Every finding on record at Crestview Specialty Care

Based on observation, staff interviews, clinical record review, and facility policy review, the facility failed to follow physician's orders for the treatment of a known facility acquired pressure ulcer and implement interventions to prevent a new pressure ulcer from developing for 1 of 2 resident (Resident #14) reviewed for pressure ulcers. Resident #14 admitted to the facility on Oct. 27, 2025, without pressure ulcers, and dependent on two staff assistance for bed mobility, transferring, and toileting assistance. Resident #14 assessed as at risk of the development of pressure ulcers. On Nov. 12, 2025, Resident #14 identified with a Stage 3 pressure ulcer on her sacrum. On Nov. 13, 2025, the primary care provider issued orders for wound treatments, an air mattress, and repositioning every 2 hours. During an observation on Nov. 19, 2025 at 8:45 AM, Resident #14 found to be without a dressing on the pressure ulcer, infection control techniques not utilized during wound care, physician orders not followed and the air mattress intervention not implemented. During a continual observation on Nov. 19, 2025 started at 1:26 PM until 4:20 PM, Resident #14 sat in a wheelchair, without reposition or toileting assistance. During an observation on Nov. 25, 2025 at 3:18 PM, Resident #14 found to be without a dressing on the pressure ulcer, a new open area on the coccyx, and the air mattress intervention not implemented. On Nov. 26, 2025, the primary care provider documented a new unstageable pressure wound overlying medial sacrum with yellow slough (sticky, non-viable) tissue. The facility reported a census of 58 residents. Pressure Staging:Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below).Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI.Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges),undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur.The State Agency informed the facility of the Immediate Jeopardy (IJ) on Dec. 01, 2025 at 11:30 AM. The IJ began on Nov. 12, 2025. Facility staff removed the immediate Jeopardy on Dec. 02, 2025 at 3:33 PM by implementing the following actions:1. Resident #14's new pressure ulcer assessed by provider on Nov. 25, 2025, provider reassessed wounds and treatment orders on Dec. 01, 2025. An air mattress was ordered on 11/25/25 and placed on Resident #14's bed on 11/26/25. Registered Dietitian reviewed Resident #14 and made dietary recommendations on 12/01/25.2. All nursing staff educated with verbal read back of education completed on Dec. 02, 2025, with training on the following: physician orders, pressure ulcer and pressure injury prevention, reporting, repositioning, and treatment. 3. An audit of all resident's skin completed on Dec. 01, 2025, to identify any further unknown skin alterations.4. A review of Braden scoring (assessment to determine residents at risk for skin breakdown) reports to identify other residents at high risk for skin breakdown, with care plans reviewed and updated as necessary.5. The Director of Nursing (DON) or designee responsible to review clinical alerts, review residents at risk for breakdown, monitor treatment orders and monitor skin/wound evaluations during morning clinical meetings.6. The DON or designee identified as responsible to complete ongoing audits of new orders and skin alterations Monday through Friday to ensure timely implementation of treatments and devices, on a weekly basis for 3 weeks, and then on a monthly basis for 2 months. The facility Administrator identified as responsible to monitor for compliance of plan with monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months. The scope was lowered from J to G at the time of the survey. Findings include:Review of Resident #14's Minimum Data Set (MDS) admission assessment, dated Nov. 02, 2025, revealed Resident #14 admitted to the facility on Oct. 27, 2025. Resident #14's Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicated a severe cognitive impairment. The list of diagnoses included Alzheimer's disease, left femur fracture, and malnutrition. The MDS indicated Resident #14 had an indwelling urinary catheter and was always incontinent of bowel. Resident #14 identified as dependent on staff assistance for all transfers, bed mobility, dressing, and toilet hygiene cares. The MDS documented Resident #14 was at risk for the development of pressure ulcers but had no unhealed pressure ulcers/injuries and no identified wounds or skin impairments at the time of admission.Review of the Care Plan, date initiated Oct. 28, 2025, revealed a Focus area to address Resident #14 at risk for pressure ulcers, with the goal that Resident #14 would remain free of skin breakdown. Interventions included, in part:a. Encourage me to weight shift while sitting up in chair. Date initiated: 10/28/25.b. Encourage my good nutritional intake. Date initiated: 10/28/25. c. I need a full skin evaluation weekly with baths or showers. Date initiated: 10/28/25.The Care Plan did not address the Stage 3 pressure ulcer to sacrum identified on 11/12/25.Review of a Braden scale evaluation performed on Oct. 30, 2025 at 8:39 PM, revealed a score of 16, indicating Resident #14 was at risk for pressure ulcer development. The Braden scale revealed the following assessment findings: a. Sensory perception: No impairments. b. Moisture: Skin is occasionally exposed to moisture. c. Activity: Resident #14 is chairfast (cannot bear their own weight and/or must be assisted into a chair or wheelchair).d. Mobility: Very limited, makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. e. Nutrition: Adequate.f. Friction and shear: Potential problem (during a move skin probably slides to some extent against sheets, chair, or other devices and maintains relatively good position in bed or chair but occasionally slides down).Review of a Braden scale evaluation, performed on Nov. 6, 2025 at 3:34 PM, revealed an unchanged score of 16. Review of the electronic health record (EHR) Nursing note, entered on Nov. 12, 2025 at 9:12 AM, revealed a new, in-house acquired, pressure ulcer identified on 11/12/25 to Resident #14's buttocks, measuring 2.95 centimeters (cm) in length by 1.7cm width. Signs and symptoms of wound infection included increased purulent (pus like) drainage, increased smell, and continuous pain.Review of the EHR Progress Note for Acute/Follow up Progress Note, dated Nov. 13, 2025, revealed, in part.Chief Complaint/Nature of Presenting Problem: SNF (skilled nursing facility) follow up, evaluate sacral wound. Wound #1 sacral; Managing Wound Provider [provider clinic name redacted] Date identified: 11/12/25; Location: Buttocks; Type of wound: Pressure; Stage: III (3); Measurement/Size: 2.95 cm in length by 1.7 cm width; Undermining/Tunneling: No; Drainage/Exudate: No; Odor: No; Tissue/Wound Bed: Slough 80%, Granulation 20%; Periwound: Erthematous; Progress: Initial evaluation; NP visualized: Yes. The Plan: Pressure injury of buttock: stage 3:a. New pressure injury to coccyx: stage 3b. Turn resident every 2 hours, while in bed, air mattressc. Cleanse wound with wound cleanser, apply no-sting barrier film. Fill with calcium alginate and cover with foam adhesive dressing. Change dressing weekly and as needed if soiled. d. Monitor wound progression weekly. Review of the EHR Skin Issues note, dated Nov. 16, 2025 at 9:24 PM, revealed Skin issue #001: Skin issue has been evaluated. Location: Buttocks - generalized. Issue type: Pressure ulcer/injury. Progress: Improving: overall wound characteristics improved. Wound acquired in-in house. Staged by: In-house nursing. Length (cm): 3.54 Width (cm): 3.84 Depth (cm): 0 Area(cm2): 11.72 Undermining: No. Tunneling: No.During an observation on Nov. 19, 2025 at 8:45 AM, Staff G, Registered Nurse (RN) entered Resident #14's room to complete wound care and dressing change for the pressure ulcer on sacrum. Resident #14 found to be lying in bed, without an air mattress. Resident #14 found with no dressing covering the sacral wound or found in the bedding; and a small amount of stool on her buttocks. The wound on the right buttock appeared to have fresh, red blood and draining present. The skin directly around the wound appeared to be red in color. Staff G commented that the wound may be bleeding due a lack of wound dressing in place. Staff G applied a pair of gloves, sprayed the wound with wound cleanser and patted it dry with gauze. Staff G then, without a change of gloves or hand hygiene, sprayed the open wound with a no-sting barrier film and placed a padded adhesive dressing over top of the wound. The calcium alginate treatment omitted from the wound care treatment. During an observation on Nov. 19, 2025 at 9:20 AM, Resident #14 left the facility for an appointment, sitting in a wheelchair. Resident #14 returned to the facility in the wheelchair 1:26 PM. During a continual observation on Nov. 19, 2025 from 1:26 PM until 4:20 PM Resident #14 remained in the wheelchair without staff offering or attempting Resident #14 with repositioning or toileting. Review of the EHR encounter note for Acute/Follow up Progress Note, dated Nov. 20, 2025 revealed in part.Chief Complaint/Nature of Presenting Problem: SNF (Skilled Nursing Facility) follow up, follow up-sacral wound, urology follow up .Wound Managing Wound Provider: [company name redacted]; Date Identified: 11/12/2025; Location: Buttocks; Type of wound: Pressure, Moisture; Stage: III (Stage 3); Undermining: No; Drainage/Exudate: No; Odor: Yes; Periwound: Erythematous, Macerated, Satellite lesion; NP Visualized: Yes.Plan:.Pressure injury of buttock, stage 3:a. Areas concerning pressure/friction is improving; appears to be a yeast/moisture componentb. Turn every 2 hours while in bed, air mattressc. DC (discontinue) alginated. Cleanse skin with no rinse skin cleanser, apply no sting barrier film BID. Cover with foam mepilex to protect the skine. Monitor wound progression weeklyReview of the EHR Administration Note, dated Nov. 23, 2025 at 7:02 AM, revealed Air mattress every shift for comfort pressure area on order.During an interview on Nov. 24, 2025 at 9:35 AM, Staff L, Certified Nursing Assistant (CNA), stated that Resident #14 was frequently incontinent of stool and dependent on staff for toilet hygiene tasks. Staff L unaware of any skin impairments or open areas to Resident #14's buttocks. During an observation on Nov. 25, 2025 at 3:18 PM, Resident #14 found to be laying supine (positioned on the back) in bed and pants were left pulled down around the resident's ankles. The sacral pressure wound lacked a foam adhesive wound dressing, and an open area was observed to coccyx. Resident #14's bed without an air mattress.During an interview on Nov. 25, 2025 at 3:20 PM, Staff A, Licensed Practical Nurse (LPN) and charge nurse for the hallway which Resident #14 resided stated she was behind on treatments all day and had not yet completed any wound care or dressing change for Resident #14. During an interview on Nov. 25, 2025 at 3:45 PM, the Director of Nursing stated Resident #14's sacral pressure ulcer treatment orders were to apply no sting barrier twice a day and cover the wound with a foam adhesive dressing and identified interventions to include repositioning Resident #14 in bed every 2 hours, cushion in wheelchair, and pressure reducing mattress on bed. The DON stated he was unaware if an air mattress for the bed was on order but would look into it. The DON reported that Resident #14 could make slight adjustments in her position and required two staff assistance to transfer from bed to chair. During an observation on Nov. 25, 2025 at 3:50 PM, the DON entered Resident #14's room, Resident #14 remained laying supine in bed and pants down around the resident's ankles. The DON assisted Resident #14 with incontinence cares to address incontinent stool on the resident's buttocks. Resident #14 stated it's bad and ouch during incontinent cares. The DON stated the sacral wound lacked a foam adhesive dressing. The DON stated Resident #14 had a new open area on the coccyx, and he would notify the providerReview of the EHR revealed a Skin Issues note, dated Nov. 25, 2025 at 3:50 PM, Skin Issues : Skin Issue: #001: Skin issue has been evaluated. Location: Buttocks - generalized. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: Yes. Wound pain (Frequency): Intermittent. Wound pain interventions: Distraction techniques. Wound pain interventions: Change in position. Relief from interventions: Yes. Staged by: In-house nursing. Length (cm): 8.53 Width (cm): 10.95 Depth (cm): 0.2 Area (cm2): 58.63 Undermining: No. Tunneling: No. Slough: 100%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: None. Periwound: Attached. Surrounding tissue: Intact. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Missing. Cleansing solution: Generic wound cleanser. Debridement: Autolytic. Primary dressing: Foam. Primary dressing: Film/Membrane. Secondary dressing: No secondary dressing applied. Modalities: None.Review of the EHR revealed, in part, an encounter note for Acute/Follow up Progress Note, dated Nov. 26, 2025.Chief Complaint/Nature of Presenting Problem: F/U skilled; Pressure Wound, UTI, urinary retention, delirium.Wound #1 Sacral pressure ulcer; Managing Wound Provider; [name of provider redacted]; Date identified: 11/25/25; Location: Medial sacrum; Type of wound: Pressure; Stage: Unstageable; Undermining/Tunneling: No; Drainage/Exudate: Serious; Odor: No; Tissue/Wound Bed: Slough %: 100; Edges: Attached, Well-defined; Periwound: Erythematous, with scratch marks, Dry; Progress: Initial evaluation; NP Visualized? Yes.Plan .New medical sacral pressure ulcer with bed obscured by yellow slough. Pt appears to be scratching herself in surrounding areas.a. Start triad to wound and surrounding areas BID (twice daily) and PRN (as needed) after episodes of incontinence.b. Recommend ROHO (brand name for an air-filled cushion used to redistribute pressure) cushion to w/c (wheelchair) at all times. During an interview on Dec. 01, 2025 at 10:47 AM, the provider stated Resident #14's pressure ulcer resulted from a mix of moisture and pressure, and expected that the pressure ulcer may worsen if treatment orders were not followed. Review of the facility policy titled, Wound Care, dated October 2010, revealed a Purpose statement which declared The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Section A. Preparation directed, in part: a. Verify that there is a physician's order for this procedure.b. Review the resident's care plan to assess for any special needs of the resident. For example, the resident may have PRN orders for pain medication to be administered prior to wound care.Section C. Steps in the procedure, listed: a. Apply treatments as indicated.Section E. Reporting directed, in part: a. Notify the supervisor if the resident refuses the wound care.b. Report other information in accordance with facility policy and professional standards of practice.

Based on staff interviews, clinical record review, and facility policy review, the facility failed to assess and follow physician treatment orders for non-pressure wound care for 2 of 3 residents (Resident #29 and Resident #2) reviewed for assessment and intervention. The facility reported a census of 58 residents. Findings include: 1. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #29 admitted to the facility on Nov. 11, 2025. Resident #29 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The list of diagnoses included peripheral vascular disease (a circulation disorder affecting blood vessels outside of the heart, can slow healing), traumatic compartment syndrome (swelling caused by an injury that can cause severe disproportionate pain) of the left lower extremity, diabetes mellitus type 2, and atrial fibrillation. The MDS indicated Resident #29 required substantial to maximal amount of staff assistance with lower body dressing, putting on/taking off footwear, bed mobility, and all transfers. The MDS documented that Resident #29 had no venous or arterial ulcers at the time of the assessment. Review of the Care Plan, initiated on 11/11/25 revealed a Focus area for Resident #29 having impairment to skin- bilateral skin area to heels with the goal that Resident #29 would have no complications related to skin impairment. Interventions included, in part: a. Educate me, my family, and caregivers of causative factors and measures to prevent skin injury. Date initiated 11/11/25. b. Provide Enhanced Barrier Precautions (EBP). Date initiated: 11/11/25. c. Monitor for and document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to the physician. Date initiated: 11/11/25. d. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes or observations. Date initiated: 11/11/25. Review of an admission evaluation, dated 11/11/25, revealed that Resident #29 had a non-pressure wound, and listed a vascular wound to the right heel and a vascular wound to the left heel. The evaluation lacked documentation of wound measurements or assessments related to appearance and healing. Review of the November 2025 Treatment Administration Record (TAR), revealed an order for bilateral heel wound care, started on 11/13/25, which instructed wounds to be cleansed with saline or soap and water, apply treatment of Medihoney sheet to the base of the wound, cover wounds with a padded dressing and wrap with gauze bandage. The wound care was ordered to be completed one time a day every Monday and Thursday. The TAR identified the following documentation: a. On 11/13/25 – no documentation present to indicate scheduled care completed. b. On 11/17/25 - Staff A, Licensed Practical Nurse (LPN) documented resident refusal c. On 11/20/25 – no documentation present to indicate scheduled care completed. Review of an electronic health record (EHR) encounter note, dated 11/13/25 revealed, in part: Chief Complaint/Nature of Presenting Problem: Skilled admission.She [Resident #29] endorses severe bilateral lower extremity pain making it very difficult for her to stand .Dressing intact to wound to BLE. Wound care is done twice weekly; reports severe pain with wound care. Will assess wounds further with dressing change Monday. Review of the EHR between 11/11/25 and 11/19/25 revealed no documentation to indicate wound assessments or treatments completed. The EHR lacked documentation to indicate provider notified of resident refusal to wound care on 11/17/25. Review of clinic notes from an Vascular Surgery appointment on 11/19/25 revealed, in part: HPI (History and Physical Information).Wounds noted on posterior aspect of bilateral ankle extending to lateral malleolus (bony knob on side of ankle) Associated with yellowish discharge on right lower extremity.Last dressing change was 9-days ago. The patient is unable to get dressing changes at subacute rehabilitation due to staffing issue. Scheduled for wound care appointment on 11/21/25.Assessment/Plan: Plan for right lower extremity angiogram with possible galloon angioplasty, follow up with wound care on 11/21/25, Regular care dressing at SNF (skilled nurse facility), ABX (antibiotic).Staff Physician Comments:. I met the patient for the first time on 11/19/2025. This is a 79 y.o. (year old) female who presents to clinic as a new patient for management of bilateral PVD R>L (peripheral vascular disease right greater than left). She is accompanied by her son and currently resides in [name of facility redacted] nursing facility. She was initially diagnosed with PVD in July 2025 when CTA (Computed Tomography Angiography – specialized imaging that uses X -ray and dye to create detailed pictures of blood vessels used for diagnoses) showed tibial (area on lower leg from knee to ankle) disease bilaterally. Today, she presents with a lateral right foot wound with evidence of surrounding erythema.She has unfortunately not had the best wound care at her nursing facility if any at all so we have provided recommendations (BID Vashe dressing changes) and also prescribed doxycycline (an antibiotic). Review of the After Visit Summary for the 11/19/25 Vascular Surgery appointment revealed the following Today's medication changes: a. Start taking doxycycline hyclate (antibiotic) for Open wound to right foot – 100 mg (milligram) capsule, 1 capsule by mouth 2 times daily for 10 days. b. Start taking sodium chloride-hypochlorous acid (VASHE, name brand of a wound wash) for Open wound of right foot – 0.033% topical solution, Apply 1 application topically 2 times daily. During an interview on 12/1/25 at 12:20 PM, Staff G, Registered Nurse (RN) stated that Resident #29's family may have been upset about wound treatments not getting done on her heels. Staff G confirmed that Resident #29 had admitted with wounds to bilateral ankles but had not personally assessed or provided wound cares/treatment as ordered to wounds. Staff G stated she was unable to get Resident #29's dressings done when scheduled to complete, but would ask the following shift to complete. During an interview on 12/2/25 at 10:45 AM, facility's Social Services Worker (SSW), stated that when speaking to Resident #29 after the Vascular Surgery appointment on 11/19/25, Resident #29 told SSW that the physician unwrapped her wound dressings, the wound was infected, and that the physician was upset that dressing change was not completed and family present at the appointment had started crying. During an interview on 12/3/25 at 1:25 PM, Staff A, Licensed Practical Nurse (LPN) denied having personally assessed or performed wound treatments on Resident #29 but had documented on 11/17/25 that Resident #29 had refused wound cares, when Resident #29 shook her head no and stated no as Staff A entered her room. Staff A denied notification sent to the provider about wound treatment refusal. During an interview on 12/3/25 at 4:30 PM, the Director of Nursing (DON) revealed an expectation of staff to assess resident wounds and perform wound care and dressing changes as ordered. 2. Review of the MDS Assessment for Resident #2 dated 11/21/25, revealed a BIMS score of 11 out of 15, which indicated a moderate cognitive impairment. Diagnosis included esophageal obstruction, dysphagia, heart failure and chronic kidney disease. The MDS indicated Resident #2 dependent on staff to meet all of her needs due to cognitive deficits and physical limitations. The MDS documented that Resident #2 had a skin tear which required applications of ointments/medications. Review of the Care Plan, initiated on 4/17/25 and revised on 11/14/25, revealed a Focus area for Resident #2 of high risk for pressure ulcers to skin related to immobility, incontinence and end of life condition -skin tear left leg. Resident #2 would remain free from infection. Interventions included, in part: a. I need a full skin evaluation weekly with bath/shower. Date initiated 6/3//25. b. I need assistance with repositioning to avoid skin friction/shearing. Date initiated: 6/3//25. c. Monitor for changes in my skin status that may indicate worsening of my pressure ulcer and notify the physician. Date initiated: 7/22/25. Review of Skin and Wound Sheets revealed: a. On 11/13/25 – a left lateral calf skin tear with an onset date of 11/13/25, In-house acquired. Length 7.4 cm (centimeters); Width 4.23 cm; Depth 0.0 cm b. On 11/20/25 - skin tear length and width and noted to be stable. Length 5.36 cm; Width 2.7 cm; Depth 0.0 cm Review of the November 2025 Treatment Administration Record (TAR), revealed the following orders: a. Start Date 11/14/25, discontinued date 11/30/25 to cleanse wound on left lateral calf with wound cleanser, apply no sting barrier cover with high performance foam and non-adhesive dressing, securing with roll gauze and wound tape until healed. Change every 5 days and PRN. Review of the TAR revealed the treatment completed on 11/14/25, 11/24/25, and 11/29/25, with no documentation to indicate the 11/19/25 scheduled treatment completed. b. Start date 11/30/25 to cleanse wound on left lateral calf with wound cleanser, apply no sting barrier cover with high performance foam and non-adhesive dressing, securing with roll gauze and wound tape until healed. Change every 5 days and PRN as needed or if soiled, macerated or needing changed. Review of the TAR revealed no documentation on 11/30/25 to indicate the scheduled treatment completed. During an observation on 11/20/25 at 1:16 PM, Resident #2 assisted by Staff I, Certified Nursing Assistant (CNA), and Staff J, CNA with a full body mechanical lift for a transfer from her wheelchair to bed. After Resident #2 positioned into bed the CNA's assisted with changing the resident's incontinence brief. Upon removal of her pants, the wound on the residents left calf noted to be covered with a gauze dressing, which slipped off the wound area. The CNA's pulled the gauze back over the wound and proceeded to reposition the resident. During an observation on 12/2/25 at 4:40 PM, Staff M, LPN and the Traveling Director of Nursing (DON) donned gloves and gown to complete wound care. Staff M removed the dressing from the wound and stated the removed dressing was not correct per the physician order. Staff M explained a foam dressing should have been applied. Staff M proceeded to complete wound care per physician orders. During an interview on 12/2/25 at 5:00 PM, the facility DON queried wound care and stated he would expect all staff to follow Enhanced Barrier Precautions (EBP), follow the medical order and date and initial the dressing change. Review of the facility policy titled, Wound Care, dated October 2010, revealed a Purpose statement which declared: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Section A. Preparation directed, in part: a. Verify that there is a physician's order for this procedure. b. Review the resident's care plan to assess for any special needs of the resident. For example, the resident may have PRN orders for pain medication to be administered prior to wound care. Section C, Steps in the Procedure directed, in part: a. Apply treatments as indicated. Section E, Reporting directed, in part: a. Notify the supervisor if the resident refuses the wound care. b. Report other information in accordance with facility policy and professional standards of practice.

Based on observations, staff interviews, clinical record review and facility policy review, the facility failed to use safe transfer techniques to prevent falls or injury for 3 of 4 residents (Resident #3, Resident #7, and Resident #50) reviewed for transfer techniques. Resident #3 experienced a fall out of a mechanical lift on 7/25/25, which resulted in a hematoma, sacral fracture and tibia fracture. The facility further failed to complete neurological assessments and check for range of motion of extremities, following a fall for 2 of 4 residents (Resident #7 and Resident #15) reviewed for accidents and hazards. The facility reported a census of 58 residents. Findings include:1. Reviewed the Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had severely impaired skills for daily decision making, with problems in both short-term memory and long-term memory. The list of diagnoses included Alzheimer's disease, bipolar disease, hip fracture, and other fracture. The MDS indicated Resident #3 dependent on staff for all care tasks, mobility, and transfers. The MDS identified that Resident #3 had one fall with major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) since the previous assessment. Review of the Care Plan, initiated on 4/4/24, revealed a Focus area for Resident #3 at risk of falls related to decreased mobility with the goal that Resident #3 would not experience any major injuries related to falls. Interventions included, in part: a. Encourage me to sit in the common area while up in wheelchair. Date initiated: 5/07/2024. b. Encourage me to use my call light for assistance and ensure it is within reach. Date initiated: 4/04/2024. c. I have a soft touch call light. Date initiated: 6/26/2024. d. Utilize a winged mattress. Date initiated: 3/28/2025. Review of a Nurses Note, dated 7/25/25 at 7:25 PM, revealed Resident #3 transferred to her bed around 7:00 PM via full body mechanical lift and during the transfer, resident fell out of the lift landing on her knees and hitting her head. The note described that Resident #3 fell to her stomach, face down received a hematoma to the left side of her head and a laceration to her left upper facial area. Resident #3 unable to provide description of incident due to cognitive impairment and was sent out to the hospital by Staff M, Licensed Practical Nurse (LPN). Review of Nurses Note, dated 7/25/25 at 9:21 PM, revealed that the writer, Staff M, LPN heard a yell for help and ran to Resident #3's room right away, upon arrival Resident #3 found lying on the floor face down with the mechanical lift left leg underneath the resident. The note described the mechanical lift to be raised in the air with the sling still attached. The provider and resident's responsible party notified of incident and Resident #3 sent to the Emergency Department (ED) via ambulance. Review of a Nurses Note, dated 7/26/25 at 2:40 AM, revealed Resident #3 returned from the hospital on 7/26/25 at 12:45 AM via ambulance. Resident has a sacrum fracture and tibial plateau (top of shin bone at the knee joint) fracture. Resident also has new orders for hydrocodone/acetaminophen (opioid pain medication) 5/325 mg (milligram) po (by mouth) every 8 hrs (hours) PRN (as needed for pain) and naloxone 4 mg 1 spray in each nostril, 98.7 (temperature), 88 (heart rate), 18 (respirations), 128/66 (blood pressure), 97% (oxygen saturation) on 4 liters oxygen. Per Nurses Note, dated 7/26/25 at 7:21 PM, Called to Resident's room to assess Resident by son at bedside, Resident sweating with damp hair and flushed face. Covers pulled back and reposition for proper alignment of torso and legs. Resident states in pain. Given pm meds with pain pill at this time. Will reassess in 10 minutes and with improvement of pain level will reposition on side and ADL (activities of daily living)/pm care will be rendered. Per Nurses Note, dated 7/26/25 at 7:31 PM, Call to on call provider to give change in condition to Resident. Call dropped. Per Nurses Note, dated 7/26/25 at 7:49 PM, Returned to room as Resident has thrown up projectile vomitus on self and foot of bed. VS (vital signs) taken BP 182/84, HR 135, O2 Sat at 86, R 14 shallow. While Resident being cleaned Call again to NP (nurse practitioner) and order received to send emergently to ER. Orders carried out. Per Nurses Note, dated 7/26/25 at 7:55 PM, 911 called for Resident transfer to ER Per Nurses Note, dated 7/26/25 at 8:05 PM, Fire department EMS (emergency medical services) here and Resident now has projectile vomits 3 more times, before transfer to stretcher and on to [name of hospital redacted] via 911 transport. Per Nursing Note, dated 7/27/25 at 10:28 AM, Received call from [name of hospital redacted} ER physician. Physician states that imaging suggests that resident may have inadvertently swallowed the crown of a tooth that may have episodes of vomiting last night. Resident remains at [name of hospital redacted] main campus. Review of a hospital Internal Medicine History and Physical note, dated 7/27/25, revealed in part: Chief Complaint: Hypoxia, Altered Mental Status. History of Present Illness:.Patient was seen in ED on 7/24/25 after she was dropped from a mechanical lift and sustained multiple sacral fractures, but was sent home [back to facility] later that day. Per the emergency department, the patient was noted to be less interactive by staff at nursing home during the day on 7/26/25.It is worth noting that there was radiopaque object seen in the stomach on her chest x-ray from 7/26, and a head CT (Computed Tomography, a type of imaging done for detailed body pictures) done on the same day showed a missing premolar implant.Imaging CT Head 7/26/25.No acute intracranial findings; Interval missing second mandibular premolar implant/crown with incompletely visualized mandible. Correlate for traumatic displacement given radiodense object in the stomach on the same day CXR (x ray image); Interval decreased left frontal scalp hematoma/contusion. Review of Nurses Note, dated 7/27/25 at 4:03 PM, revealed Resident returned from visit to [name of hospital redacted] emergency room. Currently has O2 (oxygen) at 2 LPM (liters per minute) with 93% O2 saturation. Transported from [hospital name redacted] main campus by care ambulance via stretcher with 2 attendants. Received orders as follows: Discontinue arginine, atorvastatin, famotidine, folic acid, multivitamin with mineral and naloxone, son [name reacted] aware of all orders. Review of an incident report, dated 7/25/25 at 7:00 PM revealed that Resident #3 was being transferred to her bed around 7:00 PM via mechanical lift and during transfer had fallen out of the lift sling, landing on her knees and hitting her head. Resident #3 noted to fall down to stomach, found face down, and received a hematoma to the left side of her head and a laceration to her left upper facial area. Immediate action was to call emergency services and send Resident #3 to the hospital. During an interview on 12/01/25 at 9:00 AM, Staff N, Certified Nursing Assistant (CNA), confirmed she assisted Resident #3 with mechanical lift transfer on 7/25/25 after evening meal. Staff N explained that she hooked up Resident #3 to the lift cradle style which was described as leg straps being underneath Resident #3 in a U shape instead of crossing the leg straps between the legs in an X shape. Staff N reported that the left side leg strap was looped underneath both legs and the right leg strap was looped underneath both legs. Staff N stated that the full body slings were usually crossed between the legs, but was under the impression that the sling could be hooked up in a cradle style if the resident had stiff legs or contractions. Staff N reported that another CNA was in the room assisting Resident #3's roommate and Staff N started operating the mechanical lift while the other CNA finished assisting roommate in their bed. Staff N stated that Resident #3 fell out of lift soon after raising lift above the level of wheelchair. Staff N recalled that Resident #3 had been in a sitting position, with head slightly elevated in the sling when the mechanical lift was raised and resident's bottom half came out from sling. Staff N stated that Resident #3 fell out of sling feet first landing on her knees and bumped her head on the floor. Staff N reported that Resident #3 was turned a little bit while on the floor and was noted to have a large bruise on head and resident had complained of pain her knees and hip. Staff N recalled then yelling for other CNA in room to go get the nurse as she stayed with resident. Staff N stated following the incident she was asked to write a statement and was suspended for approximately 4 days, then received education about transferring with the lifts. Staff N informed that she was told by facility leadership that the sling was not hooked up wrong, according to manufacturer guidelines, but didn't end up being safe. During an interview on 12/02/25 at 10:00 AM, Staff M, Licensed Practical Nurse (LPN) confirmed working as charge nurse on the evening of 7/25/25 and was notified by a CNA that Resident #3 had fallen. Staff M recalled being confused on how Resident #3 could have fallen due to being a full body mechanical lift. Staff M stated she ran to Resident #3's room and observed resident lying on top of the mechanical lift legs with sling still completely attached to the lift and the lift raised up to highest level. Staff M stated that she asked CNA staff not to move Resident #3 as she went out to call Emergency Services and upon returning to Resident #3's room, found resident to have been moved/turned. Staff M reported that when asking CNA staff what had happened, she was told that Staff N operated the lift by herself while the second CNA in the room's back was turned assisting roommate. Staff M stated that the sling was not attached to the lift correctly, as it was in a cradle position, in which the leg straps were straight and should have been [NAME]-crossed between the resident's legs. During an interview on 12/03/25 at 4:30 PM, Director of Nursing (DON) stated he expected that all mechanical lift transfers have two staff present for safety. The DON revealed that incident was not reported to State Agency due to Resident #3 remaining at baseline for cognition, mobility, and pain. Review of a Disciplinary Action form, signed by Supervisor and Staff N, CNA dated July 29, 2025, revealed that Staff N, CNA, disciplined for the violation of facility mechanical lift policy due to the fall that occurred on 7/25/25 when transferring Resident #3. Review of a Disciplinary Action form, signed by Supervisor and Staff P, CNA, dated July 30, 2025, revealed that Staff P disciplined for the violation of facility mechanical lift policy due to the fall that occurred on 7/25/25 when transferring Resident #3. Review of the Operator's Instructions for EZ Way Smart Lift (brand name of mechanical lift), revised on June 14, 2023, provided transferring instructions from chair, listed on pages 8 and 9, which directed, in part: The Section F. Transferring patient from chair, wheelchair, or toilet, instructed: Step 1 - Position Sling: a. Lean the patient forward several inches to place the sling behind the patient. b. With the sling handles and washing labels facing the chair back, place the sling behind the patient, keeping the center handle of the sling centered on the patient's spine. Make sure the base of the sling touches the chair seat and is two inches below the tailbone. Make sure the top of the sling is above the patient's shoulders and lean the patient back in the chair. c. Pull the legs of the sling along inside of the chair. d. To set the sling properly, you must do the following: On the patient's right side, position your right hand between the patient's hip and the sling. With your fingers, push down on the edge of the sling so it touches the base of the chair seat. Next, grasp the bottom edge of sling leg with your left hand and pull with a tug towards you. e. Lift the patient's left knee with a tug, ull the leg of the sling under the hip and thigh. Place the excess sling length over the left thigh. f. Repeat this procedure on the right side. This procedure will ensure the sling is under the patient's tail bone and behind his/her back, with the patient's weight evenly distributed on the sling. Step 3 - Attach sling to the lift: a. Take the sling leg that is lying over the patient's left thigh and attach it to the right hook on the hanger bar. b. Take the sling leg lying over the right thigh and attach it to the left hook on the hanger bar, again using the same length and color of loop strap on each side. c. Attach the straps located near the patient's shoulders to the lift hanger bar hooks, using the same length and color of loop strap on each side. Example: If you choose the shortest loop on the strap for the right shoulder, you must use the shortest loop on the strop for the left shoulder. Step 4 - Lifting the patient a. Push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, making sure all the loops on the sling are securely hooked on the hanger bars. b. Smooth the sling legs under the patient's thighs with a slight pull on the outside seam of the sling legs, if necessary. c. Lift the patient to the desired height (usually 2-3 inches above the chair) Step 5 - Transferring the patient a. Ensure there are no obstruction in the path of travel. b. Pull or push the lift using the operator's handles on the lift mast. Maneuver the lift to a desired location. 2. Review of the MDS assessment, dated 9/29/25, revealed Resident #7 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment. The list of diagnoses included Alzheimer's disease, respiratory failure, hypertension, anxiety disorder, and other (unlisted) type of fracture. Review of the Care Plan, date revised on 9/04/25, revealed a Focused area for Resident #7's risk for falls related to decreased mobility and inability to bear weight to the left wrist, with the goal that Resident #7 would not sustain serious injury through the review date. Interventions included, in part: a. Sign added to walker to remind Resident #7 to use and call for help. Date initiated: 8/29/25. b. Encourage Resident #7 to wear grippy socks versus slick socks if she chooses to walk with no shoes on. Date initiated: 6/23/25. c. Ensure that Resident #7 is wearing appropriate footwear. Date initiated: 1/05/24. d. Non-skid strips applied beside the bed and chair. Date initiated: 3/11/25. e. Physical Therapy to evaluate and treat as ordered or as needed. Date initiated: 1/05/24. f. Utilize a soft touch call light. Date initiated: 3/11/25. Review of the Care Plan, date initiated 1/05/24, revealed a Focused area for activities of daily living which identified the following interventions, in part: a. Assistance of one staff for ambulation with hand hold, no walker at this time related to wrist fracture. Date revised: 9/03/25. b. One staff assistance to stand and pivot transfer between surfaces. Date revised: 9/03/25. c. Non weight bearing status to left upper extremity. Date initiated: 9/04/25. During an observation on 11/19/25 at 9:01 AM, Resident #7 began to stand from the dining room table, Staff R, CNA, noticed and approached Resident #7. Staff R pulled the dining room chair away from table as Resident #7 stood, no gait belt was applied to assist the resident with safety/stability prior to initiating ambulation assistance. Resident #7 fell onto her bottom and another staff member present in the dining room went to notify the nurse of the fall. At 9:05 AM, several staff members entered the dining room, which included the charge nurse for Resident #7, Staff G, RN. Staff brought in a wheelchair and gait belt to assist with getting Resident #7 up from the floor. Nursing staff completed a check of Resident #7's neurological status and vital signs, no Range of Motion (ROM) of extremities checked, to assess for pain or difficulty moving the upper or lower extremities before moving the resident. Three staff used a gait belt and assisted Resident #7 to a standing position, the fourth staff brought a wheelchair behind the resident to sit in, then transported the resident to her room via wheelchair. During an interview on 11/19/25 at 9:15 AM, Staff R, CNA stated when she pulled the dining room chair back, Resident #7 just went down and bumped her chin on the table. Staff R reported that Resident #7 stated she felt dizzy and complained of back pain post fall. When queried if either nurse assessed Resident #7's ROM before moving the resident, Staff R stated that nurses had felt the resident's arms and legs before assisting her off the floor. During an interview on 11/19/25 at 9:20 AM, Staff G, RN, stated she did not personally perform a check of Resident #7's ROM and was unsure if the other nurse present had checked Resident #7's ROM before assisting the resident up from the floor. Review of an incident report completed by Staff G, RN, dated 11/19/25 at 9:00 AM, documented that Staff G was notified of a fall in the dining room that occurred when a staff member was assisting Resident #7 to get up from the table and go back to her room. The incident report revealed that Resident #7 complained of being very dizzy, became weak, and was lowered to the floor. The report informed that Resident #7 complained of her back hurting, was dizzy, and did not feel well. Three staff assisted Resident #7 up from the floor using a gait belt and assisted her into a wheelchair, then transported the resident to her room. Staff G documented that Resident #7 was found to have a very low blood pressure and was assisted to lay in bed with feet elevated. Staff G documented that neurological assessments would be followed per guidelines and that provider was notified of the incident. Review of Resident #7's documented vital signs revealed that on 11/19/25 at 9:21 AM, the blood pressure reading was 60/35 and at 9:23 AM, the blood pressure reading was 76/43. Review of Resident #7's list of assessments, revealed a Neurological Evaluation (check of mental status/alertness, cranial nerves, motor skills, sensory perception, reflexes, coordination, and gait used for early detection of changes that may be related to a head injury) was initiated on 11/19/25. Review of the Neurological Assessment initiated on 11/19/25, revealed that an initial neurological assessment was completed and that the follow up assessments had been left incomplete. Review of a Skin Assessment, dated 11/21/25, revealed a new bruise to Resident #7's right chin that measured 1.68 centimeters (cm) length, by 1.81cm in width. During an interview on 11/20/25 at 11:00 AM, Staff S, CNA, reported that Resident #7 required one staff assistance using a walker and gait belt to transfer and ambulate. Staff S working on Resident #7's hallway was unaware of Resident #7 having any recent falls or incidents. During an interview on 11/20/25 at 11:35 AM, Staff G, RN, identified that the facility's fall protocol included assessing the resident for pain, injury, dizziness, ROM, and complete neurological checks if the resident hit their head. Staff G reported that Resident #7 required the assistance of one staff member to transfer using a gait belt due to losing balance at times and history of falling. Staff G stated that the follow up from Resident #7's fall on 11/19/25 included monitoring for dizziness, continuing to complete neurological assessments, and provider notification. Staff G confirmed that Resident #7 obtained a bruise on her chin during the fall on 11/19/25. During an interview on 12/02/25 at 4:30 PM, the DON revealed the expectation of nurses to check a resident's ROM prior to moving a resident post fall. The DON stated neurological assessments would be completed per protocol for unwitnessed falls and falls in which the resident hit their head. 3. Review of the MDS assessment, dated 10/03/25, revealed Resident #15 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. The list of diagnoses included Non-Alzheimer's dementia, schizophrenia, and congestive heart failure. Review of the Care Plan, initiated on 5/29/24 and revised on 11/26/25, revealed the Focus area: I am at risk for falls. I prefer to crawl on the floor for mobility at times as I am unsteady to walk. I do not wait for assistance for transfers or use call light. Interventions included, in part: a. Encourage me to use my call light for assistance. Date initiated: 5/29/24. b. I need a safe environment without clutter. Date initiated: 11/26/25. c. Offer resident toileting assistance before and after meals. Date initiated: 5/26/25. d. Reminder sign in bathroom to call for help. Date initiated: 9/15/25. e. Reminder sign in room to call for help with transfer. Date initiated: 9/22/25. Review of the Care Plan, initiated on 1/19/24, revealed a Focus area for Activities of Daily Living (ADLs) with the goal that Resident #15 would continue to participate during ADLs as condition allows. Intervention included, in part: a. Independent with wheelchair mobility. Date initiated: 1/19/24. b. One staff assistance with bed mobility. Date initiated: 1/19/24. c. One staff assistance with toileting. Date initiated: 1/19/24. d. One staff assistance with transfers using the walker. Date initiated: 1/19/24. e. One staff assistance with upper and lower body dressing. Date initiated: 1/19/24. Review of a nursing note, dated 11/15/25 at 5:19 AM, revealed Staff T, LPN, documented that Resident #15 was observed on the floor near his bed and wheelchair. The note informed that Resident #15 had been incontinent of urine, was noted to be gathering clothing and stated he didn't fall. The note revealed that Resident #15 denied pain, had full ROM per his baseline, refused check of vital signs, and Care Plan reflected that resident likes to crawl on the floor at times. Review of Resident #15's list of assessments performed, revealed that a Fall Risk Evaluation was completed on 11/26/25. The list of assessments revealed that a Neurological Evaluation was not initiated on 11/25/25. Review of a Fall Risk Evaluation, dated 11/26/25, documented a score of 14, which indicated that Resident #15 was at high risk for falls. The fall evaluation identified that Resident #15 had intermittent confusion, 3 or more falls in the past 3 months, was chair bound, had a change in medication within the previous 5 days, and had 3 or more predisposing diseases that put him at risk for falls. During an interview on 12/03/25 at 3:00 PM, Staff T, LPN, confirmed documenting Resident #15 had been observed on the floor in his room on 11/26/25 at 5:19 AM. Staff T stated that she received education from the facility following this documentation, that although Resident #15's Care Plan identified that he liked to crawl on the floor at times, finding him on the floor would still be considered an unwitnessed fall and protocol for an unwitnessed fall should have been followed. Staff T stated that going forward, she would follow protocol for an unwitnessed fall in this situation. During an interview on 12/03/25 at 4:30 PM, the DON reported that Resident #15 required one staff assistance with transferring and toileting. The DON revealed an expectation that neurological evaluations are completed following an unwitnessed fall. #4. The MDS for Resident#50 dated 10/3/25, listed diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, osteoporosis, and hip fracture. The MDS reflected Resident #50 dependent on 2 or more staff for chair-to-chair transfer. The BIMS identified a score of 3 out of 15, severe cognitive impairment. The Care Plan for Resident#50 dated 9/28/23, included Activities of Daily Living (ADL's) revision on 11/28/2023 directed she required maximum assistance of 2 with walker for transfers. During an observation on 12/02/2025 at 9:18 AM, Staff K, CNA in the east lounge stood in front of Resident #50, reached her arms under Resident #50 arms as Resident #50 sat in her wheel chair and lifted Resident #50 and completed a stand pivot transfer (SPT) without a gait belt in to the recliner in the lounge. During an interview on 12/02/2025 at 9:20 AM, the Traveling Director of Nursing (DON) reported she expected the staff to use a gait belt (GB) with SPT. During an interview on 12/02/2025 at 9:22 AM, Staff K, CNA confirmed she alone transferred Resident#50 from the wheel chair to the recliner in the East lounge and failed to use a GB. She reported other staff asked her to move Residnet#50 into the recliner and she just moved her. During an interview on 2/03/2025 at 2:22 PM, the Administrator reported she expected the staff to transfer residents according to their Care Plan and use a GB. during a SPT. Review of the facility policy titled, Safe Lifting and Movement of Residents, dated 7/2017, revealed a Policy Statement which declared In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Policy Interpretation and Implementation section policy directed, in part: a. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. b. Manual lifting of residents shall be eliminated when feasible. c. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's preferences for assistance; Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. d. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. e. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. f. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. g. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies; Provides training on safety, ergonomics and proper use of equipment; and continually evaluates the effectiveness of workplace safety and injury-prevention strategies. Review of the facility policy titled, Neurological Assessment, revised Oct. 2010, revealed a Purpose Statement to provide guidelines for a neurological assessment: 1. Upon physician order; 2. When following an unwitnessed fall; 3. Subsequent to a fall with suspected head injury; or 4. When indicated by resident condition. The General Guidelines, section directed: a. Neurological assessments are indicated: upon physician order; following an unwitnessed fall; following a fall or other accident/injury involving head trauma; or when indicated by the residents condition. b. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). c. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. Review of the facility policy titled, Falls- Clinical Protocol, dated March 2018, revealed a Assessment and Recognition section, which directed, in part: a. The nurse shall assess and document/report the following: Vital signs; Recent injury, especially fracture or head injury. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; Neurological status; Pain; Frequency and number of falls since last physician visit; Precipitating factors, details on how fall occurred; All current medications, especially those associated with dizziness or lethargy; and All active diagnoses. b. Falls should be identified as witnessed or unwitnessed events.

Based on observation, interview, and facility policy review, the facility failed to maintain a clean environment and resident equipment. The facility reported a census of 58 residents.Findings include:1. During an observation on 11/18/25 at 10:50 AM, a full body mechanical lift located in the 100 hallway had a brown colored smear on the left side of lift leg. On Nov. 19, 2025 at 12:32 PM, the brown smear remained on the mechanical lift leg. During an observation on 11/18/25 at 11:06 AM, a mechanical sit to stand lift on the 200 hallway, had the foot plate heavily soiled with various debris. On Nov. 19, 2025 at 12:35 PM, the debris remained on the foot plate of the sit to stand lift. During an observation on 11/18/25 at 8:50 AM, a high back wheelchair kept in the hallway, outside of room [ROOM NUMBER], had a yellow stained towel kept on the wheelchair seat. At 12:19 PM, the wheelchair remained in the hallway, outside of room [ROOM NUMBER] and the yellow stained towel rested on the seat. During an observation on 11/19/25 at 12:39 PM, the bathroom in resident room [ROOM NUMBER] had brown spots and smears on the floor near the toilet, and a soiled incontinence pad rested on the bed. During an interview on 11/20/25 at 11:00 AM, Staff S, Certified Nursing Assistant (CNA), reported that all staff were responsible for cleaning the mechanical lifts and that CNAs were primarily responsible for changing bed linens, changing incontinence pads, and making the resident's beds. Staff S stated that soiled incontinence pads should not be left on the bed due to infection control. During an interview on 11/24/25 at 9:35 AM, Staff L, CNA, reported that CNAs were responsible for cleaning the mechanical lifts, changing bed linens, changing incontinence pads, and making resident's beds. Staff L stated that soiled incontinence pads should be changed immediately for the health and safety of residents. Review of the facility policy titled, Cleaning and Disinfection of Environmental, revised August 2019 revealed a Policy Statement which declared Environmental surfaces will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. The Policy Interpretation and Implementation section directed, in part: a. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibility soiled. b. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.

Based on clinical record review, facility policy review and staff interviews, the facility failed to provide enough qualified staff members to provide nursing and related services to meet the specific, individualized needs for 1 of 2 residents reviewed for sufficient staff (Resident #6). The facility reported a census of 58 residents. 1.The Minimum Data Set (MDS) Assessment for Resident #6 dated 6/13/25, reflected a Brief Interview for Mental Status (BIMS) of 9 out of 15, indicating moderate cognitive impairment. The MDS identified Resident #6 required moderate assistance for toileting, bathing and personal hygiene. Resident #6 is frequently incontinent and the resident is not on a toileting program. The Care Plan for Resident #6 dated 7/5/24, and revised on 7/15/25, revealed activities of daily (ADL) self-care deficit which required moderate assistance for bathing and partial assistance for personal hygiene. Review of ADL Self Care-Shower/Bath Sheet revealed Resident #6 did not receive a bath or shower from 11/14/25 through 11/30/25 a period of 17 days. During an interview on 11/12/25 at 2:10 PM, Staff D, Certified Nursing Assistant (CNA) stated they do not have enough staff scheduled on a routine basis and are not able to get all of their personal care completed. It has been brought to management's attention numerous times and nothing changes. During an interview on 11/12/25 at 4:40 PM, Staff G, Registered Nurse (RN),she stated there is definitely a lack of staff working at the facility at any given time. All of the shifts need additional certified nursing staff working. She stated not all of the resident cares can get done with the lack of staff on some shifts. Staff G stated she has reported cares not getting done to management including the Director of Nursing, (DON) numerous times and has not noticed a difference. 2. During an interview on Nov. 25, 2025 at 3:18 PM, Staff A, Licensed Practical Nurse (LPN), worked on the 200 hallway from 6:00 AM to 6:00 PM, reported she had been unable to complete scheduled AM wound care treatments when a medication aide was not scheduled, due to being tasked with passing medication in addition to charge nurse duties. During an interview on Dec. 01, 2025 at 12:20 PM, Staff G, Registered Nurse (RN), reported that at times she would need to pass on wound treatments to the next shift when unable to complete due to being without a medication aide or assisting CNA staff, if short staffed, to complete care tasks. During an interview on Dec. 01, 2025 at 9:00 AM, Staff N, CNA, worked on the 2:00 PM to 10:00 PM shift and reported that she would often be the only CNA available for a hallway, with approximately 25 residents, many of which required 2 staff members to assist with mechanical lift transfers. Staff N notified that there had been times on 2nd shift in which all residents would receive a room tray for supper due to not enough staff available to get residents up to the dining room and residents who required feeding assistance would be helped in their rooms one at a time. Staff N stated that 5 resident baths would be scheduled on her shift and when only one or two CNAs worked, the baths would not always be completed. During an interview on 11/18/25 at 4:15 PM, the Administrator stated she is new to this position but staffing concerns are one of her top priorities. She is aware that low staffing numbers have been a concern in the building. Review of the Facility Assessment, dated Dec. 01, 2025, revealed: a. Section titled: Daily staffing patterns, identified that daily staffing patterns were consistent based on the census of residents and additional staff would be scheduled as needed related to resident needs and acuity. The section identified the following: Staffing is based on the residents' acuity and staffing strengths; Department Heads are assigned a Quality Assurance checklist for portions of the building weekly, including call light audits. On weekends, the Weekend Manager performs call light audits and door alarm checks. b. Section titled: Contingent Staffing, revealed that the facility has a process to assess staffing levels based on employee call outs due to illness or unforeseen circumstance and directed the following: The charge nurse notifies the specific department head of the call in as soon as possible. Dietary and Environmental handle calling in their employees that are off or filling the shifts as needed. The DON and scheduler begin calling all employees that are off and filling in the calendar to request additional nursing staff through staffing agencies. In the interim the DON/Designee directs a supervisor to help until other staff can be called in. Nursing staff will be directed by their charge nurse to change assignments as needed to fulfill the needs of the residents until proper staffing levels can be obtained.

Based on observations, staff interviews and facility policy review the facility failed to ensure the infection control practices of hand hygiene during the administration of insulin and wound care, and the use of Enhanced Barrier Precautions utilized as required to reduce the transition of multidrug resistant organisms during high contact resident care for 3 of 4 residents (Resident #2, Resident #14, and Resident #41) reviewed for infection control. The facility reported a census of 58 residents.Findings include: 1. During an observation on 11/25/2025 at 8:43 AM, Staff A, Licensed Practical Nurse (LPN) entered Resident#41's room and explained she needed to administer insulin pen and her Lantus. Nurse administered the Lantus into her left arm and administered the pen into the back of the right arm. Staff A failed to wear gloves as she administered the insulin to Resident#41. During an interview on 12/01/2025 at 12:32 PM, Staff G, Registered Nurse (RN) reported for insulin administration nursers are expected to wear gloves due to the risk of blood borne pathogens. During an interview on 12/02/2025 at 9:17 AM, the facility Infection Preventionist (IP) reported she expected the Nurses to wear gloves when administering insulin. 2. During an observation on 11/20/25 at 1:16 PM, Staff I, Certified Nursing Assistant (CNA) and Staff J, CNA performed peri-care for Resident #2. Neither wore a gown during the care. After completing cares neither Staff I or Staff J changed their gloves or washed their hands prior to assisting the resident with readjusting her clothing and repositioning her in bed. During an interview on 11/20/25 at 3:40 PM, Staff I, CNA stated she had been nervous when completing observed cares for Resident #2. She stated she was not prepared to clean up bowel incontinence. Staff I explained the process for when to wear and change gloves and stated that was not done during the observation. Staff I also stated both she and Staff J, CNA knew the resident had a wound and they should have used Enhanced Barrier Precautions. During an interview on 12/3/25 at 3:05 the Traveling Director of Nursing (DON) and the Infection Preventionist stated Resident #2 had a wound and is on Enhanced Barriers Precautions (EBP). They stated EBP signage should have been put on the door last week and thinks it was accidentally taken down, the necessary Personal Protective Equipment (PPE) inadvertently removed. They stated all staff are expected to follow EBP guidelines. 3. Review of the Care Plan, initiated on Oct. 27, 2025, revealed that Resident #14 had an indwelling urinary catheter and listed the intervention to provide Enhanced Barrier Precautions (EBP). The Care Plan lacked identification or interventions related to Resident #14's Stage 3 pressure ulcer to the sacrum. During an observation on Nov. 19, 2025 at 8:45 AM, Staff G, RN entered Resident #14's room to complete wound care and dressing change for a Stage 3 pressure ulcer on Resident #14's sacrum. No additional Personal Protective Equipment (PPE) (i.e. gown) applied to meet the facility requirements of EBP during care tasks provided for residents with indwelling catheters and open wounds. Staff G applied a pair of gloves, sprayed the wound with wound cleanser and patted it dry with gauze then, without changing gloves between dirty and clean tasks, sprayed the open wound with a no-sting barrier film and placed a padded adhesive dressing over top of the wound. During an interview on Nov. 20, 2025 at 11:30 AM, Staff G, RN stated Resident #14 required EBP due to her indwelling catheter and identified that gloves should be changed between dirty and clean tasks. During an interview on Nov. 25, 2025 at 3:50 PM, the DON reported that gown and gloves were required EBP to be worn for residents with an indwelling catheter or chronic wound. The DON revealed an expectation of nurses to maintain infection control during wound care by changing gloves between dirty and clean tasks. The facility provided a policy titled Gloves dated 4/2018, that directed it is the protocol of this facility that latex or vinyl gloves are worn where there is a likelihood of coming in contact with blood, body fluids or other potential, infectious materials.

Based on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide a respectful, dignified environment and care to 3 out of 10 residents reviewed (Residents #14, #16, and #44). The facility reported a census of 58 residents. Findings Include:1. The Minimum Data Set (MDS) Assessment for Resident #16 dated 9/26/25, revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #16 dependent on staff for toileting, personal hygiene and meeting physical needs related to immobility. The Care Plan for Resident #16 dated 7/5/24, and revised on 7/15/25, identified resident required moderate assist, from two persons for toileting, EZ Stand lifts (brand name of a type of lift that assists a person from a sitting position to a standing position and then staff are able to push the resident in a safe manner to the desired location), upper and lower body dressing and resident is dependent on staff to assist and escort to activities. During an observation on 11/12/25 at 5:15 PM, Staff F, Certified Nurse Aide (CNA), delivered a meal to Resident #16. As the staff member entered the room the resident asked her if it was the correct meal. The staff member lifted the tray cover and said, No, it is fish, I will go get you the alternative. The resident advised that they are aware, she doesn't eat fish and she is never asked what she would like and the staff most often bring her back a hotdog. The resident was not asked what she wanted and not given any options for alternatives. The resident shared that they fix the meal and you either like it or you don't. The alternative is whatever they bring you. The resident was served a loose meat sandwich, which was not on the menu or the alternative menu. During an interview on 11/12/25 at 5:25 PM, Staff F, CNA, queried about the meal served to Resident #16 and she stated the meal trays aren't always correct but she should have asked the resident what she wanted instead of just bringing something back. She stated that she did not know what items were on the alternative menu. Staff F expressed concern that there is not enough staff and sometimes they are not able to get everything done. 2. During an interview on 11/12/25 at 1:40 PM, Resident #44 stated he has bowel incontinence and has frequent diarrhea. He stated he does not have the ability to control his bowels and it is unpleasant and embarrassing. Resident #44 sat in his wheelchair, and wore a t-shirt and sweat pants. An odor of feces and urine noted in his room, with what appeared to be dried feces on the resident's sheets and the floor. When queried, the resident indicated the sheets were soiled last night Review of the Care Plan for Resident #44, dated 10/11/23 revealed a Focus area to address I have diarrhea and bowel incontinence. Interventions included: I request to have barriers placed in the bathroom covering the walls d/t (due to) my bowel incontinence. The Care Plan, dated 10/11/23 included a Focus area address Activities of Daily Living (ADL's). Interventions included, in part: Toileting – Ax (assist) x 1 – commode over toilet seat; Upper Body Dressing – Ax 1; Lower Body Dressing – Ax 1. During an observation on 11/13/25 at 11:15 AM, in Resident #44's bathroom what appeared to be dried feces noted on the surface around the toilet. During an observation on 11/17/25 at 8:55 AM, in Resident #44's room what appeared to be dried feces noted on the floor between the bed and the bathroom, and the bed sheets were visibly soiled with a brown substance. During an observation on 11/18/25 at 12:25 PM, in Resident #44's room the sheets on the bed noted to be soiled, and what appeared to be dried feces noted on the bathroom floor. On 11/19/25 at 7:55 AM, the Dietary Manager was queried. She advised she had entered Resident #44's room in the past and has seen his sheets soiled. Document titled, Job Description: Certified Nursing Assistant identified the following as a responsibility of a Certified Nursing Assistant: Performs incidental housekeeping and maintenance tasks as may arise during the course of regular duties, in order to maintain a clean, safe, pleasant environment for residents, visitors, and staff. 3. Review of Resident #14's MDS assessment, dated 11/2/25, revealed that Resident #14 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. The list of diagnoses included Alzheimer's disease, left femur fracture, and malnutrition. The MDS indicated Resident #14 was always incontinent of bowel and dependent on staff assistance for all transfers, bed mobility, dressing, and toilet hygiene cares. Review of the Care Plan, date initiated 10/28/25, revealed a Focus area to address activities of daily living (ADLs). Interventions included, in part: I am dependent on two staff for assistance with bed mobility. I am dependent on two staff for assistance with upper and lower body dressing. During an observation on 11/25/25 at 3:18 PM, Resident #14 found to be laying supine (on back) in bed, perineal area was without an incontinent product in place, and pants were left pulled down around the resident's ankles. During an observation on 11/15/25 at 3:50 PM, the Director of Nursing entered Resident #14's room, Resident #14 remained lying supine in bed without incontinent product to cover perineal area, and pants continued to be left down around the resident's ankles. Resident #14 stated she was cold, the DON assisted resident with incontinence cares and dressing. During an interview on 11/25/25 at 3:45 PM, the DON stated that residents should not be left with pants down around ankles in bed, unless the resident had requested this. Review of the policy titled, Facility Resident Rights, Policy Statement, revised December 2016. Policy Interpretation and Implementation section included, in part: Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to, in part: a. A dignified existence; b. Be treated with respect, kindness and dignity;

Based on clinical record review, staff interviews and facility policy review the facility failed to obtain consent for an antipsychotic medication for one out of five residents reviewed for unnecessary medications (Resident#6). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #6 dated 6/13/25, listed diagnoses of Non-Alzheimer's dementia, and depression. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 9 out of 15, moderate cognitive impairment. The High-Risk Drug Classes: Use and Indication section lacked an antipsychotic medication used in the 7 day look back period. The MDS assessment for Residnet#6 dated 9/12/25, listed diagnoses of Non-Alzheimer's dementia, and depression. The MDS reflected a BIMS score of 11 out of 15, moderate cognitive impairment. The High-Risk Drug Classes: Use and Indication section reflected an antipsychotic medication with indication used in the 7 day look back period. The MDS revealed antipsychotics were received on a routine basis. The Care Plan for Resident #6 date 12/11/2025, failed to include the use of an antipsychotic medication. The Progress Note dated 7/15/2025 at 5:28 PM reflected Resident #6 saw the provider who ordered risperidone 0.25 milligrams (mg) two times a day. The Progress Note dated 7/15/2025 at 9:14 PM identified risperidone tablet 0.25 mg give 1 tablet by mouth two times a day related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Progress Note for Resident #6 dated 6/15/25 through 7/15/25 failed to include consent from the resident's responsible party.Review of the facility Evaluations revealed a lack of an Informed Consent for Psychotropic Medication dated July, 2025 for risperidone. On 12/03/2025 at 9:18 AM, the Registered Nurse (RN) | Regional Director of Clinical Services reported the consents are in the evaluation. On 12/03/2025 at 11:01 AM, the Administrator reported the facility failed to obtain consent for Resident#6 risperidone when it started in July to 12/3/25. On 12/03/2025 at 12:19 PM, Staff A, Licensed Practical Nurse (LPN) reported the nurse who got the order for a psychotropic medication needed to call the family or the resident and obtain the consent for use. She stated the consent is documented in the chart. The facility provided a policy titled Antipsychotic Medication Use dated 12/2016, identified informed consent will be obtained.

Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to provide twice weekly bathing for 4 of 5 resident (R#6, R#29, R#43, and R#60) and failed to provide assistance with incontinence cares for 1 of 5 residents (Resident #15) reviewed for activities of daily living (ADLs). The facility reported a census of 58 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 10/3/25, revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severe cognitive impairment. The list of diagnoses included Non-Alzheimer's dementia, schizophrenia, and congestive heart failure. The MDS identified Resident #15 incontinent of bladder, and occasionally incontinent of bowels. Review of Resident #15's Care Plan, initiated on 1/19/24, revealed a Focus area to address activities of daily living (ADL's). Interventions included, in part: a. Mobility - independent with wheelchair. Date initiated: 1/19/24. b. Toileting – Ax 1 (assist of 1). Date initiated: 1/19/24. c. Transfer – Ax 1 with walker. Date initiated: 1/19/24. d. Lower Body Dressing – Ax 1. Date initiated: 1/19/24. During an observation on 11/18/25 at 11:02 AM, Resident #15 self-propelled wheelchair down 200 hallway, away from his room, towards the dining room. The front of the residents' pants and shirt near his waist visibility wet. Staff L, Certified Nursing Assistant (CNA) reported that Resident #15 was very independent and would not let staff change him, Staff L stated she would try to reapproach him, then walked away from Resident #15. At 11:07 AM, Staff L set clothing on Resident #15's bed and then notified Resident #15 that there was clothing on his bed to change into. At 11:12 AM, Resident #15 entered his room and shut the door, no staff entered room to assist Resident #15 with dressing or incontinence cares. During an interview on Dec. 03, 2025 at 4:30 PM, the Director of Nursing (DON) reported that Resident #15 often had an altered reality and could be non-compliant with cares. The DON informed that staff should reapproach Resident #15 and try to talk with him about completing incontinent cares. The DON identified that Resident #15 required the assistance of one staff member for transfers and toileting hygiene. The DON stated that Resident #15 would not be able to clean himself up if he had been incontinent. 2. Review of the MDS assessment, dated 11/17/25, revealed that Resident #29 had a BIMS score of 14 out of 15, which indicated intact cognition. The MDS indicated Resident #29 did not exhibit rejection of care behavior. and had not exhibited rejection of care behavior. The MDS identified that Resident #29 required substantial to maximal staff assistance with bathing/showering. Review of the census report revealed that Resident #29 admitted to the facility on [DATE] and discharged from the facility on 11/19/25. Review of Resident #29's Care Plan, initiated on 11/11/25, revealed a Focus area to address activities of daily living. Interventions included, in part Bathing – 1 am A x 1. Review of the facility bathing record, dated between 11/01/25 and 11/30/25, revealed that Resident #29 had no documented baths during her 11/11/25 to 11/19/25 stay at the facility. baths documented while residing in the facility. No incidents of refusals to bath documented in the record. 3. Review of the MDS assessment, dated 11/17/25, revealed that Resident #43 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. The MDS indicated Resident #43 had not exhibited rejection of care behavior. The MDS identified that Resident #43 required substantial to maximal staff assistance with bathing/showering. Review of Resident #43's Care Plan, initiated on July 18, 2925, revealed a Focus area to address activities of daily living. Interventions included, in part: Bathing – I am moderate Ax 1. Review of the facility bathing record, dated between 11/06/25 and 12/01/25, revealed the following documentation of Resident #43's baths/showers: a. On 11/06/25, bath not attempted due to medical condition or safety concerns. b. On 11/10/25, bath not attempted due to medical condition or safety concerns. c. On 11/13/25, Resident #43 refused a bath. d. On 11/20/25, bath was not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. e. On 11/24/25, Resident #43 not available for bath. f. On 11/27/25, Resident #43 dependent on staff assistance with the bathing task. The bathing documentation revealed that Resident #43 had no bath for 7 days, between the dates of 11/06/25 and 11/13/25. On 11/13/25 Resident #43 refused to bathe. Resident #43 then went another 14 days, between the dates of 11/13/25 and 11/24/25, without a bath/shower. During an interview on Nov. 24, 2025 at 11:35 AM, Staff L, CNA, stated that Resident #43 never refuses cares and likes to be clean. Staff L reported that it had been a while since she had given Resident #43 a shower. 4. Review of the MDS assessment, dated Oct. 30, 2025, revealed that Resident #60 admitted to the facility on [DATE]. Resident #60 had a BIMS score of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #60 had not exhibited rejection of care behavior. The list of diagnoses included adult failure to thrive, intellectual disability, bipolar disorder, and cellulitis of lower limbs. Review of Resident #60's Care Plan, initiated on Oct. 26, 2025, revealed a Focus area to address activities of daily living. Interventions included, in part: Bathing – I am a substantial assist of 1. Review of the facility bathing record, dated between 11/04/25 and 11/19/25, revealed one entry documented on 11/16/25 that Resident #60 had refused a bath/shower. The bathing documentation revealed that Resident #60 had no bath for 12 days, between the dates of 11/04/25 and 11/16/25. On 11/16/25 Resident #60 refused to bathe. Resident #60 then went another 3 days, between the dates of 11/16/25 and 11/19/25, without a bath/shower. Further review of the electronic health record revealed a lack of documentation to indicate Resident #60's received a bath between an admission date of 10/24/25 and 11/19/25, a period of 27 days. During an interview on 11/24/25 at 11:35 AM, Staff L, CNA, stated that Resident #60 would rarely refuse to shower as he liked to be clean. Staff L denied having personally assisted Resident #60 with bathing. Staff L stated that if a resident refused to bathe, staff were expected to reapproach, try again at another time, and let the nurse know about refusal. During an interview on 12/01/25 at 9:00 AM, Staff N, CNA, stated that the 2:00 PM to 10:00 PM shift would have 5 resident baths scheduled and when only one or two CNAs worked, the baths would not always be completed. During an interview on 12/3/25 at 4:30 PM, the DON revealed an expectation that CNA staff document and report to the nurse any resident refusals of bathing, or if staff were unable to complete a scheduled bath. The DON was unable to provide additional bathing record documentation. 5. Review of the MDS assessment for Resident #6, dated 6/13/25, revealed a BIMS score of 9 out of 15, which indicated a moderate cognitive impairment, The MDS indicated Resident #6 frequently incontinent, and required moderate assistance for toileting, bathing and personal hygiene. Review of the Resident #6's Care Plan, dated 7/5/24, revealed a Focus area to address activities of daily living. Interventions included, in part: Bathing – I am Moderate Ax 1, and Personal Hygiene – I am Partial Ax 1. During an observation on 11/24/25 at 2:20 PM, Resident #6 appeared unshaven and with greasy hair. His clothing appeared dirty. During an observation on 11/25/25 at 8:20 AM, Resident #6 sat in the dining room. He appeared unkept and to be wearing the same clothes as observed on 11/24/25. During an interview on 12/3/25 at 2:30 PM, Staff L, CNA queried regarding Resident #6 refusing to shower or take a whirlpool bath. Staff L stated she has never known Resident #6 to refuse to shower or sit in the whirlpool tub as he loves his baths. Staff L stated the facility does not have a bath aid and there are days they are short staffed and showers do not get done. Review of the facility bathing record revealed between 11/13/25 and 12/1/25 Resident #6 a. Received a bath on 11/13/25. b. On 11/17/25 staff documented Not applicable-Not attempted c. On 11/20/25 staff documented resident refused. d. On 11/27/25 staff documented not attempted due to environmental limitations (e.g., lack of equipment, weather constraints). e. On 12/1/25 staff documented the resident was dependent on staff and did none of the effort to complete the activity. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised on March 2018 revealed a Policy Statement which declared Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on staff interviews, employee file review and facility policy review the facility failed to complete 3 out of 3 employee annual reviews. The facility reported a census of 58 residents. Findings include: Review of nursing employee files reviewed:a. The Annual Review for Staff C, Licensed Practical Nurse (LPN) listed a hire date of 3/11/2024. The unsigned Annual Review reflected no other reviews completed.b. The Annual Review for Staff D, Certified Nurse Aid (CNA) listed a hire date of 5/4/2023. The unsigned Annual Review reflected her last Annual Review completed on 5/22/2024.c. The Annual Review for Staff E, CNA listed a hire date of 6/22/2014. The unsigned Annual Review reflected her last Annual Review completed on 6/22/2024.During an interview on 12/03/2025 at 11:32 AM, the Administrator reported she has no further evaluations for Staff C, D and E. During an interview on 2/03/2025 at 3:05 PM, the Administrator stated she expected employee evaluations completed annually and as needed.The Performance Review policy undated directed to ensure that team members perform their jobs to the best of their abilities, they must be recognized for good performance and receive appropriate feedback for improvement when necessary. Consistent with this goal, supervisors will evaluate all team members, regardless of their status and performance on a timely and ongoing basis.Performance reviews will be completed on a team member's first anniversary date and annually thereafter, and may be more frequent based on the supervisor's discretion, for example, if a team member is promoted or transferred to a new position.

Based on observations, staff interviews and facility policy review the facility failed to remove expired medication from 1 out of 2 medications carts and failed to check the medication refrigerator temperatures on 1 out of 2 refrigerators on a scheduled basis. The facility reported a census of 58 residents. Findings include: 1. During an observation on 11/25/2025 at 7:45AM Staff A, Licensed Practical Nurse (LPN) on the [NAME] wing found a Humalog insulin bottle dated 10/12/25 and the Lantus insulin dated 9/25 for Resident#41. Staff A looked in the cart for other opened insulin for Residnet#41 and failed to locate ant non expired insulin for Resident #41. Staff A reported she needed to replace the expired insulin. Staff A went and got the needed insulin from the emergency kit and dated them as she opened them. During an interview on 12/03/2025 at 12:13 PM, the Administrator reported they follow the manufacturer's guidelines on when medication expire. During an interview on 12/03/2025 at 12:51 PM, the Director of Nursing (DON) reported per the guide on the pharmacy sheet all insulins are only good for 28 days. The facility provided a document titled Recommend Expiration Date undated, that directed insulin after 28 days. 2. During an observation on 11/24/2025 at 10:37 AM, a document titled Med Room Refrigerator temps posted on the refrigerator in the west Hall Medication room. The document, dated 11/2025 recorded refrigerator temperatures on 7 of the possible 24 days. During an interview on 12/01/2025 at 11:28 AM, the DON reported he expected the refrigerator temperatures taken and logged daily. A review of the facility policy, titled Refrigerators and Freezers, dated 2014, directed this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observefood expiration guidelines.The Policy Interpretation and Implementation section directed: b. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.

Based on observations, facility document review, staff interviews and facility policy review the facility failed to post the daily staffing for 4 out of the 6 days of the survey. The facility reported a census of 58 residents. Findings includeDuring observations the Daily Staffing information failed to be posted on 11/19/25, 11/25/25, 12/01/25 and 12/02/25. During an interview on 12/02/2025 at 12:50 PM, the traveling Registered Nurse (RN), Director of Nursing (DON) stated she thought either the facility DON, Business Office Manager or the Administrator completed and posted the Daily Staff information. During an interview on 12/02/2025 at 12:55 PM, the Administrator reported she did not know who completed the Daily Staff posting. At 2:15 PM, the Administrator reported she needed the DON to get the Staff Posting from his computer.During an interview on 12/02/2025 at 3:35 PM, the DON reported he failed to complete the Staff postings. He reported the night shift nurse is expected to the complete on post daily. The DON reported he has not tracked if the information is posted. The DON reported the Daily Staff posting are hung on the wall near the other posting. On 12/2/25 at 3:36 PM, the Administrator reported the facility did not have a policy to address a Daily Staff posting.

Based on staff interview, facility document review and review of the Summary Statement of Deficiencies, the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to prevent repeated quality deficiencies identified during the current recertification survey. The facility reported a census of 58 residents.Finding include:Review of the Summary Statement of Deficiencies, dated 11/21/24 listed a citation at F0686 scope and severity (S/S) of G (Actual Harm that is not Immediate Jeopardy (IJ)), and F0725 S/S E (no actual harm with the potential for more than minimal harm that is not IJ) The QA notes dated 12/18/24 reflected possible tags from complaint and survey F0686 followed by the wound clinic (WC) at hospital. The note reflected the facility assessment updated to reflected the staffing needs of the residents. The survey dated 12/3/25, identified a concern at F0686 at IJ (Immediate Jeopardy which means a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) and a concern at F0725 at S/S E.During an interview on 12/03/2025 at 2:22PM, the Administrator confirmed the repeat concerns identified and the need to address the pattern of deficiencies. The facility provided the Quality Assurance and Performance Improvement (QAPI) Plan dated 3/2020, that directed The responsibilities of the QAPI Committee are to:a. Collect and analyze performance indicator data and other information;b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services;c. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process;d. Utilize root cause analysis to help identify where identified problems point to underlying systematic problems;e. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care;f. Establish benchmarks and goals by which to measure performance improvement;g. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; andh. Communicate all phases of the QAPI process to the Administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities.

Based on observation, clinical record review, policy review and staff interview the facility failed to prevent the recurrence of a pressure ulcer for 1 of 2 residents reviewed (Resident #27). The facility reported a census of 54 residents. Findings include: The State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities, revised 8/08/24, provided the following information on the staging of pressure ulcers: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue pressure injury. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis (middle layer of skin) Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat (soft fat that is located just beneath the skin and can be pinched) may be visible in the ulcer and granulation tissue (new tissue, sign of healing) and epibole (curled or rolled wound edges) are often present. Slough (yellowish/white material in a wound bed) and/or eschar (dead tissue, dark in color) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Minimum Data Set (MDS) assessment dated [DATE], for Resident #27 revealed a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated a severe cognitive impairment. The MDS list of diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, and bullous pemphigoid (an autoimmune disorder causing raised blisters on the skin). The MDS indicated Resident #27 as dependent on staff for dressing her lower body and putting on/taking off footwear. The Braden Scale for Predicting Pressure Sores Risk assessment dated [DATE], resulted in a score of 14 out of 18. Per the document scoring key, a score of 13 to 14 indicated a moderate risk for a pressure injury. The Braden Scale assessment dated [DATE], resulted in a score of 10 out of 18. A score of 10-12, per the scoring key, indicated a high risk of pressure injuries. The Care Plan, initiated on 10/21/24, included a Focus area to address I have impairment to my skin. The Interventions, in part, included; Bilateral prafo (Protective Relief Ankle Foot Orthosis (medical device, such as brace or splint) boots to feet, initiated on 8/30/24. on Resident #27's feet. The Visual/Beside Kardex Report (name of a documentation system) as of 11/21/24, Dressing section directed the use of Bilateral prafo boots to feet. The Wound Evaluation & Management Summary Note, from the wound provider for Resident #24, dated 9/23/24, revealed Stage 4 pressure wound to the left heal (resolved on 9/23/24). Recommendations: Off-Load wound; reposition per facility protocol; Recommend no shoes. Please use non-skid socks. The Physician Progress Note dated 10/24/24, documented Wound, Date identified: 10/14/24; Location: L (left) heel; Type of wound: Pressure; Measurement/Size: 3.24 x 1.87 x 2.11 (measured in centimeters). Plan: Pressure injury to left heel, stage 2. Previous stage 4 ulcer in this site. It had resolved 9/23/24. New stage 2 in this area. Skin prep twice daily. Apply Profo boots while in wheelchair and in bed. Signed [name redacted] FNP (Family Nurse Practitioner) on [DATE] at 2:49 PM. The Physician Progress Note dated 10/31/24, History of Present Illness: She presents to be seen for L heel wound. She recently was treated for a stage 4 ulcer on this heel that had been resolved 9/23 [2024] but another one has begun. It appears she is getting wounds from pressure in her wheelchair and/or bed. Today it was evaluated and has decompensated. The note documented, in part; Location: L heel Type of wound: pressure ulcer; Measurement/Size: 2.34x1.72x1.74 (measured in centimeters); Progress: Worsening. Plan: Pressure injury to deep tissue of left heel. Apply skin prep to L heel wound twice daily. Use Profo boots at all times (in and out of bed). Signed [name redacted] on [DATE] at 12:54 PM. A review of Physician Orders revealed an order dated 11/4/24 for Heel protectors to bilateral heels at all times. The Wound Evaluation dated 11/19/24, completed by conducted Staff A, Licensed Practical Nurse (LPN) documented the wound measured 1.97 cm x 1.07cm x 2.31cm. During an observation on 11/19/24 at 12:27 PM, Resident #27 sat in her wheelchair, while eating lunch with assistance from staff. The resident wore a tennis shoe on her right foot. The left foot unable to be visualized as covered with a blanket. During an interview on 11/19/24 at 11:42 AM, Staff A, LPN explained when she went in the resident's room this morning to check the wound she took off a tennis shoe on the resident's left foot as she felt it was too tight and probably exacerbating the problem. Staff A stated the left heel was clear new skin back in September and now was back to measuring as a wound. She felt it just kept coming back. During an interview on 11/19/24 at 1:44 PM, Staff B, Certified Nursing Assistant (CNA) explained she got Resident #27 up for the morning. She made sure the peri area was clean and then put the resident's pants on and transferred her to the wheelchair. She then put both tennis shoes on the resident. She noted she was a bit confused about the shoes as she had heard different things as to when the resident was supposed to wear them. She knew Resident #27 always wore the protective boots at night but wasn't sure about when she was in the wheelchair. She admitted to forgetting to put on another piece of protective equipment as well. During an interview on 11/19/24 at 2:11 PM, the Family Nurse Practitioner (FNP) explained she expected the resident to wear Prafo boots on both feet at all times. She noted the resident was usually in her socks as she doesn't walk. The FNP expressed the recurrence of the pressure ulcer could have been prevented. It The left heel was fully healed in September. She could not say for certain that wearing shoes would cause it to come back; more than anything when the resident not having anything on her feet to protect them was when it comes back. However, it was fully healed and recurred. During an interview on 11/21/24 at 10:04 AM, the Director of Nursing (DON) explained Resident #27 is supposed to wear bilateral heel protectors at all times. She acknowledged she was not aware staff had placed tennis shoes on the resident. She recognized the first pressure ulcer had healed, and they were currently in the process of healing the recurrent one. A facility policy, revised October 2020, titled Wound Care, 10/2010 Purpose statement declared The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The Preparation section instructed staff, in part to; a. Verify there is a physician's order b. Review the resident's care plan to assess for any special needs of the resident.

Based on observations, resident and staff interviews, and facility policy review the facility failed to respond to call lights within 15 minutes for 4 of 4 residents reviewed (Res #6, #12, #50, #204) and the facility failed to staff according to the Facility Assessment for seven out of eleven days reviewed. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) for Resident #12. The BIMS resulted in a score of 14 out of 15 which indicated intact cognition. The MDS list of diagnoses included amputation, non-Alzheimer's dementia, and stroke. The MDS indicated the resident as dependent on staff to roll left and right, sit to lying, lying to sitting on side of the bed, chair/bed-to-chair transfer, and transfer to toilet toileting needs. During a continuous observation on 11/19/24 starting at 12:50 PM, Resident #12's turned on his call light. Staff A, Licensed Practical Nurse (LPN) turned off the call light and administered his insulin. Personal cares were not provided at that time. The resident called out he needed to go to the bathroom after the LPN left. Staff B, Certified Nursing Aide (CNA) arrived at 1:08 PM to toilet the resident. 2. The MDS dated [DATE], for Resident #204 documented a BIMS score of 15 out of 15 which indicated intact cognition. The MDS list of diagnoses included normal pressure hydrocephalus (fluid on the brain), morbid obesity, and adult failure to thrive. The MDS revealed the resident had not attempted a chair/bed-to chair transfer, or toilet transfer due to a medical condition or safety concerns. The MDS indicated the resident as always incontinent of bladder and bowel. During a continuous observation on 11/20/14 starting at 9:12 AM, Resident #204 turned on her call light. Staff C, LPN checked in with resident at 9:25 AM, turned off the light, and stated she would send helpers down. At 9:27 AM, Staff D, Certified Medication Aide (CMA) administered medications to the resident and did not assist her with personal cares. During an interview at 9:34 AM, Resident #204 stated she continued to wait for assistance. The Activities Coordinator turned the light back on at 9:43 AM for assistance. Two CNA's arrived to assist Resident #204 at 9:45 AM. During an interview on 11/19/24 at 11:17 AM, a resident family member stated the facility does not have enough staff on second shift-they often have only one CNA on each hall and that isn't good for residents who are a 2 assist. Friday, Saturday, and Sunday residents have to eat in their rooms for dinner because they do not have enough staff to transfer them all to the dining room. The family member stated this occurs randomly on average 3-4 nights per month. During an interview with 11/20/24 10:12 AM, Staff E, CNA explained the expectation was for staff to answer call lights in two minutes or less. They turn off the light and can leave and return if the resident needs the staff to get something like water. With personal cares staff are supposed to do that right then and there. If someone needs assist of two she would turn off the call light, get another helper, and come right back to assist. CMA's are allowed to assist if someone has been waiting. During an interview on 11/20/24 at 10:17 AM, Staff F, CNA explained she was told there was a 5, 7, and 15-minute window to answer the call light. Staff F stated the facility being short on staff a lot of time it's not really possible. It can take up to 20-25 minutes before they get to the residents. She felt really bad about it but with being short staffed there's nothing they can do. This happens mainly on the weekend. She thought it was ok for other staff turn the light off and let CNA's know right away that they are needed, but if they are short staffed they will forget to go to the room. They leave the light on in that case. CMA's can help with cares as well if they are at a point to stop. During an interview on 11/20/24 at 10:26 AM, the Director of Nursing (DON) explained she expected call lights to be answered in 15 minutes or less as per state regulations. Staff should not turn off the light and not come back. They need to take care of the call light the first time they are in there. CMA's are able to help. They need to prioritize as they do have that two-hour window to pass medications. 48452 3. The MDS for Resident #6 dated 10/18/24, documented the resident had a BIMS score of 14 out of 15 which indicated intact cognition. The MDS list of diagnoses included atrial fibrillation (irregular heart beat), hallucinations, and diabetes mellitus. The Care Plan, Date Initiated 10/11/2023, included a Focus area to address I am at risk for falls. I do not wait for assistance to transfer. Interventions included, in part; Continue to educate me I am not independent with tranfers, initiated on 7/8/24; Encourage me to use my call light for assistance, initiated on 10/11/23; and I have a sign on my walker reminding me to call for assistance, initiated on 12/6/23. During an interview on 11/18/24 at 11:13 AM, Resident #6 stated the facility could work on answering call lights faster. He reported it took at least 20-30 minutes for lights to be answered. When asked how often that happened, he stated at least every other day and that it happened on all shifts. 4. The MDS for Resident #50 dated 10/10/24, documented the resident had a BIMS score of 14 of 15 which indicated intact cognition. The MDS list of diagnoses included atrial fibrillation, metabolic encephalopathy (chemical imbalance in the blood that affects the brain), and cellulitis (skin infection). The MDS assessed Resident #50 dependent on staff for chair/bed-to-chair transfer, transfer to the toilet, and for personal hygiene. The Care Plan, Date Initiated: 10/21/24 included a Focus area to address I am at risk for falls. Interventions included, in part; Encourage me to use my call light for assistance, initiated on 10/21/24. During an observation on 11/18/24 at 1:15 PM, Resident #50 sat in his wheelchair at the entrance to his room. He shared it took a long time for call lights to be answered here. When asked how long, he stated 20 minutes or more. He reported he knows this because of observation and because the staff tells him. The facility policy, revised March 2021, titled Answering the Call Light, Purpose statement declared The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure direct staff to: 1. Identify yourself and politely respond to the resident by his/her name . a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's requires requires another staff member, notify the individual c. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2. If assistance is needed when you enter the room, summon help by using the call signal. The policy did not specify a time frame in which calls should be answered. 34821 5. A review of the Daily Staffing Plan in the Facility assessment dated [DATE], identified the need for: a. Two licensed nurses on day, evening & night shift. b. Two medication aids on days c. Six CNAs on the day shift d. Four CNAs on the 2 shift e. Three CNAs on the night shift. The Nursing Daily Assignment sheet dated 10/26/24 (Saturday), listed two nurses, one CMA, and four CNA's for the 0600 -1400 (6:00 AM -2:00 PM) shift. The Nursing Daily Assignment sheet dated 10/27/24 (Sunday), listed two nurses, and three CNA's for the 0600-1400 shift. The Nursing Daily Assignment sheet dated 11/2/24 (Saturday), listed two nurses, two medication Aids and four CNA's for the 0600-1400 shift. The Nursing Daily Assignment sheet dated 11/3/24 (Sunday), listed two nurses and five CNA's for the 0600-1400 shift. The Assignment sheet for the 1200-2200 (2:00 PM to 10:00 PM) shift listed two nurses, one CMA, and two CNA's. The Nursing Daily Assignment sheet dated 11/10/24 (Sunday), listed two nurses, one CMA and four CNA's for the 0600-1400 shift. The Nursing Daily Assignment sheet dated 11/16/24 (Saturday) listed two nurses, one CMA, and five CNA's for the 0600 - 1400 shift. The Nursing Daily Assignment sheets dated 11/20/24 (Wednesday), listed two nurses two CMA's, and 5 CNA's with one CNA on orientation for the 0600 -1400 shift. During an interview on 11/20/24 at 1:41 PM, the DON reported the Assistant Director of Nursing (ADON) completed the schedule. During an interview on 11/21/24 at 9:23 AM, the DON reported the call light system is old and they are unable to produce call light records or logs. The DON and the ADON reported the staffing of 6 CNAs on the day shift each CNA has about 8- 10 residents for each CNA to care for. The DON reported at times she will find the CNA sitting at the nurses' station, when asked what they are doing they tell her they are charting. The DON reported the CNAs will complain that they need more help. She reported they have the number of resident here, some of the resident can do almost everything independently and just need 5 minutes of help each a few times a day. She stated some residents need a little more care and some need a lot of care. She said the CNA job is busy and they should be able to get things done. During an interview on 11/21/24 at 10:28 AM, Staff I, Registered Nurse (RN) reported the facility has good and bad days with staffing. During an interview on 11/21/24 at 1:10 PM, the DON and the ADON reported they struggled with the weekend schedule to get it covered. The DON stated they do the best they can to get it covered and come in themselves to work. They both acknowledged that resident have complained of waiting to long for help. The ADON reported she added her self and the DON to the assignment sheets when they work the floor.

Based on observations, facility policy review and staff interviews the facility failed to use hand hygiene during a noon meal service in an attempt to prevent cross contamination of food. The facility reported a census of 54 residents. Findings include: The following observations occurred during the noon meal service on 11/19/24, starting at 11:46 AM: a. At 12:04 PM, Staff H, [NAME] after taking a pan of food out of the oven, wiped his right hand on the side of his shirt. b. At 12:05 PM, Staff G, [NAME] touched with her left hand while she walked into the dining room. Staff G then pushed a plate service cart into the kitchen. Without washing her hands, Staff G returned to the serving line. While Staff G stirred a mixture of lettuce and cheese, a portion of the mixture spilled out. Staff G caught the spilled mixture with her bare left hand and put it back in to the pan used for preparation. c. At 12:11 PM, Staff G put a serving ladle down, and wiped her left hand on her left knee. She then touched a cart, and without washing her hands returned to plating food. During the service, Staff G picked up resident meal request slips, waded them up and threw them into the garbage. Staff G then put on one glove, picked up a bowl and put in near other dirty items. Staff G took off the glove, and without washing her hands resumed plating and serving food. d. At 12:17 PM, both Staff G and Staff H left the serving area to go to the dining room. Both pushed carts back into the room. Staff G picked up a paper from the floor and put it on the cart. She did not wash her hands. Staff H wiped his fingers on the right side of his shirt and went back to the serving line without washing his hands. During an interview on 11/19/24 at 12:45 PM, the Certified Dietary Manager (CDM) stated she expected staff to wash their hands before they started serving and if they got anything on their hands. When asked about movements through the kitchen and dining room, she stated they should wash them no matter where they move. During an interview on 11/20/24 at 2:55 PM, the CDM confirmed handwashing had been covered in orientation, and infection control covered in on-going training. She stated she had already spoken with the staff and felt they were nervous during the meal service. A facility policy, revised on 3/9/2020, titled Handwashing, Policy statement declared Hands shall be washed in accordance with established procedures in order to prevent contagion and to protect residents from infections. The Procedure, step #2 Hands will be washed directed staff, in part to wash hands when: g. After hand contact with unclean equipment and work surfaces, soiled clothing, and rags. l. Leaving and returning to the kitchen/prep area. m. Anytime a task is changed.

Based on facility policy review, and staff interviews the facility failed to have an Infection Preventionist who completed specialized training in infection prevention and control. The facility reported a census of 54 residents. Findings include: During an interview on 11/19/24 at 12:45 PM, the Director of Nursing (DON) and Regional Nurse Consulted stated the facility does not currently have a certified Infection Preventionist (IP). The DON stated the Assistant DON is currently taking the required classes and hopes to be done with the course by the end of the week. During an interview on 11/20/24 at 12:54 PM the DON suggested the IP interview should perhaps be conducted with the regional personnel as she is not certified and new to the position. In a follow-up with the Regional Director of Operations, she stated she was not a nurse and would have to collaborate with the Regional Nurse Consultant and the DON to decide who would be best to completed the interview as no IP is currently on staff. The facility policy, revised September 2017, titled Surveillance for Infections, Policy Statement declared The Infection Preventionist will conduct ongoing surveillance for Healthcare-Acquired Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions.

Based on clinical record review, facility notification documents, and staff interviews the facility failed to notify the Office of the State Long-Term Ombudsman (OSLTO) of two separate resident transfers to the hospital for 1 of 3 residents reviewed for hospitalization s (Resident #2). The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) for Resident #2 dated 4/30/24 documented the resident had a Brief Interview for Mental Status ) of 13 of 15 which indicated intact cognition. The MDS list of diagnoses included cancer, schizophrenia, and excoriation (skin picking) disorder. The Care Plan initiated 4/25/24, revealed the resident had Focus areas to address impaired cognitive function, risk for skin and soft tissue infection, required mental health support for anti-depressants, anti-anxiety medications, and anti-psychotics, and had diabetic ulcers on 8 fingers. Clinical record review revealed Resident #2 transferred to the hospital on the following dates: 05/20/24, 06/03/24, 08/29/24, and 10/30/24 The facility provided Notice of Transfer Forms for May, June, August, and October 2024. The Notice did not included Resident #2 for the May and June transfers to the hospital. During an interview on 11/21/24 at 09:26 AM, the Administrator stated the facility social worker was responsible for submitting all discharges monthly to the OSLTO. When asked how it was decided if a transfer to the hospital should be submitted, the Administrator stated it depended on if the transfer was overnight. She acknowledged one of the missing transfers included a same day return and the other was a 5 day hospital visit. During an interview on 11/21/24 at 12:21 PM, the Social Services Director stated she reviewed the electronic health record every morning she was in the building for discharges. When asked how she decided if a resident's transfer should be included on the ombudsman report, she stated she did not include them if they returned the same day.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to administer medication as the physician ordered for one of three residents reviewed. (Resident #2). Findings include: The MDS (Minimum Data Set) dated 6/25/2024 revealed Resident #2 had no cognitive impairment. The MDS dated [DATE] revealed the resident had mild cognitive impairment. The MDS reported the resident had diagnoses including acute congestive heart failure, chronic kidney disease stage III, atrial fibrillation, and pneumonia. The resident's Care Plan revealed the resident had altered respiratory status and used oxygen, initiated 6/19/2024. The Care Plan directed staff to administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor for signs and symptoms of respiratory distress and report to physician as needed: increased respirations; decreased pulse oximetry; increased heart rate (tachycardia); restlessness; diaphoresis; headaches; lethargy; confusion; empty (coughing up blood); cough; pleuritic pain (pain in the chest with inhale or exhale); accessory muscle usage; skin color changes to blue/gray. Resident #2 admitted to the ED (emergency department) on 7/29/2024 with shortness of breath. The ED noted indicated he had Acute hypoxic (low oxygen levels) respiratory failure. He discharged back to the facility on [DATE] with the following new physician orders: albuterol sulfate 90 mcg (micrograms), 2 puffs inhalation every 6 hours as needed; Prednisone 60 mg (milligrams) oral daily; Tiotropium bromide (Spiriva Respimat) 2.5 mcg, 2 puffs inhalation daily. The resident also received an order for furosemide (diuretic) 40 mg oral daily, 40 mg oral every morning, for a total of 80 mg (your normal dose is 40, this is in addition for 5 days only). The resident's Progress Notes included: Effective Date: 07/29/2024 12:18 New order to send resident out to University of Iowa ED to be evaluated due to a change in condition including abnormal vital signs and edema. 7/30/2024 - late entry: Staff D at 12:00 - Resident returned from the hospital with new orders to start Albuterol, prednisone, Spiriva Respimat. Not Notified. 8/1/2024 - Nurse Practitioner. Resident has not received new medications from 7/30/2024: prednisone, albuterol nebulizer, Spiriva, increased furosemide. Very dysgenic (SOB), lethargic and without breathing treatments and prednisone since readmission. This 80 y.o. male was seen today in follow up of his recent hospitalization . He was sent out on 7/29 for decreased oxygenation, decreased BP, increased work of breathing,worsening edema. He had adjustments to his furosemide over the past week without any improvement. He returned to the branch the next day with new orders for albuterol nebs, Spiriva, prednisone and increased furosemide. Today, nursing reports his new orders have not been entered into computer and he hasn't been getting the prednisone or breathing treatments since readmission. He is very dyspneic, lethargic and his oxygen saturations are low to mid 80's. He will be sent back out as he is at maximum 5 L per NC of O2 and oxygen sats still low at 84%. Plan: COPD (Chronic Obstructive Pulmonary Disease) exacerbation: Was given Duonebs with improvement in the ED; Orders for albuterol, Spiriva and prednisone burst ordered upon discharge from the ED. Has not had since coming back, which could account for the worsening of his exacerbation. Discharge back to hospital. On 8/6/2024 the resident readmitted to the facility. On 8/10/2024 the resident discharged from the facility and returned to the hospital with decreased oxygen saturation levels and increased lethargy. The resident passed away at the hospital on 8/11/2024. The Medication Error Incident Report dated 8/1/2024 prepared by Staff D, former DON (Director of Nursing) included: Resident was sent to the hospital for SOB and exacerbation of COPD. Resident was sent back with new medications. Medication was not entered into the eMAR (electronic Medication Administration Record) by the staff nurse. Resident is unable to recall events. The medication error was found by the regional nurse, and the physician was notified. The charge nurse and DON were educated. The Summary of alleged incident included: Date of incident: 8/1/2024. Date of investigation: 8/2/2024. Resident returned from the hospital for new medication orders to start. These orders were not put into the system and resident did not receive his medications. Resident was sent back to the hospital and that is when it was realized that he never received his new medications from his last hospital visit. Root Cause Analysis: New orders were not put into PCC (Point Click Care) upon resident's readmission back to the facility from the hospital. Conclusion: Patient was re-hospitalized . The facility Past Non-Compliance Checklist included: Plan of Correction: Education provided to nursing staff, charge nurse responsible to complete on any admission or transfer in from the hospital followed by double noting by two nurses. The EMS (Emergency Medical Services) report dated 8/1/02024 at 3:14 p.m. included: Arrived with patient upright in bed, complained of SOB (shortness of breath) that started early this morning. Lungs are coarse bilaterally, oxygen on at 5 liters via nasal canula, normally the patient is on 3 liters. Oxygen saturation levels running at about 88% since SOB started this morning. Patient states care center has been giving him puffs but won't let him use nebulizer. Feels fluid buildup in his legs has increased since he has been back at care center. Patient requested to have nebulizer treatment. Nebulizer Albuterol 2.5 mixed with Ipratropium 0.5 mg. given. Patient reports feeling better with initial dose but still SOB. Nebulizer given times two, transported to hospital. The hospital discharge summary dated 8/6/2024 included: Reason for Admission: Shortness of Breath (Started today. Given his inhaler at care center. 85% for EMS. Given nebulizer by EMS. Now 90 % on 3 L (liters). Normally uses 3 L at Crestview. ) Hospital Course - In short, this is a [AGE] year-old male who presents to the hospital with acute on chronic respiratory failure secondary to restrictive lung disease/interstitial lung disease and sleep apnea. Patient was started on prednisone, oxygen supplementation and breathing treatments. Patient also was started on IV (intravenous) Lasix (diuretic). This did improve patient's respiratory status that he is now at baseline. He is now ready to be discharged back to his skilled nursing facility with a Medrol Dosepak (steroid). Family also requested that we stop his anticoagulant as he is a risk factor for falls. This has been accommodated. Patient stable to be discharged . Principal Diagnosis (definitive condition responsible for the admission): Acute hypoxic on chronic hypercapnic (too much carbon dioxide in your blood), respiratory failure (HCC). The Death Certificate filed 8/21/2024 included: Time of death: 8/11/2024 at 4:25 a.m. Immediate cause of death: Acute on chronic hypoxic and hypercapnic respiratory failure. On 9/4/2024 at 8:30 a.m., Staff F, physician reported the resident missed medications and that resulted in him returning to the hospital, but it did not result in his death. On 8/10/2024 when the resident returned to the hospital in ICU (Intensive Care Unit), he made the decision to withdraw cares. He had acute and chronic respiratory failure but they probably could have brought him around. His primary diagnosis of pulmonary arterial hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart) combined with heart failure and lung disease caused him to have real problems. Since it was his choice to withdraw treatment, we cannot say it was his demise. On 9/4/2024 at approximately 9:00 a.m., Staff D (former DON) reported working as the director of nursing from April until August 21, 2024. When Resident #2 returned from the hospital on 7/30/2024, Staff E, agency nurse gave the re-admission papers to Staff D. Staff E failed to put the new orders in the system. Staff D placed the admission papers in her office and exited the building due to feeling ill. On 7/30/2024, Staff A texted Staff D and informed her the resident's new orders had not been entered into the system. Staff D instructed her to call the hospital and physician to get the resident's records. On 8/1/2024, the corporate regional nurse caught the error and questioned Staff D, and indicated the resident had to return to the hospital. The facility had to file a self report with the state. On 8/16/2024 Staff D received a written warning that included: Resident admitted with new orders that were not placed in resident's orders creating a significant medication error. The ADON (Assistant Director of Nursing) reached out to you for guidance. She was told to reach out to the hospital for a copy of orders that were in your office which could have been accessed more timely, which would have been in the best interest of the resident. This instance resulted in a self report. On 9/4/2024 at 9:30 a.m., Staff E, RN (Registered Nurse) reported he worked for an agency. On 7/30/2024 Resident #2 returned from the hospital around noon. Staff E assisted the paramedics transfer the resident to his bed. Staff E handed the resident's admission paperwork to Staff D and Staff D said thank you. The resident arrived during a busy time and Staff E had no time to enter the medication orders into the system. Staff E indicated it was Staff D's responsibility to handle the admission. On 9/3/2023 at 2 p.m., Staff A, ADON reported working on 7/30/2024. Around 7:30 p.m. Staff A noticed the resident had a couple of new medications delivered. Another nurse, Staff G reported the resident had not been readmitted into the system. Staff A notified Staff D that the resident had been admitted with no orders. Staff D revealed the orders were locked in her office, and that afternoon she had to leave work as she was feeling ill. Staff A called the hospital but they were unable to provide the orders as the resident's records had been sent to medical records. The resident failed to receive the new medications. The facility policy Administering Medications revised April 2019 included: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. 6. Medications errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking photograph attached to medical record; and b. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation and resident and staff interviews, the facility failed to respect personal property and possessions when they searched the resident's room without consent for one of three residents reviewed. (Resident #3). The facility reported a census of 54 residents. Findings include: The MDS (Minimum Data Set) assessment tool dated 6/14/2024 revealed Resident #3 had no cognitive impairment, transferred from one surface to another independently, used a wheel chair for mobility and had diagnoses including post-polio syndrome, rheumatoid arthritis, and paraplegia. On 9/4/2024 at 1:00 p.m., the resident self transferred from the commode to the nearby bed and sat upright with the support of pillows. The resident described a situation where staff searched her room without her consent while she was not present. Staff left her belongings unorganized and she could tell someone had gone through them. Staff told the resident they were looking for her roommate's television remote, and they failed to find it. On 9/3/2024 at 1:40 p.m., Staff A, ADON (Assistant Director of Nursing) reported the resident reported staff went through her belongings. Her roommate's remote was missing, the resident had a physician's appointment and staff went through her things without her knowledge. Staff were educated after the incident and told the resident had to know and give permission for them to search belongings. On 9/3/2024 at 10:50 a.m. and 1:30 p.m., Staff B, DON (Director of Nursing) reported she instructed staff not to go through resident's belongings without their knowledge. The resident's roommate had things come up missing like the remote and staff searched the resident's side of the room. When Staff B learned of it, she educated staff. The facility's Resident Rights policy revised December 2016 included: Resident Rights Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity. c. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on staff interview, clinical record review, and facility document review, the facility failed to accurately assess resident conditions and implement appropriate interventions in a timely manner for 2 of 9 residents reviewed for accurate assessment. The facility failed to adequately assess and document a resident's worsening gastrointestinal illness symptoms that included stomach ache, abdominal tenderness and emesis that occurred over a 4 day period, failed to notify the medical provider of that resident's symptoms and seek treatment orders for 4 days, the resident required emergent medical treatment in the hospital emergency room (ER) and died within 6 hours of ER admission (Resident #10), failed to accurately assess and document a resident's worsening edema (swelling caused by fluid retention) and inability to urinate for 2 days that required hospitalization (Resident #8), and failed to correctly transcribe a physician's order for insulin for 1 of 3 residents reviewed (Resident #11) for following physician's orders. That failure resulted in missed insulin doses and the resident's hospitalization for Diabetic Ketoacidosis. The facility reported a census of 61 residents. Findings include: 1. The Admission MDS assessment dated [DATE] revealed Resident #10 had diagnoses that included traumatic brain injury, left sided hemiplegia (paralysis on 1 side of the body), diabetes, gastroesophageal reflux, anxiety and bipolar depression, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated moderate cognitive impairment, without symptoms of delirium present. The resident had clear speech, no hearing deficits, sometimes was able to make himself understood and sometimes was able to understand others, and able to ambulate and toilet himself independently. The resident had a Power of Attorney (POA) for decision making and responsible for directing the resident's care as needed. Physician orders directed staff to administer the following medications: Tums Chewable 500 mg tablets, 2 tablets oral every 4 hours as needed for stomach upset (start date of [DATE]). Metformin (an antidiabetic medication) 1000 mg administered oral daily (start date of [DATE]). Jardiance (an antidiabetic medication) 10 mg administered oral daily (start date of [DATE]). A Focus area for Diabetes initiated [DATE] on the resident's Nursing Care Plan directed staff: a. Diabetes medication as ordered by doctor. Monitor for and document side effects and effectiveness. Date Initiated: [DATE] b. Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. Date Initiated: [DATE] c. Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: [DATE] The facility's Change of Condition policy, dated as last reviewed in February, 2021, directed staff: 1. Promptly notify the resident or their responsible party, and attending physician of changes in the resident's physical or mental condition or status. 2. Notify the physician when there is a significant change in the resident's condition. Significant change described as a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Nursing Progress Notes revealed the following entries: [DATE] at 9:22 p.m. Staff F, RN, stated: Resident complained of stomach ache this shift. Sprite given to him he then requested Tylenol. Tylenol provided resident refused to eat dinner, then continued to sit in his room and pull call light excessively each time staff went in room it was for miscellaneous things not related to stomach ache. This nurse assessed resident, abdomen soft non tender non distended bowel sounds active in all quadrants resident stated last bowel movement (BM) was this morning. This nurse asked resident to describe stomach ache resident stated he was nauseous. This nurse educated resident about eating an actual meal and reduce his soda and cookie intake. Resident verbalized understanding and within a few minutes later resident pulled call light for soda and oatmeal cream pie. Resident continued to pull call light every couple minutes this nurse asked resident if he wanted to be sent to the hospital resident declined. Resident continues to pull call light excessively. [DATE] at 3:56 a.m. Staff G, RN, stated: Resident has been consistently pulling call light back to back within seconds or minutes of each other throughout this shift for miscellaneous things, blanket adjustments, for snacks, help adjusting the pillow, complains of stomach ache - vital signs stable, temperature 97.8, oxygen via nasal canula with saturation of 92%, respirations 18, pulse 92 regular, blood pressure ,d+[DATE], bowel sounds active in 4 quadrants, resident reports last BM ,d+[DATE] in AM, resident reports passing flatus, abdomen nondistended, soft, resident reports tenderness in center of quadrants with palpation - no mass felt. resident educated on better food choices as resident historically drinks several sodas a day back to back and eating junk snacks throughout the day as well. The residents clinical record lacked documentation of resident's condition on [DATE]. [DATE] at 9:45 a.m. Staff H, LPN, stated: Staff reported resident has been vomiting all weekend and hasn't been eating. Resident is pale with dark circles around his eyes. Vitals were taken and recorded and are within normal limits. Resident reported no discomfort, chest pain or shortness of breath. Resident did not eat breakfast today. Lungs clear upon auscultation. Last BM was [DATE] and was large in size. Spoke with Nurse Practitioner at 9:45 a.m , orders for Zofran 8 mg every 8 hours as needed for vomiting and a CBC (complete blood count) with differential and CMP (comprehensive medical provide) laboratory tests ordered for [DATE]. Resident to be sent to the hospital if keeps vomiting and not taking fluids for dehydration. [DATE] at 10:59 a.m., Staff H, LPN stated: Staff reported to this nurse resident was becoming confused and had complaints of shortness of breath. Oxygen saturation was 95% room air and resident had complaints of shortness of breath, called Nurse Practitioner at 10:28 a.m., asked if resident could be sent out , the Nurse Practitioner approved the order, called non-emergent transport at 10:50 a.m., ambulance arrived at 11:09 a.m. The ER Physician Progress Note dated [DATE] described upon their arrival at the facility, the ambulance staff found resident in acute hypoxic respiratory failure that required 6 liters of oxygen per minute, hypotensive (low blood pressure) with systolic pressure (the higher of the 2 numbers recorded for blood pressure results) of 80. The resident was cool to touch and ambulance crew unable to palpate pulses. Norepinephrine (a sympathomimetic drug used to treat critically low blood pressure) administered intravenously (IV) started, the staff unable to obtain a blood pressure after the medication started, and 250 milliliters of IV fluid administered prior to the resident's arrival in the ER. Once in the ER, the resident continued with acute respiratory failure symptoms, required aggressive treatment that included intubation (large tube inserted through the mouth, placed into the lungs and used for mechanical ventilation), a large amount of vomitus occurred during the procedure, another tube then inserted through the nose and into the stomach, attached to suction with immediate returns of 3 liters (approximately 1 gallon) of dark brown liquid (symptom of a bowel obstruction), bowel obstruction confirmed by a CT (computed topography) scan of the stomach and aspiration pneumonia (occurred during intubation with vomitus) confirmed by CT scan of chest. The resident's oxygen saturation level did not increase above the low 70 percent range (normal 97 to 100 percent) despite aggressive efforts, several medications were administered without success to improve the resident's blood pressure, the resident treated unsuccessfully with cardiopulmonary resuscitation (CPR) for circulatory and respiratory failure, and acute respiratory distress syndrome (ARDS), small bowel obstruction, acute kidney injury from dehydration and acute pancreatitis diagnosed at the time of the resident's death on [DATE]. Staff interviews revealed: [DATE] at 2:39 p.m., Staff L, RN, stated she worked the evening shift on [DATE] (2 p.m. to 10 p.m.), at first the resident asked for a Coke, she told him he had just had 3, then the resident said he had a stomach ache, she told him the Coke wouldn't help, it was getting close to supper time, he'd just ate 6 oatmeal cream pie cookies. She told him to eat a regular meal at supper, the resident had ate 1 or 2 bites of supper and asked again for a Coke, then asked for another oatmeal cream pie cookie. The resident went to bed shortly after that, put the call light on and wanted Tylenol for a stomach ache, located by his navel. The resident denied nausea, she assessed his abdomen, it was soft, he reported his last BM 2 days earlier, rated the pain at a 1 on a 0 to 10 pain scale, with 10 assigned to the worst pain, she didn't want to give him Tylenol because he hadn't really ate anything for supper. She asked him if he wanted to be sent out (sent to the ER) the resident didn't want to go, and she documented he refused to be sent out. She did not notify his POA about his condition, or consult with his Physician or Nurse Practitioner. When she checked on him later in the shift he said he felt better. [DATE] at 5:17 p.m., Staff M, RN, stated she worked the night shift (10 p.m. to 6 a.m.) starting on [DATE]. the resident had complained of a stomach ache, nothing serious, he is known to eat a lot of junk food and soda, he didn't complain of nausea and didn't throw up on that shift. She then worked a double shift starting at 6 a.m. on [DATE], to 10 p.m. that day, staff reported the resident had an emesis on the day shift, she didn't know if the resident had ate any meals that day or his food intake, and didn't believe the resident had any symptoms that required further assessment or intervention. [DATE] at 5:08 p.m., Staff K, RN, stated she worked from 6 p.m. on [DATE] to 6 a.m. on [DATE], and again at 6 p.m. on [DATE] to 6 a.m. the following morning, she checked on the resident on rounds a few times, he was asleep most of the night, used the call light a couple of times and wanted the aides (Certified Nursing Assistant's or CNA's). [DATE] at 11:40 a.m., Staff I, CNA, stated she worked the day shift on [DATE], around 6:30 a.m., the resident had thrown up, she got him cleaned up, told the nurse, Staff M, RN. The resident went to breakfast, then napped. The resident ate lunch, and wasn't aware of any more emesis on [DATE]. When she worked the day shift on [DATE], they said in report that he didn't feel good and the resident didn't seem like himself. He'd thrown up before breakfast that morning but was still talking, she told the nurse, Staff H, LPN, to look at him. [DATE] at 7:39 p.m., Staff H, LPN, stated she worked the day shift (6 a.m. to 2 p.m.) on [DATE], there wasn't any information related to anything abnormal about Resident #10 passed along in the nurse to nurse shift report that morning, and Staff I, Certified Nursing Assistant's (CNA), told her to look at him, he'd been vomiting for 2 days. The resident was seated in the [NAME] hall common area, he was extremely pale, area around his eyes looked black, the resident said he'd been vomiting. Staff informed her he had only been eating oatmeal cream pie cookies and pop, and not eating food. She took his vital signs, they were normal, and as she assessed the resident he vomited a moderate amount of dark brown liquid. The resident didn't complain of pain at the time, she kept an eye on him, he didn't look right, she called the Nurse Practitioner who gave orders for Zofran, lab work orders for the following day, and to sent him out if he couldn't keep food and fluid down. Within a short time, less than 20 minutes, he looked worse, she called the Nurse Practitioner again and obtained an order to send the resident to the hospital ER. She contacted and informed the DON, Staff J, and the DON told her she was upset about this because she had directed other nursing staff to notify the Nurse Practitioner of the resident's symptoms and obtain orders. After she called for an ambulance and within the time it took to print the paperwork for his transfer, the resident's condition had worsened and he was struggling to breathe. The ambulance staff arrived around the same time and they said he looks terrible. [DATE] at 11:58 a.m. Staff J, RN and current DON, stated she was in the facility on [DATE] and had directed Staff L, RN, to notify the Nurse Practitioner of the resident's condition that day, and expected nursing staff to assess resident's when they had changes in condition, notify the Physicians or Nurse Practitioners and responsible resident party's as appropriate, seek treatment orders when needed, and also notify her of resident condition changes. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, peripheral vascular disease, hypertension (high blood pressure), diabetes and renal insufficiency and bilateral leg amputations below the knee. The Nursing Admission Assessment form completed [DATE] revealed the resident had edema (swelling of the body caused by retained fluid), without further description of location or amount, and continent of urine. The Hospital Discharge Summary dated [DATE] revealed the resident recently hospitalized for hematuria (blood in the urine) that required transfusion with 2 units of blood, a high grade urothelial cancer (involving the urethra) suspected, currently hospitalized for diarrhea with abdominal cramps, and to discharge to a nursing home with medication orders that included: 1. Amiodorone (an anti-arrhythmic heart medication) 200 milligrams (mg) administered oral daily. 2. Torsamide (a diuretic medication) 20 mg administered oral daily. 3. Spironolactone (a diuretic medication) 12.5 mg administered oral daily. 4. Metoprolol Succinate (an anti-hypertension medication) Extended Release (ER) 25 mg administered oral daily. 5. Trospium Chloride (an antispasmodic medication for the bladder) 20 mg administered oral daily. Pharmacy records revealed revealed: The identified medications were delivered to the facility on [DATE]. On [DATE] the pharmacy delivered the same medications to the facility again. The February, 2024 Medication Administration Record (MAR) revealed the resident did not receive the Amiodorone until [DATE], and did not receive the other identified medications until [DATE]. During an interview on [DATE] at 2:11 p.m., the facility's Corporate Nurse stated the pharmacy had used the resident's Hospital Discharge Summary for a medication list, sent those medications to the facility on [DATE] with documented delivery, and staff should have been able to administer those medications on [DATE]. The problem was the former Director of Nursing (Staff B, RN) admitted the resident on [DATE] but didn't complete the admission assessment or enter the medication orders in the computer until [DATE], that should have been completed the day before and the nursing staff would have had the directives for administration on the resident's Medication Administration Record if the process was completed when it should have been. The Corporate Nurse stated nursing staff should accurately and adequately document abnormal resident assessments, and the nursing staff that couldn't find the resident's medication should have checked in the Medication Room, if not there she could have asked the other nurse on duty for assistance, or contacted a manager on call, and most of the resident's ordered medications were in the facility's Emergency Medication Kit and she could have administered medications from that supply if she could not locate the medications, there was no reasonable excuse for the nurse not to administer the resident's medications that day. The Admission Assessment documents completed [DATE] at 11:26 a.m. by Staff B, Registered Nurse (RN) and the former Director of Nursing (DON) described the resident had edema (swelling caused by fluid retention), without description of the amount or location, the resident continent of urine, without further description of deficits or difficulties, and the resident did not have any pain. An Activity of Daily Living (ADL) Assistance problem initiated [DATE] on the Nursing Care Plan directed staff: Toileting - 2 staff assist required, urinal at bedside. Transfer - 2 staff assist required, with Hoyer mechanical lift. The ER Physician Progress Note dated [DATE] revealed the resident presented due to inability to urinate caused by retraction of the glans penis into the shaft, treated for a urinary tract infection and urine outflow obstruction due to glans penis inversion and exacerbation of chronic kidney disease, the resident able to retract and manipulate the penis foreskin to aid with urination, and instructed to do that to allow urine to exit and prevent backflow into the foreskin. A follow-up urology appointment was scheduled for [DATE] and a follow-up cardiology appointment was scheduled for [DATE], and prescription given for Amiodorone 200 mg administered oral daily. Nursing Progress Notes revealed the following entries: A Nursing Progress Note dated [DATE] at 2:30 p.m. transcribed by Staff B, RN stated: Received a phone call from resident's family member stating that resident was requesting to go back to the hospital due to his increased discomfort and bladder pain. Resident transferred to the hospital emergency room (ER) via ambulance. (No documentation of assessment transcribed by the nurse). [DATE] at 9:34 a.m. Staff D, LPN, documented: Attempted to call pharmacy to receive medications for resident due to medications not in medication cart. On call pharmacist resistant on sending medications and questioned nurse where medications went. Contacted DON, informed her of situation, she stated she would contact the on call pharmacist. DON called this nurse back and stated the pharmacy is sending resident's medications this morning. A physician order dated [DATE] directed staff to elevate the resident's scrotum with a rolled towel due to edema. The resident's clinical record lacked any documentation of assessments of the resident's edema, pain, or difficulty with urination, until the following Nursing Progress Note entry: [DATE] at 2:15 a.m. Staff E, RN, documented: Resident assisted to commode around 1:30 a.m. Only able to urinate very small amount, less than 25 milliliters (approximately 5 teaspoons) of thick, cloudy, yellow fluid. Complains of pain to abdominal area rated at 10 out of 10 on pain scale, and that it is more swollen than previous days. Painful upon palpation. This nurse attempted to pull foreskin back, but it is too swollen. Resident reports he can barely eat or drink because he is too uncomfortable and wants to be seen at hospital. Notified on-call provider, order to send to ER, 911 called for transport. An ER to Hospital Admission Physician Progress Note dated [DATE] described the resident presented after unable to urinate for 2 days, treatment required included urinary catheterization by a Urologist physician, and the resident hospitalized with diagnoses that included urinary retention with suspected bladder malignancy, urinary tract infection, acute kidney injury and acute on chronic systolic heart failure. 48888 3. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. Resident #11 received insulin injections on 7 days of the reference period. Diagnoses included Diabetes Mellitus, cancer, and liver transplant status. MDS indicated a life expectancy of less than 6 months with hospice services. The Care Plan, revised on [DATE], lacked focused area for insulin administration, blood sugar monitoring, or signs and symptoms of high or low blood sugars for Resident #11's diagnosis of Diabetes Mellitus. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated [DATE], lacked scheduled insulin order in place between the dates of [DATE] and [DATE] and lacked scheduled blood sugar checks between the dates of [DATE] and [DATE]. The [DATE] MAR and TAR included the following orders: -Lantus (insulin glargine) solution 100 units per milliliter(ml). Inject 4 units subcutaneously two times a day related to Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Started on [DATE] and discontinued on [DATE]. -Lantus (insulin glargine) solution 100 units/ml. Inject 4 units subcutaneously one time a day for Diabetes. Started on [DATE] and discontinued on [DATE]. -Novolog (insulin aspart) Solution subcutaneous injection with meals related to Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease following blood sugar sliding scale: if blood sugar between ,d+[DATE] give 1 unit, ,d+[DATE]= 2 units, ,d+[DATE]= 3 units, ,d+[DATE]= 4 units, ,d+[DATE]= 5 units. Blood sugar greater than 400, notify the provider. Started on [DATE], discontinued on [DATE], and restarted on [DATE]. -Blood sugar checks before meals related to Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Started on [DATE] and discontinued on [DATE]. -Blood sugar checks once a week every Monday related Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Held between the dates of [DATE] through [DATE] and revealed a start date for [DATE]. Review of the Nursing Progress Notes between the dates of: [DATE] through [DATE] revealed the following entries: 1. On [DATE] at 04:32 AM, Resident #11 observed to be pale, clammy, and difficult to arouse. Blood sugar recorded as 37. Hospice notified, facility received verbal orders to administer Glucagon 1 milligram(mg) per vial, discontinue the evening dose of Lantus (insulin glargine), discontinue the sliding scale Novolog (insulin aspart), and perform blood sugar check once per week. Nursing documented administration of Glucagon 1 mg at 04:40 AM. 2. On [DATE] at 05:28 AM: Nursing documentation for follow up blood sugar of 78. 3. On [DATE] at 09:45 AM: Note indicated Resident #11's insulin and blood sugar checks had been discontinued the previous day and reported no noted symptoms of hypoglycemia (low blood sugar). 4. On [DATE] at 05:48 PM: A change in condition assessment completed for altered mental status and other change in condition. Assessment revealed an altered level of consciousness, more assistance with activities of daily living required, general weakness, and decreased mobility. Change of condition assessment also informed there had been a change in medications. 5. On [DATE] at 05:48 PM: Family notification of Resident #11's condition change with documentation that the family had been upset about discontinued insulin and blood sugar checks. Facility also notified Hospice of Resident #11 condition change and blood sugar reading message of HIGH (HI). Orders received from Hospice for an as needed Novolog (insulin aspart) solution, following previous sliding scale order and Lantus (insulin glargine), 4 units in the morning. Nurse documented 5 units of Novolog given following as needed sliding scale order. 6. On [DATE] at 06:09 PM: Blood sugar continued to read as HIGH (HI), Hospice notified. 7. On [DATE] at 06:10 PM: Resident #11 lethargic with pale, clammy skin, and fruity smelling breath. Facility notified family and discussed the insulin changes that occurred on [DATE], family stated they thought Resident #11 would continue to receive a morning dose of insulin and blood sugars would be checked if a change in condition occurred. Hospice provider notified and advised that the morning dose of Lantus (insulin glargine) is to continue. Blood sugar continued to read HIGH (HI) after the 5 units of Novolog (insulin aspart) administered. Facility received verbal order to immediately transport Resident #11 to the Hospital for possible Diabetic Ketoacidosis. 8. On [DATE] at 02:00 AM: The Hospital informed facility that Resident #11 would be admitted for Diabetic Ketoacidosis. The Incident Report, dated [DATE], completed by Director of Nursing (DON), revealed that during review it is noted that order received was to discontinue the evening dose of Lantus (insulin glargine) but both morning and evening doses were discontinued. Resident #11 sent to the emergency room as an immediate action taken. Additionally the DON contacted Nurse who took orders on [DATE] and provided education. The facility self-reported incident to the Department of Inspections, Appeals, and Licensing. A statement, signed and dated [DATE] by Staff A, Licensed Practical Nurse (LPN), revealed orders received from Hospice provider to discontinue evening dose of Lantus (insulin glargine), discontinue sliding scale insulin, and check blood sugar once per week. Staff A informed that Resident #11's blood sugar rechecked and read a higher result that was within normal limits. The facility provided document, titled Past Non-Compliance Checklist, dated [DATE], revealed the following corrective actions taken for the resident (Resident #11) affected by incident: Past non-compliance completed to include diabetic management, hospice orders, review of the shift to shift report, review of the 24 hour report, and review of the order listing report. All telephone orders must be printed off for a second nurse to validate the accuracy of new orders daily Monitoring of compliance during morning clinical meetings. Ongoing monitoring of compliance with Quality Assurance and Performance Improvement (QAPI).

Based on clinical record review, staff interviews, and facility investigation review, the facility ailed to ensure staff protected and prevented potential abuse for 1 of 61 residents (Resident #5). The staff failed to identify an unknown male who entered the facility, spent an unknown amount of time with Resident #5, who was cognitively impaired, transferred the resident twice without assistance, then staff found the unknown male shirtless with his pants around his ankles, lying in bed with the resident; the resident observed to be crying. ). This failure resulted in possible distress for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. On April 13, 2023 at 10:30 AM, the State Survey Agency informed the facility the staff's failure to identify and prevent the stranger from accessing Resident #5 created an Immediate Jeopardy situation, which began on April 5, 2023. The facility staff removed the immediacy on April 5, 2023, when the facility staff implemented the following Corrective Actions: a. The facility staff locked the doors to the facility. b. Placed a visitor sign-in book near the entrance to the facility. c. Educated the staff on the interventions. d. Educated the staff on how to handle visitors the staff do not recognize. e. Educated the residents and their families on the new process which required the visitors to sign-in when they visit a resident. The facility staff's actions lowered the scope and severity from a J to a D at the time of the survey, after the State Survey Agency staff verified the facility staff had implemented the education and additional corrective actions. The facility staff identified a census of 61 residents, including 26 cognitively impaired residents. Findings Include: 1. Resident #5 admitted to the facility on [DATE] according to the Admission Record. The Minimum Data Set (MDS), dated [DATE], identified Resident #5 with severe cognitive impairment, required extensive assistance from 2 staff to transfer from 1 surface to another, failed to ambulate, severely impaired vision, and moderate difficulty with the ability to hear. The MDS documented the resident with diagnoses including dementia and left hip pain. The Care Plan identified Resident #5 was a fall risk and directed staff to provide a low bed and remove the recliner from the room. Resident #5 transferred from 1 surface to another with the use of a mechanical Hoyer lift and 2 staff. The Care Plan indicated the resident had concerns including hard of hearing and legally blind and it directed staff to approach calmly. The Order Summary Report revealed the resident had physician orders including Trazodone 25 mg twice a day for dementia and anxiety. Review of Resident #5's Progress Notes, dated 4/5/2023 at 2:55 p.m., entitled Incident, Accident, Unusual Occurrence authored by Staff A, Director of Nursing (DON) documented, staff found visitor in room with resident. The Visitor had himself exposed; and the visitor was escorted out of the room to the front lobby. Resident was fully dressed, not in distress at this time and with normal behavior/affect. No complaint of pain or discomfort. Head to toe assessment completed without concern. Nephew notified, he declined further assessment at this time. Nurse Practitioner notified. The local Police Department's Call for Service Record, dated 4/5/2023 at 2:53 p.m. revealed an officer was dispatched to the facility at 2:54 p.m. for a possible assault. The front door of the facility was unlocked and open to the public. Facility staff reported that they found the unknown male in the resident's bed under the covers, lying with the resident, and the unknown male's pants pulled down. When facility staff made contact with the unknown male, it appeared the male was pushing the resident's hands away from the unknown male's crotch under the covers. At no time did staff visualize the male's genitals. A physical assessment found no findings that the resident had been assaulted. The resident was found to be wearing clothing and underwear at the time the male and the resident were found in bed. The facility Administrators did not want the male to return to the facility. The male claimed he was taken in by the resident (housed) [AGE] years ago and learned from a friend that the resident was at the facility. The male stated he entered the facility, found the resident eating lunch and contacted her. He wheeled her to her room where they were both in bed, and he got more comfortable by opening his belt and sliding his pants down in bed. He said there were no sexual acts between him and the resident. He said he would not return to the property. The Service Record documented the unknown male was sent to the Hospital for a court ordered in-patient psychiatric evaluation. The Facility Investigation included the following timeline: a. On 4/5/2023 at 10:30 a.m., a Certified Nursing Assistant (CNA) noted a male visitor in facility walking around, appearing to look for someone. b. At 11:00 a.m., CNA noted male pushing Resident #5 in her wheelchair. Male noted calling resident Mom. c. At 11:10 a.m., CNA approached by male, by the lunch room, where he asked where resident's room was. CNA told him where her room was and he said thank you. d. At 11:45 a.m., other resident informed that the male was her brother and he had just gotten off work. e. At 12:00 noon, CNA noted resident at her table at lunch, and male was not with her. f. At 12:30 - 12:45 p.m., CNA noted male entering the facility again and observed walking up East hall. CNA pointed him to West hall. g. At 1:00 p.m. and after, male noted pushing resident in her wheelchair throughout the facility. Also seen standing next to the resident in her wheelchair in the common area. h. At 2:50 p.m., CNA's found male in resident's bed without clothing on. Immediately got DON and when entered room noted resident with head at foot of bed, still with clothing on and jumpsuit unzipped half way in back. Staff immediately got male out of resident's bed and escorted to the front lobby. Police were called. Male stated he was a distant cousin of resident. Police arrived and detained male. Facility was later notified the male admitted to Psychiatric Unit at a local Hospital. Assessment of resident completed and no issues noted. No signs of distress noted, with normal behaviors and affect noted. i. At 3:00 p.m., the resident's Nephew notified. He stated he was not aware of who the male visitor is, and never heard of him. Declined sending resident to the emergency room (ER) for an assessment when asked. The Facility's Interventions implemented included: a. Male visitor detained by police. b. Visitor Sign In log initiated. c. Communication sent to all responsible parties/residents. d. Doors locked so visitors must be left in. e. Education provided to staff on: Visitor Sign In log, and monitoring and communication of suspicious behaviors of visitors to management staff. The Facility's Conclusion: Incident with unknown male visitor being found unclothed in resident's bed is confirmed. No signs or symptoms of physical or sexual abuse noted. No changes in mood and affect noted after incident. Facility took all precautions necessary to mitigate another similar incident of this type. During an interview on 4/11/2023 at 9:50 a.m., Staff A, DON indicated on 4/5/2023, around lunch time, she was in her office and Staff J, CNA came to her and said there was a man sitting in the East common area and he looked a little dirty. Staff A thought maybe he was a family member. Staff J left and the male went to West hall. Staff J returned and said he was a family member. After lunch he was seen pushing Resident #5 around in her wheelchair. Around 2:40 p.m., Staff K, CNA and Staff L, CNA came to her office and said something was weird. They observed the resident's head at the foot of the bed and they heard a man say they were just cuddling. They observed him in bed next to her, she was on her right side, facing him. He was covered with a blanket and she was fully dressed. Staff A and Staff D, Registered Nurse (RN) went to the resident's room and observed the same. Staff A asked what was going on and the male said I am just trying to help her sleep. Staff A asked him why he had no clothes on and he said he did have clothes on. Staff A said having pants around your ankles in not having clothes on. Staff D left to notify the Administrator and call the Police. The male told Staff A he was a distant cousin of the resident and he had picked her up and got her into bed. The resident has partial blindness and said nothing, but was tearful. As the Administrator entered, the male sat up at the side of the bed and pulled up his pants under the blanket. Staff escorted the male to the front lobby and informed him he was to stay until police arrived. The Police arrived, notified the Sheriff and they questioned the unknown male and the resident. The resident had no recall of the events when questioned by the facility staff. The nephew revealed he had never heard of the man and the resident only had 3 relatives. Police found the male had an involuntary court mental health committal, due to an earlier incident at a public library. Police also said they picked the unknown male up that same day and dropped him off at a nearby trailer park. Staff D performed a head to toe assessment with no concerns. Police took the male to a local hospital for psychiatric commitment and evaluation. Staff were educated, doors were locked between second and third shifts, and a visitor log was initiated. On 4/7/2023, the facility added a door bell at the front entrance for visitors to ring and doors were locked 24/7. The resident's roommate, Resident #9 said the male tried to put Resident #5 into Resident #9's bed first, and Resident #9 informed the unknown male that Resident #5's bed was on the other side. No staff reported observations of the male approaching other residents. During an interview on 4/11/2023 at 1:50 p.m., Staff J, CNA reported that on 4/5/2023 she worked from 6 AM - 2 PM on East hall. She observed a strange appearing man with dirt on his face and clothing. He appeared to be homeless and sat down in a chair closer to the Nurse's Station after lunch, as if he was waiting for someone. He did not say anything and Staff J did not ask him anything. Staff J felt uncomfortable, so she went and told Staff A, DON when the unknown male got up and started walking. He sat down on a chair near the Nurse's Station, near a female resident, but the resident's back was towards Staff J. Staff A came out of her office, looked over towards the Nurse's Station, and said the unknown male must have been someone's family member. About 30 minutes later, Staff J saw the unknown male walk Resident #5, in her wheel chair, down the East hall heading towards the Dining Room. He did not say anything, but the resident said help me, which she does a lot, so Staff J did not think anything of it. Staff J assumed the unknown male was her family member, and told Staff A he must have been [Resident #5's] family member. Staff J was not involved in anything after that. The next day, Staff J received education about knowing who is in the building. Before, in order to get in a visitor had to push a button and it stopped the alarm from going off. Now a visitor had to ring the doorbell. The staff also require visitors to sign in, ask who the visitor was, and who the visitor was at the facility to see. On 4/11/2023 at 2:05 p.m., Staff M, CNA reported working for an outside staffing agency, and worked at the facility for 1 month on the day shift. On 4/5/2025, Staff M worked on the West hall. Close to lunch time, Staff M observed the male sitting on the sofa in the TV area on West hall, watching TV with the residents. Staff M thought the male was someone's family member. Staff M never saw him after that, did not talk to him, just got a glimpse of him. Staff M stated staff received education to include that even if they know someone, they should always ask the visitor to sign the Visitor Log, ask who the visitor was here to visit, and how they were related. On 4/11/2023 at 2:12 p.m., Staff G, CNA revealed that on 4/5/2023 she worked on East Hall. Staff G saw the man when he was pushing Resident #5 in her wheelchair down East hall, shortly after lunch. He did not say anything and appeared dirty. The resident was quiet. The facility is now locked 24 hours a day. If someone comes to the facility, the staff have to ask the visitor to sign in with their phone number and who they are here to see. On 4/11/2023 at 2:15 p.m., Staff N, RN reported she worked for a Staffing Agency for 13 months, and worked at facility for [AGE] years. On April 5th, she worked on both halls along with two Med Aides. She was charting in the break room around 12:45 p.m., when she saw the man walk past her doorway towards East Hall. He was alone. She was in Staff A's room, charting and staff came to her office and reported there was a man in Resident #5's bed, before 3 p.m. Staff N did not notice any changes in the resident's behavior. Staff N stated staff received education including now, the facility locked the doors, everyone rings the door bell, and visitors sign in. On 4/11/2023 at 2:28 p.m., Staff O, CNA reported working on 4/5/2023. The first she saw the gentleman, she was in the dining room, around lunch time. He was walking from East Hall to West Hall and did not say anything. Staff O thought it looked odd; he kept walking like he knew where he was going. He did not go up to any residents. The next time I saw him, he was pushing Resident #5 in her wheel chair going across the Dining Room again. He said nothing and she kept saying her name. The Dining Room was mostly empty by that time. Staff O stated did not see him or the resident again and Staff O left at 2 p.m. On 4/11/2023 at 2:40 p.m., Staff L, CNA revealed on April 5th, 2023, she worked on the West Hall, Resident #5's hall from 6 a.m. - 6 p.m. Around lunch time Staff L observed the male visitor and assumed he was here to see a family member. She did not expect anything like what occurred, to happen. Three staff worked on West that day, and if Resident #5 was not out in the day room, she would have assumed somebody already assisted her to bed. Second shift begins at 2 p.m., and staff pass water and check on the residents. Staff K, CNA observed Resident #5 in bed and summoned Staff L to the room. Staff K and Staff L ran to get Staff A, DON and Staff C, Administrator. The curtains on the resident's side of the room were closed, the male had a blanket over him, his pants were all the way down, and he had no shirt on. Staff L peaked through the curtain, the male, talking in a low voice was difficult to understand. After the man was out and the Police were here, Staff L, Staff K and Staff D went in to check on the resident. She was just lying there, she had a one-piece, full body jumpsuit on that zipped up the back. The jumpsuit was half way unzipped in the back but her shoulders were still covered. She was crying. Staff D assessed the resident, she had no skin issues or anything out of the ordinary. Her brief was still on. I stripped the bed right away and sent it to laundry. I did not see anything on the sheets. The resident has never mentioned the incident. They had a Staff Meeting that day and were informed of what happened. They were instructed if they see anyone out of the ordinary in the building to question them, and ask what is the relation to the person they want to see. Doors are currently locked with door bell, and they added a Visitors Sign-In Book. On 4/11/2023 at 3:00 p.m., Staff K, CNA reported working on April 5th, 2023 from 2 - 10 p.m. on West Hall. Staff K walked into Resident #5's room around 2:30 p.m. as Staff K passed water. The curtain was drawn and Resident #5's wheel chair was empty. The staff do not normally pull the resident's curtain as she is a fall risk. The resident's head was at the foot of the bed, and Staff K said what the heck. A male said we are just cuddling. At first, Staff K just saw his face and then Staff K noticed he did not have a shirt on and he was covered waist down with her blanket. The resident was fully dressed and lay facing him. His back was against the wall and she was on the room side of the bed. The resident said nothing. Staff K left the room and saw Staff L, and said did you see that? she said what? Staff K reported she saw a man without clothes in bed with the resident. They ran to Staff A and Staff C. Staff D also arrived. Staff K heard Staff A ask the male who he was and how he knew the resident. Staff K told the male he was inappropriate and needed to get out of the bed. As he walked out, he zipped up his jacked and said I will get out of the way. Staff A said no, you will stay until the Police come. Staff C stood at the front door until the Police arrived. The Police interviewed Staff K. That afternoon, Staff A passed around a photo of the man, told everyone what happened, and if they saw him they were to alert Staff K immediately. The doors were locked and they added a Visitors Sign-In Log. On 4/11/2023 at 3:10 p.m., Staff D, RN, MDS Coordinator, revealed that on 4/5/2023, she observed the male visitor seated next to Resident #5 in the West Lounge after lunch. The next time she saw the unknown male, Staff A had asked Staff D to go with Staff A, because a CNA reported seeing a man lying in bed next to Resident #5. Staff D went and saw the man lying in bed with the resident. He was laying closer to the wall and they were facing each other. He did not have a shirt on and his pants were down around his ankles. Staff A began asking questions and Staff D went to get the Administrator and called 911. Staff A and Staff C walked the male visitor down to the front lobby area. Staff D assessed the resident and assisted the aides in doing incontinence cares. Staff D did not see any marks, abrasions or bruising, Resident #5 was fully dressed, and Resident #5's clothing was intact. The zipper down the back of Resident #5's jumpsuit was partially unzipped; however, her shoulders were covered. The resident had cognitive deficits and she baseline repeatedly calls out and cannot remember. Staff D did not observe the resident crying, but Resident #5 resisted cares. Staff D did not observe the linens, did not notice any wet spots, and nothing appeared to be out of place. The aide stripped the bed and sent it to laundry. Staff D spoke to Resident #5's roommate (Resident #9) who said Resident #9 had been out of the room and when Resident #9 returned, Resident #9 saw Resident #9 and the unknown male in Resident #9's bed. Resident #9 told the unknown male that was Resident #9's bed, so the unknown male picked Resident #5 up and carried Resident #5 to the other bed. When Staff A asked the unknown male who he was, he said he was a distant nephew. Later, the unknown male said the resident had taken him in 20 - [AGE] years ago, so they were not blood related. The resident's nephew (and responsible party for Resident #5) had never heard of the unknown male. Following the incident, the staff notified families that someone entered the facility posing as a family member. The staff locked the doors, added a Sign-In Log asking who the visitor was here to visit, and what their relationship was to the resident. Staff are to follow the visitor to be sure the staff knows where they are going and the person knows who they are. Prior to the incident, the main door was not locked, but a visitor had to press a button to release an alarm. The door was locked at night around 9:30 p.m. The staff ordered a door bell with a longer range, so it reaches the back Dining Room. The phone number is also posted outside the front door. The administration educated staff with a Stand-Up Meetings for every shift following the incident. The staff had photos of the individual posted and they educated staff they were to call the Police if anyone saw the unknown male near the building. On April 11, 2023 at 3:45 p.m., Staff P, Licensed Practical Nurse (LPN)/Agency Nurse, reported she worked on 4/5/2023 from 1:30 - 9:30 p.m. on the West Wing. She was in a resident's room and then saw Staff A tell a man near Resident #5's room to stay until the Police came. A CNA said there had been a strange man in the building. Later, they had a Staff Huddle where Administration explained the incident and passed around a photo of the man. Staff P saw the Police arrive and interview the CNA who witnessed the incident. Resident #5 was anxious after the event. Resident #5 would normally cry out, but Resident #5's crying out after the incident was not normal for Resident #5. Resident #5 refused medication but, did eventually take her pills. Staff P gave the resident an anxiety medication before Resident #5 went to bed. The CNA's did not report anything out of the ordinary. After the incident, visitors have to sign in and out and the doors were locked. Anyone wishing to enter has to ring a doorbell. On 4/12/2023 at 11:45 a.m., Staff C, Administrator, reported that on 4/5/2023 around lunch time, a man entered the facility. Visitors only had to push a button near the front door and enter. The male visited Resident #5 and no other residents. Staff discovered the unknown male in Resident #5's room. When Staff C entered the room, Staff C observed the male sitting at one end of the bed. The unknown male had no shoes and wore pants with a belt and a shirt. The unknown male said he was getting ready to take a nap. Staff D called 911 and Police arrived 5-10 minutes later. Staff saw no signs of semen. Staff C interviewed residents and staff. Staff K and Staff L were the first 2 staff to witness the incident and reported it immediately. They implemented a rapid response to determine the next thing to do. Staff A followed up with the resident's family and they declined to send her to the emergency room for further evaluation. The facility staff instituted a Visitor's Log and reviewed the situation with all staff, expectations and what action would be taken. Doors were locked on second and third shift. On 4/12/2023 at 12:30 p.m., Staff A also reported on 4/5/2023, when she stepped out of her office the unknown male sat at the lounge near the West Nurse's Station, with his back towards her. Staff A voiced that the unknown male must be a resident's family member and Staff J responded yes, the other Aides said he was a resident's family member. Staff A did not know if anyone actually asked the unknown male what his relationship was to any residents. Staff D, RN said Resident #5's hands were under the blanket, and the unknown male was pushing Resident #5's hands away. Staff A saw Resident #5's hands under the blanket, but did not know where they were. Staff A did not see the male's genitals. When he scooted towards the end of the bed, he had the blanket over himself and then he stood and zipped his pants. The resident was quiet during this time. Staff K, CNA saw the man around 2:45 p.m. and the Police arrived around 3:00 PM. Staff D interviewed all of the alert and oriented residents. The male visitor told Staff A he was Resident #5's distant cousin. On April 13 at 7:50 a.m., Staff E, CNA reported working on 4/5/2023. Around 11:00 - 11:30 a.m., Staff E sat at the Nurse's Station charting and observed the male visitor walk by. He did not say anything and appeared as though he knew where he was going, which is why Staff E did not say anything to him. Around noon, Staff E observed the unknown male walking alone, as he circled between East and West Halls. Around 1:30 p.m., the unknown male pushed Resident #5 in her wheelchair from East to West Halls. The resident said her normal help me. Staff E observed the male visitor in the resident's room while Staff K went to get Staff A. The curtains were closed, both the resident and the male visitor's heads were at the foot of bed, and were covered by blankets. The resident had her clothes on. She did not sound distressed, with the resident just stating her name. Staff E did not observe any behavior changes after the incident and she did not see the resident crying. On April 17 at 9:45 a.m., Staff R, Medication Aide reported that she worked on 4/5/2023 and saw the male visitor 3 times. The first time, when Staff R passed medications in the Dining Room, near the end of the meal. The unknown male came from the West Hall looking as though he was looking for someone. About 15 minutes later, he walked by with Resident #5. The unknown male said nothing to anyone, and the resident said where are you? The third time, Staff R sat at the Nurse's Station and the unknown male was being walked out by Staff A. On April 17 at 12:09 p.m., Staff Q, CNA reported working on 4/5/2023. During lunch Staff Q came to the Shower Room to check her schedule on West hall. Staff Q had pushed Resident #5 to the lounge after lunch and noted the male visitor was standing next to the resident and Resident #5 had her arm around the unknown male's waist. Staff Q did not hear them say anything and Staff Q told the unknown male that he could sit down on the chair to talk to Resident #5. Staff Q never saw them after that, and Staff Q went home at 2:00 p.m. The next time Staff Q worked, she received education regarding the Visitor's Log, what to do if they observe a suspicious person, and Staff Q reported another in-service was presented to review everything. On 4/17/2023 at 12:40 p.m., Staff F, CNA reported working on the East Hall on 4/5/2023. Staff F saw the male visitor walking over from the East Hall to the West Hall before lunch, between 10:30 a.m. and 11:00 a.m. The next time Staff F saw the unknown male, he was pushing Resident #5 around in the wheel chair, before lunch. The male visitor never entered the lunch room. He pushed Resident #5 around the facility. The resident ate in her typical spot. Around 11:30 a.m., the unknown male asked Staff F where the resident's room was, as he was pushing the resident at that time. Staff F told the unknown male down the hall, to the left and her name should be on the door. The next time Staff F saw the unknown male was after lunch. From 11:30 a.m. until the resident came to the dining room to eat, Staff F did not know what happened. The resident sat at the table around noon. Around 1 p.m., Staff F saw the unknown male standing by the front door. He looked a little confused and Staff F told him remember, I told you, her room is down the other way. Staff F did not see the unknown male again until the Police arrived. After the incident, the staff had a meeting and were told what they needed to do the next time there was an unknown visitor. People enter the building, and staff trust they are there to see their family or friends. The unknown male looked like he could have been Resident #5's son; he seemed about the right age. After the incident, the facility implemented a Visitor Log, locked doors, and installed a door bell. Staff need to ask anyone who enters the building, who they are there to see and how they are related. The man looked like he was trying to find someone, and the next thing Staff F knew, the unknown male was pushing Resident #5. Staff F assumed Resident #5 was who the unknown male was looking for. Review of the Facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April, 2021 included: a. Policy Statement: 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. b. Policy Interpretation and Implementation: The resident Abuse, Neglect and Exploitation Prevention Program consists of a facility-wide commitment and resource allocation to support the following objectives: Under point #1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to the following: 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. Under point #2. Develop and implement policies and protocols to prevent and identify: a. Abuse or mistreatment of residents; b. Neglect of Residents.

Based on clinical record review, staff interviews, and facility investigation review, the facility failed to ensure staff provided adequate nursing supervision for 2 of 3 residents reviewed for accidents and hazards (Resident #5 and #1). The staff failed to identify an unknown male who entered the facility, spent an unknown amount of time with Resident #5, who was cognitively impaired , transferred the resident twice without assistance, then staff found the unknown male shirtless with his pants around his ankles, lying in bed with the resident; the resident observed to be crying. ). This failure resulted in possible distress for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. On April 13, 2023 at 10:30 AM, the State Survey Agency informed the facility the staff's failure to identify and prevent the stranger from accessing Resident #5 created an Immediate Jeopardy situation, which began on April 5, 2023. The facility removed the immediacy on April 5, 2023, when the facility staff implemented the following Corrective Actions: a. The facility staff locked the doors to the facility. b. Placed a visitor sign-in book near the entrance to the facility. c. Educated the staff on the interventions. d. Educated the staff on how to handle visitors the staff do not recognize. e. Educated the residents and their families on the new process which required the visitors to sign-in when they visit a resident. The facility also failed to provide adequate supervision for a resident with a history of falls who sustained a fall from a wheelchair (Resident #1). The facility's actions lowered the scope and severity from a J to a D at the time of the survey, after the State Survey Agency staff verified the facility staff had implemented the education and additional corrective actions. The facility staff identified a census of 61 residents. Findings Include: 1. Resident #5 admitted to the facility on [DATE] according to the Admission Record. The Minimum Data Set (MDS), dated [DATE], identified Resident #5 with severe cognitive impairment, required extensive assistance from 2 staff to transfer from 1 surface to another, failed to ambulate, severely impaired vision, and moderate difficulty with the ability to hear. The MDS documented the resident with diagnoses including dementia and left hip pain. The Care Plan identified Resident #5 was a fall risk and directed staff to provide a low bed and remove the recliner from the room. Resident #5 transferred from 1 surface to another with the use of a mechanical Hoyer lift and 2 staff. The Care Plan indicated the resident had concerns including hard of hearing and legally blind and it directed staff to approach calmly. The Order Summary Report revealed the resident had physician orders including Trazodone 25 mg twice a day for dementia and anxiety. Review of Resident #5's Progress Notes, dated 4/5/2023 at 2:55 p.m., entitled Incident, Accident, Unusual Occurrence authored by Staff A, Director of Nursing (DON) documented, staff found visitor in room with resident. The Visitor had himself exposed; and the visitor was escorted out of the room to the front lobby. Resident was fully dressed, not in distress at this time and with normal behavior/affect. No complaint of pain or discomfort. Head to toe assessment completed without concern. Nephew notified, he declined further assessment at this time. Nurse Practitioner notified. The local Police Department's Call for Service Record, dated 4/5/2023 at 2:53 p.m. revealed an officer was dispatched to the facility at 2:54 p.m. for a possible assault. The front door of the facility was unlocked and open to the public. Facility staff reported that they found the unknown male in the resident's bed under the covers, lying with the resident, and the unknown male's pants pulled down. When facility staff made contact with the unknown male, it appeared the male was pushing the resident's hands away from the unknown male's crotch under the covers. At no time did staff visualize the male's genitals. A physical assessment found no findings that the resident had been assaulted. The resident was found to be wearing clothing and underwear at the time the male and the resident were found in bed. The facility Administrators did not want the male to return to the facility. The male claimed he was taken in by the resident (housed) [AGE] years ago and learned from a friend that the resident was at the facility. The male stated he entered the facility, found the resident eating lunch and contacted her. He wheeled her to her room where they were both in bed, and he got more comfortable by opening his belt and sliding his pants down in bed. He said there were no sexual acts between him and the resident. He said he would not return to the property. During the Police Department staff's investigation of the incident, the police department staff discovered that the unknown male had an outstanding court order for an involuntary mental health commitment, and the police department staff arranged for the unknown male to go to a hospital for inpatient psychiatric evaluation. The Facility Investigation included the following timeline: a. On 4/5/2023 at 10:30 a.m., a Certified Nursing Assistant (CNA) noted a male visitor in facility walking around, appearing to look for someone. b. At 11:00 a.m., CNA noted male pushing Resident #5 in her wheelchair. Male noted calling resident Mom. c. At 11:10 a.m., CNA approached by male, by the lunch room, where he asked where resident's room was. CNA told him where her room was and he said thank you. d. At 11:45 a.m., other resident informed that the male was her brother and he had just gotten off work. e. At 12:00 noon, CNA noted resident at her table at lunch, and male was not with her. f. At 12:30 - 12:45 p.m., CNA noted male entering the facility again and observed walking up East hall. CNA pointed him to West hall. g. At 1:00 p.m. and after, male noted pushing resident in her wheelchair throughout the facility. Also seen standing next to the resident in her wheelchair in the common area. h. At 2:50 p.m., CNA's found male in resident's bed without clothing on. Immediately got DON and when entered room noted resident with head at foot of bed, still with clothing on and jumpsuit unzipped half way in back. Staff immediately got male out of resident's bed and escorted to the front lobby. Police were called. Male stated he was a distant cousin of resident. Police arrived and detained male. Facility was later notified the male admitted to Psychiatric Unit at a local Hospital. Assessment of resident completed and no issues noted. No signs of distress noted, with normal behaviors and affect noted. i. At 3:00 p.m., the resident's Nephew notified. He stated he was not aware of who the male visitor is, and never heard of him. Declined sending resident to the emergency room (ER) for an assessment when asked. Interventions implemented included: a. Male visitor detained by police. b. Visitor Sign In log initiated. c. Communication sent to all responsible parties/residents. d. Doors locked so visitors must be left in. e. Education provided to staff on: Visitor Sign In log, and monitoring and communication of suspicious behaviors of visitors to management staff. Conclusion: Incident with unknown male visitor being found unclothed in resident's bed is confirmed. No signs or symptoms of physical or sexual abuse noted. No changes in mood and affect noted after incident. Facility took all precautions necessary to mitigate another similar incident of this type. During an interview on 4/11/2023 at 9:50 a.m., Staff A, DON indicated on 4/5/2023, around lunch time, she was in her office and Staff J, CNA came to her and said there was a man sitting in the East common area and he looked a little dirty. Staff A thought maybe he was a family member. Staff J left and the male went to West hall. Staff J returned and said he was a family member. After lunch he was seen pushing Resident #5 around in her wheelchair. Around 2:40 p.m., Staff K, CNA and Staff L, CNA came to her office and said something was weird. They observed the resident's head at the foot of the bed and they heard a man say they were just cuddling. They observed him in bed next to her, she was on her right side, facing him. He was covered with a blanket and she was fully dressed. Staff A and Staff D, Registered Nurse (RN) went to the resident's room and observed the same. Staff A asked what was going on and the male said I am just trying to help her sleep. Staff A asked him why he had no clothes on and he said he did have clothes on. Staff A said having pants around your ankles in not having clothes on. Staff D left to notify the Administrator and call the Police. The male told Staff A he was a distant cousin of the resident and he had picked her up and got her into bed. The resident has partial blindness and said nothing, but was tearful. As the Administrator entered, the male sat up at the side of the bed and pulled up his pants under the blanket. Staff escorted the male to the front lobby and informed him he was to stay until police arrived. The Police arrived, notified the Sheriff and they questioned the unknown male and the resident. The resident had no recall of the events when questioned by the facility staff. The nephew revealed he had never heard of the man and the resident only had 3 relatives. Police found the male had an involuntary court mental health committal, due to an earlier incident at a public library. Police also said they picked the unknown male up that same day and dropped him off at a nearby trailer park. Staff D performed a head to toe assessment with no concerns. Police took the male to a local hospital for psychiatric commitment and evaluation. Staff were educated, doors were locked between second and third shifts, and a visitor log was initiated. On 4/7/2023, the facility added a door bell at the front entrance for visitors to ring and doors were locked 24/7. The resident's roommate, Resident #9 said the male tried to put Resident #5 into Resident #9's bed first, and Resident #9 informed the unknown male that Resident #5's bed was on the other side. No staff reported observations of the male approaching other residents. During an interview on 4/11/2023 at 1:50 p.m., Staff J, CNA reported that on 4/5/2023 she worked from 6 AM - 2 PM on East hall. She observed a strange appearing man with dirt on his face and clothing. He appeared to be homeless and sat down in a chair closer to the Nurse's Station after lunch, as if he was waiting for someone. He did not say anything and Staff J did not ask him anything. Staff J felt uncomfortable, so she went and told Staff A, DON when the unknown male got up and started walking. He sat down on a chair near the Nurse's Station, near a female resident, but the resident's back was towards Staff J. Staff A came out of her office, looked over towards the Nurse's Station, and said the unknown male must have been someone's family member. About 30 minutes later, Staff J saw the unknown male walk Resident #5, in her wheel chair, down the East hall heading towards the Dining Room. He did not say anything, but the resident said help me, which she does a lot, so Staff J did not think anything of it. Staff J assumed the unknown male was her family member, and told Staff A he must have been [Resident #5's] family member. Staff J was not involved in anything after that. The next day, Staff J received education about knowing who is in the building. Before, in order to get in a visitor had to push a button and it stopped the alarm from going off. Now a visitor had to ring the doorbell. The staff also require visitors to sign in, ask who the visitor was, and who the visitor was at the facility to see. On 4/11/2023 at 2:05 p.m., Staff M, CNA reported working for an outside staffing agency, and worked at the facility for 1 month on the day shift. On 4/5/2025, Staff M worked on the West hall. Close to lunch time, Staff M observed the male sitting on the sofa in the TV area on West hall, watching TV with the residents. Staff M thought the male was someone's family member. Staff M never saw him after that, did not talk to him, just got a glimpse of him. Staff M stated staff received education to include that even if they know someone, they should always ask the visitor to sign the Visitor Log, ask who the visitor was here to visit, and how they were related. On 4/11/2023 at 2:12 p.m., Staff G, CNA revealed that on 4/5/2023 she worked on East Hall. Staff G saw the man when he was pushing Resident #5 in her wheelchair down East hall, shortly after lunch. He did not say anything and appeared dirty. The resident was quiet. The facility is now locked 24 hours a day. If someone comes to the facility, the staff have to ask the visitor to sign in with their phone number and who they are here to see. On 4/11/2023 at 2:15 p.m., Staff N, RN reported she worked for a Staffing Agency for 13 months, and worked at facility for [AGE] years. On April 5th, she worked on both halls along with two Med Aides. She was charting in the break room around 12:45 p.m., when she saw the man walk past her doorway towards East Hall. He was alone. She was in Staff A's room, charting and staff came to her office and reported there was a man in Resident #5's bed, before 3 p.m. Staff N did not notice any changes in the resident's behavior. Staff N stated staff received education including now, the facility locked the doors, everyone rings the door bell, and visitors sign in. On 4/11/2023 at 2:28 p.m., Staff O, CNA reported working on 4/5/2023. The first she saw the gentleman, she was in the dining room, around lunch time. He was walking from East Hall to West Hall and did not say anything. Staff O thought it looked odd; he kept walking like he knew where he was going. He did not go up to any residents. The next time I saw him, he was pushing Resident #5 in her wheel chair going across the Dining Room again. He said nothing and she kept saying her name. The Dining Room was mostly empty by that time. Staff O stated did not see him or the resident again and Staff O left at 2 p.m. On 4/11/2023 at 2:40 p.m., Staff L, CNA revealed on April 5th, 2023, she worked on the West Hall, Resident #5's hall from 6 a.m. - 6 p.m. Around lunch time Staff L observed the male visitor and assumed he was here to see a family member. She did not expect anything like what occurred, to happen. Three staff worked on West that day, and if Resident #5 was not out in the day room, she would have assumed somebody already assisted her to bed. Second shift begins at 2 p.m., and staff pass water and check on the residents. Staff K, CNA observed Resident #5 in bed and summoned Staff L to the room. Staff K and Staff L ran to get Staff A, DON and Staff C, Administrator. The curtains on the resident's side of the room were closed, the male had a blanket over him, his pants were all the way down, and he had no shirt on. Staff L peaked through the curtain, the male, talking in a low voice was difficult to understand. After the man was out and the Police were here, Staff L, Staff K and Staff D went in to check on the resident. She was just lying there, she had a one-piece, full body jumpsuit on that zipped up the back. The jumpsuit was half way unzipped in the back but her shoulders were still covered. She was crying. Staff D assessed the resident, she had no skin issues or anything out of the ordinary. Her brief was still on. I stripped the bed right away and sent it to laundry. I did not see anything on the sheets. The resident has never mentioned the incident. They had a Staff Meeting that day and were informed of what happened. They were instructed if they see anyone out of the ordinary in the building to question them, and ask what is the relation to the person they want to see. Doors are currently locked with door bell, and they added a Visitors Sign-In Book. On 4/11/2023 at 3:00 p.m., Staff K, CNA reported working on April 5th, 2023 from 2 - 10 p.m. on West Hall. Staff K walked into Resident #5's room around 2:30 p.m. as Staff K passed water. The curtain was drawn and Resident #5's wheel chair was empty. The staff do not normally pull the resident's curtain as she is a fall risk. The resident's head was at the foot of the bed, and Staff K said what the heck. A male said we are just cuddling. At first, Staff K just saw his face and then Staff K noticed he did not have a shirt on and he was covered waist down with her blanket. The resident was fully dressed and lay facing him. His back was against the wall and she was on the room side of the bed. The resident said nothing. Staff K left the room and saw Staff L, and said did you see that? she said what? Staff K reported she saw a man without clothes in bed with the resident. They ran to Staff A and Staff C. Staff D also arrived. Staff K heard Staff A ask the male who he was and how he knew the resident. Staff K told the male he was inappropriate and needed to get out of the bed. As he walked out, he zipped up his jacked and said I will get out of the way. Staff A said no, you will stay until the Police come. Staff C stood at the front door until the Police arrived. The Police interviewed Staff K. That afternoon, Staff A passed around a photo of the man, told everyone what happened, and if they saw him they were to alert Staff K immediately. The doors were locked and they added a Visitors Sign-In Log. On 4/11/2023 at 3:10 p.m., Staff D, RN, MDS Coordinator, revealed that on 4/5/2023, she observed the male visitor seated next to Resident #5 in the West Lounge after lunch. The next time she saw the unknown male, Staff A had asked Staff D to go with Staff A, because a CNA reported seeing a man lying in bed next to Resident #5. Staff D went and saw the man lying in bed with the resident. He was laying closer to the wall and they were facing each other. He did not have a shirt on and his pants were down around his ankles. Staff A began asking questions and Staff D went to get the Administrator and called 911. Staff A and Staff C walked the male visitor down to the front lobby area. Staff D assessed the resident and assisted the aides in doing incontinence cares. Staff D did not see any marks, abrasions or bruising, Resident #5 was fully dressed, and Resident #5's clothing was intact. The zipper down the back of Resident #5's jumpsuit was partially unzipped, however her shoulders were covered. The resident had cognitive deficits and she baseline repeatedly calls out and cannot remember. Staff D did not observe the resident crying, but Resident #5 resisted cares. Staff D did not observe the linens, did not notice any wet spots, and nothing appeared to be out of place. The aide stripped the bed and sent it to laundry. Staff D spoke to Resident #5's roommate (Resident #9) who said Resident #9 had been out of the room and when Resident #9 returned, Resident #9 saw Resident #9 and the unknown male in Resident #9's bed. Resident #9 told the unknown male that was Resident #9's bed, so the unknown male picked Resident #5 up and carried Resident #5 to the other bed. When Staff A asked the unknown male who he was, he said he was a distant nephew. Later, the unknown male said the resident had taken him in 20 - [AGE] years ago, so they were not blood related. The resident's nephew (and responsible party for Resident #5) had never heard of the unknown male. Following the incident, the staff notified families that someone entered the facility posing as a family member. The staff locked the doors, added a Sign-In Log asking who the visitor was here to visit, and what their relationship was to the resident. Staff are to follow the visitor to be sure the staff knows where they are going and the person knows who they are. Prior to the incident, the main door was not locked, but a visitor had to press a button to release an alarm. The door was locked at night around 9:30 p.m. The staff ordered a door bell with a longer range, so it reaches the back Dining Room. The phone number is also posted outside the front door. The administration educated staff with a Stand-Up Meetings for every shift following the incident. The staff had photos of the individual posted and they educated staff they were to call the Police if anyone saw the unknown male near the building. On April 11, 2023 at 3:45 p.m., Staff P, Licensed Practical Nurse (LPN)/Agency Nurse, reported she worked on 4/5/2023 from 1:30 - 9:30 p.m. on the West Wing. She was in a resident's room and then saw Staff A tell a man near Resident #5's room to stay until the Police came. A CNA said there had been a strange man in the building. Later, they had a Staff Huddle where Administration explained the incident and passed around a photo of the man. Staff P saw the Police arrive and interview the CNA who witnessed the incident. Resident #5 was anxious after the event. Resident #5 would normally cry out, but Resident #5's crying out after the incident was not normal for Resident #5. Resident #5 refused medication but, did eventually take her pills. Staff P gave the resident an anxiety medication before Resident #5 went to bed. The CNA's did not report anything out of the ordinary. After the incident, visitors have to sign in and out and the doors were locked. Anyone wishing to enter has to ring a doorbell. On 4/12/2023 at 11:45 a.m., Staff C, Administrator, reported that on 4/5/2023 around lunch time, a man entered the facility. Visitors only had to push a button near the front door and enter. The male visited Resident #5 and no other residents. Staff discovered the unknown male in Resident #5's room. When Staff C entered the room, Staff C observed the male sitting at one end of the bed. The unknown male had no shoes and wore pants with a belt and a shirt. The unknown male said he was getting ready to take a nap. Staff D called 911 and Police arrived 5-10 minutes later. Staff saw no signs of semen. Staff C interviewed residents and staff. Staff K and Staff L were the first 2 staff to witness the incident and reported it immediately. They implemented a rapid response to determine the next thing to do. Staff A followed up with the resident's family and they declined to send her to the emergency room for further evaluation. The facility staff instituted a Visitor's Log and reviewed the situation with all staff, expectations and what action would be taken. Doors were locked on second and third shift. On 4/12/2023 at 12:30 p.m., Staff A also reported on 4/5/2023, when she stepped out of her office and saw the male, the unknown male sat at the lounge near the West Nurse's Station, with his back towards Staff A. The unknown male was sitting with his back to Staff A. Staff A said that the unknown male must be a resident's family member. Staff J indicated that Staff J believed the unknown male was a resident's family member, because the other CNA's told Staff J that the unknown male was a resident's family member. Staff A did not know if anyone actually asked the unknown male what was his relationship to any residents. Staff D, RN said Resident #5's hands were under the blanket, and the unknown male was pushing Resident #5's hands away. Staff A saw Resident #5's hands under the blanket, but did not know where they were. Staff A did not see the male's genitals. When he scooted towards the end of the bed, he had the blanket over himself and then he stood and zipped his pants. The resident was quiet during this time. Staff K, CNA saw the man around 2:45 p.m. and the Police arrived around 3:00 PM. Staff D interviewed all of the alert and oriented residents. The male visitor told Staff A he was Resident #5's distant cousin. On April 13 at 7:50 a.m., Staff E, CNA reported working on 4/5/2023. Around 11:00 - 11:30 a.m., Staff E sat at the Nurse's Station charting and observed the male visitor walk by. He did not say anything and appeared as though he knew where he was going, which is why Staff E did not say anything to him. Around noon, Staff E observed the unknown male walking alone, as he circled between East and West Halls. Around 1:30 p.m., the unknown male pushed Resident #5 in her wheelchair from East to West Halls. The resident said her normal help me. Staff E observed the male visitor in the resident's room while Staff K went to get Staff A. The curtains were closed, both the resident and the male visitor's heads were at the foot of bed, and were covered by blankets. The resident had her clothes on. She did not sound distressed, with the resident just stating her name. Staff E did not observe any behavior changes after the incident and she did not see the resident crying. On April 17 at 9:45 a.m., Staff R, Medication Aide reported that she worked on 4/5/2023 and saw the male visitor 3 times. The first time, when Staff R passed medications in the Dining Room, near the end of the meal. The unknown male came from the West Hall looking as though he was looking for someone. About 15 minutes later, he walked by with Resident #5. The unknown male said nothing to anyone, and the resident said where are you? The third time, Staff R sat at the Nurse's Station and the unknown male was being walked out by Staff A. On April 17 at 12:09 p.m., Staff Q, CNA reported working on 4/5/2023. During lunch Staff Q came to the Shower Room to check her schedule on West hall. Staff Q had pushed Resident #5 to the lounge after lunch and noted the male visitor was standing next to the resident and Resident #5 had her arm around the unknown male's waist. Staff Q did not hear them say anything and Staff Q told the unknown male that he could sit down on the chair to talk to Resident #5. Staff Q never saw them after that, and Staff Q went home at 2:00 p.m. The next time Staff Q worked, she received education regarding the Visitor's Log, what to do if they observe a suspicious person, and Staff Q reported another in-service was presented to review everything. On 4/17/2023 at 12:40 p.m., Staff F, CNA reported working on the East Hall on 4/5/2023. Staff F saw the male visitor walking over from the East Hall to the West Hall before lunch, between 10:30 a.m. and 11:00 a.m. The next time Staff F saw the unknown male, he was pushing Resident #5 around in the wheel chair, before lunch. The male visitor never entered the lunch room. He pushed Resident #5 around the facility. The resident ate in her typical spot. Around 11:30 a.m., the unknown male asked Staff F where the resident's room was, as he was pushing the resident at that time. Staff F told the unknown male down the hall, to the left and her name should be on the door. The next time Staff F saw the unknown male was after lunch. From 11:30 a.m. until the resident came to the dining room to eat, Staff F did not know what happened. The resident sat at the table around noon. Around 1 p.m., Staff F saw the unknown male standing by the front door. He looked a little confused and Staff F told him remember, I told you, her room is down the other way. Staff F did not see the unknown male again until the Police arrived. After the incident, the staff had a meeting and were told what they needed to do the next time there was an unknown visitor. People enter the building, and staff trust they are there to see their family or friends. The unknown male looked like he could have been Resident #5's son; he seemed about the right age. After the incident, the facility implemented a Visitor Log, locked doors, and installed a door bell. Staff need to ask anyone who enters the building, who they are there to see and how they are related. The man looked like he was trying to find someone, and the next thing Staff F knew, the unknown male was pushing Resident #5. Staff F assumed Resident #5 was who the unknown male was looking for. Review of the Facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April, 2021 included: a. Policy Statement: 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. b. Policy Interpretation and Implementation: The resident Abuse, Neglect and Exploitation Prevention Program consists of a facility-wide commitment and resource allocation to support the following objectives: Under point #1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to the following: 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. Under point #2. Develop and implement policies and protocols to prevent and identify: a. Abuse or mistreatment of residents; b. Neglect of Residents. 2. Resident #1 admitted to the facility on [DATE], discharged to the Hospital on 1/3/2023, and was readmitted to the facility on [DATE] with Hospice Services. The resident discharged to a Hospice Facility on 1/20/2023. The MDS, dated [DATE], revealed the resident was identified with severe cognitive impairment, required extensive assistance of staff to transfer from one surface to another and had 1 fall since admission or prior assessment, with no injury; and 2 falls with injury, not major. The resident had diagnoses including Parkinson's disease, diabetes and repeated falls. Resident #1's Care Plan identified the resident with a fall risk. The Care Plan directed staff to anticipate needs, place a body pillow in bed, place concave mattress on bed, and follow fall protocol if Resident #1 fell . On 10/22/2022, the Care Plan added: please do not leave me in my wheelchair unattended in my room for my safety, and therapy evaluation request for positioning while in wheelchair. On 1/3/2023, the Care Plan added: please leave me in bed for safety unless staff present. The resident's Progress Notes included the following entries on falls: a. On 10/11/2022 at 2:15 p.m., staff found the resident on the floor next to his bed. Neurological examination within normal limits. b. On 10/18/2022 at 1:30 p.m., staff found the resident on the floor in his room near the dresser, with no injury. c. On 10/28/2022 at 8:00 a.m., resident fell after he leaned forward in his wheelchair in the dining room, with no injury. d. On 1/3/2023 at 1:15 p.m., Staff D, Registered Nurse (RN) observed the resident lying face down on floor with legs under wheelchair, and foot pedals on. The resident received a laceration to his head, skin tear left hand, abrasion right knee. Placed in isolation room for COVID positive. Staff states the resident was in the wheelchair, in preparation for noon meal. Sent to emergency room (ER) for evaluation of head injury. The Incident Report, dated 1/3/2023 at 1:30 p.m., included the nurse was called to Resident #1's room by the CNA. The resident had been sitting in his wheel chair waiting for lunch, but was found lying face down on the floor with his legs underneath his wheel chair. Foot pedals were still on the wheelchair. Staff turned him over and noted abrasions to the left side of his head and a moderate amount of bleeding. Resident placed in isolation room today due to a positive COVID test. Resident assessed and able to move all extremities and does not show signs of pain, except the resident called out when the staff rolled the resident over. No internal or external rotation to extremities. Pupils assessed, equal, reactive, and round. Vitals taken and neurological checks initiated. Abrasions cleansed. Assisted resident back to bed with body pillow in place, call light in reach and bed lowered to the floor. Medical Doctor (MD), wife and Director of Nursing (DON) notified. The Hospital Note revealed that the resident presented to the hospital after being found on the ground at the Nursing Home. The resident's wife reported the resident's mental status declined the past few years, and the resident received Comfort Cares twice in the past but was rem