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

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