Every finding on record at Samaritan Nursing and Rehab

Based on interview and record review, the facility did not ensure injuries of unknown origin were reported to the State Agency (SA) for 2 residents (R) (R2 and R3) of 3 sampled residents.R2 sustained a right thumb fracture of unknown cause on 7/9/26. The SA was not notified of the injury of unknown origin.R3 was diagnosed with a dislocated left hip during an orthopedic appointment on 5/29/26. The SA was not notified of the injury of unknown origin. Findings include: The facility's Abuse, Neglect, and Exploitation Policy, revised 7/15/26, indicates: .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse .Reporting/Response: .B. The Administrator will follow up with government agencies during business hours to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by State Agencies . 1. R2 was admitted to the facility on [DATE] and had a diagnosis of cerebral infarction with hemiplegia and hemiparesis. A Minimum Data Set (MDS) assessment, dated 6/4/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 8/18/26, Surveyor reviewed R2's medical record and noted swelling of the right thumb was discovered on 7/8/26. An X-ray revealed a fracture. The facility completed an investigation, including resident and staff interviews, but did not identify a cause for the injury. The facility did not report the injury of unknown origin to the SA. On 8/18/26 at 3:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility forgot to submit an injury report to the SA for R2 and stated they are working on procedures to ensure injuries of unknown origin are reported timely. 2. R3 was admitted to the facility on [DATE] and had diagnoses including fracture of the left femur, left artificial joint, repeated falls, and neurocognitive disorder. An MDS assessment, dated 5/18/26, stated R3 had a BIMS score of 4 out of 15, indicating severely impaired cognition. The MDS assessment also indicated R3 was dependent on staff for transfers and toileting, required substantial/maximal assistance with dressing and partial/moderate assistance with hygiene, and had a wheelchair for mobility. On 8/18/26, Surveyor reviewed R3's medical record which indicated they fell in the facility on 5/18/26. R3 was transferred to the emergency room (ER) and diagnosed with a left hip dislocation that could not be fixed in the ER. An Orthopedist was consulted and completed a reduction of the dislocation. R3 reported improved pain at rest and was discharged back to the facility for rehab. A physician note on 5/19/26 indicated a follow-up orthopedic appointment was scheduled for 5/26/29, however, the appointment was rescheduled for 5/29/26. During the appointment on 5/29/26, the orthopedic clinic identified a dislocated hip. R3 was transferred to the hospital for further evaluation. The facility did not report the injury of unknown origin to the SA. On 8/18/26 at 2:41 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R3 fell on 5/18/26 and had a dislocated left hip that was reduced at the hospital. NHA-A also verified R3 had a follow-up orthopedic appointment on 5/29/26 where a dislocated left hip was again discovered. NHA-A indicated the facility did not investigate the injury of unknown origin because R3 did not return to the facility. NHA-A indicated the facility had a different Director of Nursing (DON) at the time and R3 had a history of hip dislocations.

Based on interview and record review, the facility did not thoroughly investigate an injury of unknown origin for 1 resident (R) (R3) of 2 sampled residents. A dislocated hip was identified during R3's orthopedic appointment on 5/29/26. The facility did not investigate the injury of unknown origin. Findings include:The facility's Abuse and Neglect policy, dated 7/15/26, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: .6. Providing complete and thorough documentation of the investigation. R3 was admitted to the facility on [DATE] and had diagnoses including fracture of the left femur, left artificial joint, repeated falls, and neurocognitive disorder. A Minimum Data Set (MDS) assessment, dated 5/18/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. The MDS assessment also indicated R3 was dependent on staff for transfers and toileting, required substantial/maximal assistance with dressing and partial/moderate assistance with hygiene, and had a wheelchair for mobility. On 8/18/26, Surveyor reviewed R3's medical record and noted they fell in the facility on 5/18/26. R3 was transferred to the emergency room (ER) and diagnosed with a left hip posterior dislocation. The dislocation could not be fixed in the ER. An orthopedist was consulted and completed a reduction of the dislocation. R3 reported improved pain at rest and was discharged back to the facility for rehab. A physician note on 5/19/26 indicated a follow-up orthopedic appointment was scheduled for 5/26/29, however, the follow-up appointment was rescheduled for 5/29/26. During the appointment on 5/29/26, the clinic determined R3 had a dislocated left hip. R3 was sent to the hospital for further evaluation. The facility did not investigate the injury of unknown origin. On 8/18/26 at 2:41 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R3 fell on 5/18/26 and had a dislocated left hip that was reduced at the hospital. NHA-A verified a dislocated left hip was again discovered during R3's follow-up orthopedic appointment on 5/29/26. NHA-A indicated the facility did not investigate the injury of unknown origin because R3 did not return to the facility. NHA-A indicated the facility had a different Director of Nursing (DON) at the time and R3 had a history of hip dislocations.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 70 of 71 residents residing in the facility.The facility did not ensure monitoring and documenting of cooling temperatures.The facility did not properly monitor dishwashing temperatures or conduct dishwashing in a manner that ensured dishes were washed and properly sanitized.The facility did not wash and sanitize dishes in the three-compartment sink per manufacturer's guidelines or the facility's policy.The facility did not consistently label food stored for resident consumption with received or open dates.The facility did not obtain food temperatures in a manner to prevent cross-contamination.Findings include:Food Cooling: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3 501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcuis (C) (135 Farenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less.The 2022 FDA Food Code documents at section 3 501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3 501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.During the initial kitchen tour with [NAME] (CK)-F on 5/11/26 at 5:07 PM, Surveyor observed the following pre-cooked and cooled items in the walk-in cooler:~ A steam table container labeled Beef 5-10~ A steam table container labeled Chili 5-9~ A steam table container labeled Noodles 5-9~ A steam table container labeled Hot dogs 5-9~ A steam table container labeled Hot dogs 5-3~ An unlabeled and undated steam table container with what appeared to be chicken strips~ A steam table container labeled [NAME] 5-9~ A steam table container labeled Bacon 5-9~ Two undated steam table containers labeled MMS meat. Surveyor observed pre-cooked minced meat saved for future resident consumption in the containers. ~ A steam table container labeled Eggs 5-9During a continuous kitchen observation that began on 9:27 AM on 5/12/26, Surveyor observed the above pre-cooked food items still in the cooler for resident consumption. Surveyor also observed a container labeled Hamburgers 5-11 in the walk-in cooler. Surveyor interviewed CK-F who indicated the facility does not have a cooling log and places pre-cooked food for resident consumption in the cooler. During a kitchen tour with Dietary Manager (DM)-E that began at 1:58 PM on 5/12/26, DM-E indicated the facility had a food cooling log. DM-E showed Surveyor the cooling log which contained none of the pre-cooked items observed in the cooler. DM-E indicated the facility pre-cooks food and saves leftovers. DM-E indicated the facility's policy and procedure is for food to be cooled properly and for staff to monitor the temperatures of foods saved or pre-cooked. Surveyor and DM-E toured the coolers. DM-E verified all pre-cooked food saved for resident consumption should be on the food cooling log to ensure proper cooling. Dishwashing:The facility's undated Warewashing 101 policy indicates: .Dish Machine Start-Up .Ensure machine is meeting the correct wash and rinse temperatures (see NSF data label posted on machine). Test sanitizing requirements .High temp = 160 surface temp .During a continuous kitchen observation that began at 9:27 AM on 5/12/26, Surveyor observed staff wash dishes. Surveyor observed Dietary Aide (DA)-G on the clean side of the dishwasher and another staff on the dirty side. DA-G wore gloves and an apron during dishwashing. DA-G removed two racks of clean dishes to dry. DA-G then went to the dirty side, cleaned food off of a dish, and put a rack of dirty dishes in the dishwasher. DA-G then returned to the clean side and removed clean dishes from the dishwasher to dry. DA-G did not remove gloves or an apron or complete hand hygiene. DA-G then went to the dirty side, cleaned food off of dishes, and loaded the dishes in the dishwasher. With the same gloved hands and apron, DA-G removed a clean rack of dishes to dry. Surveyor observed DA-G continuously move from the dirty to clean side of the dishwasher without removing gloves or an apron, or washing hands between tasks. Surveyor noted the dishwasher data plate indicated the machine was a high temperature washer; the wash temperature should be 160 degrees F and the sanitizer temperature should be 180 degrees F. Surveyor observed the dishwashing temperature log. The bottom of the form indicated high temperature wash 150 to 160 degrees F.During a kitchen tour with DM-E that began at 1:58 PM on 5/12/26, DM-E indicated kitchen staff are assigned to dishwashing. The policy and procedure for dishwashing is to have two staff to ensure one staff works on the dirty side and one staff handles the clean side, including hand hygiene and removing an apron if having to complete tasks on the opposite side. DM-E indicated the wash temperature of the dishwasher should be 150 to 160 degrees F. When Surveyor indicated the May 2026 dish log contained two entries, DM-E indicated DM-E would provide the March through May 2026 dish logs to Surveyor. DM-E indicated kitchen staff frequently do not start a new page with a new month.On 5/14/26, Surveyor reviewed the facility's dish logs for March, April, and May 2026 and noted the following:~ March 2026: Wash was documented at 180 to 181 degrees F throughout the month. Rinse was documented at 181 to 184 degrees F with one documentation of 178 degrees F throughout the month; Parts per million (PPM) was documented at 300 PPM consistently throughout the month.~ April 2026: Wash was documented at 170 to 186 degrees F throughout the month. Rinse was documented at 162 to 181 degrees F with 38 of 90 entries documented below the required 180 degrees F sanitization temperature. PPM was documented at 200 to 300 throughout the month. ~ May 2026: Wash was documented at 170 to 180 degrees F with one entry at 142 F and the dishwasher shut down for maintenance on 5/12/26. Rinse was documented at 118 degrees F (on 5/12/26) to 182 degrees F with 23 of 34 entries documented below the required 180 degrees F sanitization temperature. PPM was documented at 200 to 300 throughout the month. On 5/14/26 at 10:34 AM, Surveyor interviewed DM-E who indicated the dishwashing machine was a high temperature machine. DM-E indicated staff place a Hydrion Quat Sanitizer test strip near the exit of the clean side and document the temperature. DM-E indicated Quat Sanitizer strips are also used to test PPM which should be documented on the dishwashing machine. DM-E confirmed DM-E did not know the difference between a chemical sanitizer machine and a high temperature warewashing machine. Surveyor reviewed the facility's dishwashing machine data plate with DM-E who verified the data plate indicates a high temperature wash should reach 160 degrees F and a high temperature sanitization cycle should reach 180 degrees F. Quat Sanitizer:The facility's undated Warewashing 101 policy indicates: .Sanitizer test papers are most accurate when testing sanitizer solutions at 75 F.During an initial kitchen tour that began at 5:07 PM on 5/11/26, Surveyor interviewed CK-F who indicated staff wash dishes, including the cooks' dishes, and prepare sanitizer buckets in the three-compartment sink. CK-F indicated the log hung near the three-compartment sink is where staff document the time sanitizing buckets are prepared and record the PPM of the sanitizing solution. Surveyor reviewed the three-compartment sink log and noted Hydrion Quat Sanitizer strips on the clipboard. Surveyor noted the log did not contain the temperature of the sanitizing solution prior to testing.During a continuous kitchen observation conducted with DM-E on 5/12/26, DM-E verified the temperature of the sanitizing solution in the three-compartment sink is not tested prior to testing PPM. DM-E verified the temperature of the sanitizing solution should be 75 degrees F prior to testing per the facility's policy. Food Storage:The facility's Safe Storage of Food policy, dated 9/1/21, indicates: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . During an initial kitchen tour that began at 5:07 PM on 5/11/26, Surveyor and CK-F observed the following open and undated foods in the dry storage area and coolers:~ An undated steam table container labeled beef base ~ Two undated steam table containers labeled onion and an undated plastic wrapped onion ~ A bag of shredded cheese~ A container of salad~ A package of hot dogs~ Two bags of dinner rolls~ Five packages of lunch meat~ A container of Silk soy milk~ A gallon of milk~ A steam table container of MMS meat in the walk-in cooler~ Two unlabeled and undated steam table containers of what CK-F indicated was pork for lunch on 5/12/26.~ Seven cans of sausage gravy ~ Two cans of fancy tomatoes~ Two cans of sauerkraut~ Three cans of pimento pepper~ A tub of cream cheese frosting~ Two boxes of au gratin potatoesDuring a kitchen tour with DM-E that began at 1:58 PM on 5/12/26, DM-E verified the items observed in the dry storage area and cooler were unlabeled, undated, and/or open. DM-E indicated staff should label all food with a received date, an open date, and an item description if leftovers or prepped food are for an upcoming meal.Food Temperatures:The facility's Record of Food Temperatures policy, revised 1/2026, indicates: .Food temperatures will be verified using a thermometer which is clean, sanitized, and calibrated to ensure accuracy. During a continuous dining observation that began at 11:35 AM on 5/12/26, Surveyor observed DA-G obtain food temperatures at the steam table prior to lunch service. DA-G obtained the temperature of pork fried rice for regular, minced and moist, and pureed consistencies without sanitizing the thermometer between the regular and modified textures. On 5/13/26 at 2:15 PM, Surveyor interviewed DM-E who indicated staff are trained in the proper procedure for obtaining food temperatures and staff know to use a sanitizing wipe between obtaining temperatures.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 71 residents (R) residing in the facility. The facility's infection surveillance line lists did not contain all pertinent information for identification, tracking, reporting, investigating, and mitigating infections.R59 was diagnosed with urinary tract infections (UTIs) in April and May 2026. R59 was not included in the facility's surveillance data for April.The facility did not ensure contact precautions were implemented and personal protective equipment (PPE) was provided for R4 who had a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) (a type of bacteria resistant to many antibiotics) with an open wound.R40 had an indwelling catheter and was not on enhanced barrier precautions (EBP). Findings include: The facility's Infection Prevention and Control Program, revised 3/2026, indicates: .The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee .The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigation of exposures of infectious diseases .A system of surveillance is used for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement . The facility's Transmission Based (Isolations) Precautions policy, revised 3/2026, indicates: .9. Initiation of Transmission-Based Precautions: .An order for TBP will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission .The order will specify the type of precaution and reason .Signage that includes instructions for use of specific pesonal protective equipment (PPE) will be placed in a conspicuous location outside the resident's room .either the Centers for Disease Control and Prevention (CDC) category of TBP (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage .The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on TBP .10. Contact Precautions: .Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment .Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens .Residents experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained .should be placed on contact precautions even before a specific organism has been identified .Contact precautions will be used for residents infected or colonized with multidrug-resistant organisms (MDROs) in the following situations: 1. When a resident has wounds, secretions, or excretions that are unable to be covered or contained . The facility's Enhanced Barrier Precautions policy, dated 4/2026, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs) .EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .An order for EBP will be obtained for residents with any of the following .indwelling medical devices (e.g., urinary catheters) even if the resident is not known to be infected or colonized with an MDRO. 3. Implementation of EBP: a. Make gowns and gloves available immediately near or outside the resident's room .b. Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities .4. High-contact resident care activities include: .Device care or use: .urinary catheters . 1. On 5/14/26, Surveyor reviewed infection control documentation provided by the facility for January through May 2026. The documetation did not contain surveillance information that mapped or tracked infections to identify trends or potentially mitigate infections. In addition, the surveillance data did not contain monthly analyses for follow-up activity. On 5/14/26 at 1:43 PM, Surveyor interviewed Regional Nurse Manager (RNM)-W who indicated the facility's policy indicates the facility should complete a map of infections for each month that indicates the trends and percentages of infections and should present the data at monthly Quality Assurance and Performance Improvement (QAPI) meetings. On 5/14/26 at 1:43 PM, Surveyor interviewed Infection Preventionist (IP)-H who indicated IP-H did not map infections except on an erasable board which did not currently contain any mapping. IP-H indicated IP-H attended one QAPI meeting (February 2026) and had provided one month of infection percentages during the meeting. IP-H indicated paper mapping of infections was not filled out in the facility's infection control binder and there was no monthly analyses of surveillance data or potential follow-up activity from January through May 2026. 2. On 5/11/26, Surveyor reviewed R59's medical record. R59 had diagnoses including dementia with behavioral disturbance, chronic kidney disease stage 4, and type 2 diabetes. R59 had urinary tract infections (UTIs) on 4/9/26 and 5/8/26. R59's Minimum Data Set (MDS) assessment, dated 5/8/26, stated R59 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. R59 had an activated Power of Attorney for Healthcare (POAHC). On 5/13/26, Surveyor reviewed the facility's infection control surveillance line lists and noted R59 was not on the April 2026 surveillance line list. On 5/14/26 at 11:49 AM, Surveyor interviewed IP-H who indicated R59 was diagnosed with a UTI in April and was also diagnosed and treated for conjunctivitis in April. IP-H verified R59 was not on the infection surveillance list and indicated R59 was missed. IP-H indicated R59 should be on the line list to ensure tracking and trending of infections is documented per the facility's policy and procedure. 3. Between 5/11/26 and 5/14/26, Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE] and had diagnoses including cellulitis of lower left limb, cellulitis of lower right limb, other streptococcus as the cause of diseases, proteus (mirabilis) (morganii) as the cause of diseases, bacterial infections of unspecified site, acute pyelonephritis, open wound of the great toe, and methicillin-resistant Staphylococcus aureus (MRSA) infection as the causes of diseases classified elsewhere. R4's MDS assessment, dated 4/8/26, stated R4 had a BIMS score of 12 out of 15, indicating moderately impaired cognition. R4's care plan indicated R4 was on contact isolation precautions related to a MRSA-colonization wound. R4's Medication Administration Record (MAR) indicated staff should use contact precautions for R4 related to MRSA and risk of infection. On 5/11/26 at 7:40 PM, Surveyor observed R4's room which contained a contact precautions sign near the door. The sign stated, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . Surveyor observed a storage unit affixed to R4's door that contained a box of gloves. Surveyor noted other storage areas on the unit were empty. Surveyor did not observe any gowns. Surveyor also did not observe a receptacle near the exit of R4's room to dispose of used PPE. On 5/11/26 at 7:40 PM, Surveyor observed Certified Nursing Assistant (CNA)-AA enter R4's room without doning a gown and close the door. At approximately 7:45 PM, Surveyor observed CNA-AA exit R4's room with 3 clear plastic bags of soiled clothing and an incontinence brief in CNA-AA's ungloved hand. Surveyor interviewed CNA-AA who indicated R4 asked to be put to bed so CNA-AA provided care and transferred R4 to bed. While speaking with CNA-AA in the hallway, Surveyor observed CNA-AA reenter R4's room without donning a gown or gloves or completing hand hygiene. CNA-AA indicated CNA-AA was making sure CNA-AA had removed all of the soiled clothing and garbage. CNA-AA did not know CNA-AA needed to wear a gown and gloves to enter R4's room or to provide care for R4. CNA-AA thought CNA-AA only had to wear PPE if CNA-AA provided wound care. On 5/11/26 at 7:48 PM, Surveyor observed CNA-BB enter R4's room without donning a gown or gloves. CNA-BB did not complete hand hygiene prior to entering or exiting the room. CNA-BB did not know CNA-BB needed to don a gown and gloves to enter R4's room. CNA-BB read the contact precautions sign near R4's door and verified CNA-BB should have worn PPE. CNA-BB indicated CNA-BB would not have been able to wear a gown because there weren't any available in the storage unit on R4's door. On 5/11/26 at 7:59 PM, Surveyor observed CNA-CC load gloves and gowns into the PPE storage unit on R4's door and enter R4's room with two PPE receptacles. One bin was labeled gowns and the other was labeled garbage. CNA-CC did not don a gown or gloves prior to entering the room and did not complete hand hygiene prior to entering or exiting the room. CNA-CC read the contact precautions sign near R4's room and verified CNA-CC should have worn a gown and gloves and completed hand hygiene prior to entering R4's room. On 5/11/26 at 8:02 PM, Surveyor observed CNA-DD knock and enter R4's room. CNA-DD did not don a gown or gloves or complete hand hygiene prior to entering or exiting the room. CNA-DD indicated CNA-DD did not have to wear PPE because CNA-DD did not provide care for R4. After reading the contact precautions sign, CNA-DD verified CNA-DD should have worn a gown and gloves to enter R4's room. On 5/13/26 at 12:40 PM, Surveyor interviewed Wound Care Registered Nurse (WCRN)-EE who indicated R4 was on contact precautions due to MRSA in the urine. WCRN-EE indicated staff should don a gown and gloves prior to entering R4's room. On 5/12/26 at 1:58 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident with MRSA should be on contact precautions. DON-B indicated staff should be aware of and follow TBP, including contact precautions when indicated. DON-B indicated DON-B provided additional training for staff to understand the difference between contact precautions and enhanced barrier precautions (EBP), including the need to complete hand hygiene and don and doff PPE, including scenario training to identify which situations require PPE. 4. Between 5/11/26 and 5/13/26, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including obstructive and reflux uropathy and infection, and inflammatory reaction due to indwelling urethral catheter. R40's MDS assessment, dated 4/30/26, stated R40 had a BIMS score of 13 out of 15, indicating intact cognition. R40 had an activated POAHC. R40's care plan, dated 4/29/26, indicated R40 had a catheter for urinary retention and obstructive and reflux uropathy and had failed voiding trials. R40 was prone to UTIs and was admitted to the facility with a catheter-associated UTI. The care plan did not indicate R40 was on EBP. On 5/11/26 at 6:38 PM, Surveyor interviewed R40 in R40's room. Surveyor did not observe an EBP sign on or near R40's door or a PPE cart nearby. On 5/11/26 at 6:46 PM, Surveyor interviewed Registered Nurse (RN)-X who verified the entrance to R40's room did not contain an EBP sign or PPE cart. RN-X indicated EBP is only implemented if a resident with a catheter has an MDRO. On 5/13/26 at 8:30 AM, Surveyor interviewed DON-B who verified an EBP sign and PPE cart should be outside R40's room. On 5/13/26 at 1:30 PM, Surveyor noted there was not an EBP sign or PPE cart outside R40's room. On 5/13/26 at 1:40 PM, Surveyor interviewed CNA-Y who described catheter care as donning gloves and cleansing the catheter tubing with an alcohol wipe before and after emptying. CNA-Y indicated CNA-Y did not wear a gown during the process. CNA-Y verified there was not an EBP sign or PPE cart outside R40's room.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. Two medication carts contained expired medication and syringes. One medication storage room contained expired medication and syringes. This practice had the potential to affect more than 4 of the 71 residents residing in the facility.The medication cart on 4 North contained 1 opened box of expired Mucinex DM, 1 opened bulk bottle of expired calcium with vitamin D, 9 expired Bisacodyl suppositories, and 8 expired syringes.The medication cart on 3A contained 1 opened bulk bottle of expired calcium with vitamin D and 12 expired syringes.The fourth floor medication storage room contained 1 expired bottle of Advil and 2 expired boxes of syringes.Findings include:The facility's Medication Storage policy, revised 12/2025, indicates: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.On 5/12/26 at 12:43 PM, Surveyor observed the 4 North medication cart with Mediation Technician (MT)-M who verified the following medications and medical supplies were expired:~ One opened box of Mucinex DM with an expiration date of 1/2026~ One opened bulk bottle of calcium 600 milligrams (mg) plus vitamin D 10 micrograms (mcg) with an expiration date of 4/2026~ Eight 1 milliliter (ml) 25 G syringes with expiration dates of 2/28/26~ Nine 10 mg Bisacodyl suppositories with expiration dates of 6/2025On 5/12/26 at 1:05 PM, Surveyor observed the third floor 3A medication cart with Licensed Practical Nurse (LPN)-S who verified the following medication and medical supplies were expired:~ One opened bulk bottle of calcium 600 mg plus vitamin D 10 mcg with an expiration date of 4/2026~ One 1 ml 25 G syringe with an expiration date of 2/28/26~ Eleven 3 ml 25 G 1-1/2 inch syringes with expiration dates of 2/28/26On 5/12/26 at 1:33 PM, Surveyor observed the fourth floor medication storage room with Director of Nursing (DON)-B who verified the following medication and medical supplies were expired:~ One unopened bottle of Advil (ibuprofen) 100 mg 24 chewable grape flavored tablets with an expiration date of 4/2026~ Two unopened boxes of 3 ml 25 G 1-1/2 inch syringes (100 in each box) with expiration dates of 2/28/26On 5/12/26 at 1:45 PM, Surveyor interviewed DON-B who indicated medication carts and storage rooms should not contain expired medications and medical supplies.

Based on staff interview and record review, the facility did not screen, educate, or offer the COVID-19 vaccination to 3 residents (R) (R10, R59, and R7) of 5 sampled residents.R10's COVID-19 vaccination form signed on 6/13/25 was incomplete. The form did not indicate whether R10 consented to or declined the vaccination. R10's medical record did not indicate whether or not a COVID-19 vaccine was provided.R59's medical record did not indicate R59 was offered or declined a COVID-19 vaccination since admission on [DATE].R7's medical record did not indicate R7 was offered or declined a COVID-19 vaccination since admission on [DATE].Findings include:The facility's Infection Prevention and Control Program, revised 3/2026, indicates: Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. The resident's medical record includes documentation that indicates, at a minimum, the following: i. The resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; and ii. Each dose of COVID-19 vaccine administered to the resident, or iii. If the resident did not receive the COVID-19 vaccine due to medication contraindications or refusal.1. On 5/14/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had a diagnosis of dementia. R10's Minimum Data Set (MDS) assessment, dated 2/7/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severely impaired cognition.Surveyor reviewed a signed COVID-19 form, dated 6/13/25, that didn't indicate whether R10 accepted or declined the vaccine. Acceptance or refusal of the vaccine was not documented in R10's medical record.On 5/14/26 at 10:12 AM, Surveyor interviewed Infection Preventionist (IP)-H who indicated there appeared to be an x by decline but could not be certain. IP-H reviewed R10's medical record and verified there were no progress notes or documentation to indicate R10 had accepted or declined the COVID-19 vaccine.On 5/14/26 at 10:18 AM, Surveyor interviewed Regional Nurse Manager (RNM)-W who indicated R10's COVID-19 form was signed on 6/13/25 but did not indicate whether R10 accepted or declined the vaccine. RNM-W reviewed R10's medical record and verified there was no documentation to indicate the vaccine was administered. RNM-W indicated if a resident signs consent for a vaccine, the resident should receive the vaccine.2. On 5/14/26, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had diagnoses of heart failure and diabetes. R59's MDS assessment, dated 5/8/26, stated R59 had a BIMS score of 5 out of 15, indicating severely impaired cognition.On 5/14/26, Surveyor reviewed R59's medical record which did not contain documentation to indicate R59 was screened, educated, or offered a COVID-19 vaccine.On 5/14/26 at 10:25 AM, Surveyor interviewed RNM-W who verified R59's medical record did not contain a signed consent or declination for the COVID-19 vaccine. RNM-W stated the facility's practice is to offer the COVID-19 vaccine.On 5/14/26 at 10:27 AM, Surveyor interviewed IP-H who indicated staff should offer the COVID-19 vaccine upon admission and annually.3. On 5/14/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of diabetes. R7's MDS assessment, dated 2/24/26, had a BIMS score of 5 out of 15, indicating severely impaired cognition.On 5/14/26, Surveyor reviewed R7's medical record which did not contain documentation to indicate R59 was screened, educated, or offered a COVID-19 vaccine.On 5/14/26 at 10:29 AM, Surveyor interviewed RNM-W who confirmed R7's medical record did not indicate R7 received a COVID-19 vaccine.On 5/14/26 at 10:30 AM, Surveyor interviewed IP-H who confirmed R7's medical record did not indicate an up-to-date COVID-19 vaccine was offered.

Based on staff interview and record review, the facility did not ensure influenza and pneumococcal vaccines were administered for 1 resident (R) (R10) of 5 sampled residents.R10 signed consent for influenza and pneumococcal vaccines on 2/24/26. R10 did not receive the vaccines.Findings include:The facility's Influenza Vaccination policy, revised 1/19/26, indicates: Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refused to receive the vaccine .Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record or the staff's medical file.The facility's Pneumococcal Vaccine policy, revised 1/2026, indicates: Each resident will be offered a pneumococcal immunization .A consent form shall be signed prior to administration of the vaccine and filed in the individual's medical record.On 5/14/26, Surveyor reviewed R10's medical record. R10 had a diagnosis of dementia. R10's Minimum Data Set (MDS) assessment, dated 2/7/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severely impaired cognition.R10's medical record contained an influenza and pneumococcal vaccine form, signed on 2/4/26, that indicated R10 consented to up-to-date influenza and pneumococcal vaccines. R10's vaccination record did not indicate R10 received the vaccines on or after 2/4/26. R10's immunization record indicated R10 was due for influenza and pneumococcal vaccines.On 5/14/26 at 10:12 AM, Infection Preventionist (IP)-H acknowledged the influenza and pneumococcal vaccination form signed on 2/4/26 indicated R10 consented to both vaccines. IP-H did [NAME] have documentation to indicate either vaccine was administered to R10.On 5/14/26 at 10:25 AM, Surveyor interviewed Regional Nurse Manager (RNM)-W who indicated since consent for influenza and pneumococcal vaccines was signed on 2/4/26, R10 should have received both vaccines.

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 2 residents (R) (R59 and R6) of 8 sampled residents.R59's medical record indicated R59 had urinary tract infections (UTIs) in April and May 2026 and was treated with antibiotic therapy. R59's UTIs were not included on the facility's infection surveillance line list, including criteria for antibiotic therapy. R6's medical record indicated R6 was started on antibiotic therapy for a UTI in May 2026 without completed criteria that indicated R6 had a UTI.Findings include: The facility's Infection Prevention and Control Program, revised 3/26, indicates: This facility maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection .The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigation of exposures of infectious diseases .An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program .Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. C. The infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program . The facility's Antibiotic Stewardship Program, revised 1/2026, indicates: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .The antibiotic stewardship program leaders uses existing resources to support antibiotic stewards' efforts by working the following partners: Infection Preventionist uses expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation, and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resident resistant organisms .4. The program includes antibiotic use protocols and a system to monitor antibiotic use .Antibiotic use shall be measured by monthly prevalence, antibiotic starts, and/or antibiotic days of therapy . 1. On 5/11/26, Surveyor reviewed R59's medical record. R59 had diagnoses including dementia with behavioral disturbance, chronic kidney disease stage 4, type 2 diabetes mellitus, and UTI (dated 4/9/26) with antibiotic treatment of Macrobid 100 milligrams (mg) twice daily, changed to Bactrim SS (sulfamethoxazole-trimethoprim 400/80 mg) 1 tablet by mouth twice daily for five days. R59 also had a UTI on 5/8/26 with antibiotic treatment of Macrobid 100 mg for seven days. R59's Minimum Data Set (MDS) assessment, dated 5/8/26, stated R59 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. R59 had an activated power of attorney (POA) for healthcare decisions. On 5/13/26, Surveyor reviewed the facility's infection control surveillance line lists. Surveyor noted R59's UTIs in April and May 2026 were not documented on the infection surveillance line lists, including documentation of the culture, the antibiotic prescribed, the length of the antibiotic, and infection criteria as to wheter R59 met the criteria for antibiotic therapy. On 5/14/26 at 11:49 AM, Surveyor interviewed Infection Preventionist (IP)-H who indicated R59 was diagnosed with a UTI in April and May 2026 and diagnosed and treated for conjunctivitis in April 2026. IP-H confirmed R59 received antibiotic therapy for a UTI in April and May 2026. IP-H indicated the facility follows the McGeer criteria for infections and documents the criteria is met through an assessment in the resident's medical record. IP-H verified R59's prescribed antibiotics for a UTI and conjunctivitis in April and a UTI in May were not on the infection surveillance line list. IP-H verified R59's antibiotics were not documented with the appropriate data for antibiotic stewardship and assessments were not completed for the UTIs and conjunctivitis infections in April and May. IP-H indicated the infections, criteria, and antibiotics were not documented or monitored in accordance with the facility's policies and procedures and were missed. 2. On 5/14/26, Surveyor reviewed R6's medical record. R6 had diagnoses including UTI and vascular dementia. R6's MDS assessment, dated 4/2/26, had a BIMS score of 8 out of 15, indicating moderately impaired cognition. Surveyor reviewed the facility's antibiotic stewardship documentation and noted R6 was started on antibiotic therapy for a UTI on 5/5/26. The antibiotic stewardship documentation to did not indicate R6 met the criteria for a UTI that should be treated with an antibiotic. On 5/14/26 at 1:19 PM, Surveyor interviewed IP-H who indicated documentation of criteria for a UTI should have been completed. IP-H indicated if R6 had not met the criteria for antibiotic treatment, the physician should have been updated to stop any unnecessary antibiotic therapy.

Based on observation, staff and resident interview, and record review, the facility did not ensure it served food at a safe and palatable temperature for 2 residents (R) (R72 and R37) of 2 sampled residents.On 5/12/26, R72 and R37 were served hot food that was below the recommended temperature of 135 degrees Fahrenheit (F) and cold food that was above the recommended temperature of 41 degrees F.Findings include: The facility's Record of Food Temperatures policy indicates: Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing disease .Food temperatures will be checked on all items prepared in the dietary department. 2. Hot foods will be held at 135 degrees Fahrenheit (F) or greater .4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees F .8. If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food. 9. Potentially hazardous food that is cooked and cooled must be reheated so all parts of the food reach an internal temperature of 165 degrees F for at least 15 seconds before holding for hot service .11. No food will be served that does not meet the Food Code standard temperatures.1. From 5/11/26 through 5/13/26, Surveyor reviewed R72's medical record. R72 was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture of the right humerus, diabetes, and chronic kidney disease. R72's Minimum Data Set (MDS) assessment, dated 4/6/26, stated R72 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.On 5/11/26 at 7:49 PM Surveyor interviewed R72 who indicated food was not cooked right, didn't taste the way it should, and was always cold. R72 indicated R72 usually just eats the cold food but it is not appetizing. R72 expressed displeasure and indicated R72 received food R72 did not want. R72 indicated R72 recently did not want what was on R72's meal tray and asked for a hot dog, however, the kitchen sent the same thing that was on R72's tray. A Certified Nursing Assistant (CNA) eventually got R72 a hot dog. On 5/12/26 at 12:47 PM, Surveyor observed Dietary Aide (DA)-L prepare room trays for the lunch meal. DA-L prepared R72's tray and obtained temperatures of the food. The pork fried rice was 130 degrees F, the egg roll was 134 degrees F, and the Jell-O was 43 degrees F. The food did not meet the Food Code standard temperatures for hot or cold food.2. From 5/11/26 through 5/13/26, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] with diagnoses that included fracture around internal prosthetic left knee joint, fracture of left femur, and anemia. R37's MDS assessment, dated 4/19/26, had a BIMS score of 14 out of 15, indicating intact cognition.On 5/11/26 at 8:44 PM, Surveyor interviewed R37 who stated food ran the gauntlet from being horrid to very good. R37 stated food was served in Styrofoam cups on 5/10/26 (Mother's Day), including soup, stale crackers, and iceberg lettuce. R37 indicated there was no protein and the meal was sparse. R37 stated R37 kept extra food in R37's room in case the food was not palatable.On 5/12/26 at 12:47 PM, Surveyor observed DA-L prepare room trays for the lunch meal. DA-L prepared R37's tray and obtained temperatures of the food. The pork fried rice was 125 degrees F, the egg roll was 128 degrees F, and the Jell-O was 48 degrees F. (Of note: R37's tray was the last to be prepared and the last to be placed in the food cart for delivery to residents on the East wing.) R37's food was not reheated or cooled to the proper temperature prior to being placed in the cart and did not meet the Food Code standard temperatures for hot or cold food.On 5/12/26 at 12:49 PM, Surveyor interviewed DA-L and asked what food holding temperatures should be and the procedure for if food is not at the proper temperature. DA-L indicated hot foods should be 135 degrees F and cold foods should be under 50 degrees F. If the food is not at the correct temperature, dietary staff should call the kitchen and notify the cook. Surveyor observed DA-L put R37's hot food (which was below 135 degrees F) and R37's cold food (which was above 41 degrees F) on the tray without contacting the cook.On 5/12/26 at 12:56 PM, Surveyor requested a sample tray from DA-L after R37's food was plated and placed in the cart. DA-L was only able to give Surveyor an eggroll since there was only enough food made to feed the residents. The eggroll looked and tasted good, but was lukewarm. On 5/12/26 at 1:01 PM, Surveyor interviewed R37 who indicated R37 did not yet receive a lunch tray.On 5/12/26 at 1:06 PM, Surveyor interviewed and observed CNA-N who indicated kitchen staff usually prepare food and put it in the delivery cart. CNA-N indicated CNA-N donned a gown and gloves to deliver R37's tray but removed the PPE since CNA-N did not have a mask. (Of note: R37 was on enhanced barrier precautions (EBP) for wounds and PPE was not required to deliver a tray.) CNA-N left R37's tray on the food cart and left the cart door open.On 5/12/26 at 1:15 PM, Surveyor observed CNA-O deliver R37's tray. The food cart door was left open while trays were being delivered.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R3 and R35) of 16 sampled residents. R3 had medication in R3's room. R3 did not have an order to self-administer medication or a self-administration of medication assessment that indicated R3 could safely and accurately self-administer medication. In addition, R3 did not have a care plan for self-administration of medication or to store medication at the bedside. R35 had medication in R35's room. R35 did not have an order to self-administer medication or a self-administration of medication assessment that indicated R35 could safely and accurately self-administer medication. In addition, R35 did not have a care plan for self-administration of medication or to store medication at the bedside. Findings include: The facility's undated Resident Self-Administration of Medication policy indicates: .A resident may only self-administer medication after the facility's Interdisciplinary Team (IDT) has determined which medications may be self-administered safely .When determining if self-administration is clinically appropriate for a resident, the IDT should consider the following: The resident's physical capacity to swallow without difficulty, open medication bottles, administer injections; The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; The resident's capability to follow directions and tell time to know when medications need to be taken; The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and side effects .The resident's ability to ensure medication is stored safely and securely .The results of the assessment are recorded on the Medication Self Administration Assessment Form .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other residents .All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party The care plan must reflect resident self-administration and storage arrangements for such medications .1. On 5/11/26 at 7:52 PM, Surveyor interviewed R3 and observed medication in R3's room. R3 indicated R3 used the medications. R3 indicated several of the bottles were stoma powder and the other medications were for R3's wounds. Surveyor observed the following medications (not including 6 bottles of stoma powder and two bottles of barrier spray) on a table in R3's room: ~ A container of lidocaine 2% zinc oxide 12% (primarily used to treat discomfort of hemorrhoids, anal fissures, and minor skin irritations) with a pharmacy label that contained R3's name ~ A bottle of Puracyn Plus Spray (a hypochlorous acid solution for cleansing, irrigating and debriding wounds) without a pharmacy label On 5/11/26, Surveyor reviewed R3's medical record which indicated R3 was admitted to the facility on [DATE]. R3 had diagnoses including rectal cancer, liver cancer, peritoneal cancer, and anxiety. R3's Minimum Data Set (MDS) assessment, dated 3/7/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R3's Medication Administration Record (MAR) did not contain orders for bedside medication, self-administration of medication, or for the lidocaine and Puracyn medications. R3's medical record did not contain a self-administration of medication assessment. R3's care plan did not include bedside medication or self-administration of medication. On 5/12/26 at 12:47 PM, Surveyor observed the lidocaine and Puracyn in R3's room. On 5/14/26 at 9:13 AM, Surveyor observed the lidocaine and Puracyn in R3's room. On 5/14/26 at 9:20 AM, Surveyor interviewed Registered Nurse (RN)-Z who indicated residents should not have medications in their rooms. RN-Z indicated if medication is found in a resident's room, staff should remove the medication and check if the resident has orders. If not, staff should call the physician and obtain an order. On 5/14/26, Surveyor requested R3's self-administration of medication assessment. On 5/14/26 at 8:50 AM, Nursing Home Administrator (NHA)-A indicated a self-administration of medication assessment for R3 had not been done. NHA-A indicated there should be a physician's order for all medications and an order for all bedside medications. NHA-A indicated a self-administration of medication assessment should completed for all residents who have bedside medications. NHA-A indicated bedside medication and self-administration of medication should be a part of a resident's care plan if applicable. 2. On 5/11/26 at 7:16 PM, Surveyor interviewed R35 and observed medications in R35's room. Surveyor noted the following medications on a table at the end of R35's bed in view from the door into the hallway: ~ An unopened earwax removal kit ~ An unopened container of simethicone 250 milligrams (mg) (for gas relief)~ An unopened container of Soothe XP eye drops On 5/11/26 at 8:07 PM, Surveyor interviewed R35 who indicated R35 needed the medications. R35 indicated R35 asked family to bring the medications a while ago because R35 was embarrassed about having gas during cares and want to prevented it if possible. R35 indicated R35 needs the eye drops for cataracts and R35 sometimes gets earwax build up that staff won't clean. On 5/11/26, Surveyor reviewed R35's medical record which indicated R35 was admitted to the facility on [DATE]. R35 had diagnoses including congestive heart failure, chronic kidney disease, type 2 diabetes, and peripheral vascular disease. R35's MDS assessment, dated 3/31/26, stated R35 had a BIMS score of 13 out of 15, indicating intact cognition. R35's MAR did not contain physician orders for the earwax removal kit or Soothe XP eye drops. R35 had an order for simethicone oral tablet 80 mg, give one tablet by mouth as needed (PRN) for gastroesophageal reflux disease (GERD) (start date 1/2/26). Surveyor noted the order contained a different strength than the 250 mg tablets observed in R35's room. R35 did not have orders for bedside medications or self-administration of medication. R35's medical record did not contain a self-administration of medication assessment. R35's care plan did not include bedside medications or self-administration of medication. On 5/12/26 at 12:42 PM, Surveyor observed the simethicone tablets, earwax removal kit, and Soothe XP eye drops in R35's room. The medications were visible from the hallway. On 5/13/26 at 8:28 AM, Surveyor observed the simethicone tablets, earwax removal kit, and Soothe XP eye drops in R35's room. The medications were visible from the hallway. On 5/14/26 at 9:10 AM, Surveyor observed the simethicone tablets, earwax removal kit, and Soothe XP eye drops in R35's room. The medications were visible from the hallway. On 5/14/26 at 9:20 AM, Surveyor interviewed RN-Z who indicated residents should not have medications in their rooms. RN-Z indicated if medications are found in a resident's room, staff should remove the medication and check if the resident has orders. If not, staff should call the physician to obtain an order. On 5/14/26, Surveyor requested R35's self-administration of medication assessment. On 5/14/26 at 8:50 AM, NHA-A indicated a self-administration of medication assessment for R35 had not been done. NHA-A indicated there should be a physician's order for all medications and an order for all bedside medications. NHA-A indicated a self-administration of medication assessment should be completed for all residents who have bedside medications. NHA-A indicated bedside medications and self-administration of medication should be a part of a resident's care plan if applicable.

Based on observation, staff interview, and record review, the facility did not ensure adequate nursing oversight for the administration of as needed (PRN) narcotic medication for 1 resident (R) (R5) of 1 sampled resident.Medication Technician (MT)-M administered PRN hydromorphone HCL (a narcotic pain medication) to R5 and completed pre-and post-pain assessments without a licensed nurse.Findings include:The facility's Medication Technician job description, signed by MT-M on 5/8/23, indicates: The Medication Technician (MT) plays an essential role in supporting safe, accurate, and timely medication administration for residents under the supervision of licensed nursing staff and in accordance with state regulations, facility policies, and scope of practice.From 5/12/26 to 5/14/26, Surveyor reviewed R5's medical record. R5 had a diagnosis of heart failure. R5's Minimum Data Set (MDS) assessment, dated 4/16/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition.R5's medical record contained an order, dated 5/5/26, for hydromorphone HCL oral tablet 2 milligrams (mg), may give 1-2 tablets every 1 hour PRN for mild to moderate pain.On 5/12/26 at 12:28 PM, Surveyor observed MT-M speak with R5 who indicated R5's left lower extremity pain was a 9 on a scale of 1 to 10 (with 10 being the worst pain.) MT-M reviewed R5's Medication Administration Record (MAR) and indicated MT-M would give R5 two 2 mg tablets of hydromorphone HCL. MT-M informed Surveyor the medication was ordered 1-2 tablets every hour as needed for pain. MT-M removed 2 tablets of hydromorphone HCL from a locked narcotic box in the medication cart and wrote the time, date, name of the medication, and amount of remaining tablets in the facility's narcotic monitoring book. MT-M administered the medication to R5.R5's medical record indicated MT-M reassessed R5's pain on 5/12/26 at 1:52 PM which was documented as 0 out of 10.On 5/13/26 at 10:15 AM, Surveyor interviewed MT-M who indicated if a resident can inform MT-M the resident is in pain, MT-M can administer PRN medication, including narcotics. MT-M indicated if it is less obvious what the resident needs, MT-M consults with the nurse. MT-M indicated MT-M asked an unnamed nursing manager to let Hospice know R5 was complaining of left lower extremity pain after administering hydromorphone HCL on 5/12/26.On 5/13/26 at 10:25 AM, Surveyor interviewed Registered Nurse (RN)-P who indicated MT-M can administer PRN narcotic medication without consulting a nurse. RN-P indicated RN-P glances at MARs for residents who receive medication from MT-M and stated MT-M is good about letting nurses know about any concerns.On 5/13/26 at 2:59 PM, Surveyor interviewed Director of Nursing (DON)-B who was not certain of the facility's policy but indicated a Medication Technician should have a nurse talk to a resident before administering hydromorphone so the nurse can complete an assessment. DON-B also indicated a Medication Technician should inform a nurse prior to administering PRN narcotic medication.

Based on observation, staff interview, and record review, the facility did not provide appropriate cather care and services for 1 resident (R) (R40) of 2 sampled residents. R40 had an indwelling catheter and was prone to urinary tract infections (UTIs). R40's catheter bag was in contact with the floor on multiple occasions.Findings include:The Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee - Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (2009) indicates: .III. Proper Techniques for Urinary Catheter Maintenance .B. Maintain unobstructed urine flow .2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.Between 5/11/26 and 5/13/26, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including obstructive and reflux uropathy and infection, and inflammatory reaction due to indwelling urethral catheter. R40's Minimum Data Set (MDS) assessment, dated 4/30/26, stated R40 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R40 had an activated Power of Attorney for Healthcare (POAHC) who assisted with healthcare decisions.R40's care plan, dated 4/29/26, indicated R40 had a catheter for urinary retention and obstructive and reflux uropathy and had failed voiding trials. R40 was prone to urinary tract infections (UTIs) and was admitted to the facility with a catheter-associated UTI.On 5/11/26 at 6:38 PM, Surveyor interviewed R40 in R40's room. R40's catheter bag was hung underneath R40's wheelchair and in contact with the floor. On 5/11/26 at 6:46 PM, Surveyor interviewed Registered Nurse (RN)-X who verified R40's catheter bag was on the floor. RN-X donned gloves and readjusted the catheter bag so it was not touching the floor.On 5/13/26 at 8:30 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R40's catheter bag should not be on the floor.On 5/13/26 at 1:30 PM, Surveyor noted R40's catheter bag was hung underneath R40's wheelchair and in contact with the floor.On 5/13/26 at 1:40 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-Y who verified R40's catheter bag should not be on the floor and should be hung higher on the wheelchair.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R10, R51, and R42) of 4 sampled residents.R10 was known to smoke. A smoking assessment, dated 11/25/25, indicated R10 required assistance with smoking. The facility did not reassess R10 for smoking. R51 was known to smoke. A smoking assessment, dated 9/10/25, indicated R51 did not smoke. The facility did not reassess R51 for smoking. R42 was known to smoke. The facility did not complete a smoking assessment for R42. Findings include: The facility's Resident Smoking policy, dated 12/2025, indicates: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .5. All residents will be asked about tobacco use during the admission process, and during each Quarterly or Comprehensive Minimum Data Set (MDS) assessment process. 6. Residents who smoke will be further assessed, using the resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all . On 5/12/26, Surveyor reviewed a list of residents who smoke provided by Nursing Home Administrator (NHA)-A. R10 and R51 were on the list. 1. On 5/12/26, Surveyor reviewed R10's medical record. R10 had diagnoses including cerebral ischemia, metabolic encephalopathy, anoxic brain damage, and dementia with other behavioral disturbance. R10's MDS assessment, dated 2/7/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. R10 had an activated decision maker. R10's care plan, dated 7/4/25, indicated R10 smokes and R10's sister assists R10 who does not ask staff to smoke. The care plan indicated R10 requires monitoring and support for safe tobacco use. The care plan contained an intervention to monitor for safe smoking practices and supervise smoking per policy. R10's medical record contained a smoking assessment, dated 11/25/25, that indicated R10 required assistance with smoking and R10's smoking materials should be stored at the nurses' station. On 5/13/26 at 3:08 PM, Surveyor interviewed NHA-A who indicated the smoking assessment completed on 11/25/25 was the last smoking assessment completed for R10. NHA-A indicated assessments should have been completed in February and May of 2026. 2. On 5/13/26, Surveyor reviewed R51's medical record. R51 had diagnoses including alcoholic cirrhosis of liver, pyogenic arthritis, and chronic obstructive pulmonary disease (COPD). R51's MDS assessment, dated 3/19/26, stated R51 had a BIMS score of 15 out of 15, indicating intact cognition. R51 had an activated decision maker. R51's care plan, dated 10/31/25, indicated R51 will adhere to the facility's tobacco/smoking policies (initiated 5/24/24) and contained an intervention to conduct a smoking safety evaluation on admission and as needed (initiated 5/24/24). R51's medical record indicated (on 9/10/25) that R51 was not a smoker. On 5/13/26 at 3:08 PM, Surveyor interviewed NHA-A who indicated R51 smokes and NHA-A would obtain R51's most recent smoking assessment. NHA-A indicated R51 should have had a smoking assessment completed after the 9/10/25 assessment that indicated R51 was not a smoker. Surveyor also requested an updated list of residents who smoke. On 5/13/26, Surveyor reviewed a smoking assessment for R51, dated 5/13/26, that indicated R51 does not smoke. Surveyor again reviewed R51's care plan which indicated was a smoker. On 5/14/26 at 10:25 AM, NHA-A provided Surveyor with an updated list of residents who smoke. NHA-A confirmed R51 smokes and requires assistance with smoking. NHA-A verified residents on the list, including R51, do not have up-to-date smoking assessments. 3. Between 5/11/26 and 5/13/26, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including diabetes and dementia. R42's MDS assessment, dated 4/21/26, stated R42 had a BIMS score of 15 out of 15, indicating intact cognition. The MDS assessment indicated R42 did not use tobacco. R42 had a Guardian who assisted with healthcare decisions. R42's care plan, dated 4/18/26, indicated R42 requires supervision while smoking and the charge nurse should be notified immediately if R42 violates the facility's smoking policy. R42's medical record did not contain a smoking assessment. On 5/12/26 at 9:54 AM, Surveyor interviewed Guardian (GRD)-T via phone. GRD-T indicated R42 smokes and has had no accidents, including dropping ashes or sustaining burns. GRD-T stated R42's smoking supplies are kept by staff. On 5/12/26 at 11:52 AM, Surveyor interviewed R42 who indicated R42 smokes independently and keeps R42's smoking supplies. On 5/12/26 at 11:54 AM, Surveyor interviewed Registered Nurse (RN)-P who verified R42 had R42's smoking supplies but is supposed to store the supplies at the nurses' station and request them when R42 wants to smoke. RN-P indicated RN-P was not aware of any smoking accidents/hazards for R42. On 5/12/26 at 12:53 PM, Surveyor observed R42 smoking on the patio in a safe manner. R42 obtained and returned smoking supplies to the nurse. On 5/13/26 at 3:07 PM, Surveyor interviewed NHA-A who verified the facility did not have a smoking assessment for R42.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure the comprehensive plan of care was reviewed and revised for 1 resident (R) (R59) of 22 sampled residents.R59's care plan was not revised to reflect the level of assistance R59 required to complete activities of daily living (ADLs). In addition, the care plan did not contain updated interventions to assist R59 with completing ADLs.Findings include:The facility's Comprehensive Care Plans policy, revised 12/2025, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS) assessment .Other factors identified by the Interdisciplinary Team (IDT), or in accordance with the resident's preferences, will also be addressed in the plan of care .The comprehensive care plan will be reviewed and revised by the IDT after each Comprehensive and Quarterly MDS assessment.The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be use to monitor the residents progress . On 5/11/26, Surveyor reviewed R59's medical record. R59 had a diagnosis of dementia with other behavioral disturbance. R59's Minimum Data Set (MDS) assessment, dated 5/8/26, stated R59 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairmemt. R59 had an activated Power of Attorney for Healthcare (POAHC).On 5/11/26 at 6:33 PM, Surveyor interviewed R59's POAHC (POAHC-R) who expressed concern that staff do not assist R59 with toileting. POAHC-R stated POAHC-R came in daily to assist with changing R59's brief. POAHC-R stated R59 had a recent decline, was enrolled in Hospice services, and required assistance with hygiene after toileting. POAHC-R indicated R59 does not realize R59 requires assistance and staff do not assist R59. POAHC-R indicated R59 has behavioral concerns and refuses to allow staff to assist at times. POAHC-R stated despite R59's refusal of cares, staff are required to assist R59. POAHC-R also had skin and urinary tract infection concerns because R59 was not assisted with brief changes. On 5/12/26, Surveyor reviewed R59's care plan which indicated R59 had a history of refusing cares, including showers (initiated 11/4/25). The care plan contained a goal that R59 will not have any adverse effects from refusals of showers (revised 11/12/25). The care plan contained the following interventions: Encourage R59 to allow staff to assist with changing R59's brief. If R59 refuses, reapproach multiple times and make supervisor aware of the refusals (initiated 5/11/26); Encourage R59 to allow cares to be completed. Staff should attempt multiple times throughout the shift if R59 refuses cares, including showers (initiated 11/4/25). The care plan indicated R59 can toilet self with stand-by assistance from staff (initiated 11/21/25).A progress note, dated 5/8/26, indicated R59 refused to let anyone help and repeatedly stated, Get out of here and leave me alone. Staff called POAHC-R to assist, notified the physician, and obtained a urinalysis. (Of note: R59's medical record did not contain any other notes that indicated R59 refused assistance with cares.) On 5/13/26 at 8:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-U who indicated R59 is independent with most things, requires stand-by assistance with toileting, and refuses showers at times. CNA-U indicated staff ask R59 multiple times, however, R59 still refuses and does not receive cares some days. CNA-U stated asking R59 multiple times is the only intervention CNA-U knows to assist with helping R59 when R59 refuses cares. CNA-U indicated staff do not check on R59 or ask if R59 requires assistance in the bathroom because R59 is a stand-by assist only and staff do not assist with toileting, wiping, or changing R59's brief. CNA-U was unsure if R59 required more assistance since CNA-U last worked with R59. On 5/13/26 at 12:42 PM, Surveyor interviewed POAHC-R who met with the facility and discussed concerns that R59's care plan is not updated and does not reflect the level of assistance R59 requires. POAHC-R believes staff are not aware of the level of assistance R59 requires for brief changes and toileting and indicated R59 requires more than stand-by assistance for toileting. POAHC-R stated R59's care plan should be more individualized and contain relevant and current interventions for R59's level of need. On 5/14/26 at 9:25 AM, Surveyor interviewed Regional Consultant (RC)-C and Director of Nursing (DON)-B. DON-B indicated R59 can be resistant to staff assisting with cares but allows POAHC-R to assist. DON-B confirmed POAHC-R frequently completes cares for R59. DON-B indicated R59 inconsistently changes R59's brief after incontinence episodes and stated staff offer assistance multiple times during the day however R59 declines. DON-B indicated R59 also declines assistance from POAHC-R at times. DON-B confirmed no other interventions have been attempted to assist R59 with accepting care from staff or to increase assistance with hygiene after toileting. DON-B indicated the facility will try to use different staff members or look at other interventions to assist R59 and confirmed R59's care plan should be updated.

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 staff (Registered Nurse (RN)-I) of 8 staff reviewed for caregiver background checks. The facility did not ensure a Certificate of Release or Discharge from Active Duty (DD214) was received from RN-I prior to RN-I's employment on 8/5/24.Findings include:The facility's undated Abuse, Neglect and Exploitation policy indicates: Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials check shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.The Wisconsin Department of Health Services (DHS) Wisconsin Background Check and Misconduct Investigation Program Manual, dated 10/2025, indicates new employees or contractors can temporarily work for up to 60 days pending official Department of Justice (DOJ) results, provided they meet strict conditions: .The employer must provide active supervision during the entire 60-day period, which includes periodic direct observation of the caregiver.On 5/13/26 at approximately 3:00PM, Surveyor reviewed background check information for 8 employees, including RN-I.RN-I was hired on 8/5/24. RN-I's Background Information Disclosure (BID) form indicated RN-I was discharged from the United States (US) Armed Forces in 2024 which was within the last 3 years of hire. The BID form indicated to attach a copy of a DD214 form if discharged within the last 3 years. The BID form was signed and dated by RN-I on 8/20/24 but did not contain a DD214 form.On 5/13/26 at 3:43 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not have a DD214 form for RN-I but requested RN-I obtain the form on 5/13/26 and provide it to the facility.

Based on observation and staff interview, the facility did not ensure nurse staffing was posted daily. This practice had the potential to affect all 71 residents residing in the facility.The facility did not post nurse staffing on 5/12/26 or 5/14/26.Findings include:Division of Quality Assurance (DQA) memo 12-020 Clarification Concerning Posting Requirements for Nurse Staffing indicates: .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift .The information that is posted must include the following: .3. The total number of staff directly responsible for resident care per shift for each of the following categories: licensed (Registered Nurses (RNs), Licensed Practical Nurses (LPNs)), and unlicensed (Certified Nursing Assistants (CNAs)). (For example, 1 RN, 2 LPNs, 4.5 CNAs.) The number of RNs must be separate from the number of LPNs. 4. The actual hours worked per shift for each of the following categories: licensed (RNs, LPNs), and unlicensed (CNAs). 5. Resident census .Information is to be posted daily and must be present at the start of each shift. Nursing homes can choose to post staffing information for the entire day or for the current shift .Upon entrance to the facility on 5/12/26 and throughout the day, Surveyor did not observe a nurse staffing posting.On 5/13/26 during an environmental tour of the third floor at 10:19 AM, the fourth floor at 10:22 AM, and the ground floor at 12:47 PM, Surveyor did not observe a nurse staffing posting.On 5/13/26 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified nurse staffing was not posted. NHA-A indicated nurse staffing should be posted and visible to staff, residents, and visitors.On 5/13/26 at approximately 1:30 PM, Surveyor observed a nurse staffing posting on the ground floor.On 5/14/26 during an environmental tour of the third floor at 10:45 AM, the fourth floor at 10:48 AM, and the ground floor at 10:51 AM, Surveyor did not observe a nurse staffing posting.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R10) of 10 sampled residents.On 2/15/26, Certified Nursing Assistant (CNA)-J observed R1 crying and R6's hand in R1's shirt touching R1's breast. The facility did not implement preventative safety measures to ensure the safety of R1. In addition, the facility did not complete thorough behavior monitoring and behavior tracking for R6. On 2/11/26, CNA-N observed R10 in R9's room touching R9's private area inside R9's upper thigh. The facility did not complete thorough behavior monitoring and behavior tracking for R10 and did not develop a care plan to address the fact that R10 appeared to target and fixate on R9.The facility's failure to prevent cognitively impaired residents from being sexually abused by residents with a history of inappropriate sexual behavior led to a finding of immediate jeopardy that began on 2/11/26. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 4/1/26 at 3:55 PM. The immediate jeopardy was removed on 4/14/26. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 1/5/24, indicates: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse .Prevention of Abuse, Neglect and Exploitation: .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict .Investigation of Alleged Abuse, Neglect and Exploitation: .B. Written procedures for investigations include: .6. Providing complete and thorough documentation of the investigation. 1. From 3/30/26 to 4/1/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, depression, anxiety, and encephalopathy. R6's Minimum Data Set (MDS) assessment, dated 12/11/25, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R6 had severely impaired cognition. The MDS assessment also indicated R6 had verbal behavior toward others (threatening others, screaming at others, cursing at others) on 1 to 3 days during the observation period and physical behavior toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) on 1 to 3 days during the observation period. R6 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. According to an interview with CNA-J on 3/31/26 at 10:31 AM, R6 had inappropriately grabbed CNA-J in the past.R6's behavior care plan, initiated 9/9/24, indicated R6 had a history of inappropriately grabbing staff during cares. The care plan included an intervention, initiated 2/25/25, for cares in pairs due to sexually inappropriate behavior toward staff. No safety interventions were added to the care plan following the incident on 2/15/26.From 3/30/26 to 4/1/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, anxiety, and depression. R1's MDS assessment, dated 12/10/25, indicated R1 was rarely to never understood with short-term and long-term memory issues and severely impaired cognition. The MDS assessment indicated R1 wandered on 1 to 3 days during the observation period. R1 had an activated POAHC to assist with healthcare decisions.R1's behavior care plan, initiated 3/16/25, indicated R1 had a history of hallucinations, agitation with staff during cares, wandering the unit and into other rooms, taking others' belongings, striking out, refusing cares, crawling out of bed, and crying unprovoked. The care plan included the following interventions:~ Encourage R1 to remain outside of arm's length of other residents (dated 9/14/25).~ Provide a calm and safe environment to allow R1 to express feelings as needed (dated 3/16/25).~ Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed (dated 3/16/25). R1's plan of care was not updated with preventative safety measures following the 2/15/26 incident and did not include a care plan for past trauma.On 3/31/26, Surveyor reviewed the facility's investigation, dated 2/15/26, which included a written and signed statement (dated 2/15/26) from CNA-J that indicated on 2/15/26 at approximately 6:20 PM, R1 was crying and R6 grabbed R1's hand to comfort R1. Two minutes later, CNA-J observed R6's hand in R1's shirt and grabbing R1's right breast. R1 and R6 were separated. When CNA-J asked what R6 was doing, R6 indicated R6 was trying to comfort R1. R6 made sexual comments about CNA-J when CNA-J took R6 back to R6's room. CNA-J stated R1 was still in tears but calmed down a little when given a stuffed animal.On 3/31/26 at 10:31 AM, Surveyor interviewed CNA-J who indicated CNA-J was in the dining room after supper on 2/15/26 and observed R1 crying. R6 appeared to be comforting R1. CNA-J turned back around after removing meal trays and observed R6's hand in R1's shirt. When CNA-J intervened, CNA-J had to remove R6's hand from R1's right breast. CNA-J brought R6 back to R6's room and assisted R6 to bed. CNA-J stated the incident was reported to nursing staff. CNA-J was aware R1 and R6 were placed on 1:1 supervision. CNA-J was unsure if other preventative safety measures were implemented as a result of the incident. CNA-J confirmed CNA-J was positive about what CNA-J observed because CNA-J had to physically remove R6's hand from R1's right breast. On 3/31/26 at 9:29 AM, Surveyor interviewed R1's activated POAHC (POAHC-K) who stated POAHC-K was contacted by a nurse in mid-February who stated staff observed a resident with a hand in R1's shirt near R1's breast. The nurse stated the residents were separated and the facility would report the incident to the State Agency. POAHC-K stated R1 has had increased behaviors with unconsolable crying and wandering since the incident. POAHC-K stated R1 became more emotional at times when R1 had a urinary tract infection (UTI). POAHC-K stated R1 had a history of sexual assault from when R1 was a young adult. POAHC-K indicated R1 could have been retraumatized by the incident on 2/15/26 which could be a contributing factor to R1's increased behaviors.On 3/30/26 at 12:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-S who indicated POAHC-K mentioned that R1 had past trauma but did not provide specifics and LPN-S did not inquire further. LPN-S verified R1 wanders in and out of other residents' rooms and staff intervene and redirect R1. On 3/30/26 at 12:55 PM, Surveyor interviewed Unit Manager (UM)-T who stated staff have to watch R6 due to R6's sexually inappropriate behavior toward staff. UM-T was aware of an incident in which R6 had a hand in R1's shirt and indicated it was why R6 was placed on 1:1 supervision. UM-T was not involved in the investigation or follow-up. UM-T stated UM-T spoke with POAHC-K who stated R1 had a history of being sexually molested which could explain R1's frequent crying after the incident with R6. UM-T was unsure when POAHC-K provided the information and stated Social Services Designee (SSD)-G might know. UM-T confirmed R1 wanders the halls and goes into other residents' rooms on occasion. UM-T stated R1 is tearful almost every day. On 3/30/26 at 1:04 PM, Surveyor interviewed SSD-G who indicated R1 becomes tearful at times, has a history of being argumentative with other residents, and goes in and out of other residents' rooms. SSD-G verified R6 had inappropriate sexual behavior toward staff. SSD-G was unaware of inappropriate sexual behavior toward other residents aside from the 2/15/26 incident with R1. SSD-G denied awareness of past trauma for R1. R6's behavior tracking (monitoring for yelling/screaming at staff, refusal of care, grabbing at staff) indicated documentation was to be completed every shift. Documentation indicated the following:~ January 2026: R6 had 3 documented occurrences of sexually inappropriate behavior and 6 documented occurrences of grabbing. Of the 93 total entries for behavior tracking, 25 entries (approximately 27%) were missing or incomplete.~ February 2026: R6 had no documented occurrences of sexually inappropriate behavior or grabbing. Of the 84 total entries for behavior tracking, 71 entries (approximately 85%) were missing or incomplete. ~ March 2026: R6 had 1 documented occurrence of sexually inappropriate behavior and 2 documented occurrences of grabbing. Of the 90 total entries for behavior tracking, 67 entries (approximately 74%) were missing or incomplete. Progress notes in R6's medical record, dated 2/15/26, 2/17/26, and 2/18/26, indicated R6 was on 1:1 supervision. R6's medical record did not include 1:1 documentation for 2/16/26 or documentation indicating when 1:1 supervision was discontinued. On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, Director of Nursing (DON)-B, Regional Nurse Consultant (RNC)-F, and RNC-L. NHA-A stated staff notify NHA-A or DON-B when incidents occur. NHA-A and DON-B are responsible for completing the investigation with the assistance of regional nurses. When asked what safety measures were implemented to protect residents, RNC-L stated within 48 hours of the incident, RNC-L assessed R6 who was completely dependent on staff for care and mobility; therefore, R6 was removed from 1:1 supervision. RNC-L stated the facility rearranged seating in the dining room and encouraged male residents to sit with other males and female residents to sit with other females. RNC-F stated R1 gets tearful when R1 has a UTI and was prescribed a course of antibiotics. When asked about documentation for 1:1 supervision, RNC-L stated the facility's schedule specifies which staff are to provide 1:1 supervision. RNC-L acknowledged the schedule does not indicate which resident the 1:1 staff is for. When Surveyor asked about behavior monitoring/tracking and pointed out the missing entries for R6, an explanation was not provided.From 3/30/26 to 4/1/26, Surveyor made several inquiries regarding care plan updates. The facility could not provide evidence that preventative safety measures were implemented and added to R6 and R1's care plans following the 2/15/26 incident. The facility's 2/15/26 investigation did not include preventative safety measures for R1's frequent tearfulness, wandering, or intrusive behaviors. The investigation also did not include safety measures to protect other residents from R6's sexually inappropriate behavior.2. From 3/30/26 to 4/1/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with behavioral disturbance, bipolar disorder, anxiety disorder, depression, and history of traumatic brain injury. R10's MDS assessment, dated 3/18/26, had a BIMS score of 4 out of 15 which indicated R10's cognition was severely impaired. R10 had an activated POAHC to assist with healthcare decisions. A behavioral psych note, dated 1/24/26, indicated R10 had a history of hypersexual behaviors.R10's care plan did not include a history of inappropriate sexual behavior prior to the incident below on 2/11/26. A progress note in R10's medical record, dated 2/11/26, stated a CNA reported that R10 entered another resident's room (R9) and appeared to touch R9's pubic area and thigh over R9's clothing. R10 was removed from the room and placed in the common area for 1:1 monitoring. Labs were ordered and R10 was started on paroxetine (an antidepressant medication) 20 milligrams (mg) daily for hypersexual behavior.From 3/30/26 to 4/1/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including dementia, depression, anxiety, and Wernicke's encephalopathy (a life-threatening acute neurological emergency caused by severe thiamine deficiency that includes confusion, eye abnormalities, and an unsteady/uncoordinated gait.) R9's MDS assessment, dated 2/7/26, had a BIMS score of 3 out of 15 which indicated R9's cognition was severely impaired. R9 had an activated POAHC to assist with healthcare decisions. R9 passed away on 3/26/26. On 4/1/26 at 11:26 AM, Surveyor interviewed CNA-N who indicated CNA-N retrieved a lift outside R9's room on 2/11/26 and observed R10 in the room. CNA-N stated R9 was in a wheelchair facing the TV and R10 was in a wheelchair facing R9 on R9's right side. CNA-N stated CNA-N observed R10 touch R9's private area inside the thigh. CNA-N removed R10 from the room and reported the incident to the nurse. CNA-N stated R10 was placed on 1:1 supervision and moved to a different unit. CNA-N stated R10 had a history of sexually touching R10's self in front of others and being verbally and physically inappropriate with female staff. CNA-A did not observe the behavior with any other residents. CNA-N stated R10 had a history of targeting R9 and CNA-N redirected R10 away from R9 in the past. (Of note: R10's care plan did not include R10's history of targeting R9.)On 4/1/26 at 12:06 PM, Surveyor interviewed LPN-O who was aware R10 was sexually inappropriate with staff and was aware of an incident between R10 and R9. LPN-O denied witnessing R10 be inappropriate with other residents but stated R10 hyper fixated on R9 and gravitated toward and tried to enter R9's room. LPN-O stated R10 often had to be redirected away from R9. LPN-O stated since R9 passed away, R10 had not focused on any other residents. LPN-O confirmed R10 remained on 1:1 supervision because R10 continued to be sexually inappropriate with female staff. On 4/1/26 at 12:17 PM, Surveyor interviewed CNA-P who often worked with R10 and confirmed R10 was sexually inappropriate toward female staff. CNA-P stated R10 was particularly drawn to R9 and often tried to go in R9's room. Staff redirected R10. CNA-P was not aware of R10 being sexually inappropriate with any other residents. On 4/1/26, Surveyor reviewed the facility's investigation which included the following: ~ A written statement from CNA-Q stated on 2/11/26 at approximately 9:45 AM, CNA-Q was walking down the hall and observed R10 trying to enter R9's room. CNA-Q redirected R10 to the dining room.~ A written statement from CNA-R stated on 2/11/26, CNA-R observed R10 exit R9's room. CNA-Q did not observe any inappropriate behavior. The investigation contained 8 additional staff interviews in which 5 staff members indicated they saw R10 go into other residents' rooms. R10 had an order for valproic acid (a mood stabilizer) 10 milliliters (ml) twice daily for hypersexual behaviors. R10's behavior tracking (monitor for sexual inappropriate verbal or physical touch and increased wandering) every shift indicated the following:~ January 2026: R10 had 4 documented occurrences of wandering and no documented occurrences of inappropriate sexual behavior. Of the 93 total entries for behavior tracking, 37 entries (approximately 40%) were missing or incomplete.~ February 2026: R10 had no documented occurrences of wandering and 2 documented occurrences of inappropriate sexual behavior. Of the 84 total entries for behavior tracking, 66 entries (approximately 79%) were missing or incomplete.~ March 2026: R10 had 4 documented occurrences of wandering and 7 documented occurrences of inappropriate sexual behavior. Of the 90 total entries for behavior tracking, 69 entries (approximately 77%) were missing or incomplete.On 3/31/26 at 2:40 PM, Surveyor interviewed DON-B and RNC-F. DON-B provided staff education on 1:1 companion care following the 2/11/26 incident. DON-B stated R10 remained on 1:1 supervision and was seen by behavioral health. RNC-F stated RNC-F interviewed CNA-N who originally reported that CNA-N observed R10 touch R9 inappropriately. RNC-F stated CNA-N recanted the statement and indicated CNA-N did not know for sure what CNA-N saw. Surveyor reported to RNC-F that CNA-N confirmed with Surveyor that CNA-N saw R10 touch R9 inappropriately. Although R9 had not expressed signs of trauma from being inappropriately touched, using the reasonable person concept it is likely that a reasonable person who is in a vulnerable position would feel extreme fear, anxiety, and distress when violated sexually and when safety needs are not met.The failure to supervise a resident with a history of wandering, targeting other residents, and being verbally and physically sexually inappropriate, created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The immediate jeopardy was removed on 4/14/26, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: 1. Implemented 1:1 supervision (companion care) for R1, R6, and R10.2. Provided staff education on notification and reporting allegations of abuse, recognizing and managing behaviors, and companion care, including how to redirect/intervene for the safety of residents and those around them.3. Reviewed/revised behavior monitoring for R1, R6, and R10, including changes in condition, companion care, and monthly behavior meetings to address needs.4. Reviewed/revised care plans for R1, R6, and R10 and scheduled care conferences to further address needs.5. Implemented audits to be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.

Based on staff interview and record review, the facility did not have a qualified Social Worker. This practice has the potential to affect all 75 residents residing in the facility. Social Services Designee (SSD)-G did not meet the necessaray requirements for a qualified Social Worker in a facility licensed for 131 beds. Findings include: On 4/1/26 at 1:25 PM, Surveyor interviewed SSD-G who started working at the facility in June of 2025 and confirmed SSD-G was the facility's Social Services Designee. SSD-G verified SSD-G was not certified or licensed as a Social Worker and did not have a degree in a related field. SSD-G stated SSD-G had previous experience working in another facility where a Social Worker worked with SSD-G. On 4/1/26 at 1:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility has 131 licensed beds. NHA-A confirmed SSD-G is not a licensed or certified Social Worker. NHA-A was aware a facility with more than 120 beds requires a full-time qualified Social Worker.

Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 6 residents (R) (R6, R1, R10, R9, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not report the allegation of abuse to the SA. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not report the allegation of abuse to the SA. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 stated R1 hit R7 and showed staff R1's reddened left palm. The facility did not report the allegation of abuse to the SA.On 12/23/25, staff observed R8 punch R1 in the arm after R1 grabbed R8's walker. The facility did not report the allegation of abuse to the SA. On 3/6/26, R1 struck and threw a glass of orange juice at R9. The facility did not report the allegation of abuse to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 1/5/24, indicates: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse. 2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse to the State Agency (SA) and other officials in accordance with state law.VII. Reporting/Response.1. Reporting of all alleged violations to the Administrator, SA, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Between 3/30/26 and 4/1/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, depression, anxiety, and encephalopathy. R6's Minimum Data Set (MDS) assessment, dated 12/11/25, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R6 had severely impaired cognition. R6 had an activated Power of Attorney for Healthcare (POAHC). Between 3/30/26 and 4/1/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, anxiety, and depression. R1's MDS assessment, dated 12/10/25, indicated R1 was rarely to never understood with short-term and long-term memory issues and severely impaired cognition. R1 had an activated POAHC.On 3/31/26, Surveyor reviewed an investigation that included a written and signed statement, dated 2/15/26, from CNA-J that indicated on 2/15/26 at approximately 6:20 PM, R1 was crying and R6 grabbed R1's hand to comfort R1. Approximately two minutes later, CNA-J observed R6's hand in R1's shirt and grabbing R1's right breast. R6 and R1 were separated. When CNA-J asked what R6 was doing, R6 stated R6 was trying to comfort R1. R6 made sexual comments about CNA-J when CNA-J took R6 back to R6's room. CNA-J indicated R1 was in tears but calmed down a bit when given a stuffed animal. On 3/31/26 at 10:31 AM, Surveyor interviewed CNA-J who confirmed the events from the written statement and stated CNA-J was positive about what CNA-J observed because CNA-J had to physically remove R6's hand from R1's right breast.On 3/31/26 at 12:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse Consultant (RNC)-F, RNC-L, and [NAME] President of Clinical Operations (VPCO)-V. After RNC-F indicated the facility did not report the incident because CNA-J recanted CNA-J's original statement, Surveyor informed the group that CNA-J confirmed the incident with Surveyor. NHA-A stated staff notify either NHA-A or DON-B when an incident occurs. NHA-A and the regional nurses review the incident and determine whether or not to report it to the SA. NHA-A and DON-B are responsible for reporting incidents of abuse. NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V confirmed the allegation of sexual abuse that occurred on 2/15/26 was not reported to the SA. 2. Between 3/30/26 and 4/1/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with behavioral disturbance, bipolar disorder, anxiety disorder, depression, and history of traumatic brain injury. R10's MDS assessment, dated 3/18/26, had a BIMS score of 4 out of 15 which indicated R10 had severely impaired cognition. R10 had an activated POAHC. Between 3/30/26 and 4/1/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including dementia, depression, anxiety, and Wernicke's encephalopathy (an acute neurologicl emergency caused by a severe deficiency of thiamine leading to brain damage in the thalamus and brainstem; symptoms includes confusion and loss of coordination). R9's MDS assessment, dated 2/7/26, had a BIMS score of 3 out of 15 which indicated R9's cognition was severely impaired. R9 had an activated POAHC and passed away on 3/26/26. A progress note in R10's medical record, dated 2/11/26, indicated a CNA reported that R10 entered (R9's) room and appeared to touch (R9's) pubic area and thigh over the clothing. R10 was moved to the common area for 1:1 monitoring. On 4/1/26 at 11:26 AM, Surveyor interviewed CNA-N who indicated CNA-N retrieved a lift outside R9's room on 2/11/26 and observed R10 in R9's room. R9 was in a wheelchair facing the TV. R10 was in a wheelchair facing R9 on R9's right side. CNA-N stated CNA-N observed R10 touch R9's private area inside the thigh. CNA-N removed R10 from the room and reported the incident to the nurse. CNA-N stated CNA-N was 100% sure that CNA-N saw R10 touch R9 inappropriately. On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. When RNC-F indicated the facility did not report the incident to the SA because CNA-N recanted CNA-N's original statement, Surveyor informed the group that CNA-N confirmed the event with Surveyor. NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V confirmed the incident on 2/11/26 was not reported to the SA. 3. Between 3/30/26 and 4/1/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of dementia. R7's MDS assessment, dated 11/3/25, had a BIMS score of 6 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated POAHC. An incident report, dated 9/14/25, stated R1 and R7 had a verbal dispute and were separated. R1 stated R1 hit R7 and showed staff R1's reddened left palm. The report indicated R1's red palm could be due to R1 self-propelling a wheelchair. The report indicated R1 had increased agitation and started rambling. R7 could not provide an account of the incident.On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. NHA-A stated NHA-A was not employed by the facility on 9/14/25 and was not familiar with the incident. DON-B, RNC-F, RNC-L, and VPCO-V confirmed the incident on 9/14/25 was not reported to the SA.4. Between 3/30/26 and 4/1/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had a diagnosis of dementia with behavioral disturbance. R8's MDS assessment, dated 2/4/26, had a BIMS score of 5 out of 15 which indicated R8 had severely impaired cognition. R8 had an activated POAHC. A progres note in R1's medical record, dated 12/23/25, indicated R1 aggressively grabbed (R8's) walker and (R8) punched R1 in the arm. An incident report, dated 12/23/25, indicated R1 was self-propelling a wheelchair in the hallway and came upon R8 using a wheeled walker. When R1 grabbed R8's walker, R8 made a punching motion toward R1. The report indicated neither R1 or R8 were interviewable due to dementia. On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. NHA-A stated NHA-A was not employed by the facility on 12/23/25 and was not familiar with the incident. DON-B, RNC-F, RNC-L, and VPCO-V confirmed the incident on 12/23/25 was not reported to the SA. 5. An incident note, dated 3/6/26, indicated R1 was attempting to get on the elevator when (R9) invaded R1's personal space. R1 threw a glass of orange juice in (R9's) direction. R9 could not recall the incident. A progress note in R1's medical record, dated 3/6/26, indicated R1 attempted to enter the elevator independently. During the incident, R1 struck (R9) and threw orange juice at (R9). R1 also attempted to hit staff. R1 cried excessively and appeared emotionally distressed. Staff intervened and redirected R1. A follow-up note to the 3/6/26 progress note, dated 3/10/26, indicated R1 appeared to strike (R9) during the interaction but no contact was made. On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V confirmed the incident on 3/6/26 was not reported to the SA.

Based on staff interview and and record review, the facility did not ensure allegations of abuse were thoroughly and accurately investigated for 6 residents (R) (R6, R1, R9, R10, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 told staff R1 hit R7 and showed staff R1's reddened palm. The facility did not ensure the allegation of abuse was thoroughly investigated or ensure safety interventions to prevent recurrence were appropriate. On 12/23/25, staff observed R8 punch R1 in the arm after R1 grabbed R8's walker. The facility did not ensure the allegation of abuse was thoroughly investigated or ensure safety interventions to prevent recurrence were appropriate. On 3/6/26, R1 attempted to enter the elevator, threw a glass of juice at R9, and appeared to strike R9. The facility did notensure the allegation of abuse was thoroughly investigated or ensure ongoing behavior monitoring was completed. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 1/5/24, indicates: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when allegations or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation .3. Identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; and 6. Providing complete and thorough documentation of the investigation. 1. Between 3/30/26 and 4/1/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, depression, anxiety, and encephalopathy. R6's Minimum Data Set (MDS) assessment, dated 12/11/25, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R6 had severely impaired cognition. R6 had an activated Power of Attorney for Healthcare (POAHC). Between 3/30/26 and 4/1/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, anxiety, and depression. R1's MDS assessment, dated 12/10/25, indicated R1 was rarely to never understood and had short-term and long-term memory issues with severely impaired cognition. R1 had an activated POAHC. On 3/31/26, Surveyor reviewed an investigation that included a written and signed statement, dated 2/15/26, from CNA-J. The statement indicated CNA-J was in the dining room on 2/15/26 at approximately 6:20 PM and observed R1 crying. R6 grabbed R1's hand to comfort R1. Two minutes later, CNA-J observed R6's hand in R1's and shirt grabbing R1's right breast. R1 and R6 were separated. When CNA-J asked what R6 was doing, R6 indicated R6 was trying to comfort R1. R6 made sexual comments about CNA-J when CNA-J took R6 to R6's room. CNA-J indicated R1 was in tears but calmed down a bit when given a stuffed animal. On 3/31/26 at 10:31 AM, Surveyor interviewed CNA-J who confirmed the incident in CNA-J's written statement and stated CNA-J was positive about what CNA-J observed because CNA-J had to physically remove R6's hand from R1's right breast. An incident report for R1, dated 2/15/26, indicated R1 was tearful in the common area which was usual behavior for R1 since R1 tended get emotional while looking for dad. R1 had a history of chronic urinary tract infections (UTIs). R1's family indicated R1 gets more tearful when R1 has a UTI. The incident report indicated a peer (R6) held R1's hand to comfort R1. A few minutes later, (CNA-J) told the nurse it appeared (R6's) hand made contact with R1's upper right extremity. An incident report for R6, dated 2/15/26, indicated staff saw R6 sitting by (R1) attempting to console (R1). R6 tapped (R1) on the arm to stop (R1) from crying. On 3/31/26 at 12:26 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-F who completed the incident reports for R1 and R6. RNC-F stated RNC-F was not originally notified of the incident but assisted with the investigation. When asked why the incident reports did not match CNA-J's witness statement, RNC-F stated CNA-J recanted the original statement and told RNC-F that CNA-J did not actually see any contact. When Surveyor stated CNA-J told Surveyor that CNA-J was certain of the contact because CNA-J had to remove R6's hand from R1's breast, RNC-F did not provide a definitive response regarding why the incident reports did not match the witness statement. R6's behavior care plan, initiated 9/9/24, indicated R6 had history of inappropriately grabbing staff during cares. The care plan included an intervention, initiated 2/25/25, for cares in pairs due to sexually inappropriate behavior toward staff. R6's care plan did not include updated safety interventions following the 2/15/26 incident. R1's behavior care plan, initiated 3/16/25, indicated R1 had a history of hallucinations, agitation with staff during cares, wandering the unit and into other rooms, taking others' belongings, striking out, refusing cares, and crawling out of bed. The care plan also indicated R1 had a history of crying unprovoked. R1's care plan was not updated to include preventative safety measures following the 2/15/26 incident. R6's behavior symptoms charting (monitoring for yelling/screaming at staff, refusal of care, grabbing at staff), indicated the following: ~ February 2026: R6 had no documented occurrences of sexually inappropriate behavior and no documented occurrences of grabbing. Of the 84 total entries for behavior tracking, 71 entries (approximately 85%) were missing or incomplete. ~ March 2026: R6 had 1 documented occurrence of sexually inappropriate behavior and 2 documented occurrences of grabbing. Of the 90 total entries for behavior tracking, 67 entries (approximately 74%) were missing or incomplete. Progress notes in R6's medical record, dated 2/15/26, 2/17/26, and 2/18/26, indicated R6 was on 1:1 supervision. R6's medical record did not include 1:1 documentation for 2/16/26 or documentation indicating when 1:1 supervision was discontined. R1's behavior symptoms charting indicated the following: ~ February 2026: R1 had 4 documented occurrences of frequent crying and no documented occurrences of wandering. Of the 84 total entries for behavior tracking, 62 entries (approximately 74%) were missing or incomplete. ~ March 2026: R1 had 4 documented occurrences of frequent crying and no documented occurrences of wandering. Of the 93 total entries for behavior tracking, 77 entries (approximately 83%) were missing or incomplete. A note included in the incident report for R6, dated 2/18/26 and completed by RNC-L, indicated R6 had poor dexterity, needed assistance to feed self, and had difficulty holding onto items. The note indicated staff were unsure if R6 truly touched (R1). On 3/31/26 at 12:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, RNC-F, RNC-L, and [NAME] President of Clinical Operation (VPCO)-V. NHA-A stated staff notify either NHA-A or DON-B when incidents occur. NHA-A and DON-B are responsible for completing the investigation with assistance from the regional nurses. When Surveyor asked what safety measures were implemented to protect residents following the incident on 2/15/26, RNC-L stated within 48 hours of the incident, RNC-L assessed R6 who was completely dependent on staff for care and mobility. R6 was removed from 1:1 supervision. RNC-L stated the facility also rearranged seating in the dining room. Male residents were encouraged to sit with male residents and female residents were encouraged to sit with female residents. RNC-F indicated R1 gets tearful when R1 has a UTI and stated R1 started a course of antibiotics. When Surveyor asked for documentation that 1:1 supervision was provided, RNC-L stated the facility's schedule specifies staff who are assigned 1:1 supervision for residents. RNC-L acknowledged the schedule doesn't specify which resident the 1:1 supervision is for. An explanation was not provided regarding the missing behavior monitoring and tracking entries. On 4/1/26 at 12:20 PM, Surveyor observed lunch in the dining room and observed R6 raise R6's hand to R6's face on 3 occasions. R6 did not appear to have difficulty with arm motion. Between 3/30/26 and 4/1/26, Surveyor asked about care plan updates several times. The facility did not provide evidence that preventative safety measures were implemented and added to R6 and R1's care plans following the 2/15/26 incident. 2. Between 3/30/26 and 4/1/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with behavioral disturbance, bipolar disorder, anxiety disorder, depression, and history of traumatic brain injury. R10's MDS assessment, dated 3/18/26, had a BIMS score of 4 out of 15 which indicated R10's cognition was severely impaired. R10 had an activated POAHC. Between 3/30/26 and 4/1/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including dementia, depression, anxiety, and Wernicke's encephalopathy (an acute neurological emergency caused by a severe deficiency of thiamine leading to brain damage in the thalamus and brainstem; symptoms include confusion and loss of coordination.) R9's MDS assessment, dated 2/7/26, had a BIMS score of 3 out of 15 which indicated R9's cognition was severely impaired. R9 had an activated POAHC and passed away on 3/26/26. A progress note in R10's medical record, dated 2/11/26, indicated a CNA reported that R10 entered (R9's) room and appeared to touch (R9's) pubic area and thigh over R9's clothing. R10 was moved to the common area for 1:1 monitoring. On 4/1/26 at 11:26 AM, Surveyor interviewed CNA-N who stated CNA-N observed R10 in R9's room when CNA-N retrieved a lift from outside R9's room on 2/11/26. CNA-N stated R9 was in a wheelchair facing the TV. R10 was in a wheelchair facing R9 on R9's right side. CNA-N stated CNA-N observed R10 touch R9's private area inside the thigh. CNA-N removed R10 from the room and reported the incident to the nurse. CNA-N stated CNA-N was 100% sure CNA-N saw R10 touch R9 inappropriately. An incident report for R10, dated 2/11/26, indicated a CNA reported to the nurse that R10 entered (R9's) room. R10 was taken to the nurses' station and placed on companion care. An incident report for R9, dated 2/11/26, indicated a CNA reported to the nurse that (R10) was found in R9's room. (R10) was immediately removed from the room. R10's medical record indicated R10 should be monitored for sexually inappropriate verbal or physical touch and increased wandering every shift. R10's behavior tracking indicated the following: ~ February 2026: R1 had no documented occurrences of wandering and 2 documented occurrences of inappropriate sexual behavior. Of the 84 total entries for behavior tracking, 66 entries (approximately 79%) were missing or incomplete. ~ March 2026: R1 had 4 documented occurrences of wandering and 7 documented occurrences of inappropriate sexual behavior. Of the 93 total entries for behavior tracking, 72 entries (approximately 77%) were missing or incomplete. On 3/31/26 at 2:40 PM, Surveyor interviewed DON-B and RNC-F. DON-B provided documentation of staff education on 1:1 companion care following the 2/11/26 incident. DON-B stated R10 remains on 1:1 supervision and is seen by behavioral health. DON-B stated supporting evidence of 1:1 supervision is reflected on the nursing schedules which indicate which staff are assigned to companion care. Surveyor noted the facility's schedules indicated several staff were assigned to companion care. When asked how the facility determines which staff are assigned to which residents, DON-B did not respond. RNC-F stated RNC-F interviewed CNA-N who originally reported that CNA-N witnessed R10 touch R9 inappropriately. RNC-F stated CNA-N recanted the statement and indicated CNA-N did not know for sure what CNA-N saw. Surveyor informed RNC-F that CNA-N confirmed with Surveyor that CNA-N saw R10 touch R9 inappropriately. 3. Between 3/30/26 and 4/1/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of dementia. R7's MDS assessment, dated 11/3/25, had a BIMS score of 6 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated POAHC. An incident report for R7, dated 9/14/25, indicated R7 had a verbal dispute with (R1). R7 and (R1) were separated. Nursing assessments were completed with no injuries noted. R7 could not provide an account of the incident. An incident report for R1, dated 9/14/25, indicated R1 had a verbal dispute with (R7). Staff separated R1 and (R7) and stated R1 hit R7. R1 showed staff R1's left palm which was red. The report indicated R1's red palm could be due to self-propelling in a wheelchair. The report indicated R1 had increased agitation and started rambling. The facility's investigation indicated a safety intervention was added to encourage R1 to remain out of arms reach of other residents. (Of note: R1's medical record indicated R1 had severely impaired cognition with short- and long-term memory loss.) On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. NHA-A stated NHA-A was not employed by the facility on 9/14/25 and was not familiar with the incident. When Surveyor asked about preventative safety interventions, the information was not provided. When Surveyor asked about the appropriateness of a reminder for a resident with advanced dementia, NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V did not provide a direct answer. 4. Between 3/30/26 and 4/1/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had a diagnosis of dementia with behavioral disturbance. R8's MDS assessment, dated 2/4/26, had a BIMS score of 5 out of 15 which indicated R8 had severely impaired cognition. R8 had an activated POAHC. A progress note in R1's medical record, dated 12/23/25, indicated R1 aggressively grabbed (R8's) walker and (R8) punched R1 in the arm. An incident report for R1, dated 12/23/25, indicated R1 was self-propelling a wheelchair in the hallway and came upon (R8) who had poor safety awareness and dementia. (R8) was walking with a wheeled walker and invaded R1's personal space. (R8) made a punching gesture toward R1 when R1 grabbed (R8's) walker. R1 then swung at (R8's) hand. R1 could not provide a description of the incident. The root cause of the incident was determined to be behavioral symptoms related to dementia combined with insufficient supervision in a shared common area. The report contained the following corrective actions: ~ Increase supervision in hallways, especially during high traffic times.~ Assess R1 for behavioral triggers and update R1's care plan.~ Provide structured activities or engagement to reduce wandering/approaching behaviors.~ Educate staff on early intervention when residents approach others.~ Consider seating placement adjustments to reduce resident interactions that may lead to conflict.~ Implement individualized behavior management strategies.~ Conduct staff in-services on dementia-related behaviors and de-escalation.~ Evaluate the environment for safety, resident flow, and spacing. R1's care plan did not include updated safety interventions following the incident on 12/23/25. An incident report for R8, dated 12/23/25, indicated R8 was walking down the hallway with a wheeled walker. (R1) approached R8 and grabbed R8's walker. R8 made a pushing motion toward (R1's) hand. R8 was not intervieweable due to dementia and did not recall the incident. R8 was reminded to be aware of and honor personal space. Between 3/30/26 and 4/1/26, Surveyor requested the facility's full investigation for the incident on 12/23/25. Surveyor noted the investigation did not include staff or witness statements, staff education, updated care plans, or behavior management strategies. On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V. NHA-A stated NHA-A was not employed by the facility on 12/23/25 and was not familiar with the incident. Surveyor asked about preventative safety interventions; however, the information was not provided. When Surveyor asked about the appropriateness of education and reminders for residents with advanced dementia, NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V did not provide a direct answer. 5. An incident note for R1, dated 3/6/26, indicated R1 was attempting to get on the elevator when (R9) invaded R1's personal space. R1 threw a glass of orange juice in (R9's) direction. R1 could not give an account of the incident. R1 was placed on 1:1 supervision. A progress note in R1's medical record, dated 3/6/26, indicated R1 attempted to enter the elevator independently. During the incident, R1 struck (R9) and threw orange juice at (R9). R1 also attempted to hit staff. R1 cried excessively and appeared emotionally distressed. Staff intervened and redirected R1. A follow-up note to the 3/6/26 progress note, dated 3/10/26, indicated R1 appeared to strike (R9) during the interaction but no contact was made. Between 3/30/26 and 4/1/26, Surveyor requested the facility's full investigation for the 3/6/26 incident. Surveyor noted the investigation did not include staff or witness statements. Surveyor reviewed R1's behavior tracking for March 2026 which indicated R1 had the following behaviors after 3/25/26: ~ Episodes of frequent crying on 3/26/26 and 3/29/26~ Episodes of frequent crying, yelling/screaming, and wandering on 3/31/26 On 3/31/26 at 12:50 PM, Surveyor interviewed NHA-A, DON-B, RNC-F, RNC-L, and VPCO-V who indicated R1 was placed on 1:1 supervision and tested for a UTI following the incident. 1:1 supervision was discontinued on 3/25/26 after R1 completed a course of antibiotics and behaviors related to the UTI resolved.

Based on observation, staff, resident, and resident representative interview, and record review, the facility did not provide the necessary care and services to promote healing and/or prevent wounds from worsening for 3 residents (R) (R1, R2, and R4) of 3 sampled residents reviewed for non-pressure related wounds.R1 had a left total knee arthroplasty (a surgical procedure that replaces the damaged surfaces of the knee joint with artificial parts made of metal and plastic) in 2016. On 10/31/24, R1 reported pain, redness, and swelling in the left knee and lower leg. On 10/31/24, Wound Care Physician (WCP)-F recommended a magnetic resonance image (MRI) scan and an orthopedic consult. An MRI was ordered on 11/7/24 and scheduled for 12/5/24. The MRI was canceled due to insurance concerns. The MRI was rescheduled for 12/28/24 and canceled again due to insurance concerns. The facility did not provide further assistance to obtain an MRI or schedule an orthopedic consult. R1 received multiple courses of oral antibiotics between November 2024 and January 2025 without resolution of symptoms. On 1/27/25, R1 was transferred to the emergency room (ER) for on-going knee pain and had suspected loosening of the left knee hardware. A discharge summary indicated R1 needed an MRI and follow-up appointment with orthopedics. The facility did not ensure either were scheduled or completed. On 2/3/25, R1 was ordered another course of oral antibiotics which were not administered. On 2/6/25, R1 was transferred to the hospital due to warmth, increased redness, and swelling in the left leg and diagnosed with a septic joint. R1 underwent a total knee revision, a joint wash-out to clean out infection/fluid, and placement of an antibiotic spacer in the knee joint. R1 returned to the facility on 2/20/25 with a wound vac on the left knee, a peripherally inserted central catheter (PICC) line, and a six-week course of intravenous (IV) antibiotics. R1 discharged home on 3/31/25 and has experienced on-going pain and loss of function due to the left knee infection. The facility's failure to implement physician recommendations and treat R1's ongoing pain and symptoms of infection in the left knee created a finding of immediate jeopardy that began on 1/27/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 11/6/25 at 2:40 PM. The immediate jeopardy was removed on 11/6/25; however, the deficient practice continues at a scope/severity level G (actual harm/isolated) as evidenced by the following examples:On 10/7/25, R2's right lower extremity (RLE) surgical wound re-opened. A treatment order was not implemented and the wound worsened. R2 saw an in-house wound doctor on 10/23/25. The wound was debrided (a procedure to remove dead, damaged, or infected tissue to promote healing) and doxycycline (an antibiotic) was ordered. (This example is being cited at a level G). On 11/4/25, R4's bilateral lower extremity (BLE) wounds were treated with lidocaine and gentian violet. R4's coccyx wound was treated with Iodosorb. R4 did not have physician orders for the treatments.Findings include: The facility's Skin Management Guideline policy, dated 11/28/17, indicates: Purpose: To ensure residents who are admitted to the facility are evaluated to determine appropriate measures to be taken by the Interdisciplinary Team (IDT) to determine appropriate treatment modalities for wounds according to industry standards of care. 1.On 11/4/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including history of falls, bilateral knee total arthroplasty, anxiety, and depression. R1's most recent Minimum Data Set (MDS) assessment, dated 3/31/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 had an activated Power of Attorney for Healthcare (POAHC) and discharged home from the facility on 3/31/25. A comprehensive care plan, revised 12/2/24, indicated R1 had a cellulitis infection of the left knee with a goal of remaining free from complications related to infection. The care plan contained an intervention to administer antibiotics per physician orders. A wound note, dated 10/31/24, indicated R1 had continued knee pain, warmth, and inflammation. Medical Doctor (MD)-H recommended an MRI of the left knee and an orthopedic consult. A nursing note, dated 10/31/24, indicated Wound Care Physician (WCP)-F assessed R1's left knee. The wound had improved; however, the knee was pink and warm to the touch. WCP-F expressed concern for the hardware in the knee and recommended labs and an MRI. A nursing note, date 11/2/24, indicated R1's left knee was erythematous (abnormally red and inflamed), warm, swollen, and painful (which were symptoms of a potential infection). R1 was upset and requested additional imaging. A Nurse Practitioner (NP) visit note, written by NP-I and dated 11/4/24, did not address R1's knee pain, redness, or swelling. A physician visit note, written by MD-G and dated 11/5/24, indicated R1 continued to have severe left lower extremity pain that limited R1's functionality. R1 expressed a desire to improve R1's function. A wound note, dated 11/7/24, indicated R1 wanted an MRI at R1's orthopedic office. Recommendations included an MRI of the left knee and an orthopedic consult. MD-H ordered an MRI that was scheduled for 12/5/24. A nursing note, dated 11/13/24, indicated R1 complained of left knee pain and had swelling. A physician visit note, written by MD-G and dated 11/13/24, indicated WCP-F told R1 that R1 needed more imaging of the left lower extremity (LLE) due to ongoing pain and swelling. A wound note, dated 11/14/24, indicated R1 had a pending MRI of the left knee. Recommendations included an MRI of the left knee and an orthopedic consult. A physician visit note, written by MD-H and dated 11/15/24, indicated R1 reported left knee pain and was disappointed/frustrated. An MRI was pending. A wound note, dated 11/21/24, indicated R1's wound was resolved. Recommendations included an MRI of the left knee and an orthopedic consult. A physician visit note, written by MD-G and dated 11/26/24, indicated R1 had soft tissue swelling in the left knee and reported posterior (back) and anterior (front) pain with gentle range of motion (ROM). The redness had increased and there was possible warmth and bogginess. An NP visit note, written by NP-I and dated 11/29/24, indicated R1 had a new complaint of worsening left knee pain with increased warmth and redness. An MRI was scheduled for 12/5/24. NP-I ordered doxycycline (an antibiotic) 100 milligrams (mg) twice daily for 10 days. A nursing note, dated 11/30/24, indicated R1 was prescribed doxycycline for cellulitis. R1's left knee was slightly swollen. A nursing note, dated 12/1/24, indicated R1's knee was warm to the touch, red, and slightly swollen. A nursing note, dated 12/5/24, indicated R1's MRI was canceled because insurance did not provide authorization. A nursing note, dated 12/8/24, indicated R1 was monitored for antibiotic use and complained of knee pain. An NP visit note, written by NP-I and dated 12/12/24, indicated R1 was angry due to continued knee pain. There were no new orders. A physician visit note, written by MD-G and dated 12/13/24, indicated R1 reported ongoing severe left knee pain despite wound healing. R1's MRI was canceled due to an insurance issue because the wound was fully healed. A physician visit note, written by MD-H and dated 12/18/24, indicated R1 reported knee pain and was followed by wound care who recommended an MRI. Given R1's ongoing pain, it was reasonable to request additional imaging. An MRI was ordered and pending scheduling. A social services note, dated 12/19/24, indicated R1 wanted an MRI of the left knee and felt R1 may need surgery. R1 agreed to a physical therapy referral. A physician visit note, written by MD-G and dated 12/23/24, indicated R1 reported worsening left knee pain including pain with light touch and stated the knee swelled and reddened with frequent use. R1 hoped an MRI would be completed on 12/28/24. R1 required assistance to get out of bed the night before and oxycodone (a narcotic pain medication) was not effective. A nursing note, dated 12/24/24, indicated R1 reported pain and had a linear, red blanchable area from the left knee to mid-shin that was warm to the touch. An MRI was scheduled. A social services note, dated 12/26/24, indicated R1 was worried about the knee and hoped an MRI could be done in the hospital (on 12/28/24). A nursing note, dated 12/26/24, indicated R1's left knee was painful, red, and warm to the touch. The knee and shin were pink and slightly swollen. R1 had increased discomfort during therapy. R1 agreed to go to the ER for evaluation. An ER visit note, dated 12/26/24, indicated R1 had ongoing pain and redness in the left knee and started cephalexin (an antibiotic) 500 mg three times daily for cellulitis. R1 had an outpatient orthopedic referral due to potential loosening of the left knee hardware and chronic knee pain for the last 4 to 5 months. A nursing note, dated 12/27/24, indicated ER staff stated R1 didn't need an MRI. The MRI was canceled per R1's request. A nursing note, dated 1/3/25, indicated R1's last dose of cephalexin was administered; however, R1's lower leg was still pink, edematous, and warm to the touch. Cephalexin was reordered at 500 mg three times daily for 7 days. A physical therapy note, dated 1/6/25, indicated R1 was referred secondary to left knee pain which limited R1's safety and independent performance of mobility tasks. R1 required increased caregiver assistance for bed mobility, transfers, and ambulation. A nursing note, dated 1/23/25, indicated R1 complained of bilateral knee pain and had mild edema and slight left knee discoloration. A nursing note, dated 1/24/25, indicated a photo of R1's left knee was sent to MD-J who indicated R1 should go the ER for imaging for a possible infection. R1 was upset and stated if R1 didn't need imaging at the hospital before R1 didn't need it that night. A nursing note, dated 1/26/25, indicated R1 refused to go to the ER and had a pink tone down the left shin. A nursing note, dated 1/27/25 at 7:54 AM, indicated R1's left knee and shin were visibly swollen and red. R1 was not on antibiotics and refused to go the ER or anywhere for evaluation other than R1's orthopedic surgeon. A nursing note at 3:36 PM, indicated R1 agreed to go to the ER. An infection note, dated 1/27/25, indicated R1 completed a course of antibiotics with little effectiveness and was transferred to the ER for evaluation due to ongoing knee concerns. An ER visit note, dated 1/27/25, indicated an X-ray showed soft tissue swelling of the distal thigh and around the knee, lucencies (areas of less dense tissue which could include infection) in the medial, anterior femoral, and tibial components of the knee, and hardware loosening in the patellar component. The findings were suspicious for loosening, infectious or mechanical. A nursing note, dated 1/28/25, indicated R1 returned from the ER. Imaging indicated fluid around the knee. R1 required an MRI and a follow-up appointment with orthopedics. A nursing note, dated 1/31/25, indicated R1's leg was red and warm to the touch. R1 was educated on making a follow-up appointment with orthopedics to have an MRI. A nursing note, dated 2/1/25, indicated R1's left knee and shin were red, swollen, and warm to the touch. R1 refused to go to ER and requested an MRI at a specific hospital. A nursing note, dated 2/2/25, indicated R1's left knee and leg were red, swollen, and warm to the touch. R1 continued to decline hospitalization and stated R1 wanted to see R1's orthopedic surgeon. A nursing note, dated 2/3/25, indicated R1 thought there were children in R1's room. R1 had left leg redness, swelling, and warmth. R1 declined to go to the ER and stated the ER doesn't provide the MRI that R1 needs. A nursing note, dated 2/6/25, indicated R1's left leg was swollen, warm to the touch, and redness had spread further down the leg. R1 agreed to go to the hospital for evaluation. R1 was supposed to start an antibiotic (Cefaclor) on 2/3/25. The pharmacy stated the antibiotic would arrive in the evening on 2/3/25 and stated the same on 2/4/25. The pharmacy stated the medication was delayed on 2/5/25 but should be in that day. R1's February 2025 Medication Administration Record (MAR) contained an order for Cefaclor (an antibiotic) 500 mg twice daily for cellulitis. Cefaclor was not documented as administered on 2/3/25, 2/4/25, 2/5/25, or 2/6/25. Hospital notes from 2/6/25 to 2/20/25 indicated R1 had a temperature of 101.1 degrees en route to the hospital. R1's c-reactive protein (CRP) (which indicates inflammation) and sedimentation rates (which indicates infection/inflammation) were elevated. The orthopedic team twice attempted an arthrocentesis (a procedure where a needle is inserted into a joint to remove synovial fluid). A culture grew gram positive cocci indicative of methicillin-susceptible staphylococcus aureus (MSSA) infection. Infectious disease was consulted and prescribed IV cefazolin 2 grams every 8 hours for 6 weeks. On 2/13/25, R1 underwent a left total knee revision, wash out, and antibiotic spacer placement. A physician visit note, written by MD-G and dated 2/25/25, indicated R1 had chronic bilateral knee pain likely worsened by a left knee joint infection and was prescribed antibiotics. R1 expressed frustration regarding the events that led to the diagnosis and the initial MRI that was missed. An orthopedic note, written by Orthopedic Surgeon (OS)-L and dated 2/25/25, indicated R1 was weight bearing as tolerated on the LLE while in a knee immobilizer. R1 had an order for a dry dressing change daily and follow-up in four weeks. R1's February and March 2025 Treatment Administration Records (TARs) contained orders to change R1's knee dressing with Xeroform once daily (beginning 2/28/25 and ending 3/25/25). Surveyor noted the following dates of concern: ~ On 3/3/25, the treatment was not documented as completed. No additional documentation was provided. ~ On 3/11/25, R1 was at an activity. There was no evidence that the treatment was offered or completed later. ~ On 3/12/25, R1 was not available. No additional documentation was provided. R1's medical record indicated R1 was at the facility on 3/12/25. ~ On 3/15/25, R1 was not available. No additional documentation was provided. R1's medical record indicated R1 was at the facility on 3/15/25. ~ On 3/20/25, the treatment was not documented as completed. No additional documentation was provided. ~ On 3/24/25, R1 was at an activity. There was no evidence that the treatment was offered or completed later. On 11/4/25 at 10:30 AM, Surveyor interviewed R1 who verified R1 had ongoing redness, swelling, warmth, and left knee pain for several months. R1 stated WCP-F recommended R1 have an MRI and orthopedic consult due to hardware concerns in the knee. R1 verified the MRI scheduled for 12/5/24 was canceled due to insurance concerns. R1 canceled the MRI scheduled for 12/28/24 because ER staff told R1 it was unnecessary and R1 was concerned insurance wouldn't pay for it. R1 stated the facility did not honor R1's request to see R1's orthopedic surgeon and did not schedule any orthopedic appointments despite several recommendations from WCP-F and the ER. R1 stated R1 is still undergoing physical therapy for the left knee which has not been the same since the infection and causes R1 ongoing anxiety, pain, and a loss of independence. On 11/4/25 at 12:15 PM, Surveyor interviewed WCP-F who verified WCP-F recommended an MRI and orthopedic consult for R1 due to ongoing pain, redness, and swelling despite the wound being healed. WCP-F had concerns about the hardware in R1's knee and a possible internal infection. WCP-F verified the recommendations were discussed with MD-H. WCP-F was not aware if any of the recommendations were completed. On 11/4/25 at 5:35 PM, Surveyor interviewed R1's POAHC (POAHC-M) who verified R1's MRIs were canceled due to insurance concerns. POAHC-M was not aware of any orthopedic consults that were scheduled until after R1's hospitalization in February. POAHC-M expressed concern for how the facility handled R1's left leg. On 11/5/25 at 1:12 PM, Surveyor interviewed Orthopedic Registered Nurse ([NAME])-K who worked with OS-L. [NAME]-K verified R1 was not seen by OS-L prior to 2/6/25. [NAME]-K confirmed R1 was diagnosed with a septic joint and had a total knee revision with washout and placement of an antibiotic spacer. [NAME]-K stated increased redness, swelling, warmth, and pain are signs of an infected joint, especially with no other cause noted, and the orthopedic office would want to be informed right away so labs and imaging could be completed. [NAME]-K stated the risk of an untreated septic joint included sepsis (a life-threatening systemic infection) and potential loss of the limb. On 11/5/25 at 12:34 PM, Surveyor asked Regional Nurse Consultant (RNC)-C and [NAME] President of Clinical Operations (VPCO)-D their expectations for recommendations/referrals. RNC-C stated if a timeframe is not indicated by the referring physician, a referral or recommendation should be scheduled as soon as possible. RNC-C stated WCP-F's recommendations were relayed to MD-H who ordered an MRI and labs to determine if an orthopedic consult was needed. RNC-C verified an MRI was not completed, only X-ray imaging at the ER on [DATE] and 1/27/25. RNC-C confirmed staff were unsure if lab work was completed in-house prior to R1's hospitalization on 2/6/25 and could not verify if an orthopedic consult was completed after multiple recommendations from MD-H and a recommendation from the ER. In addition, RNC-C was not aware that R1 did not receive Cefaclor from 2/3/25 to 2/6/25. RNC-C stated staff should notify the Director of Nursing (DON) and/or physician if a medication/treatment is delayed due to pharmacy concerns. RNC-C verified if a resident refuses or is unavailable for a treatment, staff should reapproach the resident at a later time and document whether the treatment was refused or completed. The failure to treat a resident's ongoing left knee pain, redness, warmth, and swelling by completing referrals, imaging, treatment orders, and administering antibiotics resulted in serious harm for R1 and led to a finding of immediate jeopardy. The immediate jeopardy was removed on 11/6/25; however, the deficient practice continues at a scope/severity level G (actual harm/isolated) as indicated by R2's example and as the facility continues to implement the following action plan: Identified other residents with current wounds and assessed for signs/symptoms of infection, including redness, warmth, pain and swelling, and ensured referrals, consults, imaging, lab work, antibiotics, and wound treatments were administered. Educated licensed nursing staff on the facility's wound management policy and protocol to follow-up on skin issues as well as updating/documenting dressing changes. All wound orders were reviewed by the DON/designee to ensure accuracy and timely follow-up. Conducted skin audits weekly for 4 weeks. Education to be provided when indicated. 2. On 11/4/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including history of basal cell carcinoma on the right lower extremity (RLE) surgically removed, multiple sclerosis (MS), and edema. A care plan, initiated 3/14/22, indicated R2 had the potential for pressure ulcer development related to MS and a history of ulcers. The care plan contained an intervention to administer treatments as ordered and monitor for effectiveness. A care plan, initiated 4/5/23, indicated R2 received diuretic therapy related to edema. The care plan contained an intervention for Tubigrips (compression stockings) below the knee to base of toes, on every morning and off at night. On 3/25/25, R2 had a basal cell carcinoma removed from the RLE. A wound clinic progress note, dated 10/1/25, indicated R2's bilateral lower legs were healed but contained bruising that should be monitored. A pad was applied to the bruising and medium compression grips. The note contained an order for Tetra-Grips daily until R2 received compression stockings and to follow-up with the wound clinic as needed. R2's TAR contained the following orders: ~ Monitor R2's legs daily for 2 weeks (dated 10/1/25). ~ Take picture of bilateral legs for 2 weeks every Monday (dated 10/1/25). R2's TAR did not indicate the order was completed on 10/6/25. An order note, dated 10/13/25, indicated the camera could not be found. ~ R2's RLE had a pinpoint opening and R2 requested cushioning to protect the bilateral lower extremities (BLEs). An order to cleanse with soap and water, pat dry, apply Comfort foam to areas, and secure with Tubigrips on Monday/Wednesday/Friday was initiatedn on 10/7/25 and discontinued the same day. An in-house wound assessment, completed 10/7/25, indicated a wound on R2's right medial malleolus (inner ankle) measured 0.1 centimeters (cm) x 0.1 cm and contained light serosanguineous drainage and fragile surrounding tissue. The wound contained a pinpoint opening with bloody drainage that was observed on R1's Tubigrip. The treatment was soap and water and foam with a secondary Tubigrip dressing. R2 requested a foam dressing to cover the area. The facility was awaiting orders from the physician. An order progress note, dated 10/8/25 and related to the 10/1/25 order to monitor R2's legs daily, indicated R2's dressing was clean, dry, and intact. There were no further wound assessments or treatments documented for R2's right medial malleolus until 10/20/25. A progress note, dated 10/20/25 at 10:24 PM, indicated R2 was followed by wound care and had an arterial ulcer on the right medial malleolus that was larger in size than previously documented on 10/7/25. The wound currently measured 6 cm x 4 cm. The wound bed was red with scant serosanguineous drainage. The edges were attached with no odor. There were no current treatment orders. The foam dressing was removed. The wound was cleansed with normal saline, patted dry, and a new dressing was applied. R2 denied increased pain or discomfort and stated the wound had been like that for approximately a week. R2 requested to see the wound clinic. A message was left for the MD to obtain a treatment order. The PM supervisor asked the night nurse to have wound care assess the wound in the morning. An order, dated 10/21/25, indicated to cleanse R2's right inner ankle wound, apply Iodosorb, and cover with Mepilex daily and as needed. The order was discontinued on 10/31/25. R2 saw the in-house wound physician on 10/23/25. A progress note indicated R2 had a wound on the right medial shin. R2's RLE contained mild edema and the foot was warm. The wound measured 4 cm x 1 cm x 0.1 cm. The surface area was 4 cm squared with an open ulceration area that was 2.4 cm squared. The periwound radius contained erythema, induration, and moderate serosanguineous drainage. The treatment was to apply Iodosorb gel once daily and as needed if saturated, soiled, or dislodged (for 30 days) and a gauze island dressing with border once daily and as needed if saturated, soiled, or dislodged (for 30 days). R2 was also prescribed doxycycline (an antibiotic)100 mg twice daily for 14 days. R2's October 2025 TAR did not indicate the treatment was completed on 10/28/25. RNC-C indicated during an interview on 11/4/25 at 4:24 PM, that the wound treatment was completed by the wound nurse but was not signed out. On 11/4/25 at 12:07 PM, Surveyor interviewed R2 who indicated staff inconsistently completed wound care for R2's right leg which had healed and then reopened and worsened. R2 thought the wound worsened because of staffs' inconsistency. R2 saw the in-house wound doctor who started R2 on antibiotics. R2 chose to go back to R2's previous wound clinic and stated the wound had improved. On 11/4/25 at 4:24 PM, Surveyor interviewed RNC-C who confirmed a wound care order was entered in R2's medical record after R2's wound was discovered on 10/7/25 but was discontinued the same day. A new order was not entered when the initial order was discontinued. Due to the fact that a wound care order was not transcribed correctly in R2's medical record on 10/7/25, R2's wound was not assessed or treated until 10/20/25. During this timeframe, the wound deteriorated and grew in size. R2 saw the wound doctor on 10/23/25 and was started on antibiotics for the wound. 3. On 11/4/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including sepsis, systemic sclerosis with lung involvement, Raynaud's disease (causes some areas of the body, such as fingers and toes, to feel numb and cold in response to cold temperatures), and pulmonary hypertension due to scleroderma. R4's MDS assessment, dated 9/21/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4 was responsible for R4's healthcare decisions. R4's medical record contained the following wound orders: ~ Bilateral lower extremity: Cleanse, apply Iodosorb, cover with methylene blue and ABD pad, secure with Kerlix, change daily every day shift for open area (dated 10/24/25) ~ Coccyx wound: Cleanse with soap and water, pat dry, skin prep peri wound, apply Medihoney, cover with bordered gauze every day shift for open area (dated 11/2/25). On 11/4/25 at 10:52 AM, Surveyor observed Registered Nurse (RN)-E provide wound care to R4's BLE and coccyx wounds. RN-E removed the lower extremity dressings and sprayed both wounds with lidocaine. Surveyor observed a purple color in between R4's toes. RN-E indicated the color was due to gentian violet which staff used every other day. RN-E then removed R4's coccyx dressing, cleansed the wound with soap and water, and applied Iodosorb. On 11/4/25 at 11:25 AM, Surveyor interviewed RN-E who indicated the facility was out of Medihoney which was on back order. RN-E indicated the MD was aware and allowed staff to use Iodosorb instead. On 11/4/25 at 3:19 PM, Surveyor interviewed DON-B who verified R4 did not have orders for lidocaine, gentian violet, or Iodosorb to replace Medihoney.

Based on staff interview, resident representative interview, and record review, the facility did not ensure adequate assistance and supervision to prevent falls was provided for 1 Resident (R) (R4) of 7 sampled residents.R4 had left-sided hemiparesis (paralysis on one side of the body) because of a cerebrovascular accident (CVA) and required assistance for bed mobility. On 8/26/25 at approximately 8:00 AM, R4 rolled out of bed while Registered Nurse (RN)-C was providing care and sustained an orbital floor blowout fracture with herniated extraconal fat (a trauma-induced break in the thin bone separating the eye socket from the sinuses, allowing fat from around the eye to bulge into the sinus cavity). The facility's fall investigation indicated the fall occurred because R4 was not positioned appropriately in bed and rolled out of bed when RN-C turned away to get a brief. R4 was transferred to the hospital on 8/26/25 and returned to the facility the same day. R4 had an episode of vomiting that was reported by facility staff to Hospice staff on 8/27/25. Hospice notes also indicated R4 experienced intermittent confusion and swallowing concerns. The facility did not ensure thorough post-fall monitoring was completed and did not update a physician regarding R4's change of condition. R4 passed away at the facility on 8/30/25. The Medical Examiner's report indicated R4's cause of death was a concussion in the setting of Parkinsonism with R4's right orbital fracture and history of CVA listed as significant conditions. The facility's failure to adequately assist and supervise a resident with left-sided hemiparesis who rolled out of bed, sustained an orbital fracture, and passed away four days later created a finding of immediate jeopardy that began on 8/26/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 10/9/25 at 10:15 AM. The immediate jeopardy was removed on 10/12/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include:The facility's Fall Evaluation Safety Guideline policy, dated 11/28/17, indicates: Any failure to maintain an appropriate lying, sitting, or standing position resulting in a resident's sudden, unintentional relocation either to the ground or into contact with another object below the resident's starting point defines a fall .The intent of this guideline is to ensure the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through: 1) Identification of hazards and risks; 2) Evaluation; 3) Implementation; 4) Monitoring; 5) Analysis. The facility's Falls Investigation Guideline, dated 12/20/22, indicates: .4) If the fall involved a resident hitting their head and/or neck, initiate neurological evaluation .9) Document relevant post-fall clinical findings such as, but not limited to, vital signs, neurological checks, pain, swelling, bruising, alterations in skin integrity, range of motion, decreased mobility, and change in level of consciousness in the resident's record. It is also desirable to note the absence of such significant findings to demonstrate that the patient is being monitored appropriately .11) Monitor the resident and observe for changes for a minimum of 72 hours. From 10/7/25 to 10/8/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including Parkinsonism, history of CVA with left-sided hemiparesis, and stage 4 pressure ulcer of the sacral region. R4's Minimum Data Set (MDS) assessment, dated 8/15/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R4 had intact cognition. R4 was responsible for R4's healthcare decisions. (A Significant Change MDS assessment, dated 5/15/25, indicated R4 required partial to moderate assistance for rolling left to right.) A fall report, dated 8/26/25, indicated at approximately 8:00 AM, RN-C provided wound care for R4 who was in bed on a pressure-reducing air mattress. R4's brief was soiled, and RN-C began incontinence care. When RN-C rolled R4 on the left side (away from RN-C and toward the wall), R4 hit R4's head on the wall. RN-C rolled R4 on the right side (toward RN-C) to examine R4's head. RN-C then turned away to get a brief and R4 rolled out of bed. R4 hit R4's head on the metal bed frame and landed on the floor. The report indicated R4's bed was locked, and the air mattress was properly inflated. R4 was transferred to the Emergency Department (ED) for evaluation. An ED Encounter note, dated 8/26/25, indicated R4 was in bed situated against the wall when RN-C began wound care. When RN-C turned R4 onto R4's left side, R4 hit R4's head on the wall. R4 stated RN-C turned R4 on the right side to evaluate R4's head and then R4 rolled off the bed and onto the floor. R4 stated R4 fell approximately 3 feet. R4 had an abrasion above the right eyebrow with significant bruising and tenderness along the inferior orbital bones. A computed tomography (CT) scan showed a new acute right orbital floor blowout fracture with herniated extraconal fat and minimal presumed swelling of the non-herniated inferior rectus muscle. An X-ray of the right hip was completed and indicated there were no fractures or new acute findings. R4 returned to the facility 8/26/25. R4's Functional Performance care plan contained an intervention, initiated 3/19/25, that indicated R4 required the assistance of 2 staff with rolling - 1 staff on both sides of the bed and to roll left and right. R4's Skin Integrity care plan contained an intervention, initiated 8/27/25, for wound care to be done in the morning with the assistance of 2 staff - 1 person on each side of the bed. A progress note, dated 8/26/25, indicated R4 returned from the ED at 1:10 PM. A treatment order, dated 8/26/25, indicated to monitor R4 every shift for 72 hours until 8/26/25 (which was did not equate to 72 hours). The order did not include neurological checks and was discontinued on 8/26/25 at 11:59 PM. Monitoring included blood pressure, pulse, respirations, oxygen saturation, and pain level. Surveyor noted monitoring was completed on the 8/26/25 PM shift and the 8/26/25 into 8/27/25 night (NOC) shift, however, neuro checks were not completed. A Neurological Observation Evaluation, dated 8/26/25 at 1:04 PM, was completed upon R4's return from the hospital. A Neurological Record, dated 8/27/25, indicated neuro checks were completed:~ On 8/27/25 at 10:00 AM. (The Neurological Record did not include neuro checks on the 8/27/25 PM shift.)~ On the 8/27/25 into 8/28/25 NOC shift. (The Neurological Record did not include neuro checks on the 8/28/25 AM or PM shifts.)~ On the 8/28/25 into 8/29/25 NOC shift.A Fall Report, dated 8/27/25, contained a root cause analysis that indicated when RN-C turned R4 to examine R4's head, R4 was on the right side (which was R4's strong side) with R4's weak left leg positioned straight out. R4's position resulted in a top-heavy effect and momentum that caused R4 to roll to the left side as RN-C turned to get a clean brief. A new intervention was implemented that indicated R4 required the assistance of 2 staff with bed mobility due to left-sided weakness. The fall report indicated RN-C was educated on how to properly position a resident with unilateral weakness. On 10/7/25 at 12:23 PM, Surveyor interviewed RN-C who confirmed RN-C was providing care when R4 fell out of bed. RN-C stated R4 required the assistance of 1 staff to roll in bed at the time of the fall and indicated that prior to assisting a resident, RN-C reviews the resident's care plan and checks the back of the resident's door for the Kardex (an abbreviated care plan used by nursing staff). On 10/7/25 at 12:27 PM, Surveyor interviewed Regional Nurse Coordinator (RNC)-D who indicated R4 required the assistance of 1 staff for bed mobility prior to the fall. RNC-D indicated an intervention for 2 staff with bed mobility was added after the fall. When Surveyor indicated a care plan intervention with an initiation date of 3/19/25 indicated R4 required the assistance of 2 staff for bed mobility, RNC-D indicated the intervention was initiated on 8/27/25 after the fall (as indicated on R4's Skin Integrity care plan above) and the 3/19/25 initiation date for the intervention on R4's Functional Performance care plan was incorrect.On 10/7/25 at 3:22 PM, Surveyor interviewed Hospice Nurse (HN)-L who verified R4 fell out of bed on 8/26/25 and sustained an orbital fracture and a suspected concussion. HN-L stated R4 had a change in condition following the fall that was consistent with a concussion, including intermittent confusion, swallowing concerns, and vomiting. HN-L provided Surveyor with Hospice notes and stated facility staff reported 2 episodes of vomiting, including one on the afternoon of 8/27/25.A Hospice Visit Note, dated 8/27/25 with a visit time of 9:08 PM, indicated R4's family reported a change in condition to Hospice during the visit. The note indicated R4 was alert and oriented x 3 during the visit but was less responsive than usual and had increased difficulty with swallowing. Facility staff were asked to complete frequent checks during the night. A Hospice Visit Note, dated 8/28/25 and written by HN-L with a visit time of 9:26 AM, indicated R4 was recovering from a fall with orbital fracture and a suspected concussion. The note indicated R4 appeared more confused than baseline. During lunch, HN-L sat with R4 and noted a significant delay (30 seconds) between bite initiation and swallow. R4 also had difficulty following single-step commands related to chewing and swallowing with raised concern for oral-motor coordination. Speech Therapy was notified. The note also indicated R4 had a vomiting episode on the afternoon of 8/27/25 that was reported to Hospice by facility staff. HN-L contacted R4's inactivated Power of Attorney for Healthcare ((POAHC)-M) regarding R4's status and likely concussion. On 10/8/25 at 2:56 PM, Surveyor interviewed Director of Rehabilitation (DOR)-N who was also the facility's Speech Therapist. DOR-N verified R4 had a decline in swallowing post-fall. DOR-N stated Speech Therapy would have provided services sooner, however, R4 wanted to wait until R4's hip pain resolved. DOR-N stated an evaluation completed on 8/29/25 indicated R4 was holding foods and liquids and required supervision for meals.A Speech Therapy Evaluation, dated 8/29/25 and completed by DOR-N, indicated R4 had a 5 to 7 second delay with eating and had increased tremors which required assistance. R4 could look down but not complete a chin tuck. DOR-N attempted a chin tuck three times with R4 who was not able to follow directions. Max cues were required to assist R4 with swallowing. R4 demonstrated a 20 second delay. The evaluation indicated DOR-N met with the Hospice nurse, educated staff, and wrote on the 24-hour board that R4 should eat all meals in the dining room for supervision and feeding assistance. The evaluation indicated the Hospice nurse informed DOR-N that R4 vomited the day before and likely had a concussion because of the fall. (R4's medical record did not indicate a physician was updated on the suspected concussion or R4's change in condition.) On 10/8/25 at 11:08 AM, Surveyor interviewed RNC-D who stated Director of Nursing (DON)-B and RNC-D reviewed R4's fall and spoke with RN-C. RNC-D stated based on what was reported, RN-C did not have R4's flaccid side positioned appropriately in bed. As a result, R4 rolled onto R4's left side and fell off the bed. RNC-D stated if RN-C had positioned R4 properly, R4's fall could have been prevented.On 10/8/25 at 12:36 PM, Surveyor interviewed DON-B who indicated DON-B and RNC-D educated RN-C and issued a final warning of discipline due to the seriousness of the incident. When Surveyor asked if other staff were educated on proper positioning, DON-B stated DON-B would get back to Surveyor. Follow-up was not provided.An Employee Coaching Form, dated 9/4/25, indicated RN-C repositioned R4 in bed on R4's side and turned away to get supplies. When RN-C turned away, R4 rolled out of bed. R4 was transferred to the ED and diagnosed with an orbital fracture. The form indicated RN-C will ensure a resident is properly positioned prior to turning away or leaving the bedside, will ensure a resident is centered properly in bed when turned, and will ask for assistance with positioning if needed.On 10/8/25 at 1:38 PM, Surveyor interviewed [NAME] President of Success (VPS)-K and RNC-D. RNC-D stated neurological checks should be completed every 15 minutes x 4, every 30 minutes x 4, every hour x 2, and then once per shift for 2 days. RNC-D stated because R4 was transferred to the hospital immediately after the fall, only every shift checks were required when R4 returned. VPS-K and RNC-D were unsure why there was a line through the 8/28/25 PM shift neuro checks. RNC-D verified the checks should have been completed.On 10/7/25 at 3:33 PM, Surveyor interviewed POAHC-M via phone who stated R4 threw up at least once per day after the fall until R4 passed away on 8/30/25. POAHC-M stated staff did not report the vomiting episodes to POAHC-M, however, POAHC-M reported the episodes to staff if they occurred when POAHC-M was at the facility. POAHC-M stated a grievance form was completed and submitted to the facility; however, POAHC-M had not heard from the facility. POAHC-M stated R4 vomited during POAHC-M's visit on 8/30/25. When POAHC-M attempted to assist R4, POAHC-M realized R4 was not breathing. POAHC-M yelled for R4 to take a breath and called for help. A Concern/Comment Report submitted by R4's family on 9/2/25 indicated on 8/27/25 at approximately 12:00 PM, R4 threw up on R4's clothes during a visit with family. Family requested that R4 be changed. When other family members visited at 5:30 PM, R4 was wearing the same clothes. The investigation summary stated DON-B reviewed the 8/27/25 schedule and interviewed all staff who worked the AM shift. DON-B indicated staff denied knowledge that R4 had vomited. On 10/8/25 at 10:51 AM, Surveyor interviewed DON-B, VPS-K and RNC-D. DON-B verified DON-B investigated the grievance and indicated all AM shift staff were interviewed and unaware that R4 had vomited. When Surveyor asked if PM shift staff were interviewed, DON-B stated DON-B did not interview PM shift staff and did not have evidence that R4 vomited or had a change in condition. VPS-K stated R4 did not have a change in condition, so physician notification was not necessary. RNC-D stated neurological checks and a BIMS assessment were completed and showed no change in condition. ~ On the 8/27/25 into 8/29/25 NOC shift. On 10/7/25 at 12:37 PM, Surveyor interviewed Medical Examiner (ME)-E who completed R4's death investigation. ME-E stated after a discussion with R4's family and Hospice staff, a post-mortem CT scan was completed on 9/3/25 and showed no signs of bleeding. ME-E stated after review of R4's fall, Hospice notes, and R4's medical record, ME-E concluded R4's death was an accident due to the fall. The Medical Examiner's report indicated R4's cause of death was a concussion in the setting of Parkinsonism. A Death Certificate Summary, completed by ME-E, listed R4's manner of death as an accident, with sub manner listed as fall. The cause of death was listed as a concussion in the setting of Parkinsonism with other significant conditions contributing to the death, including right orbital floor blowout fracture and history of a CVA. The failure to properly position a resident with left-sided hemiparesis and properly monitor and assess the resident following a fall created a reasonable likelihood for serious harm or injury, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 10/12/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:1. Reviewed, screened, and updated care plans for residents with diagnoses of hemiparesis and falls related to bed mobility. 2. Met with Hospice staff to ensure effective communication in real time regarding changes in condition. Updates should be given to the DON or designee before Hospice staff leave the building.3. Educated facility and agency staff on bed mobility, post-fall assessments, and changes in condition prior to their next scheduled shift.4. Initiated bed mobility and change in condition competencies for 4 weeks to ensure staff follow proper techniques and protocols. Ad hoc education to be provided immediately when indicated.

Based on staff interview and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R1) of 6 sampled residents. During the night (NOC) shift on 9/24/24-9/25/24, Licensed Practical Nurse (LPN)-D observed R2 touch R6's leg and try to kiss R6. LPN-D immediately separated R2 and R6 and documented the incident in R2's medical record. Following the incident, no interventions were put in place to ensure the safety of R6 or other residents. On 9/25/24 at approximately 11:00 AM, Registered Nurse (RN)-C observed R1 and R2 in the lounge. R2 had one arm around R1's shoulders and the other hand inside R1's brief. R2 moved R2's hand back and forth while R1 attempted to push R2's hand away. RN-C separated the residents, placed R2 on 1:1 supervision, and notified supervisory staff. The facility's failure to implement interventions to supervise a resident with previous sexually inappropriate behavior and keep residents safe from further abuse created a finding of immediate jeopardy that began on 9/25/24. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 10/8/24 at 3:13 PM. The immediate jeopardy was removed on 10/9/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 1/5/24, indicates in part: Sexual abuse is non-consensual sexual contact of any type with a resident .III. Prevention of Abuse, Neglect, and Exploitation: A. Establishing a safe environment by establishing policies and protocols for preventing sexual abuse, such as identifying when, how, and by whom determinations of capacity to consent to sexual contact will be made .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident needs and behaviors which might lead to conflict . On 10/8/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, stroke, and encephalopathy (brain dysfunction). R2's most recent Minimum Data Set (MDS) assessment, dated 9/16/24, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC). Nursing notes, dated 9/11/24 and 9/19/24, indicated R2 made sexually inappropriate comments to staff. A nursing note, dated 9/20/24, indicated R2 inappropriately touched staff. A nursing note written by LPN-D, dated 9/24/24, indicated R2 made sexually inappropriate comments to staff and attempted to kiss a resident (R6) and had to be pulled away. (R6 has diagnoses including Alzheimer's disease, dementia with behavioral disturbance, anxiety, and depression. R6's most recent MDS assessment, dated 8/29/24, had a BIMS score of 1 out of 15 which indicated R6 had severe cognitive impairment. R6 had an activated POAHC.) On 10/8/24, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) on 10/2/24. The FRI indicated: On 9/25/24 at approximately 11:00 AM, RN-C observed R1 and R2 in the lounge on the third floor. RN-C observed R2 with R2's left arm around R1's shoulders and R2's right hand moving back and forth inside R1's brief. RN-C observed R1 push down and away on R2's right hand. RN-C removed R1 from the lounge and notified RN-C's supervisor. (R1 has diagnoses including Alzheimer's disease, dementia with behaviors, and depression. R1's most recent MDS assessment, dated 8/16/24, had a BIMS score of 0 out of 15 which indicated R1 had severe cognitive impairment. R1 had a legal guardian to assist with healthcare decisions.) NHA-A and Director of Nursing (DON)-B submitted an initial report to the SA on 9/25/24 and initiated an investigation. The investigation indicated a skin check was completed for R1. R2 was placed on continuous 1:1 supervision. R2's room was moved to a different hallway. R1 and R2 were provided with psychiatric follow-up. R1 and R2's physicians, representatives, and local law enforcement were notified. R1 and R2's care plans were updated. Other residents were interviewed regarding potential abuse. R2's care plan was updated on 9/26/24 to address R2's sexually inappropriate behavior toward residents and staff. On 10/8/24 at 2:39 PM, Surveyor interviewed LPN-D regarding R2's behavior during the 9/24/24-9/25/24 NOC shift. LPN-D verified LPN-D observed R2 touch R6's knee and ask R6 multiple times to kiss R2. LPN-D observed R2 lean in and try to kiss R6 before LPN-D intervened. LPN-D verified R6 was cognitively impaired and could not consent to a sexual relationship. LPN-D stated LPN-D documented the behavior in R2's medical record and notified the oncoming AM shift nurse about the incident. LPN-D verified R2 was not placed on 1:1 supervision until later in the day on 9/25/24 after the incident between R1 and R2. On 10/8/24 at 12:38 PM, Surveyor interviewed NHA-A and DON-B regarding R2's sexually inappropriate behavior. NHA-A and DON-B were not aware that R2 was sexually inappropriate toward R6 prior to the incident between R1 and R2 on 9/25/24. DON-B verified R2 was not placed on increased supervision until after 11:00 AM on 9/25/24. NHA-A stated R1 was offered a head-to-toe exam by RN-C but confirmed R1 and R1's representative were not offered a Sexual Assault Nurse Exam (SANE). When Surveyor asked NHA-A for proof of staff education, NHA-A stated staff were educated on the incident between R1 and R2 and R2's 1:1 supervision during huddles and the education was not documented. On 10/10/24, NHA-A provided Surveyor with signed education sheets for staff which included 44 of the facility's approximately 130 staff members. Several of the sheets did not include the date of the education or what information was provided during the huddle. On 10/11/24, Surveyor reviewed a police report regarding the incident between R1 and R2. The report indicated RN-C observed R1 and R2 in a common area with R2's hand moving back and forth in R1's pants. Officers interviewed R1 and R2. R1 was unable to respond to questions. R2 denied the incident occurred and was deemed incoherent by officers. The case was forwarded to Adult Protective Services (APS) and no charges were filed. The failure to supervise a resident with a history of inappropriate sexual behavior toward a resident and staff created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 10/9/24 when it completed the following: 1. Placed R2 on 1:1 supervision and moved R2 to a different unit. 2. Initiated facility-wide education on abuse and 1:1 supervision. 3. Completed psychosocial interviews with R1, R2, and R6. 4. Updated R1, R2, and R6's care plans. 5. Notified R1, R2, and R6's physicians, representatives, and local law enforcement. 6. Interviewed residents and staff and initiated monitoring for changes in behavior of non-interviewable residents.

Based on observation, record review, and interview, the facility did not ensure the environment remained free from accident hazards and assistive devices to prevent accidents for 2 (R1 and R3) of 3 residents reviewed for falls. R1 had a fall while using a sit-to-stand lift on 10/12/2022 that was not reported, documented, or investigated. No interventions were put in place to prevent future falls or injuries. On 10/13/2022, R1 was using a sit-to-stand lift and had an unresponsive episode while sitting on the toilet with the sit-to-stand lift in place and R1 sustained a fractured humerus. No evaluation was completed on R1's use of the sit-to-stand lift to determine if the lift was appropriate for R1 to use after 10/12/2022 or if a total lift was more appropriate to prevent harm. R3 had a fall on 11/3/2022 and the interdisciplinary team determined a scoop mattress would be an appropriate intervention to prevent future falls. The scoop mattress intervention was not added to R3's Falls Care Plan. A scoop mattress was not observed on R3's bed. R3 had a fall on 12/5/2022 out of the wheelchair and Dycem was observed on R3's wheelchair cushion. The Dycem was not added to R3's Falls Care Plan. Findings: The facility Policy and Procedure entitled Accident(s), Incident(s), dated 7/30/2018, states: 2) An initial care plan will be developed for any resident that is determined to be at risk for falls. a) if at risk for falls, the house fall protocol will be implemented. 3) This care plan is communicated to appropriate staff members. 4) Care plans and assessments should be re-evaluated at a minimum of quarterly, with any new change of condition and/or accident/incident as deemed necessary. 5) If a fall occurs, the facility will provide nursing and/or emergency care as needed per facility's policy and procedure standards of practice and follow Incident Report Investigation Checklist. When an accident or incident occurs: .3) Complete Accident/ Incident Investigation Checklist at time of accident/incident with all staff present. a) If accident/incident is not witnessed; or the resident is not able to verbalize a probable cause; or the nurse is unable to determine a probable cause; or there is an injury in a suspicious location, and/or resident has injury has a suspicious [sic] origin i) The Nurse must interview staff on duty on the unit and take a statement from the staff members using Staff Statement Tool. ii) The Nurse or designee must interview the staff and write statements for the staff member.5) If a fall related incident: . i) Update fall assessment in electronic medical record prior to shift ending - nurse on duty is responsible; if completed by an LPNN, a RN must co-sign. ii) Update fall Care Plan with immediate fall interventions - nurse on duty is responsible.9) Add to 24-hour communication board. 10) IDT team will review accident/ incident next business day. R1 was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's Disease, major depressive disorder, constipation, dysphagia, and anxiety disorder. R1's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00 and coded R1 as needing extensive assistance with transfers, toilet use, dressing, and hygiene. R1 was admitted into Hospice on 11/15/2022 and passed away on 11/17/2022. R1 was not observed during the survey. R1's Activities of Daily Living Care Plan had the following interventions in place on 10/10/2022: -Toilet Use: extensive assistance of one with EZ stand, R1 wears incontinence brief, provide with perineal care and help adjust clothing. -Transfer: Extensive assistance from 1 person, a stand-up lift (may require 2 assist in/out of bed for setup/removal). R1's Falls Care Plan had the following interventions in place on 10/10/2022: -Anticipate and meet R1's needs. -Be sure R1's call light is within reach and encourage R1 to use it for assistance as needed; R1needs prompt response to all requests for assistance. -Educate about safety reminders and what to do if a fall occurs. -Fall mat next to bed when in bed. -Follow facility fall protocol. -Physical therapy evaluate and treat as ordered and as needed. -Review information on past falls and attempt to determine cause of falls; record possible root causes; alter/remove any potential causes if possible; educate as to causes. On 12/13/2022 at 12:54 PM, Surveyor requested all fall investigations regarding R1 from Director of Nursing (DON)-B. On the Request for Therapy Screen form, Rehab Director-D completed the form on 10/18/2022 indicating R1's foot slipped off the back of the foot plate of the EZ stand on 10/10/2022 and R1 was lowered to the floor. The Fall Care Plan was reviewed, and the Fall Care Plan indicated R1 had a fall on 10/10/2022 with the following intervention implemented on 10/18/2022: staff education and assess grip pad on foot plate of EZ stand. Surveyor did not find any documentation in R1's medical record of a fall that R1 sustained on 10/10/2022. DON-B provided Surveyor with the incident report that was initiated on 10/17/2022 of R1's fall dated 10/12/2022 in which R1's foot slipped in the EZ stand and R1 was lowered to the bed. The fall investigation stated it was later determined that R1 had been lowered to the floor and then transferred to the bed. In an interview with DON-B on 12/15/2022 at 1:19 PM, Surveyor asked DON-B to clarify the date of R1's fall because the Falls Care Plan and the Request for Therapy Screen form indicated the fall occurred on 10/10/2022. DON-B stated R1's fall occurred on 10/12/2022 and not 10/10/2022. DON-B stated the IDT was investigating another incident involving R1 when it was discovered that R1 had been lowered to the floor on 10/12/2022 by facility staff when R1's foot slipped from the EZ stand. DON-B was aware there was no documentation by nursing staff on 10/12/2022 of R1's fall and DON-B stated the nurse was educated in the proper documentation that was needed after a fall. Surveyor noted a late entry of the fall on 10/12/2022 was not put in R1's medical record . Surveyor noted no investigation into R1's fall with the use of the EZ stand was completed on 10/12/2022 and no interventions were implemented on 10/12/2022 to prevent future falls or injuries. Surveyor noted R1 was not assessed in the use of the EZ stand to determine if the EZ stand was an appropriate transfer device for R1. On 10/13/2022 at 7:13 AM in the progress notes, nursing charted the Registered Nurse (RN) was called into R1's room by a certified nursing assistant (CNA.) Nursing charted R1 was observed on the sit-to-stand lift slumped over to right side while sitting on the toilet. Nursing charted R1 was unresponsive for thirty seconds upon the nurse arriving in the room and R1 slowly regained responsiveness with verbal and tactile stimuli. Nursing charted R1's vital signs and noted R1 to be hypotensive (low blood pressure) 88/47, pulse 104, respirations 10-12. On 10/13/2022 at 7:33AM in the progress notes, nursing charted the Nurse Practitioner (NP) was called and was informed of R1's syncopal (passing out) episode. Nursing charted the NP gave orders to recheck R1's vital signs and monitor; the NP informed the nursing staff member that R1 was a comfort focus and to encourage fluids and eating. On 10/13/2022 at 10:12 AM in the progress notes, nursing charted Tylenol 650 mg was given to R1 for left shoulder pain. Surveyor noted R1 had not requested or complained of pain to the left shoulder in the past. On 10/13/2922 at 2:36 PM in the progress notes, nursing charted the NP was notified R1 was back to baseline, Tylenol was given for arm pain, and R1 did not have any more syncope episodes. On 10/13/2022 at 7:43 PM in the progress notes, nursing charted a blue/purple bruise was noted to R1's left upper arm during PM cares that measured 4 cm x 5 cm. On 10/14/2022 at 8:59 AM in the progress notes, nursing charted the CNA alerted the nurse that R1 had blister in the bruise on the left upper arm. Nursing charted the blood blister and bruising likely occurred on 10/13/2022 when R1 became unresponsive in the EZ stand and the skin was pinched. Nursing charted a further assessment showed increased pain, guarding (protecting arm,) and vocal complaints of pain from R1 was noted with touch and movement. Nursing charted the NP was notified and a new order for skin prep to blister twice daily and x-rays STAT (as soon as possible) to the left shoulder, clavicle, humerus, radius, and ulna were ordered. On 10/14/2022 at 12:26 PM in the progress notes, nursing charted the facility was notified that R1's x-ray of the left humerus indicated an acute fracture of the cervical neck. R1's Activities of Daily Living Care Plan was revised on 10/14/2022 with the following intervention: transfer R1 with a Hoyer lift. EZ stand transfers were discontinued. On 10/18/2022 at 09:54 AM in the progress notes, the IDT charted the root cause of R1's fall was due to R1's foot slipping from the EZ stand resulting in R1 needing to be lowered to the floor. The recommended interventions were staff education and assess the grip pad on the foot plate of the EZ Stand. Surveyor noted the IDT note on 10/18/2022 did not indicate when R1 had a fall from the EZ stand and no other documentation was found regarding a fall on 10/10/2022 or 10/12/2022. In an interview on 12/13/2022 at 1:30PM, CNA-C stated CNA-C got R1 up and transferred to the toilet using the EZ stand on 10/13/2022. CNA-C stated CNA-C was washing R1 up with R1 standing in the EZ stand, and R1 went limp so CNA-C lowered R1 onto the toilet and ran to the door, yelled for help and put all the call lights on in the room. CNA-C stated the nurse came to do vital signs, got R1 aroused awake and went to call the NP. CNA-C stated CNA-C attempted to get R1 up again using the EZ stand and R1 passed out again, so CNA-C lowered R1 to toilet and left to get CNA-F. CNA-C stated CNA-C and CNA-F attempted to get R1 up again to put the Hoyer lift sling under R1 using the EZ stand and R1 passed out again. CNA-C and CNA-F got the Hoyer lift and transferred R1 back to bed. CNA-C stated R1 had total of three episodes of unresponsiveness and the nurse was aware of all of them but was only present for the first episode. CNA-C stated CNA-C became aware R1 has had fainting episodes in the past but only through word of mouth and had never experienced it until the episode on 10/13/2022. Surveyor asked CNA-C if R1 had complained of any pain. CNA-C stated R1 was saying ow when being lifted in the sling with the Hoyer lift. In an interview on 12/13/2022 at 2:44 PM, Surveyor spoke with Rehab Director-D regarding the request for a therapy screen for transfer assessment after the fall on 10/12/2022 when R1's feet slipped off EZ stand. Rehab Director-D stated the form was completed on 10/18/2022 after the IDT meeting of which Rehab Director-D is a part of met on 10/17/2022. Rehab Director-D stated the NP discontinued the transfer assessment order from R1's fall on 10/12/2022 due to R1 sustaining a fractured arm on 10/13/2022 and being on comfort care. Rehab Director-D stated R1 was never assessed for transfer status after the fall on 10/12/2022. Rehab Director-D stated R1 was last seen for therapy on 2/2022 for physical therapy and Occupational therapy for position changes. Rehab Director-D stated R1 was given another wheelchair at that time. Rehab Director-D stated the IDT meets daily and investigates the falls of residents from the previous day. Rehab Director-D stated Rehab Director-D did not know why the IDT did not meet after the fall on 10/12/2022 until 10/17/2022. On the Request for Therapy Screen form completed on 10/18/2022, the interventions listed on the form were to educate the nurse and Certified Nursing Assistant (CNA) regarding reporting incidents, proper transfer training, and maintenance work order to check the foot plate of the EZ stand. The request of the therapy screen originated from the Fall Committee. The therapy response to the request per Rehab Director-D was discontinued due to R1's current status on 10/18/2022 with an arm fracture and the request for comfort care. In an interview on 12/13/2022 at 2:52 PM, Surveyor asked Registered Nurse (RN)-E about R1 after the syncopal episodes on 10/13/2022. RN-E stated RN-E was told about the bruise on R1's arm on the bicep area from the CNA. RN-E stated RN-E went to assess R1 and R1 had no pain at the time and no swelling noted. RN-E stated RN-E was moving R1's arm around and R1 never said anything about pain. RN-E stated R1 had no complaints of pain all shift and was surprised when came RN-E came in the next day and the area was more bruised. RN-E stated RN-E figured it was because when R1 was slumped over during the fainting episode, maybe R1 was pulled by the CNA to sit up. RN-E was not aware of R1 having difficulty with the EZ stand or previous episodes of syncope while in EZ stand. In an interview on 12/15/2022 at 11:16 AM, Surveyor asked CNA-F about R1's episode of unresponsiveness on 10/13/2022. CNA-F stated CNA-F was called to R1's room by CNA-C to help with R1's transfer with the EZ stand because R1 had passed out. CNA-F was unsure if R1 ever came to when trying to get up off toilet. CNA-F remembered R1 saying ow when being transferred in the Hoyer lift. CNA-F stated CNA-F did not hear a crack or pop when lifting R1 up. CNA-F did not recall hearing about an incident of R1's feet slipping off the EZ stand during a transfer. In an interview on 12/15/2022 at 12:57 PM, Surveyor spoke with Rehab Director-D who had talked with other rehab staff and looked back at notes for clarification after the last interview with Surveyor. Rehab Director-D clarified that initially the IDT did not think R1 had a fall on 10/12/2022, but when the IDT reviewed the information on 10/17/2022, they felt R1 had a fall and then the investigation with staff interviews began. In an interview on 12/15/2022 at 1:20 PM, Surveyor asked Director of Nursing (DON)- B about R1's fall on 10/12/2022. DON-B stated that R1's fall on 10/12/2022 was brought to DON-B's attention on Monday 10/17/2022. DON-B stated the investigation into the incident found it was a fall and that R1 had to be lowered to the floor when the feet slipped off the EZ stand. DON-B stated the CNA went to get a nurse and the nurse stated it was ok to put R1 back to bed without assessing R1. DON-B stated staff have been educated as a whole about using EZ stands and all the gripper strips on the EZ lifts have been changed. DON-B stated LPNs are instructed to call 911 if no RN is in the building and this policy has been implemented after R1's fall occurred. On 12/15/2022 at 2:25 PM, Surveyor met with Nursing Home Administrator (NHA)-A and DON-B to review the concerns regarding R1's falls and transfer status. Surveyor shared the concern R1 had a witnessed fall on 10/12/2022 while using the EZ stand that was not documented in R1's medical record and no investigation to the cause of the fall or interventions were completed until 10/18/2022, six days after the fall occurred. Surveyor shared the concern R1 was not assessed to determine if the EZ stand transfer was an appropriate transfer device after the fall on 10/12/2022 and R1 sustained a fractured arm on 10/13/2022 while using an EZ lift. No further information was provided at that time. *)R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, diabetes, heart failure, coronary artery disease, anxiety, and alcohol abuse. R3's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R3 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 and codded R3 as needing extensive assistance with bed mobility and transfers and did not ambulate in the room or hallway. R3 had a history of falls prior to admission and was admitted to the facility after sustaining a fracture to the left hip that was surgically repaired. R3's Risk for Falls Care Plan was initiated on 8/12/2022 with the following interventions: -Be sure the call light is in reach and encourage R3 to use it for assistance as needed. R3 needs prompt response to all requests for assistance. -Ensure R3 is wearing appropriate footwear (shoes or gripper socks) when ambulating or mobilizing in wheelchair. -Follow facility fall protocol. R3's Risk for Falls Care Plan was revised on 9/3/2022 with the following intervention: ensure R3 has heel lift boots on at all times when in bed to off load. R3's Risk for Falls Care Plan was revised on 9/22/2022 with the following intervention: place wheelchair within reach at all times. On 11/1/2022 at 12:30 AM in the progress notes, nursing charted R3 was found lying on the right side on the floor next to the bed. R3 was assessed by a Registered Nurse (RN) and was found to have no injuries and no complaints of pain. Nursing charted R3 had heel boots on, the call light was in reach, the bed was in low position and the care plan was followed. Nursing charted R3 had last been seen at 12:10 AM. Nursing charted R3 stated R3 had been dreaming and rolled off the bed. Nursing charted the immediate intervention put in place was a fall mat. On 11/1/2022 at 9:47 AM in the progress notes, the interdisciplinary team (IDT) met and determined the fall mat was an appropriate intervention. R3's Risk for Falls Care Plan was revised on 11/1/2022 with the following intervention: 11/1/2022 fall - mat on floor next to bed. The facility implemented a second Risk for Falls Care Plan on 11/2/2022 with the following interventions: -Assist R3 with ambulation and transfers, utilizing therapy recommendations. -Determine R3's ability to transfer. -Evaluate fall risk on admission and as needed. -If a fall occurs, alert provider. -If a fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. -If R3 is a fall risk, initiate fall risk precautions. On 11/3/2022 at 5:28 PM in the progress notes, nursing charted R3 was found lying down net to the bed with blankets around R3's body. Nursing charted R3 was down for a nap and R3 stated R3 rolled off the bed. Nursing charted the fall mat was in place and R3 did not sustain any injuries. On 11/4/2022 at 9:52 AM in the progress notes, the IDT determined a scoop mattress was an appropriate intervention to prevent future falls. Surveyor noted R3's Risk for Falls Care Plan was not revised to include the scoop mattress intervention. On 12/5/2022 at 7:45 PM in the progress notes, nursing charted R3 had been sitting in the wheelchair watching TV and the wheelchair was noted to be tipped forward and R3 was sitting on the foot pedals. Nursing charted R3 had reached forward and slid off the seat. Nursing charted Occupational Therapy evaluation for wheelchair positioning was the immediate intervention. On 12/6/2022 at 9:47 AM in the progress notes, the IDT determined Dycem on the cushion and a therapy evaluation were appropriate interventions to prevent future falls. Surveyor noted R3's Risk for Falls Care Plan was not revised to include the Dycem on the wheelchair cushion or a therapy evaluation. In an interview on 12/13/2022 at 1:05 PM, Licensed Practical Nurse (LPN)-G stated resident care plans are on the back of the resident's bathroom door so anyone can help with transfers or any other cares or see what is on the care plan. On 12/13/2022 at 1:25 PM, Surveyor observed R3 sleeping in bed. The bed was in a low position, a fall mat was on the floor next to the bed, and the call light was in reach. The mattress in place was not a scoop mattress. Multiple pillows were placed on the side of the bed opposite the wall. Surveyor observed Dycem on R3's wheelchair cushion. Surveyor observed R3's Care Plan on the back of the bathroom door. A scoop mattress and Dycem for the wheelchair cushion were not listed on the care plan. In an interview on 12/13/2022 at 2:30 PM, Surveyor asked Certified Nursing Assistant (CNA)-C if R3 had any interventions in place to prevent falls. CNA-C stated R3 gets a fall mat on the floor, but CNA-C stated R3 had only been on the unit for a couple of weeks so did not know R3 very well yet. Surveyor asked CNA-C if R3 should have Dycem in the chair. CNA-C stated the Dycem may have been put in the chair from the other unit to keep R3 from sliding out of the chair because R3 had really long legs, but CNA-C did not know if the Dycem should have been on the cushion or not. On 12/15/2022 at 10:30 AM, Surveyor observed R3 asleep sitting in the wheelchair in R3's room. The call light was in reach, the fall mat was up against the wall, and the mattress in place on the bed was a regular mattress, not a scoop mattress. In an interview on 12/15/2022 at 11:10 AM, Surveyor asked Director of Nursing (DON)-B what the facility process was for reviewing and revising Care Plans. DON-B stated Care Plans are reviewed quarterly, with significant changes, and as needed. Surveyor asked DON-B how falls are investigated, and Care Plans revised after a fall. DON-B stated the IDT meets the next day after a fall occurs to review the fall and determine interventions to address the cause of the fall and then the Care Plan is updated with that intervention. DON-B stated the nursing process is used to develop Care Plans and education has been started with the nurses on the floor to update Care Plans. In an interview on 12/15/2022 at 1:00 PM, Surveyor asked Rehab Director-D if R3 was screened on 12/5/2022 after R3 slid out of the wheelchair. Rehab Director-D stated R3 was already on case load and the fall on 12/5/2022 was discussed on 12/6/2022 with the IDT, of which Rehab Director-D is a part of. Rehab Director-D stated Dycem under the wheelchair cushion is standard for all residents. Rehab Director-D stated R3 has a small upper body and long legs so Rehab Director-D may have put the Dycem on top of the wheelchair cushion at that time but could not recall for certain. Rehab Director-D stated since R3 was already on Physical Therapy caseload, options had been prepared prior to therapy seeing R3 to address the fall out of the wheelchair and the Dycem was implemented on 12/7/2022 when R3 was seen by therapy. Surveyor asked Rehab Director-D if a scoop mattress was discussed with the IDT after R3's fall on 11/3/2022. Rehab Director-D could not recall a scoop mattress as part of the conversation. In an interview on 12/15/2022 at 1:19 PM, Surveyor reviewed with DON-B R3's falls. Surveyor asked DON-B if R3 had a scoop mattress placed on the bed after the fall on 11/3/2022 when the scoop mattress was the recommendation. DON-B stated DON-B would check with maintenance to see if a scoop mattress was ordered and placed on the bed. DON-B stated R3 had changed rooms in the last week or so and the scoop mattress may not have moved with R3. Surveyor asked DON-B if R3's Care Plan should have been revised with Dycem on top of the wheelchair cushion after R3's fall on 12/5/2022. DON-B stated Dycem is a standard on all wheelchairs under the cushion and the Dycem on top of the cushion should have been added to the Falls Care Plan because that is an extra intervention. In an interview on 12/15/2022 at 2:00 PM, DON-B provided the maintenance work order for R3's scoop mattress: the mattress was ordered and placed on the bed on 11/4/2022. DON-B stated R3's bed was not moved when R3 changed rooms. R3 changed rooms on 11/29/2022. DON-B stated if the scoop mattress had been on the Care Plan, the scoop mattress would have moved with R3, or the staff would have been aware R3 needed a scoop mattress. Surveyor noted R3 did not have a scoop mattress on the bed since 11/29/2022. No further information was provided at that time.

Based on observation, interview, and record review, the facility did not ensure that 1 (Resident #19) of 24 residents was provided an environment that was free of accident hazards. Resident #19 was provided a tub bath, using the facility's Apollo Tub. When the resident was removed from the tub, but still seated on the tub chair, the top of the tub chair disengaged from the base of the chair. Resident #19 fell backwards and hit her head. She was sent to the hospital where she received 5 staples to repair a laceration to the back of her head. After the resident fell , the facility did not analyze the hazards and risks to identify what may have caused Resident #19's fall. Findings include: Resident #19's medical record was reviewed 6-29-15 by Surveyor # . Resident #19 is [AGE] years old. According to her 5-7-15 MDS (Minimum Data Set) Resident #19 requires the assistance of one staff person when bathing. Her 5-6-15 care plan notes that she is alert and oriented times three and is able to make her needs known. According to the medical record, Resident #19 was sent to the hospital emergency roiagnom on [DATE], where she received 5 staples to a laceration on the back of her head. A CAT Scan of her neck and head was negative. The medical record did not document the cause of Resident #19's injury. On 6-29-15 at 9:40 am, Surveyor # interviewed Resident #19 and asked her about the accident. Resident #19 said that she was in the tub chair and fell backwards. She said that she was unsure what happened; but then stated, I understand now that they have to lock the shower chair. On 6-29-15 at 10 am, Surveyor # interviewed RN Manager - O. She said that Resident #19 had a fall during a bath. RN - O said that the chair was not locked and the resident tipped backwards. RN - O said that the DON could provide additional information via the facility's fall investigation. On 6-29-15, Surveyor # received the facility's Incident Report from the DON. The information was limited. The report noted: Tub chair fell off base when moving out of tub causing res to fall backwards. CNA - R was a Pool CNA and had provided Resident #19 with the tub bath at the time that the accident occurred. CNA - R provided the following statement. When I took her out of the tub the top fell off the base. The Comments section noted the following. Pool CNA re-instructed on use of tub chairs and to notify staff if has any concerns about any equipment. Apollo tub rep contacted to re-inservice all staff. On 6-29-15 at 11:20 am, Surveyor # interviewed the DON to ask for additional information. The DON said that she only knew that there was a clip/click that CNA - R did not engage. The DON said: All of our staff (non-pool) knew how to connect this. Surveyor # asked what part of the tub chair was not connected. DON said that she had no additional information and was only told that something did not click. The DON said that the facility had determined and ruled out any type of mechanical malfunction with the tub and the tub chair. When asked if staff had been re-in-serviced, the DON said that CNA - R had been shown how to use the tub after the incident. The DON said that further questions related to in-service could be directed to RN - S, who is the Inservice Director. On 6-29-15 at 1:10 PM, Surveyor # interviewed RN - S and asked what had caused Resident #19 to fall from the tub chair. RN - S said that it was thought that the brakes on the wheels of the tub chair had not been locked. RN - S said that most CNAs, but not all, had been re-inserviced to lock the brakes on the wheels of the tub chair. RN - S said that she was not responsible for and had not re-inserviced pool staff. As the situation was discussed further, RN- S said that she was not exactly sure what had caused the accident. Surveyor # asked how the facility could be reasonably sure that the incident would not recur if the facility had not identified the root cause of the accident. When Surveyor # asked who at the facility would be responsible for identifying the root cause, RN - S said that she was in charge of the facility's QAPI (Quality Assurance and Performance Improvement) program. When asked how she could appropriately in-service staff when the facility had not identified what may have caused the accident; RN - S said that she had simply re-inserviced all staff on the entire tub bath procedure. RN - S said that a representative from the Apollo Tub Company would be at the facility on July 9th or 14th to re-inservice all staff. On 6-29-15 at 1:20 PM, Surveyor # again spoke to the DON. Surveyor # asked for additional information to determine if the facility had analyzed the accident and attempted to determine what may have caused the accident. The DON said that all she knew was that it had something to do with clicking, but that she did not know what mechanism on the tub had not been clicked. The DON confirmed that the facility had not attempted to rule out operator error by having CNA - R re-enact how she had removed Resident #19 from the tub on the day of the accident. Surveyor # noted that the statement from CNA - R was quite brief (see above) and asked if the facility had further interviewed the CNA to obtain additional information. The DON confirmed that the facility had not obtained a more detailed statement from the CNA that outlined the steps the CNA had taken when removing Resident #19 from the tub. The DON re-iterated that Plant Operations Manager - T had reviewed all of the tubs after the accident and found no problems. The DON said that Surveyor # could speak with Staff - T. On 6-29-15 at 2:30 PM, Surveyor # interviewed Plant Operations Manager - T. He said that the facility maintenance department had checked all of the tubs at the facility after the accident. All tubs were working and the maintenance department did not identify any equipment problems with the tubs. Staff - T said that no repairs were made to the tubs, but staff may have tightened some screws. Staff - T said that the facility had planned for a representative from the Apollo Tub Company to visit the facility to check each of the tubs. On 6-29-15 at 2:45 PM In-Service Director - S provided Surveyor # with a list of the staff that had not yet been re-inserviced on the operation of the Apollo Tub. Staff - S confirmed that there were 17 CNAs who had the responsibility of providing baths to resident and had not yet been re-inserviced on how to use the Apollo Tub. The survey team shared the preceding information with the Administrator and DON during the exit conference on 6-29-15 at 4 PM. The Administrator said that he had concerns with the findings and wanted to provide additional information to Surveyor # . On 6-30-15, the Administrator faxed additional information to Surveyor # . Surveyor # reviewed the information on 7-1-15. On 7-2-15 from 9:40 am until 10:40 am, the Administrator and Surveyor # reviewed and discussed the faxed information that had been provided by the Administrator. The Administrator said that prior to the Recertification Survey, the facility had completed an extensive examination of the Apollo Tub. The Administrator clarified that the cause of the fall could not have been that the wheels on the tub chair had not been locked. The chair is designed so that a resident can be moved while sitting in the chair, which requires that the wheels are unlocked. The facility tested this by putting a staff person in the tub chair and pushing the person in the tub chair up and down the hallway. During this re-enactment, the seat did not disengage from the chair and the staff person did not fall out of the chair. The Administrator said that the facility had determined that 3-5 mechanisms on the tub chair needed to be disengaged in order for the seat to dislodge from the base of the chair. Surveyor # asked the Administrator how the facility knew that CNA - R had not incorrectly operated the tub chair and that this caused the resident to fall. The Administrator said that CNA - R had provided tub baths to residents before and after the accident and there had been no other accidents. The Administrator confirmed that the facility had not requested that CNA - R re-enact removing Resident #19 from the tub, so that the facility could rule out operator error. The Administrator confirmed that the facility had not obtained a more detailed statement from CNA - R describing in detail how she had removed Resident #19 from the tub. It should be noted that CNA - R's statement simply said that when she took the resident out of the tub, the top fell out of the base. However according to the Administrator, if 3-5 mechanisms on the tub were not engaged the chair could dislodge. The facility had not interviewed CNA - R to determine if she had engaged these 3-5 mechanisms to ensure that the Apollo Tub and chair were used correctly. Without this information, the facility had not thoroughly analyzed the accident to identify the potential hazards and put a plan into place to prevent a recurrence of an accident with the Apollo Tub.