do anything so vile. She denied the allegations and the hand-written note lacked any reference to forced sexual acts. The complaint unit from The Department of Inspections, Appeals, and Licensing (DIAL) confirmed in an email on 11/28/23 that the facility reported the incident on 10/24/23 at 9:35 PM. The Sheriff's Office Incident Report dated 11/1/23 at 6:22 PM, reflected that a Sheriff's Office Representative interviewed Resident #1 about allegations of sexual abuse. She said that during her time as a resident in the nursing home, Staff I, CNA, sexually abused her. She stated that while taking care of her, Staff I would touch and kiss her inappropriately on the back of the neck and on her feet. She said that 2-3 weeks prior to her discharge, she went outside the facility to have a cigarette and it had been raining. Staff I asked if she would like to have her cigarette in his car and she agreed. He wheeled her to the car and while in the vehicle, he forced her to perform oral sex on him. She described the vehicle as a small red car parked by the row of trees near the highway. On 11/14/23 at 2:15 PM, the Police Officer who interviewed Resident #1 on 11/1/23 described her as forthcoming but very embarrassed when she came in to the report abuse. He said that when she tried to describe what happened, she stumbled and had difficulty describing the sexual act. She mentioned being heavily medicated while at the facility and could not give consent. She told the officer that Staff I sent her a sexually explicit video of himself. On 11/13/23 at 10:30 AM Staff P, Former Office Manager, said that she no longer worked at the facility. She felt that the administration was looking for some reason to terminate her because she questioned them on reporting the events to the proper authorities. Staff P said that she heard about the allegations of abuse later in the day on 10/24/23 and sent a text to the Regional Manager at 5:30 PM, expressing that they should report the event. She then she got a call back from corporate that Resident #1 recanted the allegations so they did not think they needed to report it. She said that when she came into work on the 25th, her office had been in shambles because they were looking through for missing orders. They suspended her because of the missing orders. On 11/14/23 at 9:00 AM the Regional Director of Nursing said that their leadership team had a rapid response phone call regarding the concern with Resident #1 on 10/24/23. She said that most of the conversation was related to the concern about money exchange from resident to staff. The conversation included very little discussion regarding sexual innuendos. She said that the Administrator conveyed to them that Staff I only made a motion that simulated masturbation. The meeting did not include anything about allegations of forced sexual activity. On 11/14/23 at 2:50 PM the Regional Manager said the rapid response team did not get all the information, or accurate information from the Administrator to determine the next steps. She said that had they known all the details, they would have made different decisions. According to the facility policy titled; Mandatory Reporting Abuse Investigation dated November 2019. All allegations of resident abuse need reported immediately. Administrator or his/her designee will designate a member of management to investigate the alleged incident to include: review of assessment of resident injury, assess the resident for injury, provide notification to primary care provider, and attempt to obtain witness statements (oral and/or written) from all known witnesses. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination (blame) or intimidation.

Based on clinical record review, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to adequately planned transfers for 1 of 3 residents reviewed (Resident #1). The facility discharged Resident #1 abruptly after allegations of abuse to a homeless shelter that did not know of her transfer. The homeless shelter did not have nurses on staff to meet her medical needs and they did not have any staff overnight. The homeless shelter transferred Resident #1 to the hospital as she could not safely remain in the homeless shelter. After arriving to the homeless shelter, Resident #1 began to stumble and fall. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing personal items for residents on 11/10/23. iv. Discharge/transfer policy, highlighted resident-initiated discharge including meeting the needs of the resident welfare on 11/10/23. v. Supervision of outdoor visits on 11/13/23. b. The facility interviewed residents on all the alert and oriented residents on 11/11/23. In addition, the facility audited the remaining residents for any non-verbal signs of abuse. c. The facility updated the Agency Orientation Checklist to include Abuse Protocol to highlight dependent adult abuse reporting policy and professional boundaries. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), and malignant neoplasm of upper lobe (lung cancer). The assessment indicated that Resident #1 almost always had pain. The Care Plan included the following Focuses dated 10/3/23: a. Resident #1 planned to rehab to home. The Goal listed that Resident #1 would transition back to the community. b. Activities of daily living (ADLs). The Interventions directed that Resident #1 could independently provide her own hygiene, toilet use, and transfers. c. Resident #1 is independent in the facility. The Interventions reflected that Resident #1 used a front wheel walker. On 11/6/23 at 2:13 PM, Resident #1 said that when she reported her abuse to a couple of staff members, somehow, they twisted the story around. Due to this she did not trust anyone at the facility any more. She said that the Administrator came into her room one day, yelling, and told her that she had to leave because the staff reported that she provided sexual favors for cigarettes. Resident #1 said that staff took her outside to have cigarettes, and she shared with a couple of them. Staff I sexually attacked her. She could not remember the date when Staff I took her to his car and made her perform oral sex on him. Resident #1 said when planning her discharge, the Social Worker (SW) told her that she planned to help her find housing so her son could come and live with her. The SW offerred a homeless shelter as option but her son could not go there due to his age. She said she felt like the facility kicked her out because of the lies told about her. On 10/24/23, the Regional MDS Coordinator (RC) added the following to Resident #1's Care Plan: a. Staff caught Resident #1 outside in front of the building smoking. b. Resident #1 had a behavior problem that involved manipulating staff, and making up stories that did not happened. According to a Social Services Behavior History Evaluation dated 9/26/23 at 9:28 AM, Resident #1 did not make accusatory statements, described her as not worried, not anxious, not tearful, and did not have mood swings. The follow-up Behavioral History completed on 10/10/23 at 1:58 PM resulted with the same conclusion. On 11/13/23 at 8:47 AM the RC described her role as to oversee the MDS coordination for the facilities in the region. She said that she would be in the building about once a week but she would mainly spend her time with the MDS staff and leadership, resulting in her not being very familiar with the residents. She said that they talked about the residents in morning meetings. She acknowledged that she made the addition to Resident #1's Care Plan on 10/24/23. She explained it as a group effort to include that area of focus, based on Resident #1 sharing and using snacks to her advantage with staff. She said that Resident #1 told a story about how the hospital tied her down and she received the wound on her wrist from that, but she did not know about examples of any made-up stories while at the facility. When asked about allegations against Staff I, she said she did not know anything about that staff member, or allegations of abuse. She maintained that in their leadership meeting when she changed the care plan on 10/24/23, they did not talk about the abuse allegations. On 11/13/23 at 9:00, Staff D, Registered Nurse (RN), said that when RC came to the morning leadership meeting that she attended on 10/24/23, they discussed Resident #1's abuse allegations about Staff I. On 11/8/23 at 11:12 AM the Social Worker (SW) reported the transfer of Resident #1 to the homeless shelter as appropriate as she came from there per her lifestyle choice. Resident #1 always had a goal to discharge and reunite with her son. When asked if she told the staff at the shelter the level of need before sending Resident #1 to the shelter, she replied yes and no. The SW continued by expressing Resident #1's behaviors related to impulsivity and lack of follow through. When inquired about Resident #1's level of medical needs, she responded that therapy told her that Resident #1 could use a walker. The Regional Director of Nursing arranged to get her a walker to take with her but she wanted to get out. She said that after Resident #1's admission to the shelter, she called 911 that night, but she did not know what happened after that. She denied knowing anything about Staff I or cigarettes. She maintained that she had Resident #1's permission to make the arrangements to go to the shelter. On 11/9/23 at 10:45 AM during a telephone call, the SW said that the Administrator reached out to the homeless shelter to ask about admitting her. Afterwards, she made the transportation arrangements. She said that she got a call from a very upset shelter representative the next day about Resident #1 and said that she faked a heart attack. They sent her to the hospital, and they could see what she was like. The SW told her that they could not take her back because of her behaviors and manipulation. She met all her goals and she wanted to go to there. When questioned about if she sent Resident #1's medical information with her, she replied no, as a homeless person off the street did not come into a shelter with their medical diagnosis information. As that is what they do. On 11/13/23 at 3:00 PM the SW said that they put a discharge checklist on the wall in her office so they can go down the list and make sure they are hitting on the planning points. She said the 24-hour notice challenged her with the need to get the transportation. The SW had a conversation with Resident #1 about discharge on Friday or Monday. She questioned about he being okay to discharge sooner as they had a 4-hour notice. Resident #1 reported she was fine with it, as it was better because then her sister did not have to come and get her. A review of a voice recording from the transportation company, dated 10/25/23 at 7:28 AM, revealed that the SW called for a ride at that time without Resident #1 in the room with her. When the SW made the arrangements, she chose the 4-hour pick-up time and said that works for me. They finalized the arrangements and once the company found a driver, they would notify them of the time of arrival. On 11/14/23 at 12:12 PM a representative for the transportation company said that they usually only offer the 4-hour pickup option for an emergency; such as going to hospital or an important appointment, but they usually did a 48-hour pickup. On 11/15/23 at 8:00 AM Staff N, Registered Nurse (RN), said that on the morning of the discharge the Administration rushed her to get a 7-day supply of medications prepared to send with Resident #1. Early that morning, Resident #1 went around to say good bye to other residents and staff. Later that morning when she found out that she only had a half hour to get everything together and packed she started to cry. Resident #1 expressed that she felt like the facility was kicking her out. Staff N said that she understood that they had a plan for discharge but it came very abruptly. Staff N reported she had concerned that Resident #1 went to a homeless shelter without nursing services especially when the provider just changed her hypertension medication that needed monitoring. On 11/9/23 at 12:15 PM, Staff H, Housekeeping Staff, said that on the morning of 10/25/23, she loaded up the remainder of Resident #1's belongings in her personal vehicle and drove them to the shelter. The transportation provider came with a very small car and they could not get all her items in that vehicle. As she helped Resident #1 pack her things, she appeared very angry, crying, and said that she felt the facility kicked her out. She kept asking to speak to someone above the Administrator about what was happening. She got to the shelter with Resident #1 items at about 1:30 PM that day. On 11/9/23 at 8:15 AM Shelter Staff 1 (SS1) called back and said that the transportation company just dropped Resident #1 off at the shelter with no paperwork and no phone call. She said they did not typically accept residents from a hospital or nursing home that way. They need to know what level of care the resident required so they can determine if they are appropriate or if they can handle them. On 10/25/23 around 1:00 PM the transportation company dropped her off. Initially, the cab driver dropped her off at a safe house intended for domestic violence victims. The driver did not know what to do with her when they would not accept her there, so, they called the facility, who told them to take her to the homeless shelter. SS1 did the intake herself and then she had to leave early that day. Her daughter worked there in the afternoon and she called 911 due to Resident #1 shaking, falling, and unstable around 4:00 PM in the afternoon. At 6:15 AM on 10/26/23 the hospital returned her soiled back at the shelter. They got her a room to clean up and she talked to a friend on the phone. Around 11:00 AM on the 10/26/23, Resident #1's friend came and picked her up. She said she did not know what happened from there. They try not to get too involved in the resident's lives or situations once they leave the shelter. She said the facility made her very upset for just dropping off Resident #1 without first having a consultation on her level of need. She explained that we have children here and do not have nursing staff. She did call and talk to the SW who said that she did not make the arrangements and indicated that they would not take Resident #1 back because she made allegations against staff. On 11/13/23 at 7:26 AM SS1 that she knew for a fact that no one talked to Shelter Staff 2 (SS2) before Resident #1 showed up at their door. She said that when they get residents from a facility or hospital, they put them on a list. When Resident #1 showed up she checked the list, which did not include her. SS2 called back to the facility the next day and talked to the SW but not before. SS1 was very sure of that because she is the manager, they all stay on top of who is calling and who is on the list. When Resident #1 showed up at their door, she told them that she did not know where they sent her. She said that they will never do business with that facility ever again or with that SW lady. On 11/13/23 at 2:32 PM SS2 said that the first day she talked to anyone at the facility was the day that Resident #1 showed up at their door. They write down their notes or document on the computer and they have no notes that someone contacted them regarding Resident #1 coming there. Resident #1 was at the door, concerned about the driver because he was on the phone with the facility. Originally, he went to the wrong place first and then did not know what to do with her things. Then the SW called back just after Resident #1 got there and SS2 told her that Resident #1 could barely walk, shook, and had shortness of breath. Resident #1 worried about holding up the driver. SS2 recalled her surprise when they started unloading all of Resident #1's things and said that they could only allow 2 bags. SS2 said that Resident #1 he had a TV and everything. SS2 talked to the SW on the phone telling her about Resident #1 not stable and she did not know if they could take care of her there. The SW told her that because of her behaviors they could not take her back. She told the SW that they did not know about her coming, the SW responded that she was sure someone took care of that. Staff 2 started the intake and later called non-emergent care to pick her up because she seemed so unstable. She did come with some medications, they are responsible for taking them on their own. Staff 2 said if Resident #1 stayed there before, it was a long time ago because she did not have a record of her being there. The Encounter Note dated 10/24/23 at 12:00 AM signed by the Advanced Registered Nurse Practitioner (NP) on 10/26/23 at 8:08 PM reflected that Resident #1 saw the NP on 10/24/23. At that time, Resident #1 cried and stated that she had a lot of pain. They discussed getting her an appointment with the pain clinic. Resident #1 told her about her leaving the facility in 1-2 days, as the staff falsely accused her of being inappropriate with a staff member. She planned to leave and be at the homeless shelter for 6 months. The provider received a call from the facility on 10/25/23 indicating that day they planned to discharge Resident #1. The NP recommended to follow-up for medication refills in six months and she would provide a 7-day supply of medications. The Blood Pressure Summary and Pulse (HR, an elevated pulse is over 100) Summary reviewed on 11/9/23 included the following results (low blood pressure considered to be below 90/60): a. 10/17/23 at 4:14 PM 89/60, HR 112 b. 10/18/23 at 3:17 PM 96/62 c. 10/19/23 at 2:23 PM 84/55 HR 112 The Communication - With Physician Note dated 10/24/23 at 4:33 PM reflected the NP came to the facility and wrote the following new orders: a. Discontinue clonidine (hypertension medicine) b. Discontinue Coreg (hypertension medicine) c. Start Metoprolol 25 MG (hypertension medicine that lowers pulse) d. Complete lipids, complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), and a hemoglobin A1C (lab test that measure your blood sugars over three months) labs, then repeat in 6 months. A prescription dated 10/24/23 at 4:22 PM returned from the pharmacist noting that discontinuation of clonidine should not happen abruptly. Please consider tapering gradually and monitor for rebound hypertension. The Communication - With Physician Note dated 10/25/23 at 2:09 AM indicated that the Pharmacy faxed that discontinuation of clonidine should not happen abruptly due to rebound hypertension (withdrawal syndrome that occurs when discontinuing antihypertensive drugs abruptly, leading to a rapid increase in blood pressure without symptoms). The facility notified the NP via fax. The Nurses Note dated 10/25/23 at 10:58 indicated the facility received a telephone order from the NP to discharge with current medication and treatment orders to the homeless shelter. The Orders - Administration Note dated 10/25/23 at 10:02 AM indicated that Resident #1 did not receive her dressing change or lab work because she discharged home. The Discharge Summary dated 10/25/23 at 12:00 PM identified that Resident #1 discharged to the homeless shelter on 10/25/23. Resident #1 refused to provide a primary care physician or a preferred pharmacy upon discharge. She gave verbal agreement of an accurate account of her items at discharge. The facility notified Resident #1's Case Worker and lawyer of her discharge. The Order Note dated 10/25/23 at 1:59 PM, the NP gave a new order to decrease clonidine to 0.1 mg daily instead of discontinuing. On 11/14/23 at 10:04 AM the Pharmacist reported a clinical concern of an increased risk of rebound hypertension with an abrupt stop of clonidine. The Pharmacist recommended a titrated decrease with monitoring. She said that with an abrupt stop to the medication she would recommend twice a day blood pressure monitoring. The Clinical Physician's Orders listed the clonidine 0.2 milligrams twice daily as discontinued on 10/24/23. On 11/14/23 at 10:42 AM Staff N, Registered Nurse (RN), said that if the NP discontinued the medication on 10/24/23, she would not have included it with the 7-day supply. On 11/13 at 1:39 PM The Director of Nursing (DON) stated that she could not find a copy of the list of medications that went with the resident upon discharge. On 11/14/23 at 9:00 AM the Regional Director of Nursing (RDON) said that she assisted with Resident #1's discharge. She maintained that she gave her a list of her medication, diagnoses, Care Plan, and a summary of her stay. She said that while she went through the discharge with Resident #1, the Administrator poked her head in the room. Resident #1 called her a bitch but did not say why the Administrator upset her. She said that Resident #1 did not share any concerns with her and she had offered her other avenues to file grievance but she was not interested. She maintained that they planned the discharge since 10/9/23. Resident #1 knew about it and agreed to the transfer. She said that as they packed things up, Resident #1 said that she thought that she could only have 3 bags of items at the shelter, but the SW disagreed with her, and said that they would take all her things. 11/15/23 at 11:08 AM The Director of Nursing (DON) said that she did not know that they discontinued Resident #1's abruptly and that the pharmacy recommended not to stop the medicine abruptly. She agreed that Resident #1's blood pressure (BP) needed monitoring after the medication change. She did not assist with the discharge due to her not being available when all the discharge activity and decisions happened. She said that she did not know if anyone consulted nursing to see about any reason why they should delay Resident #1's discharge. According to the Discharge Summary dated 10/25/23 the most recent vital signs included in the summary included a blood pressure taken on 10/19/23 at 84/55 and a pulse of 112 beats per minute. On 11/16/23 at 10:58 AM Staff D said that they consulted her with the discharge planning for Resident #1 and that she knew about going to the homeless shelter. She did not know about the change in medication or the recommendation from pharmacy to follow up with blood pressure (BP) monitoring. She said that ideally, she would have liked to see a set of vitals on the day of discharge. If the Resident #1 status had concerns, they would arrange for a follow-up with the receiving entity. She maintained that the facility did a well-planned and safe discharge. With BP concerns, perhaps a BP cuff would have been appropriate for the resident to use. She said that the resident was aware enough to manage her health needs but when there were medication changes close to discharge it can be concerning. When asked why the facility rushed to discharge Resident #1 or why they did not wait to monitor her for a couple of days, Staff D expressed that they did not rush the discharge. She added that the transportation arrangements made it seem that way, but they could not control that. The Transfer or Discharge Documentation policy revised December 2016 directed that if a resident transferred or discharged , the facility must document the details of the transfer or discharge in the medical record, and communicate appropriate information to the receiving health care facility or provider. The facility may initiate transfer or discharge for the following: a. Necessary for the resident's welfare and the facility cannot meet their needs. b. The resident's health improved significantly so that the resident no longer needs the care or services. c. The resident's clinical or behavioral status endangered the safety of individuals in the facility. d. The resident's clinical or behavioral status endangers the health of individuals in the facility. e. The resident failed to pay after reasonable and appropriate notice. f. Facility ceases to operate.

Based on clinical record review, law enforcement incident review, facility policy review, resident and staff interviews, the facility failed to keep residents safe from sexual abuse and financial exploitation for 1 of 3 residents (Resident #1). Resident #1 reported a male Certified Nurse Aide (CNA) forced her to perform sexual acts on him. In addition, that male CNA and another CNA transferred money from her account using an electronic money transferring service. Despite the allegation of sexual abuse from the male CNA to Resident #1, the facility failed to prevent him from working with other vulnerable residents in the corporation. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing personal items for residents on 11/10/23. iv. Discharge/transfer policy, highlighted resident-initiated discharge including meeting the needs of Resident #1 welfare on 11/10/23. v. Supervision of outdoor visits on 11/13/23. b. The facility interviewed residents on all the alert and oriented residents on 11/11/23. In addition, the facility audited the remaining residents for any non-verbal signs of abuse. c. The facility updated the Agency Orientation Checklist to include Abuse Protocol to highlight dependent adult abuse reporting policy and professional boundaries. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), and malignant neoplasm of upper lobe (lung cancer). The assessment indicated that Resident #1 almost always had pain. The Care Plan included the following Focuses dated 10/3/23: a. Resident #1 planned to rehab to home. The Goal listed that Resident #1 would transition back to the community. b. Activities of daily living (ADLs). The Interventions directed that Resident #1 could independently provide her own hygiene, toilet use, and transfers. c. Resident #1 is independent in the facility. The Interventions reflected that Resident #1 used a front wheel walker. The Discharge Summary note dated 10/25/23 at 12:00 PM, reflected that the facility discharged Resident #1 to a homeless shelter on 10/25/23. The Sheriff's Office Incident Report dated 11/1/23 at 6:22 PM, reflected that a Sheriff's Office Representative interviewed Resident #1 about allegations of sexual abuse. She said that during her time as a resident in the nursing home, Staff I, CNA, sexually abused her. She stated that while taking care of her, Staff I would touch and kiss her inappropriately on the back of the neck and on her feet. She said that 2-3 weeks prior to her discharge, she went outside the facility to have a cigarette and it had been raining. Staff I asked if she would like to have her cigarette in his car and she agreed. He wheeled her to the car and while in the vehicle, he forced her to perform oral sex on him. She described the vehicle as a small red car parked by the row of trees near the highway. On 11/14/23 at 2:15 PM, the Police Officer who interviewed Resident #1 on 11/1/23 described her as forthcoming but very embarrassed when she came in to the report abuse. He said that when she tried to describe what happened, she stumbled and had difficulty describing the sexual act. She mentioned being heavily medicated while at the facility and could not give consent. She told the officer that Staff I sent her a sexually explicit video of himself. On 11/6/23 at 2:13 PM, Resident #1 said that when she reported her abuse to a couple of staff members, somehow, they twisted the story around. Due to this she did not trust anyone at the facility any more. She said that the Administrator came into her room one day, yelling, and told her that she had to leave because the staff reported that she provided sexual favors for cigarettes. Resident #1 said that staff took her outside to have cigarettes, and she shared with a couple of them. Staff I sexually attacked her. She could not remember the date when Staff I took her to his car and made her perform oral sex on him. She said that he treated her nice and spent time with her. She thought that she may have gave him the wrong impression when she sent him texts. He then sent her a video of him pleasuring himself. When asked to share the sexually explicit video for the investigation, on 11/9/23 Resident #1 sent the video of a male masturbating. The phone revealed that Staff I sent it from his phone. In addition to the text transactions, Resident #1's phone included the transfer of money from her account to Staff I's Cash App on 10/16/23. On 11/15/23 at 2:20 PM, Resident #1 said that she took a lot of pain medications at the facility, that made her mind fuzzy, and she could not be clear on the actual date of the incident. She remembered that Staff I sent the sexually explicit video after the incident, but before the Cash App transfer because he told her about the video when he had her in the car (A screenshot of text messages between Staff I and Resident #1 confirmed that Staff I sent the explicit video on 10/12/23). Resident #1 said that initially, she felt very safe with Staff I. He spent time with her, took an interest in her, and they joked around a lot. Even though she could mostly do things independently, he would come into her room and help her with things. She said that he changed her bedding after being incontinent. This confused her, she did not understand why he would do that kind of thing, and then show an interest in her. One time he helped her with a nightgown that had a string on the back at the neckline. He tied the string and then kissed her on the neck without saying anything. This surprised and confused her about the interaction. Another time, as she put on her socks, Staff I was in the room. He offered to put one on, held her foot, stoked it and said you have beautiful feet, then kissed her foot. She felt surprised by this but no one said anything and he acted like it was no big deal. She said used a wheelchair on the night that Staff I took her to his car. He wheeled her down to the area with trees, in the dark and pouring down rain. He laughed and joked with her until they got into the car. Once inside, his mood changed, he pulled a bottle of Crown Royal (alcohol) out from under his car seat and told her that he started drinking it at the beginning of the day. She said that he then put on some loud, dirty music. She said that he shared with her that he made and recorded his own music. She reported the lyrics as violent. Due to the darkness, she did not see his penis outside his pants. With his right hand he grabbed the back of her neck, pulled her hair, and shoved her head into his lap. She said that while she had his penis in her mouth, she could see a bright light coming from his phone in his left hand. She knew that meant that he videotaped her. Resident #1 said that after the incident, she went directly to her room and did not talk to anyone. She remembered that Staff I did not work for several days after the incident. Then they never talked about the event. Resident #1's Clinical Physician's Orders reviewed on 11/14/23 at 10:14 AM included the following medications that could cause drowsiness: a. Dilaudid (opioid pain medication) 2 milligrams (mg) every 4 hours as needed for pain b. Lorazepam (antianxiety medication) 0.5 mg every 12 hours as needed c. Trazodone (antidepressant used for sleep) 100 mg at bedtime d. Morphine (opioid pain medication) sulfate 30 mg twice a day. A review of the weather history indicated that it rained with showers on 10/12/23 in the area. Timesheet records show that Staff I worked on 10/12/23 from 6:02 PM - 10:43 PM. Resident #1's text messages revealed that she sent Staff I a message at 9:57 PM on 10/12/23, then again at 10:58 PM in which she reminded him to send the video. He then sent the video, and on 10/13/23 at 7:42 PM he sent a message to her asking how are you?. She did not respond to that message until 10/15/23 at 8:16 PM and said that she was not feeling well. On the 16th at 5:24 PM she offered to Cash App some money to him if he would buy her some cigarettes. At 10:38 PM a transfer of $10.00 went from Resident #1's account to Staff I's account, with another $21.00 sent on 10/18/23 at 2:03 PM. Resident #1's Cash App included a transaction on 10/22/23, of $22.00 sent to Staff F's, CNA, account. On 11/16/23 at 8:56 AM Staff F admitted that she accepted money from Resident #1's Cash App to buy her some pop and chips. She said she knew it was not right. On 11/8/23 at 10:48 AM, Staff A, Dietary Aide (DA), said that on the evening of 10/23/23 while she waited outside the facility for a ride after her shift, she sat on the patio with Resident #1. At that time, Resident #1 told her that Staff I bought her cigarettes. He would take her phone and transfer money into his own Cash App. She told her that he took her to his car one night and forced her to perform oral sex. She said that they were drinking alcohol and she did not want anyone to know about it. Staff F, Nurse Aide (NA), then stopped over and entered the conversation when Resident #1 told them that she had a video, but her phone needed to charge, so she could not show them. She described Resident #1 as trembling when she told them the story. Staff A said Resident #1 reported being afraid of what he might do if he knew she told anyone. On 11/8/23 at 10:32 AM, Staff F said that on the evening of 10/23/23, while Resident #1 sat outside with Staff A, she approached them. Staff A looked at Resident #1 and asked can I tell her? Resident #1 shook her head yes and Staff A proceeded to tell her that Staff I sent her a video of himself masturbating. They agreed that they needed to report that to the Administrator. The next morning around 10:00 AM they both went in the next morning. On 11/8/23 at 2:18 PM, the Administrator said that on 10/24/23, a couple of staff members told her that there was a situation with Staff I buying cigarettes for Resident #1, and that he used a Cash App on his phone. The Administrator said that she had Staff I come into her office that morning. He showed her the Cash App receipt on his phone for $10.00, and she suspended him from the building. When asked about the allegations of sex, the Administrator said that she confronted Resident #1 about providing sexual favors for cigarettes, but she denied it. She said that Staff I denied any sexual activity with Resident #1. He acknowledged that he would take her out to smoke but denied anything sexual. The Administrator said that Resident #1 wrote a letter stating that it was false and denied everything. A hand-written note dated 10/24/23 at 8:52 AM, signed by Resident #1, indicated that the Administrator had confronted Resident #1 and accused her of providing sexual favors for cigarettes. Resident #1 reported being very upset by the allegations, and that she would never do anything so vile. She denied the allegations and the hand-written note lacked any reference to forced sexual acts. On 10/24/23, the Regional MDS Coordinator (RC) added the following to Resident #1's Care Plan; a. Staff caught Resident #1 outside in front of the building smoking. b. Resident #1 had a behavior problem that involved manipulating staff, and making up stories that did not happened. According to a Social Services Behavior History Evaluation dated 9/26/23 at 9:28 AM, Resident #1 did not make accusatory statements, described her as not worried, not anxious, not tearful, and did not have mood swings. The follow-up Behavioral History completed on 10/10/23 at 1:58 PM resulted with the same conclusion. On 11/13/23 at 8:47 AM the RC described her role as to oversee the MDS coordination for the facilities in the region. She said that she would be in the building about once a week but she would mainly spend her time with the MDS staff and leadership, resulting in her not being very familiar with the residents. She said that they talked about the residents in morning meetings. She acknowledged that she made the addition to Resident #1's Care Plan on 10/24/23. She explained it as a group effort to include that area of focus, based on Resident #1 sharing and using snacks to her advantage with staff. She said that Resident #1 told a story about how the hospital tied her down and she received the wound on her wrist from that, but she did not know about examples of any made-up stories while at the facility. When asked about allegations against Staff I, she said she did not know anything about that staff member, or allegations of abuse. She maintained that in their leadership meeting when she changed the care plan on 10/24/23, they did not talk about the abuse allegations On 11/13/23 at 9:00, Staff D, Registered Nurse (RN), said that when RC came to the morning leadership meeting that she attended on 10/24/23, they discussed Resident #1's abuse allegations about Staff I. On 11/6/23 at 1:33 PM, Staff J, NA, said that Resident #1 would spent most of her days in her room sleeping, then she came out in the evenings and nights. In the days leading up to her discharge, she started coming out more in the evenings and interacted with others. She would ask to go outside even after dark and/or cold out and sit on the bench on the porch. She could not go too far with her walker before getting fatigued. On 11/6/23 at 1:38 PM Staff K, CNA, said that Resident #1 only went out at night and would sit out there for long periods of time. She sat with Staff I for more than an hour. One-night Staff I came back inside after 11:00 PM and his shift ended at 10:00 PM. On 11/6/23 at 3:49 PM, Staff L, CNA, said that she witnessed Staff I spending time with Resident #1 outside on the patio. They would be out there for over an hour. On 11/8/23 at 11:55 AM, Staff M, CNA, said she only worked at the facility a couple of times and she would never go back. She said that the last day she worked at the facility, the Administrator yelled at Resident #1, giving her only 30 minutes to pack up her room and leave. She described Resident #1 as crying and shaking. She said that Resident #1 told her that Staff I raped her and he took a video of it. While Staff M helped Resident #1 pack her things on 10/25/23, the Administrator and her yelled at each other. Resident #1 appeared very upset. On 11/8/23 at 8:17 AM, Staff E, Registered Nurse (RN), said that she worked the overnight shifts. She described Resident #1 as good with the staff and the other residents. Resident #1 had food items delivered to the facility, she was kind, and would share her snacks. She would often see her out on the patio. Staff I would work until 10:00 PM and then spend time with Resident #1 outside. On 11/8/23 at 3:30 PM, Staff Q, CNA, said that she did not see any interactions between Resident #1 and Staff I. She did report that she saw the video of him masturbating. Staff Q said that she worked with him before. She described him as very invasive and would get into your bubble. She said that Resident #1 told her about Staff I forcing her head in his lap to perform oral sex and that he recorded it. On 11/9/23 at 8:50 AM, Staff I said that on 10/24/23, his schedule had him working a 6a-6p shift. At around 9:00 AM, the Administrator called him into her office. She asked him if he purchased cigarettes for a resident, he told her that he did and showed her the Cash App. He said the lady sent me money and I bought her cigarettes. The Administrator asked him if he ever took Resident #1 in his car to go purchase cigarettes and he told her that he did not. He said he chose to leave the facility on 10/24/23 because he would not feel comfortable working there anymore. He said that he went to a sister facility and finished up a shift that same day. He denied having any kind of relationship with Resident #1 and said that he would sit with her a little bit on the patio. He denied sending her any messages and said that he did not feel he did anything wrong with accepting her money for the purchase of cigarettes. Staff I went on to say that he worked in different states and did not have a problem with buying things for residents. Staff I said that he did not spend much time with Resident #1. When asked if he thought that she had the wrong impression about their relationship, Staff I asked what the questions were about and did not understand the reason for the interview. He maintained that the Administrator did not bring up or ask about any sexual interactions between him and Resident #1. Staff I then chuckled and said that he worked as an intelligence officer and learned to record things. He thought that he may have a recording of the interaction between himself and the Administrator. He said I am keeping my magnetism, I can overcome obstacles . I am a [NAME] worker. He said that the company begged him to work other shifts since 10/24/23. He mentioned three other facilities that he completed shifts after the 24th. He did not understand that if they thought he did something wrong, why they allowed him to continue to work for the company? He reported feeling upset and described the allegations as preposterous. On 11/9/23 at 5:40 PM, Staff C, CNA, said that Resident #1 went out at night and she knew when what time she could her pain pills. Resident #1 would go out and sit on the patio for hours, Staff C did not know what she did out there for so long, I got work to do. She said that Staff I would hang around outside long after his shift ended at 10:00 PM. Sometimes he slept in his red car overnight in the parking lot at the facility. She described Staff I as flirty with some staff members. On 11/14/23 at 9:00 AM the Regional Director of Nursing said that their leadership team had a rapid response phone call regarding the concern with Resident #1 on 10/24/23. She said that most of the conversation was related to the concern about money exchange from resident to staff. The conversation included very little discussion regarding sexual innuendos. She said that the Administrator conveyed to them that Staff I only made a motion that simulated masturbation. The meeting did not include anything about allegations of forced sexual activity. On 11/14/23 at 2:50 PM the Regional Manager said the rapid response team did not get all the information, or accurate information from the Administrator to determine the next steps. She said that had they known all the details, they would have made different decisions. A review of the personal file for Staff I included a Corrective Action Form dated 10/25/23. The form described the infraction on 10/23/23 as a resident reported that she transferred money to him on a mobile app to purchase cigarettes for her. He received a verbal warning not to take money for any reason from a resident. The verbal warning did not include any references to a sexual abuse allegation. According to an annual facility survey report dated 10/19/22, Staff I recorded a resident without her consent or knowledge. His personal file lacked a corrective action form or any indication that the facility addressed that incident with him. Staff I's timesheet showed that he continued to work with vulnerable elderly population in their facilities on 10/24/23 from 2:04 PM - 7:02 PM, 10/28/23 from 10:19 PM - 6:14 AM, and on 10/30/23 at 10:01 PM - 6:00 AM. According to the Dependent Adult Abuse policy dated November 2019 directed that all residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included prohibiting nursing staff from taking pictures that result in person degradation, including the taking or use of photographs or recording in any manner.

Based on interviews with residents, staff and law enforcement, record review and policy review the facility failed to adequately investigate allegations of abuse for 1 of 3 residents reviewed (Resident #1). After Resident #1 reported allegations of sexual and financial abuse, the administration only addressed the exchange of money but minimized and failed to fully investigate the allegations of sexual abuse. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 10/23/23 on 11/9/23 at 4:00 PM. The facility removed the IJ and decreased the scope to a D on 11/13/23 with the following actions: a. The facility provided the following education: i. Dependent adult abuse and sexual abuse including consensual vs. non-consensual education and the need to immediately report the allegation on 11/10/23. ii. Spotting Signs of Elder Abuse to include caretaker boundaries on 11/10/23. iii. The facility's expectations regarding purchasing personal items for residents on 11/10/23. iv. Discharge/transfer policy, highlighted resident-initiated discharge including meeting the needs of the resident welfare on 11/10/23. v. Supervision of outdoor visits on 11/13/23. b. The facility interviewed residents on all the alert and oriented residents on 11/11/23. In addition, the facility audited the remaining residents for any non-verbal signs of abuse. c. The facility updated the Agency Orientation Checklist to include Abuse Protocol to highlight dependent adult abuse reporting policy and professional boundaries. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), and malignant neoplasm of upper lobe (lung cancer). The assessment indicated that Resident #1 almost always had pain. The Care Plan included the following Focuses dated 10/3/23: a. Resident #1 planned to rehab to home. The Goal listed that Resident #1 would transition back to the community. b. Activities of daily living (ADLs). The Interventions directed that Resident #1 could independently provide her own hygiene, toilet use, and transfers. c. Resident #1 is independent in the facility. The Interventions reflected that Resident #1 used a front wheel walker. On 11/8/23 at 10:48 AM, Staff A, Dietary Aide (DA), said that on the evening of 10/23/23 while she waited outside of the facility for a ride after her shift and sat with Resident #1 on the patio. Resident #1 told her that Staff I, Certified Nurse Aide (CNA), bought her cigarettes, then he took her phone and transferred money into his own Cash App. After this, Resident #1 told Staff A that he took her to his car one night and forced her to perform oral sex on him. Resident #1 said that they were drinking alcohol and she did not want anyone to know about it. Staff F, Nurse Aide (NA), then stopped over and entered the conversation when Resident #1 told them that she had a video from Staff I, but she needed to charge her phone, so she could not show them. She said that Resident #1 trembled when she told them the story and expressed fear of what he might do if he knew she told anyone. On 11/8/23 at 10:32 AM, Staff F said that on the evening of 10/23, Resident #1 sat outside with Staff A and when she approached, Staff A looked at her and asked can I tell her? Resident #1 shook her head yes and Staff A proceeded to tell her that Staff I sent her a video of himself masturbating. They agreed that they needed to report this to the Administrator. The next morning at around 10:00 AM they both went in to talk to the Administrator. On 11/6/23 at 2:13 PM, Resident #1 said that when she reported her abuse to a couple of staff members, somehow, they twisted the story around. Due to this she did not trust anyone at the facility any more. She said that the Administrator came into her room one day, yelling, and told her that she had to leave because the staff reported that she provided sexual favors for cigarettes. Resident #1 said that staff took her outside to have cigarettes, and she shared with a couple of them. Staff I sexually attacked her. She could not remember the date when Staff I took her to his car and made her perform oral sex on him. She said that he treated her nice and spent time with her. She thought that she may have gave him the wrong impression when she sent him texts. He then sent her a video of him pleasuring himself. On 11/8/23 at 2:18 PM, the Administrator said that on 10/24/23, a couple of staff members told her about a situation with Staff I buying cigarettes for Resident #1, and that he used a Cash App on his phone. The Administrator said that she had Staff I come into her office that morning. He showed her the Cash App receipt on his phone for $10.00, and she suspended him from the building. When asked about the allegations of sex, the Administrator said that she confronted Resident #1 about providing sexual favors for cigarettes, but she denied it. She said that Staff I denied any sexual activity with Resident #1. He acknowledged that he would take her out to smoke but denied anything sexual. The Administrator said that Resident #1 wrote a letter stating that it was false and denied everything. A hand-written note dated 10/24/23 at 8:52 AM, signed by Resident #1, indicated that the Administrator confronted Resident #1 and accused her of providing sexual favors for cigarettes. Resident #1 reported being very upset by the allegations, and that she would never do anything so vile. She denied the allegations and the hand-written note lacked any reference to forced sexual acts. According to an untitled and undated facility investigation, two staff members reported to the Administrator that Resident #1 voiced concerns about Staff I. She indicated that the concerns were related to the purchase of cigarettes and when Resident #1 went to Staff I's car to get cigarettes, he made a gesture of oral sex while outside his car. When asked about the incident, Resident #1 denied that it occurred. The investigation indicated that Resident #1 had a history of making false stories and exaggerating events to gain attention. The Administrator separated Staff I from the facility and he admitted to purchasing cigarettes for Resident #1. The investigation statement included comments that the staff member who reported the abuse, had a history of making allegations against Staff I, and that many staff and residents at the facility had a history of making false allegations against African Americans. The statement indicated the facility contacted law enforcement on 10/24/23. The investigation included an undated list of resident interviews, the investigation lacked staff interviews, and a resident assessment. On 11/14/23 at 8:47 AM a representative from the sheriff's office went through the files to see if they got any calls from the facility on 10/24 or 10/25 about possible abuse with Resident #1 as the victim. The staff reported that they did not have any calls from the facility regarding abuse allegations. On 11/9/23 at 8:50 AM, Staff I said that on 10/24/23, his schedule had him working a 6a-6p shift. At around 9:00 AM, the Administrator called him into her office. She asked him if he purchased cigarettes for a resident, he told her that he did and showed her the Cash App. He said the lady sent me money and I bought her cigarettes. The Administrator asked him if he ever took Resident #1 in his car to go purchase cigarettes and he told her that he did not. He said he chose to leave the facility on 10/24/23 because he would not feel comfortable working there anymore. He said that he went to a sister facility and finished up a shift that same day. He denied having any kind of relationship with Resident #1 and said that he would sit with her a little bit on the patio. He denied sending her any messages and said that he did not feel he did anything wrong with accepting her money for the purchase of cigarettes. Staff I went on to say that he worked in different states and did not have a problem with buying things for residents. Staff I said that he did not spend much time with Resident #1. When asked if he thought that she had the wrong impression about their relationship, Staff I asked what the questions were about and did not understand the reason for the interview. He maintained that the Administrator did not bring up or ask about any sexual interactions between him and Resident #1. Staff I then chuckled and said that he worked as an intelligence officer and learned to record things. He thought that he may have a recording of the interaction between himself and the Administrator. He said I am keeping my magnetism, I can overcome obstacles . I am a [NAME] worker. He said that the company begged him to work other shifts since 10/24/23. He mentioned three other facilities that he completed shifts after the 24th. He did not understand that if they thought he did something wrong, why they allowed him to continue to work for the company? He reported feeling upset and described the allegations as preposterous. On 11/14/23 at 9:00 AM the Regional Director of Nursing said that their leadership team had a rapid response phone call regarding the concern with Resident #1 on 10/24/23. She said that most of the conversation was related to the concern about money exchange from resident to staff. The conversation included very little discussion regarding sexual innuendos. She said that the Administrator conveyed to them that Staff I only made a motion that simulated masturbation. The meeting did not include anything about allegations of forced sexual activity. On 11/14/23 at 2:50 PM the Regional Manager said the rapid response team did not get all the information, or accurate information from the Administrator to determine the next steps. She said that had they known all the details, they would have made different decisions. The Dependent Adult Abuse Protocols November 2019 instructed that upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, the facility will accomplish this by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility According to the facility policy titled; Mandatory Reporting Abuse Investigation dated November 2019 directed that all allegations of resident abuse need reported immediately. Administrator or his/her designee will designate a member of management to investigate the alleged incident to include: review of assessment of resident injury, assess the resident for injury, provide notification to primary care provider, and attempt to obtain witness statements (oral and/or written) from all known witnesses. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination (blame) or intimidation. The section titled Initial/Immediate Protection during Facility Investigation instructed that Upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, the facility will accomplish this by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee will be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. The facility must maintain the separation until the Department concludes its investigation and issues the written results of its investigation. Note: if the Department of Inspections, Appeals, and Licensing (DIAL) determines there was abuse (even though the facility did not substantiate the abuse), there is risk that DIAL could cite the facility with Immediate Jeopardy, for allowing an abuser to have access to other residents while the investigation continued.

Based on interviews, record review and policy review the facility failed to prevent retribution to a resident and a staff member for 1 of 3 residents (Resident #1). Resident #1 reported that a male Certified Nurse Aide (CNA) sexually abused her. After the facility learned of the allegations on 10/24/23, they discharged Resident #1 to a homeless shelter on 10/25/23 with only approximately 30 minutes to pack. In addition, Staff P reported that the facility suspended her after she confronted the Administrator regarding the need to report the abuse. The facility suspended Staff Q from work for not reporting abuse within 2 hours after she learned about the allegation. At the time she reported the allegation, the facility already knew from other staff. The facility asked her to share information related to the abuse to speed up their investigation so she could return to work sooner. Due to the facility's treatment of Resident #1 after the facility learned of the allegation of abuse, caused Resident #1 to become afraid and cry during an exchange of yelling between her and the Administrator. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment reflected that Resident #1 did not have behaviors. Resident #1 required limited assistance from one person for transfers, dressing, toilet use, and personal hygiene. The MDS listed Resident #1 as frequently incontinent of urine and always continent of bowel. The MDS included diagnoses of disorder of the kidney, heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, depression, Post-Traumatic Stress Disorder (PTSD), and malignant neoplasm of upper lobe (lung cancer). The assessment indicated that Resident #1 almost always had pain. The Care Plan included the following Focuses dated 10/3/23: a. Resident #1 planned to rehab to home. The Goal listed that Resident #1 would transition back to the community. b. Activities of daily living (ADLs). The Interventions directed that Resident #1 could independently provide her own hygiene, toilet use, and transfers. c. Resident #1 is independent in the facility. The Interventions reflected that Resident #1 used a front wheel walker. On 11/6/23 at 2:13 PM, Resident #1 said that when she reported her abuse to a couple of staff members, somehow, they twisted the story around. Due to this she did not trust anyone at the facility any more. She said that the Administrator came into her room one day, yelling, and told her that she had to leave because the staff reported that she provided sexual favors for cigarettes. Resident #1 said that staff took her outside to have cigarettes, and she shared with a couple of them. Staff I sexually attacked her. She could not remember the date when Staff I took her to his car and made her perform oral sex on him. Resident #1 said when planning her discharge, the Social Worker (SW) told her that she planned to help her find housing so her son could come and live with her. The Women's and Children's Shelter was an option but her son was too old to go there. She said she felt like the facility kicked her out because of the lies told about her. On 11/8/23 at 2:18 PM, the Administrator said that on 10/24/23, a couple of staff members told her about a situation with Staff I buying cigarettes for Resident #1, and that he used a Cash App on his phone. The Administrator said that she had Staff I come into her office that morning. He showed her the Cash App receipt on his phone for $10.00, and she suspended him from the building. When asked about the allegations of sex, the Administrator said that she confronted Resident #1 about providing sexual favors for cigarettes, but she denied it. She said that Staff I denied any sexual activity with Resident #1. He acknowledged that he would take her out to smoke but denied anything sexual. The Administrator said that Resident #1 wrote a letter stating that it was false and denied everything. A hand-written note dated 10/24/23 at 8:52 AM, signed by Resident #1, indicated that the Administrator confronted Resident #1 and accused her of providing sexual favors for cigarettes. Resident #1 reported being very upset by the allegations, and that she would never do anything so vile. She denied the allegations and the hand-written note lacked any reference to forced sexual acts. On 11/14/23 at 2:15 PM, the Police Officer who interviewed Resident #1 on 11/1/23 described her as forthcoming but very embarrassed when she came in to the report abuse. He said that when she tried to describe what happened, she stumbled and had difficulty describing the sexual act. She mentioned being heavily medicated while at the facility and could not give consent. She told the officer that Staff I sent her a sexually explicit video of himself. The Encounter Note dated 10/24/23 at 12:00 AM signed by the Advanced Registered Nurse Practitioner (NP) on 10/26/23 at 8:08 PM reflected that Resident #1 saw the NP on 10/24/23. At that time, Resident #1 cried and stated that she had a lot of pain. They discussed getting her an appointment with the pain clinic. Resident #1 told her about her leaving the facility in 1-2 days, as the staff falsely accused her of being inappropriate with a staff member. She planned to leave and be at the homeless shelter for 6 months. The provider received a call from the facility on 10/25/23 indicating that day they planned to discharge Resident #1. The NP recommended to follow-up for medication refills in six months and she would provide a 7-day supply of medications. On 10/24/23, the Regional MDS Coordinator (RC) added the following to Resident #1's Care Plan: a. Staff caught Resident #1 outside in front of the building smoking. b. Resident #1 had a behavior problem that involved manipulating staff, and making up stories that did not happened. According to a Social Services Behavior History Evaluation dated 9/26/23 at 9:28 AM, Resident #1 did not make accusatory statements, described her as not worried, not anxious, not tearful, and did not have mood swings. The follow-up Behavioral History completed on 10/10/23 at 1:58 PM resulted with the same conclusion On 11/13/23 at 8:47 AM the RC described her role as to oversee the MDS coordination for the facilities in the region. She said that she would be in the building about once a week but she would mainly spend her time with the MDS staff and leadership, resulting in her not being very familiar with the residents. She said that they talked about the residents in morning meetings. She acknowledged that she made the addition to Resident #1's Care Plan on 10/24/23. She explained it as a group effort to include that area of focus, based on Resident #1 sharing and using snacks to her advantage with staff. She said that Resident #1 told a story about how the hospital tied her down and she received the wound on her wrist from that, but she did not know about examples of any made-up stories while at the facility. When asked about allegations against Staff I, she said she did not know anything about that staff member, or allegations of abuse. She maintained that in their leadership meeting when she changed the care plan on 10/24/23, they did not talk about the abuse allegations. On 11/13/23 at 9:00, Staff D, Registered Nurse (RN), said that when RC came to the morning leadership meeting that she attended on 10/24/23, they discussed Resident #1's abuse allegations about Staff I. On 11/9/23 at 12:15 PM, Staff H, Housekeeping Staff, said that on the morning of 10/25/23, she loaded up the remainder of Resident #1's belongings in her personal vehicle and drove them to the shelter. The transportation provider came with a very small car and they could not get all her items in that vehicle. As she helped Resident #1 pack her things, she appeared very angry, crying, and said that she felt the facility kicked her out. She kept asking to speak to someone above the Administrator about what was happening. She got to the shelter with Resident #1 items at about 1:30 PM that day. On 11/8/23 at 11:12 AM the Social Worker (SW) reported the transfer of Resident #1 to the homeless shelter as appropriate as she came from there per her lifestyle choice. Resident #1 always had a goal to discharge and reunite with her son. When asked if she told the staff at the shelter the level of need before sending Resident #1 to the shelter, she replied yes and no. The SW continued by expressing Resident #1's behaviors related to impulsivity and lack of follow through. When inquired about Resident #1's level of medical needs, she responded that therapy told her that Resident #1 could use a walker. The Regional Director of Nursing arranged to get her a walker to take with her but she wanted to get out. She said that after Resident #1's admission to the shelter, she called 911 that night, but she did not know what happened after that. She denied knowing anything about Staff I or cigarettes. She maintained that she had Resident #1's permission to make the arrangements to go to the shelter. On 11/9/23 at 10:45 AM during a telephone call, the SW said that the Administrator reached out to the homeless shelter to ask about admitting her. Afterwards, she made the transportation arrangements. She said that she got a call from a very upset shelter representative the next day about Resident #1 and said that she faked a heart attack. They sent her to the hospital, and they could see what she was like. The SW told her that they could not take her back because of her behaviors and manipulation. She met all her goals and she wanted to go to there. When questioned about if she sent Resident #1's medical information with her, she replied no, as a homeless person off the street did not come into a shelter with their medical diagnosis information. As that is what they do. On 11/13/23 at 3:00 PM the SW said that they put a discharge checklist on the wall in her office so they can go down the list and make sure they are hitting on the planning points. She said the 24-hour notice challenged her with the need to get the transportation. The SW had a conversation with Resident #1 about discharge on Friday or Monday. She questioned about he being okay to discharge sooner as they had a 4-hour notice. Resident #1 reported she was fine with it, as it was better because then her sister did not have to come and get her. A review of a voice recording from the transportation company, dated 10/25/23 at 7:28 AM, revealed that the SW called for a ride at that time without Resident #1 in the room with her. When the SW made the arrangements, she chose the 4-hour pick-up time and said that works for me. They finalized the arrangements and once the company found a driver, they would notify them of the time of arrival. On 11/15/23 at 8:00 AM Staff N, Registered Nurse (RN), said early that morning, Resident #1 went around to say good bye to other residents and staff. Later that morning when she found out that she only had a half hour to get everything together and packed she started to cry. Resident #1 expressed that she felt like the facility kicked her out. Staff N said that she understood that they had a plan for discharge but it came very abruptly. Staff N reported that she had concerns that Resident #1 went to a homeless shelter without nursing services especially when she needed monitoring as the provider just changed her hypertension. On 11/9/23 at 8:15 AM Shelter Staff 1 (SS1) called back and said that the transportation company just dropped Resident #1 off at the shelter with no paperwork and no phone call. She said they did not typically accept residents from a hospital or nursing home that way. They need to know what level of care the resident required so they can determine if they are appropriate or if they can handle them. On 10/25/23 around 1:00 PM the transportation company dropped her off. Initially, the cab driver dropped her off at a safe house intended for domestic violence victims. The driver did not know what to do with her when they would not accept her there, so, they called the facility, who told them to take her to the homeless shelter. SS1 did the intake herself and then she had to leave early that day. Her daughter worked there in the afternoon and she called 911 due to Resident #1 shaking, falling, and unstable around 4:00 PM in the afternoon. At 6:15 AM on 10/26/23 the hospital returned her soiled back at the shelter. They got her a room to clean up and she talked to a friend on the phone. Around 11:00 AM on the 10/26/23, Resident #1's friend came and picked her up. She said she did not know what happened from there. They try not to get too involved in the resident's lives or situations once they leave the shelter. She said the facility made her very upset for just dropping off Resident #1 without first having a consultation on her level of need. She explained that we have children here and do not have nursing staff. She did call and talk to the SW who said that she did not make the arrangements and indicated that they would not take Resident #1 back because she made allegations against staff. On 11/13/23 at 7:26 AM SS1 that she knew for a fact that no one talked to Shelter Staff 2 (SS2), before Resident #1 showed up at their door. She said that when they get residents from a facility or hospital, they put them on a list. When Resident #1 showed up she checked the list, which did not include her. SS2 called back to the facility the next day and talked to the SW but not before. SS1 was very sure of that because she is the manager, they all stay on top of who is calling and who is on the list. When Resident #1 showed up at their door, she told them that she did not know where they sent her. She said that they will never do business with that facility ever again or with that SW lady. On 11/13/23 at 2:32 PM SS2 said that the first day she talked to anyone at the facility was the day that Resident #1 showed up at their door. They write down their notes or document on the computer and they have no notes that someone contacted them regarding Resident #1 coming there. Resident #1 was at the door, concerned about the driver because he was on the phone with the facility. Originally, he went to the wrong place first and then did not know what to do with her things. Then the SW called back just after Resident #1 got there and SS2 told her that Resident #1 could barely walk, shook, and had shortness of breath. Resident #1 worried about holding up the driver. SS2 recalled her surprise when they started unloading all of Resident #1's things and said that they could only allow 2 bags. SS2 said that Resident #1 he had a TV and everything. SS2 talked to the SW on the phone telling her about Resident #1 not stable and she did not know if they could take care of her there. The SW told her that because of her behaviors they could not take her back. She told the SW that they did not know about her coming, the SW responded that she was sure someone took care of that. SS2 started the intake and later called non-emergent care to pick her up because she seemed so unstable. She did come with some medications, they are responsible for taking them on their own. SS2 said if Resident #1 stayed there before, it was a long time ago because she did not have a record of her being there. On 11/13/23 at 10:30 AM Staff P, Former Office Manager, said that she no longer worked at the facility. She felt that the administration was looking for some reason to terminate her because she questioned them on reporting the events to the proper authorities. Staff P said that she heard about the allegations of abuse later in the day on 10/24/23 and sent a text to the Regional Manager at 5:30 PM, expressing that they should report the event. She then she got a call back from corporate that Resident #1 recanted the allegations so they did not think they needed to report it. She said that when she came into work on the 25th, her office had been in shambles because they were looking through for missing orders. They suspended her because of the missing orders. On 11/15/23 at 2:20 PM Staff Q, CNA, explained that the facility suspended her from working pending investigation, because she did not report allegations of abuse within 2 hours. When she learned about the incident, the facility already knew about the incident from someone else. She said that the facility told her that their investigation could speed up if she could provide a copy of any video or text messages that exchanged between Resident #1 and Staff I. On 11/14/23 at 9:00 AM the Regional Director of Nursing (RDON) said that she assisted with Resident #1's discharge. She maintained that she gave her a list of her medication, diagnoses, Care Plan, and a summary of her stay. She said that while she went through the discharge with Resident #1, the Administrator poked her head in the room. Resident #1 called her a bitch but did not say why the Administrator upset her. She said that Resident #1 did not share any concerns with her and she had offered her other avenues to file grievance but she was not interested. She maintained that they planned the discharge since 10/9/23. Resident #1 knew about it and agreed to the transfer. She said that as they packed things up, Resident #1 said that she thought that she could only have 3 bags of items at the shelter, but the SW disagreed with her, and said that they would take all her things. The Dependent Adult Abuse Protocols dated November 2019, described the procedure for keeping resident free from abuse include screening and training employees, protection of residents and prevention, identification, investigation and timely reporting of abuse, neglect, mistreatment, and misappropriation of proper, without the fear of recrimination or intimidation.

Based on observation, interview and record review the facility failed to adequately monitor residents that had a high-risk for pressure ulcers for one of two residents reviewed (Resident #16). Resident #16 had a facility-acquired pressure on the bottom of his foot that was not discovered or documented until it measured over 7 centimeters in total area and was blackened. Despite Resident #16 receiving a bath the day before the discovery of the unstageable pressure wound, the staff denied knowledge of the wound. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Unstageable pressures are difficult to diagnose because the bottom of the sore is covered by slough debris that appears tan, yellow, green or black. Retrieved from: Stages of Pressure Ulcers: Stages, Treatments, and More (healthline.com) on 10/19/23. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The assessment identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #16 required extensive assistance from one person with dressing and hygiene. Resident #16 required total dependence from two staff for bathing. The MDS included diagnoses of adult failure to thrive, acute cystitis with hematuria (urinary tract infection with blood), type 2 diabetes mellitus with foot ulcer, chronic ulcer of the left heel and midfoot. The Care Plan included the following Focus areas dated: a. 7/26/23: Resident #16 had a communication problem. The Intervention revised 9/11/23 indicated that he could communicate by writing. He had a white board and a marker. b. 9/11/23: Due to Resident #16 refusing to take a bath or a shower outside of his room, the staff are to provide a bed bath three times a week. The Intervention dated 9/11/23 directed to rinse and dry his skin well, then apply lotion to his dry areas. c. 9/28/23: Resident #16 had a pressure on the bottom of his right foot due to a device. The Interventions dated 9/28/23 indicated the following: i. Administer treatments as ordered and monitor for effectiveness. ii. Follow facility policies/protocols for the prevention/treatment of skin breakdown. iii. Remove the footboard to his bed. iv. Weekly treatment documentation to include the measurement of each area of the skin breakdown's width, length, depth, type of tissue, and exudate (drainage). d. Revised 10/4/12: Resident #16 had a history of skin impairment to his lower right leg, left upper thigh, and moisture associated area to his buttocks. The Interventions indicated the following: i. 7/26/23: Educate Resident #16, his family, and his caregivers of what causes skin injuries and how to prevent them. ii. 7/26/23: Monitor for and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to physician. iii. 7/26/23: Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes or observations. iv. 7/31/23: Follow wound care orders per the physician's instructions. Resident #16's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] at 4:37 PM identified a score of 12, indicating a high risk for developing pressure injuries. The Skin Observation Tool - V2 indicated that Resident #16 did not have any skin issues on the following days: a. 8/11/23 b. 8/18/23 c. 9/11/23 d. 9/18/23 e. 9/26/23 The Encounter Note dated 9/26/23 indicated that Resident #16 had a new pressure ulcer to the bottom of his right foot. The cause of his wound appeared to be from his pressing his foot against the foot board at the end of his bed. The staff removed the footboard to prevent further injury. The area is black and boggy. The wound measures 4.86 by (x) 3.9 x 2.15 centimeters (cm). The plan directed to clean the wound with betadine daily and leave open to air. The Incident, Accident, Unusual Occurrence Note dated 9/26/23 at 2:00 PM labeled Late Entry indicated that the nurse found a dark black scab to the bottom of Resident #16's foot. The wound appeared unstageable due to eschar (black dead) tissue. The nurse notified Resident #16's provider due to them being at the facility. The Wound Evaluation report dated 9/26/23 at 2:27 PM showed a picture of Resident #16's injury on the plantar area of his right foot. The wound appeared dark, with a pink surrounding tissue, and a large piece of peeling dry yellow appearing skin. The evaluation listed the injury as a new, in-house acquired unstageable pressure injury, and seven hours old. The total area measured 7.09 cm, length 3.56 cm, and width 2.71 cm. The rest of Resident #16's bottom of his foot flaked with dry yellow colored skin. The evaluation indicated that the wound had 100% eschar scab with a thin dark pink outer perimeter. When questioned about pain, Resident #16 shook his head denying pain. On 10/18/23 at 1:30 PM Staff A, Registered Nurse (RN), said that she first discovered the pressure area on Resident #16's right foot on 9/26/23. Resident #16 usually had his socks on while in bed and the staff encouraged him to move around more. She said Resident #16 refused baths so the staff provided him bed bathes. She said that when she first discovered the injury, it was like a leathery, black scab. They determined that he pushed his foot against the bed caused his wound, so they removed the foot board from his bed. She said he often refused cares. Staff A explained that when he came to the facility, he had the same type of wound on his left foot, but that healed. The ADL - Bathing Assistance & Schedule: Monday, Wednesday and Saturday response document indicated that Resident #3 had a bed bath on 9/25/23 at 1:10 PM. On 10/18/23 at 2:50 PM Staff F, Certified Nurse Aide (CNA), said that she gave Resident #16 many bed baths, but she did not clean the lower portion of his body because she had difficulty tolerating cleaning feet, so Staff E, CNA, did the lower part. She said that Resident #16 usually had on stockings on his feet throughout the day. On 10/19/23 at 9:19 AM, Staff E said that she cleaned Resident #16's feet before, but she had not seen his for about month. She did not know that he had a black spot on the bottom of his right foot. On 10/19/23 at 10:40 AM, the facility's Advanced Registered Nurse Practitioner (ARNP) reported that she only seen Resident #16's foot ulcer on the 9/26/23. At that time the foot ulcer appeared black. She could not say what it may have looked like before it turned black or what staff should have recognized as early warning signs. She could not say for sure how long the pressure may have been present before it someone discovered the black wound bed. The Ulcers/Skin Breakdown policy revised September 2019 instructed that the physicians would help prevent and mange pressure ulcers, consistent with established guidelines. The incidence of new pressure ulcers would be minimized to the extent possible.

Based on clinical record review, observations, facility policy review, resident, and staff interview the facility failed to assure that the alarm system worked properly to alert the staff to residents leaving the facility unattended for 3 of 6 reviews (Residents #1, #2, and #3). On 8/11/23 in the night, an on-duty staff member discovered Resident #1 in his wheelchair near Highway 20. The facility staff did not know that he left the building, that the alarms did not go off, and they thought that he went to bed. The survey determined that the staff failed to respond to door alarms, while 2 of 6 Wander Guard (WG) alarms did not work at the time of survey. This failure resulted in an Immediate Jeopardy situation to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 11, 2023, on August 16, 2023 at 5:33 PM. The Facility Staff removed the Immediate Jeopardy on August 16, 2023 with the following actions: a. Staff were educated on the following: - Door alarm response with resident at risks for wandering - Missing resident procedure - Complete a head count if no one observed the reason for the alarm sounding - When an alarm is sounding, staff members must physically inspect the parameter to ensure they know who exited. - Only when the outside staff member returns from the parameter inspection, may the alarm be silenced. At that time an all clear will be communicated. b. Steps completed: - The facility completed a WG door audit. - Residents that wore WGs had a WG door audit completed. If the WG alarm did not sound, the resident received a new WG bracelet, and the facility activated the WG bracelet placed on 8/15/23 correctly. Both WG bracelets were validated for functionality on 8/16/23. The facility provided education to nurses on how to activate the WG, how to read the meter for activation, and how to check the battery. - The facility completed a missing resident drill on 8/16/23 and would continue weekly for six weeks on various shifts. The scope lowered from a J to D prior to the end of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use. He used a manual wheelchair most of the time. The MDS included diagnoses of multiple sclerosis (MS), anxiety disorder, and depression. The Fall Risk Assessment completed on 8/11/23 reflected that Resident #1 had a high risk for falls with intermittent confusion. The Care Plan Focus revised 3/26/23 indicated that Resident #1 used antianxiety medication related to an anxiety disorder. Due to his diagnoses and personality, he is very stubborn and does not ask for help at all. The Interventions directed the following: a. 3/6/23: Administer his antianxiety medications as ordered by the physician. Monitor for side effects and effectiveness every shift. b. 3/24/23: Please encourage and remind him to ask for help, as he tends to forget. The Care Plan Focus revised 4/7/23 reflected that Resident #1 had a risk for falls due to MS, attention deficit hyperactivity disorder (ADHD), and poor safety choices. The Care Plan Focus revised 8/13/23 indicated that Resident #1 could not transfer independently but is impulsive and non-compliant with asking for assistance. An updated BIMS assessment observed on 8/12/23 at 12:23 PM that showed that Resident #1 scored a 14, indicating intact cognition. The undated facility form titled Investigation Worksheet for Missing Resident, indicated that the door alarm worked but indicated not applicable as the time the alarm sounded. The worksheet listed 8:25 PM as the last time staff saw Resident #1 before being found in the driveway by dietary staff at 8:43 PM. The worksheet listed that an incident report is not needed due to their investigation. The investigation reflected that facility provided education to Resident #1 about the sign-out log and sign posting. The Care Plan Focus dated 8/15/23 indicated that Resident #1 could sign himself out of the facility as he chose, the staff were to provide reminders. A review of the Resident Sign Out sheets from 7/15/23 - 8/16/23 revealed that Resident #1 did not sign himself out during that time frame. According to the handwritten statement dated 8/11/23 by Staff C reflected that on 8/11/23 at 6:00 PM, Resident #1 fell and experienced agitation for most of the evening. Resident #1 wanted to contact his family but when he could not get a hold of anyone, he stated that he was going to have to walk home. Then he wandered around the nurses' station and hall 1. At 8:04 PM Staff C observed him in his room with the door closed, yelling out swear words. Resident #1 returned to the hallway about 8:15 PM, then returned to his room around 8:25 PM. At 8:43 PM, Staff A reported to Staff C about Resident #1 being outside. Staff D's handwritten statement dated 8/11/23 reflected that they pulled Resident #1 back into the facility around 8:00 PM. At that time, the facility alarms did not sound. At 8:15 PM, Staff D reported that he pulled him back into the facility. Then from 8:30 PM until 9:00 AM they assisted another aide with a resident. Staff A's handwritten statement dated 8/11/23 indicated that the last time they saw Resident #1, he rolled himself down the 100 hall towards his room [ROOM NUMBER]-15 minutes before the incident. Staff A explained the last time they heard the facility's alarm sound was when another resident's family left the building approximately 8:30 PM - 8:50 PM. Staff A reported that Staff B told them about Resident #1 being outdoors around 9 PM -9:10 PM. After learning of this, Staff A ran to get the nurse on duty, then went outside to meet Staff N halfway up the driveway. The WG did not sound and the door alarm did not go off at the time Resident #1 left. Staff B's handwritten statement dated 8/11/23 reflected that they found Resident #1 by the entrance to the parking lot around 8:55 PM - 9:00 PM, about 20 feet from highway 20. When they stopped to ask him what he was doing out and about and where he was headed. He said that he was going to see his friend. Staff B told Resident #1 to stay there and she would try to contact his friend. The Staff N arrived and she asked them to stay with Resident #1 as she went to find a CNA and the nurse on duty. On 8/16/23 at 4:00 PM, the Director of Nursing (DON) said that she had checked all the WG alarms over the previous weekend. When asked if an incident occurred that caused her to check them, she replied that a resident failed to sign out as instructed, but they did not consider it an incident. She said that Resident #1 wore a WG alarm due to his risk for falls and they expected him to stay on the porch. Due to the incline in the sidewalk, if unsupervised he could fall. She said that Resident #1 could leave the facility because he could make his own decisions. On 8/16/23 at 4:30, Staff E said that Resident #1 was aware and had a pretty good memory, but she questioned some of his decision-making skills. For example, the previous week he asked for a razor to shave and he ended up shaving his head. She didn't think that he had a clear understanding of the dangers of being out in the highway. He got very angry earlier in the evening, kicking the door in his bedroom. On 8/16/23 at 4:50 PM, Staff F, Registered Nurse (RN), said Resident #1's decision-making skills were not up to par, especially with the stress of his recent divorce. One the day she came in, he said it was the worst day of his life, I'm just going to leave. She did not think that he was suicidal but he was depressed. He hadn't followed the rules to sign out and he probably thought that he was safe to be on the highway in his wheelchair. On 8/16/23 at 5:30 PM observed Resident #1 in the dining room sitting in his wheelchair. He propelled himself with his feet and was uncoordinated in these movements. The dining room appeared full of residents waiting for their meal. The dining room had no staff, with Resident #1 sitting at the end of a long table. A frail person in a wheelchair attempted to move from one end of the room to the other and Resident #1 saw that they had trouble. He propelled himself over to that person, grabbed their arm with one hand and with the other hand, moved the chairs out of the way. He pushed himself backwards in his chair and pulled her across the room. Other residents hollered out at him to stop and he eventually let go of her arm. On 8/17/23 at 8:11 AM the Administrator said that they determined Resident #1 was safe and could make his own decision to leave the building. She did not think that he was in danger and said that he could not get to the highway because there were too many potholes in the driveway and he would not be able to get his wheelchair through them. She said that the plan they had in place to have him sign out kept him safe. The corporate nurse said that they talked to him about not leaving the property and he was cognizant enough to sign himself out. On 8/17/23 at 10:40 AM, as Resident #1 sat in his wheelchair by the door going to the 200 hallway and another resident sat in a chair near the nurses' station. He asked her to help him and said I'm going to stand up and I want you to get paper that is under the cushion. He grabbed the doorframe and stood up out of his wheelchair, then he reached around to lift the cushion so she could get a paper out. Two nurses came over and helped stabilize him then got what he wanted. On 8/17/23 at 8:11 AM the Administrator stated that Resident #1 was safe and able to make his own decision to leave the building. She did not think that he was in danger and said that he couldn't have gotten to the highway because there were too many potholes in the driveway he wouldn't have been able to get his wheelchair through them. She said that the plan they had in place to have him sign out was keeping him safe. The corporate nurse said that they had talked to him about not leaving the property and he was cognizant enough to sign himself out. 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. She required limited assistance from one person for transfers, walking, and toilet use. She primarily used a walker for locomotion. The Care Plan Focus dated 3/7/23 indicated that Resident #2 had an impaired cognition/dementia or impaired thought processed related to Alzheimer's disease. The Intervention dated 6/19/23 reflected that Resident #2 used a WG for safety due to her statements of leaving the facility. On 8/16/23 at 3:47 PM, watched Staff F bring Resident #2 from her room, walked her out the door through the breezeway to the outside, her WG did not alarm. She got the tester, put it up to the WG, and the light on the tester turned green. Staff F believed that this indicated that the WG worked. She said that she just put the WG on Resident #2 the previous day. 3. Resident #3's MDS assessment dated [DATE] listed an admitted [DATE]. The MDS identified a BIMS score of 1, indicating severely impaired cognition. He required extensive assistance from two persons for bed mobility, transfers, toilet use, and walking. The Care Plan Focus revised 3/27/23 indicated that Resident #3 required assistance from staff with grooming and personal hygiene. The Intervention related to toilet use dated 1/27/23 instructed that Resident #3 required assistance from one person for toilet use. Upon entrance into the facility on [DATE] at 1:45 PM a door alarm sounded and after five beeps, it stopped. No staff came out to the area to investigate. On 8/16/23 at 3:35 PM, watched Staff F retrieve the WG tester and put it up against the wristband of Resident #3. The tester did not turn green and she did not know how to tell if it was reading correctly. Staff F then pushed Resident #3 in his wheelchair through the front doors and the WG did not alarm. On 8/16/23 at 3:44 PM witnessed a visitor go out the front door a door alarm sounded but no one came out to investigate. On 8/16/23 at 3:45 PM, the Administrator looked at the WG and the tester, then said that the WG did not get properly activated. On 8/16/23 at 4:05 PM another lady came into the facility, the door alarm sounded, no one came to check the cause for the alarm, and then the alarm stopped sounding. The facility's Removal Plan included an in-depth analysis of the elopement, the staff believed that the Director of Nursing (DON) monitored the front door from her office, so they shut off the alarm, assuming the DON had validated that it was clear. The WG bracelets did not sound, due to one not being activated because the nurse didn't know how to do that. On 8/17/23 at 7:15 AM, the Maintenance Manager (MM) said that the WG alarms had a battery life of 90 days. They put a new WG on all six residents, but one WG did not get activated (Resident #2) and one did not function (Resident #3). The undated staff education from the facility's online education system labeled Managing Elopement defined elopement as when a resident left the facility without the necessary supervision. The Physical Plant Preventative Maintenance policy dated July 2010 listed the Procedure Description as checking door alarms/Wander Guard systems. The form directed to check all the equipment daily at each shift, including weekends. The secondary (battery device) activate device to ensure operable, check casing, and door attachment. The policy instructed to check the Wander Guard per the manufacturer instructions. The maintenance department would check the door alarms on their scheduled work days. The undated WG Blue Reference Guide, indicates that the WG blue tag transmits messages to the controller when it is in proximity to a controlled door. The WG blue detector can test the tag's battery life. The Reference Guide recommended to use the WG blue detector to check the tag battery at least once a week.

Based on clinical record review, staff interviews, and facility record review, the facility failed to report allegations of abuse to the Iowa Department of Inspections and Appeals (DIA) within 24-hours. In addition, the facility failed to conduct and document thorough investigations of alleged allegations of abuse, failed to prevent and protect the residents from further potential abuse during the investigation for 4 out of 20 residents reviewed (Residents #6, #8, #11 and #20). The facility reported a census of 33 residents. Findings included: The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of 3/22/2023 at 1:04 PM. The Facility Staff removed the Immediate Jeopardy on 4/20/23 at 4:23 PM through the following actions: - Education completed to report all allegations of abuse including physical, mental, psychosocial, sexual and verbal and misappropriation, immediately to their supervisor. - The management received education to report to DIA and or local law enforcement within two hours if applicable. - Education completed to the management to fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. - Education to all staff of the compliance line number and DIA abuse hotline the need to report to more than one person. If they feel that the matter is not handled they need to continue to notify other personnel for immediate action to assure that the residents are always safe. - The facility will complete the ongoing investigation and report any additional findings to the Quality Assurance and Performance Improvement (QAPI) team for recommendation if any. - The facility sent a text to all employees that did not work at that time staff education. These employees will review all the education prior to the next shift worked. - The facility will randomly conduct staff and resident interviews to assure compliance is maintained. - Concerns identified will be reported and addressed in the facility QAPI committee meetings for additional intervention as indicated. - An education posttest is conducted randomly daily to determine the retention of the training. The scope lowered from a K to an E at the time of the survey after ensuring the facility implemented education and their policy and procedures. 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had an intact cognition. The MDS indicated the Resident #6 required the assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses of a stroke, Parkinson's Disease, and post-traumatic stress disorder. The Care Plan Focus dated 3/30/23 identified Resident #6 needs to alert staff when he needs the restroom. In an interview on 4/19/23 at 12:26 PM Resident #6 reported times when she asked Staff C, Certified Nurse Aide (CNA), to help her to the bathroom she wouldn't help her and made her wait. Resident #6 added that the other CNA's did not make her wait until she had an accident in her pants. She explained that she had 5 to 8 accidents in her pants because Staff C made her wait to use the bathroom. Resident #6 stated that Staff C verbally put her down a lot. Staff C said that she always asked for help and put her down for asking for help. Staff C said that she could take care of herself more. She reported that she felt really depressed. She started throwing herself on the floor so that they would move her to a different facility. Staff C frightened her when she raised her voice. Resident #6 said it made her think back to her alcoholic father, it scared her. She would raise her voice basically whenever she worked. Resident #6 reported that she told someone, she told a CNA that Staff C raised her voice too, but could not remember who. Resident #6 explained that she told more than one person but she could not remember who she talked to. In an interview on 4/17/23 at 3:16 PM Staff G, CNA, reported that Resident #6 informed her that he asked Staff C for help. Staff C replied, why would she help him? He did not do her job for her. Staff G reported that they did not submit a report to the Administrator or DON. 2. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified that he usually could make themselves understood and usually understood others. The MDS indicated Resident #8 required the extensive assistance of two persons for bed mobility, transfers and toilet use. The MDS included diagnoses of a stroke, quadriplegia (inability to move all four limbs), and repeated falls. The Care Plan Focus dated 4/13/23 indicated that Resident #8 had a behavior problem, increased depression, and has made a statement about self-harm to his primary care provider (PCP). The Focus included an Intervention that directed the staff to approach him and speak to him in a calm manner. In an interview on 4/19/23 at 1:11 PM, Resident #8 described Staff C as rough during routine care. Resident #8 stated, Staff C helped him transfer into bed and he almost did a somersault. Resident #8 remarked the incident as frightening and jarring. Resident #8 reported that he told a nurse about the event but he could not recall the nurse's name. 3. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had an intact cognition. The MDS indicated the Resident #8 required the assistance of one person for personal hygiene and the extensive assistance of 2 persons bed mobility, transfers and dressing. The MDS included diagnoses of paraplegia (inability to move a portion of their body), neurogenic bladder (loss of control of urine) and involuntary movements. The Care Plan dated 4/28/23 for Resident #11 instructed staff to monitor his need for additional assistance with mobility and activities of daily living. The Care Plan also instructed staff to set up dressing, grooming supplies, and allow the resident to participate as able. In an interview on 4/19/23 at 1:01 PM, Resident #11 stated that Staff C asked him to take a shower and he told her okay. Resident #11 explained that he told Staff C, that she did his hair, back, and legs. She said no, that she did everything and would do it quickly. Resident #11 reported Staff C as rough and rough on his private parts too. Resident #11 added that told her that he wanted to do it himself but she wouldn't let him. Resident #11 could not recall the exact date of when it occurred but stated it happened within the last month. Resident #11 reported that he may have told a CNA. 4. Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified them as able to make themselves understood and understand others. The MDS indicated Resident #20 required the extensive assistance of two persons for bed mobility, transfers and toilet use. The MDS included diagnoses of repeated falls, Diabetes Mellitus with circulatory complications, and anxiety. The Care Plan dated 3/30/23 directed the staff to encourage Resident #20 to use the call light for assistance. The Care Plan also showed that Resident #20 could not transfer independently as she required a mechanical lift or EZ Stand for transfers. In an interview on 4/19/23 at 2:11 PM, Resident #20 stated Staff C told her that she peed her pants all the time. Resident #20 stated that she didn't need to pee all the time. She explained that she is a human being, not a kid or an animal, that upset her. Resident #20 stated that she reported Staff C but she did not remember which person she told. She confirmed who she told worked at the facility. In an interview on 4/17/23 at 3:33 PM Staff F, CNA, explained that she witnessed Resident #21 sitting in her wheelchair and asked Staff C to push her down the hall. Staff C replied that she could not push her, because of her being too fat. Staff F recalled another event involving Resident #2 and Staff C. Staff F stated that she thought Staff C tossed him into bed or something because she heard a noise and then she heard him scream, so she went in there. Resident #2 told me to get Staff C away. Staff F explained that she told Staff C to leave and as she left she slammed the door. Staff F also recalled a time Resident #13 needed help. Staff F reported Staff C as being mad, so she slammed Resident #13's door when she went in there. Staff F stated that she reported these accounts to the Administrator and the previous DON. Staff C reviewed her timecard, then cited the exact date and time she spent at the facility talking with the Administrator and the previous DON. Review of Staff F's time card matched the exact date and times given. In an interview on 4/19/23 at 10:43 AM, Staff D, CNA, described Staff C, CNA, as direct and did not give the residents an option on whether to help themselves bathe, she did it all. Staff D said that Staff C could be rude and direct to residents. Staff C stated that she did not submit a report to the Administrator or DON. In an interview on 4/19/22 at 11:46 PM, the Administrator denied knowledge of complaints or issues with Staff C prior to her dismissal. The Administrator stated that she sometimes verbally corrected her in the hall if she heard something, but that's all. The Administrator denied documenting the verbal corrections. Review of an email from the Administrator dated 4/24/22 at 3:21 PM identified Staff C is not an employee of the facility and confirmed they did not have any corrective actions for her at the building. The Identifying Abuse dated April 2021 instructed the following 1. Abuse of any kind against residents is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in the facility that preventing abuse requires staff education, training, support, a facility-wide culture of compassion, and caring. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. a. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. c. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 5. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. a. Corporal (physical) punishment used to control behavior is recognized as a form of abuse. 6. Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse. a. Not responding to a resident's request for assistance, which results in care deficits, is abuse. 7. Verbal abuse includes any verbal, written or gesture communication (including sounds) directed at a resident within a hearing distance, regardless of his or her ability to comprehend or disability. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021 directed that the 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 restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. 3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 7. Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities; b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; c. instruct staff regarding appropriate ways to address interpersonal conflicts; and d. help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by Federal requirements. 10. Protect residents from any further harm during investigations. 11. Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect, mistreatment or misappropriation of property. 12. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. In an interview on 4/24/23 at 3:22 PM, the interim Director of Nursing (DON), reported that Staff C, CNA, is no longer able to work at any of the affiliated facilities.

Based on clinical record review, facility record review, family interview and staff interview the facility failed to prevent new pressure ulcers from developing and failed to prevent a pressure ulcer from deteriorating for 2 of 3 residents reviewed (Resident #3 and 4). The facility reported a census of 30. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 7, indicating severe impaired cognition. The MDS documented that he required extensive assistance of two people for bed mobility, transfers, walking in his room, dressing, and toilet use; and extensive assistance of one person for eating and hygiene. The MDS included diagnoses of COVID-19, hypertension, dementia, Parkinson's disease, depression, metabolic encephalopathy and idiopathic gout. The MDS listed a weight of 156 pounds and that he did not have a loss or gain of 5 percent or more in the previous month. The MDS documented that he did not have any pressure ulcers but had a risk for developing pressure ulcers. Resident #3's MDS assessment dated [DATE] listed a discharge date of [DATE] to an acute hospital. The MDS identified that Resident #3 had severely impaired for cognition. The MDS documented he required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and hygiene. The MDS documented that he did not have any pressure ulcers. Resident #3's MDS assessment dated [DATE] listed a reentry date of 12/7/22 from an acute hospital. The MDS listed that Resident #3 had one stage I pressure ulcer. The Care Plan Focus dated 2/16/23 documented that Resident #3 had impaired cognitive function related to metabolic encephalopathy, dementia and Parkinson's disease. The Care Plan Focus dated 2/16/23 documented that Resident #3 required staff assistance for all of his activities of daily living. The Intervention revised 1/24/23 instructed that Resident #3 required assistance with all meals. The Intervention dated 1/3/22 directed the staff that he required assistance of two for bed mobility and transfers with the front wheeled walker. The Care Plan revised 2/16/23 documented that Resident #3 had a risk for pressure ulcers. The Intervention dated 12/13/22 informed staff that he had an acquired pressure ulcer and to use heel boots on heels at all times. The Care Plan lacked any other interventions dated before 2/16/23 after the development of the pressure ulcer or prior to discharge from the facility. The Nursing/Therapy Communication Note dated 12/7/22 at 3:25 PM labeled LATE ENTRY indicated that Resident #3 returned from the hospital as a new hospice patient. The Skin and Wound Evaluation V5.0 dated 12/13/22 at 8:20 PM indicated that Resident #3 had an in-house acquired stage one pressure ulcer to his left heel. The Evaluation indicated the wound was new. The wound measured 4.1 centimeters (cm) in length and width with no depth. The Orders section listed the wound as healable. The section labeled Additional Care listed customized shoe wear with no other interventions indicated in the section. The Nurses Note dated 12/13/22 at 7:30 PM indicated that Resident #3 had a stage I pressure area to his left heel. The nurse completed an assessment, then notified hospice and daughter. The staff applied an air mattress to his bed and ensured his heel protectors were in place. The SPN - Dietary Note dated 12/14/22 at 5:23 AM documented by the Regional Dietitian (RD) indicated that Resident #3 recently admitted to hospice care. The note listed Resident #3's current body weight (CBW) as 157.6 pounds. The RD noted that Resident #3's weight remained stable (155.6-157.8 pounds for 180 days). The RD documented that Resident #3's weight is appropriate for his age with a body mass index (BMI) of 25.4 (measurement of body fat based on height and weight). Resident #3 observed to have a decreased intake to sips-50% at meals on a full liquid diet. On 12/10/22 Resident #3's diet got downgraded. He received whole milk with all meals. He required limited to extensive assistance at meals with liquids being served in a sippy cup. No supplements ordered. Resident #3 had a stage I pressure ulcer to his left heel. Resident #3 had a Braden score (pressure risk score) of 11, indicating high risk for developing pressure ulcers. MNA (Mini Nutritional Assessment, Malnutrition assessment) score of 8 indicated he had a nutritional risk. Resident #3's PCP to be updated on MNA score with recommendations for house supplement 120 cubic centimeters (cc) every day to help meet his nutritional needs. He is at high risk for weight loss due to poor oral intake at meals and anticipated continued decline. The Skin and Wound Evaluation V5.0 dated 12/21/22 at 2:54 PM indicated that Resident #3 had an in-house acquired deep tissue injury to his left heel. The Evaluation indicated the wound was one week old. The wound measured 3.4 cm in length and 4.6 cm width with no depth. The Orders section listed the wound as healable. The section labeled Additional Care listed a mattress with pump and other. No additional areas marked in the section. The section labeled Progress indicated the wound was stable with prafo (pressure relief ankle foot) boots and air mattress in place. The Progress Notes lack any documentation from 12/17-12/27/22. The Skin and Wound Evaluation V5.0 dated 12/28/22 at 5:34 PM indicated that Resident #3 had an in-house acquired deep tissue injury to his left heel. The Evaluation indicated the wound was two weeks old. The Evaluation lacked measurements. The Orders section listed the wound as healable. The section labeled Additional Care listed a cushion, a mattress with pump, and other. No additional areas marked in the section. The section labeled Progress indicated the wound was stable. The Notes section indicated that hospice was present for assessment with no new orders. No signs or symptoms of infection the staff would continue to be evaluated. The Order Note dated 12/28/22 at 4:34 PM listed that Resident #3 had a weight loss. A doctor gave a new order for Medpass supplement four ounces twice a day. The Progress Notes revealed the resident went 14 days without any nutritional supplement. The Skin and Wound Note dated 1/4/23 at 1:39 PM indicated that Resident #3 had an in-house acquired deep tissue injury to his left heel. The Evaluation indicated the wound was one month old. The wound measured 3.6 cm in length and 4.4 cm width with no depth. The Orders section listed the wound as healable. The section labeled Additional Care listed a mattress with pump and other. No additional areas marked in the section. The section labeled Progress indicated the wound was stable. The Skin and Wound Evaluation V5.0 dated 1/10/23 at 2:26 PM indicated that Resident #3 had an in-house acquired deep tissue injury to his left heel. The Evaluation indicated the wound was one month old. The wound measured 4.5 cm in length and 4.4 cm width with no depth. The Orders section listed the wound as slow to heal, wound healing is slow or stalled but stable, little/no deterioration. The section labeled Additional Care listed a foam mattress and heel suspension/protection device. No additional areas marked in the section. The section labeled Progress indicated the wound was stable. The Skin and Wound Evaluation V5.0 dated 1/18/23 at 3:15 PM indicated that Resident #3 had an in-house acquired deep tissue injury to his left heel. The Evaluation indicated the wound was one month old. The wound measured 5.2 cm in length and 5.1 cm width with no depth. The Orders section listed the wound as slow to heal, wound healing is slow or stalled but stable, little/no deterioration. The section labeled Additional Care listed a mattress with pump and other. No additional areas marked in the section. The section labeled Progress indicated the wound was stable with prafo boots and air mattress in place. The Skin and Wound Evaluations revealed the resident went up to 8 days between pressure ulcer assessments and the facility failed to measure the pressure ulcer on 12/28/22. The evaluations revealed the pressure ulcer deteriorated. On 2/16/23 at 1:02 PM Resident #3's daughter reported that when he admitted to the facility he did not have any open areas but when he discharged he had a pressure ulcer on his heel. She explained that since he discharged they all cleared up, so she felt like they did not take care of him. On 2/22/23 at 12:00 PM the Director of Nursing (DON) stated she could not find any orders or notifications to the provider in regards to his pressure ulcer of his left heel except for when they notified hospice on 12/13/22. She said that once they notified hospice they expected them to handle the pressure ulcer. On 2/22/23 at 12:48 PM the DON stated the facility assesses pressure ulcers weekly and are expected to notify hospice. She stated she expects the provider to be notified of any deterioration. On 2/22/23 at 4:41 PM the DON stated she checked with hospice and they did not have anything else regarding orders or interventions for the pressure ulcer after 12/13/22. 2. Resident #4's Admission MDS assessment dated [DATE] listed an entry date of 10/14/22. The MDS identified a BIMS score of 14, indicating intact cognition. The MDS documented that she required extensive assistance of two people for bed mobility, transfers, dressing and toilet use; and required extensive assistance of one person for eating and hygiene. The MDS documented she did not receive a bath in the seven day look back period. The MDS listed Resident #4 as frequently incontinent of bowel and bladder. The MDS included diagnoses of atrial fibrillation, hypertension, renal insufficiency, arthritis, osteoporosis, other fracture, chronic obstructive pulmonary disease, encounter for orthopedic aftercare, and abdominal aortic aneurysm. The MDS documented that she had one Stage I pressure ulcer on admit and had a risk for developing pressure ulcers. The MDS listed that she had a surgical wound and moisture associated skin damage. The MDS indicated that Resident #4 had a pressure reducing device for her bed, surgical wound care, and application of nonsurgical dressings. The Skin & Wound Evaluation V5.0 dated 10/15/22 moisture associated skin damage to her coccyx documented as present on admit and measuring 7.3 cm in length and 7.9 cm in width. The Care Plan dated 10/16/22 indicated that Resident #4 had a pressure related injury to her skin. The Intervention directed the following: - 10/16/22: Assess, record and monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements/declines to the physician. - 10/16/22: Monitor, remind, assist to turn and reposition frequently. - 12/13/22: Air Mattress ordered - 12/13/22: Please cleanse, apply sacral Mepilex, change every three days and as needed until healed or discontinued. The Skin & Wound Evaluation V5.0 dated 10/17/22 stage I pressure her coccyx documented as present on admit and measuring 2.7 cm in length and 5.3 cm in width. The Skin & Wound Evaluation V5.0 dated 10/23/22 stage I pressure her coccyx measured 5 cm in length and 4 cm in width with no depth. No evidence of infection with no exudate. Area documented as healable with a foam mattress in place. The Skin & Wound Evaluation V5.0 dated 10/28/22 stage I pressure to her coccyx measured 2.2 cm in length and 1 cm in width. The Skin & Wound Evaluation V5.0 dated 11/2/22 stage I pressure to her coccyx measured 3.5 cm in length, 7.4 cm in width and no depth. Surrounding tissue fragile with erythema. The Care Plan Focus dated 11/3/22 indicated Resident #4 had occasional bladder incontinence. The Goal dated 11/3/22 documented that Resident #4 would not experience any skin conditions from incontinence. The Skin & Wound Evaluation V5.0 dated 11/10/22 stage I pressure to her coccyx documented as present on admit measuring 0.9 cm in length and 2.2 cm in width. Foam mattress in place and area documented as improving. The Care Plan Focus revised 11/10/22 for Resident #4 documented that she required assistance from staff with grooming and personal hygiene related to her activity intolerance. The Plan Interventions dated 1/4/23 directed the following - Resident #4 required extensive assistance of two staff for bathing/showering. - Resident #4 required extensive assistance of two staff to turn and reposition in bed The Skin & Wound Evaluation V5.0 dated 11/19/22 stage I pressure to her coccyx documented as present on admit measuring 0.6 cm in length and 0.4 cm in width. Area documented as improving. The Skin & Wound Evaluation V5.0 dated 11/29/22 stage I pressure to her coccyx documented as present on admit measuring 0.6 cm in length and 0.5 cm in width. Foam mattress in place and area documented as improving The Skin & Wound Evaluation V5.0 dated 12/4/22 stage I pressure her coccyx documented as present on admit measuring 1.8 cm in length and 1.7 cm in width. Foam mattress in place and area deteriorating due to irritation from her bed pan. The Skin & Wound Evaluation V5.0 dated 12/13/22 stage II pressure to her coccyx documented as present on admit measuring 3.7 cm in length and 7.1 cm in width with 10 percent epithelial tissue present and 90 percent granulation tissue present. Area documented as deteriorating with air mattress ordered on 12/13/22. The Skin and Wound Evaluations revealed the facility went 9 days without assessing it 12/4 to 12/13/22 and the area deteriorated. The Skin & Wound Evaluation V5.0 dated 12/21/22 stage II pressure to her coccyx documented as present on admit measuring 1.7 cm in length and 1.5 cm in width with slough present and documented as deteriorating. Noted to be on an air mattress with a pump. The Skin & Wound Evaluation V5.0 dated 12/26/22 stage II pressure to her coccyx documented as present on admit measuring 2.4 cm in length and 2.8 cm in width. Area documented as deteriorating. The Discharge MDS dated [DATE] documented that she did not receive a bath in the seven day look back period. The MDS listed Resident #4 as frequently incontinent of bowel and bladder. The MDS indicated that Resident #4 had one stage II pressure ulcer. Resident #4's October 2022 Treatment Administration Record (TAR) included the following orders: - 10/19/22: Mepilex to coccyx. The order directed to change on bath days every Wednesday and Saturday and as needed (PRN) for skin protection. - 10/21/22: Apply Aquaphor to Resident #4's coccyx twice a day and PRN. The TAR lacked documentation of treatments to the coccyx from 10/15/22 until 10/19/22. On 2/16/23 at 12:30 PM Resident #4's daughter explained that her mother did not get a bath or have her hair washed regularly. She said that Resident #4's skin not being cleaned caused it to break down more. She stated the staff left her in bed from 11/17 until her discharge on 12/30/22. Resident #4's daughter reported that they never attempted to get her up. She said that sitting in urine too long caused Resident #4's skin to break down. The facility policy Pressure Ulcers/Skin Breakdown dated September 2017 documented the following: Outcomes: - Incidence of new pressure ulcers will be minimized to the extent possible. - Healing of existing pressure ulcers will be optimized to the extent possible. - The facility will be able to show that failure of a pressure ulcer to heal was medically unavoidable. Monitoring: - During resident/patient visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly healing wounds. -- This should be based on looking at the wound periodically and on reviewing pertinent information about the patient. - The physician will help guide the Care Plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. - Healing may be delayed or may not occur, or additional ulcers may occur because of unmodifiable factors or because of care-related process problems. - Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.

Based on observations, clinical record review, facility record review, and staff interview the facility failed to provide supervision to prevent a fall with injury for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 30. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) Score of 13, indicating intact cognition. The MDS documented he required extensive assistance of two people for toilet use; extensive assistance of one person for eating and bathing; minimal assistance of two people for bed mobility, transfers, walking and dressing; and minimal assistance of one person for hygiene. The MDS listed Resident #1 as frequently incontinent of urine and occasionally incontinent of bowel. The MDS included diagnoses of a stroke, atrial fibrillation, hypertension, benign prostatic hyperplasia, and hemiplegia. The MDS listed that Resident #1 had two or more falls with no injury and one fall with an injury since the previous assessment. The Fall Risk Evaluation dated 11/30/22 documented Resident #1 scored 17, indicating a high risk for falls. The Care Plan Focus revised 12/6/22 listed that Resident #1 had a risk of falls. The Interventions directed the following: - 6/16/22: appropriate footwear including nonskid socks when in bed - 11/30/22: do not leave unsupervised on the toilet - 8/25/22: encourage him to use his call light - 11/30/22: encourage him to use his bedside urinal - 1/4/23: do not leave in the dining room without assistance - 1/4/23: room change to hall two for increased supervision - 1/13/23: Requested bowel medication review from primary care provider (PCP) - 2/11/23: seating at assist table - 2/13/23: one-way slide (prevents forward movement but allows backward movement) in chair at all times. The Incident, Accident, Unusual Occurrence Note dated 12/6/22 at 1:26 PM indicated that the staff found Resident #1 sitting on the floor wearing gripper socks next to his bed in front of his wheelchair with his head resting against the side of his bed. The floor appeared dry and uncluttered. Resident #1 denied hitting his head. The nurse completed a head-to-toe assessment and started neurological (neuro) checks. Resident #1 could move extremities with no injuries noted. The staff assisted Resident #1 with a gait belt off the floor and into his wheelchair. The Incident, Accident, Unusual Occurrence Note dated 12/20/22 at 3:38 AM indicated a nurse found Resident #1 lying on the floor on his back with right arm behind his head and legs crossed. Resident had one slipper on and one lying next to his foot. Resident #20 reported that he decided to lay down and then stated he tried to get up to go check on his roommate. No injuries noted. Resident encouraged to turn on his call light for help but to remain in bed and let staff check on his roommate. The Incident, Accident, Unusual Occurrence Note dated 12/25/22 at 3:28 PM staff witnessed Resident #1 stand unassisted in the bathroom and slowly sit on the floor. Resident #1 reported that he got tired. No signs of injury. The Incident, Accident, Unusual Occurrence Note dated 12/27/22 at 6:45 PM an aide answered Resident #1's call light and found him sitting on the floor in the bathroom. Resident #1 stated he didn't fall, that he sat himself down on the floor, and then pulled the light for help. The Certified Nurse Aide (CNA) assisted Resident #1 with standing himself up with no complaints of discomfort voiced. The Incident, Accident, Unusual Occurrence Note dated 1/2/23 at 9:55 PM a nurse heard a loud noise from the dining room. Observed Resident #1 laying on his back next to the table with his arm tucked behind his head. Observed small laceration to lower lip following fall. Moves legs and arms without difficulty. The Incident Report dated 1/6/23 at 6:50 PM documented that staff found Resident #1 on his back in front of his TV with his feet close to the bathroom. The staff assisted Resident #1 to the bathroom with his gait belt and two staff. Resident #1 did have a bowel movement (BM). Resident #1 reported that he felt like he had to have a BM all day but could not have one. Resident had hard sole shoes on and called the light not on. Vitals within normal limits for Resident #1. Residents received a laxative within the last eight hours prior to his fall. Resident #1 stated he lost his balance trying to take himself to the bathroom. A head-to-toe assessment completed with range of motion (ROM) within normal limits. Resident #1 had a skin tear on the back of his left hand. Injuries reported post incident left hip trochanter fracture. Predisposing physiological factors include incontinence, gait imbalance, and impaired memory. The Communication - with Physician Note dated 1/7/23 at 1:29 AM indicated that the staff found Resident #1 on the floor in his room. He stated he was going to the bathroom. He did not use his call light, wait for assistance, or use his walker. ROM and neuro checks within normal limits. Resident #1 did not know if he hit his head. No redness or raised areas noted. Resident #1 had a crescent shaped 1-centimeter (cm) skin tear to the top of his left hand. Initially complained of left knee pain. No disfigurement, redness, or edema to the area. After some time, Resident #1 stated the knee felt much better. The nurse planned to continue to monitor for any changes. The Orders - Administration Note dated 1/7/23 at 3:44 AM indicated that Resident #1 took two 325 milligrams (mg) acetaminophen (pain medication) tablets for generalized discomfort and a headache. The Orders - Administration Note dated 1/7/23 at 12:17 PM revealed that Resident #1 took two 325 mg acetaminophen tablets for complaints of knee pain. The charge nurse okayed the administration. The Orders - Administration Note dated 1/7/23 at 5:10 PM documented that Resident #1 received a 5-325 mg Norco tablet for pain. The Nurses Note dated 1/8/23 at 7:30 AM resident continues with left hip pain. Does not bear weight on the left leg. Son updated per phone and expressed wishes to transport Resident #1 by private care to the emergency room (ER). The Nurses Note dated 1/8/23 at 10:30 AM revealed that Resident #1 left per private vehicle to go to ER for a hip evaluation. The Nurses Note dated 1/8/23 at 2:01 PM indicated that Resident #1's son called to inform the facility that Resident #1 got admitted to the hospital. The Diagnostic Radiology Report dated 1/8/23 revealed an acute left femoral neck fracture (hip fracture) in near anatomic (body structure) alignment. The Impression listed a proximal left femoral neck fracture. The History and Physical dated 1/8/23 documented Resident #1 was brought into the ED (emergency department) for a fall two days ago with left knee pain. His fall was not witnessed but reportedly he fell going to the bathroom. His Power of Attorney (POA) stated that he is very obsessed with going to the bathroom regularly. The Assessment/Plan section listed a proximal left femoral neck fracture. The SPN - Admit/Re-Admit Note dated 1/13/23 at 11:56 AM resident readmitted to the facility. Surgical incision to his left hip has an intact dressing that should not be removed until his next appointment. Two persons assist for transfers. Resident #1 has new acute pain and uses medication and/or non-pharmacological interventions for pain management. The Order Note dated 1/13/23 at 12:12 PM indicated an order for Norco 5-325 mg one tablet by mouth every 6 hours as needed for pain. The Nursing/Therapy Communication Note dated 1/13/23 at 4:12 PM physical therapy evaluation completed and resident to transfer with assistance of two people. The Incident, Accident, Unusual Occurrence Note dated 1/26/23 at 4:00 PM resident returned from an appointment and the driver reported Resident #1 slid out of his wheelchair onto his wheelchair pedals. Resident #1 denied pain but stated it was cold down there and a rough ride. Two people assisted Resident #1 into his wheelchair. He moved all extremities with ease. The bus driver reported the wheelchair had its brakes on, Resident #1 had on a seat belt, and tied down on. The Nurses Note dated 2/5/23 at 6:57 PM indicated a nurse was summoned to 200 hall due to staff witnessing a fall around 9:45 AM. The nurse observed Resident #1 lying on his back in the doorway and stating that he slipped out of his wheelchair. Resident #1 denied pain or hitting his head. The wheelchair cushion laid on the floor in front of Resident #1. Non-skid socks on feet, the floor appeared dry without clutter and adequate lighting. The assessment determined that Resident #1 did not have shortening or rotation of his extremities. Resident #1 did not have bruising or redness noted. Two staff assisted Resident #1 with a gait belt to a standing position and transferred him to a wheelchair. The Incident Report dated 2/11/23 at 9:00 AM indicated that Resident #1 sat in a wheelchair drinking tea at the dining room table when Resident #1 slid out of his wheelchair landing on his buttocks on the floor. Resident #1 denied pain and had no injuries observed at the time of the incident. On 2/13/23 at 3:18 PM observed Resident #1 in his room resting in bed. He stated he has been up to the bathroom a lot today. His call light is in reach but noted his urinal in the bathroom on the back of the toilet, he had regular socks on, and no one-way slide noted in his chair. On 2/13/23 at 3:20 PM the Nurse Consultant stated fall interventions carry over from the care plan to the tasks in electronic health record (EHR) for the aides to make sure they are in place and followed. On 2/14/22 the Tasks tab of the EHR for Resident #1 directed staff to make sure he wore non-skid socks while in bed, to make sure he had the one-way slide in his chair at all times, and to encourage him to use his bedside urinal. On 2/14/23 at 9:10 AM observed Staff A, CNA, and Staff G, CNA, provide toileting assistance for Resident #1. Observed a gripper one-way slide in Resident #1's wheelchair on top of the cushion with a note to keep it in his wheelchair at all times. Staff G lowered Resident #1's bed and placed the call light in front of him attached to the bedding. Resident #1 had non-skid socks on and over the bed table next to the bed without a urinal. Observed the urinal on the back of Resident #1's toilet. The CNAs failed to place it next to Resident #1 prior to leaving the room. On 2/14/23 at 10:30 AM observed the Care Plan fall focus with a revised intervention dated 2/13/23 that directed the staff that he has a one-way slide in his chair at all times. On 2/21/23 at 1:10 PM observed Resident #1 in bed and wearing non-skid gripper socks, with his bed in low position, his call light in reach, but no urinal observed in his room and the one-way slide is not in his wheelchair but he does have a gripper pad under the wheelchair cushion. On 2/21/23 at 3:00 PM Staff F, Registered Nurse (RN), stated the nurse needs to investigate any new falls and add a new intervention. On 2/22/23 at 12:30 PM the Interim Administrator stated with every fall the nurse is expected to assess Resident #1, investigate the fall, implement a new fall intervention, update the Care Plan with the intervention and communicate it to the staff so it is initiated that day. On 2/23/23 at 5:00 PM the Interim Administrator stated the facility did not have a non-major injury form for the fall that occurred on 12/6/22.

Based on observations, clinical record reviews, staff and resident interviews, the facility failed to implement interventions when residents showed signs and symptoms of a Urinary Tract Infection ([CONDITION(S)]) for two of four residents reviewed (Resident #1 and #87) for catheter care and UTIs. Resident #1 had a suprapubic urinary catheter that had blood tinged urine and low urinary output for a week. Staff failed to communicate these concerns to the physician. Resident #87 experienced blood in his urine for 4 days. The facility collected a urine sample but staff failed to follow up when the sample did not get to the lab. The facility reported a census of 37 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 required extensive assistance from one person for bed mobility, toilet use, and dressing. Resident #1 had an indwelling catheter and occasionally had urinary incontinence. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus revised 6/21/22 indicated that Resident #1 had a suprapubic catheter related to a history of [CONDITION(S)]. The connected interventions dated 6/21/22 directed staff to assess for the following a. Signs and symptoms of a [CONDITION(S)] b. Ongoing assessment of color, clarity, and character of his urine. The Hospitalist History and Physical (H&P) dated 6/2/22 at 7:57 PM recorded that Resident #1 presented that day to the emergency room (ER) from his home with increased weakness, lower abdominal pain, redness, and drainage around his suprapubic catheter site. The report indicated that Resident #1 had an output of 250 cubic centimeters (cc) of urine in a 24-hour period. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Normal urination is [PHONE NUMBER] cc each day if a person intakes two liters of fluid throughout the day. Retrieved on 7/12/22 from: Urine Output: What's Normal and What's Not? | MD-Health.com The Hospital's Discharge Summary printed on 6/7/22 at 11:46 AM documented that Resident #1 required inpatient skilled nursing facility services. The Summary included instructions related to [CONDITION(S)] and UTIs. On 6/27/22 at 10:03 AM, Staff P, Certified Nurse Aide (CNA), and Staff T, CNA, provided cares to Resident #1 while in his room. Resident #1's right leg had a subpubic urinary catheter strapped to it. The urinary catheter bag had very little but very dark urine. The CNAs explained Resident #1's urine always looked dark, almost red. Resident #1 asked for some ice water and said that he didn't have any water yet that morning. His water pitcher sat over by the sink. On 6/27/22 at 10:54 AM Resident #1 explained that he had been feeling so, so. Resident #1 said that he had a catheter and he had some trouble with it leaking at times. Resident #1 reported being frustrated because it hadn't been that long ago that he could get to the restroom by himself. Resident #1 added that since his hospitalization he needed a lot more help. Progress Notes Review The SPN - Admit/Re-admit note dated 6/7/22 at 12:35 PM recorded that Resident #1 had a urinary catheter. The note lacked assessment of Resident #1's urinary status such as color, clarity, and amount. The SPN - Skilled Evaluation note dated 6/8/22 at 6:41 AM Resident #1 recieved assistance in the night with emptying his subrapubic urinary catheter bag. Resident #1 assisted with emptying it. The urinary catheter bag had yellow urine until it got last emptied and then the urine appeared red. The nurse documented that they would continue to monitor. The SPN - Skilled Evaluation note documented Resident #1's indwelling catheter as patent with yellow urine on the following dates a. 6/11/22 at 1:35 PM b. 6/12/22 at 1:37 PM The SPN - Skilled Evaluation note documented Resident #1's indwelling catheter as patent and draining clear amber urine on the following dates a. 6/13/22 at 6:43 PM b. 6/14/22 at 2:24 PM c. 6/15/22 at 2:45 PM d. 6/18/22 at 3:18 PM e. 6/19/22 at 11:14 PM f. 6/21/22 at 12:55 PM g. 6/22/22 at 1:29 PM h. 6/24/22 at 5:24 PM i. 6/25/22 at 12:49 PM The Orders - General Note from eRecord dated 6/26/22 at 5:28 PM documented that the nurse noted earlier in the shift that Resident #1 had urine in his brief with only a small amount of urine in his leg bag. Resident #1's abdomen assessed to be soft and not distended. An as needed urinary catheter change completed with immediate return of 200 cc dark urine. The nurse encouraged Resident #1 to drink plenty of fluids. Resident #1 reported that he felt some pressure relief. The Appointment/Visit Note dated 6/27/22 at 3:27 PM Resident #1's Advanced Registered Nurse Practitioner (ARNP) visited. The nurse discussed his dark urine, open area at his suprapubic urinary catheter site, and about his overall depressed mood. The ARPN gave new orders, Resident #1 notified of the new orders, and the nurse notified the pharmacy. Daily urine output documented in June 2022: 6/20/22; 150 cc 6/22/22: 0 cc 6/23/22: 50 cc 6/24/22: 600 cc 6/25/22: 0 cc 6/26/22: 200 cc 6/27/22: 850 cc The History and Physical dated 6/28/22 at 6:15 PM documented the Chief Complaint as a [CONDITION(S)] associated with cystostomy (surgical creation of an opening into the bladder) catheter. Resident #1 received a suprapubic catheter due to [CONDITION(S)] on 5/27/22. Resident #1 went to a rehab center to stay on 6/7/22. Resident #1 had progressive weakness with dark/blood colored urine for the past week. Resident #1's weakness progressed to the extent that he couldn't walk so he came to the ER. Resident #1's assessment indicated that he had red urine and decreased urinary output. The lab work showed an elevated white blood cell count (WBC) of 10.85 (reference range 4.0 to 10.0) and a positive urinalysis (UA). The Assessment and Plan recorded a catheter associated with [CONDITION(S)] with the plan to stop his blood thinner, get blood cultures, and get urine cultures. On 6/28/22 at 11:33 AM Staff P, CNA, said that Resident #1's urine looked dark since his admission. Staff P described Resident #1's urine as coffee ground consistency. On 6/29/22 at 9:51 AM Staff H, CNA, reported Resident #1's urine usually looked pretty dark. She explained that she notified the nurses at the end of each shift about his urine output. Staff H continued to say that during shift report the staff usually didn't talk about Resident #1 very much. On 6/29/22 at 12:44 PM Staff I, LPN, said that Resident #1's urine always appeared amber in color with clots. She denied having any CNAs report to her about his low urine output. Staff I added that she would expect them to report concerns of less than 100 cc in a shift. Staff I denied ever looking at his output documentation. On 6/29/22 at 9:46 AM Staff J, CNA, said that she always thought that because of his very dark urine, it didn't look healthy. She explained Resident #1 usually had pretty low urinary output. Staff J added that she would have reported his output to the nurse if Resident #1 had less than 100 cc of urine in a shift. On 6/29/22 at 12:19 PM Staff K, LPN, explained that she documented Resident #1's urine as amber. She added that the urine's amber color would come and go, with it sometimes being lighter in color. Staff K reported that she told the Director of Nursing (DON) that Resident #1 needed an appointment with the urologist. Staff K acknowledged that she knew of his low urinary output, she said because of that she told them to get the urologist appointment. Staff K denied looking at Resident #1's urinary output documentation. On 6/29/22 at 10:13 AM Staff B, Registered Nurse (RN), said that Resident #1 had blood tinged urine since his admission and but denied knowing if the doctor knew about it. Staff B said that she notified Resident #1's provider on 6/27/22 but not before that time. She denied knowing of his low urinary output. Staff B stated that she expected the staff to notify her with urinary outputs less than 400 cc in a day. Staff B denied looking at Resident #1's documentation for his urinary output. On 6/29/22 at 8:59 AM the ARNP said she ordered a UA for Resident #1 on Monday, June 27th. She didn't see Resident #1's urine when she visited on the 27th because the bag got emptied before she saw him. She reported that she didn't receive notification about the color Resident #1's urine before Monday or that he had very little output. The ARNP reported that she would expect to be contacted within 24-hours of a low urinary output with a baseline of 30 cc an hour. On 7/5/22 at 1:00 PM the DON said that as Resident #1 had a new suprapubic catheter; it was not uncommon for a new catheter site to have some blood. The DON appeared surprised that none of the CNA's thought to tell the nurses of his low urinary output. She commented that the ARNP came to the facility twice a month, without any problems. The DON denied knowing if any of the nurses discussed Resident #1's urinary color with the ARNP when she did her rounds. The DON said that she expected anything less than 30 cc an hour would be reported to the nurse. The Order Note dated 7/11/22 at 2:14 PM recorded that Resident #1 returned from the hospital. Resident #1 saw urology and had a recent urinary catheter change. Resident #1 received antibiotic therapy while at hospital. His urine continued to be bloody or brown in color per the hospital nurse. The hospital nurse added that the physicians knew that Resident #1's urine continued to be ruddy brown or red in color. 2. Resident #87's MDS dated [DATE], identified a BIMS score of 13, indicating intact cognition. Resident #87 required extensive assistance of two persons for bed mobility, transfers, and toilet use. The MDS indicated Resident #87 as frequently incontinent of urine and bowel. Resident #87 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Focus revised on 6/26/22 identified Resident #87 as having impaired cognitive functioning. The included intervention dated 6/10/22 directed staff to monitor, document, and report any change in cognitive status. The Care Plan Focus revised 6/29/22 documented that Resident #87 took an anticoagulant (blood thinner) therapy of [MEDICATION(S)] related to chronic [CONDITION(S)]. The included intervention dated 6/10/22 directed staff to monitor for side effects (unusual bruising, bleeding gums, purpura purple-colored spots and patches that occur on the skin, and in [MEDICATION(S)] membranes, including the lining of the mouth, and changes in mental status which indicate hyper-coagulation a condition that causes your blood to clot more easily than normal) and effectiveness. The Care Plan lacked documentation related to Resident #87's incontinence of urine or bowel. On 6/26/22 at 1:40 PM Resident #87's son expressed concerns that his father experienced blood in his urine and it took four days to get an antibiotic. Progress Notes review The Orders - General Note from eRecord dated 6/23/22 at PM documented collection of a urine specimen from Resident #87 that got delivered to the clinic. The Orders - General Note from eRecord dated 6/23/22 at 1:09 PM documented that the ARNP visited. The nurse reported Resident #87's observed bloody colored urine and increased frequency. The ARNP gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse notified Resident #87's son of the order. The SPN - Skilled Evaluation dated 6/24/22 at 1:33 AM indicated that Resident #87 continued to have blood in his urine. The Nurses Note dated 6/25/22 at 9:31 AM recorded that Resident #87 continued to have bloody urine. Resident #87's urine appeared bright red with clots. The nurse attempted to track the UA sent that Thursday, but didn't have results. The nurse called the ARNP and after a half hour without a return phone call, the nurse contacted the facility's ARNP. The nurse reported Resident #87 had blood and clots for three days. The facility ARNP gave an order to have the ER evaluate Resident #87. Resident #87's son noted at the facility and would take him to the ER. The Nurses Note dated 6/25/22 at 10:13 AM indicated that Resident #87's son took him to the ER. The Nurses Note dated 6/25/22 at 4:15 PM documented that Resident #87 returned to the facility from hospital with his son with new orders to take [MEDICATION(S)] 500 milligrams (mg) every 12 hours for seven days. The IDT Note dated 6/27/22 at 1:41 PM identified an unsuccessful attempt to track down the results from the UA collected on 6/23/22. On 6/28/22 at 8:45 AM Resident #87's son reported that Resident #87 had blood in his urine for four days before they got him an antibiotic. He said that the staff knew of his father's blood tinged urine. He said that finally on Saturday morning, the 25th, he took his dad to the ER himself, got a UA and an antibiotic started. The staff kept telling him that they were waiting for results from the UA but they hadn't got a response from the lab. On 6/29/22 at 8:48 AM the hospital lab services said that they didn't have a urine sample from the facility for a long time and they had nothing for Resident #87. On 6/29/22 at 1:16 PM, the ARNP from the clinic said that they received a urine sample from the facility on 6/23 without a label. The nurse from the clinic called over to the facility to find out who the resident was, but they didn't get a returned call until it was too late, and they had to destroy the urine sample. On 7/7/22 at 10:20 AM the DON indicated the charge nurse as responsible for following up on doctor orders or lab results. The DON explained that typically, they got a response from the lab within a day on a UA. She knew that the urine sample didn't have a label that went to the clinic because she took the phone call from the clinic questioning the urine sample. The DON said that she thought the nurse followed up with the clinic. The DON reported being gone for three days so she didn't know that staff were still waiting for the results. The Catheter Care, Urinary policy revised 9/14 directed staff to observe residents for complications related to urinary catheters. The policy indicated the staff should check for unusual appearance such as color and blood in the urine. The policy informed the staff to notify the physician with the unusual appearance concerns. The Output, Measuring and Recording policy revised 10/14 directed the staff to report information in accordance with the facility policy and professional standards of practice.

Based on hospital record reviews, clinical record reviews, and staff interviews, the facility failed to prevent accidents for 1 of 3 residents reviewed (Resident #88) for falls. Staff L, Certified Nursing Assistant (CNA), transferred Resident #88 by himself in the evening and without the use of a gait belt. At the time Staff L transferred Resident #88 alone, he fell and sustained a [CONDITION(S)] as a result. The facility reported a census of 37 residents. Findings include: Resident #88's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Resident #88 required extensive assistance of one person for bed mobility, transfers, and toilet use. Resident #88's diagnoses included [CONDITION(S)], type two diabetes, heart failure, abnormalities of gait and balance. Resident #88's MDS assessment dated [DATE] documented that she required extensive assistance of two persons for bed mobility, transfers and toilet use. The Incident Report dated 3/19/21 at 6:30 PM documented that Staff L transferred Resident #88 to the bathroom, she lost her balance, and landed on the floor. Staff L transferred Resident #88 without the use of a gait belt. Resident #88 got transferred to the hospital, where she got diagnosed with a [CONDITION(S)]. The Fall Investigation for CNA's dated 3/19/21 documented by Staff L that he assisted Resident #88 to the toilet. At the time, he noticed that she started to let go of the walker and fell . Staff L recorded that the following new interventions that could have helped prevent the fall a. Apply a gait belt b. Use a wheelchair for her transfer c. Use two assist for Resident #88 in the evening d. Receive a full report at shift change, not just a sheet with the residents listed e. Better training needed The Fall Investigation for CNA's dated 3/19/21 signed by an unidentified staff documented that they suggested new interventions as the following a. Apply a gait belt b. Use a wheelchair for her transfer c. Use two assist for Resident #88 in the evenings or after naps. d. A full report at shift change, instead of receiving a piece of paper with highlighted assistance level. The History & Physical Final Report signed 3/20/21 at 5:07 PM, indicated Resident #88 presented to the emergency room (ER) from a local nursing home with a chief complaint of hip pain. Resident #88 went to the hospital the day before after a mechanical fall while at the nursing home. Resident #88 presented that day with a right elbow laceration, while there she didn't complain of hip pain. On 3/20/21 in the morning, Resident #88 complained of pain at the nursing home to her right hip. Resident #88 returned to the ER, where X-rays performed revealed a right intertrochanteric (three to four inches from the hip joint) fracture. Resident #88's got placed in medical inpatient status with the anticipated length of stay of three days. The Care Plan Focus revised 4/16/21 documented that Resident #88 as at risk for falls due to a balance problem. Resident #88 used a four wheeled walker with an assist of one and her abilities fluctuate. The intervention dated 3/25/21 directed staff when transferring Resident #88 to use a gait belt. On 7/5/22 at 3:20 PM Licensed Practicing Nurse (LPN) Staff I remembered that Resident #88 had a couple of falls. She thought that the fall on 3/19/21 was when she lost her balance when she was being ambulated to the restroom and went to the floor. She said that the CNAs' called her to the room and completed an assessment and there was a skin tear. She did not remember if the resident was in pain. She knew that the CNA did not use the gait belt for this transfer. She said that they are educated about the importance of using a gait belt but she acknowledged that not all of the staff use them all of the time. The resident was on the floor in front of her wheelchair and bathroom. On 7/5/22 at 12:32 PM Staff L said that he didn't remember much about Resident #88's fall because it happened a long time ago. Staff L said that he got taught in school to use a gait belt. Staff L explained that he had orientation at the facility where they showed him where things were and how to use the equipment. Staff L refused further questioning. On 7/5/22 at 12:42 AM Staff M, CNA, remembered Resident #88's fall in March of 2021. Resident #88 laid on the floor for a while before the nurse got summoned to the room. Staff M said that several CNA's discussed what to say and how to word the incident. Staff M reported that Resident #88 cried and moaned with her legs twisted under her. She sat halfway up tilted toward the wall with her legs under her. Staff M said that many of the staff did not use a gait belts for transfers. Staff M declared that other falls happened when staff didn't use a gait belt but she couldn't remember the residents' names. On 7/7/22 at 10:20 AM, the Director of Nursing (DON) said that she expected everyone to use a gait belt whenever assisting a resident with ambulation and transfers. She said that she'd known some of the staff didn't always use a gait belt but not recently. When asked if she had knowledge of a fall happening because staff didn't use a gait belt, she responded that she only knew of Resident #88 and that happened with an agency staff member. The DON said that she notified the agency that he did not use safety precautions. She explained that agency staff got orientation before they could work independently on the floor. The Agency Orientation Checklist - C.N.A. dated and signed on 3/21/21 (2 days after Resident #88's fall) by Staff L and Staff I, Licensed Practical Nurse (LPN). The checklist included a section about gait belts that indicated that any assisted ambulation/transfer of residents required the use of a gait belt.