Every finding on record at Cura of Monticello

Based on record review and interview, the facility failed to ensure residents' comprehensive care plans were updated to include Enhanced Barrier Precautions (EBP) interventions for 3 of 3 residents reviewed (R11, R14, and R28) who met criteria for EBP. Furthermore, based on observation, interview and document review, the facility failed to ensure resident care plans and TASK sheets contained information for 1 of 1 resident (R1) in the sample who received oxygen. Findings include: R11R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic congestive heart failure (a condition in which the heart has a reduced ability to pump blood effectively), hypertension (persistently elevated blood pressure), arthritis (inflammation of joints causing pain and stiffness), depression (a mood disorder causing persistent sadness and loss of interest), atrial fibrillation (an irregular and often rapid heart rhythm), pain in the right and left hands, bilateral blindness with category 3 severe visual impairment (profound vision loss), a stage 2 pressure ulcer (partial-thickness skin loss), congenital glaucoma (elevated eye pressure present at birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS also identified R11 was blind, at risk for falls, and had one stage 2 pressure ulcer. R11's electronic medical record (EMR), reviewed on 1/14/26, identified R11 required Enhanced Barrier Precautions due to wounds on the coccyx and back of the thigh. Review of R11's comprehensive care plan revealed no interventions addressing Enhanced Barrier Precautions, including the use of gowns and gloves during high-contact resident care activities, staff instructions, or infection control measures. There was no evidence the care plan had been revised to reflect R11's infection prevention needs. R14R14's annual MDS dated [DATE], identified R14 had intact cognition and required assistance with ADLs. R14's diagnoses included arthritis (joint inflammation causing pain and stiffness), osteoporosis (decreased bone density increasing fracture risk), anxiety disorder (persistent excessive worry and fear), depression (mood disorder causing persistent sadness and loss of interest), chronic obstructive pulmonary disease (COPD) (a chronic lung disease causing airflow limitation), respiratory failure (inability of the lungs to adequately exchange oxygen and carbon dioxide), displaced bimalleolar fracture of the right lower leg (fracture involving both ankle bones with bone displacement), complex regional pain syndrome (a chronic pain condition affecting a limb), neuralgia and neuritis (nerve pain and nerve inflammation), dysphasia (difficulty swallowing), lymphedema (swelling due to lymphatic fluid buildup), and chronic respiratory failure with hypoxia (long-term inadequate oxygen levels in the blood). The MDS indicated R14 received oxygen therapy and had no pressure ulcers or wounds. R14's EMR, reviewed on 1/14/26, identified R14 required Enhanced Barrier Precautions due to a pressure ulcer on the right medial ankle. Review of R14's comprehensive care plan revealed no interventions addressing Enhanced Barrier Precautions, including the use of gowns and gloves during high-contact resident care activities, staff instructions, or infection control measures. There was no evidence that the care plan had been revised to reflect R14's infection prevention needs. R28R28's quarterly MDS dated [DATE], identified cognition was coded as not assessed, and the resident required assistance with ADLs. R28's diagnoses included progressive neurological conditions (disorders affecting the brain and nervous system that worsen over time), Parkinson's disease with dyskinesia with fluctuations (a movement disorder causing tremors, rigidity, and involuntary movements that vary in severity), hypertension (chronically elevated blood pressure), non-Alzheimer's dementia (decline in memory, thinking, and reasoning not caused by Alzheimer's disease), anxiety disorder (persistent excessive fear or worry), psychotic disorder (loss of contact with reality, including delusions or hallucinations), hallucinations (perceiving sights, sounds, or sensations that are not present), obstructive sleep apnea (repeated airway obstruction during sleep causing breathing pauses), and adjustment disorder with anxiety (an emotional or behavioral response to stress causing anxiety symptoms). R28's EMR, reviewed on 1/14/26, identified R28 required Enhanced Barrier Precautions due to wounds on the right and left buttocks. Review of R28's comprehensive care plan revealed no interventions addressing Enhanced Barrier Precautions, including the use of gowns and gloves during high-contact resident care activities, staff instructions, or infection control measures. There was no evidence the care plan had been revised to reflect R28's infection prevention needs. During an interview on 1/15/26 at 10:10 a.m., nursing assistant (NA)-D confirmed staff relied on posted signage to determine which precautions residents were on. NA-D confirmed R11, R14, and R28 were on EBP precautions but was unsure of the reason and stated the residents had been on precautions for a long time. NA-D stated staff were to don gloves, a gown, and a face mask when assisting residents with high-contact ADLs. During an interview on 1/15/26 at 10:24 a.m., NA-E confirmed R11, R14, and R28 were on EBP precautions and had been on them for some time. NA-E confirmed staff relied on isolation signage and did not reference the care plan for EBP guidance. NA-E stated staff were to don gloves, a face mask, and a gown when assisting residents with high-contact cares. During an interview on 1/15/26 at 1:02 p.m., the registered nurse clinical coordinator (RN)-C and assistant director of nursing (ADON)-B confirmed R11, R14, and R28 required EBP and that EBP were not addressed in the residents' care plans. RN-C and ADON-B stated EBP should be included in the care plan, so staff are aware of how to care for each resident and understand the reason for the precautions. R1 R1's admission record documented the diagnoses of essential hypertension, paroxysmal atrial fibrillation and asthma. R1 was admitted to the facility after a hospital stay for pneumonia. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 required assistance with activities of daily living (ADLs), received oxygen and was moderately cognitively impaired. During observation and interview on 1/12/26 at 10:47 a.m., R1 stated she was admitted to the facility from a hospital after she fell due to pneumonia at home. R1 was wearing a nasal cannula for oxygen, no date was found to indicate when the tubing was last changed. Noted the cannula prongs (the parts placed in the nares of the nose) had a slight tan color (normally clear in color). R1 was unable to remember when her oxygen tubing was last changed. In review of R1's care plan, initiated 11/18/25, did not document the use of oxygen, only [Self-Care] deficit related to pneumonia, acute respiratory failure, neither the goal nor the approach sections documented the use of oxygen. A review of the Task section in Point Click Care (PCC – electronic medical record) for R1, also lacked documentation R1 was receiving oxygen therapy. In an interview on 1/15/26 at 1:41 pm, nursing care manager (RN)-B and assistant director or nursing (ADON)-A, after review of the R1's care plan and TASK section of the PCC, RN-B verified the documents lack the documentation R1 utilized oxygen (RN-B updated the TASK sheet before providing a copy to surveyor). The facility policy, entitled: Care Plans, Comprehensive Person – Centered (effective date: 02/2025) indicated the following: 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. b. The resident's physician (or primary healthcare provider) is integral to this process.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 of 5 residents (R4, R14, and R1) reviewed for oxygen services. Findings include: R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease or end-stage renal disease (advanced kidney failure associated with heart disease requiring dialysis or transplant), hypertension (chronically elevated blood pressure), diabetes mellitus (a metabolic disorder causing elevated blood glucose levels), non-Alzheimer's dementia (progressive cognitive decline not related to Alzheimer's disease), hemiplegia (paralysis affecting one side of the body), depression (a mood disorder characterized by persistent sadness and loss of interest), chronic obstructive pulmonary disease or COPD (a chronic lung disease causing airflow limitation), dependence on renal dialysis (requirement for dialysis due to kidney failure), and dependence on supplemental oxygen (requirement for oxygen therapy to maintain adequate oxygenation). During observation and interview on 1/12/26 at 3:19 p.m., R4 had an oxygen concentrator behind the recliner with attached oxygen tubing and a humidifier (bubbler). The oxygen tubing and bubbler were not labeled or dated. The bubbler contained visible condensation. R4 stated she wore oxygen at night and required staff assistance to apply it. R4 further stated she was not aware of when staff last changed the tubing or humidifier, and neither item was labeled nor dated to reflect when it was last changed. R4's electronic medical record, reviewed on 1/14/26, revealed no documentation indicating the oxygen tubing or bubbler had been changed within the previous 23 days. Further record review revealed not applicable was documented on the assigned tubing and bubbler change dates of 12/30/25, 1/5/26, and 1/13/26. The record revealed the last documented tubing change occurred on 12/23/25. R14 R14's annual MDS dated [DATE], identified R14 had intact cognition and required assistance with ADLs. R14's diagnoses included anxiety disorder (persistent excessive worry and fear), depression (a mood disorder causing persistent sadness and loss of interest), chronic obstructive pulmonary disease or COPD (a chronic lung disease causing airflow limitation), respiratory failure (inability of the lungs to adequately exchange oxygen and carbon dioxide), and chronic respiratory failure with hypoxia (long-term inadequate oxygen levels in the blood). The MDS indicated R14 received oxygen therapy. During observation on 1/12/26 at 12:09 p.m., R14 received oxygen via nasal cannula with attached oxygen tubing. The oxygen tubing was not labeled or dated and had a brown-tinged appearance, tubing is usually clear. R4's electronic medical record, reviewed on 1/14/26, revealed no documentation indicating the oxygen tubing or bubbler had been changed within the previous 30 days. Further record review revealed not applicable was documented on the assigned tubing change dates of 12/16/25, 12/23/25, and 1/6/26, and no was indicated on 1/14/26. The record revealed the last documented tubing change occurred on 12/3/25. During an interview on 1/15/26 at 10:10 a.m., nursing assistant (NA)-D stated it was the nurse's responsibility to change oxygen supplies. NA-D confirmed R4's and R14's oxygen tubing was not labeled or dated. During an interview on 1/15/26 at 10:24 a.m., trained medication aide (TMA)-E stated she changed a resident's oxygen supplies if it appeared in her charting tasks. TMA-E was not aware of how often oxygen supplies should be changed. TMA-E stated oxygen supplies should be labeled and dated when changed. TMA-E confirmed R4's and R14's oxygen tubing was not labeled or dated. During an interview on 1/15/26 at 1:02 p.m., the registered nurse clinical coordinator (RN)-C and assistant director of nursing (ADON)-B stated oxygen tubing and bubbler components should be changed weekly and were scheduled for overnight nursing staff to complete. RN-C and ADON-B stated supplies should be labeled and dated with the date changed. RN-C and ADON-B confirmed R4's tubing and bubbler had not been changed weekly and were last documented as changed on 12/23/25. RN-C and ADON-B further confirmed R14's tubing had not been changed weekly and there was no documentation indicating it had been changed within the past 30 days. ADON-B stated weekly replacement was important for infection control and respiratory care standards. R1 R1's admission record documented the diagnoses of essential hypertension, paroxysmal atrial fibrillation and asthma. R1 was admitted to the facility after a hospital stay for pneumonia. R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 required assistance with activities of daily living (ADLs), received oxygen and was moderately cognitively impaired. During observation and interview on 1/12/26 at 10:47 a.m., R1 stated she was admitted to the facility from a hospital after she fell due to pneumonia at home. R1 was wearing a nasal cannula for oxygen. Date of last time tubing and cannula was changed was not visualized, but noted the cannula prongs (the parts placed in the nares of the nose) had a slight tan color (normally clear in color). R1 was unable to remember when her oxygen tubing was last changed. Interview on 1/13/26 at 5:53 p.m., registered nurse (RN)-A stated the night shift was responsible for the changing of resident oxygen tubing. Further daily observations on 1/13/26 (at 1:06 p.m., 1:47 p.m. and 4:17 p.m.), 1/14/26 (at 9:20 a.m., 10:12 a.m. and 2:32 p.m.), and 1/15 26 at 7:53 a.m., continued to note the oxygen tubing was undated and appear not to have been changed. During observation on 1/14/26 at 9:20 a.m., R1 was observed to be lying in bed with only one of the two cannula prongs in her nose, with the other on her left cheek. The prong on her cheek was noted to have a slight tan color (prongs are normally clear plastic in color). During an interview on 1/15/26 at 1:41 p.m., nursing care manager (RN)-B and assistant director or nursing (ADON)-A stated it was the responsibility of the night shift nurse to change out all oxygen supplies, including nasal cannulas. ADON-A stated the night shift had a [Night] Shift Checklist which documented weekly/daily assignments the night shift staff were to complete. RN-B provided a copy of the checklist which indicated Tuesday night the staff were to Change [oxygen] tubing, [nebulizer] set ups (date and initial) and Reorder [oxygen supplies from [Northwestern] Respiratory. RN-B and ADON-A stated the staff should know which residents on their assignments receive oxygen but this information does show up in the TASK section of the resident's chart, and was not on the medication or treatment record. During observation and interview on 1/15/26 at 1:55 p.m., with RN-B in R1's room, R1's extension tubing was laying on the floor and no dating was noted. RN-B stated she would change out the tubing now and place a new cannula for when resident returned. The facility policy, entitled: Oxygen Administration – Log Term Care (effective date 02/2024) indicated in section J-1 the following: Nasal cannulas, mask, or mouth pieces are to be replaced weekly and as needed. All extension tubing is to be changed monthly and as needed.

Based on observation, interview, and record review, the facility failed to ensure the resident was provided adequate supervision and assistive devices to prevent avoidable accidents for 1 of 4 residents reviewed (R11) for accidents. Findings include:R11's annual Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition, was blind, and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic (congestive) heart failure (reduced heart pumping ability), hypertension (high blood pressure), arthritis (joint inflammation and pain), depression (mood disorder), atrial fibrillation (irregular heart rhythm), pain in the right and left hands, blindness in the right and left eyes, category 3 (severe visual impairment), a stage 2 pressure ulcer (partial-thickness skin loss), congenital glaucoma (increased eye pressure from birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS further identified R11 utilized a wheelchair for mobility and was at risk for falls.R11's quarterly MDS dated [DATE], identified R11 had intact cognition, was blind, and required assistance with ADLs. R11's diagnoses included chronic systolic (congestive) heart failure, hypertension, arthritis, depression, atrial fibrillation, pain in the right and left hands, blindness in the right and left eyes, category, a stage 2 pressure ulcer, congenital glaucoma, and Barrett's esophagus without dysplasia. The MDS further identified R11 utilized a wheelchair for mobility and was at risk for falls.Video footage (VF) dated 4/29/25, on family member (FM)-A phone was provided and was reviewed with FM-A on 1/13/26 at 6:39 p.m. The VF showed nursing assistant (NA)-H entered R11's room and asked how she could help R11, to which R11 responded, you know. NA-H stated, I don't know. R11 asked NA-H to take the call light and place it on the table. NA-H took the call light from R11, placed it on the corner of the nightstand, and deactivated the call light by pressing the button on the wall. NA-H stated, we are doing rounds now, how can I help you? R11 then handed NA-H her water pitcher and asked her to move it to the table, which NA-H did. R11 next asked NA-H to move her Bible from the bedside table to the table, which NA-H also did. R11 then asked NA-H to move the bedside table, and NA-H moved the bedside table to an area in front of the nightstand. R11 asked NA-H to get her wheelchair while R11 was removing her blanket and moving her feet closer to the edge of the bed. NA-H stated, I will be right back. It is not five yet. I am doing rounds, and I am not doing this, so I will be right back, okay. The VF showed R11 grasped the assist bar on the side of the bed and sat herself upright. NA-H stated, I am in the middle of rounds, retrieved R11's wheelchair from across the room, placed it next to the bed, and exited the room without applying the wheelchair brakes. R11 stood and stated, why did you move all that stuff on me, and this is not where I told you to put it either. R11 then took the call light from the corner of the nightstand and felt her way to the table to place the call light on the table. R11 then turned and attempted to move the bedside table closer to the table and reached for the arm of the wheelchair. The wheelchair rolled backward, causing R11 to fall forward, strike the bedside table, and land on her left side. The VF captured R11 stating, Ouch, good grief. You wouldn't be doing this stuff. I wouldn't be falling if you let me get up. Stupid people. Approximately 10-15 seconds later, NA-H reentered the room, observed R11 sitting on the floor, and R11 stated, Why do you always do this stuff to me? Why can't you just leave things alone and let me get up? NA-H then exited the room into the hallway and called out for assistance. R11 stated, You wouldn't have to have help if you left things alone and let me do it. Leave me alone and let me do what I have to do. No, you have to be moving things around differently. You want me to fall. NA-H then applied the wheelchair brakes and stood next to R11 while waiting for assistance. NA-G entered the room and positioned herself on R11's right side, while NA-H stood on R11's left side. NA-G and NA-H grasped under R11's arms and lifted her off the floor, R11 was not able to fully extend her legs, and placed her into the wheelchair. NA-H stated to NA-G, I think she slipped on the table, and then went to open the bathroom door. The video footage then ended.R11's care plan initiated 1/17/25 indicated the following:Focus area: Vision: Has severely impaired vision - is legally bind since birth, initiated on 11/18/2016.Goal was for R11 to continue to be aware of her surroundings as evidenced by verbal reports through the next review date.Care plan directed staff to discuss with R11 prior to rearranging any items in her room so she would be aware of where items were located.Focus area: Falls: Potential for Falls and Significant Injury r/t severely impaired vision, bedbound experiences bladder and bowel incontinence; requires items in room to remain in same place/position, tends to prefer to keep door to room closed, has an electric lift recliner- however is not using; hx of refusing transfer belt to be used at times; can utilize her call light; able to direct staff where to place her call light per her preference and was initiated on 8/7/2017.Goal was for R11 to remain free from falls through next review with the following interventions in place:Do not rearrange room - Date Initiated: 08/07/2017Dycem UNDER w/c Cushion Date Initiated: 05/02/2022Encourage resident to use call light for assistance when needed. Encourage resident to elevate legs/feet daily. - Date Initiated: 04/10/2022Encourage resident to wear appropriate footwear/shoes PRN Date Initiated: 08/07/2017Hearing evaluations as requested PRN Date Initiated: 05/02/2021R11 has an electric lift recliner in room. She is not using at this time. Family will use while visiting. Date Initiated: 04/23/2021Journs bed in wide position to reduce risk of falls with injury. Date Initiated: 10/07/2022Keep call light within reach in bedroom and encourage to utilize it. Verbalize placement PRN. Date Initiated: 10/07/2022R11's electronic medical record (EMR) reviewed 4/20/25 through 5/31/25 completed. Facility document, Post-Fall Investigation, was initiated on 4/29/25, but failed to indicate if the fall was reviewed at the interdisciplinary team meeting and did not include new or updated fall interventions. R11's progress notes failed to include if a nursing assessment, including vital signs and assessment for pain or injury, was completed prior to staff assisting R11 from the floor. R11's progress note dated 4/29/25 at 6:57 a.m., indicated, Witnessed fall in the resident's room because the resident leaned over to the table for support during transfer. The table slid over and the resident fell. The resident had a new bruise to her left elbow. No bleeding. No deep skin tear.Document provided by facility of R11's x-ray of Left foot dated 5/3/25, included the following information:Indication: Fall. Unable to bear weight.Findings/impression: Degenerative (gradual deterioration of tissues in the body, often associated with aging) changes are present at the interphalangeal joints (hinge joints allowing for flexion and extension of toes), first metatarsophalangeal joint (located at the base of each toe) and at the tarsometatarsal joints (located in the midfoot). There is diffuse osseous demineralization (bones have lost a significant amount of minerals, leading to weakened bone structure). There is a non displaced fracture (bone cracks or breaks but maintains proper alignment) at the third (middle) metatarsal neck (just below the head of the bone located below the toe) and questionably at the fourth metatarsal neck. R11's progress note dated 5/9/25 at 10:52 a.m., indicated, After interviews completed by multiple staff members and the resident regarding the resident's fall, it was not witnessed based on the communication reported to the facility administrator. RN [registered nurse] updated by clinical leadership regarding this note.During interview on 1/12/26 at 3:02 p.m., R11 stated she activated her call light for assistance with getting up and a nursing assistant entered the room and asked what she needed. R11 stated she requested help getting up. R11 stated the nursing assistant told her she was busy and left the room after moving her belongings. R11 stated she attempted to put items back where they belonged and fell. Staff then entered the room and picked me up by my arms and put me in my wheelchair and didn't check me out at all.During interview on 1/13/26 at 6:39 p.m., FM-A stated R11 activated the call light and a nursing assistant responded and informed R11 she did not have time to assist R11 out of bed and needed to complete rounds, stating she would return in approximately five minutes. R11 was left sitting on the edge of the bed. R11's personal items were not within reach, the call light was wrapped around the bedside table, and the wheelchair brakes were not locked. FM-A stated R11 attempted to reposition her items, unwrapped the call light, and felt for the wheelchair. When R11 attempted to stand, the unlocked wheelchair moved, causing R11 to fall onto her side. The nursing assistant entered the room after the fall, did not ask if R11 was okay, repositioned the wheelchair, applied the brakes, and called for assistance. R11 was picked up from the floor, placed into a wheelchair, and taken to the bathroom without an assessment being completed at that time, with vital signs obtained later. FM-A stated the fall was documented inaccurately and noted the nursing assistant stated the fall was witnessed despite not being present in the room at the time of the fall. FM-A further stated management was notified and expressed concern R11 should not have been moved from the floor prior to nursing assessment and vital signs should have been obtained immediately. FM-A stated R11 later reported pain along her entire side and sustained fractures to two toes, and months later an X-ray revealed a torn rotator cuff which FM-A felt was related to the fall.During interview on 1/14/26 at 1:51 p.m., NA-G stated she was working down another hall when NA-H informed her R11 had fallen. NA-G stated when she entered R11's room, R11 had already been assisted up and was seated in her wheelchair. NA-G stated NA-H told her R11 attempted to get up independently and pushed the bedside table, which led to the fall. NA-G stated facility policy required nursing assistants to wait to move a resident after a fall until a nurse completed an assessment. NA-G further stated, despite the policy, residents were often assisted off the floor based on how they normally transferred. NA-G stated nursing administration later questioned her regarding the fall, and she reported a concern that the registered nurse (RN)-D did not enter R11's room to complete a post-fall assessment. NA-G was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 1:58 p.m., RN-D stated R11 activated the call light and NA-H entered the room to respond. RN-D stated NA-H then notified her of the fall while she was administering medication at the medication cart. RN-D stated she called NA-G to get the mechanical lift and instructed staff to get her up while she continued passing medications. RN-D stated when she entered the room, R11 had already been lifted using the mechanical lift and was seated on the toilet. RN-D stated she observed R11's ankle was swollen and R11 reported pain. RN-D stated she asked R11 if she wanted to go to the hospital, and R11 declined. RN-D stated if a resident fell, a post-fall risk assessment should be completed, vital signs obtained, neurological checks initiated due to the fall being unwitnessed, and the resident's family and provider notified, with all findings documented in the medical record. RN-D was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 2:53 p.m., NA-H stated she was completing rounds with a co-worker when she entered R11's room and observed R11 on the floor. NA-H stated she called for the nurse, who was passing medications at the time. NA-H stated the co-worker, NA-G, and the nurse, RN-D, entered the room and assisted R11 off the floor while she continued completing rounds. NA-H was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 2:35 p.m., registered nurse clinical coordinator (RN)-C stated she began working at the facility in June 2025 and was unfamiliar with this fall. RN-C stated if a resident fell, staff should utilize a falls checklist and ensure the resident was stable. RN-C stated nursing staff should be notified immediately to complete an assessment, obtain vital signs, and complete required documentation. RN-C stated the resident should then be assisted up using a mechanical lift. RN-C stated the nurse should complete an initial safety assessment and notify the resident's provider and family, with all information documented in the medical record.During interview on 1/14/26 at 2:41 p.m., assistant director of nursing (ADON)-A stated she began working at the facility in June 2025. ADON-A stated the facility had a policy in place and staff were instructed to review the policy and were walked through required procedures. ADON-A stated the policy was relatively new and initiated by corporate. ADON-A stated staff were instructed to call for the nurse using the walkie-talkie system, after which the nurse would assess the resident and obtain vital signs. ADON-A stated the policy required use of a mechanical lift (Hoyer) to assist residents off the floor following a fall. ADON-A stated she did not recall additional details related to the incident.Multiple interviews were attempted with facility nursing leadership; however, leadership working at the time of the incident was either not available or no longer employed at the facility and current leadership reported they were unaware of the fall and related investigation.The Facility Fall Management policy dated 6/26 indicated nursing staff, in collaboration with members of the interdisciplinary team, would strive to identify residents' specific risk factors and respond to modifiable risk factors contributing to residents' fall history and implement interventions to reduce residents' risk of falling and minimize complications from falls.

Based on record review and interview, the facility failed to ensure weekly skin assessments were completed as scheduled for 1 of 1 residents (R14) reviewed for completion of skin assessments. Furthermore, based on observation, interview and document review, the facility failed to ensure residents care plans were implemented for 1 of 1 resident (R41) in the sample who received occupational therapy orders for positioning. Findings included: R14 R14's annual Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and required assistance with activities of daily living (ADLs). R14's diagnoses included arthritis (joint inflammation resulting in pain and stiffness), osteoporosis (decreased bone density with increased fracture risk), anxiety disorder (persistent excessive worry and fear), depression (mood disorder characterized by persistent sadness and loss of interest), displaced bimalleolar fracture of the right lower leg (fractures involving both ankle bones with displacement), complex regional pain syndrome (chronic pain condition associated with abnormal nerve response following injury), neuralgia and neuritis (nerve pain and nerve inflammation), dysphasia (difficulty with swallowing and/or speech related to neurological impairment), and lymphedema (swelling due to impaired lymphatic drainage). R14's care plan dated 1/5/26. identified R14 was at risk for impaired skin integrity and required weekly head-to-toe skin assessments. Record review on 1/15/26. revealed weekly skin assessment documentation was missing for the weeks of 1/8/26 and 1/15/26. No nursing notes, skin assessment forms, or wound monitoring records included the required assessments were completed. During an interview on 1/15/26 at 10:10 a.m., nursing assistant (NA)-D stated nurses completed the skin assessments weekly on residents' bath days. NA-D stated when nursing assistants assisted residents in the shower or tub room, they contacted the nurse by walkie-talkie, who either came to complete the skin assessment or completed it later in the resident's room. During an interview on 1/15/26 at 10:24 a.m., trained medication aide (TMA)-E stated nurses completed weekly skin assessments on residents' bath days. During an interview on 1/15/26 at 1:02 p.m., the registered nurse clinical coordinator (RN)-C and assistant director of nursing (ADON)-B stated weekly skin assessments were required for residents at risk for skin breakdown and confirmed staff were responsible for completing and documenting the assessments each week. RN-C and ADON-B stated R14's weekly skin assessments were not completed as scheduled and could not provide documentation showing the assessments were performed. RN-C and ADON-B confirmed the last documented skin assessment was completed on 1/1/25. ADON-B stated skin assessments were important for R14 due to a history of wounds, incontinence, limited mobility requiring chair use, and fragile skin. Review of the facility policy titled Skin Integrity Maintenance and Pressure Injury Prevention, dated 9/25, indicated residents were assessed for potential risk for skin breakdown and interventions were initiated to prevent skin alterations. The policy required staff to observe resident skin condition by completing a weekly skin audit upon admission, readmission, weekly, and as needed. R41 R41 admission record and Diagnosis Listing documented the diagnoses of Parkinson's disease, and major depression episode. R41 quarterly Minimum Data Set (MDS), dated [DATE], with a correction assessment completed on 1/6/26, indicated R41 required substantial/maximal assistance with most activities of daily living (ADLs), received substantial/maximal assistance with transferring and positioning and was moderately cognitively impaired. A review of R41's electronic medical records (EMR), MISC section (miscellaneous section of EMR for scanned documentation), an occupational therapy assessment (dated 4/7/25), the occupational therapist provided the following information and orders for R41: Positioning: keep custom WC reclined back at least 10 + degrees for optimal midline positioning. In review of R41's care plan printed 1/15/26, and nursing assistant Kardex printed 1/15/25, documented and directed nursing staff to recline R41's adaptive WC to assist in sitting more upright and prevent leaning. On 1/12/26 at 12:17 p.m., R41 was observed in his room, partially seated in adaptive wheelchair (WC). R41's upper body was leaning over the grab bar attached to his bed, attempting to get into bed. Staff were alerted. On 1/13/26 at 1:43 p.m., R41 was in his room leaning to the right over right side of WC. Nursing assistant (NA)-F just entered the room to make his bed. NA-F told R41 she would be laying him down once his bed was made. On 1/14/26 at 9:14 a.m., R41 had wheeled self into the bathroom and was attempting to self-transfer on to the toilet. Staff were alerted. On 1/14/2026 at 10:05 a.m., R41 was wheeling around his room in his WC leaning to the right and reaching down to his feet and front wheels on the WC. On 1/15/26 at 7:36 a.m., R41 was in room in WC, leaning forward in WC, playing with front WC wheels and talking to self. During all general observations from 1/12/26 through the morning of 1/15/26, R41's WC and WC back were always observed in a 90-degree position compared to the WC seat. During interview on 1/15/26 7:57 a.m., nursing assistant (NA)-A stated R41 is always leaning in the WC, but there are times he sits more upright on his own. NA-A could not remember if R41 was in a standard or adaptive WC. At 8:04 a.m., NA-A turned to NA-B and asked NA-B what type of WC R41 had. NA-B stated R41 had a standard WC. In an interview on 1/15/26 at 9:28 a.m., nursing care manager (RN)-A and assistant director of nursing (ADON)-A stated the facility had requested and ordered a new WC, with the medical supply company adapted for R41. Occupational therapy worked with R41 and the staff after it was delivered. During an interview on 1/15/26 10:21 a.m., occupational therapist (OTR)-A stated upon entering R41's room he was currently sitting at a 90/90 (defined as: resident's WC back was completely upright, to the seat - not reclined) showing how the adaptive WC tilts in place. OTR-A stated the purpose of the 10+ degree reclining was to allow R41 to sit up more straight by using his own body's gravity. OTR cued R41 to sit up straight, which he did, but then returned to the leaning to the right over the WC arm rest. OTR-A stated she was unaware of R41's leaning issues, and stated she would have to have nursing obtain orders for her to evaluate. OTR-A stated nursing should be letting therapy know when a resident might need to be seen and re-evaluated. A policy was requested, but was informed the facility did not have a policy specific to therapy orders for positioning.

Based on record review and interview, the facility failed to ensure the Brief Interview for Mental Status (BIMS) assessment was completed and accurately coded for a quarterly and/or admission Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed (R28 and R20). In addition, the facility failed to ensure a physical restraint assessment was completed for 1 of 1 resident reviewed (R8) for accuracy of assessment. R28 R28's quarterly MDS dated [DATE], identified cognition was coded as not assessed. R28 required assistance with activities of daily living (ADLs). R28's diagnoses included progressive neurological conditions (disorders affecting the brain and nervous system that worsen over time), Parkinson's disease with dyskinesia with fluctuations (a movement disorder causing tremors, rigidity, and involuntary movements that vary in severity), hypertension (chronically elevated blood pressure), non-Alzheimer's dementia (decline in memory, thinking, and reasoning not caused by Alzheimer's disease), anxiety disorder (persistent excessive fear or worry), psychotic disorder (loss of contact with reality, including delusions or hallucinations), hallucinations (perceiving sights, sounds, or sensations that are not present), obstructive sleep apnea (repeated airway obstruction during sleep causing breathing pauses), and adjustment disorder with anxiety (emotional or behavioral response to stress causing anxiety symptoms). R28's annual MDS dated [DATE], identified the resident had intact cognition, was alert, able to communicate, and capable of responding to questions during routine care and nursing assessments during the same assessment reference period. During an interview on 1/15/26 at 12:06 p.m., the corporate MDS nurse (MDS-C) confirmed the BIMS assessment was not completed for the quarterly MDS and was coded as not assessed when the MDS was submitted. MDS-C stated no clinical justification or documentation existed to support the decision to code the BIMS as not assessed. Review of federal MDS guidelines required facilities to attempt and accurately code the BIMS for residents able to participate to ensure accurate assessment of cognitive status. Review of the facility policy titled Minimum Data Set, Management of, Long Term Care, dated 1/26, indicated the facility was responsible for ensuring the MDS was accurately and comprehensively completed. The policy further stated all MDS assessments and records would be completed and electronically encoded into the facility's electronic medical record and transmitted to the state database in accordance with current regulations. R20 R20's admission Minimum Data Set (MDS) dated [DATE], identified R20's cognition was coded as not assessed. R20 was dependent on staff assistance with activities of daily living (ADL's). R20's diagnoses included hypertensive heart and chronic kidney disease with heart failure (chronic high blood pressure leading to heart failure and reduced kidney function), hyperlipidemia, benign prostatic hyperplasia (enlarged prostate causing urinary symptoms), history of transient ischemic attack (brief episode of neurological dysfunction), retention of urine, repeated falls, and anemia. Review of R20's electronic medical record (EMR) admission through 1/15/26, failed to indicate there was a brief interview for mental status (BIMS) completed for R20. R20's care plan reviewed 1/14/26 failed to address R20's cognitive status. When interviewed on 1/15/26 at 12:06 p.m., the corporate MDS nurse (MDs)-C stated BIMS assessment was expected to be completed at admission, quarterly and when there was a significant change. MDS-C reviewed R20's assessments, stated she was unable to locate a BIMS assessment in R20s EMR and should have been completed. Review of federal MDS guidelines required facilities to attempt and accurately code the BIMS for residents able to participate to ensure accurate assessment of cognitive status. Review of the facility policy titled Minimum Data Set, Management of, Long Term Care, dated 1/26, indicated the facility was responsible for ensuring the MDS was accurately and comprehensively completed. The policy further stated all MDS assessments and records would be completed and electronically encoded into the facility's electronic medical record and transmitted to the state database in accordance with current regulations. R8 R8's quarterly MDS dated [DATE], indicated R8 was cognitively intact and was dependent on staff for ADLs. R8's diagnoses included quadriplegia (paralysis that affects all limbs), dysphagia, autonomic dysreflexia (overreaction of nervous system), cramp and spasm. R8's care plan dated 11/3/25, indicated R8 utilized a seat belt in the wheelchair due to quadriplegia with core instability. R8 was able to stated when he wanted the seat belt on and off. On 1/12/26 at 3:44 p.m., observed R8 in wheelchair with seatbelt buckled. On 1/13/26 at 1:03 p.m., R8 was observed in wheelchair with seatbelt buckled. On 1/14/26 at 2:28 p.m., R8 was observed seated in wheelchair with seatbelt buckled. R8 stated he was unable to buckle and/or unbuckle the belt himself, had staff apply the seatbelt when placed in the wheelchair. R8 only unbuckled when going back into bed. R8 stated he preferred to have the seatbelt in place for safety and had never had skin concerns related to the seatbelt. Review of R8's EMR on 1/14/26 at 9:21 a.m., failed to indicate there was a physical device assessment completed regarding the use of a seatbelt for R8. When interviewed on 1/15/26 at 1:41p.m., assistant director of nursing (ADON)-A stated physical device assessments were expected to be completed on admission, quarterly and any significant change. ADON-A reviewed R8's EMR, ADON located a physical device assessment completed on 1/8/26, however the assessment did not address R8 utilizing a seatbelt in the wheelchair, further stating that was odd since R8 has utilized the seatbelt for as long as she could remember. ADON-A stated the assessment was important to ensure safe use of the seatbelt and whether it would be considered a restraint. Facility Physical Device Assessment – Long Term Care policy dated 4/2023, indicated a physical device assessment would be completed to determine the potential for use of restraints based on the residents' condition and medical symptoms. The policy further indicated ongoing re-assessment of the effectiveness and continued need would be completed through the duration of use.

Based on observation, interview, and record review, the facility failed to ensure residents were provided care in a manner that promoted dignity and respect by failing to offer and perform routine grooming services, specifically shaving, for 2 of 2 residents (R14 and R28) reviewed for personal hygiene. In addition, the facility failed to ensure a catheter bag containing urine was concealed from public view for 1 of 1 residents (R20) reviewed with a catheter.Findings included: R14 R14's annual Minimum Data Set (MDS) dated [DATE], identified R14 had intact cognition and required assistance with activities of daily living (ADLs). R14's diagnoses included arthritis (joint inflammation causing pain and stiffness), osteoporosis (decreased bone density increasing fracture risk), anxiety disorder (persistent excessive worry and fear), depression (mood disorder causing persistent sadness and loss of interest), chronic obstructive pulmonary disease (COPD) (chronic lung disease causing airflow limitation), respiratory failure (inability of the lungs to adequately exchange oxygen and carbon dioxide), displaced bimalleolar fracture of the right lower leg (fracture involving both ankle bones with bone displacement), complex regional pain syndrome (chronic pain condition affecting a limb), neuralgia and neuritis (nerve pain and nerve inflammation), dysphasia (difficulty swallowing), lymphedema (swelling due to lymphatic fluid buildup), and chronic respiratory failure with hypoxia (long-term inadequate oxygen levels in the blood). During observation on 1/12/26 at 12:02 p.m., R14 was observed in the dining room with several long white hairs along the right side of her jawline and chin measuring approximately one inch in length. During observation on 1/13/26 at 1:04 p.m., the white chin hair remained present along the right side of R14's jawline and chin. During observation and interview on 1/14/26 at 9:14 a.m., R14 continued to have chin hairs present and stated she did not like having them and stated staff needed to assist her with shaving. During observation on 1/15/26 at 10:18 a.m., R14 exited the tub room with facial hair still present. Staff assisted R14 to activities and did not offer to assist R14 with shaving. R14's electronic medical record (EMR), reviewed 4/20/25 to 1/15/26, revealed the following: R14's care plan, dated 1/5/26, revealed R14 required staff assistance with personal hygiene and grooming. EMR lacked documentation indicating staff offered shaving assistance or that R14 refused shaving. R28 R28's quarterly MDS dated [DATE], identified R28's cognition was not assessed and indicated R28 required assistance with ADLs. R28's diagnoses included progressive neurological conditions (disorders causing gradual decline in nervous system function), Parkinson's disease with dyskinesia with fluctuations (neurodegenerative disorder causing tremors, rigidity, and involuntary movements with symptom variability), hypertension (high blood pressure), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (persistent excessive worry and fear), psychotic disorder (condition involving impaired reality perception), hallucinations (seeing or hearing things not present), obstructive sleep apnea (repeated breathing interruptions during sleep), and adjustment disorder with anxiety (emotional response to stress causing anxiety). R28's annual MDS dated [DATE], identified R28 had intact cognition and required assistance with ADLs. During observation and interview on 1/12/26 at 1:04 p.m., R28 was observed with long facial hair extending beyond the chin and upper lip, with uneven growth. R28 stated he preferred to be clean shaven and stated he needed staff assistance with shaving. During observation on 1/13/26 at 1:46 p.m., R28's facial hair remained present. During observation on 1/14/26 at 9:11 a.m., R28 was observed exiting the tub room following his bath, and facial hair remained present. During observation and interview on 1/14/26 at 2:21 p.m., R28's facial hair remained present. R28 stated he had received a bath that morning, but staff had not assisted him with shaving and stated staff still have to do that. During observation on 1/15/26 at 7:27 a.m., R28's facial hair remained present. R28's EMR, reviewed 4/20/25 to 1/15/26, revealed the following: R28's care plan, dated 10/22/25, indicated R28 required staff assistance with personal hygiene and grooming. EMR lacked documentation indicating staff offered shaving assistance or that R28 refused shaving. EMR also identified a task for staff to assist R28 with shaving every morning; however, the task was documented as completed (yes) on 1/13/26 and 1/14/26 despite observations and interview with R28 to indicate shaving was not performed. During interview on 1/15/26 at 10:10 a.m., nursing assistant (NA)-D stated NAs assisted residents with shaving. NA-D stated when chin hair was observed, staff could assist the resident with shaving at that time, otherwise it would be completed on bath days. NA-D stated both R14 and R28 required staff assistance with shaving and preferred to be clean shaven. During interview on 1/15/26 at 10:24 a.m., NA-E stated whichever staff member noticed facial hair on a resident should immediately assist the resident with shaving or ensure it was addressed on bath days. During interview on 1/15/26 at 1:02 p.m., the registered nurse care manager (RN)-C and assistant director of nursing (ADON)-B stated they expected staff to assist residents with shaving on bath days or whenever facial hair was observed. RN-C and ADON-B stated R28 was very particular about shaving and that being clean shaven was very important to him. RN-C and ADON-B confirmed both R14 and R28 should have been assisted with shaving by staff. ADON-B stated assisting residents with shaving was important for the resident's dignity. R20 R20's admission MDS dated [DATE], identified R20 was dependent on staff for activities of daily living (ADLs). Diagnoses included Hypertensive heart and chronic kidney disease with heart failure, hyperlipidemia, benign prostatic hyperplasia (enlarged prostate causing urinary issues by pressing on the urethra), and retention of urine. R20 had an indwelling catheter. During observation on 1/12/26 at 10:17 a.m., R20 was seated in common area watching television (TV) with urine catheter bag hung from leg rest on wheelchair, no cover was in place. Yellow colored urine was observed in the bag. On 1/13/26 at 3:37 p.m., observed R20 seated in his room, door open, observed from the hallway R20's catheter bag was uncovered with yellow urine observed in the bag. On 1/13/26 at 5:55 p.m., R20 was observed in the main dining room, catheter bag was hung, uncovered, on R20's wheelchair, with yellow urine visible. On 1/14/26 at 9:44 a.m., R20 was seated in his room, catheter bag uncovered with yellow urine visible. On 1/15/26 9:57 a.m., R20 observed seated in his room, uncovered catheter bag was hung on side of leg rest on wheelchair with yellow urine visible from the hallway. When interviewed on 1/15/26 at 11:00 a.m., nursing assistant (NA)-A stated R20 did not use a leg bag for his catheter. NA-A stated catheter bags had a blue privacy flap attached to the bag to protect dignity of residents with catheters. NA-A and surveyor observed R20's catheter bag, NA-A stated, Oh he doesn't have a flap, NA-A further stated since the bag did not have a flap it should have been placed in a privacy bag. When interviewed on 1/15/26 at 11:48 a.m., licensed practical nurse (LPN)-A stated privacy bags were available and should be in place when a resident has left their room. LPN-A stated the catheter bags usually had a privacy flap which protected residents' dignity especially in the dining room, LPN-A stated, I know I don't want to look at someone's urine. When interviewed on 1/15/26 at 1:41 p.m., assistant director of nursing (ADON)-A stated the expectation was for the privacy and dignity of residents, catheter bags were to be placed in a privacy bag or a bag with a privacy flap was to be used. Facility Quality of Life-Dignity policy dated 10/2025, indicated demeaning practices and standards of care that compromise dignity are prohibited, staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered.

Based on record review and interview, the facility failed to ensure a resident was assessed, as scheduled, for the ability to safely self-administer a prescribed nebulizer treatment for 1 of 1 resident reviewed (R14). Specifically, the facility failed to complete required assessments to determine the resident's continued ability to self-administer nebulizer treatments in accordance with facility policy and professional standards of practice. This deficient practice resulted in the potential for improper medication administration, missed or ineffective treatments, and respiratory compromise.Findings included:R14's annual Minimum Data Set (MDS) dated [DATE] identified R14 had intact cognition and required assistance with activities of daily living (ADLs). R14's diagnoses included chronic obstructive pulmonary disease [COPD] (chronic lung disease causing airflow limitation), respiratory failure (inability of the lungs to adequately exchange oxygen and carbon dioxide), dysphasia (difficulty with swallowing and/or speech related to neurological impairment), and chronic respiratory failure with hypoxia (long-term inability to maintain adequate blood oxygen levels). The MDS indicated R14 received oxygen therapy.During observation on 1/15/26 at 9:14 a.m., R14 was observed sitting in her wheelchair in her room with her eyes closed and her head hanging forward. The nebulizer mask was not fully sealed around R14's mouth and nose, and the medication canister was empty while the machine continued to run.Physician's order dated 11/5/25, included scheduled nebulizer treatments of Ipratropium-Albuterol inhalation solution 3 mg (milligrams)/3 mL(milliliters) three times daily related to chronic obstructive pulmonary disease.Physician's order dated 1/13/23, approved R14 to self-administer the treatment after nursing setup and assessment.Review of R14's clinical record revealed the last documented self-administration assessment was completed on 3/24/25. This assessment indicated R11 was able to self-administer nebulizer treatments after medication was set up. The record indicated further assessments were required to be completed quarterly (6/25, 9/25, and 12/25) to evaluate R14's ongoing ability to safely and effectively self-administer nebulizer treatments, including proper equipment setup, medication preparation, administration technique, and recognition of adverse effects. Further record review for dates 4/2025 through 1/14/2026, revealed no evidence nursing staff reassessed R14's competency for self-administration at the facility-defined reassessment intervals. During interview on 1/15/26 at 10:24 a.m., trained medication aide (TMA)-E stated she was not sure which residents had self-administration orders and was not aware where to locate that information. TMA-E stated she set up R14's nebulizer solution at 9:00 a.m., assisted R14 with applying the nebulizer mask, turned the nebulizer machine on, and then left the room. TMA-E stated R14 usually turned the nebulizer machine off once the treatment was completed. During interview on 1/15/26 at 1:02 p.m., the registered nurse care manager (RN)-C and assistant director of nursing (ADON)-B stated self-administration assessments were required to be completed quarterly and confirmed R14's last assessment was completed on 3/24/25. RN-C and ADON-B stated R14 should have had three assessments completed since that date to ensure she remained able to safely self-administer nebulizer treatments. RN-C and ADON-B confirmed observation of R14's nebulizer running without staff supervision would be considered self-administration of medications. The facility's Medication Self-Administration by Residents policy, dated 2/24, indicated residents were permitted to self-administer medications only in accordance with specified procedures. The policy required interdisciplinary team review and a competency assessment addressing medication safety, physical and cognitive ability, understanding of medication purpose and side effects, ability to follow instructions and timing, knowledge of refusal rights, and safe storage practices. The policy further required residents to demonstrate competency through return demonstration, with continued approval dependent on quarterly interdisciplinary review and compliance with physician orders and facility procedures.

Based on interview and record review, the facility failed to ensure a resident was informed of the medications being administered at the time of administration in accordance with the resident's expressed preferences and right to make informed choices for 1 of 1 resident (R11) reviewed. Specifically, the facility failed to verbally identify medications prior to administration for a resident who was blind and had requested to be informed of all medications received. Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic (congestive) heart failure (reduced heart pumping ability), hypertension (high blood pressure), arthritis (joint inflammation and pain), depression (mood disorder), atrial fibrillation (irregular heart rhythm), pain in the right and left hands, blindness in the right and left eyes, category 3 (severe visual impairment), pressure ulcer, stage 2 (partial-thickness skin loss), congenital glaucoma (increased eye pressure from birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS also identified R11 was blind and required assistance with medication administration.During an interview on [DATE] at 6:39 p.m., family member (FM)-A stated R11 and the family had repeatedly requested staff inform R11 of what medications she was receiving prior to each medication administration due to her blindness. FM-A stated this concern had remained unresolved, as staff continued to administer medications without consistently informing R11 of what medications she was receiving.During observation on [DATE] at 7:29 a.m., trained medication aide (TMA)-E prepared R11's medications and placed them in applesauce. TMA-E entered R11's room and administered the medications using a spoon. TMA-E did not inform R11 what medications were being administered.During an interview on [DATE] at 7:31 a.m., TMA-E stated she did not tell R11 what medications she was receiving and stated that if R11 questioned what she was receiving, she would then tell her.During an interview on [DATE] at 7:38 a.m., R11 stated she was unable to see medications and relied on staff to tell her what medications she was receiving. R11 stated staff often administered medications without explaining what they were or why they were given. R11 has requested staff inform her of each medication prior to administration, but staff had not done so. R11 stated when she asked, staff were short with her, so she stopped asking. When asked how she felt about not being informed of her medications, R11 stated, It is what it is. I guess I haven't died or gotten sick yet.Record review revealed special instructions on R11's profile and banner in the electronic medical record (EMR) indicated R11 requested to receive medications in private and requested to be informed of all medications at every medication pass.R11's care plan, reviewed date of [DATE], indicated R11 would receive medications based on preferences listed in Special Instructions, with review by the RN clinical coordinator annually and as needed.During an interview on [DATE] at 1:02 p.m., the registered nurse clinical coordinator (RN)-C and assistant director of nursing (ADON)-B confirmed R11 was blind and stated staff were expected to explain medications when administering them. RN-C and ADON-B stated it was important because R11 could not see and had the right to know what medications she was receiving.The facility Quality of Life policy, dated 10/25, indicated residents would be assisted in maintaining and enhancing self-esteem and self-worth. The policy stated staff shall keep residents informed and oriented to their environment, explain procedures before they were performed, and inform residents in advance of changes to usual routines or surroundings.

Based on record review and interview, the facility failed to ensure the resident's representative was notified after a fall for 1 of 1 resident (R11) reviewed for notification of change. Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic (congestive) heart failure (reduced heart pumping ability), hypertension (high blood pressure), arthritis (joint inflammation and pain), depression (mood disorder), atrial fibrillation (irregular heart rhythm), pain in the right and left hands, blindness in the right and left eyes, category 3 (severe visual impairment), pressure ulcer, stage 2 (partial-thickness skin loss), congenital glaucoma (increased eye pressure from birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS also identified R11 was blind and at risk for falls.R11's electronic medical record (EMR) reviewed 4/20/25 to 1/15/26 indicated an incident report dated 4/29/25, documented R11 was found on the floor in her room after attempting to transfer from bed to wheelchair. Nursing staff assisted R11 back into the wheelchair. Record failed to include documentation the resident's family or legal representative was notified of the fall or informed of the post-fall assessment findings. During an interview on 1/13/26 at 6:39 p.m., R11's family member (FM)-A stated she had not been notified by the facility of the fall that occurred on 4/29/25. FM-A stated she became aware of the fall only after viewing video footage from the camera in R11's room. FM-A stated she contacted the facility to discuss the incident and stated she would not have known the fall had occurred if she had not seen the video.During an interview on 1/15/26 at 2:06 p.m., the assistant director of nursing (ADON)-A confirmed the resident's family should have been notified after the fall and acknowledged there was no documentation of notification in the medical record.The facility Falls policy, dated 6/25, indicated staff would notify the resident's representative after completing the Post-Fall Investigation.

Based on record review and interview, the facility failed to ensure accurate reporting of an alleged violation involving resident neglect for 1 of 1 incident reviewed involving (R11). Specifically, the facility reported inaccurate information related to a resident fall with injury, which did not accurately reflect the circumstances and outcome of the accident. This deficient practice resulted in the potential for delayed or inappropriate oversight, failure to ensure resident protection, and noncompliance with federal reporting requirements.Findings include:R11's annual Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition, was blind, and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic (congestive) heart failure (reduced heart pumping ability), hypertension (high blood pressure), arthritis (joint inflammation and pain), depression (mood disorder), atrial fibrillation (irregular heart rhythm), pain in the right and left hands, blindness in the right and left eyes, category 3 (severe visual impairment), a stage 2 pressure ulcer (partial-thickness skin loss), congenital glaucoma (increased eye pressure from birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS further identified R11 utilized a wheelchair for mobility and was at risk for falls.R11's quarterly MDS dated [DATE], identified R11 had intact cognition, was blind, and required assistance with ADLs. R11's diagnoses included chronic systolic (congestive) heart failure, hypertension, arthritis, depression, atrial fibrillation, pain in the right and left hands, blindness in the right and left eyes, category, a stage 2 pressure ulcer, congenital glaucoma, and Barrett's esophagus without dysplasia. The MDS further identified R11 utilized a wheelchair for mobility and was at risk for falls.R11's electronic medical record (EMR) reviewed 4/20/25 through 1/15/26 revealed R11 experienced a fall on 4/29/25 that resulted in injury. Review of the EMR, incident report, and nursing documentation indicated the resident sustained injuries requiring assessment and intervention.R11's progress note dated 4/29/25 at 6:57 a.m., indicated, Witnessed fall in the resident's room because the resident leaned over to the table for support during transfer. The table slid over and the resident fell. The resident had a new bruise to her left elbow. No bleeding. No deep skin tear.Further record review revealed R11 underwent an x-ray of her foot on 5/3/25, after family member (FM)-A requested further evaluation. Review of the x-ray results indicated R11 sustained fractures to multiple toes as a result of the fall. Post-fall documentation confirmed the injuries required medical evaluation and treatment. Review of the EMR and facility investigation revealed the facility did not submit a corrected or amended report after identifying discrepancies in the reported information. An untitled word document located in the facility investigation folder indicated, On 5/1/2025 at around 4:00 p.m., the administrator and RN went to visit with the resident and family to address their concerns, including:There was no communication to them about the fall.On camera footage, no one asked if the resident was okay.Prior to the fall, a staff member did not lock the brakes on her chair, and the daughter stated the chair should always be locked as a standard for the resident.The daughter stated the aide said, I'm too busy, to help the resident.The daughter believed the aide stood outside/on the edge of the room and observed the resident attempting to be independent rather than helping her because the aide was quickly present after the fall to assist.There was no vital signs machine available immediately after the fall.The incident occurred around 4:50 a.m. on the NOC shift.Review of the facility document, Vulnerable Adult Reporting checklist dated 5/3/25, indicated no staff re-education was completed, as the facility documented the resident self-transferred, which the document indicated led to the fall.Review of the facility's report submitted to the State Agency (SA) on 5/3/25, indicated notification was received to facility that a fracture was found upon x-ray of R11's left foot. R11 had been experiencing pain in her left foot after a self transfer that resulted in a fall. R11 was transferred herself to wheelchair and slid out on to the ground on left side. Fracture may have occurred due to that fall on 4/29. The fall was investigated on 5/1 and interviews with resident were completed, as well as with the staff who were working at the time of the fall. R11's progress note dated 5/9/25 at 10:52 a.m., indicated, After interviews completed by multiple staff members and the resident regarding the resident's fall, it was not witnessed based on the communication reported to the facility administrator. RN [registered nurse] updated by clinical leadership regarding this note.Review of the facility's 5-day report submitted to the SA on 5/9/25, indicated the facility's summary revealed R11 liked to get up at an earlier time in the morning and did not think the staff were coming to help her fast enough. R11 pushed her table back and tried sitting on her wheelchair but there was no breaks on the wheelchair so she slipped onto her left side onto the floor. Later a fracture was discovered and initial report submitted. Two of the staff members who were working at the time reported that a fall occurred when they were doing rounds. One staff member went into R11's first, and than another came in and assisted with care due to the fall. Verified a fracture took place probable due to Fall occurred on 4/29/25 when R11 self-transferred. Facility indicated there was no perpetrator in this incident. Review of the facility's report submitted to the required reporting entity indicated the fall was reported inaccurately, including incorrect or incomplete information regarding the circumstances surrounding the fall. The information reported was inconsistent with the facility's internal documentation and R11's medical record. Multiple interviews were attempted with facility nursing leadership; however, leadership employed at the time of the incident was either unavailable or no longer employed by the facility. Current facility leadership reported they were unaware of the fall and the related investigation.According to the facility's investigation, the following interviews were conducted by facility leadership following R11's fall:Nursing assistant (NA)-G Statement: 5/1/2025 Employee was working with another resident and the RN said that there was a fall with R11. The other co-worker NA-H was working with another resident and saw R11's call light and said that she was working with another resident, and she would come back. R11 maybe got impatient and when NA-H got back she heard screaming and R11 was on the floor and a couple minutes later NA-G came in. There was just the two of them and the RN asked if there were any injuries and there was small cut on elbow, a bruise on her shoulder and something red on her right leg but was unsure if it was from the fall. A couple of minutes later the RN came in to do a skin check. Employee took vitals after the resident was put in her chair.NA-H Statement: 5/3/2025 NA-H was working at 4:30 AM doing rounds and working with a resident, and saw that R11's call light was on. She went in and said, can I help you? R11 said you know, I would like to get dressed and then NA-H told the resident that she would be back because she was in the middle of rounds and that she would back as she was in the middle of cares so she would be back. NA-H went to the other residents room and then after she was done with the other resident she heard screaming, and searched to see who it was and found that it was R11, as she checked two rooms close by hearing the screaming. When she went in R11 was already on the floor so she went and stood by her and asked if she was okay, R11 said that someone put something in her way and NA-H thought R11 had moved the table, and told R11 that no one had put anything in her way. NA-H called the nurse to come and do vitals and her co-worker came in, and helped put R11 in her chair. After this NA-H left the residents room.During interview on 1/14/26 at 1:51 p.m., NA-G stated she was working down another hall when NA-H informed her R11 had fallen. NA-G stated when she entered R11's room, R11 had already been assisted up and was seated in her wheelchair. NA-G stated NA-H told her R11 attempted to get up independently and pushed the bedside table, which led to the fall. NA-G stated facility policy required nursing assistants to wait to move a resident after a fall until a nurse completed an assessment. NA-G further stated that despite the policy, residents were often assisted off the floor based on how they normally transferred. NA-G stated nursing administration later questioned her regarding the fall, and she reported a concern that the registered nurse (RN)-D did not enter R11's room to complete a post-fall assessment. NA-G was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 1:58 p.m., RN-D stated R11 activated the call light and NA-H entered the room to respond. NA-H then notified her of fall while she was administering medication at the medication cart. RN-D stated she called NA-G to get the mechanical lift and instructed staff to, get her up, while she continued passing medications. RN-D stated when she entered the room, R11 had already been lifted using the mechanical lift and was seated on the toilet. She observed R11's left ankle was swollen and R11 reported pain. RN-D stated she asked R11 if she wanted to go to the hospital, and R11 declined. RN-D stated if a resident fell, a post-fall risk assessment should be completed, vital signs obtained, neurological checks initiated due to the fall being unwitnessed, and the resident's family and provider notified, with all findings documented in the medical record. RN-D was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 2:53 p.m., NA-H stated she was completing rounds with a co-worker when she entered R11's room and observed R11 on the floor. NA-H stated she called for the nurse, who was passing medications at the time. NA-H stated the co-worker, NA-G, and the nurse, RN-D, entered the room and assisted R11 off the floor while she continued completing rounds. NA-H was not able to recall why their interview was different with the surveyor than it was with the facility.During interview on 1/14/26 at 2:41 p.m., the assistant director of nursing (ADON)-A stated she began employment at the facility in June 2025. ADON-A reviewed the investigation and confirmed the fall was reported with inaccurate details and acknowledged the report did not fully or accurately reflect the incident as it occurred. ADON-A stated she did not recall additional details related to the incident.The facility's Vulnerable Adult Policy, dated 11/2025, indicated it was the responsibility of the facility to ensure all alleged violations involving abuse, neglect, injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than two (2) hours after the allegation was made if the events causing the allegation involved abuse or resulted in serious bodily injury, or not later than twenty-four (24) hours if the events did not involve abuse and did not result in serious bodily injury. Reports were required to be made to the facility administrator and other required officials, including the State Survey Agency and Adult Protective Services, where state law provided jurisdiction in long-term care facilities, in accordance with state law and established procedures. The policy further required all personnel to comply with applicable state and local laws regarding incidents of actual or suspected maltreatment, pursuant to 42 CFR S483.12(c)(1).The policy defined neglect as:Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision, that were reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical or mental capacity or dysfunction of the vulnerable adult, and which was not an accident or therapeutic conduct.The absence or likelihood of absence of care or services, including but not limited to food, clothing, shelter, health care, or supervision, necessary to maintain the physical or mental health of the vulnerable adult, which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety, or comfort.

Based on record review and interview, the facility failed to ensure the Office of the Ombudsman for Long-Term Care was notified of a resident's transfer to the hospital and subsequent discharge from the facility for 2 of 2 residents (R70 and R72) reviewed as a closed record.Findings include: R70 R70's admission Minimum Data Set (MDS) dated [DATE], identified R70's cognition was not assessed and R70 required assistance with activities of daily living (ADLs). R70's diagnoses included traumatic subdural hemorrhage with loss of consciousness, status unknown (bleeding between the brain and skull caused by trauma, potentially affecting neurological function), hypertension (chronic elevated blood pressure increasing cardiovascular risk), and heart failure (a condition in which the heart is unable to pump blood effectively to meet the body's needs). Record review revealed R70 was transferred to the hospital on [DATE], and was later discharged from the facility on 11/24/25. Review R70's complete medical record, facility transfer documentation, R70's discharge paperwork, and Ombudsman notification logs revealed no evidence or documentation indicating the Office of the Ombudsman for Long-Term Care was notified of R70's hospital transfer or discharge from the facility. R72 R72's admission Minimum Data Set (MDS) dated [DATE], identified R72 was cognitively intact and required assistance with activities of daily living (ADLs). R72's diagnoses included traumatic congestive heart failure (chronic condition where the heart muscle weakens and can't pump enough oxygen-rich blood), atherosclerotic heart disease (heart disease caused by plaque buildup in artery walls), diabetes, chronic kidney disease stage 3, peripheral vascular disease (narrowing and blockage, or spasm of blood vessels), hypertension (chronic elevated blood pressure increasing cardiovascular risk) and osteoarthritis (chronic generative joint disease where protective cartilage breaks down). Record review revealed R72 discharged home on [DATE]. Review of the R72's complete medical record, facility transfer documentation, R72's discharge paperwork, and Ombudsman notification logs revealed no evidence or documentation indicating the Office of the Ombudsman for Long-Term Care was notified of R72's discharge from the facility. During an interview on 1/15/26 at 12:17 p.m., the social services designee (SSD) stated she attempted to fax the Ombudsman weekly on Fridays all transfers and discharges that had occurred during the week. The SSD stated she used the same fax cover sheet, which did not indicate the date or time, and she did not receive confirmation that the fax was successfully sent. The SSD confirmed the facility did not have documentation verifying the Ombudsman was notified of R 70's transfer/discharge or R72's discharge and confirmed the facility could not provide evidence such notification occurred. Review of the facility's Discharge Policy, dated 2/25, revealed the policy required notification to the Ombudsman for resident transfers and discharges.

Based on observation, interview, and record review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) during resident care for 1 of 1 resident (R14) observed. In addition, the facility failed to discontinue isolation precautions that were no longer clinically indicated for 2 of 3 residents (R11 and R14) reviewed for infection control. Findings include:R11R11's quarterly Minimum Data Set (MDS) dated [DATE] identified R11 had intact cognition and required assistance with activities of daily living (ADLs). R11's diagnoses included chronic systolic congestive heart failure (a condition in which the heart has reduced ability to pump blood effectively), hypertension (persistently elevated blood pressure), arthritis (inflammation of joints causing pain and stiffness), depression (a mood disorder causing persistent sadness and loss of interest), atrial fibrillation (an irregular and often rapid heart rhythm), pain in the right and left hands, bilateral blindness with category 3 severe visual impairment (profound vision loss), a stage 2 pressure ulcer (partial-thickness skin loss), congenital glaucoma (elevated eye pressure present at birth), and Barrett's esophagus without dysplasia (abnormal esophageal lining without precancerous changes). The MDS also identified R11 had one stage two (partial-thickness skin loss) pressure ulcer.Throughout the week of the survey, R11 remained on EBP precautions with EBP precaution signage posted on the outside of the door, and personal protective equipment (PPE) was stored in a hanging organizer on the door.Record review on 1/15/26, revealed R11 was placed on EBP precautions on 6/16/25, for infection-related concerns related to wounds. Further record review on 1/15/26, revealed documentation indicated R11 no longer met criteria for EBP precautions. However, precaution signage and isolation status remained in place with no documented reassessment or order to discontinue precautions.R14R14's annual MDS dated [DATE], identified R14 had intact cognition and required assistance with ADLs. R14's diagnoses included arthritis (joint inflammation causing pain and stiffness), osteoporosis (decreased bone density increasing fracture risk), anxiety disorder (persistent excessive worry and fear), depression (mood disorder causing persistent sadness and loss of interest), chronic obstructive pulmonary disease (COPD) (a chronic lung disease causing airflow limitation), respiratory failure (inability of the lungs to adequately exchange oxygen and carbon dioxide), displaced bimalleolar fracture of the right lower leg (fracture involving both ankle bones with bone displacement), complex regional pain syndrome (chronic pain condition affecting a limb), neuralgia and neuritis (nerve pain and nerve inflammation), dysphasia (difficulty swallowing), lymphedema (swelling due to lymphatic fluid buildup), and chronic respiratory failure with hypoxia (long-term inadequate oxygen levels in the blood). The MDS indicated R14 received oxygen therapy and did not have any pressure ulcers or wounds.During observation on 1/12/26 at 1:32 p.m., nursing assistant (NA)-F assisted R14 from the wheelchair to the bathroom utilizing a mechanical lift (EZ Stand) while R14 remained on EBP isolation precautions. NA-F did not don required PPE (gown) prior to resident contact and provided hands-on assistance with toileting and hygiene without following EBP precautions. NA-F exited the room without performing hand hygiene. Throughout the week of the survey, R14 remained on EBP precautions with EBP precaution signage posted on the outside of the door, and PPE was stored in a hanging organizer on the door.R14's electronic medical record, reviewed on 1/15/26, revealed R14 was placed on EBP precautions on 4/14/25, for infection-related concerns related to wounds. Further record review on 1/15/26 revealed documentation indicated R14 no longer met criteria for EBP precautions; however, precaution signage and isolation status remained in place with no documented reassessment or order to discontinue precautions.During an interview on 1/12/26 at 2:04 p.m., NA-F confirmed R14 was on EBP precautions and confirmed she did not don the required PPE before assisting R14 to the bathroom as she was not aware as it was her first time assisting R14 due to being an agency staff and her first day at the facility. During an interview on 1/15/26 at 10:10 a.m., NA-D stated staff relied on posted signage to determine which precautions residents were on. NA-D confirmed both R11 and R14 were on EBP precautions but was unsure of the reason and stated both residents had been on precautions for a long time. NA-D stated staff were to don gloves, a gown, and a face mask when assisting residents, on EBP, with high-contact ADLs.During an interview on 1/15/26 at 10:24 a.m., NA-E confirmed R11 and R14 were on EBP precautions and had been on them for some time. NA-E stated R14 was on precautions for a wound on her foot that had been healed for a while. NA-E stated staff were to don gloves, a face mask, and a gown when assisting residents, on EBP, with high-contact cares.During an interview on 1/15/26 at 1:02 p.m., the registered nurse clinical coordinator (RN)-C and assistant director of nursing (ADON)-B stated R11 had been placed on EBP precautions for a wound on the coccyx and back of the thigh that had healed. RN-C and ADON-B stated wound care had been discontinued on 12/24/25. RN-C and ADON-B confirmed R11 remained on EBP precautions and stated precautions should have been removed on 12/24/25. RN-C and ADON-B stated R14 had been placed on EBP precautions for a pressure ulcer on the right medial ankle that had healed. RN-C and ADON-B stated wound care had been discontinued on 11/5/25. RN-C and ADON-B confirmed R14 remained on EBP precautions and stated precautions should have been removed on 11/5/25. RN-C and ADON-B confirmed staff were expected to follow EBP precautions for R14 as long as precautions remained posted.The facility's Enhanced Barrier Precautions policy, dated 3/25, indicated the facility used EBP precautions as recommended by the Centers for Disease Control and Prevention (CDC) to reduce transmission of multidrug-resistant organisms (MDROs) through the use of gowns and gloves during high-contact resident care activities. The policy stated MDROs may be indirectly transferred from resident to resident during high-contact care activities. The policy indicated EBP precautions were intended to remain in place for the duration of a resident's stay or until resolution of the wound that placed the resident at higher risk. The policy further indicated EBP precautions, utilizing a minimum of gown and glove use, were to be initiated for high-contact resident care activities including transferring, providing hygiene, and assisting with toileting.

Based on observation, interview and document review, the facility failed to ensure residents wheelchairs were kept clean for 1 of 1 resident (R41) in the sample whose wheelchair (WC) was stained with food debris.Findings include:R41's admission record and Diagnosis Listing documented the diagnoses of Parkinson's disease, and major depression episode.R41's quarterly Minimum Data Set (MDS) dated [DATE], with a correction assessment completed on 1/6/26, indicated R41 required substantial/maximal assistance with most activities of daily living (ADLs), received substantial/maximal assistance with transferring and positioning and was moderately cognitively impaired.On 1/12/26 at 12:17 p.m., R41 was observed in his room, partially seated in adaptive wheelchair (WC) and his upper body leaning over the grab bar attached to his bed, attempting to get into bed. Staff were alerted. It was noted that the right seat area of R41's WC and WC cushion had stains, which were yellow and white and food debris, chunks of food and dried liquid. The stains and food debris was was covering roughly a three inch x three inch are of the WC cushion, the visible under-sling seat which the cushion sat on. On 1/13/26 at 1:43 p.m., R41 was in room leaning to the right over right side of WC. Food debris was still present.During a breakfast dining room observation of R41, on 1/15/26 at 8:16 a.m., R41 was sitting at a dining room table feeding himself after staff set up. R41 was holding on the dining room table with his left hand, while still leaning to the right, feeding himself. As R41 fed himself, his mouth was over the same location of the staining and food debris observed on his WC seat support and cushion. A copy of the nursing assistant kardex was requested but not received. During an observation on 1/15/26 at 9:28 AM, nursing care manager (RN)-B also noted food debris on the right corner and cushion of R41's chair. RN-B stated the WCs are supposed to be cleaned al least weekly by the night shift staff. RN-B stated the WC cleaning is listed on the nursing assistant Kardex. RN-B stated it would be the facility's expectation that when a resident's chair is noted to be soiled, the staff should clean it when they see it. A copy of the nursing assistant kardex was requested but not received. A facility policy for the cleaning of wheelchairs was requested but not received

Based on observation, interview and document review the facility failed to ensure the facility was monitoring dialysis access site for 1 of 2 residents (R40) reviewed for dialysis. R40's annual Minimum Data Set (MDS) dated [DATE], identified R40 was cognitively intact and was independent with activities of daily living (ADLs) with exception of needing assistance with toileting and showering needs. R40 had diagnoses which included end stage 4 renal disease (kidney failure), dependance on hemodialysis (artificial blood filtration to remove waste and excess fluids), chronic pain, osteoarthritis and hypertension. Review of R40's electronic medical record (EMR) failed to identify an order for facility staff to assess R40's central venous catheter (CVC, port inserted in chest used for dialysis) for bleeding, to ensure CVC is secure and for signs of infection including redness, swelling, drainage, tenderness, warmth. During interview on 1/15/26 at 11:48 a.m., licensed practical nurse (LPN)-A stated there is no order that she was aware of to assess the CVC but knew R40 received dialysis so did look at the CVC site. When interviewed on 1/15/26 at 1:41 p.m., assistant director of nursing (ADON)-A stated R40 previously had a arteriovenous (AV) fistula (surgical creation of artery connected to vein in arm for access point for dialysis) that had failed before getting the CVC. ADON-A reviewed R40's orders and was unable to locate an order to assess the CVC site. ADON-A stated an order to assess the CVC site was expected to be in place, assessment was important for the health and safety of a resident that received dialysis. Facility hemodialysis, Care of a Resident with policy dated 8/2025, indicated licensed staff will monitor for complications related to hemodialysis which may include but not limited to bleeding, leg cramps, seizures, headache, fatigue, chest pain, and signs/symptoms of infection.

Based on observation, interview and document review, the facility failed to ensure survey results were placed in a prominent place and contained or directed where to obtain the last three years of survey results. This had the potential to affect all 64 residents residing in the facility, along with family, visitors and staff.Findings include:During interview on 1/14/26 at 1:09 p.m., R4 stated was not sure where the survey results were kept. During observation and interview on 1/15/26 at 12:14 p.m., business office manager (BOM) stated the binder that had, Resource Book, on the front of it had the survey results in it, there was a tab for survey results. Observed white, three ring, binder on edge of reception desk within easy reach of anyone. Binder had a front, clear, pocket and contained a white piece of paper that included the facility name and, Nursing Home Residents' Resource Binder. The edge of binder included the facility name and, Documents Available for Review. However, there was no indication on outer part of binder that survey results were inside. No signage was observed regarding where survey results were located for review. When interviewed on 1/15/2026 12:46 p.m., regional director of operations (RDOO) stated survey results were located in a binder in the front lobby area, there should be a sign that stated where to locate the survey results. RDOO stated no indication of location of results made them hidden from anyone that wanted to review them. RDOO expected there was the signage, and the binder should have indicated facility name - Survey Results, so residents, visitors and staff could review if desired. Facility policy regarding survey results was requested, however, none was provided.

Based on observation, interview and document review, that facility failed to comprehensively assess and implement interventions for 1 of 2 residents (R26) reviewed for pressure ulcers. R26 developed pressure ulcers after splint placement for ankle fracture resulting in actual harm when the facility did not clarify orders for monitoring or when to remove the splint. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact and received extensive assistance to complete activities of daily living (ADL's) including dressing, grooming and bathing, R26 required extensive assistance of two staff with transfers and toileting. R26's care plan, also indicated a self-care deficit related to weakness, unsteady balance, impaired cognition, tends to fatigue easily, and history of knee buckling. The care plan dated 2/5/25, directed staff to provide extensive assistance of two staff with transfers and toileting. Progress note dated 3/12/2025 at 5:59 p.m., indicated at 5:15 p.m. R26 was lowered to the ground after twisting ankle during assisted transfer. R26 was transferred by ambulance to the emergency room (ER) due to right ankle pain, swelling and decreased ability to move the ankle. Progress note dated 3/12/2025 at 11:43 p.m., R26 returned from the hospital with no new medication orders. R26 rated pain eight out of 10, ice was applied to right ankle. After Visit Summary dated 3/12/25, identified R26 was diagnosed with sprain of right ankle with instructions to wear air splint for comfort and stability, elevate, ice and rest, take pain medication as needed, return to the emergency room if symptoms worsen. Progress noted dated 3/20/2025 at 11:00 p.m., indicated R26's ankle was noted to be weepy, had been wearing a splint since the fall on 3/12/25. R26 had increased pain and swelling, when splint was removed to assess, was noted to have open areas on both sides of the ankle. R26 had a temperature of 99.4. Orders were obtained from the nurse practitioner (NP) to send R26 to the ER. Progress note dated 3/21/2025 2:37 a.m., indicated R26 was admitted to the hospital with cellulitis (bacteria infection of the skin and underlying tissue), pressure injury, and closed fracture of the right ankle. Review of R26's progress notes, physician orders and care plan, identified an order to wear air splint for comfort and stability. However, R26's electronic medical record failed to identify any indication or physician order to assess/monitor right ankle and splint between placement of splint on 3/12/25 and 3/20/25 when facility removed the splint after R26 had increased pain and swelling. Emergency Department note encounter date 3/20/25, indicated R26 was last in theER on [DATE], after twisting her ankle. R26 was advised symptomatic treatment and ankle brace. it appears that the ankle brace had not been removed since then. Today when brace removed, R26 noted to have redness and ulcer on both medial aspect (inner) and lateral aspect (outside) of right ankle. Progress note dated 3/24/2025 at 3:05 p.m., R26 readmitted from hospital with diagnosis of ankle fracture, open area on right ankle When observed on 4/14/25 at 6:58 p.m., R26 had a cast on right foot, when asked R26 stated I fractured my ankle. When interviewed on 4/16/2025 at 10:57 a.m., licensed practical nurse (LPN)-B stated if an order was not clear or parts were missing, the nurse needed to call the provider to clarify the orders. When interviewed on 4/16/25 10:59 a.m., LPN-A stated orders from a hospital return are entered by the health unit coordinator (HUC) and checked by two nurses or entered by a nurse and checked by another nurse. If an order does not make sense or is missing information, the nurse is responsible to contact the provider to get directions. LPN-A confirmed the order for R26's splint should have been clarified for specific instructions. When interviewed on 4/16/25 at 12:45 p.m., nurse practitioner (NP) stated the air splint should have been removed to provide cares, however, NP did not clarify how often the splint should have been removed for cares. If the staff had any questions about the splint they should have called and asked for clarification. Based on what was on the ER note the cause of the cellulitis and pressure sores resulted from the air splint not being removed. When interviewed on 4/16/25 at 2:52 p.m. the director of nursing (DON) stated no order was entered to remove the splint and check the skin. DON stated she expected when a resident returned with a removable device the nurses should get parameters/orders to remove and check the skin underneath, this was not done for R26. DON was unable to locate any procedure or process changes that were made to ensure that this did not occur again. Facility provided policy Transcription Processing Provider Orders - Long Term Care dated 1/2025, indicated transcribe order to the electronic medication administration record (EMAR)/electronic treatment administration record (ETAR). However the policy did not address clarifying orders.

Based on observation, interview and document review, the facility failed to comprehensively investigate a fall for 1 of 3 residents (R26), who had a fall while being transferred. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact and received extensive assistance to complete activities of daily living (ADL's) including dressing, grooming and bathing, R26 required extensive assistance to 2 staff with transfers and toileting. R26's care plan, also indicated a self-care deficit related to weakness, unsteady balance, impaired cognition, tends to fatigue easily, and history of knee buckling. The care plan dated 2/5/25, directed staff to provide extensive assitance of two staff with transfers and toileting. Progress note dated 3/12/2025 at 5:15 p.m., indicated R26 had a staff assisted fall at 1715 (5:15 p.m.) resident was lowered to the ground after twisting ankle during assisted pivot transfer with two staff. Injuries: right ankle pain and swelling after twisting it during transfer. R26 did not have full range of motion in right foot. R26 transferred to the hospital. R26's post-fall investigation form indicated R26 had a fall on 3/12/25 at 5:15 p.m., while being assisted to the bathroom, when ankle twisted during the transfer and R26 was lowered to the floor. The provided recap of the incident indicated R26 was lowered to the ground after twisting ankle during assisted pivot transfer with two staff. R26 was transferred to the hospital emergency room . However, there was no interviews with the staff involved during the transfer included with the investigation. Progress note dated 3/20/2025, at 11:00 p.m. Indicated R26 had increased pain and swelling in ankle, R26 was transferred to the hospital emergency room for evaluation. Progress note dated 3/21/2025, 2:37 a.m. indicated R26 was admitted to the hospital with cellulitis (bacteria infection of the skin and underlying tissue), pressure injury, and closed fracture of the right ankle. Facility reported incident to state agency 3/21/25, facility then completed investigation into R26's fall which occurred 3/12/25. During facility investigation was found during transfer on 3/12/25, R26 received assistance of one staff during pivot transfer resulting in R26 twisting ankle requiring being lowered to the floor. During interview on 4/16/25 at 10:58 a.m., trained medication aid (TMA)-A stated R26 needed assistance of two staff during transfers prior to her fall when she broke her ankle. During Interview on 4/16/25 at 10:59 a.m., licensed practical nurse (LPN)-A stated before R26 had the fall R26 required assistance of two staff with transferring and toileting. During interview on 4/16/25 12:27 p.m., nursing assistant (NA)-A stated she was transferring the resident herself, during the transfer R26 was unable to move her foot when she attempted to assist R26 to the wheelchair. NA-A stated R26 was then lowered to the floor, NA-A then called for assistance. During interview on 4/16/25 2:52 p.m., director of nursing (DON) stated at the time of the fall R26 required assist of two with transfers and toileting needs. When DON initially was informed of the fall, she was told there were two staff when R26 was transferred. DON stated she did not ask staff that were there what happened until after R26 had been admitted to the hospital with an ankle fracture. During the investigation at that time it was discovered R26's care plan was not followed and had been transferred by one person. Facility policy Fall Management - Long Term Care dated 2/2025, indicated responding to a resident fall obtain information from the resident and/or any witnesses's pertaining to the circumstances of the fall, obtain information from the staff on the unit/within the area prior to or during the fall.

Based on observation, interview and document review, the facility failed to assess the resident and determine safety for 1 of 1 resdients (R1) reviewed for self-administration of medications (SAM). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. R1's admission record printed 2/29/24, included diagnoses of chronic pain, depression, end stage renal disease, and dependance on renal dialysis (kidneys are no longer able to function properly). R1's medication review report printed 2/29/24, included orders for self-administration of eye drops and self-administration of oral medications after nurse set up. Medication review report did not include Orajel or generic equivalent. On 2/26/24 at 3:24 p.m., a red box of generic topical oral pain medication was observed on R1's bedside table. R1 stated she self-administers gel for tooth pain. On 2/28/24 at 2:16 p.m., a red box of generic topical oral pain medication was noted on R1's bedside table. R1 left the facility three times per week for dialysis. These appointments kept her out of the facility for a few hours each time, leaving room unattended. Interview on 2/28/24 at 10:29 a.m., trained medication assistant (TMA)-A stated she would immediately inform a nurse on duty when she found a medication in a resident's room that was not on the medication list. TMA-A stated residents needed to have a self-administration order that specifically noted it was safe for resident to store the medication in their room. Interview on 2/29/24 at 10:42 a.m., director of nursing (DON) stated when someone wanted to self-administer medications, the facility completed an assessment to ensure safety. The resident was assessed yearly or with a change in condition that may have affected their ability to self-administer medication. The facility would have obtained an order from the provider indicating the resident was allowed to self-administer the specific medication. The medication would have needed to be stored in a locked drawer or box in the resident's room. DON stated it was important to complete the assessment to ensure the resident was able to safely administer the medication. It was important for the medication to be kept in a secure area to ensure other residents did not have access to the medication. Facility policy titled Medication Self Administration by residents- Long Term Care dated February 2024, included residents would have been evaluated by an intradisciplinary team to determine ability, cognitive status and the resident's understanding of medication. Residents were to demonstrate understanding of when to take the medication and potential side effects before they would be approved to self-administer. Facility policy included medication would be stored in a locked drawer or compartment. A physician order was necessary if the resident wanted to keep their medication at the bedside.

Based on interview and document review, the facility failed to ensure oxygen therapy was provided per physician orders for 1 of 3 residents (R1) when R1, who required continuous oxygen (O2), had her oxygen removed by a nursing assistant (NA). This resulted in an immediate jeopardy (IJ). The immediate jeopardy began on [DATE], when R1's O2 was removed by a nursing assistant (NA). R1 went limp and unresponsive after approximately 9 minutes in the bathroom. R1 subsequently died . The administrator and director of nursing (DON) were notified of the immediate jeopardy at 3:39 p.m. on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore issued at Past Noncompliance. Findings include: R1's Face Sheet printed [DATE], identified R1 was admitted to the facility on hospice care [DATE] with diagnoses which included: chronic respiratory failure with hypoxia (a condition in which the body or region of the body is deprived of adequate oxygen supply at the tissue level, causing restlessness, confusion, anxiety, shortness of breath, rapid breathing and rapid heartbeat), pulmonary fibrosis, malignant neoplasm of right upper lobe of lung, and dependence on supplemental oxygen. On [DATE], a progress note indicated R1 had moderately impaired cognition. R1's Kardex printed [DATE], directed staff to notify the nurse prior to transfers so her oxygen level could be increased per orders. R1's Physician Orders dated [DATE] directed oxygen 5 liters (L) per minute at rest, and ,d+[DATE] L per minute at exertion, titrate for comfort. R1's Physician Orders dated [DATE] directed 5 L per minute at rest, and ,d+[DATE] L per minute with exertion. Titrate for comfort via high flow rate nasal cannula. On [DATE], R1's Weight and Vitals Summary indicated at 11:57 a.m. R1's O2 saturation (O2 sats, the level of oxygen in one's bloodstream. Normal is ,d+[DATE]%) was 88%. At 2:07 p.m. R1's O2 sats was 85%. At 4:09 p.m. R1's O2 sats was 90%. On [DATE] at 5:30 p.m., a progress note indicated at 4:55 p.m. R1 was noted to be unresponsive on the floor, and she did not have oxygen (O2) on. R1 was immediately placed on O2 at 15 L, and slow shallow breaths were noted. R1 was assisted to bed. R1's vital signs ceased at 5:02 p.m. The facility investigation indicated on [DATE] at 4:44 p.m., NA-A went into R1's room. At 4:46 p.m. NA-A exited R1's room. At 4:47 p.m. R1's bathroom call light went on. NA-B answered the call light seconds later. R1's call light went off, and NA-B exited R1's room at 4:48 p.m. At 4:49 p.m. R1's call light went on, and seconds later NA-B went into R1's room. At 4:52 p.m. NA-B exited R1's room partially running. At 4:53 p.m. RN-A entered R1's room. On [DATE] at 10:58 a.m., registered nurse (RN)-D indicated R1 required continuous O2 otherwise her oxygen saturation level would drop. In addition, RN-D stated R1 required an increase in O2 whenever R1 was going to do any activity, and NA's were expected to notify a licensed nurse prior to moving R1. On [DATE] at 11:45 a.m., RN-A stated R1's oxygen order indicated R1 required O2 via nasal cannula at 5 L when resting and required an increase in O2 to maintain O2 saturation levels when transferring or doing an activity. RN-A stated on [DATE], a NA alerted him R1 was on the floor. RN-A entered R1's bathroom and observed her on the floor, unconscious, without O2. R1 was transferred to her bed. RN-A listened to R1's heart and lung sounds and stated there was nothing there. RN-A confirmed he was not made aware R1 was going to be transferred to the toilet, so he did not increase R1's oxygen, nor ensure it was on. On [DATE] at 12:12 p.m., NA-A stated [DATE] was the first day she had assisted R1. NA-A stated at approximately 4:50 p.m. she answered R1's call light. She observed R1 sitting in her wheelchair, holding the call light, and her nasal cannula was on, hooked up to the room concentrator. NA-A stated she observed R1 being shaky, jumpy, and sweating a lot, and she appeared to be very anxious. NA-A stated she asked R1 if she could remove her O2 and R1 replied yes. NA-A removed R1's O2 and brought R1 into the bathroom using her wheelchair. When R1 was assisted to the toilet, R1 had a loose bowel movement. NA-A directed R1 to place the call light on when she finished, and NA-A left the bathroom. NA-A stated a few minutes later, NA-B came and reported R1 had fallen. NA-A stated when she entered R1's bathroom, R1 was on the floor unconscious, with both calves and feet tucked under her thighs. NA-A stated RN-A entered the bathroom and immediately questioned where R1's O2 was, and placed her nasal cannula on. NA-A stated R1 was placed into bed and took ,d+[DATE] spaced out breaths. R1 would not respond, and RN-A stated R1 had passed. NA-A confirmed she did not review R1's Kardex prior to assisting R1, and stated staff never explained the importance of that oxygen. NA-A stated she did not inform RN-A of R1's condition prior to assisting her to the bathroom, and was not aware R1 required an increase in O2 prior to transfers. On [DATE] at 12:38 p.m., NA-C indicated R1 required oxygen use which was very important due to R1's diagnoses. NA-C indicated on [DATE], she had transferred R1's source of O2 from the portable to the room concentrator. NA-C indicated she would compare flow rate of the source they are removing the resident from and ensure the flow rate matched on the next source. Further, NA-C confirmed she was unaware NA's could not apply or remove O2 or notifying a licensed nurse to increase R1's O2 prior to transferring R1. On [DATE] at 1:00 p.m., RN-C indicated R1 required continuous O2, and confirmed she was not aware R1 required an increase in O2 while transferring or completing any activity. On [DATE] at 1:26 p.m., NA-D stated R1 required continuous O2 and staff were expected to move R1's O2 room concentrator with her when she would use the bathroom, but NA's were not allowed to remove a resident's O2 or change source of O2. On [DATE] at 2:56 p.m., NA-B stated R1 was a new admit and [DATE] was the first time NA-B had assisted R1. NA-B stated he answered R1's bathroom call light at approximately 4:55 p.m., and observed R1 sitting on the toilet without O2. NA-B stated he was unaware R1 required the use of continuous O2 at that time. NA-B stated R1 was not finished at that time and did not notice anything different with R1 at that time. NA-B stated he returned approximately a minute later to assist R1 with transferring off the toilet and back into her wheelchair. NA-B stated when R1 stood up she went limp, and he assisted R1 to the floor. R1 was unresponsive. NA-B stated he exited R1's bathroom to find RN-A. NA-B stated he did not review R1's Kardex prior to assisting R1. On [DATE] at 3:41 p.m., hospice RN-E stated facility staff had reported on [DATE], R1 was in the bathroom without O2 on and went unresponsive. Staff assisted R1 into bed where she took a few breaths and then passed. Further, RN-E indicated R1 required continuous O2 5 L at rest and with any exertion or activity such as transferring or toileting, R1 required an increase in O2 above 5 L. In addition, RN-E confirmed R1 not having O2 applied could have contributed to R1's death. On [DATE] at 4:14 p.m., RN-B indicated R1 required continuous O2 and with any activity R1 would require an increase in O2. RN-B stated on [DATE], she was called to R1's room along with RN-A. Upon arrival to R1's bathroom, RN-B state R1 was observed on the floor, with no O2 on, and R1 appeared pale but breathing. RN-B stated O2 was applied and increased O2 to 15 L, R1 was assisted into bed and passed away. RN-B inquired why R1's O2 was not on to which NA-A stated she took R1 to the bathroom, approximately 9 minutes prior to incident, and was unaware R1 couldn't have the O2 off. On [DATE] at 4:45 p.m., the director of nursing (DON) stated on [DATE], NA-A removed R1's nasal cannula prior to assisting her with toileting and transferring. The DON stated NA-A did not notify RN-A prior to transferring R1, as R1's Kardex directed. The DON stated NA-B assisted R1 to transfer off the toilet and did not notify RN-A prior to transfer as R1's Kardex directed, as well as NA-B did not recognize or was not aware R1 required continuous oxygen. Further, DON staff were expected to review each resident's Kardex prior to start of their shift. On [DATE] at 10:13 a.m., the DON was interviewed again. The DON stated by not receiving O2, R1 could sustain hypoxia, restlessness, lethargy, cyanosis, sweating, elevated heart rate, loss of consciousness and death. On [DATE] at 11:24 p.m., the hospice medical director stated by not receiving O2, R1 was put at increased risk of loss of consciousness and/or death. On [DATE] at 11:35 a.m., the DON stated majority of all staff education regarding oxygen monitoring and hypoxia was completed by [DATE]. On [DATE] at 1:47 p.m., the facility medical director stated by R1's O2 not being applied put her at risk for an adverse outcome such as death due to R1's number of different pulmonary diagnoses. The Oxygen Administration-Long Term Care policy dated ,d+[DATE], identified licensed nurses and trained medication aids (TMA) may only regulate liter flow rates according to provider orders. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: NA-A was removed from the facility pending investigation and was provided immediate education on reviewing each resident's Kardex prior to start of shift. All nursing staff were educated on the facility policy related to oxygen monitoring which included identifying licensed nurses and trained medication assistants only can adjust oxygen rate and source as well as reviewing each residents Kardex prior to the beginning of the shift; and orientation for both licensed nurses and nursing assistants have been revised to include facility specific policy related to oxygen monitoring.

Based on interview and document review the facility failed to complete a drug regimen review for residents ordered psychotropic drugs to receive gradual dose reductions for 1 of 5 residents (R9) who were reviewed for unnecessary medications. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had intact cognition, a Patient Health Questionnaire score of 1 suggesting minimal depression which may not require treatment, a diagnosis of depression and was receiving an antidepressant. R9's diagnosis list dated 1/6/23, indicated Major Depressive Disorder, single episode, unspecified. R9's order summary report dated 1/6/23, listed an order for Citalopram tablet 10 milligrams one time per day related to Major Depressive Disorder, Single episode, unspecified with a start date of 9/8/21. R9's care plan dated 12/20/22, indicated a potential for drug interactions and adverse affects related to the use of multiple medications including the use of an antidepressant secondary to diagnosis of depression and directed staff that a monthly medication regimen review by the facility pharmacy consultant was to be completed and any recommendations were to be forwarded to the resident provider for review. R9 had documentation of pharmacy consultant reviews being completed every month over the past 13 months with no recommendation for a dose reduction of R9's Citalopram. When interviewed on 1/6/22, at 8:21 a.m. the director of nursing (DON) stated she was unable to identify a recommendation for a reduction in R9's Citalopram dose or a rationale as to why not. The DON also stated that there had been no attempts by the facility to reach out to the pharmacy consultant or R9's provider for a gradual dose reduction of her Citalopram dose or to obtain the rationale as to why not. When interviewed on 1/6/23, at 8:52 a.m. the facility Pharmacy Consultant (Pharm D) stated the recommendation for a dose reduction of R9's Citalopram was something they had missed in their monthly medication regimen reviews and they would have recommended R9's provider think about a reduction/discontinuation or provide rationale as to why not. The facility policy Psychotropic Medication Management dated February of 2022, identified that each resident's drug/medication regimen is managed and monitored which includes the implementation of gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medications in an effort to discontinue these drugs. The policy defined a gradual dose reduction as the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. The policy also indicated that within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practioner has initiated a psychotropic medication, the facility must attempt a gradual dose reduction in two separate quarters (with at least one month between attempts), unless clinically contraindicated. After the first year, a gradual dose reduction must be attempted annually, unless clinically contraindicated.

Based on interviews and document review, the facility failed to ensure 1 of 4 residents (R1) reviewed was free from significant medication errors when facility staff administered the entire contents of a bottle of [MEDICATION NAME] sublingual 0.4 mg tablets to R1. Findings include: R1's record was reviewed. R1 was admitted to the facility on (MONTH) 3, (YEAR). R1's [DIAGNOSES REDACTED]. R1's progress note dated (MONTH) 29, (YEAR), at 9:38 p.m. indicated R1 had a small emesis and complained of chest pain at 7:40 p.m. R1 experienced intermittent episodes of unresponsiveness and became pale. The same note indicated R1's blood pressure was 154/109 with a heart rate of 89 beats per minute. R1's progress note indicated a facility nurse contacted the nurse practitioner and received an order for [REDACTED]. R1's blood pressure was 99/62. R1's progress note indicated R1's blood pressure was 79/50 at 8:40 p.m. The same progress note indicated the facility staff called 911 and transferred R1 to the emergency department (ED) at approximately 9:00 p.m. R1's physician orders [REDACTED]. R1's progress note dated (MONTH) 29, (YEAR), at 9:45 p.m., indicated R1's blood pressure was difficult to obtain and his pulse was approximately 120 beats per minutes. R1's progress note dated (MONTH) 30, (YEAR), at 12:30 a.m. entitled Orders Administration Note indicated R1's medication order to administer one [MEDICATION NAME] 0.4-milligram (mg) tablet sublingually for chest pain. The progress note further indicated facility staff administered the incorrect dose and that R1 incorrectly received the entire bottle. The progress note indicated the bottle contained 25 [MEDICATION NAME] 0.4 mg tablets. During an interview on (MONTH) 17, (YEAR), at 11:12 a.m., Nurse-1 (N1) stated that R1 developed chest pain so N1 updated R1's nurse practitioner who ordered [MEDICATION NAME] sublingual 0.4 mg. N1 stated she had to retrieve the [MEDICATION NAME] for R1 from the emergency-kit (e-kit) as R1 did not have a supply of [MEDICATION NAME]. N1 stated that the [MEDICATION NAME] bottle from the e-kit was stored inside a plastic bag that had instructions that included the written statement Take the whole bottle please. N1 stated she discussed this instruction with another nurse (N2) but she misunderstood N2's statement and misinterpreted the instructions to mean administer the entire bottle to R1. N1 stated that when R1's blood pressure dropped and his status declined further, she realized her mistake and informed the nurse supervisor. N1 stated she helped send R1 to the ED immediately. During an interview on (MONTH) 11, (YEAR), at 4:43 p.m., Nurse-2 (N2) stated that he was present when N1 retrieved [MEDICATION NAME] for R1 and that N1 did ask for clarification regarding the written statement to Take the whole bottle please of [MEDICATION NAME]. N1 stated that he did tell N2 to take the whole bottle meaning to remove the entire bottle from the e-kit. N2 stated he did not intend nor did he understand that N1 interpreted the instructions to mean administer all the pills to R1. R1's physician orders [REDACTED]. The policy entitled Med Administration - Long Term Care, dated (MONTH) (YEAR), indicated personnel administering medications will check the six rights of administration, including the correct dose.

Based on observation, interview and document review, the facility failed to ensure 1 of 4 residents (R1) reviewed for accidents was transferred according to the plan of care. R1 had been assessed to transfer with assistance of two staff and a mechanical lift. R1 sustained actual harm when during a transfer with one staff, without a mechanical lift, R1 slid off the bed and broke the ankle and tibia bone in her left leg. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had moderate cognitive impairment and required extensive staff assistance with all transfers. R1's plan of care dated 6/3/15, indicated the resident was to be transferred with assist of two staff using a mechanical lift. R1's Visual/ Bedside Kardex Report (contains specific resident information regarding cares) dated 2/17/18, indicated the resident required assist of two staff using a mechanical lift for transfers. A facility investigation dated 2/23/18, indicated on 2/17/18, nursing assistant (NA)-E attempted to transfer R1 using an assist of one from the wheelchair to the bed. During the transfer R1 slid off the bed onto the floor. NA-E called licensed practical nurse (LPN)-D for assistance. The documentation indicated R1 initially had no pain at the time of the fall. After LPN-D assessed R1, four staff members assisted the resident into bed using a mechanical lift. The following day, R1 complained of pain in the left ankle. An X-ray was obtained on 2/18/18, and determined R1 had a [MEDICAL CONDITION] shaft of the left tibia and a [MEDICAL CONDITION] lateral malleolus (bone on the outside of the ankle). According to investigation documentation, NA-E had stated she'd thought R1 was an assist of one staff and had looked at the wrong part of R1's Kardex. After reviewing the plan of care, NA-E stated she tried to find another staff to assist her but was unable to locate anyone so she'd placed R1's wheelchair next to the bed and attempted to transfer R1 by herself. NA-E stated she transferred the resident onto the bed and the resident slid off the bed onto the floor. During interview and observation on 3/20/18, at 10:30 a.m. R1 was observed seated in her wheelchair with a hard cast on her left foot/leg. R1 stated she did not have any pain in her ankle/leg and stated she was unable to recall how she obtained the injury. During interview on 3/20/18, at 12:05 p.m. NA-E stated she had been working at the facility for approximately one week prior to R1's fall. NA-E stated she had not transferred R1 prior to 2/17/18, but had access to R1's Kardex and plan of care. NA-E stated she had read R1's Kardex wrong and thought the resident required only one staff assist with transfers. NA-E stated she had transferred the resident to the bed, but when she sat R1 on the edge of the bed R1 slid off and fell to the floor. NA-E confirmed she was trained to read each resident's Kardex and the plan of care. NA-E stated she utilized the Kardex for all residents when assisting them with cares and understood how to interpret the Kardex for individual resident needs. During interview on 3/20/18 at 12:25 p.m., the director of nursing (DON) stated NA-E was suspended from work when the investigation was being completed for R1's fall. The DON stated when she interviewed NA-E, NA-E had initially stated she read R1's Kardex wrong, and then stated she may have been looking at another resident's Kardex. After the DON and NA-E reviewed the resident's Kardex and plan of care to see what may have been misinterpreted by NA-E, NA-E had stated she looked for another staff member to assist with transferring R1 but was unable to locate anyone so she'd gone ahead and transferred the resident alone. The DON stated NA-E's employment with the facility was terminated. During interview on 3/20/18, at 12:55 p.m. LPN-D stated on 2/17/18, NA-E had called her to R1's room for assistance. LPN-D said R1 was sitting on the floor next to the bed and there was not a mechanical lift in the resident's room. LPN-D stated she had spoken to NA-E about R1's fall and NA-E had stated she'd misread R1's Kardex and thought the resident was an assist of one. A policy was requested on following the resident plan of care but not provided.

Based on interview and document review, the facility failed to develop and implement an abuse prevention plan which included notification of the administrator and state agency immediately upon discovery of alleged abuse allegations by staff and/ or residents. This directly effected 11 of 13 residents, R64, R60, R90, R98, R6, R1, R29, R55, R106, R52 and R15 in the sample that were reviewed for abuse. The lack of developed abuse prevention plan which instructed staff on how to protect residents in the facility against potential abuse constituted an immediate jeopardy for R64, R60, R90, R98, R6, R1, R29, R55, R106, R52 and R15. The systemic failure to report and thoroughly investigate incidents of potential abuse/neglect along with limited training to their employees about the abuse process had the potential to affect all 84 residents who currently reside in the facility. The acting administrator and the Director of Nursing (DON) were notified at 2:00 pm on 12-9-11 of the immediate jeopardy at a L level. The facility initiated an IJ removal plan which included review and revision of the abuse prevention plan and training provided to all staff on each shift prior to any resident contact. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The immediacy was removed at 3:20 pm on 12-14-11 and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm, widespread. In addition, the facility failed to train staff regarding abuse prohibition practices for 9 of 9 employees (NA-A, NA-B, NA-D, NA-F, NA-G, NA-H, NA-I, NA-D,and NA-J) reviewed. Findings include: Review of the facility policy titled Vulnerable adults dated 2/2010 indicated mandated reporters are required to make an immediate report (within 24 hours) when there is reason to believe a VA (vulnerable adult) has been maltreated, or they have knowledge a VA has sustained a physical injury which is not reasonably explained. The policy directed a suspected incident should be reported immediately to one of the following: "Department director, administrative supervisor (identified as an RN working at the hospital as a charge nurse), social service staff, chief nursing officer, Chief compliance officer, or chief executive officer. Upon notifications, one of the persons listed above will take over details of the investigation and determine if the incident is reportable." The policy did not direct staff to call the administrator immediately about any alleged abuse, neglect, injury of unknown origin or misappropriation of resident property but rather to investigate the incident and then they would determine if the "incident is reportable." During interview from 1:15 p.m. to 1:25 p.m. on 12/7/11, with registered nurse (RN)-B, licensed practical nurse (LPN)-B, housekeeper (HSK)-A and social worker (SW) director all had different responses on who to contact if they were informed of an alleged abuse, neglect, or injury of unknown origin incident. These individuals stated the would either contact social services, or the director of nursing, or the RN supervisor. None of them stated they would contact the administrator. The undated Vulnerable adult reporting checklist for rehab and extended care directed staff if maltreatment was determined to be reportable, a report must be filed with the Common Entry point (CEP) and to the Office of Health Facility Complaints (OHFC) (state agency) within 24 hours. If suspected maltreatment/ potential reportable incident occurs during regular business hours notify your supervisor, administrative supervisor, or social services and they will take over the internal investigation and decide if the situation requires reporting. When a situation requires reporting notify the following via email: Administrator, Social services Director (SS) and Director of Nursing (DON). The policy did not indicate to contact the state agency immediately about any alleged abuse, neglect, injury of unknown origin or misappropriation of resident property but rather to investigate the incident and then they would determine if the "situation requires reporting." Also, the policy did not direct staff how to thoroughly investigate an allegation of abuse, neglect, injury of unknown origin or misappropriation of resident property. R64 was sent to the emergency roiagnom on [DATE] and was diagnosed with [REDACTED]. A thorough investigation about the injury was not completed, nor was fracture reported to the administrator or state agency. The facility investigation sheet dated 3-25-11 signed by the Social Service director (SS)-A indicated that on 2-23-11 the top of R64 right hand "appears swollen and bruised." R64 stated they (nursing assistants) "hit my hand on door frame when they brought me to the bathroom." The facility investigation identified dates of 3-5-11, 3-6-11, 3-12-11 of R64 hitting her elbows, wrists on the doorframes while being transferred with staff assistance and a mechanical lift, or the right hand was swollen. On 3-24-11 R64 had a right wrist X-ray which "relieved right wrist fracture that was already forming callous..." The facility investigation concluded R64 "...was a poor historian...likely received the injury 3-12-11 when elbow was bumped... There is no evidence of maltreatment with this situation rather is a sudden, unforeseen accident." The facility investigation did not identify which nursing assistants worked with R64 nor were there any interviews with staff regarding what may have happened. Also, there were no interviews with R64. During interview at 9:20 a.m. on 12-8-11 the director of nursing (DON) stated R64 wrist fracture was considered "an accident", so it was not reported to the administrator or state agency. Although R64 had a significant injury which could not be explained, the facility did not report it to the administrator and state agency, nor was the fracture thoroughly investigated. Resident 60 (R60) reported two staff members were rough with her on 8-6-11. Although the facility was aware of R60's allegations, this incident was not reported to the state agency until 8-18-11 and the administrator was not notified immediately of the rough treatment. The undated facility investigation identified on 8-6-11 R60 accused two staff members, Nursing assistant (NA)-A and NA-F, being "...rough with her and forced her to take a bath even though she told them multiple times she did not want to take a bath." R60 stated she was upset and crying while NA-A and NA-F were making fun of her, and R60 screamed when NA-F opened R60's contracted left hand. During interview at 2:05 p.m. on 12-7-11 Registered Nurse (RN) D indicated she was notified of the incident regarding R60 during shift report on 8-7-11. She stated she helped with the investigation and notified CEP (common entry point) on 8-7-11 but did not notify the state agency because the facility reporting book "is confusing, it runs in circles." She stated she sent the Director of Nursing (DON) an email about the incident and also tried to page the on call social worker who works at the hospital but did not hear back. RN-D did not notify the administrator about the incident. Although R60 reported staff was rough with her on 8-6-11, the facility did not report the incident to the administrator or state agency immediately. The incident was reported to the state agency on 8-18-11, 12 days after the incident occurred. R60 reported another resident touched her inappropriately and made her feel uncomfortable. This was not investigated or reported to the administrator or state agency. Review of R60's Interdisciplinary progress notes dated 7-3-11 indicated "resident had complained of another resident kissing her cheek and touching her breast. Social service notified. Staff notified to keep resident safe and separate from resident, states that the other resident 'may be a lesbian, but it is her actions that make me uncomfortable.' States other resident 'says I'm special to her.' Resident will be monitored for safety." During interview at 9:20 a.m. on 12-8-11 Social Worker (SW) B stated she was not working the week of the July 4th holiday. When she returned to work she had many emails and must have missed this email regarding R60 being inappropriately touched. She stated she did not completed an investigation about R60's allegation of being inappropriately touched by another resident. SW-B verified the administrator and state agency were not notified of the inappropriate touching of R60, even though R60 was uncomfortable about the incident on 7-3-11. R90 was observed during the evening shift on 10-23-11, being sworn at using vulgar language by NA-D. The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. A facility incident report dated 10-24-11, indicated NA-D was observed by an unknown NA, to swear at R90 and said, ""said the F word to him when she left the room." The conclusion of the facility investigation indicates," (NA-D) did not intend to verbally abuse the (stated resident)." Although the facility was aware of NA-D used vulgar language with R90, the state agency was not notified until 10-24-11 and the administrator was not notified until after the incident had been completely investigated, date unknown. R98 was observed during the evening shift on 10-23-11, being told by NA-D that "he belonged in a mental institution." The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. A facility incident report dated 10-24-11, indicated that on 10-23-11 NA-D told R98 that "he belonged in a mental institution." The facility investigation indicated that "witness interviews collaborated that NA-D made a comment to (R98) 'some people up in the mental health unit in St Cloud would like him and he would get along with them really well." Although the facility was aware of NA-D told R98 "he belonged in a mental institution", the state agency was not notified until the following day and the administrator was not notified until after the investigation was completed, date unknown. R6 NA-D was observed by a staff member during the evening shift on 10-23-11 pulling off R6 headband and stating "Take that out of your hair. That looks terrible!" The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. The facility investigation reported dated 10-28-11, "concluded a direct observer said (NA-D) was curling R6's hair after her bath and R6 had put her headband on her head and NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" Upon interview, NA-D denied making this statement. Although the facility was aware of NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" The state agency was not notified until the following day and the administrator was not notified until the investigation was completed. At 9:20 a.m.. on 12/8/11, interview with the DON stated she was aware of the multiple incidences with NA-D that occurred on 10/23/11. The DON verified the state agency was not notified until the following day and the administrator was not notified until the investigation was completed. R1 was observed being allegedly verbally abused by NA-A. The facility was aware of this allegation, and did not investigate the incident nor was the administrator or state agency notified of the alleged verbal abuse. During interview at 9:45 a.m. on 12-9-11, NA-C stated approximately three weeks ago she and NA-A was removing R1 from the bedpan. NA-A told R1, "Your poop stinks so [***] ing bad I can hardly stand it!" NA-C stated she told SW-B about the incident that day, but unsure if the incident was investigated. During interview at 11:10 a.m. on 12-9-11 SW-B stated she spoke with NA-C about other concerns approximately three weeks ago but did not recall the incident concerning R1. Although NA-C stated she spoke to SW-B regarding the incident with R1 there was no investigation about the incident, nor was the administrator or state agency notified of the alleged verbal abuse. R29 experienced alleged neglect which was not thoroughly investigated or reported to the administrator or state agency. During interview at 10:46 a.m. on 12/08/11 NA-C stated earlier this fall NA-P reported to her that NA-A was over heard telling a housekeeper (HSKP)-A not to make R29's bed and leave it in high position to prevent R29 from getting into bed. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the director of nursing (DON) stated there was no investigation about the incident nor was it reported to the administrator or state agency. The DON stated, "It was decided after review, staff were protecting her from falls due to her thought process that day." The DON stated this incident was "unsubstantiated," even though an investigation was never completed and this incident was not reported to the administrator or state agency. R55 experienced alleged abuse/neglect which was not thoroughly investigated or reported to the administrator or state agency. During interview at 10:46 a.m. on 12/08/11 Nursing Assistant (NA)-C stated earlier this fall NA-A was observed leaving R55's room. R55's window was open, the bed covers/sheet were pulled back and the privacy curtain pushed back while R55 was in bed with just her night gown. NA-C over heard NA-A stating, "she has slept long enough". NA-C stated she reported the incident to the nurse working that day, and was unsure if the incident was ever investigated. During 2 interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the DON stated this incident was "unsubstantiated." Even though an investigation about the incident was not completed, nor was it reported to the administrator or state agency. R106 experienced alleged abuse which was not investigated or reported to the administrator or state agency. During interview at 12:00 noon on 12/08/11, NA-P stated she witness R106 who was asleep in his wheelchair being pushed into the wall by NA-A. R106 was startled by this action, and NA-A laughed. The incident has been reported to the charge nurse that evening but was unsure if an investigation was completed. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11, the DON stated the incident was "unsubstantiated." Even though an investigation about the incident was not completed, nor was it reported to the administrator or state agency. R52 experienced physical abuse which was not reported to the administrator or state agency. R52 had [DIAGNOSES REDACTED]. R 52 most recent quarterly ((MDS) dated [DATE] indicated R52 was cognitively impaired, had physical behavioral symptoms directed towards others, verbal behaviors, and needed extensive assistance with all activities of daily living. The facility's investigation notes dated 6/6/11 indicated that on 6/6/11, trained medical assistant (TMA)-A informed RN-H she was frustrated with R52's behavior. RN-H went to R52's room. NA-B was observed by RN-H slapping R52's hand "I heard it and saw it and I asked her to leave." The employee was removed from the schedule on 6/6/11 and returned to work on 6/15/11. During review of NA-B's employee file a "Performance Improvement Action Plan" dated 6/7/11 was completed by the DON and union representative, which indicated "On 6/6/11 while providing cares for a resident on second floor you slapped/batted at the resident with your hand. This was observed by coworkers." The Action plan also indicated "The standard of care for residents is to allow choice...It is never acceptable to slap/bat a resident..." During interview at 12:30p.m. on 12-9-11 the DON stated while NA-B was working with R52 he was swinging his arms out. NA-B should have removed herself from the situation instead of doing what she did. NA-B was suspended and reprimanded with a verbal warning. Even though the facility was aware that NA-B slapped R52's hand, they did not notify the state agency or the administrator of this incident. R15 experienced alleged verbal abuse. The facility did not thoroughly investigate the incident nor was the administrator or state agency notified of the incident. During interview at 9:45a.m. on 12/9/11 NA-C stated about two weeks ago housekeeping (HSKP)-A observed NA-B tell R15 "why are you so [***] ing crabby?" NA-C stated HSKP-A was afraid to report NA-B so NA-C told SS-B about the incident but was unsure if the incident was investigated. During interview at 11:10 a.m. on 12/9/11 SS-B stated she received a report that R15 was upset with NA-B. SS-B stated she talked with R15 who did not have any concerns so an investigation was ever conducted nor was the administrator or state agency notified of the alleged abuse. During interview at 9:20 a.m. on 12-8-11 the DON stated the administrator is not notified immediately regarding Vulnerable adult incidents. She stated if it is determined to be reportable, they will send the administrator an email while doing the investigation. During interview at 10:00a.m. on 12/12/11 the administrator stated he has always been available to the staff, especially for the last seven months. He had not been informed of any of the incidences for R60, R52, R98, R90, R15, R6, R1, R64, R29, R55, and R106 which the survey team investigated. He then stated "how can you fix something if you have not been informed." The facility failed to provide on-going employees annual training as identified by their Vulnerable Adults policy, for 9 of 9 direct care staff (NA-A, NA-B, NA-D, NA-F, NA-G, NA-H, NA-I, NA-D,and NA-J) files reviewed. The facility policy [PHONE NUMBER] titled Vulnerable Adults, updated 2-2010, identified on page 13 Training. The Training section indicated, "During new employee orientation and there after annually all employees will be provided education on The Vulnerable Adult Act, facility policy, reporting procedures and information on how to and to whom they may report concerns without fear of retribution. Employees will also be instructed on appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of stress, and burnout that may lead to abuse and prevent violence in the workplace." Employee files NA-A, NA-B, NA-D, NA-F, NA-G, NA-H, NA-I, NA-D, and NA-J. were reviewed for abuse prohibition training. Review of employee files for NA-I, NA-B, NA-A revealed they had attended a sexual abuse inservice on 3/4/11 and NA-G had attended the same inservice on 3/7/11. This inservice failed to include abuse prohibition practices such as: how to recognize signs of burnout, frustration and stress that may lead to abuse and did not define what constitutes abuse, neglect and misappropriation of property in the course syllabus or handouts. Review of employee files for NA-I, NA-G and NA-A revealed they had attended a dementia training inservice on 9/21/11. This inservice failed to include abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout, frustration and stress that may lead to abuse, or what constitutes abuse, neglect an misappropriation of resident property. NA-F had completed a "safety swarm Gamma-G " inservice on 6/23/11. This inservice failed to include abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; how to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect and misappropriation of resident property. NA-J and NA-H's employee files failed to contain any information about training they received in the last year on issues related to abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; how staff should report their knowledge related to allegations of abuse without fear of reprisal; how to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect and misappropriation of resident property. During interview with the facility's Human Resource Director (HR-D) at 9:30 a.m. on 12/13/11, stated she thought all components had been provided between a dementia inservice held on 9/23/11; an elder care sexual abuse inservice and the Swank Health Care training. However, none of the 9 employee files reviewed had been to all three inservice's. She stated the education department was responsible to ensure all training was provided. If anyone missed attending these inservice's, they could "make up the attendance" but this had not been completed for these training's. At 2:00p.m. on 12/9/11 the DON and acting administrator were informed of the Immediate Jeopardy due to the lack of investigation, lack of facility policy and appropriate reporting to the administrator and state agency regarding allegations of abuse, neglect, and injuries of unknown origin. This systemic failure to report and complete a thorough investigation of the incidents of alleged abuse, neglect, and injures of unknown origin along with adequate staff education had the potential to affect all 84 residents who currently reside in the facility. On 12-14-11 the facility submitted a plan of correction which include revision of the Abuse prevention plan to include notifying the administrator and state agency immediately, training for all staff including resident aggression, how to recognize care giver burnout, and vulnerable adult training. In addition the administrator will be available to the facility every morning for a daily meeting to ensure compliance with reporting requirements. At 9:37a.m. thru 10:30a.m. on 12/14/11 interviews were done with RN MDS Coordinator, NA-M, Housekeeping-B, NA-C, TMA-B, TMA-C, SS-B, SS-A, NA-J, RN-J, NA-N, LPN-D and were all able to explain their responsibility for identification of incidents of potential mistreatment, internal reporting, resident protection, immediate notification to the administrator, investigation and external reporting as defined in the revised plan. The facility was made aware the IJ was removed at 3:20 pm on 12-14-11 and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm, pattern.

Based on interview and document review, the facility failed to ensure residents were free from staff verbal, physical abuse and neglect for 10 of 13 residents reviewed R60, R1, R29, R55, R106, R90, R98, R6, R52, and R15. The facility was aware of staff and resident accusation regarding 4 staff members, NA-A, NA-F, NA-D, and NA-B. Although the facility had several reports that these staff members were mistreating residents, they failed to ensure these allegations were thoroughly investigated, and that NA-A, NA-F, NA-D, and NA-B received additional training and were adequately monitored to prevent further resident abuse and neglect. The lack of the facility's failure to protect these residents constituted an immediate jeopardy for R60, R1, R29, R55, R106, R90, R98, R6, R52, and R15. The systemic failure to provide training, monitoring and fully investigate incidents of verbal, physical abuse and neglect which were consistently identified by the same NA's had the potential to affect all 84 residents in the facility. The acting administrator and the Director of Nursing (DON) were notified at 2:00 pm on 12-9-11 of the immediate jeopardy at a K level. The facility initiated an IJ removal plan that included review and revision of the abuse prevention plan and training was provided to all staff on each shift prior to resident contact. The facility started a thorough investigation of incidents that involved NA-A, NA-D and NA-B, educated and disciplined NA-A, NA-D and NA-B per facility policy. NA-F was no longer employed by the facility. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The plan also included how the facility would monitor staff to ensure the residents were not abused or neglected. The immediacy was removed at 3:20 pm on 12-14-11 and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm, pattern. Findings include: NURSING ASSISTANT-(NA)-A AND NA-F Resident 60 (R60) reported two staff members NA-A and NA-F were rough with her on 8-6-11 during a bath. The facility did not ensure NA-A and NA-F received any additional training or monitoring to ensure she did not work with R60, even though R60 was fearful of NA-A. Also, there was no monitoring to ensure other residents cared for by NA-A and NA-F were not being abused. R60 had [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified R60 had no cognitive impairments and was totally dependent on staff for personal hygiene and bathing. During interview at 12:10 p.m. on 12-8-11 R60 stated she was afraid of nursing assistant (NA)-A and NA-F because on 8-6-11 they made her take a bath and were "making fun of me" and hurt her contracted hand. She stated NA-F was no longer employed by the long term care facility, but NA-A was still working there and "When I see her I just want to run the other way... but I can't." She indicated NA-A still provided cares to her but had not taken care of her in the last week because the residents family member (FM)-A "said something" to the RN charge nurse last time she was visiting. She stated "I just want them to both stay away from me, that was scary." During telephone interview at 12:40 p.m. on 12-8-11 FM-A stated the facility called her on 8-7-11 about the tub bath incident which occurred on 8-6-11. She stated R60 told her several times she was scared of NA-A and NA-F and had episodes of feeling afraid that NA-A was going to come in her room and hurt her when no one else was around. FM-A stated she was told by the facility NA-A would not longer be taking care of her mother. The undated facility investigation identified on 8-6-11 R60 accused two staff members, Nursing assistant (NA)-A and NA-F, being "...rough with her and forced her to take a bath even though she told them multiple times she did not want to take a bath." The investigation indicated that R60 stated she was upset and crying while NA-A and NA-F were making fun of her, "it seemed like they were laughing at me." NA-A and NA-F told R60 she was "having a pity party for one." When NA-F opened R60's contracted left hand, R60 "...started screaming..." The investigation also indicated that NA-Z walked by the tub room while R60 was receiving a bath from NA-A and NA-F. NA-Z stated, "she did hear the NAR's laughing...she entered the tubroom as they finished the bath and that (resident name) looked upset." The investigation indicated to prevent a reoccurrence of this incident NA-A and NA-F had been reassigned to a different wing. Review of NA-A and NA-F employee record indicated they did not receive additional training or monitoring after the incident to ensure they did not work with R60, or abuse other residents they were working with. NA-A employee files indicated she had attended a sexual abuse inservice on 3/4/11. This training did not identify education on abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout, frustration and stress that may lead to abuse, or what constitutes abuse, neglect an misappropriation of resident property. During review of NA-A's employee file and verified by the human resource director at 3:25 p.m. on 12/9/11, NA-A's last employee performance review had been completed 3/31/10. There were no performance evaluation in over 20 months to determine areas of weakness or training needs. Review of NA-F employee file indicated she completed a "safety swarm Gamma-G " inservice on 6/23/11. This inservice failed to include abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; how to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect and misappropriation of resident property. There was no indication that NA-F received additional training after the 8-6-11 incident. Currently NA-F was no longer employed by the facility. Review of the facility schedules from 8/6/11 to 12/12/11 revealed NA-A worked on the same wing that R60 resided 11 times since the incident on 8-6-11. During interview at 8:32 a.m. on 12/8/11 the schedule coordinator (SC)-H stated she was responsible to develop the monthly schedules for the nursing assistants at the nursing home. SC-H was not aware that NA-A had ever had any restrictions on where NA-A was scheduled to work. SC-H further stated due to the union contract she would not be allowed from restricting any staff member from working in a certain area of the building or with any particular resident. If a resident did not want a certain staff member caring for them, it would be up to the nurse aides to trade residents amongst themselves. SC-H stated she would not get involved with this situation. During interview at 3:11p.m. on 12/8/11 the DON stated after the incident R60 was given a little extra "TLC (tender loving care)." She stated she personally talked to R60 and once "she was back at baseline" she felt it was okay for NA-A to work with her again. She verified she did not directly ask R60 if it was okay if NA-A worked with her again or if she was afraid of NA-A. The DON was unable to provide an information or date of when the conversation occurred, or when NA-A was allowed to work with R60 again. She stated NA-A was monitored by the charge registered nurse (RN)'s who are responsible to monitor all NA's and if there were any concerns they were to let her know. She stated she had not heard of anymore concerns regarding NA-A and R60. During interview at 1:10 p.m. on 12/8/11 RN-A (a charge nurse who was responsible for monitoring the NA's) stated there were no nursing aides that have been on any special monitoring that she was aware of. If any special monitoring needed to be done social services or human resources would be responsible to complete this. RN-A verified NA-A worked on both floors, either wings and gave residents baths. RN-A stated she never heard R60 not wanting NA-A to care for her. During interview at 1:40 p.m. on 12/8/11 RN-D (a charge nurse who was responsible for monitoring the NA's) and SS-A both stated NA-A had been re-assigned to just north hallway for a short time around July 2011. She was to avoid caring for R60, due to R60's anxiety. R60 had multiple medication changes around that time due to anxiety. After her medication adjustment, she was alright with NA-A caring for her, neither RN-D or SS-A had spoken to R60 and asked her if it was alright for NA-A to care for her. They both stated they thought the DON had spoken to R60 at some point. During interview at 8:00 a.m. on 12-9-11 RN-E (a charge nurse who was responsible for monitoring the NA's) stated she has not heard of any specific problems with any NA's requiring specific monitoring. The only problem she was aware of was that NA-A was consistently late for work. Although the RN's were responsible to monitor NA-A, they were not aware about any past allegations to ensure adequate monitoring had been completed so NA-A was not abusing other residents. Although R60 reported staff was rough with her on 8-6-11, the facility did not ensure NA-A and NA-F received any additional training or monitoring to ensure they did not work with R60, even though R60 was fearful of NA-A. R1 received assistance with personal cares from NA-C and NA-A. NA-A was observed being verbally abuse to R1 making rude inappropriate comments. The facility did not provide additional training or monitoring of NA-A actions to ensure they protected R1 and other residents of verbal abuse by NA-A. R1 Quarterly MDS dated [DATE] identified the resident had no cognitive impairments, no memory problems, and needed extensive to total assistance with most ADL's. During interview at 9:45 a.m. on 12-9-11, NA-C stated approximately three weeks ago she and NA-A was removing R1 from bedpan. NA-A told R1, "Your poop stinks so [***] ing bad I can hardly stand it!" NA-C stated she told social worker (SW)-B about the incident that day, but unsure if the incident was investigated. During interview at 10:55 a.m. on 12-9-11 R1 acknowledged she remembered NA-C making rude comments about her when been taken off the bedpan. During interview at 11:10 a.m. on 12-9-11 SW-B stated she spoke with NA-C about other concerns approximately three weeks ago but did not recall the incident concerning R1. Although NA-C stated she spoke to SW-B regarding the incident with R1 there was no investigation completed about the incident. R29 experienced potential abuse and neglect from NA-A, which was not thoroughly investigated. The facility did not provide additional training or monitor of NA-A actions to ensure they protected R29 and other residents of verbal abuse by NA-A. R29 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated R29 was cognitively intact, displayed no behaviors, and needed extensive assistance with transferring and bed mobility. During interview at 10:46 a.m. on 12/08/11 NA-C stated earlier this fall NA-P reported to her that NA-A was over heard telling a housekeeper (HSKP)-A not to make R29's bed and leave it in high position. During interview at 12:00 p.m. on 12/08/11 NA-P stated she observed and heard NA-A telling housekeeper (HSKP)-A that "(R29) spent too much time in bed" and not to make R29's bed and leave it in high position. NA-P stated HSKP-A approached her and asked her if the bed making policy had changed. NA-P told HSKP-A there were no changes to the policy and she should make R29 bed and leave the bed in low position. This would prevent a possible fall if R29 tried to climb into bed when it was in the high position. During observations on 12/05/11 from 4:00 p.m until 8:00 p.m., 12/06/11 from 8:30 a.m. until 12:00 noon and 12/08/11 at 12:00 noon, R29 was observed siting alone in her room, either watching television or listening to the radio. Each observation she was observed sitting in her wheel chair and the bed was in low position. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the director of nursing (DON) stated there was no investigation about the incident although NA-A had a history of [REDACTED]. The DON stated, "(R29) has good and bad days due to her mental health issues. It was decided after review, staff were protecting her from falls due to her thought process that day" and the incident was "unsubstantiated." Even though the incident was never investigated and NA-A had a history of [REDACTED]." R55 experienced potential abuse/ neglect by NA-A which was not thoroughly investigated. The facility did not provide additional training or monitoring of NA-A actions to ensure they protected R55 and other residents of verbal abuse by NA-A. Resident (R55) had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated R55 was moderately cognitively impaired, displayed no behaviors, and required extensive assistance of 1-2 staff for all activities of daily living. At 10:46 a.m. on 12/08/11 Nursing Assistant (NA)-C stated earlier this fall NA-A was observed leaving R55's room. R55's window was open, the bed covers/sheet were pulled back and the privacy curtain pushed back while R55 was in bed. NA-C stated you could see R55 from the hall with just her night gown on and the window was open, blowing cold air. NA-C over heard NA-A stating,"she has slept long enough". NA-C stated she reported the incident to the nurse working that day, but NA-A continued to work with R55 and was unsure if the incident was ever investigated. A copy of the above investigation was requested. The hand written social worker (SS)-A notes dated 10/26/11, indicated the following was reported by NA-A: " window was open about an inch or so. Curtain covered open window, feet were covered and covers were within reach. Window open cause I was trying to get her up. I figured cause window was open. Was by her feet she would want to get up by the time I got back." The hand written notes also indicated, the following comments from the DON: "DON expressed concern of window being open and only 40 degrees this morning, little fat mass, light weight gown on, fallen just last evening before, concerns with resident being cold puts her at risk to want to try to get out of bed, potential fall risk. Resident has set off call alarm and was shivering." During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the DON stated there was no investigation about the incident but this incident was "unsubstantiated." Even though the incident was never investigated and NA-A had a history of [REDACTED]." R106 experienced potential abuse/ neglect by NA-A which was not investigated. The facility did not provide additional training or monitoring of NA-A actions to ensure they protected R106 and other residents of verbal abuse and neglect by NA-A. R106 had [DIAGNOSES REDACTED]. R106 last quarterly Minimum Data Set (MDS), dated [DATE], indicated he was moderately cognitively impaired, required extensive assistance with all activities of daily living (except eating), and displayed no behaviors. During interview at 10:46 a.m. on 12/08/11 NA-C stated in November 2011 she heard NA-A, used her foot to push R106 backwards into the dining room wall while he slept in his wheel chair (WC). NA-A action startled R106 and advised the surveyor to talk with NA- P who witnessed the event. During interview at 12:00 noon on 12/08/11, NA-P verified she witness R106 being pushed into the wall by NA-A using her foot. NA-P stated NA-A caught the attention of another NA (NA-O) by saying "watch this", and NA-A laughed when R106 became startled when he hit the wall with his wheelchair. Review of the investigation (undated) identified four interviews with associated dates. The first interview was conducted the day after the incident occurred, on 11/09/11 by the reporter, NA-P who confirmed the above incident. The second interview, dated 11/22/11 (15 days after the incident occurred) indicated that licensed practical nurse (LPN-E), stated R106 alarm was going off, and that R106 was rocking back and forth in his WC but did see R106 against the wall. She was not sure how he got there. The third interview, also dated 11/22/11 (15 days after the incident), was of NA-O who verified what R106 was doing and stated NA-A was not even there that day, "if I had thought someone had done something inappropriate (kick a WC), I would've been down here right way." NA-O also stated she was, "in and out answering call lights so I didn't see/hear much". The fourth interview was of NA-A on 11/29/11 (22 days after the incident) who stated that R106 rocked himself back into a corner and that she "woke him up to move him out of the range of the alarm". During telephone interview at 3:30 p.m. on 12/08/11 NA-O stated she, NA-A and NA-P were assisting residents during the brunch meal. She stated that R106 kept rocking in his wheelchair setting off the alarm. She did not see NA-A push his W/C with her foot. However, she did verify that she was not in the dining room the entire meal while she was assigned to answer resident call lights on the floor. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11, the DON verified the above information was the only investigation about the incident. Although there were several staff witnesses that observed R106 against the wall in his wheelchair and NA-P who observed the incident, a thorough investigation was not completed even though NA-A had prior accusations of resident abuse and neglect. At 3:11p.m. on 12/8/11, during interview the DON stated after NA-A was back to work, they could work on either unit or floor. NURSING ASSISTANT (NA)-D R90 was observed by an unknown NA during the evening shift on 10-23-11, being verbally abused by NA-D who was using vulgar language. The facility did not provide monitoring of NA-D actions to ensure they protected R90 and other residents of verbal abuse by NA-D. R90's quarterly MDS dated [DATE] indicated he was cognitively intact, and was dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated on 10-23-11 NA-D "swore at him (resident name)." The investigation indicated NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation indicated NA-D was observed by an unknown NA, to swear at R90 and, ""said the F word to him when she left the room." This incident was reported to the "NOC RN" who then informed the director of nursing (DON) and licensed social worker. Further facility investigation identified, "LPN reports (NA-D) informed her that she (NA-D) said the F word to (resident name) when she left his room." Interview with NA-D denies that she swore at R90. "The conclusion of the facility investigation indicates (NA-D) did not intend to verbally abuse the (stated residents)." To prevent recurrence NA-D was provided education, written disciplinary action and reassigned to 1st floor. The investigation indicated, "In interviews with NA-D, she expressed a preference to work on 1st floor stating she feels her skills are better utilized with the short term rehab population." Review of the facility schedules from 10/23/11 to 12/12/11 revealed NA-D had worked on second floor 5 times, where R90 resides. Although the facility was aware of NA-D used vulgar language with R90, the facility failed to ensure adequate monitoring of NA-D was completed to ensure she did not verbally abuse R90 along with other residents she was caring for. R98 was observed during the evening shift on 10-23-11, being told by NA-D that "he belonged in a mental institution." The facility did not provide monitoring of NA-D actions to ensure they protected R98 and other residents of verbal abuse and neglect by NA-D. R98 quarterly MDS dated [DATE] indicated he had moderate cognitive impairment and was dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated that on 10-23-11 NA-D told R98 that "he belonged in a mental institution." The investigation indicated NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation "witness interviews collaborated that NA-D made a comment to (R98) 'some people up in the mental health unit in St Cloud would like him and he would get along with them really well." The undated facility investigation indicated that interview with NA-D revealed she meant this in a joking manner. Conclusion of the facility investigation "NA-D did not intend to verbally abuse R98." NA-D indicated personal stressors precipitated the statements and NA-D did not intend to verbally abuse the residents. To prevent recurrence NA-D was provided education and was provided a written disciplinary action and reassigned to 1st floor. The investigation indicated, "In interviews with NA-D, she expressed a preference to work on 1st floor stating she feels her skills are better utilized with the short term rehab population." Review of the facility schedules from 10/23/11 to 12/12/11 revealed NA-D had worked on second floor 5 times, where R98 resides. Although the facility was aware of NA-D told R98 "he belonged in a mental institution", the facility failed to ensure adequate monitoring of NA-D was completed to ensure she did not verbally abuse R98 along with other residents she was caring for. R6 NA-D was observed by a staff member during the evening shift on 10-23-11 pulling off R6 headband and stating "Take that out of your hair. That looks terrible!" The facility did not provide monitoring of NA-D actions to ensure they protected R6 and other residents of verbal abuse and neglect by NA-D. R6 quarterly MDS dated [DATE] indicated she was cognitively intact, and dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated on 10-23-11 NA-D was observed by a staff member pulling off R6 headband and stating "Take that out of your hair. That looks terrible!" NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation reported dated 10-28-11, "concluded a direct observer said (NA-D) was curling R6's hair after her bath and R6 had put her headband on her head and NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" Upon interview, NA-D denied making this statement. To prevent recurrence NA-D was provided education and was provided a written disciplinary action. NA-D was reassigned to 1st floor. The investigation indicated, "In interviews with NA-D, she expressed a preference to work on 1st floor stating she feels her skills are better utilized with the short term rehab population." Review of the facility schedules from 10/23/11 to 12/12/11 revealed NA-D had worked on second floor 5 times where R6 resides. Although the facility was aware that NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" the facility failed to ensure adequate monitoring of NA-D was completed to ensure she did not verbally abuse R6 along with other residents she was caring for. At 9:20 a.m.. on 12/8/11, interview with the DON stated she was aware of the multiple incidences with NA-D that occurred on 10/23/11 via e-mail on 10/24/11 at 1:18 a.m. The DON stated she told NA-D the facility would try to schedule her on 1st floor, but they can't always guarantee she would be able to work there. The DON stated she "felt" once NA-D completed the on-line education she could provide cares with the residents on 2nd floor. In addition, she stated NA-D was being monitored by the RN's on the floor and they are "watching her close." At 10:38am on 12/8/11, interview with the facility staffing coordinator who does the facility schedule indicated NA-D could work on either floor and NA-D was working on second floor tonight (12-8-11) orientating a new employee. During interview at 2:45 p.m. on 12-8-11 LPN-A stated she had seen NA-D being rude to residents "several times." Several weeks ago she heard her say to R15 no one comes to visit her because she is so mean. LPN-A told NA-D this was inappropriate to say, but did not report the incident to anyone. She stated NA-D had been working on 1st floor for a few weeks, but has been up on 2nd floor "more often the last 2 weeks." Review of the facility schedules from 10/23/11 to 12/12/11 revealed NA-D had worked on second floor five times. At 10:38am on 12/8/11, interview with the staffing coordinator indicated NA-D can work on either floor and that she is working on second floor tonight to orientate a new employee. During interview at 1:10 p.m. on 12/8/11 RN-A she stated there were no nursing aides that have been on any special monitoring that she was aware of. If any special monitoring needed to be done social services or human resources would be responsible to complete this. RN-A verified NA-D worked on both floors, and either wings. She thought maybe NA-D was not to care for R60 at one time, but didn't know when or why this was. During interview with trained medication aide (TMA)-A at 1:15 p.m. on 12/8/11, she stated NA-D worked on both floors and either wings. TMA-A was not aware if NA-D had any restrictions from working with any particular resident. During interview at 1:22 p.m. on 12/8/11 LPN-C stated NA-D was never restricted from working with any particular resident that she is aware of. She verified NA-D work on both floors and wings of the facility. At 3:11p.m. on 12/8/11, during interview the DON stated after NA-D was back to work, they could work on either unit or floor. The DON stated she had the charge RN's monitor them. If there were any concerns they are to let her know. She stated they talked about this in their daily morning meetings. NURSING ASSISTANT (NA)-B R52 was observed being slapped by NA-B. The facility did not complete additional teaching or monitoring to ensure NA-B did not abuse other residents. R52 had [DIAGNOSES REDACTED]. R52 most recent quarterly ((MDS) dated [DATE] indicated R52 was cognitively impaired, had physical behavioral symptoms directed towards others, verbal behaviors, and needed extensive assistance with all activities of daily living. The current plan of care updated 12/2/11 indicated R52 was vulnerable... may be unable to identify and/or escape a hazardous situation, may be unable to identify, recall or report abuse. The care plan intervention indicated "provide staff education re:specific approaches for this resident mood/behavior and/or specific vulnerabilities PRN ( as needed). The care plan also indicated R52 is "at risk for alteration in mood r/t long-term placement, senile dementia with [MEDICAL CONDITION], "combat fatigue"/[MEDICAL CONDITIONS] per family report, explosive personality , hearing loss. Interventions included: provide unhurried, consistent routines, explain what you are going to do, if resident combative, provide for safety, leave and re-approach, remove residents that may escalate the situation, approach at a later time if resistive. During review of NA-B's employee file a "Performance Improvement Action Plan" dated 6/7/11 was completed by the DON and union representative, which indicated "On 6/6/11 while providing cares for a resident on second floor you slapped/batted at the resident with your hand. This was observed by coworkers. You failed to remove yourself from an escalating situation." The Action plan also indicated "The standard of care for residents is to allow choice, be flexible and follow the care plan to promote best outcomes. It is never acceptable to slap/bat a resident..." The facility's investigation notes dated 6/6/11 indicated on 6/6/11, trained medical assistant (TMA)-A informed RN-H she was frustrated with R52's behavior. RN-H went to R52's room. RN-H observed NA-B slapping R52's hand "I heard it and saw it and I asked her to leave." NA-B was removed from the schedule on 6/6/11 and returned to work on 6/15/11. During interview at 9:00 a.m. on 12/9/11 SS-B stated she was not aware of the hand slapping with R52 and NA-B. At 12:30p.m. the DON stated while NA-B was working with R52 he was swinging his arms out and she should have removed herself from the situation instead of doing what she did. The DON stated she reprimanded with a verbal warning and suspended NA-B. DON further stated NA-B was being monitored by the RN's on the floor to ensure there were no more incidents. Even though the facility was aware NA-B slapped R52's hand, did not ensure NA-B was monitored when working with R52 or other residents she cared for. R15 received alleged verbal abuse from NA-B that was not thoroughly investigated nor did the facility complete any additional teaching or monitoring to ensure NA-B was not abusing other residents. R15 had [DIAGNOSES REDACTED]. At 9:45a.m. on 12/9/11 during interview NA-C stated about two weeks ago a housekeeping (HSKP)-A observed NA-B tell R15 "why are you so [***] ing crabby?" NA-C stated HSKP-A was afraid to report NA-B so NA-C told SS-B about the incident. At 10:10a.m. on 12/9/11 during interview with R15 she stated staff are rough. Some of them "hurt my legs they are so rough I tell them I am in pain and they just laugh at me. The one girl laughs at me". R15 stated she did not know the staff names "because their name tags are always flipped over" so she could not see their names. At 11:10 a.m. on 12/9/11 during interview with SS-B she stated she received a report that R15 was upset with NA-B. SS-B stated she talked with R15 and R15 had no concerns so an incident report and investigation was never conducted. SS-B was unable to provide any investigation of the incident or any interview with R15, NA-B or HSKP-A about the incident. Even though HSKP-A witnessed the incident. Also, there was no indication that NA-B completed any additional teaching or monitoring to ensure NA-B was not abusing other residents. Although NA-A, NA-F, NA-D, NA-B had several incidents of verbal, physical abuse and neglect, these nursing assistants were not consistently provided additional training or supervision to prevent further resident abuse and neglect. During interview at 1:15 p.m. on 12/7/11, Registered Nurse (RN)-B stated she has worked as the charge nurse and has supervised staff, but has never had to specifically monitor any nurse aides for appropriate care delivery or interaction with residents. During interview with RN-C at 9:05 a.m. on 12/8/11, she stated she has enough time on the night shift to supervise staff, but had never been asked to monitor care or staff/resident interaction on any particular staff person. During interview with RN-A at 1:10 p.m. on 12/8/11 she stated there were no nursing aides that have been on any special monitoring that she was aware of. If any special monitoring needed to be done social services or human resources would be responsible to complete this. During interview at 3:11p.m. on 12/8/11 the DON stated nursing assistants are monitored by the charge registered nurse (RN)'s who are responsible to monitor all NA's and if there were any concerns they were to

Based on interview, record review, and policy review the facility failed to ensure all allegations of potential abuse, neglect, and injuries of unknown source were immediately reported to the administrator and to the state agency, along with conducting a thorough investigation for 12 of 13 residents in the sample reviewed for abuse, R64, R60, R90, R98, R6, R1, R29, R55, R106, R52, and R15. The lack of identification, investigation, resident protection, and reporting constituted immediate jeopardy for R64, R60, R90, R98, R6, R1, R29, R55, R106, R52, and R15. The acting administrator and the Director of Nursing (DON) were notified at 2:00 p.m. on 12-9-11 of the immediate jeopardy at a K level. The systemic failure of identification, investigation, resident protection, and reporting incidents of potential abuse/neglect had the potential to affect most residents in the facility. The facility initiated an IJ removal plan that included review and revision of the abuse prevention plan and training was provided to all staff on each shift and prior to resident contact. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The IJ was removed at 3:20 pm on 12-14-11 and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm, pattern. Findings included: R64 was sent to the emergency roiagnom on [DATE] and was diagnosed with [REDACTED]. R64 had [DIAGNOSES REDACTED]. However, the Quarterly MDS from 3-30-11 identified R64 was cognitively intact with no memory problems. During interview at 11:35 a.m. on 12-8-11 R64 stated her wrist was broke several months ago. She stated it was broke because the "Aides" (nursing assistants) ran her wrist/ hand into the door frame when taking her out of the bathroom with the lift. The facility investigation sheet dated 3-25-11 signed by the Social Service director (SS)-A indicated that on 2-23-11 the top of R64 right hand "appears swollen and bruised." R64 stated they (nursing assistants) "hit my hand on door frame when they brought me to the bathroom." The facility investigation identified the following: On 2-25-11 "right hand slightly bruised." On 3-5-11 "Right elbow bumped on door frame while being transferred to dining room...resident previously bumped right wrist on door frame that area is swollen and painful..." On 3-6-11 "right wrist continues to be swollen..." On 3-12-11 R64 accused an (unknown) NA "...of bumping her elbows on the door frame and stated, "They do this all the time."" The resident was "reminded about keeping elbows in while transferring..." On 3-24-11 R64 had a right wrist X-ray which "relieved right wrist fracture that was already forming callous..." The facility investigation indicated R64 "...was a poor historian due to inability to provide consistent details...The fracture can be explained by the documentation that shows evidence of the resident bumping both her elbow and wrist on several occasions during a EZ stand transfers despite staff encouragement for adjustment... It is determined that resident most likely received the injury 3-12-11 when elbow was bumped as there was no indication of pain or discomfort between the last time she was bumped and 3-12-11. There is no evidence of maltreatment with this situation rather is a sudden, unforeseen accident." The facility investigation did not identify which nursing assistants worked with R64 on 3-12-11 nor was there any interviews with staff regarding what may have happened on this date. Also, there was no interview of R64, although the MDS identified she was convexly intact with no memory problems during this time frame. Also, the facility indicated that on 2-23-11, R64 left hand was swollen/bruised and R60 told staff they "hit my hand on door frame when brought me in bathroom." Although this was identified, there was no investigation about this incident even though this was the first time R64's wrist was observed to be "swollen and bruised." During interview at 9:20 a.m. on 12-8-11 the DON stated R64 wrist fracture was considered "an accident", so it was not reported to the state agency. She also stated the incident was not reported to the administrator. Although R64 had a right wrist fracture diagnosed on [DATE], the investigation indicated R64 right wrist was swollen and bruised on 2-23-11. At this time, there was no investigation of the incident even though R64 stated, they "hit my hand on door frame when they brought me to the bathroom" this allegation was never investigated. Also, when the fracture was identified on 3-24-11, the administrator and state agency was not notified of incident because it was determined to be "an accident." R60 reported two staff members were rough with her on 8-6-11 during a bath. Although the facility was aware of R60's allegations, this incident was not reported to the administrator immediately and the state agency was not notified of the incident until 12 days after it occurred. R60 had [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified R60 had no cognitive impairments and was totally dependent on staff for personal hygiene and bathing. During interview at 12:10 p.m. on 12-8-11 R60 stated she was afraid of NA-A and NA-F because on 8-6-11 they made her take a bath and were "making fun of me" and hurt her contracted hand. She stated NA-F was no longer employed by the long term care facility, but NA-A was still working there and "When I see her I just want to run the other way... but I can't." She indicated NA-A still provided cares to her but had not taken care of her in the last week because the residents family member (FM)-A "said something" to the RN charge nurse last time she was visiting. She stated "I just want them to both stay away from me, that was scary." During telephone interview at 12:40 p.m. on 12-8-11 R60's FM-A stated the facility called her on 8-7-11 about the tub bath incident which occurred on 8-6-11. She stated R60 told her several times she was scared of NA-A and NA-F and had episodes of feeling afraid that NA-A was going to come in her room and hurt her when no one else was around. FM-A stated she was told by the facility NA-A would not longer be taking care of her mother. The undated facility investigation identified on 8-6-11 R60 accused two staff members, Nursing assistant (NA)-A and NA-F, being "...rough with her and forced her to take a bath even though she told them multiple times she did not want to take a bath." R60 stated she was upset and crying while NA-A and NA-F were making fun of her, "it seemed like they were laughing at me." NA-A and NA-F told R60 she was "having a pity party for one." When NA-F opened R60's contracted left hand, R60 "...started screaming..." The investigation also indicated that NA-Z walked by the tub room while R60 was receiving a bath from NA-A and NA-F. NA-Z stated, "she did hear the NAR's laughing...she entered the tubroom as they finished the bath and that (resident name) looked upset." There was no indication the administrator or state agency were notified immediately regarding this incident. During interview at 2:05 p.m. on 12-7-11 Registered Nurse (RN)-D stated she was notified of the incident regarding R60 during shift report on 8-7-11, one day after the alleged incident. RN-D stated she helped with the investigation and notified CEP (common entry point) on 8-7-11 but did not know the facility also had to notify the state agency because the facility reporting book "is confusing; it runs in circles." She stated she sent the Director of Nursing (DON) an email about the incident and also tried to page the on call social worker but did not hear back. RN-D did not notify the administrator about the 8-6-11 incident. Although R60 reported staff was rough with her on 8-6-11, the facility did not report the incident to the administrator or state agency immediately. The incident was reported to the state agency on 8-18-11, 12 days after the incident occurred. R60 identified another female resident touched her inappropriately and made her feel uncomfortable. This allegation was not investigated or reported to the administrator or state agency. R60 had [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified the resident had no cognitive impairments or memory problems. Review of R60's Interdisciplinary progress notes dated 7-3-11 indicated "Resident had complained of another resident kissing her cheek and touching her breast. Social service notified. Staff notified to keep resident safe and separate from resident, states that the other resident 'may be a lesbian, but it is her actions that make me uncomfortable.' States other resident 'says I'm special to her.' Resident will be monitored for safety." There were no follow up entries in the progress notes or R60 record about this incident. During interview at 9:20 a.m. on 12-8-11 Social Worker (SW) B she stated she was not working the week of the July 4th holiday. When she came back to work she had many emails and must have missed this email regarding R60 being inappropriately touched. She stated she did not complete an investigation about R60's allegation of being inappropriately touched by another resident. SW-B verified the administrator and state agency was not notified of the inappropriate touching of R60, even though R60 was uncomfortable about the incident on 7-3-11. R90 was observed during the evening shift on 10-23-11, being sworn at using vulgar language by NA-D. The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. R90's quarterly MDS dated [DATE] indicated he was cognitively intact, and was dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated that on 10-23-11 NA-D "swore at him (resident name)." The investigation indicated NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation indicated NA-D was observed by an unknown NA, to swear at R90 and said, ""said the F word to him when she left the room." This incident was reported to the "NOC RN" who then informed the director of nursing (DON) and licensed social worker. Further facility investigation identified, "LPN reports (NA-D) informed her that she (NA-D) said the F word to (resident name) when she left his room." Interview with NA-D denies swearing. "The conclusion of the facility investigation indicates (NA-D) did not intend to verbally abuse the (stated residents)." Although the facility was aware of NA-D used vulgar language with R90, the state agency was not notified until the following day and the administrator was not notified until after the investigation was completed. R98 was observed during the evening shift on 10-23-11, being told by NA-D that "he belonged in a mental institution." The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. R98 quarterly MDS dated [DATE] indicated he had moderate cognitive impairment and was dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated that on 10-23-11 NA-D told R98 that "he belonged in a mental institution." The investigation indicated NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation "witness interviews collaborated that NA-D made a comment to (R98) 'some people up in the mental health unit in St Cloud would like him and he would get along with them really well." Although the facility was aware of NA-D told R98 "he belonged in a mental institution", the state agency was not notified until the following day and the administrator was not notified until after the investigation was completed. R6 NA-D was observed by a staff member during the evening shift on 10-23-11 pulling off R6 headband and stating "Take that out of your hair. That looks terrible!" The facility did not notified the administrator immediately, nor was this immediately reported to the state agency. R6 quarterly MDS dated [DATE] indicated she was cognitively intact, and dependent upon staff for activities of daily living (ADL). A facility incident report dated 10-24-11, indicated that on 10-23-11 NA-D was observed by a staff member pulling off R6's headband and stating "Take that out of your hair. That looks terrible!" NA-D was sent home early on 10-23-11 and placed on administrative leave pending the results of the investigation. The facility investigation reported dated 10-28-11, "concluded a direct observer said (NA-D) was curling R6's hair after her bath and R6 had put her headband on her head and NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" Upon interview, NA-D denied making this statement. Although the facility was aware of NA-D jerked the headband out of R6 hand and told her, 'Take that out of your hair. That looks terrible!'" The state agency was not notified until the following day and the administrator was not notified until the investigation was completed. At 9:20 a.m.. on 12/8/11, interview with the DON stated she was aware of the multiple incidences with NA-D that occurred on 10/23/11. The DON stated she was aware of these incidents by e-mail on 10/24/11 at 1:18 a.m. The DON verified the state agency was not notified until the following day and the administrator was not notified until the investigation was completed. R1 received assistance with personal cares from NA-C and NA-A. NA-A was observed making rude inappropriate comments to R1. R1 Quarterly MDS dated [DATE] identified the resident had no cognitive impairments, no memory problems, and needed extensive to total assistance with most ADL's. During interview at 9:45 a.m. on 12-9-11, NA-C stated approximately three weeks ago she and NA-A was removing R1 from bedpan. NA-A told R1, "Your poop stinks so [***] ing bad I can hardly stand it!" NA-C stated she told SW-B about the incident that day, but unsure if the incident was investigated. During interview at 10:55 a.m. on 12-9-11 R1 acknowledged she remembered NA-C making rude comments about her when been taken off the bedpan. During interview at 11:10 a.m. on 12-9-11 SW-B stated she spoke with NA-C about other concerns approximately three weeks ago but did not recall the incident concerning R1. Although NA-C stated she spoke to SW-B regarding the incident with R1 there was no investigation about the incident, nor was the administrator or state agency were ever notified. R29 experienced potential abuse and neglect which was not thoroughly investigated or reported to the state agency or administrator. R29 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated R29 was cognitively intact, displayed no behaviors, and needed extensive assistance with transferring and bed mobility. During interview at 10:46 a.m. on 12/08/11 NA-C stated earlier this fall NA-P reported to her that NA-A was over heard telling a housekeeper (HSKP)-A not to make R29's bed and leave it in high position. During interview at 12:00 p.m. on 12/08/11NA-P stated she observed and heard NA-A telling housekeeper (HSKP)-A that "(R29) spent too much time in bed" and not to make R29's bed and leave it in high position. NA-P stated HSKP-A approached her and asked her if the bed making policy had changed. NA-P told HSKP-A there were no changes to the policy and she should make R29 bed and leave the bed in low position. This would prevent a possible fall if R29 tried to climb into bed when it was in the high position. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the director of nursing (DON) stated there was no investigation about the incident nor was it reported to the administrator or state agency. The DON stated, "(R29) has good and bad days due to her mental health issues. It was decided after review, staff were protecting her from falls due to her thought process that day." Even though the incident was never investigated by the facility the DON, stated this incident was "unsubstantiated ." R55 experienced potential abuse/ neglect which was not thoroughly investigated or reported to the administrator or state agency. Resident (R55) had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated R55 was moderately cognitively impaired, displayed no behaviors, and required extensive assistance of 1-2 staff for all activities of daily living. At 10:46 a.m. on 12/08/11 Nursing Assistant (NA)-C stated earlier this fall NA-A was observed leaving R55's room. R55's window was open, the bed covers/sheet were pulled back and the privacy curtain pushed back while R55 was in bed. NA-C stated you could see R55 from the hall with just her night gown on and the window was open, blowing cold air. NA-C over heard NA-A stating,"she has slept long enough". NA-C stated she reported the incident to the nurse working that day, but NA-A continued to work with R55 and was unsure if the incident was ever investigated. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11 the DON stated there was no investigation about the incident nor was it reported to the administrator or state agency. Even though the incident was never investigated by the facility the DON, stated this incident was "unsubstantiated." R106 experienced alleged abuse/neglect which was not investigated or reported to the state agency or the administrator. R106 had [DIAGNOSES REDACTED]. R 106 last Minimum Data Set (a Quarterly) MDS, dated [DATE], which indicated he was moderately cognitively impaired, required extensive assistance with all activities of daily living (except eating), and displayed no behaviors. During interview at 10:46 a.m. on 12/08/11 NA-C stated in November 2011 she heard NA-A, using her foot pushed R106 backwards into the dining room wall while he slept in his wheel chair (WC) which startled R106 and that surveyor should talk with NA- P who witnessed it. During interview at 12:00 noon on 12/08/11, NA-P verified that she witness R 106 being pushed into the wall by NA-A by using her foot. NA-P stated that NA-A caught the attention of another NA (NA-O) by saying "watch this", and stated that NA-A laughed when R106 was startled awake when he hit the wall. During two interviews at 2:58 p.m. on 12/08/11 and 12:16 p.m. on 12/09/11, the DON stated there was no investigation about the incident nor was it reported to the administrator or state agency. Even though the incident was never investigated by the facility the DON, stated this incident was "unsubstantiated ." R52 had been treated roughly by staff, the incident and was not reported to the state agency or administrator. R52 had [DIAGNOSES REDACTED]. R 52 most recent quarterly ((MDS) dated [DATE] indicated R52 was cognitively impaired, had physical behavioral symptoms directed towards others, verbal behaviors, and needed extensive assistance with all activities of daily living. The current plan of care updated 12/2/11 indicated R52 was vulnerable... may be unable to identify and/or escape a hazardous situation, may be unable to identify, recall or report abuse. The care plan intervention indicated "provide staff education re:specific approaches for this resident mood/behavior and/or specific vulnerabilities PRN ( as needed). The care plan also indicated R52 is "at risk for alteration in mood r/t long-term placement, senile dementia with [MEDICAL CONDITION], "combat fatigue"/[MEDICAL CONDITIONS] per family report, explosive personality , hearing loss. Interventions included: provide unhurried, consistent routines, explain what you are going to do, if resident combative, provide for safety, leave and re-approach, remove residents that may escalate the situation, approach at a later time if resistive. During review of NA-B's employee file a "Performance Improvement Action Plan" dated 6/7/11 was completed by the DON and union representative, which indicated "On 6/6/11 while providing cares for a resident on second floor you slapped/batted at the resident with your hand. This was observed by coworkers. You failed to remove yourself from an escalating situation." The Action plan also indicated "The standard of care for residents is to allow choice, be flexible and follow the care plan to promote best outcomes. It is never acceptable to slap/bat a resident..." The facility's investigation notes dated 6/6/11 indicated on 6/6/11, trained medical assistant (TMA)-A informed RN-H she was frustrated with R52's behavior. RN-H went to R52's room. NA-B was observed by RN-H slapping R52's hand "I heard it and saw it and I asked her to leave." The employee was removed from the schedule on 6/6/11 and returned to work on 6/15/11. During interview at 9 a.m. on 12/9/11 SS-B stated she was not aware of the hand slapping with R52 and NA-B. At 12:30p.m. the DON stated while NA-B was working with R52 he was swinging his arms out and she should have removed herself from the situation instead of doing what she did. The DON stated she reprimanded employee NA-B with a verbal warning and suspended employee NA-B. Even though the facility was aware NA-B slapped R52's hand, they did not notify the state agency or the administrator of this incident. R15 received alleged verbal abuse, the facility did not thoroughly investigate and the administrator and state agency were not notified. R15 had [DIAGNOSES REDACTED]. At 9:45a.m. on 12/9/11 during interview NA-C stated about two weeks ago a housekeeping (HSKP)-A observed NA-B tell R15 "why are you so [***] ing crabby?" NA-C stated HSKP-A was afraid to report NA-B so NA-C told SS-B about the incident. At 10:10a.m. on 12/9/11 during interview with R15 she stated staff are rough some of them "hurt my legs they are so rough I tell them I am in pain and they just laugh at me. The one girl laughs at me". R15 stated she did not know the staff names "because their name tags are always flipped over" so she could not see their names. At 11:10 a.m. on 12/9/11 during interview with SS-B she stated she received a report R15 was upset with NA-B. SS-B stated she talked with R15 and she had no concerns so no incident report or investigation was ever conducted. SS-B was unable to provide any investigation of the incident or any interview with R15 or NA-B about the incident. Also there was no indication the administrator or state agency were ever notified of the incident even though this was an observed by HSKP-A. During interview from 1:15 p.m. to 1:25 p.m. on 12/7/11, with registered nurse (RN)-B, licensed practical nurse (LPN)-B, housekeeper (HSK)-A and social worker (SW) director all had different responses on who to contact if they were informed of an alleged abuse, neglect, or injury of unknown origin incident. These individuals stated, the would either contact social services, or the director of nursing, or the RN supervisor. None of them stated they would contact the administrator. MONITORING Although NA-A, NA-F, NA-D, NA-B had several incidents of verbal, physical abuse and neglect, these nursing assistants were not consistently provided additional training or supervision to prevent further resident abuse and neglect. During interview at 1:15 p.m. on 12/7/11, Registered Nurse (RN)-B stated she has worked as the charge nurse and has supervised staff, but has never had to specifically monitor any nurse aides for appropriate care delivery or interaction with residents. During interview with RN-C at 9:05 a.m. on 12/8/11, she stated she has enough time on the night shift to supervise staff, but had never been asked to monitor care or staff/resident interaction on any particular staff person. During interview with RN-A at 1:10 p.m. on 12/8/11 she stated there were no nursing aides that have been on any special monitoring that she was aware of. If any special monitoring needed to be done social services or human resources would be responsible to complete this. During interview at 3:11p.m. on 12/8/11 the DON stated nursing assistants are monitored by the charge registered nurse (RN)'s who are responsible to monitor all NA's and if there were any concerns they were to let her know. Even though the DON stated the charge RN's were to monitor and supervisor nursing assistants, RN-A, RN-C and RN-B were not aware they needed to specifically monitor certain nursing assistants to ensure verbal, physical abuse and neglect would not occur for the 84 resident who resided in the facility. The lack of identification, investigation, resident protection, and reporting constituted immediate jeopardy for R64, R60, R90, R98, R6, R1, R29, R55, R106, R52, and R15. At 2:00p.m. on 12/9/11 the DON and acting administrator were informed of the Immediate Jeopardy due to the lack of investigation, reporting to the administrator and state agency these allegations of abuse, neglect, and injuries of unknown origin. At 10:00a.m. on 12/12/11 during interview with the facility administrator he stated he had always been available to the staff. He stated he had not been informed of the incidences regarding R60, R52, R98, R90, R15, R6, R1, R64, R29, R55, and R106 which the survey team investigated. He stated "how can you fix something if you have not been informed." On 12-14-11 the facility submitted a plan of correction which include revision of the Abuse prevention plan to include notifying the administrator and state agency immediately, training for all staff including resident aggression, and how to recognize care giver burnout. In addition the administrator will be available to the facility every morning for a daily meeting to ensure compliance with reporting and investigation requirements. All staff were trained on how and when vulnerable adult reports need to be made. During interviews at 9:37a.m. thru 10:30a.m. on 12/14/11, RN-MDS Coordinator, NA-M, Housekeeping-B, NA-C, TMA-B, TMA-C, SS-B, SS-A, NA-J, RN-J, NA-N, LPN-D were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment, internal reporting, resident protection, investigation, reporting to the administrator immediately, and external reporting as defined in the revised plan. The DON and administrator were informed the IJ was removed at 3:20 pm on 12-14-11 and the scope and severity was reduced to no actual harm with a potential for no more than minimal harm, pattern.