Every finding on record at Northern Lights HCC

Based on observation and interview, the facility did not store food in accordance with professional standards for food service safety. This has the potential to affect all 41 residents who receive food from the kitchen.-Surveyor observed an opened bag of cookie dough balls, an angel food cake, potato wedges, hashbrowns, and hamburger patties with no opened date, and/or a use by date. -Surveyor observed in the common resident refrigerator two wrapped sandwiches with no information label for resident name, contents, or use by date.Findings include:Facility policy titled, General Food Preparation and Handling, reviewed 3/26, states, Food will be covered for storage and the facility policy titled, Food- Provided by Family/Visitors, reviewed 4/26, states, The storage of foods brought to residents by family or visitors will be dated, labeled, and stored in accordance with professional standards for food service safety.In accordance with professional food service safety, all prepackaged opened foods need to be dated with either an opened-on date and/or a use by date.On 08/10/26 at 9:30 AM, during initial inspection of walk-in freezer with Dietary Manager (DM) O, Surveyor observed open bags of cookie dough balls, prepared angel food cake, potato wedges, hashbrowns, and hamburger patties. All of the above did not have dates of when they were open and/or a date on which to use by. Surveyor further inspected the common resident refrigerator and noted two wrapped sandwiches not labeled with any information (contents, resident name, or date).On 08/11/26 at 11:35 AM, Surveyor interviewed DM O and asked what the expectation is for labeling foods. DM O stated the expectation is that any prepackaged food that is opened, should be labeled with an opened-on or a use by date.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all residents.-Facility staff did not cover linens during transport for delivery to residents down all hallways. -Facility staff observed carrying resident's personal linens against body while delivering items to residents and transporting linens uncovered on a cart down all hallways. -Surveyor observed staff did not disinfect lift equipment after use with R2. R2 has Enhanced Barrier Precautions (EBP). -Facility staff did not complete hand hygiene after removing gloves while providing cares (R2). -Facility staff did not provide a barrier for a urinary catheter observed lying on the floor for (R41). -Facility staff did not place clean barrier under measuring container on the floor when emptying urinary catheter bag for (R1)-Facility staff did not wipe the spout of the urinary drainage bag with an alcohol pad after emptying urine from bag for (R1). This is evidenced by: Example 1 On 08/10/2026 at 10:36 AM, Surveyor observed laundry aide (LA) I and LA J transporting uncovered laundry on a wheeled cart to resident rooms. The cart had residents' shirts and pants hanging on hangers, as well as folded resident laundry items. Surveyor observed LA I pick up folded laundry items and hold them against their chest while delivering them to multiple resident rooms. LA I was not wearing protective outerwear. On 08/11/2026 at 10:09 AM, Surveyor asked LA I and LA J what staff expectations are during transporting and delivering resident linens. LA I stated all linens needed to be covered when being transported throughout the building. LA I confirmed no laundered items should be held against the body at any time. On 08/11/2026 at 3:12 PM, Surveyor interviewed the facility's infection preventionist, Director of Nursing (DON) B, and asked what interventions are to be in place for the transportation and delivery of resident linens. DON B stated linens are to be always covered during transport. DON B stated linens should not be held against a person's body at any time. Surveyor informed DON B of LA I and LA J transporting uncovered laundry to resident rooms and LA I holding laundry items against their chest and delivering them to residents. Example 2 Facility policy titled, Mechanical Lifts (Total Body and Sit-to-Stand), with a reviewed date of November 2023, states: .Cleaning of Lifts: Mechanical lifts must be cleaned and disinfected between each resident/patient use and at terminal cleaning/discharge using an EPA-registered disinfectant.Between patients: Clean and disinfect all high-touch and resident-contact surfaces, including hand controls, push handles, side rails, spreader bar, hook/clips, seat surfaces and any visible soil on frame, wheels, and base. Clean at point of use before moving into hallway or other area. R2 was admitted to the facility on [DATE] with an indwelling foley catheter. On 08/11/26 at 10:20 AM, Surveyor observed an Evidenced Based Precautions (EBP) sign posted outside of R2's door, indicating staff must use Personal Protective Equipment (PPE) which includes a gown and gloves when providing direct care. On 08/11/26 at 10:25 AM, Surveyor observed Certified Nursing Assistants (CNA) C and CNA D bring lift equipment into R2's room. Surveyor observed CNA C and CNA D provide personal cares for R2 and use lift equipment to transfer R2 from bed to recliner in R2's room. On 08/11/26 at 10:45 AM, Surveyor observed CNA D push lift equipment into the hallway and place it against the wall. No disinfection of lift equipment was completed prior to exiting the room. Surveyor did not observe CNA C or CNA D complete disinfection of lift equipment after use in R2's room. Surveyor observed a bag attached to lift equipment containing disinfecting wipes. On 08/11/2026 at 11:02 AM, Surveyor interviewed CNA C regarding cleaning of lift equipment. Surveyor asked CNA C what the facility's practice is to clean lift equipment after use. CNA C stated staff would use the wipes stored on the lift. Surveyor asked CNA C what the typical practice is to clean the lifts after use. CNA C stated after using it. Surveyor asked if staff normally clean the lifts in the hallways. CNA C stated sometimes. Surveyor asked CNA C if this practice changes if being used in EBP room. CNA C stated yes, it should have been cleaned in the room. On 08/11/2026 at 11:16 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectation of cleaning mechanical lifts and Surveyor informed DON B of observation. Surveyor asked what DON B's expectation is for staff after using lift equipment with residents. DON B stated staff are expected to wipe down the machine in the resident's room. Example 3 Facility policy titled, Handwashing, with a reviewed date of April 2026, states: Multiple opportunities for hand hygiene may occur during a single care episode. The following are clinical indications for hand hygiene: Alcohol based hand sanitizer should be used: .immediately after glove removal. On 08/11/26 at 10:25 AM, Surveyor observed CNA C and CNA D provide direct care for R2. Surveyor observed CNA D provide peri-care and remove gloves when finished. Surveyor observed CNA D don a new pair of gloves without completing hand hygiene. CNA D then continued assisting R2 with dressing and transferred R2 from bed to a recliner. On 08/11/2026 at 11:16 AM, Surveyor interviewed DON B regarding expectation for hand hygiene and glove removal. DON B stated to use alcohol-based sanitizer or wash hands in-between glove changes. Surveyor informed DON B of CNA D removing gloves, not completing hand hygiene, and then donning a new pair of gloves. Example 4 R41 was admitted to the facility on [DATE] and has diagnosis of urinary obstruction requiring a continuous indwelling urinary catheter and history of urinary tract infections. R41 has a BIMS score of 12/15, which means cognitively intact On 08/11/2026 at 6:50 AM, Surveyor observed R41's indwelling urinary catheter drainage bag lying on floor of room, with port side down and no bag cover/barrier between the catheter and floor. R41 informed Surveyor that facility staff take care of their urinary catheter bag. R41 stated they never have a covering over the drainage bag and is aware it should not be on the floor for infection reasons. R41 stated the bag may have fallen off the bedside frame but they are unable to bend down to pick it up. On 08/11/2026 at 3:12 PM, Surveyor interviewed the facility's infection preventionist, DON B. Surveyor asked DON B what infection precautions should be considered by staff in the management of indwelling urinary catheter drainage bags. DON B stated urinary drainage bags should never be touching contaminated surfaces without a protective covering or a barrier between the bag and floor. Surveyor asked what the expectation is for privacy with urinary catheter bags. DON B stated catheter bags should have a protective covering over them. Surveyor informed DON B of R41's catheter bag not having a cover. DON B confirmed that R41's catheter drainage bag should have a protective covering over it to protect it. Example 5 Findings include: R1 was admitted on to the facility on 6/04/26 with diagnoses including obstructive uropathy and methicillin resistant staphylococcus aureus infection. On 8/11/26 at 7:10 AM, Surveyor observed Certified Nurse Assistant (CNA) N emptying R1's urinary catheter bag at bedside. Surveyor noted CNA N did not wipe the spout of the urinary bag after emptying the urine and noted liquid on the floor next to R1's catheter bag which was hanging on the bed rail. Surveyor interviewed CNA N, who reported they did not place anything on the floor before setting the collection container on the floor and some of the urine must have splashed onto the floor. CNA N also stated they did not wipe the spout of the urine bag after emptying R1's urine into the container. On 8/12/2026 at 9:18 AM, Surveyor interviewed DON B and asked what the facility process is for emptying a catheter bag. DON B stated it is the expectation for staff to place a barrier on the floor under the urine collection container and that the spout to a catheter bag be wiped with an alcohol pad after emptying it. Surveyor informed DON B of the observation of CNA N when they emptied R1's catheter bag and did not place a barrier between the floor and the container, nor wipe the spout of the catheter bag with alcohol wipe after emptying.

Based on interview and record review, the facility did not implement policies and procedures to prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. The facility did not complete timely background checks for 3 of 8 (CNA L, CNA M and Maintenance K) sampled staff.-CNA L's date of hire (DOH) was 08/17/19. The facility's most current Background Information Disclosure (BID) was completed on 02/19/21. The Integrated Background Information System (IBIS) and Department of Justice (DOJ) report were completed on 02/24/21. The facility did not complete a background check for CNA L every four years.CNA M's DOH was 09/30/14. The facility's most current BID was completed on 02/24/21. The IBIS and DOJ were completed on 02/26/21. The facility did not complete a background check for CNA M every four years.-Maintenance K's DOH was 03/13/20. The facility's most current BID was completed on 02/26/20. The facility's most current IBIS and DOJ report were completed on 03/09/20. The facility did not complete a background check for Maintenance K every four years.The facility's policy, titled HDG Managed Community Human Resources Policy, Background Checks Policy (Applicant Background Checks & Current Team member Self-Disclosure Criminal Convictions), last revised June 2021, states: .will conduct background checks on applicants and other individuals as required by federal, state, and local law. The facility policy does not address the requirement of completing a background check every 4 years. On 08/11/2026 at 1:05 PM, Surveyor reviewed the background documentation for 8 randomly selected employees. CNA L, CNA M, and Maintenance K did not have documentation of a completed background check within 4 years of the background checks conducted at hire. -CNA L's date of hire (DOH) was 08/17/19. The facility's most current Background Information Disclosure (BID) was completed on 02/19/21. The Integrated Background Information System (IBIS) and Department of Justice (DOJ) report were completed on 02/24/21. The facility did not complete a background check for CNA L every four years.CNA M's DOH was 09/30/14. The facility's most current BID was completed on 02/24/21. The IBIS and DOJ were completed on 02/26/21. The facility did not complete a background check for CNA M every four years.-Maintenance K's DOH was 03/13/20. The facility's most current BID was completed on 02/26/20. The facility's most current IBIS and DOJ report were completed on 03/09/20. The current BID was due for completion on 02/26/24. The facility did not complete a background check for Maintenance K every four years.On 08/11/2026 at 1:25 PM, Surveyor interviewed Human Resources (HR) E and asked about the facility policy and procedure for employee background checks. HR E stated background checks were run in advance of hire. On 08/11/2026 at 2:29 PM, Surveyor followed up with HR E and asked if there was a policy to conduct regular background checks after the initial process. HR E said, You mean like every year? Surveyor asked if HR E was aware of conducting background checks every 4 years and HR E stated they now remembered this. On 08/11/2026 at 2:30 PM, Surveyor asked Nursing Home Administrator (NHA) A about background check policy and procedure. NHA A confirmed the initial background check process and the requirement for employee self-disclosure. NHA A confirmed the facility did not conduct background checks beyond initial hire.

Based on interview and record review, the facility did not ensure a resident (R) received a written notice of the reason for transfer to the hospital or a written notice for a bed hold for 1 (R24) of 4 residents reviewed out of 17 sampled residents.-R24 did not receive a written notice of transfer to the hospital or a bed hold notification on 07/07/26.Findings include:R24 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes with neuropathy.On 7/27/26, R24 was admitted to the hospital following an episode of acute respiratory failure and an exacerbation of heart failure. R24's most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13/15, which means R24 has intact cognition. Record review indicated there was no documentation of a written notice of transfer or bed hold notification for R24's transfer to the hospital.

Based on observation, interview and record review, the facility did not provide adequate supervision for 2 of 3 residents reviewed for elopement risk in a sample of 17 residents (R6, R23). The facility failed to: -Place wander guard transmitter device on R6 and R23's person. The wander guard was placed on the metal frame of R23's walker and the metal frame of R6's wheelchair which is against manufacturer instructions for proper wandering transmitter device functioning. -Assess and document proper functioning of wander guard devices for R6 and R23.Findings:Facility policy titled Elopement Monitoring System Policy, last revised 04/2026, states, Residents are assessed for elopement risk.with a change in condition.Staff verify the device is functioning at each shift.Device checks and concerns are documented.Wanderer Monitoring System Adult Transmitter User Guide, release date of 06/22/2010, states, The Adult transmitter is a small device placed on the ankle or the wrist of a resident .NOTE: transmitters in use must be tested at least weekly .NOTE: To monitor a resident in a wheelchair, attach the transmitter to the seat or back of the chair as the metal on the chair can interfere with the transmitter's signal.Example 1R23 was admitted to the facility on [DATE] and has a diagnosis of dementia. R23 has a Brief Interview for Mental Status (BIMS) score of 3/15, which means severe cognitive impairment. R23's care plan, states, I have potential for elopement related to my altered cognitive status. I have a history of wandering and/or attempting to exit the facility without staff or family assistance. Interventions include.Code Alert Bracelet Placement Monitor per facility protocol.On 05/28/2026, R23 has an Elopement Risk Screen Tool score of 15, which means high risk for elopement.On 07/28/2026, a significant change in status Minimum Data Set (MDS) was completed by the facility and indicated R23 was independent when changing from sitting to standing position, chair to bed and back to chair transfers, and ambulating 50 feet with 2 attempted turns. R23's MDS was changed from independent to supervision required for ambulation of 150 feet. On 08/10/2026 at 11:14 AM, Surveyor observed R23 sitting in the recliner in their room. R23 did not have a wander guard device on their ankle or wrist. Surveyor observed R23's walker in their room with the wander guard device attached to the metal bar. On 08/11/2026 at 9:35 AM, Surveyor observed R23 not to be present in their room. R23's wheelchair was also gone from their room. R23's walker with the wander guard device was in R23's room.On 08/11/2026 at 10:07 AM, Surveyor observed R23 sitting in a wheelchair in the common area near the front entrance of facility. Surveyor observed R23 propel the wheelchair using their legs and travel past the front entrance of the facility and down the hall. Surveyor did not observe a wander guard device on R23 or R23's wheelchair. On 08/11/2026 at 10:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H and asked where the facility's wander guard alert systems were in the building. CNA H stated the main front entrance and back entrance of facility had detection systems to alert staff if an elopement takes place. CNA H confirmed if a resident wearing a wander guard bracelet attempted to elope from facility through either entrance, the system would alarm.On 08/11/2026 at 11:17 AM, Surveyor interviewed CNA G on how staff would know which residents were at risk for eloping from the facility. CNA G stated there is a binder at the front entrance desk, which includes resident names and photos of those who may attempt to leave the facility unattended. Surveyor asked CNA G if R23 was at risk for elopement and CNA G stated, No. Surveyor asked CNA G if R23 had a wander guard device in place, and CNA G stated it was on their walker. Surveyor asked CNA G what the reason is for the wander guard device to be placed on R23's walker rather than on their person. CNA G stated R23 primarily used the walker for ambulation, however since a recent COVID illness, R23 now uses a wheelchair primarily for mobility outside of their room. CNA G confirmed R23 propelled self in wheelchair throughout facility and was able to transfer self in room. On 08/11/2026 at 11:18 AM, Surveyor observed a binder at the staff desk near the front entrance, which contained a list of residents who were at risk for elopement, along with their photos. R23 and R6 were amongst residents indicated at risk for elopement.On 08/11/2026 at 3:05 PM, Surveyor observed R23 standing next to recliner in their room with the wheelchair close by. R23's walker, with the wander guard device, was next to the window. R23 was not using the walker when standing in their room.R23's physician orders for the wander guard device and Treatment Administration Record (TAR) did not indicate where the placement of R23's wander guard should be. R23's TARs for July and August of 2026 did not have documentation for checking functioning of R23's wander guard device.Example 2R6 was admitted to the facility on [DATE] and had a diagnosis of dementia.R6 has a BIMS score of 3/15, which means severe cognitive impairmentOn 07/10/2026, R6 has an Elopement Risk Screen Tool score of 20, which means high risk for elopement.On 08/11/2026, Surveyor observed R6's wander guard device to be attached to metal frame of their wheelchair. R6 was sitting in the wheelchair at time of observation.Surveyor did not find any documentation of nursing assessments of the wander guard device's proper functioning in R6's medical record.On 08/12/2026 at 7:22 AM, Surveyor asked CNA G how often staff check a resident's wander guard device for proper functioning. CNA G was not aware of this being done and informed Surveyor that CNA staff did not do the checking of the wander guards. CNA G stated they assumed nurses performed wander guard device checks.On 08/12/2026 at 10:26 AM, Surveyor interviewed Director of Nursing (DON) B and asked where the wander guard devices are placed on residents who are at risk for elopement. DON B stated the devices should be placed on a resident's wrist or ankle. DON B confirmed some residents have wander guard devices placed on their wheelchairs, but those residents cannot ambulate. DON B confirmed R23's wander guard device was placed on their walker, and they used to use their walker when ambulating in the halls and to meals, however since their recent COVID illness, R23 does not use the walker. DON B confirmed R23 self-propels in their wheelchair both in and out of their room. DON B acknowledged the wander guard manufacturer instructions advised the devices should not be placed on anything metal, including wheelchairs and walkers, as such can cause malfunctioning of the device and increase risk for residents to exit the facility without staff awareness. DON B confirmed the desk at front entrance of building was not manned by staff 24/7 and it would be possible for a resident to elope from the facility if the wander guard device was not properly placed.

Based on observation, interview and record review, the facility failed to ensure that a Peripherally Inserted Central Catheter (PICC) line was maintained in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for parenteral fluids (R1). The facility failed to: Obtain and implement active physician orders for scheduled PICC line dressing changes for R1. Document required routine clinical assessments of the PICC insertion site for localized signs and symptoms of infection. Update R1's care plan to reflect the presence of a PICC line, associated care needs, and monitoring interventions.Findings include: According to the National Library Institute <cbi.nlm.nih.gov/books/NBK594495/> central venous access devices (CVADs) may be inserted centrally or peripherally. Peripherally inserted central venous catheters (referred to as PICC lines) are primarily placed through the basilic, cephalic, or brachial veins. Assessment of the central venous access device (CVAD) should occur at least every shift and as needed. Assessment of the insertion site and surrounding area, securement device, functioning of the CVAD, and tip location. Assess for proper functioning of the device. Observe for flow of fluids and occlusion alarms. Inspect the dressing determine if the dressing is clean, intact and dated. Changing dressings over the site every two days for gauze dressings, every seven days for semipermeable dressings, or as needed if it becomes damp, loose, or visibly soiled. Check for redness, swelling, drainage ask the client if experiencing pain, numbness or tingling. Measure the external catheter and compare the measurement result to the initial placement verification results to detect any catheter migration or dislodgement. Measure the upper arm circumference measurements each shift and compare results. Ensure Luer-lock connections are secure. R1 was admitted on to the facility on 6/04/26, with a diagnosis including actinic keratoses, paraplegia and methicillin resistant staphylococcus aureus infection. On 8/10/2026 at 10:30 AM, Surveyor observed a PICC line in R1's right forearm with an intact dressing dated 8/8/26. Surveyor interviewed R1 and asked if nursing staff was changing the PICC line dressing and measuring the tubing of the PICC line or R1's arm circumference. R1 stated the PICC line had been placed in the hospital and dressing was applied at that time. R1 stated they experienced numerous infections and due to multiple health issues and hardware in their knee they were prone to infections. R1 stated the facility staff have been administering IV (intravenous) antibiotics every evening but have not changed the dressing covering the PICC line insertion nor have they measured R1's arm circumference. R1 stated the PICC line tubing itself has not been measured by facility nursing staff since they returned with the placed PICC line. R1's nursing progress notes, dated 7/29/26, stated R1 was hospitalized due to an infected left knee, requiring surgical debridement. At which time, a PICC line was placed for IV antibiotic administration.R1 returned to the facility on 8/07/26 with orders to administer Daptomycin intravenous solution reconstituted 350 MG, (Daptomycin) use 700 milligrams intravenously every night shift for right knee infection until 08/27/26 with a start date of 08/07/26. Surveyor noted an order to flush the PICC line with normal saline before administration. No orders were found for a PICC line dressing change, and R1's care plan was not updated to address R1's PICC line needs.Facility documentation did not indicate assessments of R1's PICC line placement or monitoring for signs or symptoms of an infection. R1's care plan was not updated to address their PICC line needs.On 8/12/2026 at approximately 9 AM, Surveyor interviewed Registered Nurse (RN) F, who reported they were not aware of any orders to provide PICC line measurements, to change PICC dressing, or to document monitoring of infection; however, R1 is given their IV antibiotic on night shift. On 8/12/2026 at 9:20 AM, Surveyor interviewed Director of Nursing (DON) B and asked about R1's PICC line regarding orders, assessments, and monitoring. DON B stated R1 did not have treatment orders in place to provide PICC line care other than administering the antibiotic and flushing the line. DON B stated the order to provide dressing changes to R1's PICC line and to monitor for infection or infiltration will be added to the R1's medical record today and R1's care plan will be updated.

Based on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed (R1.) R1 was a 2 person assist for transfers with the EZ stand lift. Certified Nursing Assistant (CNA) H independently transferred R1 with the EZ stand and R1 fell resulting in a 3.5 cm x 4 cm laceration of the left temporal scalp requiring transfer to the local hospital for treatment consisting of 7 staples to the temporal scalp.This is evidenced by:Facility policy titled Mechanical Lifts (Total Body and Sit-to-Stand) with a reviewed date of 04/2026 states: All mechanical lifts will be operated per the manufacturer's instructions.Sit to Stand: Assistance with the sit-to-stand lift is determined by therapy and the assistance level is documented in the Care Plan and Kardex.EZ Way Smart Stand Operator's Instructions state: The EZ Way Smart Stand was designed to be operated by one caregiver. However, depending on the situation, facility policy, and the patient's condition, two caregivers may be necessary.R1 was admitted to the facility on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting left dominant side.R1's quarterly Minimum Data Set (MDS) assessment, dated 04/01/26, noted a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment.R1's care plan, dated 01/21/25 with a target date of 06/24/26, states: Actual deficit with ADLs with a goal to have needs met. Interventions include: chair/bed transfer - 2 assist with use of EZ stand.R1's most recent PT (Physical Therapy) discharge note, dated 03/06/26, noted transfer assist of 2 using an EZ stand lift.On 04/19/26 at 12:45 PM, CNA H independently transferred R1 from the bathroom to the recliner using the EZ stand lift. R1's wife was present in the room during the transfer. As CNA H moved R1 into position with the back of R1's legs against the recliner, R1's wife asked CNA H if R1's chair could be moved closer to the TV. CNA H began to move the EZ stand to accommodate R1's wife's request as R1's wife began repositioning the recliner. CNA H then observed R1 suddenly fall straight down, out of the sling in the EZ stand, and land on the floor on R1's left side. R1's head hit the floor and began bleeding. CNA H quickly got Licensed Practical Nurse (LPN) C to assist. LPN C completed first aid and the RN manager entered shortly after to assess R1. Provider was notified and ambulance was called. R1 was transferred to the local hospital for evaluation and returned to the facility the same day.Surveyor reviewed R1's hospital records, dated 04/19/26, and noted R1 had a 3.5 cm (length) x 4 cm (depth) laceration to the left temporal scalp requiring repair with 7 staples. A CT scan and x-rays were completed without findings of fracture or other injuries.On 05/04/26 at 9:39 AM, Surveyor interviewed R1's wife regarding the incident on 04/19/26. She stated she was present in the room at the time of the incident and observed CNA H transferring R1 to the recliner. R1's wife stated she didn't remember anything abnormal happening at the time of the incident but only that R1 fell straight down out of the sling so fast, like he just collapsed. R1's wife couldn't recall any additional details. Surveyor asked if R1 had any other falls or incidents while at the facility and she stated no.On 05/11/26 at 9:33 AM, Surveyor interviewed CNA H regarding the incident. CNA H stated that she transferred R1 independently with the EZ stand lift. Surveyor asked CNA H how she determined R1's transfer status was an assist of 1. CNA H stated that she assumed R1 was an assist of 1 but did not review R1's care plan prior to assisting with the transfer to ensure this. CNA H stated she had gotten into a bad habit of not checking residents' care plans.On 05/04/26 at 11:00 AM, Surveyor observed R1 sitting in recliner in room. R1's care plan was observed in place and up-to-date and affixed to the inside closet door. Surveyor asked R1 if he remembered the incident that occurred on 04/19/26. R1 stated no. Surveyor asked R1 if he was in pain. R1 said no.On 05/04/26 at 11:40 AM, Surveyor interviewed LPN C regarding the incident. LPN C stated being unsure as to why CNA H had transferred R1 with the EZ stand independently as there were sufficient staff on duty. LPN C stated he had worked with CNA H over the past year numerous times and always felt CNA H was very competent and followed the residents' care plans. LPN C stated that CNA H likely forgot that R1 required 2 assist with the EZ stand because some residents have variable assist levels depending on their individual needs but he did not feel CNA H did it deliberately.On 05/04/26 at 1:09 PM, Surveyor interviewed Director of Nursing (DON) B regarding the incident. DON B stated in the approximate year that CNA H has been employed at the facility, there have never been any complaints or concerns regarding resident care and following care plans. DON B stated CNA H was interviewed about the incident immediately after it happened to determine why the care plan wasn't followed and CNA H stated that she didn't know R1 was a 2 assist and that she did not deliberately ignore the care plan. Afterwards, DON B completed additional training and reeducation with CNA H and all other nursing staff on the importance of reviewing resident care plans at the start of each shift.Surveyor reviewed facility's investigation of incident. A Quality Assurance Performance Improvement (QAPI) plan was initiated on 04/19/26. All nursing staff were reeducated on reviewing resident's care plans at start of shift and competency assessments using lift equipment were completed. Ongoing audits were being completed for care plan compliance and safe use of lift equipment. R1's care plan was updated to assist of 2 with Hoyer and currently being reevaluated by Physical Therapy (PT.) All residents' care plans were reviewed. CNA H received first written warning for not following R1's care plan and reeducation and training was completed.Based on Surveyor's investigation, the facility was not in compliance related to Quality of Care when staff did not follow R1's care plan for transfers resulting in a fall with actual harm. The facility recognized the deficient practice, conducted an investigation, put interventions in place, and provided staff education. The facility has no current noncompliance. This is being cited at past noncompliance actual harm/isolated.

Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 (R3) of 4 sampled residents reviewed for falls/accidents out of a total sample of 6 residents. R3 was diagnosed with a right hip fracture, identified as an injury of unknown origin and the facility did not report the injury to the state agency (SA). CMS's definition of abuse to be reported within 2 hours, as identified, in part, by 483.12(c)(1) as: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 2 hours if the events that cause the allegation do involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Findings include:R3 was admitted to the facility on [DATE] and had diagnosis that included dementia, osteopenia, falls and weakness. R3 had a brief interview of mental status (BIMS) score of 0 which means severe cognitive impairment. R3 had a legal representative for healthcare. Record review of R3's medical chart: R3 was transferred to the emergency department (ED) on 04/04/2026 after R3 complained of right leg pain during cares. Radiology testing done in the ED found a moderately displaced, mildly comminuted (broken in more than one place) proximal right femur (leg/hip) fracture. Radiology testing also confirmed severe osteopenia (loss of bone density which could lead to high risk for fracture). During R3's hospital course, it was determined through professional medical opinion that R3 was not a surgical candidate due to advanced age and multiple medical comorbidities. R3 was discharged from hospital back to the facility on [DATE] on comfort care measures. On 04/07/2026, Director of Nursing (DON) B initiated an investigation on R3's injury of unknown origin, right hip fracture. According to the investigative report and nursing documentation in R3's medical chart, R3 started to complain of right leg pain the morning of 04/03/2026. DON B interviewed several nurses and certified nursing assistants (CNAs) who worked 24 hours prior to the AM shift of 04/03/2026. All staff interviews done by DON B indicated R3 had no complaints of pain prior to 04/03/2026, and no traumas or injuries to R3 were witnessed by staff. Report stated R3's legal representative was aware of injury and R3's prognosis. As part of review of R3's fall investigation report, Surveyor did not find indication the facility reported the incident of R3's injury of unknown origin, fracture to right hip to the SA (State Agency).On 05/04/2026 at 10:36 AM, Surveyor interviewed R3's legal representative/Power of Attorney (POA) F regarding R3's injury of unknown origin, right hip fracture diagnosed on [DATE]. R3's POA was aware of the right hip fracture and that no trauma or fall was witnessed by staff. POA F stated because R3 was known to have poor bone health, it was very possible that R3's hip fractured spontaneously while R3 propelled herself with her legs in a wheelchair. POA F stated R3 has a new wheelchair and sat higher than what R3 was used to. POA F did not have any concerns of staff abuse or neglect resulting in R3's right hip fracture. On 05/04/2026 at 12:52 PM, Surveyor interviewed DON B. Surveyor asked DON B if the facility submitted a facility reported incident for R3's injury of unknown origin, right hip fracture on 04/04/2026 to the SA. DON B stated the facility did not submit a self-report on the injury of unknown origin, and DON B was not aware that one needed to be done. DON B confirmed R3's right hip fracture was considered an injury of unknown origin.

Based on observation, interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 3 residents sampled. (R1)Facility did not consistently monitor and assess R1 for changes after testing positive for COVID-19. The provider was not notified when R1 began experiencing COVID-19 symptoms.This is evidenced by:Facility policy, titled, Notification of Change, with a revision date of 11/2022, states in part: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).a need to alter treatment significantly (i.e., a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment).Nursing judgment is an integral part of the skilled care provided in the community; therefore, such judgment must be applied in a case-by-case basis in keeping with acceptable nursing practice.R1 was admitted to the facility on [DATE] with pertinent diagnoses of right lobe-lobar pneumonia, acute and chronic respiratory failure with hypoxia, emphysema, and diabetes mellitus type 2.R1's admission Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment. R1 received special treatment of continuous oxygen therapy.R1's care plan, dated 10/10/25, with a target date of 01/07/26, states, Resident has COVID-19 infection, signs and symptoms of COVID19, tested positive. Goal of free of serious complications and/or signs and symptoms of COVID-19 through review date and interventions of meds/labs/treatments as ordered, follow facility protocol for COVID-19 screening/precautions, ensure proper PPE/precautions/hygiene.R1's care plan, dated 09/26/25, with a target date of 01/07/26, states, Respiratory: diagnosis - COPD oxygen, with a goal of free of serious complications r/t diagnosis and/or medication use, and interventions: meds/labs/treatments as ordered, monitor/observe/document signs and symptoms of adverse side effects and complications related to diagnosis, review with MD for recommendations.R1's physician orders:09/25/25 Monitor for signs/symptoms (s/sx) of COVID-19 infection including Temp > 99.9F, Chills, Cough, Shortness of Breath, Difficulty Breathing, Fatigue, Muscle or Body Aches, Headache, New Loss of Taste or Smell, Sore Throat, Congestion or Runny Nose, Nausea or Vomiting, Diarrhea. every shift If any symptoms are noted, immediately implement enhanced COVID-19 precautions, including Contact & Droplet Precautions. Notify primary provider, family/responsible party administrator, & DON.09/25/25 Complete Comprehensive Skilled Note under Assessment Tab BID every evening and night shift for Medicare A.09/25/25 - 10/01/25 Supplemental Oxygen via NC at 2.5L/min.09/28/25 Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for pain or elevated temp. Not to exceed 3000 MG/day for all meds containing Acetaminophen/Tylenol.10/01/25 - 10/13/25 Supplemental Oxygen via NC at 2.5L/min. every shift10/01/25 - 10/11/25 Contact/Droplet Isolation r/t Positive Covid every shift for +Covid until 10/11/2025 23:59. May come out of room on 10/12/2025.10/01/25 - 10/11/25 Document s/sx of covid and respiratory status in progress note. every shift until 10/11/2025 23:59Surveyor reviewed R1's vital signs and MAR and noted: 09/26/25 - 09/30/25, R1's oxygen saturation with supplemental oxygen was documented between 94-97% and temperature average of 97.5.10/01/25 - 10/05/25, R1's oxygen saturation with supplemental oxygen was documented between 90-92%.10/01/25 - 10/03/25, R1's temperature was documented between 97.5 - 98.6.On 10/04/25 at 2:26 AM, R1 was administered acetaminophen. At 8:09 AM, med was noted as effective. No documentation of pain was noted at this time. Last documented temperature was on 10/03/25 at 12:21 PM of 98.On 10/04/25 at 5:55 AM, R1's temperature was 99.2.-Of note: No additional re-evaluation of temperature was documented for over 8 hours.On 10/04/25 at 3:14 PM, R1's temperature was 99.6.-Of note: No additional re-evaluation of temperature was documented for over 15 hours.On 10/05/25 at 7:27 PM, R1's temperature was 99.2.-Of note: No additional re-evaluation of temperature was documented for over 7 hours.Surveyor reviewed R1's Comprehensive Nursing Notes:09/29/25 5:17 PM: Temp 97.8 - 9/29/2025 06:00; Respiration 16.0 - 9/29/2025 06:00; Pulse 78 - 9/29/2025 06:00; Lung Sounds - Clear; NO Shortness of Breath or Trouble Breathing Noted when Sitting at Rest or Lying Flat Observed; NO cough; NO oxygen used.10/01/25 03:35: Blood Pressure - 114/49 - 10/1/2025 03:14; Temperature - T 98.6 - 10/1/2025 03:14; Pulse - P 74 - 10/1/2025 03:14; Respiration - R 18.0 - 10/1/2025 03:14; O2 sats 91%; Lung Sounds - Clear; NO Shortness of Breath or Trouble Breathing Noted when Sitting at Rest or Lying Flat Observed; NO cough; Oxygen used: Yes 3.-Of note: R1 had positive COVID-19 test completed 10/01/25 at 11:38 AM. Facility initiated isolation precautions, initiated monitoring of COVID-19 symptoms, and notified provider and APOA.10/01/25 10:17 PM: Blood Pressure - BP 117/60 - 10/2/2025 13:15; Temperature - T 97.5 - 10/2/2025 13:15; Pulse - P 79 - 10/2/2025 13:15; Respiration - R 20.0 - 10/2/2025 13:15; O2 sat 90%; Lung Sounds - Clear; NO Shortness of Breath or Trouble Breathing Noted when Sitting at Rest or Lying Flat Observed; NO cough; Oxygen used: Yes, Via Cannula 2.5LPM.R1's daily assessments continued with no changes.10/03/25 12:21 PM: COVID-19 Daily Observation Tool - Lung Sounds: clear, wheezes on exhalation. Encourage resident to cough and mild congestion noted in chest cleared.-Of note: New symptom of wheezing assessed without shortness of breath or difficulty breathing. No documentation of notifying provider of changes assessed in lung sounds from baseline of clear was noted. This was the first documentation of change in symptoms after confirmed positive COVID-19 test. Per facility policy, provider was to be notified with changes or worsening in symptoms.10/04/25 3:15 PM: Blood Pressure - BP 130/72 - 10/4/2025 15:14; Temperature - T 99.6 - 10/4/2025 15:14; Pulse - P 90 - 10/4/2025 15:14; Respiration - R 21.0 - 10/4/2025 15:14; O2 sats 92%; Lung Sounds - Rales/Crackles; NO Shortness of Breath or Trouble Breathing Noted when Sitting at Rest or Lying Flat Observed; Productive cough observed; Oxygen used: Yes, Via Cannula 3L.-Of note: No documentation of notifying provider of new productive cough, elevated temperature from baseline, increase in oxygen from 2.5 to 3 LPM, increased pulse, and change in lung sounds. No additional vital signs were assessed for over 15 hours.10/05/25 6:36 AM: Blood Pressure - 147/47; Temperature - 99.1; Pulse - 93; Respiration - 20; O2 sats 91%.-Of note: R1's temperature and pulse remained elevated from baseline and blood pressure increased. No documentation of notifying provider.10/05/25 7:29 PM: Blood Pressure - BP 147/57; Temperature - T 99.2; Pulse - P 93; Respiration - R 20.0; O2 sats 91%; Lung Sounds - Rales/Crackles Diminished; Shortness of breath with exertion observed; Non-productive cough observed; Oxygen used Via Cannula 3LPM.-Of note: New onset of shortness of breath and lung sounds of rales observed. No documentation of notifying provider of changes.10/06/25 3:06 AM: Blood Pressure - BP 111/34; Temperature - T 98.2; Pulse - P 90; Respiration - R 28; O2 sats 88%.-Of note: No assessment of lung sounds documented at this time. Provider was not notified of change until 5:23 AM, 2 hours after documentation of change in respirations and desaturation below 90%.Surveyor reviewed R1's progress notes:10/6/2025 05:59 Change of Condition What is the resident exhibiting: Covid positive and declining.Describe current condition and your current assessment: Resident is minimally responsive, only rousing to sternal rub, O2 sats 82-88% on 5LPM, Resp 22-30Physician and Family notification and responses: Provider notified at 0523 and family notified and agreed to bed hold.New orders or interventions put into place: Order to send to ED. EMS contacted at 0524, report called to hospital at 0554.-Of note: R1 was admitted to the hospital on [DATE] and discharged back to facility on 10/08/25.Surveyor reviewed R1's hospital notes:10/06/25 Chief complaint: Hypoxia (R1 arrived via EMS. Found unresponsive and hypoxic on morning rounds.) Presents to ER for evaluation of hypoxia and altered mental status. Per EMS, patient found to be unresponsive.with oxygen saturations in the low 80s. Started on oxygen by nasal cannula and patient did become somewhat more responsive. Patient's wife stated visiting resident last night and noticed R1's oxygen saturation at 83%.Physical exam: General - R1 is in acute distress. R1 is ill-appearing. Temperature: 100.6.Chest X-ray completed. Impression: Areas of atelectasis right perihilar region. Elevation left hemidiaphragm with atelectasis left lung base unchanged.CT of chest: Residual consolidative changes at each lung base left side greater than right. Left side worsened when compared to the prior study.Medical Decision Making: R1 placed on bipap upon presentation to the emergency department and oxygen saturation did improve. Found to be febrile to 100.6 for which, Rocephin started. Admit to hospital with acute hypoxemic respiratory failure, hypoxia, COVID, fever, hypoxemic respiratory failure, and acute on chronic respiratory failure with hypercapnia.10/08/25 Hospital Discharge Summary Diagnoses: acute on chronic hypoxic and hypercarbic respiratory failure, emphysema with exacerbation, severe COVID-19 infection, elevated troponin-suspected type 2 NSTEMI, hypotension-fluid responsive, CAD with remote MI, AKI on CKD2, mild hyponatremia.Hospital Course: R1 initially required BiPAP, treated with dexamethasone, bronchodilators and ceftriaxone for coverage of potential COPD exacerbation. Given rapid escalation to NIV (non-invasive ventilation), also received toculizumab (immunosuppressive drug). Quickly weaned to nasal cannula and near baseline oxygen needs.Vital signs at discharge: BP 123/59; Temp 96.7; Pulse 61; Respirations 18; O2 sats 91% on 3.5 LPM via nasal cannula.Surveyor reviewed R1's medical record for provider assessments and noted no documented assessment completed by provider after positive COVID-19 test on 10/01/25 to transfer to ER for evaluation on 10/06/25.On 11/12/25 at 6:45 AM, Surveyor interviewed Registered Nurse (RN) C regarding assessments, notifying provider of changes, and documentation. Surveyor asked RN C how a change would be assessed in residents. RN C stated that any new symptom or a change from baseline would indicate a change and the provider should be notified with observed changes. Surveyor asked RN C if a temperature of 99 or above would be considered a fever or a change. RN C stated yes, this would likely be considered a low-grade fever and staff would likely treat with standing orders of Tylenol and re-assess. Surveyor asked how often this should be re-assessed. RN C stated that the facility did not have a standing protocol related to frequency, but nursing judgment would include at least once a shift and after any interventions, like Tylenol, were given. Surveyor asked if a positive COVID-19 status would influence frequency of assessments. RN C stated yes, these residents would definitely be re-assessed more frequently and likely more than once a shift if symptoms were present. Surveyor asked RN C if an assessment noted a change in lung sounds would be something the provider would be notified of and then documented. RN C stated yes and that all communication with the provider should be documented in a progress note. Surveyor asked RN C how soon the provider should be notified. RN C stated immediately, especially with changes in level of consciousness or decrease in O2 sats.On 11/12/25 at 7:18 AM, Surveyor interviewed RN D regarding assessments, notifying provider of changes and documentation. Surveyor asked RN D what changes would be communicated with the provider in a resident confirmed positive with COVID-19. RN D stated any changes in temperature, lung sounds, or other vitals from baseline. Surveyor asked if communication with a provider is documented. RN D stated yes. Surveyor asked RN D how often vitals and assessments should be completed after recognizing a change. RN D stated not being aware of any particular timeframe, but would re-assess at least once a shift, report to the next nurse coming on-duty, and then make a note in the resident's chart.On 11/12/25 at 10:37 AM, Surveyor interviewed Director of Nursing (DON) B regarding assessments and notifying provider with changes of condition. Surveyor asked DON B if an assessment noted a change in lung sounds in a resident known COVID-19 positive should be reported to the provider. DON B stated absolutely, and that the communication should be documented in the resident's chart. Surveyor reviewed the timeline documented in R1's medical chart noting that when changes were noted, the provider was not notified. DON B stated that when the nurse noticed a new cough, changes in lungs sounds, and the elevated temperature from baseline should have been communicated to the provider immediately.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 2 of 3 residents (R) reviewed (R1 and R3).On 07/31/25, R3 had a fall resulting in fracture and treated in ER. The facility did not report this incident as possible neglect to State Agency (SA).On 10/10/25, the facility was made aware of a concern of neglect regarding R1's care. The facility did not report this allegation of neglect to State Agency.This is evidenced by:Facility policy, titled, Abuse, Neglect, and Exploitation, Suspected Crime, with a revised date of 08/2025, states in part: It is the policy of this community to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator or the community. If the events that caused the allegation involve abuse or serious bodily injury, it must be reported to the State agency immediately, but no later than 2 hours after forming the suspicion per State and Federal regulations. Events that do not involve abuse and/or do not result in serious bodily injury must be reported to the State agency no later than 24 hours as per State and Federal regulations. 7. Reporting: a. Any employee who suspects an alleged violation immediately notifies administrator. The administrator notifies the appropriate state agency immediately, following state law.Example 1R3 was admitted to the facility on [DATE] with pertinent diagnoses of neurocognitive disorder with Lewy bodies, dementia moderate with psychotic disturbance and agitation, difficulty walking, muscle weakness (generalized), and nondisplaced fracture of surgical neck of left humerus (07/31/25).R3's most recent MDS, dated [DATE], noted a BIMS score of 09, indicating moderate cognitive impairment. R3 had impaired ROM on one side of upper extremity. R3 required Partial/moderate assist with oral hygiene and walking up to 150 ft; Substantial/max assist with toileting hygiene, shower/bathe self, upper/lower dress, personal hygiene, rolling left to right, sit to lying, sit to stand, chair/bed transfer, and toilet transfer. R2 was frequently incontinent of bladder. R3 had one fall with major injury.Surveyor reviewed R3's medical record and noted the following:On 07/31/25 at 5:30 PM, R3 had unwitnessed fall in room. Nurse found R3 on floor while walking by R3's room. Nurse observed R3 on floor at foot of bed, lying on left side in a semi-fetal position. R3's head was toward doorway and feet toward windows. R3's left elbow bent with palm towards ceiling and up off floor about 30 degrees. R3 was yelling she hurts. R3 assessed and complained of pain in left shoulder, left hip, and all over. R3 stated trying to put footrest down on the recliner chair, turned around and fell. R3 stated she was not using her walker and hit her head twice on the floor. Provider, DON, and family notified. R3 was transferred to ER. IDT reviewed and investigation completed.-Hospital notes: 07/31/25: Chief complaint: left arm/shoulder pain related to fall. Discharge diagnosis: left nondisplaced humerus fracture. Discharge instructions: continuous use of left arm sling and swath; follow-up with primary provider.Surveyor reviewed facility's self-reported incidents. This incident was not reported to the State agency, and no Misconduct Report was initiated.On 11/12/25 at 8:06 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding reporting incidents. NHA A stated that the reporting of allegations and incidents are a shared responsibility of the NHA and Director of Nursing (DON). Surveyor asked NHA A which incidents should be reported to the State agency. NHA A stated all allegations of abuse, neglect, and misappropriation. Surveyor asked NHA A when a fall would be reported to the State agency. NHA A stated falls with a fracture without a known cause should be reported and investigated. NHA A stated the DON would be responsible for nursing-related incidents and reporting.On 11/12/25 at 10:22 AM, Surveyor interviewed DON B regarding reporting incidents to the State agency. DON B stated that the NHA is responsible for completing all incident reporting to the State agency. Surveyor asked DON B when a fall would be reported to the State agency. DON B stated being blurry and confused on which incidents to report regarding this. Surveyor asked DON B if the facility was able to immediately identify that R3's fall and resulting fracture did not occur due to abuse or neglect. DON B stated no, that an investigation had to be completed to ensure R3's care plan was followed to rule out neglect. Surveyor then asked DON B if this incident should have been reported to the State agency prior to completing an investigation. DON B stated yes.Example 2R1 was admitted to the facility on [DATE] with pertinent diagnoses of right lobe-lobar pneumonia, acute and chronic respiratory failure with hypoxia, emphysema, and diabetes mellitus type 2.R1's admission Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment.Surveyor reviewed R1's medical record and noted the following:On 10/01/25, R1 tested positive for COVID-19. No signs or symptoms were present at this time. Daily assessments were to be completed monitoring for new or worsening COVID-19 symptoms and to notify provider of changes.On 10/03/25, R1 was assessed to have new symptoms of wheezes present. Provider was not notified.On 10/04/25, R1 was assessed to have worsening lung sounds of rales/crackles and new onset of non-productive cough. Provider was not notified.On 10/06/25 at 5:59 AM, R1 had a change of condition noting R1 was found unresponsive with O2 saturation of 88% on 5LPM via nasal cannula and respirations of 28. Provider and family was notified. R1 was transferred to the ER for evaluation. R1 was admitted with diagnoses of acute hypoxemic respiratory failure, hypoxia, COVID, fever, hypoxemic respiratory failure, and acute on chronic respiratory failure with hypercapnia.On 10/08/25, R1 returned to the facility.Surveyor reviewed facility's complaint/grievances and noted on 10/09/25, R1's POA filed a complaint stating concern with the care R1 received prior to hospitalization on 10/06/25. R1's POA stated concern that R1's O2 sats dropped without staff doing anything until R1 was unconscious. R1's POA further stated R1's door was always closed and was hardly checked on. R1's POA stated she desired to have R1 transferred to another facility. The facility documented follow-up completed on 10/14/25 with interventions to check on R1 every 30 minutes to ensure safety and bed would be kept at low height for safety. R1's POA was still not satisfied with interventions and still wanted R1 transferred to another facility.-Of note: R1 was transferred to another facility on 10/21/25. No additional investigation was initiated related to R1's POA's allegation of neglect.Surveyor reviewed facility's self-reported incidents. This incident was not reported to the State agency, and no Misconduct Report was initiated.On 11/12/25 at 10:37 AM, Surveyor interviewed DON B regarding R1's care and POA's grievance. DON B stated that she became aware of R1's POA allegation on 10/10/25 and spoke with R1's family about their concerns. At this time, DON B provided Surveyor with a copy of the email DON B sent to the provider and NHA regarding R1's POA concerns and what the ER provider stated to R1's POA on 10/06/25. DON B stated that R1's POA was told by the ER provider that there was no way R1's respiratory condition declined that fast and that the facility should have intervened earlier to prevent this worsening. Surveyor asked DON B if this concern could be considered neglect. DON B stated yes. Surveyor asked DON B if this concern could be neglect, should it have been reported to the State agency and investigated to determine if neglect had occurred. DON B stated yes.

Based on staff interview and record review, the facility did not ensure a potential allegation of neglect was thoroughly investigated for 2 of 3 residents (R) (R1 and R3) reviewed.On 10/10/25, the facility was made aware of a concern of neglect regarding R1's care. The facility did not ensure a thorough investigation was completed related to the allegation of neglect of R1.On 07/31/25, R3 had an unwitnessed fall in R3's room. The facility did not ensure a thorough investigation was completed.This is evidenced by:Facility policy, titled, Abuse, Neglect, and Exploitation, Suspected Crime, with a revised date of 08/2025, states in part: It is the policy of this community to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator or the community.The community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to state agencies and Adult Protective Services as required by state and federal law.Definitions: Neglect: Is the failure of the community, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Serious bodily injury: is defined in section 2011(19) of the Act and means an injury involving extreme physical pain, substantial risk of death, protracted loss or impairment of the function of a bodily member, organ or mental faculty, or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.Procedure: 4. Identification: Incidents of possible abuse or neglect, such as suspicious bruising of residents, occurrences, patterns, and trends will be identified through ongoing assessment of resident conditions, incidents, resident interviews, family or resident councils, and verbal or written reports of observations. 5. Investigation: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations. c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process.Example 1R1 was admitted to the facility on [DATE] with pertinent diagnoses of right lobe-lobar pneumonia, acute and chronic respiratory failure with hypoxia, emphysema, and diabetes mellitus type 2.R1's admission Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 07/15, indicating severe cognitive impairment.Surveyor reviewed R1's medical record and noted the following:On 10/01/25, R1 tested positive for COVID-19. No signs or symptoms were present at this time. Daily assessments were to be completed monitoring for new or worsening COVID-19 symptoms and to notify provider of changes.On 10/03/25, R1 was assessed to have new symptoms of wheezes present. Provider was not notified.On 10/04/25, R1 was assessed to have worsening lung sounds of rales/crackles and new onset of non-productive cough. Provider was not notified.On 10/06/25 at 5:59 AM, R1 had a change of condition noting R1 was found unresponsive with Oxygen (O2) saturation of 88% on 5Liters Per Minute (LPM) via nasal cannula and respirations of 28 per minute. Provider and family was notified. R1 was transferred to the emergency room (ER) for evaluation. R1 was admitted with diagnoses of acute hypoxemic respiratory failure, hypoxia, COVID, fever, hypoxemic respiratory failure, and acute on chronic respiratory failure with hypercapnia.On 10/08/25, R1 returned to the facility.Surveyor reviewed facility's complaint/grievances and noted on 10/09/25, R1's Power of Attorney (POA) filed a complaint stating concern with the care R1 received prior to hospitalization on 10/06/25. R1's POA stated concern that R1's O2 sats dropped without staff doing anything until R1 was unconscious. R1's POA further stated R1's door was always closed and was hardly checked on. R1's POA stated she desired to have R1 transferred to another facility. The facility documented follow-up completed on 10/14/25 with interventions to check on R1 every 30 minutes to ensure safety and bed would be kept at low height for safety. R1's POA was still not satisfied with interventions and still wanted R1 transferred to another facility.-Of note: R1 was transferred to another facility on 10/21/25. No additional investigation was initiated related to R1's POA's allegation of neglect.Surveyor reviewed facility's self-reported incidents. This incident was not reported to the State agency, and no Misconduct Report was initiated.On 11/12/25 at 10:37 AM, Surveyor interviewed Director of Nursing (DON) B regarding R1's care and POA's grievance. DON B stated that she became aware of R1's POA allegation on 10/10/25 and spoke with R1's family about their concerns. At this time, DON B provided Surveyor with a copy of the email DON B sent to the provider and NHA regarding R1's POA concerns and what the ER provider stated to R1's POA on 10/06/25. DON B stated that R1's POA was told by the ER provider that there was no way R1's respiratory condition declined that fast and that the facility should have intervened earlier to prevent this worsening. Surveyor asked DON B if this concern could be considered neglect. DON B stated yes. Surveyor asked DON B if this concern could be neglect, should it have been reported to the State agency and investigated to determine if neglect had occurred. DON B stated yes.Example 2R3 was admitted to the facility on [DATE] with pertinent diagnoses of neurocognitive disorder with Lewy bodies, dementia moderate with psychotic disturbance and agitation, difficulty walking, muscle weakness (generalized), and nondisplaced fracture of surgical neck of left humerus (07/31/25).R3's most recent MDS, dated [DATE], noted a BIMS score of 09/15, indicating moderate cognitive impairment. R3 had impaired Range of Motion (ROM) on one side of upper extremity. R3 required Partial/moderate assist with oral hygiene and walking up to 150 ft; Substantial/max assist with toileting hygiene, shower/bathe self, upper/lower dress, personal hygiene, rolling left to right, sit to lying, sit to stand, chair/bed transfer, and toilet transfer. R2 was frequently incontinent of bladder. R3 had one fall with major injury.Surveyor reviewed R3's medical record and noted the following:On 07/31/25 at 5:30 PM; R3 had unwitnessed fall in room. Nurse found R3 on floor while walking by R3's room. Nurse observed R3 on floor at foot of bed, lying on left side in a semi-fetal position. R3's head was toward doorway and feet toward windows. R3's left elbow bent with palm towards ceiling and up off floor about 30 degrees. R3 was yelling she hurts. R3 assessed and complained of pain in left shoulder, left hip, and all over. R3 stated trying to put footrest down on the recliner chair, turned around and fell. R3 stated she was not using her walker and hit her head twice on the floor. Provider, DON, and family notified. R3 was transferred to ER. Interdisciplinary Team (IDT) reviewed, and investigation completed.-Hospital notes: 07/31/25: Chief complaint: left arm/shoulder pain related to fall. Discharge diagnosis: left nondisplaced humerus fracture. Discharge instructions: continuous use of left arm sling and swath; follow-up with primary provider.On 08/01/25: IDT Reviewed falls. New interventions implemented: 15-minute safety checks completed for 24 hours, bed at low height at Hour of Sleep (HS), and therapy to re-evaluate. R3's noncompliance with using walker during ambulation was assessed and discussed with R3 and R3's POA. Care plan updated.-Of note: Root cause was not clearly identified. Staff and residents were not interviewed. No documented education was completed with staff to prevent future falls.Surveyor reviewed facility's self-reported incidents. This incident was not reported to the State agency, and no Misconduct Report was initiated.On 11/12/25 at 10:37 AM, Surveyor interviewed DON B regarding this incident. DON B stated being unclear as to when falls with injuries had to be reported. DON B stated recognition in hindsight that this could have been potential neglect, and it should have been investigated further.

Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R) (R1, R2, R3) reviewed.R1 experienced a fall resulting in a head laceration and transfer to the emergency room (ER) for treatment. The facility did not complete a thorough investigation into root cause, implement new safety interventions, and assess head wound.R2 experienced numerous falls and the facility did not complete a thorough investigation into root cause or implement new safety interventions to prevent further falls.R3 experienced numerous falls, one with a major injury, and did not complete a thorough investigation into root cause or implement new safety interventions to prevent further falls.This is evidenced by:Facility policy, titled, Accidents/Falls-HDGR, with a reviewed date of 12/2024, states in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: 1. For all residents, a fall risk assessment is conducted upon admission, upon readmission from the hospital, annually, and with any significant change to the resident's status which puts them at a greater risk for falls. Additionally, each resident's fall risk assessment is reviewed on a quarterly basis, and any significant changes in status result in a full reassessment. 5. Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment. 6. If a fall or other incident/accident should occur, nursing/emergency care is to be provided to the resident per the facility's policy/standard of practice. Neurological observation (Neuros) will be conducted following any observation of a resident hitting their head during a fall/incident/accident or if it is unknown/not observed whether a resident actually hit their head or not during a fall/incident/accident. It should be noted even if a resident reports that head was not hit in fall was not observed, neurological assessments are required to be completed. Additionally, if a resident is sent to ER, for observation without finding and returns within 72 hours post fall, neurological checks must resume for the duration of 72 hours. 7. Any episode of a fall or other incident/accident should be documented within Point Click Care within Risk Management/Incidents. The information should be recorded in factual observed detail and not supposition of what may have occurred. Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury. Witness statements should be obtained as applicable. The administrator and Director of Nursing (DON)/Wellness should have knowledge of all reports. The interdisciplinary team will review all incident/accident. 8. The resident's physician and family/responsible person should be notified post fall/incident/accident as soon as possible, with contact documented in the resident's medical record. 9. A post-fall assessment will be conducted following any fall episode. Once the post-fall assessment is completed by nursing, the director of nurses or designee will seek additional input from the interdisciplinary team and other staff. DON/IDT [Interdisciplinary Team] Review Portion will be completed timely. The completed post-fall assessment will be maintained in the resident's medical record. 10. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented.Example 1R1 was admitted to the facility on [DATE] with pertinent diagnoses of right lobe-lobar pneumonia, acute and chronic respiratory failure with hypoxia, emphysema, and diabetes mellitus type 2.R1's admission Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 07/15, indicating severe cognitive impairment. R1 required setup assist with eating; supervision or touch assist with rolling left to right and sit to lying; Partial/moderate assist with oral hygiene, upper dress, lying to sitting, sit to stand, chair/bed transfer, toilet transfer; Substantial/max assist with toileting hygiene, shower/bathe self, lower dress, footwear, and personal hygiene. R1 had no falls.R1's care plan, dated 09/25/25, with a target date of 01/07/26, states, Actual/At Risk/ and/or Potential for Complications with OR falls with a goal to be free of falls, but if does free of serious injurie, reduced risk for falls, will have no falls through next review date, and not be injured in falls. Interventions include: 30 minute checks while in isolation (10/10/25), bed in lowest position when in bed, assistive device (grabber, toilet seat riser, bathroom bars), call light positioned for easy access, check for unmet needs - pain, toileting, hunger thirst, temperature, do not leave unattended in the bathroom, encourage/assist with non-skid shoes/socks, ensure environment is free of clutter, fall review per facility protocol, have commonly used articles within easy reach, reinforce need to use the call light to request assistance, safety devices, see rest of POC [plan of correction].R1's fall risk assessments:09/25/25 At risk - Reasoning: unfamiliar place and confusion at night, resident is a fall risk10/03/25 At risk - Reasoning: Resident is at risk for falls due to recent fall. Resident has unsteady gait and has covid. Resident has bilateral leg weakness and is on therapy caseload.R1's falls:On 09/27/25 at 10:00 AM; R1 had unwitnessed fall in room. R1 was found by Certified Nursing Assistant (CNA) sitting on floor in corner of room near window, blood on hospital gown and large puddle of blood on floor. Suspected R1 hit head on nightstand. R1 stated he was trying to use the telephone and lost his balance. RN notified of fall. R1 assessed to have 4 cm laceration on right side, back of head. First aid applied. Provider and family notified. R1 transferred to ER for evaluation. Other notes: poor safety awareness.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated.-Surveyor reviewed hospital notes:09/27/25 Chief Complaint: Fall (Pt presents from facility for unwitnessed fall; has laceration to R side of head.) estimated between 8-9 this morning. Endorsing head and neck pain. Denies pain anywhere else. Emergency Medical Services (EMS) estimates about 500 cc of blood loss based on what they saw on the floor from his laceration. Physical exam: 4 cm laceration on posterior right scalp, slowly oozing. Computed Tomography (CT) cervical spine completed: No acute fracture or malalignment of cervical spine. CT of head completed: No acute intracranial abnormality. Procedures: Laceration repair. Location: Scalp. Scalp Location: R parietal. Length: 4 cm. Depth: 3 mm. Repair type: Simple. Hemostasis achieved with: Direct pressure. Wound extent: fascia not violated and no underlying fracture. Repair method: Tissue adhesive. Approximation: Close. Dressing: Open (no dressing). Discharge instructions: Avoid combing the area with the glue or scrubbing at it. It will fall off on its own over time. If you have any other problems that may require emergent evaluation or recurrent bleeding from the laceration, you may return to be seen.-Of note: R1 returned to facility on 09/27/25. No documentation completed monitoring repaired laceration site for signs or symptoms of infection, status (intact, not intact), or measurements were noted.On 10/13/25 at 8:00 AM; R1 had un-witnessed fall in room. R1 found in bedroom in-between bathroom door and bed laying on right side/stomach with right arm under him. No injuries noted. R1 stated was trying to go to bathroom. Assessment completed. Provider and family notified.-Of note: No investigative notes to document root cause noted. No new interventions implemented.On 11/12/25 at 10:37 AM, Surveyor interviewed DON B regarding falls. Surveyor asked DON B the facility's procedure for falls. DON B stated all falls should be investigated to determine root cause, determine new interventions to prevent further falls, and the care plan updated. Surveyor reviewed the sampled residents' falls with DON B and asked why an investigation and IDT review was not completed with every fall. DON B stated not having a good answer, but that it should have been. DON B stated being aware of this concern and in the process of correcting this. Example 2R2 was admitted to the facility on [DATE] with pertinent diagnoses of traumatic subarachnoid hemorrhage with loss of consciousness, hemiplegia affecting left non-dominant side, unspecified dementia, cognitive communication deficit, and unsteadiness on feet.R2's Medicare 5-day MDS assessment, dated 10/07/25, noted a BIMS score of 09/15, indicating moderate cognitive impairment. R2 had impaired Range of Motion (ROM) on one side of upper and lower extremities. R2 required Partial/moderate assist with oral hygiene, upper dress, rolling left to right, sit to lying, and lying to sitting; Substantial/max assist with toileting hygiene, shower/bathe self, lower dressing, and footwear; Dependent assist with sit to stand, chair/bed transfer, and toilet transfer. R2 has an indwelling catheter. R2 has had no falls since admission/entry.R2's care plan, dated 08/29/25, with a target date of 02/18/25, states: Actual deficits with ADLs [Activities of Daily Living] with a goal of be more independent in bathing, dressing, grooming, bed mobility, transfers and ambulation/locomotion. Interventions include: chair/bed to chair transfer with 2 assist dependent with FWW, locomotion of 50 and 150 ft with 1 substantial/max assist and manual wheelchair, lying to sitting on side of bed with 1 partial/moderate assist, sit to stand with 2 assist dependent with FWW, toilet transfer with 2 assist dependent with FWW [Four-Wheeled Walker].R2's care plan, dated 08/29/25, with a target date of 02/18/26, states: Actual falls related to right parietal ICH, left sided weakness, cognitive deficits with forgetfulness, impulsiveness, poor safety awareness, generalized weakness with a goal to be free of falls or free of serious injuries. Interventions include: call light positioned for easy access, check for unmet needs - pain, toileting hunger, thirst, temperature, encourage/assist with non-skid shoes/socks, ensure environment is free of clutter, fall review per facility protocol, have commonly used articles within easy reach, and reinforce need to use the call light to request assistance.R2's fall assessments:8/19/25 At risk: Resident needs frequent reminders to lean forward with EZ stand, otherwise resident will lean backwards in waterski position. Resident has left sided weakness.8/22/25 At risk8/26/25 At risk: Resident is a risk for falls due to dementia, unsteady gait, and impulsiveness.9/9/25 At risk: History (Hx) of falls, impulsivity with poor safety awareness, cognitive deficit.9/16/25 At risk: High risk for falls. Resident has dementia. He is reminded to use call light but due to his cognition, he will not remember.10/1/25 At risk: High risk due to (d/t) several falls.10/18/25 At risk: Resident is unable to make needs known and will not follow instructions and self-transfer.11/5/25 At risk: Resident is at risk for falls due to unsteady gait and recent fall. Resident will self-transfer at times and lose his balance and fall.11/6/25 At risk: High risk for falls.R2's falls:On 08/20/25 at 6:30 AM; R2 had unwitnessed fall in room. CNA observed R2 sitting on buttocks on floor on right side of bed with legs straight out in front of him. No injuries. R2 stated trying to get up on feet to take a look around to see what was going on. Provider and family notified.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 08/20/25 at 4:00 PM; R2 had unwitnessed fall in room. Nursing description: R2 found on floor after he self-transferred from his wheelchair. R2 stated he just slipped. No injuries. Provider and family notified.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 08/22/25 at 3:00 PM; R2 had unwitnessed fall in room. Nursing description: Staff found R2 on his knees in front of bed on floor after attempting to self-transfer from wheelchair to bed. R2 stated, trying to move all these cars around. No injuries. Provider, DON, and family notified.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 08/26/25 at 10:50 AM; R2 had unwitnessed fall in room. CNA observed R2 sitting on buttocks in doorway leading into his room with legs straight out in front of him. No injuries. Provider and family notified.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 10/18/25 at 9:00 AM; R2 had witnessed fall in room. Nurse was waling past R2's room and observed R2 attempting to self-transfer to bathroom. Nurse attempted to stop R2 by asking R2 to wait for assist; nurse then observed R2 slide from wheelchair onto the floor. No injuries. Provider and family notified.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 11/05/25 at 9:15 AM; R2 had unwitnessed fall in room. Nursing description: R2 attempted to self-transfer to toilet, lost balance, and fell onto floor next to toilet. R2 found lying on left side with pants and brief around ankles. Spoke with R2 and R2 is in agreement with calling for help before transferring to toilet. (Call don't fall). No injuries. Intervention: Educated R2 to utilize call light before self-transferring to prevent any more falls. Provider notified.-Of note: No documentation of root cause investigation and care plan not updated. Intervention not appropriate per previous documentation of R2 self-transferring and not utilizing call light or waiting for assist. No IDT review of incident documented.On 11/06/25 at 3:50 PM, R2 had unwitnessed fall in room. R2 found sitting on floor near sink, fully clothed, brief clean and dry, shoes on. R2 unable to state what happened. R2 assessed and no injuries noted. Immediate intervention: R2 transferred to wheelchair and brought to main lounge area for better visibility. Provider, DON, and family notified.-Of note: No documentation of root cause investigation and care plan not updated. No IDT review of incident documented.Example 3R3 was admitted to the facility on [DATE] with pertinent diagnoses of neurocognitive disorder with Lewy bodies, dementia moderate with psychotic disturbance and agitation, difficulty walking, muscle weakness (generalized), and nondisplaced fracture of surgical neck of left humerus (07/31/25).R3's most recent MDS, dated [DATE], noted a BIMS score of 09/15, indicating moderate cognitive impairment. R3 had impaired ROM on one side of upper extremity. R3 required Partial/moderate assist with oral hygiene and walking up to 150 ft; Substantial/max assist with toileting hygiene, shower/bathe self, upper/lower dress, personal hygiene, rolling left to right, sit to lying, sit to stand, chair/bed transfer, and toilet transfer. R2 was frequently incontinent of bladder. R3 had one fall with major injury.R3's care plan, dated 09/14/25, with a target date of 02/18/26, states: At risk for falls related to neurocognitive disorder with Lewy Body and dementia with a goal of no falls through next review date. Interventions include: POA prefers to wait until morning to be called if nothing serious following a fall, but call if serious (03/19/25), grip strips to both sides of bed (03/19/25), CBC/BMP and UA ordered (07/26/25), 15-minute check through 08/01/25 (07/31/25), PT/OT orders (08/01/25), Risk vs. benefit discussion with family related to not using walker in room (08/01/25), 15-minute checks through AM shift 09/12/25 then d/c (09/12/25), have R3 lay down after done with supper - do not leave in room after supper in wheelchair as R3 will self-transfer (09/12/25), bed in low position at HS (08/01/25), call light positioned for easy access (09/14/25), check for unmet needs: pain, toileting, hunger, thirst, temperature, encourage/assist with non-skid shoes/socks, ensure environment is free of clutter, fall review per facility protocol, have commonly used articles within easy reach, reinforce need to use the call light to request assistance.R3's Fall Risk Assessments:7/26/25 At risk: Resident is unsteady on her feet and has a bad knee.7/31/25 At risk: multiple falls8/21/25 At risk: Resident is at risk for falls due to recent fall and bilateral leg weakness and unsteady gait.9/11/25 At risk: Resident is at risk for falls due to unsteady gait and dx of dementia. Resident forgets that she cannot walk by herself and self-transfers at times.9/14/25 At risk: Resident is at risk for falls due to unsteady gait and dx of dementia. Resident forgets that she cannot walk by herself and self-transfers at times.9/28/25 At risk: Resident is at risk for falls due to recent previous falls, unsteady gait, and safety/memory/judgement/cognition problems.R3's Falls:On 07/26/25 at 1:00 PM, R3 had unwitnessed fall in room. R3 was found on floor, face down in front of recliner. R3 stated knee was bad and trying to get into personal refrigerator. R3 complained of pain to head and right shoulder. R3 assessed and noted no injuries. Provider, DON, and family notified. IDT reviewed and investigation completed.On 07/31/25 at 5:30 PM, R3 had unwitnessed fall in room. Nurse found R3 on floor while walking by R3's room. Nurse observed R3 on floor at foot of bed, lying on left side in a semi-fetal position. R3's head was toward doorway and feet toward windows. R3's left elbow bent with palm towards ceiling and up off floor about 30 degrees. R3 was yelling she hurts. R3 assessed and complained of pain in left shoulder, left hip, and all over. R3 stated trying to put footrest down on the recliner chair, turned around and fell. R3 stated she was not using her walker and hit her head twice on the floor. Provider, DON, and family notified. R3 was transferred to ER. IDT reviewed and investigation completed.-Hospital notes: 07/31/25: Chief complaint: left arm/shoulder pain related to fall. Discharge diagnosis: left nondisplaced humerus fracture. Discharge instructions: continuous use of left arm sling and swath; follow-up with primary provider.On 08/01/25: IDT Reviewed falls from 07/26/25 and 07/31/25 simultaneously. New interventions implemented: 15-minute safety checks completed for 24 hours, bed at low height at HS, and therapy to re-evaluate. R3's noncompliance with using walker during ambulation was assessed and discussed with R3 and R3's POA. Care plan updated.-Of note: Root cause was not clearly identified.On 09/11/25 at 7:30 PM, R3 had unwitnessed fall in room. R3 was found on floor between bed and wheelchair. R3 stated falling while trying to get into bed. R3 was assessed and no injuries noted. New intervention: 15-minute safety checks. Provider, DON, NHA, and family notified.On 09/12/25: IDT reviewed fall. Medications and chart reviewed. Cause determined to be self-transferring. New interventions: 15-minute safety checks (completed for 24 hours) and to lay down after supper and not to be left in wheelchair in room after supper to prevent self-transfer. Care plan updated.On 09/28/25 at 4:00 PM, R3 had unwitnessed fall in room. Nurse walking by R3's room observed R3 was not in wheelchair where last observed. R3 was found lying on floor on left side with head by end of bed. R3 then called for assistance. R3 was unable to state what happened. R3 complained of pain in left knee. R3 was assessed and no injuries noted. Provider and family notified. Due to prior fracture related to fall, R3 was transferred to ER for evaluation.-Of note: R3's POA declined to have any radiological imaging completed in ER and R3 returned to facility without any noted injuries. No documentation of root cause investigation, no new interventions implemented, and care plan not updated. No IDT review of incident documented.On 10/25/25 at 11:35 PM, R3 had unwitnessed fall in room. R3 was found lying on floor next to dresser with pants around one ankle. Nursing description: R3 appears to have walked to her dresser and tried to put on a pair of pants. No documentation of R3 stating what happened. R3 was assessed and noted to have a small skin tear on left elbow. Wound was cleansed and dressing placed. Provider notified via note in rounding book. Intervention: bed placed in low position.-Of note: No documentation of root cause investigation, no new interventions implemented, and care plan not updated. Intervention implemented was already noted on care plan in place. No IDT review of incident documented. No documentation of family notification noted.

Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect 42 out of 43 residents that eat orally at the facility. A fan in the clean dish washing station, which had notable dust and debris, was blowing on a rack of clean dishes. The cook did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. A dietary aide was observed not properly wearing a beard restraint. This is evidenced by: Example 1 The facility policy titled, “Food Safety- Director of Food and Nutrition Services’ Responsibilities” dated 2021, states in part, “5. Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment… 8. Dishwashing guidelines and techniques will be understood by staff and carried out in compliance with state and local health codes.” On 7/28/25 at 9:47 AM, during initial tour of kitchen, Surveyor noted in the clean dish washing area a rack of dishes drying with an industrial-type fan blowing on the clean dishes. Surveyor noted fan had dust-like substance covering the back of the fan. Fan was loud and appeared to be on high. Surveyor interviewed [NAME] P about the fan blowing on the clean dishes on the drying rack. [NAME] P reported there are not usually clean dishes in front of the fan, and he turned the fan off. Example 2 The Food and Drug Administration (FDA) Food Code states in part, “4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food. On 7/29/25 at 11:27 PM, Surveyor observed [NAME] Q take the internal temperatures of the foods going from the oven into the warming table for resident’s lunch. Surveyor noted [NAME] Q would wipe probe with probe wipe and immediately put probe into the next food which was regular pork, ground pork, and pureed pork. Surveyor interviewed [NAME] Q, who stated she was not aware she was supposed to wait to allow for chemical to dry after wiping probe and before sticking it into the resident’s food. On 07/29/25 at approximately 12:00 PM, Surveyor interviewed Culinary Director R, who reported understanding the importance of waiting for the chemical to dry after wiping the food probe before immediately putting wiped probe into resident's food. Culinary Director R also reported the fan is not supposed to have been in the dishwashing area. Surveyor noted the fan in the dishwashing area had been removed. Example 3 Facility policy titled, “Employee Sanitary Practices” dated 2021, reads in part: “All employees will…. wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.” On 07/28/25 at 12:02 PM, Surveyor observed Dietary Aide (DA) I with beard net around neck and not covering beard when entering kitchen. When DA I exited the kitchen a couple minutes later, he had the beard net on the lower part of his chin only. DA I delivered a tray and returned to the kitchen. DA I exited the kitchen the third time with beard net over entire lower face including mouth/mustache.

Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for all 43 residents. Findings include: Example 1 The facility policy titled, “Enhanced Barrier Precautions” (EBP) with revised date of April 1, 2024, states, in part: “…Use of Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP will be applied, when Contact Precautions do not otherwise apply, to residents with any of the following: Wounds or indwelling medical devices, regardless of Multidrug-resistant organism (MDRO) colonization status… …precautions, including use of gown and gloves, will be used during any high contact resident care activities to include … device care (… urinary catheter…) R5 was admitted on [DATE] with diagnoses that includes obstructive and reflux uropathy and history of urinary tract infection. R5’s orders include Foley catheter care every shift. On 07/30/2025 at 10:05 AM, Survey observed Certified Nursing Assistant (CNA) N emptying R5’s catheter. CNA N had on gloves but did not have on a gown. Surveyor interviewed CNA N about EBP with R5’s indwelling catheter care. CNA N stated he is aware he should be wearing a gown with R5’s catheter care but he doesn’t always do so. On 07/29/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON) B, who stated her expectation is that a gown and gloves should be worn with cares of residents with an indwelling device such as a catheter. DON B reported the staff recently had a training on infection control and the use of proper protective equipment (PPE). Example 2 The facility policy titled, “Handwashing” revised April 2025, states, in part, “…Alcohol based hand sanitizer should be used: …Before moving from work on a soiled body site to a clean body site on the same patient…” R40 was admitted to the facility on [DATE] with diagnosis that includes Alzheimer’s disease, heart disease with heart failure, hypotension, weakness, history of falls, and candidiasis of the skin and nails. R40’s most recent Minimum Data Set (MDS), dated [DATE], indicated R40 had a Brief Interview for Mental Status (BIMs) of 6/15, indicating severe cognition impairment. R40’s MDS also indicated R40 “is incontinent of bowel and bladder, no open skin areas, and is dependent with all cares and repositioning.” On 07/29/25 at 8:44 AM, Surveyor observed CNA K and H provide incontinence care and repositioned R40. Surveyor observed CNA K perform peri care and wiped stool from R40's buttocks with a premoistened cloth. CNA K did not change gloves after contact with stool and continued to wipe R40's open skin area on upper buttocks with another wipe, and with same gloves, applied barrier cream to R40’s open wounds. CNA K continued to dress R40 with same gloves before removing them. On 07/29/25 at 8:54 AM, Surveyor interviewed CNA K, who reported she did not remove gloves or use hand hygiene after contact with soiled area and before cleaning and applying barrier cream to R40’s open skin areas, and she realized she should have. On 07/29/25 at 10:49 AM, Surveyor interviewed DON B, who stated her expectation is that proper hand hygiene and use of PPE be performed with cares of all residents. DON B reported the staff recently had a training on infection control and the use of proper protective equipment. Example 3 On 07/28/2025 at 12:13 PM, Surveyor observed CNA H assisting multiple residents (R29, R16, R9, and R26) with no hand hygiene in between. On 07/28/2025 at 12:16 PM, Surveyor observed CNA K bring R13 to the dining room table for breakfast and did not offer hand hygiene to R13. CNA K also set up R13’s breakfast touching plate, utensils, and drinks without prior hand hygiene after pushing R13’s wheelchair. Example 4 Facility policy titled, “Linen Handling,” with a revised date of 11/2022, states: “Policy: When handling, storing, processing, and transporting linens, facility personnel use procedures designed to prevent the spread of infection. Procedure: 4. Take soiled linen container/bag to the laundry room when full. 5. Dirty laundry should not be held close to a person’s body.” On 07/29/25 at 8:36 AM, Surveyor observed CNA E exit a resident’s room with dirty clothes and linens in gloved hand. Soiled linens were observed carried in CNA E’s gloved hand; no bag to contain items. CNA E carried items to end of resident hallway and disposed of in soiled linen closet. On 07/29/25 at 10:08 AM, Surveyor observed CNA E exit R28’s room, after providing cares, carrying dirty linens in gloved hand down resident hallway to soiled linen room. The dirty linens were not contained in a bag. On 07/29/25 at 11:13 AM, Surveyor interviewed CNA E regarding observation. Surveyor asked CNA E how staff are trained to transport dirty linens. CNA E stated staff are supposed to use gloves. On 07/30/25 at 7:02 AM, Surveyor interviewed Director of Nursing (DON) B regarding transporting dirty linens. DON B stated that staff are expected to transport dirty linens in a closed bag, away from the body.

Based on observation, interview and record review, the facility did not ensure 8 of 9 residents (R30, R29, R13, R18, R9, R16, R26 and R14) were treated with respect and dignity.Facility staff stood over R9, R16, R18, and R29 while assisting them to eat.Facility did not ensure residents (R30, R26, R13, R14) received meal within a similar time frame as others at the same table.Facility set up R13's meal uncovered at dining room table and R13 was not present.Findings include:Facility policy titled, Dining and Food Service, last revised on 02/15/24, reads in part: The community will enhance the resident's dining experience to promote their quality of life.On 07/28/25 at 12:05 PM, Surveyor observed R30 with no food in front of him at a table with 3 other residents eating (R9, R26, and R2). Surveyor observed R26 put utensil down and stated, Did you order? when speaking to R30. R30 responded with, I think so. R30 received meal at 12:14 PM.On 07/28/25 at 12:12 PM, Surveyor observed Certified Nursing Assistant (CNA) H standing next to R29, providing a bite of food and then moved on to assist another resident. On 07/28/25 at 12:16 PM, Surveyor observed CNA K set up R13's meal on the dining room table uncovered with R13 not present. R13 was brought to the table at 12:19 PM. On 07/28/25 at 12:21 PM, Surveyor observed CNA H standing next to R18 placing food on fork and providing R18 a bite of food.On 07/28/25 at 12:24 PM, Surveyor observed CNA H standing next to R9, cutting up food, and providing R9 with a bite.On 07/28/25 at 12:25 PM, Surveyor observed CNA H walk over to R16. R16 was back away from the table. CNA H assisted R16 closer to the table and assisted R16 with a bite of food and offered a drink while standing next to R16.On 07/29/25 at 7:41 AM, Surveyor observed 5 residents at a shared table (R26, R13, R2, R35, and R14) awaiting breakfast.On 07/29/25 at 7:43 AM, R35 received meal.On 07/29/25 at 7:48 AM, R2 received meal.Survey observed 2 wing carts of food leave the kitchen for delivery to resident rooms. The first cart left the kitchen at 7:49 AM, the second at 7:59 AM. R26, R13, and R14 still had no meal. Surveyor observed Nursing Home Administrator (NHA) A and CNA J sitting in the dining room. Surveyor had to exit the dining observation at this time.On 07/29/25 at 1:27 PM, Surveyor interviewed R21. R21 stated residents do not get their meals at the same time when sharing a table. R21 stated when the meals are delivered depends on when and how many staff are in the dining room for the meal. R21 stated sometimes trays get sent to rooms on the carts and residents must wait for staff to bring them back to the dining room before they can eat.On 07/29/25 at 2:55 PM, Surveyor interviewed NHA A and Director of Nursing (DON) B. Surveyor discussed observations of staff assisting with eating while standing.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 1 resident (R) reviewed (R28).This is evidenced by:Facility policy titled, Abuse, Neglect, and Exploitation, Suspected Crimes, with a reviewed date of 11/2024, states: Procedure: 3. Prevention: a. Staff, families, and residents are encouraged to report incidents of suspected abuse, neglect.5. Investigation: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations.R28 was admitted to the facility on [DATE], with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R28's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R28 had impaired range of motion (ROM) on both sides in upper and lower extremities.Surveyor reviewed R28's electronic medical record (EMR) and noted the following incident:On 07/04/25 at 12:30 PM, a Certified Nursing Assistant (CNA) reported to the Licensed Practical Nurse (LPN) that while providing cares to R28 in bed, a cut on R28's left eye lid measuring 2 cm was discovered. The cut was cleaned and gauze applied. R28's activated power of attorney (POA), charge nurse, and provider were notified.On 07/08/25, provider responded to monitor for change in vision and infection.-Of note: no additional documentation of incident was noted.On 07/29/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B regarding incident. DON B stated she was on vacation during this time and was unaware of the incident. DON B stated that staff did not follow procedure of notifying the administrator or other leadership to follow-up and investigate. DON B stated that this incident, if brought to her attention, would have been investigated and reported. DON B stated education would be completed with staff.

Based on observation, interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services for 1 of 13 residents (R)(R28) reviewed.R28's care plan interventions to offload heels while in bed was not updated when changed from using heel pads to wedge. This is evidenced by:Facility policy titled, Person-centered Plan of Care - Comprehensive, with a revision date of 01/2023, states: Person-centered Care: Integrated health care services delivered in a setting and manner that is responsive to the individual and their goals, values and preferences, in a system that empowers patients and providers to make effective care plans together. The care plan describes.services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Procedure: 3. Write interventions in terms of staff behavior, e.g., what the staff will do to accomplish an objective.R28 was admitted to the facility on [DATE], with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R28's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R28 had impaired range of motion (ROM) on both sides in upper and lower extremities. R28 required substantial/maximum assist with upper body dressing and rolling left to right. R28 required dependent assist with personal hygiene, sit to lying, lying to sitting, and chair/bed transfers. R28 was noted to be at-risk for pressure injuries with no current skin conditions noted.R28's CNA task list, dated 07/16/24, states: Ensure heel pads are on while in bed every shift. This task was documented as completed every shift.-Of note: R28 was observed in bed with a foam wedge in place to elevate heels off bed. No heel pads were observed on R28 at any time during survey.On 07/29/25 at 5:44 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding R28's heel pads. Surveyor asked CNA F if heel pads were used for R28. CNA F stated yes. Surveyor asked CNA F to show the heel pads. CNA F looked in room and couldn't find them. CNA F stated staff heel pads were used previously, but now a wedge is used because R28 kept pushing the heel pads off. Surveyor asked CNA F when this change occurred. CNA F stated months ago but couldn't recall exactly. Surveyor asked CNA F who is responsible for updating the changes in the CNA care tasks. CNA F stated the nurse.On 07/30/25 at 9:29 AM, Surveyor interviewed CNA D regarding heel pads. CNA D stated R28 used to use heel pads but was transitioned to the wedge a while ago. CNA D could not remember when the transition occurred, but it was some time ago. Surveyor asked why the CNA task documentation shows heel pads were applied every shift. CNA D stated this is marked complete because the wedge is put into place. On 07/30/25 at 10:12 AM, Surveyor interviewed Director of Nursing (DON) B regarding R28's care plan revisions. DON B stated the nurse should have updated R28's care plan when this was changed.

Based on observation, interview and record review, the facility did not promote the prevention of or implement interventions to prevent pressure injuries for 2 out of 4 residents (R) reviewed for pressure injuries, (R5, R40) resulting in stage II pressure injuries (PI).Findings include: R40 and R5 had open skin areas that were not reported to nursing when observed and documented by Certified Nursing Assistant (CNA) per facility policy and current standards of practice.R40 and R5, who are at risk for developing PI, did not have thorough and adequate skin integrity assessments performed by nursing staff on a weekly basis per facility policy.R40 and R5 did not have a wound care treatment plan consistent with profession standards of practice.R40 and R5 were not repositioned every 2 hours as indicate in their care plans.R40's care plan was not updated promptly to address interventions for a stage II PI.R5's care plan was not updated to address pressure relieving interventions with current use of recliner instead of previously used Broda chair.The facility policy, titled Pressure Injury/Skin Integrity, reviewed November 2024, states in part: Based on the comprehensive assessment of a resident, (the facility) will ensure: A resident receives care, consistent with the professional standards of practice. To prevent pressure injuries and does not develop pressure injuries unless the individuals clinical condition demonstrates that they were unavoidable: and . Routine ongoing documentation should be conducted related to the resident's skin condition and the resident's response to the care and treatment of the skin.The frequency of documentation shall be determined based on the resident's individual needs in accordance with accepted standards of practice, at least weekly.1) All residents admitted to the facility will receive undergo an initial skin assessment within 4 hours of admission and on a weekly basis per bathing schedule.all incontinent residents receive peri-care with application of barrier ointment/cream with each incontinent episode.2) Wound rounds will be completed weekly by a licensed nurse. 3) Weekly documentation of wounds is completed by a licensed nurse.Interventions will be implemented to mitigate the risk for potential skin breakdown, based on individual risk factors, and may include but are not limited to:a. The use of pressure redistribution devices. b. Interventions should be documented in the residents' medical record, including the resident-centered plan of care.Routine ongoing documentation should be conducted relating to the resident's skin condition and the resident's response to care and treatment of the skin. The frequency of documentation shall be determined based on the resident's individual needs in accordance with acceptable standards of practice, at least weekly.All Clinical Staff will have education provided during their orientation process as well as on a minimum of an annual basis related to, but not limited to wound care techniques, pressure injury prevention, and appropriate wound care/monitoring documentation.Example 1R40 was admitted to the facility on [DATE] with diagnosis that includes Alzheimer's disease, heart disease with heart failure, hypotension, weakness, history of falls, and candidiasis of the skin and nails.R40's most recent Minimum Data Set (MDS) dated [DATE] indicated R40 had a Brief Interview for Mental Status (BIMs) of 6/15, indicating severe cognition impairment. R40's MDS also indicated R40 is at risk for developing PIs, is incontinent of bowel and bladder, had no open skin areas, and is dependent with all cares and repositioning.R40's care plan, date initiated 03/27/24, states, in part:.At risk for skin breakdown r/t reduced mobility and need for assistance with repositioning. Also, at risk due to bowel and bladder incontinence. Currently right buttock excoriation being treated. Healed as of 11/22/2024 and revision of care plan on 01/02/25.interventions include, in part: Will have clean, dry, intact skin through next review date, barrier cream on with each incontinence change, Follow community skin protocol. Staff will keep skin as clean and dry as possible and minimize exposure to moisture. Will also keep linens clean and dry, Incontinence care with incontinent brief changes, observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. Lotion to dry skin. Review skin concerns with MD. Report any new or abnormal skin concerns such as bruises, open areas, reddened areas, tender areas, cuts or abrasions.Pressure reduction cushion in wheelchair (initiated on 3/27/24).Pressure reduction mattress on bed (initiated 3/27/24).Reposition on all rounds in bed and chair & PRN. Use lift sheet when assisting with bed mobility to avoid shearing skin during repositioning (initiated on 3/27/24) .Encourage physical activity, mobility, and ROM to maximal potential to help reduce breakdown.Provide nutritional supplements as recommended to help maintain good skin condition. Offer and encourage fluids during and between meals to help maintain good hydration. Reposition Resident on all rounds and as needed. Requires documentation. Skin Observation.Record review indicated R40's skin assessments/weekly skin checks performed by nursing staff, on 07/06/25 and 07/13/25 are documented No Skin Issues Noted. On 07/19/25 and 07/27/25 is documented redness to groin and buttock.On 07/30/25, Surveyor reviewed Certified Nursing Assistant (CNA) tasks charting which indicated R40 had skin tear on 07/01/25, 07/02/25, 07/11/25, 07/14/25, 07/15/25, 07/16/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/27/29, and 07/29/25. CNA tasks charting indicates R40 had open skin area on 07/2/25, 07/03/25, 07/04/25, 07/06/25, 07/09/25, 07/10/25, 07/13/25, 07/15/25, 07/16/25, 07/17/25, 07/18/25, 07/24/25, 07/28/25, and 07/29/25.On 07/28/25 at 10:55 AM, Surveyor observed CNAs don gowns and gloves prior to entering R40's room to provide care. Surveyor did not note any signage on R40's door nor did matrix indicate why a gown would be required for cares. Surveyor was unable to observe or interview at that time as to why CNAs donned gowns.On 07/28/2025 at 11:13 AM, Surveyor interviewed CNA K who reported they donned gowns to provide incontinence cares to R40 because R40 has an open skin area on right buttock.On 07/29/25 at 8:44 AM, Surveyor observed CNAs K and H provide incontinence care and reposition R40. Survey observed CNAs provide incontinence cares for R40. R40 had an open skin area with pink, moist tissue noted on right buttock. Per Surveyor's observation, this wound met the National Pressure Injury Advisory Panel of a stage II PI. The size appeared to be approximately 1cm in diameter, no rolled edges noted. R5 denied pain to wound area. CNA K wiped open skin area with a premoistened cleansing cloth, applied A & D to open wound, and applied baby powder to inside of R40's adult brief. CNA K reported the wound nurse was aware of R40's open skin area and told the CNAs to continue applying barrier cream to buttocks. On 07/29/25 at 8:54 AM, Surveyor interviewed CNA K, who reported open sore on R40's buttocks had been reported to RN G and the wound nurse about a week ago. CNA K reported RN G told her because R40's open skin area gets worse then gets better again, they do not need to do dressing on R40's open skin areas, and the CNAs were told to continue to apply barrier cream to open area. CNA H was present during interview and confirmed these statements.Applying barrier cream and baby powder, and leaving PI open to air, is not considered acceptable treatment in the current standards of practice for a stage II PI.On 07/29/25 at 10:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L, who reported recently taking over for RN G. LPN L stated in report from RN G, LPN L was told R40 has a wound on right buttock, and it was taken care of. When Surveyor asked what that meant, LPN L stated it meant the wound nurse was notified.On 07/29/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON) B, who reported she was made aware of R40's wound yesterday and there is a call to the provider and wound care nurse. DON B reported her expectation for a resident with a PI is that there would be wound care orders. Surveyor stated there are no orders or nursing documentation of R40's PI. DON B reported her expectation would be for a CNA that found any open skin area is that it would be reported to the nurse in charge, assessed immediately, staged by the wound care nurse, and treatment orders be put into place. Surveyor asked DON B if she thought applying A&D ointment to open skin and leaving uncovered is an acceptable treatment for R40's open skin area. DON B reported she doesn't know without having seen it.On 07/29/25 at 10:32 PM, Surveyor observed R40 in bed asleep in a semi-Fowlers position with neck pillow behind his head. Surveyor interviewed CNA M, who reported R40 was last repositioned by the PM shift staff around 9 PM, but it is not documented exactly when. CNA M reported he will do checking for incontinence changes and repositioning at midnight.On 07/30/25 at 12:14 AM, Surveyor interviewed CNA M, who reported R40 was repositioned at 11:30 pm and R40 is repositioned about every 2 hours. This would have been 2 and a half hours since R40 was repositioned. CNA charting indicated repositioning is done every 2 hours per CNA's initials. CNAs do not document a specific time done.On 07/30/25, Surveyor reviewed documentation from RN G from 07/29/25, Resident has open area to right inner buttocks and excoriation to left buttocks. Area cleansed and barrier cream applied per order. SBAR written for (provider) to review. Wound nurse notified. Voice message left for Power of Attorney (POA) to call back for update. Surveyor did not find an updated order for wound treatment in R40's medical record.On 07/30/2025 at 10:28 AM, Surveyor interviewed RN G regarding R40's open skin area. RN G reported she was unaware of R40's PI until on 07/28/25 and she didn't get a chance to document until 07/29/25. RN G reported her expectations are that CNAs report any skin changes immediately and they should be providing incontinence cares and reposition R40 every 2 hours.On 07/30/25 at 11:50 AM, Surveyor interviewed DON B, who reported R40 does have a PI, she was told it was looked at by wound care nurse, that it is a stage II, and facility is working on getting orders for treating it. DON B reported the expectation is that all residents who require assistance with repositioning get repositioned at least every 2 hours (current standards of practice for a resident with a PI would be to reposition every hour) incontinence cares are performed every 2 hours and as needed and that any open skin areas or changes in skin observed by a CNA are to be reported to nursing staff immediately. DON B reported the CNA tasks charting is not reviewed by nursing staff. DON B stated the process for all residents would be that CNAs report any skin changes to the nursing staff. The expectation is that nursing staff would follow up immediately with any reported changes in resident's skin condition and that the nurse be assessing skin areas thoroughly every week, documenting, and reporting any open skin area immediately to the provider to obtain an order for wound care treatment on that day, or if at night, immediately the next day, to notify the Power of Attorney, the Registered Dietician, and the Wound Care Nurse for wound care assessment to be added to the weekly schedule. DON B verbalized this does not seem to have happened with R40's PI and DON B plans to follow up with wound care nurse. DON B does believe the wound care nurse did look at R40's PI and is not sure why there is not documentation of this yet in R40's medical record. Example 2 R5 was admitted to the facility on [DATE] with diagnosis that includes history of transient ischemic attack and cerebral infarction, hemiplegia and hemiparesis affecting left side, weakness, spinal stenosis.R5's most recent Minimum Data Set (MDS) dated [DATE] indicates R5 had a BIMS of 7/15 indicating severe cognition impairment, was at risk for developing PIs, and that R5 is dependent with all cares and repositioning.R5's care plan, dated 5/26/25, states, in part: At Risk for impaired skin integrity including skin tears, bruising AND/OR pressure R/T non-ambulatory interventions include, in part:.Will have clean, dry, intact skin through next review date. Assist / Encourage Pressure Relief as needed / accepted.Follow community skin protocol, Incontinence care with incontinent brief changes. Observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. pay close attention to. where there may be added pressure. Weekly skin check. Lotion to dry skin. Review skin concerns with MD. Pressure reduction cushion in Broda chair (initiated on 3/22/24, revised on 5/21/25) Pressure reduction mattress on bed (initiated on 1/21/25) , Reposition Q 2 hours in bed and chair & as needed (PRN) (initiated 3/22/24) .Turn & Reposition Resident on routine rounds and as needed.Record review indicated R5's skin assessments/weekly skin checks performed on 07/01/25, 07/08/25, 07/15/25, and 07/22/25 documented No Skin Issues Noted and signed by RN G and on 07/29/25 also is documented No Skin Issue Noted and signed by LPN L.On 07/30/25, Surveyor reviewed CNA tasks charting in which indicated R5 had open skin area on 07/15/25, 07/23/25, 07/24/25, 07/25/25, and 07/29/25.On 07/29/25 at 10:32 PM, Surveyor observed R5 in bed asleep in a semi-Fowlers position. Surveyor interviewed CNA M, who reported R5 was last repositioned by PM shift around 9 PM but it is not documented exactly when. CNA M reported he will do checking for incontinence changes and repositioning at midnight.On 07/30/25 at 12:14 AM, Surveyor interviewed CNA M, who reported R5 was repositioned at 11:30 pm and R5 is repositioned about every 2 hours. This would have been 2 and a half hours since R5 was repositioned. CNA charting indicated repositioning is done every 2 hours per CNA's initials. CNAs do not document a specific time done. On 07/30/25 at 10:07 AM, Surveyor observed R5's personal cares and noted R5 had an open skin area with pink, moist tissue on his right upper buttock. Per Surveyor's observation, this wound meets the National Pressure Injury Advisory Panel of a stage II PI. Area was approximately 1.5cm x 1cm in size. R5 had barrier cream with powder caked on it around edges. R5 denied pain to wound area. R5 has a pressure reduction air mattress on his bed. R5 does not have any cushion in his recliner. Surveyor had a prior observation of R5 in recliner a large portion of the day. There was no Broda chair as indicated in R5's care plan, in R5's room.On 07/30/25 at 10:15 AM, Surveyor interviewed CNA N who reported R5 has had the skin tear for about a week. Surveyor asked which nurse CNA N reported it to; CNA N stated he works various shifts and has reported it to various nurses. CNA N stated 3-4 different nurses have looked at it. CNAs were instructed to put barrier cream on R5 buttocks/ perineal area. CNA N reported R5 is supposed to be checked for incontinence and repositioned every 2 hours. CNA N stated they try to check and reposition R5 every 2 hours but sometimes they get busy with other residents. On 07/30/2025 at 10:18 AM, Surveyor observed RN G don gloves and gown. RN G looked at wound and reported it is an open skin area. RN G attempted to scrape dried on paste of powder and barrier cream from around wound edges. Immediately after, Surveyor interviewed RN G, who reported she was not made aware of open skin area on R5 and R5's wound was not found on nurse's weekly skin check performed on 7/29/25 by RN G. RN G reported CNAs are supposed to reposition R5 every 2 hours and notify RN with any skin changes.On 07/30/25 at 11:50 AM, Surveyor interviewed DON B and asked DON B what the expectations are for repositioning residents who are at risk for skin breakdown. DON B reported the expectation is that all residents requiring assistance with repositioning are repositioned every 2 hours, incontinence cares are performed every 2 hours and as needed and that any open skin areas or changes in skin observed by a CNA it is to be reported to nursing staff immediately. DON B reported the CNA tasks charting is not reviewed by nursing staff. The expectation is that staff would follow up with any reported changes in skin condition and be assessing skin areas thoroughly weekly, documenting, and reporting any open skin area immediately to the provider in order to obtain an order for wound care treatment on that day, or if at night, immediately the next day, to notify the Power of Attorney, the Registered Dietician, and the Wound Care Nurse for wound care assessment to be added to the weekly schedule.DON B reported the care plan for R5 had not been updated to have a pressure relieving device in R5's recliner chair instead of Broda chair, as R5 no longer requires a Broda chair, and the PI was not reported or identified until today.DON B reported R40 should have had wound care orders immediately after open skin had been noted. DON B is unsure why the CNA documentation is marked as open skin areas, but this is not noted in RN charting or reviewed by the RNs for both R40 and R5. DON B stated the process would be that CNAs report any skin changes to the nursing staff. The expectation is that nursing staff would follow up immediately with any reported changes in resident's skin condition and that the nurse be assessing skin areas thoroughly every week, documenting, and reporting any open skin area immediately to the provider to obtain an order for wound care treatment on that day, or if at night, immediately the next day, to notify the Power of Attorney, the Registered Dietician, and the Wound Care Nurse for wound care assessment to be added to the weekly schedule.

Based on interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 1 out of 5 residents (R)(R28).R28's passive range of motion (PROM) exercises and application of palm guard was not completed as ordered. This is evidenced by:R28 was admitted to the facility on [DATE], with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R28's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R28 had impaired range of motion (ROM) on both sides in upper and lower extremities.R28's care plan, dated 06/27/25, with a target date of 07/23/25, states: Actual deficit with ADLs with interventions of cleanse left palm and then apply palm guard.R28's care plan, dated 06/27/25, with a target date of 07/23/25, states: Functional maintenance program: passive range of motion to upper extremities with interventions to focus on elbow, fingers, thumb, and shoulder every shift.R28's CNA care task record for 07/2025, noted PROM was not completed on: 07/01, 07/07, 07/11, 07/12, 07/15, 07/18, 07/23, and 07/28.R28's CNA care task record for 07/2025, noted cleansing of left palm and wrist guard placement was not completed on: 07/01, 07/11, 07/15, and 07/28.On 07/29/25 at 11:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding PROM and palm guard. CNA D stated staff try to complete PROM exercises with residents, but do not always have the time. CNA D stated a dedicated restorative nursing aide was established about a month ago to help with PROM. Surveyor asked about R28's palm guard. CNA D stated it is supposed to be applied in the morning, but not all staff follow the care plan.On 07/30/25 at 7:02 AM, Surveyor interviewed Director of Nursing (DON) B regarding PROM exercises and application of R28's palm guard. DON B stated that a dedicated restorative nurse aide was established about 3-4 weeks ago to complete PROM exercises for residents. DON B stated these cares should have been completed for R28.

Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents (R)(R28 and R5) reviewed.R28 was not given enteral feeding as ordered and assessment was not completed per current standard of care.R5's assessment was not completed per standard of care. This is evidenced by: Facility policy titled, “Gastrostomy Tube – Administration of Medications,” with a revision date of 10/2022, states: “Medications administered via tube will be done following current standards of practice and with a physician’s order. Procedure: 5. Check for correct placement of tube.” The National Institute of Health, 2023, recommends the position of a feeding tube be checked by measuring the visible tube length and comparing it to the length documented during x-ray verification. Older methods, including observing aspirated GI contents or the administration of air with a syringe while auscultating are unreliable and should no longer be used to verify placement. Example 1 R28 was admitted to the facility on [DATE], with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, gastrostomy status, and mild protein-calorie malnutrition. R28’s most recent quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R28 has a feeding tube in place. R28’s care plan, dated 05/02/24, with a target date of 07/23/25, states: “Feeding tube: at risk for complications with interventions to check for tube placement & gastric contents/residual volume per facility protocol and record.” R28’s orders: 02/24/25 Enteral Feed four times a day Nutren 1.5 liquid 200 ml via PEG tube, via gravity through syringe. Do not push. Flush with 60 ml water before and after each feed. 06/05/25 Check G tube placement every shift prior to medications/feedings. On 07/29/25 at 10:37 AM, Surveyor observed Licensed Practical Nurse (LPN) C administer R28’s enteral feeding. Prior to feeding, Surveyor observed LPN C place stethoscope on R28’s abdomen and connect syringe to the feeding tube. Surveyor asked LPN C what was being done. LPN C stated she was verifying placement of feeding tube by pushing air in and listening for air entering the stomach. Surveyor asked LPN C if this was the facility’s current practice for verifying placement. LPN C stated yes. Surveyor observed LPN C pour the enteral nutrition formula into a graduate container and measured out 240 ml. Surveyor asked LPN C if all 240 ml would be administered. LPN C stated yes. Surveyor observed LPN C pour approximately 60 ml of formula, attached the plunger, and connected syringe to R28’s feeding tube. LPN C then began to push the formula into R28’s feeding tube. Surveyor asked LPN C if R28’s enteral feeding was supposed to be pushed. LPN C stated yes. Surveyor informed LPN C the order stated to give by gravity and do not push. LPN C stopped the feeding and stated, “It does? Well then I guess I just made an error. I just reviewed this order with the nurse before coming in here.” Surveyor asked LPN C what the ordered feeding amount was. LPN C stated 240 ml. Surveyor showed LPN C the order noted in R28’s electronic medical record (EMR) stating 200 ml. LPN C stated she thought it said 240 ml. LPN C then removed the plunger and fed remaining formula via gravity for a total of 200 ml. On 07/30/25 at 7:02 AM, Surveyor interviewed Director of Nursing (DON) B regarding tube feeding observation. DON B stated nursing staff were trained to verify feeding tube placement by auscultating for air and was unaware the current standard of practice had changed regarding this. DON B stated she had been made aware by LPN C regarding the error in administering the formula via push instead of gravity. DON B stated that nursing staff would be educated to verify orders prior to tube feeding to ensure this error did not occur again. Example 2 R5 admitted to the facility on [DATE]. Diagnoses included dysphagia after stroke with gastrostomy tube (G-tube) for feeding purposes. MDS assessment, completed on 05/08/25, confirmed R5 scored 07/15 during BIMS, indicating a cognitive impairment. R5’s care plan included: NUTRITION/HYDRATION: Actual/At Risk and/or Potential for Complications with Nutrition/Hydration due to recent CVA (stroke) with need for tube feeding. 03/22/2024 -Pleasure feeding: nectar liquids by spoon or pureed diet with cold textures such as applesauce or pudding with safe swallow strategies; small bites (1/2 spoonful), single bites; sit up 90° for oral intake; supervision and assistance with eating; cue for double swallows; if cough noted, instruct to clear throat or wet voice; wait 30 minutes prior to laying down after oral intakes. 01/03/2025 -Tube Feedings / Flushes Per Facility Protocol Registered Dietician/MD orders: Elevate head of bed during and after tube feeding administration. Check residuals before tube feeding administration. Observe / Monitor / Document signs and symptoms of tube feeding intolerance. Observe / Monitor / Document S&S of dehydration. Notify MD/RD of concerns as needed. 03/22/2024 FEEDING TUBE: Potential for Complications with tube feeding. Tube Feeding Placed due to recent CVA. 01/21/2025 -Check for tube placement & gastric contents/residual volume per facility protocol and record. Hold feeding if >200 cc aspirated. 03/22/2024 -Keep HOB elevated 45° during and at least 30 minutes after tube feed. 03/22/2024 R5’s physician orders included: -Flush tube with 20ml of water between each medication. -Flush G-Tube with 75 ml of water before feeding. -Nutren 1.5 liquid; 275cc each feeding, four times a day provide feeding via gravity. On 07/30/25 at 8:26 AM, R5 was lying in his bed. RN G told R5 she was going to administer his tube feeding and medications. R5 nodded his head yes. RN G elevated R5’s head of bed to 45°. R5 stated he was doing well, and he had no complaints of pain. R5 told Surveyor RN G was, “great.” Surveyor observed RN G place her stethoscope on R5’s abdomen near his G-tube and insert air into the tube with a syringe. Surveyor asked RN G if it was the facility’s policy to auscultate to verify placement a G-tube, RN G stated, “Yes.” Surveyor asked RN G if the facility had provided education that auscultating to determine placement of a G-tube was no longer a standard of practice. RN G stated she was not aware.

Based on observation, interview, and record review, the facility failed to supervise a resident (R1) at risk for elopement, which resulted in R1 leaving the building unsupervised, putting R1 at risk for serious injury or death. -The facility did not ensure an unalarmed door was repaired to prevent residents from exiting without staff supervision. -The facility did not ensure R1's whereabouts were checked every 15 minutes as identified on the care plan. -The facility did not increase R1's supervision after R1 successfully eloped from the unalarmed door. The facility's failure to supervise a resident at risk for elopement created a finding of immediate jeopardy that began on 01/02/25. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on 01/22/25 at 11:05 AM. The immediate jeopardy was removed on 01/22/25, however, the deficient practice continues at a scope/severity level of E (pattern/potential for harm) as the facility continues to implement its action plan. Findings: The facility policy titled Elopement-Missing Resident reads in part, It is the policy of this community to implement all possible measures to protect/minimize any resident who attempts to elope. 1. Upon admission, all residents will be assessed for risk of elopement. 2. If a resident is found to be at risk for elopement, the care plan will include interventions for the prevention of elopement. 3. If the resident is thought to have eloped, the charge nurse will notify staff to do a room-to-room search. 6. Care plan interventions are documented or revised. 7. An immediate intervention is implemented to prevent further elopement. This may include 15-30 minute checks for at least eight hours, placement to secured unit, or use of Wander Guard. There are four residents (R1, R2, R3, and R4) in the facility who have been assessed as an elopement risk and wear Wanderguards. R1 was admitted on [DATE]. Diagnoses include Alzheimer's disease and dementia. On 11/01/24, R1 scored 04/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R1 is ambulatory without any equipment. R1's care plan included the following: -MOOD/BEHAVIOR; shows increased confusion in evening and shows distress/anxiety related to unreal thoughts. Resident wanders and looks into other resident rooms. -AT RISK FOR FALLS; At risk for fall related to Alzheimer's disease, hypertension, and history of falls. -ELOPEMENT/UNIT PLACEMENT; potential for complications with elopement and/or disruptive behaviors requiring code alert bracelet/secured area related to altered cognitive status. History of wandering and/or attempting to exit facility without staff or family assistance. -INTERVENTIONS: -03/27/24, WanderGuard placement -12/28/24, 15-minute security checks -01/02/25, 1:1 through night shift -01/02/25, HCPOA updated -01/02/25, physical body assessment -01/02/25, WanderGuard function checked -01/02/25, Medical provider updated -01/03/25, medication increase On 01/21/25 at 10:36 AM, Surveyor observed R1 in her room. Surveyor observed R1 was ambulatory and did not require a walker or wheelchair to assist with ambulation. R1 was pleasant and talked with Surveyor. Surveyor determined R1 was not able to be interviewed as she was not able to answer questions accurately due to her diagnoses. R1 was wearing a WanderGuard on her ankle. Surveyor observed R1 during the survey and noted R1 frequently sat in a chair in the common area of the facility near the front doors. On 12/16/24, the facility noted exit door A6 was not shutting properly, and the door was not latching unless it was pulled tightly to ensure it was closed. The facility ordered a new door latch. Signs were placed on door A6, reminding staff to pull the door shut tightly to ensure it is closed. The A6 door is located near the dining room, in a short hallway with two interior doors at each end. There are no resident rooms located in this hallway. A6 door opens directly to the outside of the facility and a keypad is utilized to open door A6. Door A6 is not alarmed. A6 door is used by facility staff to access the garbage dumpster and is used by staff as a smoking area. On 12/26/24, the facility received the part to fix A6 door, but did not repair A6 door. On 12/28/24, R1 eloped out the facility's front door twice within 15 minutes. Both elopements were witnessed by staff, and R1 was immediately brought back into the facility. The facility added 15-minute checks to R1's care plan. The front door is the only door in the facility alarmed with a WanderGuard alarm, which was functioning when R1 exited the building on 12/28/24. On 01/02/25 at 9:50 PM, R1 was observed in the facility common area. At approximately 10:10 PM, staff were unable to locate R1 in the facility. At approximately 10:15 PM, R1 was brought back to the facility by law enforcement. R1 was assessed and noted to not have any injuries. On 01/02/25, the weather was approximately 14 degrees with light snow. R1 was wearing a sweater, long pants, Croc shoes, and no socks. The facility added 15-minute checks and placed R1 on 1:1 through the night. Of note, 15 minute checks were implemented on 12/28/24 when R1 first eloped. This is not increased supervision for R1. The facility investigation noted R1 was found by staff from the assisted living facility (ALF) next door. The ALF staff called law enforcement, and R1 was returned to the skilled nursing facility (SNF). The facility determined R1 exited through A6 door, as this is the only door not alarmed. On 01/22/25 at 9:00 AM, Surveyor walked out A6 door towards the ALF, to determine the path R1 may have taken. The route would have taken R1 down a hill and through an employee parking lot with only one entrance/exit at the opposite end of the parking lot and is not a heavily trafficked area. R1 would have walked approximately 165 feet from the SNF to the ALF where she was found. The doors to the ALF were locked and not able to be opened from the outside. On 01/21/25, Surveyor reviewed the 15-minute checks documentation on R1 and noted from 12/28/24-01/19/25, documentation was not fully completed on 12/29/24, 12/30/24, 12/31/24, 01/01/25, 01/02/25, 01/04/25, 01/10/25, 01/15/25, 01/18/25, 01/19/25. Specifically, 15-minute check documentation was not completed on 01/02/25 from 2:00 PM through 10:30 PM. Staff responsible to complete this on 01/02/25 was Certified Nursing Assistant (CNA) F. The facility provided a copy of a verbal warning given to CNA F on 01/03/25 for failure to complete 15-minute check documentation. On 01/22/25 at 9:28 AM, Surveyor interviewed CNA F. CNA F confirmed she worked the PM shift on 01/02/25 and was responsible for caring for R1. CNA F reported she was not aware R1 had been placed on 15-minute checks, and this is why she did not complete the documentation. CNA F stated she clocked out for work at approximately 10 PM but had observed R1 in the common area of the facility about 10 minutes before her shift ended. CNA F stated she did not hear any alarms around this time. CNA F was made aware R1 had eloped from the facility as Director of Nursing (DON) B had called her after her shift. CNA F stated she was not sure which door R1 exited when she eloped from the facility but thought she may have exited through the front doors, stating, She is always near the front doors and is always looking out. On 01/22/25 at 8:35 AM, Surveyor called local law enforcement to ask about the incident. Surveyor left a voicemail message requesting a return call. On 01/22/25 at 8:39 AM, Surveyor called the ALF to speak with staff about the incident. Surveyor left a voicemail message requesting a return call. On 01/03/25, the facility's maintenance department replaced the latch on A6 door. A6 door continued to not shut properly unless the door was pulled shut. On 01/09/25, the facility had a Safety Huddle meeting regarding A6 door. The facility concluded A6 door needed to be replaced. The Safety Huddle meeting documentation indicated a plan to, Look at purchasing a new door. On 01/10/25, the facility implemented a system to check A6 door daily to ensure it latches shut after opening or closing. Surveyor observed a document posted on the wall next to A6 door, titled A6 Door Latch Checklist. Surveyor requested a copy of this checklist and noted the document was not completed on 01/11/25, 01/12/25, 01/14/25, and 01/15/25. On 01/21/25 at 11:01 AM, Surveyor observed A6 door. Surveyor observed doors at each end of the hallway were open. Surveyor observed signs on A6 door instructing staff to pull the door shut. Surveyor interviewed Maintenance Director (MD) C. MD C reported the door frame is pulling away from the building, so the latch is not the problem, but the door is not square. Surveyor observed MD C needed to forcefully pull on the door to ensure it was closed completely. Surveyor asked MD C to not forcefully pull the door shut and observed that if door A6 is not pulled shut it does not close but rests on the outside of the door frame, stopping the door from closing. Surveyor noted the temperature on this date was -21 degrees. MD C confirmed A6 door could be alarmed with door security alarms. MD C stated the doors at each end of the hall remain open for heating purposes. MD C reported he has reached out to contractors to request an estimate for purchasing a new door but had not received any return calls yet. MD C was aware R1 was at risk for elopement and stated, She walks all over this facility. On 01/21/25 at 12:20 PM, Surveyor interviewed Dietary Manager (DM) D. DM D reported A6 door does not shut all the way and stays open if it is not pulled shut. DM D stated, You really need to pull it shut. DM D confirmed the door is used frequently by staff to access the dumpster. DM D reported MD C told her, in passing, to make sure the door was shut tight. DM D reported she passed this information to her dietary staff. DM D stated the dietary staff have not received any formal education or inservice related to the A6 door or resident elopement. On 01/21/25 at 1:31 PM, Surveyor interviewed NHA A. NHA A reported the facility completed the following related to A6 door: a Safety Huddle meeting to discuss fixing the door, placed signs on the door reminding staff to pull door shut, and daily checks on the door. Surveyor informed NHA A of observations of A6 door indicating the door is still not closing properly, the door is not alarmed, the daily checks were not completed, and there is no current plan for A6 door to be replaced. NHA A stated, I get what you are saying. NHA A confirmed the doors at each end of the hall, where A6 door is located, remain open as ambulatory residents like to walk the facility for exercise, and keeping these doors open allows the residents to walk a circle within the facility. On 01/22/25 at 8:55 AM, Surveyor interviewed NHA A. NHA A stated, We did some things last night. We called a 24/7 locksmith and installed a doorbell alarm on A6 door, another alarm was ordered and will be here tomorrow. Education was provided to PM staff and NOC shift about the new alarm and to keep the two corridor doors closed and locked. Reeducated maintenance department related to A6 door. AM staff to be educated this morning. Surveyor observed the two doors at the end of the hallways where A6 door is located were closed and locked to prevent access to the area. Surveyor reviewed the weather from 01/02/25-01/21/25 and noted the average temperature during this time was -13 degrees. On 01/21/25 at 10:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G. CNA G was working on R1's hall on this day and was responsible for R1's care. CNA G reported the staff are updated with any changes at shift change or use a whiteboard for communication. Staff would be updated of residents at risk of elopement or placed on 15-minute checks through these processes. CNA G confirmed the CNAs are responsible for completing the 15-minute check documentation. CNA G stated, I think R1 is still on 15-minute checks. On 01/21/25 at 12:24 PM, Surveyor interviewed CNA E. CNA E stated the facility has not provided any education related to A6 door not closing properly, and staff have been told to make sure it's shut all the way. CNA E confirmed he was aware a resident had eloped from the facility and thought it was R1. CNA E confirmed the facility had not provided any education since R1's elopement on 01/02/25. On 01/22/25 at 9:28 AM, Surveyor interviewed CNA F. CNA F stated she has not received any education or inservice from the facility related to resident elopement or A6 door needing to be replaced. CNA F confirmed the facility has not provided education on what staff should do when a resident elopes from the facility. The facility's failure to supervise a resident at risk for elopement created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The facility removed the immediacy on 01/22/25 when they implemented the following: A6 door alarmed. A6 door aligned/adjusted door and hinges. Aligned ANSI strike plate on door jam. Repaired door closer that was not attached to the door. Installed bolts on the screws that were stripped. Adjusted the preload on the door closer. Close/locked off both back hallway doors. Reverse locks so they open with a key. Education with SNF staff regarding residents being on 15-minute checks, purpose of 15 minute checks and further direction that need to be completed on the form. Direct care staff are to complete the form based on the instructions. A6 door audits are checked daily. Maintenance staff has been trained regarding door checks on the A6 door.

Based on record review and interview, the facility did not ensure that all residents were free from sexual abuse. A male resident (R6) was witnessed by facility staff on three separate occasions touching the breasts of three different female residents. This affected 3 of 12 residents (R17, R9, R8) reviewed for abuse. Facility did not implement interventions for R6 to prevent further sexual abuse from occurring after the first incident on 12/26/20. Although R17, R9, and R8, who are cognitively impaired, did not show a reaction to having been assaulted, a reasonable person would feel angry, vulnerable, and afraid. Findings: Surveyor reviewed facility policy titled Abuse Investigations, created Dec., 2002, last revised March, 2018. The purpose of this policy is stated to be It is the policy of Northern Lights that each resident will be free from abuse .Additionally, residents will be protected from abuse, neglect, and harm while they reside at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. This policy covers the seven components that include: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting and Response. R6 is a male resident who has resided at the facility since 7/4/17. R6 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's most recent MDS (Minimum Data Set) Assessment was completed on 1/19/21. R6 was assessed to have a BIMS (Brief Interview for Mental Status) of 14, indicating being cognitively intact. R6's MDS also noted that R6 uses both a walker and a wheelchair, is steady at all times when moving from a seated to standing position, moving on and off the toilet, and making transfers between surfaces (like bed to chair). R6 did utilize an assist of 1 person for moving about on and off the unit, but was able to transfer independently without any assistance. R6's care plan contained interventions for behavioral symptoms that were started on 10/4/17. Behaviors listed were Sexual acts or remarks in the presence of female staff. This section was edited on both 9/23/20 and 1/27/21. Interventions include using only male staff to assist R6, if female staff need to assist R6 to have two staff members present, re-direct inappropriate comments, staff to remove self if needed, give privacy to self-gratify as needed, and approach resident in a professional manner. No care plan interventions, or updates, addressed safety of other residents. R6's victim information: R9 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's BIMS was 4, indicating severe cognitive decline. R9 was observed to be able to self-propel in wheelchair and did wander throughout entire facility during length of survey (4/5/21 through 4/7/21). R17 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's BIMS was 99, indicating an assessment was unable to be completed due to extremely poor cognitive function. R17 was observed during length of survey to self-propel in wheelchair throughout facility. R8 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's BIMS was 99, indicating an assessment was unable to be completed due to extremely poor cognitive function. R8 was observed during length of survey to need extensive assist of staff to ambulate around facility. If R8 is in a wheelchair R8 will not initiate self-propelling. On 4/7/21, Surveyor noted a vague progress note in R9's electronic medical record (EHR) about R9 and an incident with another resident that happened on 2/15/21. Surveyor questioned DON-B who did not have any details but stated the social worker would have more information about the notation as she was the author of the note. On 4/7/21 at 2:30PM, Surveyor interviewed SW-K who stated she kept the note vague due to the sensitive nature of the incident. SW-K stated that there was a report of a male resident that had squeezed the breast of R9, outside of clothes. This was reported by an Occupational Therapist, who reported immediately removing R9 from the area. SW-K stated she assessed R9 as soon as she heard about the incident and did not note any distress in R9, and it seemed that R9 did not recognize the situation and what just happened. SW-K stated contacting R9's POA, who didn't want a report filed with the police, and who was understanding of the situation. SW-K informed Surveyor of 2 other separate incidents that also occurred between this same male resident and 2 different female residents. Surveyor asked for any investigations SW-K had for all three incidents. First Incident Surveyor reviewed the facility's investigations for each incident: On 12/26/20 at 11:15AM, a housekeeper reported witnessing R6 rubbing his hands on the exterior of R17's blouse, from neck to waist. The charge nurse was alerted and completed an assessment of the resident that revealed no concerns stemming from the incident. The investigation contained a written statement from the housekeeper that witnessed the incident. R17's psychosocial wellbeing was monitored for the following few days and charted in EHR. Initial interventions taken were to monitor R17's psychosocial and emotional state, staff addressing behaviors, and a conversation with R6's son addressing behaviors. The investigation noted that if behaviors are not decreased, further intervention options will be discussed and implemented. There are no specific interventions noted to protect other residents from abuse after this incident. Progress Note from 12/26/20 written by RN-C showed that after incident occurred R6 was removed from area and taken to room. RN-C noted R6 was asking for hugs. When R6 was confronted about report of touching another resident R6 denied incident. On 12/28/20 at 11:22AM progress note shows R6's son had come for a visit to speak to R6 about inappropriate behavior. On 12/28/20 at 1:16PM, an Occupational Therapist emailed SW-K about further inappropriate comments made to her by R6. Second Incident On 2/15/21 at 11:15AM, an Occupational Therapist (OT) reported witnessing R6 lightly squeeze the outside of R9's clothes in the breast area. OT reported intervening right away and removed R9 from the situation, so signs of distress noted. OT went back to talk with R6 who was reported to state no wrongdoing stated, just trying to show R9 where to go as R9 gets lost sometimes. OT reported reminding R6 not to touch other residents in the facility. SW-K assessed R9 who presented at baseline - cheerful, nonsensical, kind, and attending to internal stimuli. SW-K assessed no evident negative effect on R9's psychosocial state. Nursing completed a physical assessment with no findings. Immediate interventions were to monitor R9 for mood/behaviors outside of baseline. Staff to discuss further intervention options for R6's behaviors. It was noted these behaviors were presently care planned and discussed with family. No new interventions were put into place to keep other residents safe from sexual abuse after this incident. Third Incident On 3/10/21 RN-C made a progress note at 4:28PM that CNA approached writer and social services director about incident. SS director and writer confronted res about event and res stated Did she rat me out?! She was just in my doorway, and I was just giving her a shove away from my door! Res educated again on need to not touch other residents and made aware this was not acceptable behavior at any time. I know, that's against the rules. R6's son updated and discussion had about room change to different hall. Son agreed to room change. Noted that Interdisciplinary team (IDT) would meet in the morning to discuss potential move. RN-C made a progress note at 4:36PM that R8 was assessed by RN-C with no signs of injury, skin intact, resident calm and engaging with SS director. A Progress note written on 3/10/21 by RN-C just after incident stated CNA CS (who is our CNA-L) approached writer and Social Services director, 'I just witnessed [R6's name] fondling a female resident on the breast, she was sitting in her w/c near his door and he touched her before I could get to her.' SW-K made a progress note at 4:40PM having spent approximately 20 minutes with R8 who showed no adverse effects. CNA-L gave a written statement that includes in part, Found (R6) groping (R8) at 1550. South Hall in front of #210. Resident is okay. The two were separated. (R8) placed in café. (R6) is in his room. Interventions were put into place were to monitor R8 for changes in mood/behavior that could be related to incident. No other interventions were put into place to keep other residents safe from sexual abuse. R6 did not have a room change as discussed by the interdisciplinary team. R6 resided in room [ROOM NUMBER]. R17 resided in a room [ROOM NUMBER] approximately 27 yards away. R8 resided in a room approximately 8 yards away. These residents all resided on the same hall. R6 resided in room [ROOM NUMBER] on a different hall, but was observed during survey to be independently mobile around entire facility in wheelchair. During the survey R6 is in close proximity to R17, R8, and R9 with no specific interventions in place to protect these residents or other residents from sexual abuse. Review of care plans for all 4 residents involved in these incidents revealed no updates pertaining to mood/behavior monitoring stemming from each of these situations or interventions to protect them from further sexual abuse. On 4/7/21 at 4:45PM, Surveyor interviewed RN-C about any staff education or training on abuse and/or resident to resident altercations. RN-C stated the facility does a Safety Fair annually, which was completed online in 2020. There had been no updated education given to staff since these three incidents occurred. Staff Interviews: On 4/7/21 at 3:08PM, Surveyor interviewed CNA-F who reported having worked at the facility for 3 years. CNA-F reported having training on abuse such as sheets with quizzes that they sign off on. CNA-F reported knowing there was a male resident (R6) who has touched female residents. She reported she watches him with the female residents and that only male staff, or two female staff, can work with R6. On 4/7/21 at 3:14 PM, Surveyor interviewed Nursing Support (NS) J. Surveyor asked NS-J what is facility policy regarding abuse. NS-J stated the people involved should be separated and it needs to be reported. Surveyor asked what NS-J would do if a resident to resident altercation occurred. NS-J stated the residents involved should be separated and then NS-J would get each of their stories. NS-J stated it would be reported to the front desk and to the DON-B. On 4/7/21 at approximately 3:14 PM, Surveyor interviewed CNA-I regarding abuse training. CNA-I stated she was trained to separate residents, report observations to the supervisor, write a statement of what was seen or heard, and complete an incident report. CNA-I stated R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA-I stated R6's care plan encourages male caregivers or two female caregivers. CNA-I stated she overheard R6 talk with R13 making a sexual statement of isn't she hot in reference to R30. CNA-I also stated a few weeks ago R6 was observed touching R8 sexually. CNA-I stated this happened on the night shift when R8 wheeled self down R8's hall and the sexual altercation took place at the end of R8's hallway. On 4/7/21 at 3:17PM, Surveyor interviewed NA-H who reported having worked at the facility since 8/2020. NA-H reported having had abuse training online when she took the nurse aide class. It is also in the nurse aide book, and she received an informational pamphlet. NA-H reported she would separate any residents if there was a concern and report it to the nurse. NA-H stated being aware of a male resident (R6) having issues. She has gotten this information passed along in report. NA-H stated watching residents around R6. NA-H stated that if she was touched she would be distressed. On 4/7/21 at 3:20PM, Surveyor interviewed CNA-L who stated having witnessed the incident between R6 and R8. CNA-L immediately separated the residents and reported the incident to RN-C. CNA-L reported conducting more monitoring of R6 since these incidents started. CNA-L did not recall the last abuse training he had but in general he would be sure to separate the residents and report the situation immediately to the charge nurse. CNA-L reported not seeing any changes in any of the three female residents since the incidents occurred. R6's care plan does not identify any increased monitoring that is in place since the events described above. On 4/7/21 at 3:30PM, Surveyor interviewed LPN-G who reported having worked at the facility for 2.5 years. LPN-G reported reviewing abuse at monthly meetings and having completed training on the computer. LPN-G reported if she witnessed a resident touching another resident inappropriately she would first separate the residents and then report to the charge nurse. LPN-G reported knowing of a male resident (R6) who has touched other female residents. LPN-G stated she knows there are issues because it is written down what to watch for on a form or piece of paper the supervisor gets. Surveyor asked to see this form for 4/7/21, which did not have any information about R6 needing to be monitored. The National Centers for Victims of Crimes website http://www.[NAME].org defines sexual assault as: Sexual assault takes many forms including attacks such as rape or attempted rape, as well as any unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent. Some types of sexual acts which fall under the category of sexual assault include fondling and attempted rape. Sexual assault in any form is often a devastating crime. Whatever the circumstances, no one asks or deserves to be sexually assaulted. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, .Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs .Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders

Based on interview and record review the facility did not maintain an Infection Control Program to help prevent the transmission of infection or disease during a gastrointestinal outbreak that affected 19 of the facility's residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18 and R19) and had the liklihood to affect all 53 residents. 1. The facility did not ensure the Infection Control Preventionist had received the required training needed to effectively monitor and respond to an outbreak. 2. The facility did not maintain a real time surveillance of the affected residents, their symptoms and did not track and trend patterns of affected residents. 3. The facility did not promptly notify the local health department. 4. The facility did not consult with the local health department and medical director regarding suspension of resident admissions and continued to admit residents to units with actively ill residents. 5. The facility did not manage staff by providing consistent staff wing assignments. 6. The facility did not ensure readily available personal protective equipment (gowns) for staff to wear when in contact with a symptomatic residents. 7. The facility did not provide education to staff regarding signs and symptoms or transmission prevention measures. 8. The facility did not monitor staff for compliance with transmission prevention measures. 9. The facility did not consult resident physicians regarding their symptoms and consult physicians regarding alteration in the resident plan of care. 10. The facility did not adjust the residents' plans of care or provide staff with individual approaches for resident needs. 11. The facility did not review the outbreak to develop a quality assurance plan in attempts to identify failures during the outbreak and develop a plan to prevent future failures. The facility's failures to implement infection control measures created a finding of Immediate Jeopardy beginning 1/26/20. NHA A (Nursing Home Administrator) was notifed of the immediate jeopardy on 2/18/20 at 12:30 p.m. The Immediate Jeopardy was removed on 2/18/20. However the deficient practice contines at a scope/severity level of F (potential for more than minimal harm/widespread) as the facility continues to implement its correction plan. This is evidenced by: Surveyor received the facility's final line list titled Template Line List During Noro-Virus Outbreaks and noted: ~R2 (South Unit), was the first resident who became ill with symptoms of vomiting and diarrhea starting 1/25/20. His last symptom was noted on 1/29/20. ~R1 (South Unit), had onset of vomiting and diarrhea noted on 1/26/20, with his well date (date of last symptom) noted on 1/28/20. ~R3 (North Unit), experienced symptoms of vomiting starting 1/26/20. The last symptom was noted on 1/27/20. ~R4 (West Unit), experienced symptoms of vomiting and diarrhea starting 1/26/20. The last symptom was noted on 1/27/20. ~R5 (West Unit) experienced symptoms of vomiting and diarrhea starting 1/26/20. The last symptom was noted on 1/26/20. ~R6 (West Unit), experienced symptoms of nausea, vomiting and diarrhea starting 1/26/20. The last symptom was noted on 1/26/20. According to the Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities an outbreak should be identified when 3 or more residents experience symptons within a 72 hour period and have geographic commonality (i.e., same wing or unit). The facility should have identified an outbreak beginning 1/26/20. ~R7 (North Unit), experienced symptoms of diarrhea starting 1/27/20. The last symptom was noted on 1/30/20. ~R8 (West Unit), experienced symptoms of diarrhea starting 1/28/20. The last symptom was noted on 1/29/20. ~R9 (East Unit) experienced symptoms of diarrhea starting 1/28/20. The last symptom was noted on 1/28/20. By Day 3, all 4 of the facility's wings have residents that have been affected by GI symptoms. ~R10 (West Unit) experienced symptoms of vomiting, diarrhea and fever starting 1/28/20. The last symptom was noted on 1/30/20. ~R11 (South Unit) experienced symptoms of vomiting and diarrhea starting 1/28/20. The last symptom was noted on 1/30/20. ~ R12 (South Unit) experienced symptoms of diarrhea starting 1/28/20. The last symptom was noted on 1/28/20. ~R13 (North Unit), who resided on the north wing, experienced symptoms of vomiting and diarrhea starting 1/30/20. The last symptom was noted on 1/30/20. ~R14 (North Unit) experienced symptoms of vomiting and diarrhea starting 1/30/20. The last symptom was noted on 1/30/20. ~R15 (West Unit) experienced symptoms of vomiting and diarrhea starting 1/31/20. The last symptom was noted on 1/31/20. ~R16 (East Unit) was admitted to the facility on [DATE] and experienced symptoms of vomiting and diarrhea starting 1/31/20. The last symptom was noted on 2/02/20. ~R17 (North Unit), experienced symptoms of vomiting and diarrhea starting 1/31/20. The last symptom was noted on 2/01/20. ~R18 (North Unit) experienced symptoms of diarrhea starting 1/31/20. R18's last symptom was noted on 1/31/20. ~R19 (West Unit) experienced symptoms of vomiting and diarrhea starting 2/01/20. The last symptom was noted on 2/02/20. R19 was the last documented resident affected by the outbreak. In total 19 of the 53 facility residents were affected by the outbreak. This is an affected rate of 35.84% of residents. Example 1: The facility did not ensure the Infection Control Preventionist had received the required training needed to effectively monitor and respond to an outbreak. On 2/18/20 at 8:20 a.m. Surveyor spoke with DON-B who is the designated Infection Control Preventionist (ICP). Surveyor asked DON-B what training she had received in infection control standards required for the facility's ICP role and responsibilities. DON-B indicated she has been at the facility for several years but recently assumed the responsibility of ICP. Further indicating she assumed the role in December 2019 when the former ICP was no longer employed at the facility. The DON expressed her former position was MDS (Minimum Data Set) Coordinator. The DON further expressed she had received no training prior to or since assuming the role in infection control standards required for delegation of the facilities ICP. Example 2: The facility did not maintain a real time surveillance of the affected residents, their symptoms and did not track or trend patterns of affected residents. Surveyor received and reviewed the facility policy titled GI (GastroIntestinal) Illness Surveillance and Response dated effective 3/20/09 with most recent revision on 3/08/19. The policy is based on Centers of Disease Control (CDC) standards. The policy in part states: ~Data regarding signs and symptoms of infectious and communicable disease is collected and recorded on a continual basis. Data is analyzed on an on-going basis to identify patterns and trends of symptoms and is used to guide the implementation of appropriate measures to prevent or limit the spread of infection and communicable disease among residents and staff. Protocol: 1. All staff immediately report onset of symptoms of GI illness among residents and staff to Clinical Manager/RN (Registered Nurse) Supervisor: watery stools, nausea, vomiting, abdominal framing, fever, chills. 2. Clinical Manager/RN Supervisor determines whether individual resident symptoms meet GI illness case criteria and whether the number and pattern of cases meet outbreak criteria. Resident must exhibit one of the following: two or more watery stools above what is usual within a 24-hour period or two or more emesis above what is usual within a 24 hour period or a stool culture positive for GI pathogen. Outbreak: two or more cases on a single unit or three or more cases facility wide within a 48 hour period. 3. Clinical Manger/RN Supervisor records case information on the Resident Infection Tracking Log to track emergence of cases of GI illness among residents. 4. Infection Control Professional or Clinical Manager/RN Supervisor when Infection Control Professional is not available: notifies facilities departments of symptoms and outbreak .department managers will review outbreak prevention/control measures with their department staff. Cases will be marked on the infection control blue print. 5. A final line list should be provided to the local health department 7-10 days after the last case has recovered. On 2/18/20 at 8:20 a.m. Surveyor spoke with DON-B (Director of Nursing) regarding the outbreak and the facility's surveillance of the outbreak. DON-B indicated the facility did not monitor resident GI symptoms in real time, noting the emergence of symptoms. Additionally the facility did not mark affected residents on a blue print or map for evaluation. The facility did not review the data for patterns or trends. The facility did not provide education or training to staff on outbreak prevention/control. DON-B further expressed she was currently working on a map of the affected residents and can see the benefits of the data. Further expressing the information would be helpful in identifying potential areas of improvement to manage the outbreak. Example 3: The facility did not promptly notify the local health department. The policy further states: ~The Infection Control Professional notifies the public health officer within 24 hours of identification on an outbreak. Surveyor noted the facility had met the criteria of a GI outbreak on 1/26/20 when 3 residents on the West Unit became ill with GI symptoms. Surveyor requested and received a facility timeline of outbreak control measures by the facility. The timeline indicated the health department was notified on 1/31/20 (5 days after the outbreak was identified). Surveyor was provided an email to the health department which confirmed the department was not informed of the outbreak until 1/31/20. On 2/18/20 at 8:30 a.m. Surveyor spoke with DON-B about the delay in informing the health department of the facility's GI outbreak. DON-B indicated she had been out of work with scheduled days off when the GI outbreak was identified. DON-B then became ill with GI symptoms and did not return to work until 2/03/20. In her absence, LPN-F (Licensed Practical Nurse) sent an email to the public health department on 1/31/20, informing the department of the outbreak. The facility did not report the outbreak within 24 hours of identification as required. Surveyor asked DON-B if the health department was consulted regarding collection of resident stool samples for testing of infectious pathogens. DON-B expressed she did not talk with the health department until her return to work on 2/03/20. At that point the health department indicated to not take stool samples as the facility was at the end of the outbreak. On 2/18/20 at 10:50AM Surveyor interviewed LPN-F. LPN-F stated when DON-B was out sick, she stepped up and tried to take control of the outbreak to a point. LPN-F stated she had not been designated by NHA-A or DON-B as the Infection Preventionist. LPN-F stated the person who would have, would be the the nursing supervisor RN-E (Registered Nurse), who was on vacation. LPN-F stated she started helping with assessments of residents and was the one that made the call to public health to alert the county representative there was an outbreak occurring. She did this on 1/31/20 and had received an email in response. Example 4: The facility did not consult with the local health department and medical director regarding suspension of resident admissions and continued to admit residents to units with actively ill residents. The policy further states: ~Admissions to wings affected by the outbreak may be suspended. In consultation with the Medical Director and Public Health Officer until 48 hours after the last identified case. Surveyor requested and received a facility timeline of outbreak control measures by the facility. The timeline indicated the Medical Director was notified of the facility outbreak on 1/27/20. The timeline shows no outbreak control measures as identified by discussion with the Medical Director, including discussion of suspension of resident admissions. The timeline also notes notification to the health department on 1/31/20. Again there is no evidence to show outbreak control measures, including discussion regarding suspension of facility admissions. Surveyor requested and received facility admissions records. The records show: ~3 admissions on 1/28/20 (2 residents on East Unit and 1 resident on West Unit). Surveyor reviewed the final line list and noted on 1/28/20, 1 resident on East Unit and 2 residents on West Unit were ill with GI symptoms. During the discussion with DON-B on 2/18/20 at 8:30 a.m. Surveyor asked if the Medical Director or Public Health Department were consulted regarding suspension of facility admissions. DON-B indicated they were not. Example 5: The facility did not manage staff by providing consistent staff wing assignments. The policy further states: ~Consistent staff assignments on resident units are maintained to the greatest extent possible. Staff members from all departments should not float from affected to unaffected wings. On 2/17/20 at 10:51 a.m. Surveyor spoke with CNA-I Certified Nursing Assistant). CNA-I explained during the outbreak she worked all units. She was not assigned a particular wing. The outbreak spread quickly and affected all units. On 2/17/20 at 11:02 a.m. Surveyor spoke with CNA-J. CNA-J indicated she worked all units during the facility outbreak. Staff were not instructed or assigned a particular wing. Staff were bouncing all over the place, floating to all halls. The outbreak spread fast and CNA-J indicated she became ill as well. Example 6: The facility did not ensure readily available personal protective equipment (gowns) for staff to wear when in contact with a symptomatic residents. The policy states: ~Contact Isolation precautions are implemented immediately upon emergence of symptoms consistent with GI illness in accordance with CDC guidelines. ~Wear gloves and gowns upon entry into room and when in contact with a symptomatic resident. On 2/17/20 at 10:40 a.m. Surveyor spoke with CNA-H regarding the GI outbreak. CNA-H explained the facility did not handle the outbreak well and it spread fast. CNA-H told Surveyor the facility did not have PPE carts ready, there were limited carts to one per wing, there were not enough gowns and they ran out. CNA-H said the facility eventually got some from another facility. CNA-H stated staff were entering rooms of sick residents without gowns. There was a lack of communication regarding which residents had symptoms and who was coming off precautions. There was nothing in place to tell staff what residents needed. It was a disaster, which had an impact on how it spread. On 2/17/20 at 10:51 a.m. Surveyor spoke with CNA-I Certified Nursing Assistant). CNA-I indicated the facility did not have gowns for staff to wear. Isolation carts were not set up and ready to go. Carts were missing needed supplies. Staff would have to run to other wings to look for needed supplies. Gowns could not be located in the building. One package was located in the building and staff were told by nursing to not use them and to save them for one resident who was affected by [MEDICAL CONDITION] infection. Staff were told to use hospital type gowns that are cloth and short sleeved. Staff entered rooms of sick resident to care for them without gowns on because gowns were not available. The residents who are dependent on staff for care were affected the most. Staff entered their rooms to provide care numerous times without gowns on. On 2/17/20 at 11:02 a.m. Surveyor spoke with CNA-J. CNA-J indicated there were not enough gowns. Started with some and ran out quickly. Staff were given cloth gowns to use that did not cover. Sometimes staff had to enter rooms without a gown because there were none available. Units had limited PPE carts. On 2/17/20 at 1:03PM, Surveyor interviewed MT-D (Medication Technician). MT-D stated that the outbreak was very unorganized. Communication was terrible and staff did not know which residents were going on transmission based precautions or coming off transmission based precautions. MT-D stated the facility ran out of gowns and staff were using cloth gowns that have exposed arms. Staff were getting sick and the facility was short staffed. MT-D stated DON-B was trying to help but got sick and was not able to be at facility. There was no infection control nurse at the facility and facility administration is not generally upstairs on the units. MT-D stated staff knew what they should be doing with wearing PPE (personal protective equipment) there just wasn't enough supplies available. MT-D stated there was at least one day that there were no gowns for staff to wear. On 2/17/20 at 1:35PM, Surveyor interviewed LPN-F. LPN-F stated that DON-B has been Infection Preventionist since the position was vacated. LPN-F stated there were 2 days the facility had run low on supplies. They tried to get some from the nearby assisted living facility and ended up getting some gowns from another facility in a neighboring community. LPN-F stated the staff are good at reporting issues to the nurse manager or the charge nurse for a particular shift and the nurses are good at putting residents on transmission based precautions when symptoms start. On 2/17/20 at 4:15PM, Surveyor spoke again with MT-G. MT-D stated having gotten sick and was out for four days. For the two to three days prior to getting sick there were no gowns available to use and the staff were told to wear hospital gowns instead. The facility did shut down the halls so residents were not moving about but due to staff getting sick there was low staffing. MT-G stated the staff were still running from hall to hall trying to help each other out. On 2/17/20 at 4:30PM, Surveyor interviewed NHA-A, DON-B was also in the room. NHA-A stated they had recently started a new supply ordering process that was more centralized. No one had expressed the need for an order to be placed, so the person doing the ordering did not know supplies were low. By the time they figured out they were low on gowns, it was Friday afternoon. Even if an order was placed it would not have arrived until Monday. NHA-A stated she tried to obtain gowns from pharmacies and hospitals in the area. NHA-A stated another facility in the area had some they were able to purchase. Example 7: The facility did not provide education to staff regarding signs and symptoms or transmission or prevention measures The policy states: ~The Infection Control Professional will provide education to staff regarding signs and symptoms, transmission prevention measures. And work exclusion guidelines for GI illness at the onset of an outbreak . Staff interviews indicate being provided very little information needed to manage the outbreak. On 2/17/20 at 10:40 a.m. Surveyor spoke with CNA-H regarding the GI outbreak. CNA-H explained there was a lack of communication regarding which residents had symptoms and who was coming off precautions. There was nothing in place to tell staff what residents needed. It was a disaster, which had an impact on how it spread. On 2/17/20 at 11:02 a.m. Surveyor spoke with CNA-J. CNA-J indicated staff did not have any information available regarding each resident. There was no communication, it was chaotic, and had an impact on spreading, with staff going wing to wing. On 2/18/20 at 8:30 a.m. Surveyor spoke with DON-B regarding education provided to staff with the onset of the GI outbreak. DON-B indicated staff were not provided any formal training as outlined in the facility policy. Example 8: The facility did not monitor staff for compliance with transmission prevention measures. The policy further states: ~The Infection Control professional will provide education to staff regarding signs and symptoms, transmission prevention measures .and monitor staff actively for compliance with transmission prevention protocols. Department Managers will reinforce the teaching and assist with monitoring of staff compliance. On 2/18/20 at 8:30 a.m. Surveyor spoke with DON-B regarding audits of monitoring staff adherence of donning expected PPE when caring for residents with active GI symptoms. DON-B indicated the facility did not conduct audits of monitoring staff adherence to wearing PPE when caring for residents with GI symptoms. Although staff interviews noted above indicate not donning ppe (gowns) or donning ineffective resident hospital type gowns when caring for actively ill residents the facility was not fully aware of the extent of the non-compliance due to a lack of monitoring adherence to expectation. Example 9: The facility did not consult resident physicians regarding their symptoms and alter the resident plan of care accordingly. On 2/18/20 Surveyor spoke with DON-B regarding the facility's expectation of consulting resident physicians when a change of condition occurs such as GI symptoms. DON-B indicated NP-N (Nurse Practioner) was informed of the facility GI outbreak on 1/28/20, however she was not consulted regarding individual resident symptoms for consideration of altering their plan of care. NP-N was consulted regarding R1's care, however she oversees care for R3, R5, R6, R7, R9, R10, R11, R13, R18 and R19 and did not consult with the facility regarding their symptoms or plan of care. DON-B further expressed no physician was contacted for consultation for consideration of altering plan of care for R8, R12, R14, R15, R16 and R17. DON-B further expressed each resident's physician should have been contacted for consultation and consideration of change in their plan of care. Example 10: The facility did not adjust the resident's plan of care or provide staff with individual approaches for each residents' needs. The policy states: ~Specific measures are implemented in response to resident symptoms (e.g. measures to reduce risk of transmission, alterations in the plan of care, including orders regarding volume-depleting drugs and monitoring status). Surveyor reviewed resident records and found no temporary care plans or change in resident plan of care based on each residents individual needs while ill with GI symptoms. On 2/17/20 at 3:57 p.m. Surveyor spoke with CNA-L regarding the outbreak. CNA-L further expressed residents did not have temporary care plans or updated care plans to instruct staff in resident care. On 2/17/20 at 4:04 p.m. Surveyor spoke with CNA-K. CNA-K indicated residents have care plans in their closets that are available to staff when caring for them. The care plans did not change while residents were sick with GI symptoms. On 2/18/20 Surveyor asked DON-B about individual resident care plans for each individuals needs while they were ill with GI symptoms. DON-B indicated the facility did not develop individual resident care plans to address their needs while ill with GI symptoms. DON-B further indicated physicians were not consulted and there were no change in resident orders. DON-B expressed she can now see the importance of why physicians should have been consulted and why a temporary care plan should have been developed to direct staff in approaches for individual needs. On 2/17/20 at 4:30PM, Surveyor interviewed NHA-A, DON-B was also in the room. Surveyor asked NHA-A for any care plans related to the GI illness. NHA-A stated that the facility did not complete updated or temporary care plans for those residents who got sick. They put signs up on resident doors indicating transmission based precautions are needed, use shift to shift reports to pass along info about who is on transmission based precautions and have staff follow facility protocol for outbreaks. Example 11: The facility did not review the outbreak to develop a quality assurance plan in attempts to identify failures during the outbreak and plan to prevent future failures. On 2/18/20 at 8:30 a.m. Surveyor requested evidence the facility had reviewed the outbreak or developed a quality assurance plan in attempts to identify opportunities for improvement during the GI outbreak. DON-B who leads the Quality Assurance Committee indicated the committee will be gathering next week for discussion regarding the outbreak. No plan has been developed at this point to prevent future failures of adherence to the facility's GI Illness Surveillance and Response procedures. The failure to implement an infection control program when an outbreak exists, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 2/18/20 when it had completed the following: 1. Trained the nurse management team on the facility's infection control policy and procedures as well as tracking of illnesses; 2. All direct care staff were trained on location and use of PPE; 3. All licensed staff were educated on real time surveillance before the start of the next scheduled shift; 4. All staff educated on consistent staffing during an outbreak; 5. 3 licensed nurses to enroll in the Infection Preventionist training; and, 6. Contignency supply of PPE obtained and maintained in the building.